CHAPTER XXVIII
LESSONS LEARNED
Colonel Albert J. Glass, MC, USA (Ret.)
A frequent comment by frustrated and harassed psychiatrists during World War II was that responsible authorities failed to heed the lessons learned by psychiatry in World War I. Indeed, this subject is a recurrent theme in many chapters of this history. It should be conceded, however, that there has been little agreement as to what specific psychiatric lessons were learned during World War I. Also, only meager documentary evidence was available to support this or that policy, procedure, or technique as proved by experiences in World War I. Perhaps the relatively brief as proved by experiences in World War I. Perhaps the relatively brief participation of the U.S. Army in World War I did not permit the accumulation of sufficient data to warrant conclusive statements. Regardless of reasons, the uncertainty of what was learned by psychiatry in World War I has prompted the inclusion of this final summary chapter on the major lessons of psychiatry learned in World War II.
Almost 20 years have elapsed since the end of World War II (at the time of this writing, 1965). During this period, the Korean War was fought to a stalemate (25 June 1950-27 July 1953). There have been many "brink-of-war" crises, involving the mobilization or commitment of U.S. Army Forces in Germany, Formosa, Lebanon, Greece, Vietnam, Laos, Thailand, Cuba, and other areas in some of which intermittent, small-scale combat activities have occurred. Even during relatively quiet times, the Army, also the Navy and the Air Force, has never returned to the small peacetime force that existed before World War II.
In addition, there have been marked increases in firepower by the elaboration of new and more efficient weapons and their delivery systems. The World War II Selective Service System or the "draft,"1 which was reinstituted during the Korean War, has been continued. In effect, since World War II the armed Forces have been maintained in a more or less wartime posture. These circumstances have provided an opportunity not only to utilize the lessons of World War II psychiatry but also to evaluate
1Dr. Bernard D. Karpinos, Special Assistant for Manpower Studies, Medical Statistics Agency, Office of The Surgeon General, Department of the Army, furnished the following additional information: "The World War II Selective Training and Service Act of 1940 which was permitted to expire in 1947 was reinstituted in 1948 as the Selective Service Act of 1948. (Only for a period of somewhat over one year was there no such legislation.) The 1948 act was reenacted in 1950 as the Extension Act of 1950 and established, in 1951, as the Universal Military Training and Service Act of 1951. This act has been regularly reenacted since 1951 in terms of 4-year intervals, extending, as of 1963, until 1 July 1967. See Supplement to Health of the Army, Office of the Surgeon General, U.S. Army, May 1964, Vol. 19, p. 1."
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their validity in the light of subsequent experiences in both hot and cold war periods.
MAGNITUDE OF PSYCHIATRIC DISORDERS IN MODERN WARFARE
Undoubtedly, the most important lesson learned by psychiatry in World War II was the failure of responsible military authorities, during mobilization and early phases of hostilities, to appreciate the inevitability of large-scale psychiatric disorders under conditions of modern warfare. The high admission rates for psychiatric conditions in World War I, in World War II, and in the Korean War are clearly reflected in chart 15 and table 66.2
CHART 15.-Admission rates for psychiatric conditions, by broad diagnostic categories and year, 1917-59
2Unless otherwise indicated, the statistical data in this chapter were furnished by Dr. Karpinos (see footnote 1, p. 375). By supplying this statistical report, with pertinent explanation, Dr. Karpinos made a valuable contribution to this volume, which is gratefully acknowledged with sincere thanks.-A. J. G.
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TABLE 66-Admissions rates for psychiatric conditions by broad diagnostic categories and year 1917-591
[Rate expressed as number of admissions per annum per 1,000 average strength]
Year | Diagnostic categories | |||||
Total | Psychosis | Psychoneurosis | Other psychiatric conditions | |||
Total | Mental deficiency | Character and behavior disorders and other | ||||
1917 | 9.9 | 2.7 | 3.4 | 3.8 | 2.4 | 1.4 |
1918 | 20.4 | 3.3 | 9.9 | 7.2 | 4.1 | 3.1 |
1919 | 11.3 | 2.6 | 5.9 | 2.8 | 1.2 | 1.6 |
1920 | 12.8 | 3.7 | 5.0 | 4.1 | 1.9 | 2.2 |
1921 | 10.6 | 3.1 | 4.1 | 3.4 | 1.5 | 1.9 |
1922 | 10.0 | 3.2 | 4.3 | 2.5 | .8 | 1.7 |
1923 | 11.1 | 3.7 | 4.0 | 3.4 | 1.3 | 2.1 |
1924 | 12.0 | 3.8 | 4.2 | 4.0 | 1.4 | 2.6 |
1925 | 11.8 | 3.7 | 3.7 | 4.4 | 1.6 | 2.8 |
1926 | 11.5 | 3.5 | 3.8 | 4.2 | 1.5 | 2.7 |
1927 | 12.4 | 3.6 | 3.7 | 5.1 | 2.1 | 3.0 |
1928 | 11.7 | 3.7 | 3.2 | 4.8 | 2.2 | 2.6 |
1929 | 11.6 | 4.0 | 2.9 | 4.7 | 1.9 | 2.8 |
1930 | 10.4 | 3.6 | 2.8 | 4.0 | 1.3 | 2.7 |
1931 | 9.5 | 3.9 | 2.5 | 3.1 | .7 | 2.4 |
1932 | 8.2 | 3.1 | 2.4 | 2.7 | .4 | 2.3 |
1933 | 7.8 | 2.6 | 3.1 | 2.1 | .4 | 1.7 |
1934 | 9.5 | 2.9 | 3.9 | 2.7 | .5 | 2.2 |
1935 | 9.3 | 2.9 | 3.2 | 3.2 | .6 | 2.6 |
1936 | 9.2 | 2.8 | 3.4 | 3.0 | .6 | 2.4 |
1937 | 9.2 | 2.8 | 3.7 | 2.7 | .4 | 2.3 |
1938 | 9.2 | 2.5 | 3.7 | 3.0 | .3 | 2.7 |
1939 | 9.6 | 2.6 | 3.7 | 3.3 | .3 | 3.0 |
1940 | 11.2 | 3.1 | 4.7 | 3.4 | .5 | 2.9 |
1941 | 19.6 | 3.4 | 11.7 | 4.5 | 1.2 | 3.3 |
1942 | 24.6 | 3.5 | 16.7 | 4.4 | 1.3 | 3.1 |
1943 | 38.1 | 2.6 | 29.0 | 6.5 | 2.1 | 4.4 |
1944 | 40.7 | 2.8 | 29.7 | 8.2 | 3.6 | 4.6 |
1945 | 28.2 | 2.2 | 21.6 | 4.4 | .4 | 4.0 |
1946 | 15.7 | 1.9 | 9.3 | 4.5 | .3 | 4.2 |
1947 | 18.3 | 1.5 | 9.0 | 7.8 | .3 | 7.5 |
1948 | 18.4 | 1.9 | 7.8 | 8.7 | .2 | 8.5 |
1949 | 16.6 | 1.9 | 7.0 | 7.7 | .1 | 7.6 |
1950 | 23.6 | 1.8 | 11.9 | 9.9 | .2 | 9.7 |
1951 | 25.1 | 2.8 | 12.3 | 10.0 | .3 | 9.7 |
1952 | 16.0 | 3.1 | 6.9 | 7.0 | .3 | 6.7 |
1953 | 14.6 | 2.0 | 5.5 | 7.1 | .2 | 6.9 |
1954 | 10.6 | 1.6 | 4.0 | 5.0 | .1 | 4.9 |
1955 | 10.2 | 1.5 | 3.6 | 5.1 | .1 | 5.0 |
1956 | 10.0 | 1.3 | 3.5 | 5.2 | .1 | 5.1 |
1957 | 9.2 | 1.2 | 3.1 | 4.9 | .0 | 4.9 |
1958 | 8.5 | 1.3 | 3.0 | 4.2 | .0 | 4.2 |
1959 | 8.1 | 1.3 | 2.8 | 4.0 | .0 | 4.0 |
1Fundamental changes occurred during this period with respect to both classification and nomenclature of psychiatric diagnosis. During 1917-29, psychiatric conditions were listed under "Nervous System, Diseases" and "Mental Alienation" (including alcoholic psychosis). Alcoholism without psychosis (without differentiating between acute and chronic) and drug addiction were listed under "General Diseases." During 1930-37, "Alcoholism with Psychosis" was transferred to "General Diseases," and listed alongside with the combined chronic and acute alcoholism (without psychosis). In 1937, "Paresis" was transferred and listed under "Infective and Parasitic Diseases." Since 1938, alcoholism without psychosis has been reported separately as acute or chronic. However, inasmuch as no separate classification of alcoholism by acute and chronic was available before 1938, this particular diagnosis was excluded, for consistency, from this table. (Alcoholism without psychosis was included, however, in table 67 and chart 16, inasmuch as disability discharges for alcoholism undoubtedly refer to chronic alcoholism, currently classified as a psychiatric condition.)
The diagnostic categories, as given in this table and in chart 15, include the following specific diagnoses:
Psychosis: General paresis, dementia praecox, manic depressive psychosis, alcoholism with psychosis, and other psychoses.
Psychoneurosis: Hysteria, psychasthenia, psychoneurosis, neurasthenia, neurocirculatory asthenia, and neurosis.
Other Psychiatric Conditions: Mental deficiency, character behavior disorders and other. The category "character and behavior disorders and other" includes constitutional psychopathic states, drug addiction, enuresis, and malingering (appendix A, tables 2 and 8). "Shell shock" reported for 1918 and 1919 (a rate of 1.51 for 1918, and 0.11 for 1919, per 1,000 mean strength per year), was included under "Psychoneurosis."
NOTE.-The entry .0 indicates a rate of less than .05.
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ORGANIZATION OF PSYCHIATRY FOR WAR
Failure to appreciate the magnitude of the psychiatric problem had its logical consequence in a delay in providing organizational leadership in the Surgeon General's Office. Thus, it was not until February 1942 that a small and mainly ineffective Neuropsychiatry Branch was established in that office. This branch was gradually enlarged and improved in function until finally, on 1 January 1944, some 2 years after the onset of hostilities, neuropsychiatry was elevated to the status of a representative division in the Surgeon General's Office and given sufficient staff to perform its mission adequately (ch. II).
During the crucial mobilization and early war periods, however, the lack of planning, preparation, and direction resulted in inadequate or faulty psychiatric policies and practices, wastage of psychiatric personnel, and consequent huge losses of military manpower. From these mistakes, only partial correction was later possible. It was mainly through the trial-and-error efforts of rank-and-file psychiatrists that effective methods of dealing with wartime psychiatric disorders were discovered or relearned. From these experiences were gradually evolved operational concepts and practical methods of management and treatment which were organized and welded into a comprehensive and effective program, during the later phases of World War II, by the emerging psychiatric leadership in the Surgeon General's Office.
The World War II experience clearly indicates the necessity for psychiatric leadership at the highest level of military medicine. The nucleus of such leadership at the highest level of military medicine. The nucleus of such leadership must exist as an integral component of the Surgeon General's Office during peacetime so as to be capable of rapid expansion in war. In essence, the Army Medical Service must be similarly concerned with preparation for the management of psychiatric casualties as for the more traditional problems of injury and disease. It should always be remembered that modern war produces two unique types of casualties in large numbers; namely, injuries and psychiatric disorders, both of which are caused by traumatic forces set forth by a changing and hostile environment. It is highly desirable that career military psychiatrists be developed and maintained so that they may comprise a nucleus of psychiatric leadership in the Office of The Surgeon General during peacetime and, thus, be immediately available during any mobilization or planning for war.
As World War II demonstrated, civilian psychiatrists can adapt and utilize their skills for the psychiatric problems of war, but time is required for such transition and orientation to the special problems of military psychiatry. Moreover, if newly placed in the position of leadership in the Office of The Surgeon General, civilian psychiatrists, even if of superior caliber, must have time to develop the necessary contacts with other military agencies, to understand the language, attitudes, and channels of com-
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munication of the military organization, and to learn ways and means of making needed changes to existing doctrine and programs.
It is difficult, if not impossible, for civilian psychiatric groups, such as the American Psychiatric Association, to maintain adequate interest and preparedness for military psychiatry. Preparedness for war is the responsibility of the regular Military Establishment and cannot be delegated to civilian organizations, no matter how well intentioned or motivated such groups may be.
The wisdom of psychiatric leadership by career military psychiatrists was illustrated during the Korean War. Col. John M. Caldwell, MC, Chief Psychiatric Consultant, in the Office of The Surgeon General, from 1946 to 1952, was in a position, during the conflict, to take prompt and vigorous action to implement rapidly an effective wartime psychiatric program.
To summarize: Military psychiatric leadership in the Office of The Surgeon General must be operational during peacetime and should not be discarded for reasons of expediency or economy. During war, this nucleus of career military psychiatrists can be rapidly augmented by experienced senior civilian psychiatrists. After a period of transition, the Regular Army military psychiatrists in the Office of The Surgeon General, if desired or needed, can be transferred to other assignments.
PSYCHIATRIC SCREENING
Perhaps the most widely known lesson of psychiatry in World War II was the inability of psychiatric screening to identify effectively and thus eliminate the military psychiatric problem at induction. Despite the fact that approximately 1,600,000 registrants were classified as IV-F (unfit for military service) in World War II because of mental disease and mental or educational deficiency (appendix A, table 5), indicating a disqualification rate about 7.6 times as high as in World War I (appendix A, table 7), separations for psychiatric disorders in World War II were 2.4 times as high as in World War I (appendix A, table 10).
Ginzberg and his associates,3 in evaluating the disqualifications for military service in World War II, pointed out the shortcomings of World War II psychiatric screening. One cannot quarrel with their evaluations or be surprised by their conclusions. Even during World War II, many psychiatrists engaged in induction screening were highly dubious of its effectiveness. Indeed, soon after the war, many publications by wartime psychiatrists appeared,4 attesting to the inefficiency of the psychiatric
3Ginzberg, Eli, Anderson, James K., Ginsburg, Sol W., and Herma, John L.: The Ineffective Soldier: The Lost Divisions. New York: Columbia University Press, 1959, p. 36.
4(1) Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948. (2) Bloomberg, W.: Plan for Screening, Induction, and Utilization of Manpower. Am. J. Psychiat. 105: 462-465, December 1948. (3) Egan, J. R., Jackson, L., and Eanes, R. H. Study of Neuropsychiatric Rejectees. J.A.M.A. 145: 466-469, 17 Feb. 1951. (4) Eanes, R. H.: Standards Used by Selective Service and a Follow-Up on Neuropsychiatric Rejectees in World War II. In The Selection of Military Manpower. (A symposium edited by Leonard Carmichael and Leonard C. Mead.) National Academy of Sciences, National Research Council, Washington, D. C., 1951, pp. 149-156. (5) Fry, C. C.: A Study of the Rejection Causes, Success and Subsequent Performance of Special Groups.In The Selection of Military Manpower, op. cit., 1951, pp. 133-138. (6) Brill, N. Q., and Beebe, G. W.: Some Applications of Follow-up Study to Psychiatric Standards for Mobilization. Am. J. Psychiat. 109: 401-410, December 1952. (7) Glass, A. J., Ryan, F. J., Lubin, A., Ramana, C. V., and Tucker, A. C.: I and II. Psychiatric Prediction and Military Effectiveness. U. S. Armed Forces M.J. 7: 1427-1443, October 1956; 1575-1588, November 1956. (8) Glass, A. J., et al.: III. Factors Influencing Psychiatrists. U. S. Armed Forces M. J. 8: 346-357, March 1957.
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screening procedure. In fact, so well demonstrated was the unreliability of individual psychiatric screening that the routine examination of inductees by psychiatrists was abandoned by the Army soon after the end of World War II and was not even reinstituted during the Korean War.5
In retrospect, there can be no doubt that psychiatric screening as performed during World War II was an impractical and ineffective procedure. However, it is more important from the standpoint of learning from the lessons of history to appreciate the circumstances and reasons which led to the vigorous employment of, and the unrealistic reliance upon, this instrument so that perhaps the same error may not be repeated in future wars.
Rationale for Psychiatric Screening
First, it should be recognized that belief in the efficacy and necessity of psychiatric screening had existed since World War I. Repeated references to this effect by senior medical officers appear in the annual reports of The Surgeon General, between World War I and World War II, in which the occurrence of psychiatric disorders in the peacetime Army was largely blamed upon the unsatisfactory examination of applicants for enlistment and, thus, failure to heed the lessons of World War I. Interestingly enough, there was no insistence that such examinations need be performed by psychiatrists. The detection of overt or potential mental disorders was considered quite within the capability of any mature and conscientious medical examiner with previous military experience. These year after year exhortations by senior medical officers had seemingly no effect in lowering the frequency of psychiatric disorders. Yet, belief in psychiatric screening continued. It seemed as if the examiners, during those years, were exceedingly perverse individuals who, despite being told repeatedly of their derelictions, persisted in being lax or incompetent.
Apparently, with time and a mounting need due to the heightened prospects of war, belief in screening grew into a firm conviction. Considered thus, in the mobilization period and the early phases of World War II, psychiatric screening was seized upon as the major solution to the mental health problems of modern war and advocated by a host of lay and medical leaders, both military and civilian, including a number of prominent psychiatrists.6 It must be stated, however, that many psychiatrists
5Karpinos, Bernard D.: Qualification of American Youths for Military Service. Medical Statistics Division, Office of the Surgeon General, Department of the Army, 1962, pp. 7-9.
6Glass, Albert J: Psychosomatic Medicine. In Medical Department, United States Army. Internal Medicine in World War II. Volume III. Infectious Diseases and General Medicine. [In preparation.]
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expressed doubt, advised caution, or argued against any sweeping reliance upon screening procedures (ch. VIII).
Curiously enough, when the psychiatric history of World War I is examined, little evidence is found to support the effectiveness of psychiatric screening. Yet the experiences of World War I were repeatedly referred to as proof of its validity. It is true that "Neuropsychiatry," volume X of the history of the Medical Department in World War I, contains statements favorable to psychiatric screening and strongly recommends its employment. But screening at induction or before acceptance for military service, by psychiatrists, was infrequently practiced in World War I (appendix A). Moreover, volume X furnished no information, such as followup studies, which document the effectiveness of psychiatric screening, except for the empirical impression that preembarkation screening reduced the incidence of psychiatric disorders in the American Expeditionary Forces.
As noted in chapter I, one gains the strong impression that local board medical examiners in World War I rejected only obvious neuropsychiatric disorders of which the majority were mental deficiency and epilepsy. In contrast, psychiatrists of World War II endeavored, as instructed, to identify and reject the potential as well as the relatively fewer overt neuropsychiatric problems before service. It was this effort to eliminate potential mental disorders which was responsible for the much higher rate of psychiatric rejections in World War II over that of World War I.
Indeed, the major technical lessons to be learned from the psychiatric screening experiences of World War II lies in appreciating the serious and perhaps insurmountable limitations inherent in any single cross section individual type of psychiatric or psychological examination which, before induction, attempts to render reliable judgment of future effectiveness or mental breakdown. Clearly, psychiatric prediction or any medical effort to forecast future disability is much more accurate when signs and symptoms of abnormality or disease are already present, as apparently was the case in most psychiatric "rejections" in World War I, than are attempts to predetermine the behavior of individuals, particularly when the later circumstances of assignment, associates, leadership, hardships, hazards, and other environmental variables are unknown.
More difficult to explain is why so many psychiatric authorities in World War II apparently assumed that, by interview examination alone, the later effectiveness of future soldiers could be reliability estimated, particularly when there existed no established criteria or demonstrated validity for such a predictive procedure. In this connection, there was prevalent then, as now, a widely held belief in the indestructibility or the invariable persistence of psychiatric symptomatology. Thus, it is believed that emotional or behavioral disorders, as seen at the time of clinical manifestations when usually a history of previous difficulties or pathological
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background is readily obtained, would have displayed similar symptoms, findings, and history at some prior occasion even if under entirely different circumstances and that this could have been identified, if only examined properly. This myth persists despite the day-to-day experiences of psychiatrists in the changeability of history, symptoms, and behavior even in severe mental illness, such as schizophrenia, let alone neurotic or deviant behavior syndromes.
It was this belief which accounted for repeated complaints before World War II of the improper examination of recruits. Rarely was there recognized that motivation, interview behavior, or history could be radically different at induction from that obtained under conditions of mental breakdown or maladjustment when the individual concerned must explain to himself, and others, reasons for failure. The individual motivated to enter the service views the present and past in a favorable light, which represents truth for him at this time. Conversely, the unmotivated draftee can readily consider the apprehensions of the present and the conflicts of the past as "being nervous all my life" and cite numerous examples of his unsuitability for service. The more thorough and experienced the examiner, the more evidence of neurotic tendencies or, at least, personality abnormality can be uncovered. Such was the case in World War II when sophisticated psychiatric examiners rejected a high number of inductees, but their increased efficiency in ridding the service of potential breakdowns was never proved. In fact, there is some indication that the reverse could be true (ch. VIII).
Second, and again in retrospect, reliance upon psychiatric screening can be understood as a logical extension of the denial or the failure to appreciate the magnitude of the psychiatric problem in war. In effect, the mass employment of psychiatric screening can be equated with the use of a magical device that would do away with the problem. To support this conclusion, it must be admitted that a reasonably thorough screening examination, as envisioned and advocated by psychiatrists, was accomplished in only a minority of inductees. In fact, it can be categorically stated that psychiatric screening in World War II did not receive a fair opportunity to demonstrate its effectiveness, for the following reasons:
1. In most instances, psychiatrists were permitted only 2-5 minutes or less to conduct a screening examination, usually without collateral information. This indifference in providing sufficient time for such a difficult task perhaps best illustrates the denial of the psychiatric problem in World War II by reliance upon a token process. Moreover, when psychiatrists were not available, as happened not infrequently, other physicians were designated to serve as induction station psychiatrists and, having been so named, were assumed to possess the same capability as trained and experienced psychiatrists.
Thus, as a result of the difficulties mentioned in providing sufficient time and trained personnel, more often than not psychiatric screening be-
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came a farce and the commonly used several-question examination a well-known target of World War II jest and humor.
2. As stated by Ginzberg and his associates, in "Lost Divisions," psychiatric criteria for induction varied considerably during World War II, depending upon War Department policies relative to the utilization of so-called marginal manpower. During the mobilization period before hostilities, an army of 1 million was the objective. Under these circumstances, psychiatrists were enjoined to reject all potential risks, as a superior group was desired to be trained as officers and noncommissioned officers and to serve as the cadre for a much larger army in the event of war. Unfortunately, with the outbreak of war, the same policy was continued.
In later 1943, when it became evident that manpower was not unlimited, this liberal rejection policy was reversed, and psychiatrists were instructed to accept any individual who had the capability for performing even limited military service. Thus, it was that the rejections for psychiatric reasons more often reflected War Department desires and needs relative to quality and quantity of manpower rather than the presence of a mental disorder or a potential mental disorder as found by the psychiatrist.
Post-World War II Psychiatric Screening
Finally, what has been the fate of psychiatric screening in the postwar years? As stated previously, the routine psychiatric examination for military service was discarded soon after World War II. Instead, only those draftees and applicants for enlistment are referred for psychiatric consultation who present, at the Armed Forces examination stations, definite symptoms or documentation of a mental disorder. With this change in the processing procedures, existing during the Korean War (July 1950 through July 1953), about 2 percent of youths examined for military service were disqualified for service because of psychiatric abnormalities. The overall qualification and disqualification rates for that war period were as follows:7
Qualified:1 | Percent |
| Physical Category A | 58.9 |
| Physical Category B | 11.5 |
| Physical Category C | 6.0 |
Total | 76.4 |
Disqualified:1 | |
| Administrative reasons | 2.6 |
| Failed mental test only | 7.9 |
| Failed mental test and medically disqualified | 1.8 |
| Medical reasons only2 | 11.3 |
Total | 23.6 |
Grand total | 100.0 |
1These data were derived by taking into account the entire manpower pool; namely, those who were examined by the Armed Forces examining stations for induction or enlistment, as well as those who fulfilled their military liability as a member of a Reserve unit (for example, National Guard, Reserve Officers' Training Corps, and other Reserve units). Disqualifications by the local boards for moral reasons or for manifestly disqualifying medical defects were included in these computations.
2Includes 0.5 percent for neurologic, 1.9 percent for psychiatric, and 8.9 percent for "other medical reasons," respectively.
7Karpinos, B. D.: Fitness of American Youth for Military Service. Milbank Mem. Fund Quart. 38: 214-247, July 1960.
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Parallel with the liberalized policy in regard to psychiatric screening, a more comprehensive mental testing was introduced after World War II. In 1950, the AFQT (Armed Forces Qualification Test) was instituted, designed to evaluate the examinees' "potential trainability."8 This test produced higher disqualification rates than the corresponding tests in World War II. It is of interest, therefore, to compare the rejection rates of World War II with those of the Korean War, as affected by these changes.
The disqualification rates for World War II, by broad disqualifying causes, were as follows:
| Percent rejected1 of total examined | |
Medical: | |
| Neurologic | 1.7 |
| Mental disease | 5.5 |
| Mental or educational deficiency | 4.3 |
| Other medical | 18.2 |
Total | 29.7 |
Nonmedical (administrative) | 0.5 |
Grand total | 30.2 |
1Derived from the "Distribution of Registrants 18-37 Years of Age in Class IV-F and Classes With "F" Designation by Major Disqualifying Cause, as of August 1945, World War II," as reported by the Selective Service Headquarters. (See appendix A, tables 5-7, for the detailed sources and manner of calculation.) These rates differ somewhat from those published by Ginzberg, et al., op. cit., table 8, p. 36.
The disqualification rate for the Korean War was reported as 23.6 percent (above)-a rate lower than the 29.7 in World War II. It must be recognized, however, that the examinees of the Korean War were much younger than those of World War II.9 Because of these age differentials, the highest difference in the disqualification rates of World War II and the Korean War was, as expected, for "other medical reasons."
Disqualifications for psychiatric disorders were clearly lower during the Korean War than in World War II (1.8 percent versus 5.5 percent)
8See Karpinos, "Qualification of American Youths for Military Service," op. cit., pp. 10-12, for a discussion on the development of this test; its functions; its content areas; manner of scoring; and mental grouping.
9For an approximately comparable age group, however, the World War II data show about the same rejection rate. As shown in appendix A, table 6, the rejection rate for the 18-25 age group was 22.7 in World War II.
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because of the new orientation toward eliminating at the examination stations only "gross psychiatric conditions." Relatively more were disqualified, however, on the more comprehensive mental test (AFQT): 7.9 percent failed the AFQT only (p. 745) versus 4.3 percent disqualified for mental or educational deficiency in World War II (p. 745). The combined disqualification rate for mental unfitness (psychiatric disorders and mental test failures) were the same; namely, 9.8 percent in both World War II and the Korean War.
Although it is true that the two wars are not comparable, the fact that the Korean War shows considerably lower admissions rates for psychiatric disorders than World War II (chart 15 and table 66) does not support the contention in regard to the efficacy of the psychiatric screening or the necessity of such routine screening.
As a result of World War II experience, there has been an increasing trend toward the utilization of the objective type of test for determining "potential trainability," not only for selection but also for assignment purposes. The AFQT fulfills such an objective, as it classifies the examinees on the basis of their scores on the test in five mental groups. Those who fall in the lowest mental group are disqualified; those who qualify (above mental group V) are classified in four groups, indicating progressive gradation of "trainability," for mental group IV to mental group I.
Similarly, other criteria can be utilized to separate individuals into groups which give reasonably predictable duty performance. For example, high school graduates, as a group, function significantly better in military service (95 percent) than those with only part high school attainment (90 percent); they, in turn, are more effective than grammar school graduates (80 percent).10
By means of such group criteria, selection for service can be rapidly and economically accomplished in accordance with the size of armed forces required and the available manpower resources. For example, if only a moderate sized army is desired, as was the case in 1940, induction standards can be adjusted so as to accept only superior and average groups. In times of war, general mobilization, and a relative shortage of manpower, criteria for acceptance can be lowered to include below average and even marginal groups.11
GAIN IN ILLNESS
Adverse Effects of Hospitalization
An almost universal experience of medical officers in World War II concerned the deleterious effect of hospitalization. In a significant number
10See footnote 4 (7) p. 741.
11In fact, the Army does not accept now (1965) applicants for enlistment below mental group III. It excludes not only the low mental group V but also IV. This was made possible because this complete evaluation by mental group is done at the time of examination, not after the examinees have entered the military service, as was done in World War II on the basis of the Army General Classification Test. See Supplement to Health of the Army, op. cit., p. 23.-A. J. G.
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of military personnel, hospitalization seemed to fixate symptoms, retard expected clinical improvement, and negatively influence motivation for return to duty. For these mainly ambulatory patients, it seemed evident that remaining in a sheltered hospital status, even with the restrictions of illness, represented a considerable advantage over the stress and strain of active duty. Such gain in illness or the obtaining of tangible benefits from symptoms of disability was quite well known before World War II, particularly by psychiatrists and by practitioners of industrial medicine. From the standpoint of sheer numbers, however, gain in illness in World War II was a ubiquitous phenomenon. It was a daily vexing problem for medical officers assigned to hospitals, as well as to officers serving with troops and in dispensaries, who were confronted with the persisting complaints of soldiers endeavoring to enter medical channels.
In retrospect, the large-scale occurrence of gain in illness should not have been so surprising. The phenomenon was well known in World War I and a familiar problem of military medicine between the wars. In World War II, circumstances were particularly favorable for the elaboration of gain in illness. Literally millions of men were uprooted from their homes and familiar support and subjected to regimentation, deprivations, and hazards.
Inability to adjust or adapt to the military wartime environment led to mounting tension which not infrequently resulted in deviant or apathetic behavior. More commonly, however, a variety of ill-defined psychologically induced or associated clinical disorders was produced that included (1) overt psychiatric symptoms, usually of the neurotic type; (2) persistent somatic complaints mainly in the gastrointestinal, cardiovascular, and musculoskeletal spheres, with negative findings of "organic" disease; (3) peptic ulcer, hypertension, allergic disorders, dermatological conditions, migraine, and other so-called psychosomatic diseases; and (4) unexplainable residual syndromes from major and minor injury, surgery, heat exhaustion, diseases such as pneumonia, meningitis, and rheumatic fever, and even spinal puncture.12
As previously stated, there was little planning, preparation, or even recognition that such maladjustment disorders would occur in large numbers and constitute a major military medical problem. The newly commissioned medical officers soon appreciated that many of these psychological syndromes were "functional" in nature. However, there was no organized program for their evaluation, management, or treatment. Also, at this time, individuals with persistent complaints, claiming an inability to perform duty, could only be managed by hospitalization for diagnosis and treatment. Thus, the stage was set for the mass hospitalization of such symptomatic disorders, with its inevitable complication of gain in illness. The more thoroughly symptoms were investigated, the longer the hospitalization; and the greater the gain in illness, the more convinced became
12See footnote 6, p. 741.
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patients that they had valid medical, and thus honorable, reasons for relief from duty and even discharge from the service. In the newly constructed cantonment hospitals of the time, it was common to see hundreds of these ambulatory patients, sitting and lying about on the wards or roaming the corridors and recreation areas. Under these conditions, an atmosphere was created that was highly suggestive of gain in illness to patients convalescing from so-called organic disease and injury, as well as stimulating to others, out of the hospital, to seek relief from adjustment difficulties through medical channels. One observer of the time, Eisendorfer,13 commented: "Neurosis is as contagious as a virulent infection. For every neurotic patient hospitalized there are 10 more with potential neuroses who do not require much stimulation to react in a similar manner."
Dilemma of the Medical Officer
Many frustrated medical officers unable to cope with the persistent complaints of these patients, despite their best efforts of diagnosis and treatment, explained resistance to improvement as being due to neurotic predisposition or functional overlay. Others, perhaps the majority, viewed gain in illness as a conscious evasion of duty and used such terms as "goldbricking," "malingering," and "misfits." Almost all medical officers endeavored to refer or to transfer such patients to the psychiatrist. This is illustrated by Eisendorfer's report that, in the first 6 months of 1943, of all patients admitted to Tilton General Hospital, N. J., 48 percent were examined by the neuropsychiatric service for consultation, treatment, or disposition. But psychiatric wards were also congested, and there was a chronic shortage of psychiatric personnel. Psychiatrists were especially reluctant to accept for transfer patients who had extensive hospitalization because of prolonged clinical investigation or residual symptoms from disease or injury. Such patients were overtly hostile toward any effort to remove their favorable hospitalized status. Thus, no one wanted these patients who in turn resented their physicians. An impasse was created for which medical discharge seemed to be the only solution. Medical separation was not only the easy way out for both patient and medical officer but was also recommended by official directives and prominent lay and military medical authorities, on the grounds that "there is no place in the Army for the physical and mental weakling."14
Prevention of Hospitalization
During these early years, it became apparent to many wartime psychiatrists and other medical officers that hospitalization in itself created or
13Eisendorfer, A.: Clinical Significance of Extramural Psychiatry in the War. Medicine 5: 146-149, March 1944.
14Circular Letter No. 19, Office of The Surgeon General, U.S. Army, 12 Mar. 1941.
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perpetuated illness and disability. An obvious solution was the prevention of hospitalization for the purely symptomatic disorders and maladjustment problems. Thus, in 1942, psychiatrists spontaneously moved toward the extramural management of neurotic-type disorders, which concept and practice was expanded to become the consultation service system, to be discussed later in the chapter.
Nonpsychiatric medical officers, however, also took steps to circumvent gain in illness and the deleterious effects of hospitalization. Internists and surgeons and other specialists established outpatient treatment for many conditions from pilonidal sinus and acute gonorrheal urethritis to gastrointestinal disorders and foot strain.15 In addition, beginning in 1942, programs on reconditioning were initiated in Army hospitals, which eventually grew into an organized effort directed by The Surgeon General, with the establishment of the convalescent hospital system. In reconditioning programs, patients were required to participate in increasing physical and mental activities until fit for duty.
Postwar Impact
For psychiatrists, it is of interest to note that continued hospitalization, with its adverse effects noted particularly with psychiatric patients in World War II, has produced a similar deleterious effect in the mentally ill patients in civilian institutions, who have been hospitalized for prolonged periods.
In the postwar years, along with the general trend in civil life toward outpatient management, whenever feasible, and the decreasing length of hospitalization of military personnel. There remains, however, a constant problem of gain in illness from individuals with adjustment difficulties. Psychiatric consultation services have steadily improved and usually are called upon to aid in management and treatment before hospitalization.
In any future general mobilization, gain in illness is almost certain to become again a major wartime medical problem. In this event, it is hoped that the experiences of World War II will be considered as a guide for implementation, for there was eventually evolved an adequate program for the management and control of gain in illness.
CONSULTATION SERVICES
As a consequence of the need to prevent the adverse effects of hospitalization, beginning in early 1942, there were developed, at training camps, outpatient psychiatric facilities termed "Consultation Services." Initially, consultation services provided mainly a screening and advisory
15See footnote 6, p. 741.
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function for line commanders in the elimination of noneffective trainees and the reclassification of those being trained in a skill beyond their capacities. Later, as psychiatric personnel for the first time functioned in a setting where soldiers lived and worked, they became increasingly aware that failure in training was not merely the inevitable result of defective or abnormal personality, but rather that faulty motivation and leadership, physiological strain, psychological stress, and situational pressures played a major role in evoking neurotic and maladjustment disorders.
Methodology
In time and with experience, psychiatrists and other personnel of the consultation services became more involved in activities designed to alter or influence attitudes and situational circumstances so as either to prevent emotional disorders or to provide for their early recognition and prompt management. To accomplish these objectives, psychiatric personnel learned to leave the office setting and become firsthand observers of training activities, consulting directly with commanders on referral problems. This approach also permitted relevant collateral and followup information to be gathered by visits to company areas. More important, such a decentralized or field operation brought about adequate communication and working relationships between consultation services and using agencies. Psychiatric personnel became familiar with the language and values of trainees and with the vicissitudes of training. Gradually, most psychiatrists in the consultation services became identified with the needs of the military service rather than with only the needs of the individual. In turn, line commanders came to know psychiatrists as exponents of reality rather than as persons with impractical theories.
In an effort to prevent disabling maladjustment, consultation services developed programs of lectures, aimed at the indoctrination of officers and other trainer personnel, on measures to maintain the mental health of trainees and the early recognition of emotional disability. Similarly, orientation talks were evolved for groups of newly inducted soldiers to promote better understanding and, thus, desensitization of the common emotional problems encountered in the transition from civil to military life. No convincing evidence was ever submitted to indicate that such indoctrination or orientation lectures reduced the incidence of maladjustment disorders in trainees. However, attitudes of both trainers and trainees became more accepting and supportive of anxiety, depression, frustration, nostalgia, and other emotional discomforts which commonly occur among trainees. Also, unusual or persistent symptoms or behavioral abnormalities were more readily recognized by trainer personnel as a signal for early referral to the consultation service. It is likely that the lecture programs were more effective in secondary prevention (early recognition
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and treatment) than in the primary or actual prevention of psychiatric disorders.
Summary
Consultation services in World War II demonstrated the validity of aiding the trainee while he still struggled to cope with situational difficulties. This approach proved far superior to the previous practice of hospitalization and thus removal of the individual from the area of conflict which confirmed and fixated the failure of adaptation to military service. The efforts of consultation services markedly reduced the frequency of hospitalization for trainees and was a major lesson learned by psychiatry in World War II.
This lesson was not forgotten. During the Korean War, consultation services, renamed "Mental Hygiene Consultation Services," were established at all training centers and played a prominent role in the effective psychiatric program during this period. Since the Korean War, Mental Hygiene Consultation Services have been continued on all major posts in the Zone of Interior and in all oversea divisional garrisons. Mental Hygiene Consultation Services provide consultation and treatment services not only for trainees but also for all military personnel and many civilian dependents. In effect, the mental hygiene consultation service of an army post serves the military community for primary and secondary psychiatric prevention in the same manner as a mental health service provides care to a civilian community.
DIAGNOSIS AND DISPOSITION
Faulty Nomenclature
Another important lesson learned in World War II was the influence of psychiatric diagnosis in determining the disposition of marginal military personnel. As previously indicated, with the rapid expansion of the Army, there occurred increasing numbers of persistent maladjustment and neurotic-type disorders which exhibited "gain in illness" and were apparently resistant to treatment. From the beginning, psychiatrists were uncertain as to the appropriate diagnosis for these emotional reactions which were clearly related to, or precipitated by, situational events and frequently complicated by poor motivation for military service.
At this time, however, there was no generally acceptable diagnostic term, other than "psychoneurosis," to categorize situationally induced psychological syndromes, although "simple adult maladjustment," "gastric neurosis," or similar terminology was used by some psychiatrists. As stated in chapter IX (p. 229), "psychiatric nomenclature which was barely adequate for civilian psychiatry was totally inadequate for military psychiatry." In the years following World War I, psychoneurosis had come more
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and more into common usage for almost all neurotic-type disorders. It is a curious commentary that the diagnostic term "psychoneurosis," developed by Freudian psychology to indicate a relatively fixed neurotic illness due to internalized unconscious conflict from faulty childhood psychosexual development, in time, was generalized to encompass a wide variety of situationally induced emotional reactions.
If the issue of psychiatric diagnosis was only of academic interest, the ubiquitous use of psychoneurosis would have been of little importance. However, as described in other chapters of this volume (IX, X, and XI). Army policy during the mobilization and early war years was to eliminate personnel of limited effectiveness, particularly psychiatric disorders. Especially emphasized was the careful detection and elimination of unstable persons and mental "misfits."
Under these circumstances, considerable pressure was exerted upon Army hospitals and their psychiatrists to admit and dispose of these problem soldiers. The Surgeon General had directed that disposition need not be delayed until a highly accurate diagnosis was established by prolonged and detailed study. "If an individual is obviously unfit, the psychiatrist should make the best tentative diagnosis and proceed promptly with the necessary action to dispose of the patient."16
Medical Versus Administrative Discharge
The psychiatrist, faced with increasing numbers of patients whose symptoms were quickly fixed by hospitalization and the chronic shortage of professional and ancillary assistants, could only implement the policy of disposition. Diagnosis, however, was of paramount importance. On the one hand, psychoneurosis was classified as an illness for which an honorable discharge could be readily accomplished under medical auspices by CDD (certificate of disability for discharge). On the other, a diagnosis of an inadequate or other personality disorder which was not considered an illness would result in the return of the patient to duty for possible administrative discharge because of inadaptability or undesireable habits and traits of character (section VIII, AR 615-360). Such "Section Eight" discharges could be white (honorable) or blue (without honor) with the onus of social disapproval as well as the denial of certain veteran's benefits. As described in chapter IX, the relatively new unit commanders were reluctant to initiate "Section Eight" proceedings which were not only unfamiliar, cumbersome, and time consuming, but also reflected presumed lack of leadership and command ability. Also, administrative separations required appearance before a line officer board which was often disinclined to approve such a harsh discharge for unhappy, anxious soldiers who complained of somatic or psychological symptoms and insisted that they were sick.
16Circular Letter No. 99, Office of The Surgeon General, U.S. Army, 4 Sept. 1942.
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TABLE 67-Disability discharge rates for psychiatric conditions, by broad diagnostic categories and year, 1917-591
[Rate expressed as number of discharges per annum per 1,000 average strength]
Year | Diagnostic categories | |||||
Total | Psychosis | Psychoneurosis | Other psychiatric conditions | |||
Total | Mental deficiency | Character and behavior disorders and other | ||||
1917 | 3.79 | 1.07 | 0.49 | 2.23 | 1.53 | 0.70 |
1918 | 8.90 | 1.86 | 2.05 | 4.99 | 3.28 | 1.71 |
1919 | 7.20 | 3.20 | 1.61 | 2.39 | 1.34 | 1.05 |
1920 | 10.04 | 4.53 | 1.71 | 3.80 | 1.77 | 2.03 |
1921 | 6.34 | 2.84 | 1.00 | 2.50 | 1.28 | 1.22 |
1922 | 4.51 | 2.37 | .80 | 1.34 | .48 | .86 |
1923 | 5.41 | 2.87 | .74 | 1.80 | .73 | 1.07 |
1924 | 6.19 | 3.24 | .81 | 2.14 | .85 | 1.29 |
1925 | 6.32 | 3.03 | .73 | 2.56 | .84 | 1.72 |
1926 | 6.11 | 2.89 | .83 | 2.39 | .98 | 1.41 |
1927 | 7.11 | 3.02 | .91 | 3.18 | 1.30 | 1.88 |
1928 | 6.82 | 3.19 | .67 | 2.96 | 1.43 | 1.53 |
1929 | 7.00 | 3.42 | .67 | 2.91 | 1.26 | 1.65 |
1930 | 5.72 | 2.80 | .59 | 2.33 | .82 | 1.51 |
1931 | 5.46 | 2.90 | .71 | 1.85 | .40 | 1.45 |
1932 | 3.99 | 2.38 | .54 | 1.07 | .18 | .89 |
1933 | 4.11 | 2.32 | .89 | .90 | .15 | .75 |
1934 | 4.74 | 1.97 | 1.49 | 1.28 | .29 | .99 |
1935 | 4.87 | 2.27 | 1.15 | 1.45 | .20 | 1.25 |
1936 | 4.60 | 2.11 | 1.08 | 1.41 | .24 | 1.17 |
1937 | 4.38 | 2.16 | 1.10 | 1.12 | .14 | .98 |
1938 | 3.01 | 1.82 | 1.02 | .17 | .05 | .12 |
1939 | 2.75 | 1.75 | .89 | .11 | .04 | .07 |
1940 | 3.26 | 1.98 | 1.08 | .20 | .09 | .11 |
1941 | 5.22 | 2.03 | 3.00 | .19 | .07 | .12 |
1942 | 6.87 | 2.16 | 4.37 | .34 | .22 | .12 |
1943 | 18.00 | 2.30 | 15.36 | .34 | .18 | .16 |
1944 | 11.25 | 2.47 | 8.57 | .21 | .06 | .15 |
1945 | 13.89 | 2.68 | 11.07 | .14 | .03 | .11 |
1946 | 6.85 | 2.96 | 3.76 | .13 | .01 | .12 |
1947 | 3.55 | 1.80 | 1.63 | .12 | .02 | .10 |
1948 | 3.41 | 1.60 | 1.62 | .19 | .00 | .19 |
1949 | 3.07 | 1.44 | 1.46 | .17 | .00 | .17 |
1950 | 3.22 | 1.83 | 1.18 | .21 | .02 | .19 |
1951 | 6.51 | 2.93 | 3.35 | .23 | .03 | .20 |
1952 | 3.83 | 2.21 | 1.54 | .08 | .01 | .07 |
1953 | 3.05 | 2.06 | .96 | .03 | .00 | .03 |
1954 | 2.32 | 1.68 | .63 | .01 | .00 | .01 |
1955 | 1.95 | 1.45 | .48 | .02 | .00 | .02 |
1956 | 1.36 | 1.08 | .26 | .02 | .00 | .02 |
1957 | 1.21 | .95 | .24 | .02 | .00 | .02 |
1958 | 1.09 | .88 | .19 | .02 | .00 | .02 |
1959 | 1.08 | .88 | .16 | .04 | .00 | .04 |
1See footnote to table 66. From 1949 and on, the data are preliminary and subject to modification. Since 1950 separations for disability are accomplished under the provisions of Title IV of the Career Compensation Act of 1949.
NOTE.-The entry .00 indicates a rate of less than .005.
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In truth, it was difficult for the psychiatrist to distinguish between personality disorders with situationally induced tension and somatic symptoms from so-called psychoneurosis. Thus, it is understandable that under these conditions, generally, the diagnosis of psychoneurosis and the disposition by medical discharge became the preferred solution. It satisfied the patient and the unit commander; it was consistent with current psychiatric nomenclature and was apparently approved by higher authority. As a result, there occurred a steadily mounting CDD rate for psychiatric disease, mainly psychoneurosis (chart 16 and table 67).
Further Problems
With the high rates of medical separations threatening to decimate the Army, concern reached the highest military authorities. On 11
CHART 16.-Disability discharge rates for psychiatric conditions, by broad diagnostic categories and year, 1917-59
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November 1943, the War Department reversed the previous liberal discharge policy and established a policy of salvage and maximum utilization of marginal personnel. A prompt effect of this directive was a precipitous decline of the medical discharge rate. As the months passed, maladjusted, inadequate, and other marginal-type personnel reaccumulated. Liberalization of medical and administrative discharges was alternately reestablished and rescinded, but to no avail-the assignment and disposition of these problem soldiers continued to plague military authorities, both line and medical, until the war ended. Basic to this issue for the lessons of military psychiatry was the utilization of the simple procedure of medical discharge, mainly for psychoneurosis as a solution for marginal personnel and logistic problems, including even shortages of hospital beds. The emerging psychiatric leadership at the Surgeon General's Office, under Brig. Gen. William C. Menninger, MC, had repeatedly opposed, with little success, the indiscriminate use of medical discharges and had consistently advocated treatment for neuropsychiatric disorders rather than merely a program of disposition.
Despite these protests, psychiatrists were increasingly criticized for the excessive use and abuse of "psychoneurosis." These criticisms came from both line and medical authorities and also from the Army Chief of Staff, Gen. George C. Marshall (ch. VII, pp. 131-133). Previously, the ineffectiveness of psychiatric screening, which had been instituted and strongly supported by higher authority, was blamed upon psychiatric examiners for being either "overenthusiastic" or "overcautious." Thus, it seemed that psychiatrists in World War II were fated to receive the brunt of blame for the failure of faulty manpower policies which had been established by their line and medical superiors. It must be admitted, however, that many psychiatrists, new to military service, too easily yielded to the pressure of line and other medical officers and attempted, through medical (psychiatric) auspices, the impossible task of ridding a large wartime Army of its inevitable maladjusted, poorly motivated, and otherwise marginal personnel problems.
In September 1944, the Inspector General began an extensive investigation which confirmed that "a majority of these cases are not NP conditions because medical officers wish to make patients of them, but because the line officers have been unable to make soldiers out of them. * * * a large proportion of medical discharges for 'psychoneurosis' have been brought about because of difficulty experienced by line officers in effecting the administrative discharges of inadequates and of persons inadaptable to the service." (See chapter VI, pp. 103-108.) The Inspector General, however, also reported that the term "psychoneurosis" had been abused and recommended that the diagnosis of psychoneurosis not be used for the inadequate and militarily inadaptable and for psychiatric conditions which were doubtful, mild, or borderline and for those whose prognosis was favorable for return to duty. Further, the Inspector General advocated a working
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diagnosis of combat fatigue or operational fatigue for psychiatric casualties arising out of combat or other hazardous duties.
The Surgeon General, in apparently accepting the viewpoint of his embattled Neuropsychiatry Consultants Division, defended the diagnosis of "psychoneurosis" and opposed any change in its usage as recommended by the Inspector General. After a series of conferences, however, a compromise was reached in which the generic term "psychoneurosis" would be omitted from the individual clinical records and replaced by the appropriate subtype of psychoneurosis, such as anxiety reaction or conversion reactions, which would serve as the working diagnosis. This change was incorporated in WD (War Department) Circular No. 81, issued on 13 March 1945.
Final Change in Psychiatric Nomenclature
The final change in military psychiatric nomenclature took place shortly after World War II, with the publication of WD Technical Medical Bulletin (TB MED) 203, issued on 19 October 1945. This quite thorough revision was accomplished by General Menninger after obtaining the opinions and recommendations of many military and civilian psychiatrists. The basic changes of the revised nomenclature consisted of two new diagnostic categories, as follows:
(1) Transient personality reactions-included all emotional reactions to acute and special stress. Cases where symptoms continued after removal of stress were diagnosed as the appropriate subtype of the psychoneurotic disorders. Transient personality reactions were divided into-
(a) Combat exhaustion, for the acute psychiatric casualties of combat.
(b) Acute situational maladjustments, for emotional disorders resulting from unusual or overwhelming stress under noncombat conditions.
(2) Immaturity reactions-included neurotic-type reactions to routine military stress, manifested by helpless or inadequate responses, passive obstructionism or aggressive outburts.
The new diagnostic categories made unnecessary the widespread usage of the term "psychoneurosis" for situationally induced psychiatric disorders. As a result, the incidence of psychoneurosis declined sharply and remained at low levels even during the Korean War (chart 15).
The new psychiatric nomenclature proved to be not only a major advance in military psychiatry and thus an important lesson learned in World War II, but also came to represent a significant contribution to civilian psychiatry. The essential features of TB MED 203 were accepted by the Veterans' Administration and later were incorporated in a comprehensive revision of the official psychiatric classification of the American Psychiatric Association.
Final Change in Medical Discharge
The final chapter on medical discharge was written in 1949, with the enactment of new retirement laws in which enlisted personnel were medi-
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cally discharged by the same procedures as for officers. Since retirement for disability was a complex process which involved review and approval by an agency of the Department of the Army, there occurred a marked decrease of medical separations for all causes, including psychiatric disorders. As a result, the medical discharge rate for all psychiatric reasons has continued to decline, even during the Korean War (chart 16). Thus, a solution was found for the excessive medical discharge of "psychoneurotic" cases, which consisted of both a change of psychiatric nomenclature and a tightening of the medical discharge process. The benefits of this hard-won lesson learned in World War II were continued during the Korean War and have become a permanent part of the policies and procedures of military psychiatry in the U. S. Armed Forces.
THE MAKING OF WARTIME MILITARY PSYCHIATRISTS
The marked shortage of psychiatrists in World War II has been the subject of much comment in several chapters of this volume. Attempts to overcome this shortage were only partially successful, but from the experiences of these efforts was derived an enduring lesson of military psychiatry.
As stated in chapter IV, "Education and Training," the heightened need for military psychiatrists during the war and their relative scarcity, thus making them unavailable from civilian sources, made apparent even in the early phases of World War II the necessity of training, or in some way utilizing, general medical officers for psychiatric assignments.
Initially, and for some time, many of the newly inducted physicians who had even a minimum of training or experience with mental disorders were placed in psychiatric positions. More often, however, others without such a psychiatric background, and, usually, with their consent, were simply assigned for duty in psychiatric sections of hospitals to fill existing vacancies. In some instances, a trained psychiatrist, usually the chief of the psychiatric section, was available to provide excellent on-the-job supervision. More frequently, the psychiatrist "by order" had little of any professional guidance and were forced to train themselves through "do it yourself" experiences of handling mental disorders, supplemented by readings from the literature and by occasional professional stimulation and teaching during the visits of psychiatric consultants from corps and army areas and from the Surgeon General's Office.
Surprisingly good results were obtained by this haphazard effort to increase the number of Army psychiatrists. In time, the vast majority of these medical officer "OJT's" (on-the-job trainees) became effective, practical military psychiatrists. Medical officers who were fortunate enough to be stationed with well-trained teachers of psychiatry received the equivalent of postgraduate psychiatric residency training during their period of military service. The bulk of OJT's, however, with little or no supervision
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also progressed in psychiatric skill and effectiveness. Obviously, individual differences in talent, motivation, and interest in psychological matters played a major role in the end product that was evolved.
Probably better known than the on-the-job psychiatric training were the 12-week formal courses in neuropsychiatry which were mainly conducted at the School of Military Neuropsychiatry then at Mason General Hospital, Brentwood, Long Island, N.Y. This training was specifically designed for medical officers with no previous psychiatric experience. A total of 811 students were graduated from courses given from 15 April 1944 to 22 December 1945. From all accounts, these "90-day wonders" in psychiatry also became capable military psychiatric practitioners and, as stated by Menninger, "this training program was regarded as one of the most important and successful achievements during the war" (ch. IV).
Perhaps a major factor in the rapid acquisition and utilization of psychiatric knowledge by both the OJT's and the graduates of the formal training program was the opportunity to observe readily the obvious relationships that existed between situational stress, including variations in morale, leadership, and group identification, and the production of psychiatric symptoms and apparent disability. Here were seemingly clear-cut cause and effect correlations in which the favorable results of treatment, whether the techniques of psychotherapy or reassignment and other types of environmental manipulations, could usually be noted.
The major lesson learned from these experiences was that effective wartime military psychiatrists could be obtained by on-the-job training, preferably with adequate supervision and by relatively brief formal training courses. An added bonus effect was that many, if not the majority, of both OJT's and school graduates sought formal psychiatric residency training and thereby increased the number of needed psychiatrists in civil life.
This lesson of World War II military psychiatry was also not forgotten. During the Korean War, a formal training program in neuropsychiatry, of 16 weeks' duration, was reestablished at the Medical Field Service School, Fort Sam Houston, Tex. As in World War II, graduates of this program also rendered creditable service as military psychiatrists. Again, the majority of these officers continued after military service to complete their training and become psychiatrists in civilian life.17
Since the Korean War, the small numbers of additional psychiatrists needed by the Army to fill existing vacancies have been obtained by on-the-job training at Army hospitals in which there are large psychiatric treatment centers. Usually, two to six of the newly commissioned medical officers who volunteer for such training are assigned to the psychiatric sections of the training hospitals, where they remain for the duration of their obligatory tour of service. This type of training has operated successfully to
17Forrer, G. R., and Grisell, J. L.: U. S. Army Psychiatric Training Program; Subsequent Nation-Wide Effects. Arch. Neurol. & Psychiat. 77: 218-222, February 1957.
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fill the Army needs for additional psychiatrists and has also served to swell the ranks of civilian psychiatrists.
SUMMARY
In this chapter, the editor has endeavored to discuss what he has considered to be the major lessons learned by military psychiatry in World War II. Undoubtedly, there are other and contrary valid opinions. However, he could not hope to cover the many innovations and improvisations developed by psychiatrists to cope with local problems be such problems either clinical or administrative. Unquestionably, ingenious techniques of thereapy and unique methods of applying psychiatric skills to resolve particular military community problems were evolved by individual psychiatrists. However, only those lessons learned which had a widespread utilization or universal applicability could be included in this review.
Perhaps the most important contribution of military psychiatry of World War II has not been stated. This concerns the subtle or gradual orientation of psychiatry as a result of wartime experience toward considering the emotional problems of the individual within the context of his group and his social culture, instead of almost exclusive preoccupation with intrapsychic conflict or pathology. It might be said that World War I brought the psychiatrist from behind the mental asylum walls to practice in the community, whether in an office, a clinic, or a local general hospital. World War II forced the psychiatrist to function extramurally-where soldiers lived, worked, and fought. This experience provided a firsthand opportunity for the psychiatrist to observe the effects of the group process and its impact upon attitudes, values, and finally symptoms and behavior of individuals. Psychiatrists were then able to perceive and incorporate the contributions of other social sciences, such as sociology, social psychology, and anthropology, into the framework of psychiatry. Indeed, these wartime experiences may be said to have initiated the governing concepts and practices of social psychiatry, for in essence, military psychiatry is but a form of social psychiatry.
Wartime military psychiatrists quickly appreciated the potent effects upon individual behavior of morale, leadership, and group cohesiveness. They learned to work with command in implementing changes in rules and regulations designed to decrease noneffectiveness. Finally, the present focus of civilian psychiatry upon establishing community mental health centers which aim to provide consultative services to "caretakers" and community agencies and to render treatment "as far forward as possible" can be regarded as a logical extension of the insights achieved by military psychiatry in World War II.
