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Chapter 8, Part 2

Medical Science Publication No. 4, Volume II

HISTORY AND ORGANIZATION OF A THEATER
PSYCHIATRIC SERVICE BEFORE AND AFTER 30 JUNE 1951*

COLONEL ALBERT J. GLASS, MC

As the Korean campaign fades into the past, it is appropriate at this time to set forth its experiences and lessons before they are obscured by time or distorted by tricks of memory and the pressure of more recent events. This presentation proposes to describe the organization of theater psychiatry during the Korean conflict, with special emphasis upon the psychological problems that arose during the movement warfare of the first year as contrasted with the more static combat phase that prevailed after 30 June 1951.

Prior to hostilities in Korea, Army Medical Service in the Far East Command was sufficient only for the occupation forces and their dependents. Psychiatric personnel and facilities were similarly lacking in the reserve strength required for the support of combat operations. In all, nine psychiatrists were present for duty in the Far East Command, eight of whom were Regular Army residents in psychiatry, with from 18 to 24 months of professional training, who had been placed in the theater on a temporary duty status from Fitzsimons and Letterman Army Hospitals. Psychiatric facilities were available in Army hospitals at Tokyo, Yokohama, Osaka, Fukuoka, and Okinawa. They functioned as sections in the respective medical services, except at the 361st Station Hospital in Tokyo, the "NP Center" of the Far East Command, where a separate neuropsychiatric service included open and closed wards, EEG and EST apparatus, and trained ancillary personnel in both social work and psychology. The medical consultant to the Surgeon, Far East Command, coordinated psychiatric functions in the theater as part of his supervision of professional activities in internal medicine.

The abrupt entrance of our occupation forces into the Korean fighting made it necessary to rapidly improvise medical support for the combat troops which could only come from the slender medical resources in Japan. Initially at least there was no plan or organized program for the care of psychiatric casualties. All available medical


*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


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personnel were required for the more urgent needs of first aid, evacuation, and emergency surgical care. However, in the early weeks of the Korean fighting, intradivisional psychiatric treatment would have been impractical. The constant retrograde movement of the UN forces, who necessarily fought a series of delaying actions, made even emergency medical treatment and evacuation a difficult and dangerous procedure because of enemy attacks upon our flanks, rear, and lines of communication. Psychiatric casualties were numerous but not excessive. A neurotic adaptation was of less value in this desperate and confused tactical situation, in which medical channels were also under attack, and where movement away from fear was more safely accomplished with the withdrawing combat group.

By early August 1950 the UN defenses stiffened to form a relatively stabilized line, the Pusan perimeter, which held firm despite repeated enemy assaults and penetrations. With relatively new units engaged in heavy combat, little opportunity for rest, and severe battle losses, there was created the type of tactical situation which favors the production of numerous psychiatric casualties. Their incidence during this combat phase was the highest in the Korean campaign. The holding and treatment of minor disease, injury and psychiatric patients by divisional medical elements now became a practical possibility and was in fact made mandatory by the grim necessity of rapidly conserving combat personnel to maintain the thinly manned perimeter defenses. In mid and latter August 1950, division psychiatrists were assigned and became operational in the 2nd, 24th, 25th Infantry and 1st Cavalry Divisions. They established psychiatric treatment units in or near division clearing stations and salvaged 50 to 70 percent of received patients for combat duty by a 1- to 4-day period of rest, food, and superficial psychotherapy.

Before and after division psychiatry was established, psychiatric evacuees from the combat zone were sent to the one evacuation hospital in Pusan. Although this unit had an assigned psychiatrist, lack of facilities permitted only the retention of non-transportable seriously ill and injured patients for treatment. It was therefore necessary to evacuate the vast bulk of received psychiatric patients to southern Japan, where they were transhipped to the 361st Station Hospital in Tokyo. Approximately 1,800 psychiatric casualties were evacuated from Pusan during July, August, and early September of 1950. The 361st Station Hospital rapidly expanded its psychiatric facilities, but despite an increase of its professional staff, flown from the Zone of Interior, only 50 percent of psychiatric patients were salvaged for even noncombat duty. Bed space limitations forced the evacuation of the remainder to the U. S. A.


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What lessons in combat psychiatry can be learned from this initial phase of the Korean conflict? When one considers the extremely unfavorable tactical conditions, limited facilities and scant personnel, medical support can be said to have been performed with outstanding effectiveness. Moreover, division psychiatry became operational within 6 to 8 weeks after an unprepared onset of hostilities, in contrast to an almost 2-year delay in establishing a similar program in World War II. Yet in Korea, as in World War II, steps to prevent and salvage psychiatric casualties were taken after the need became glaringly apparent. With Korea added to our previous experiences in modern warfare, there is now sufficient evidence accumulated to indicate clearly that psychiatric casualties can be expected to occur with the same certainty as battle wounds. Moreover, any delay in instituting measures for their control and treatment is particularly unfortunate since psychiatric casualties usually have their highest frequency in the early fighting of a campaign. Then heavy battle losses are common, the tactical situation is often confused and units new to combat have not yet acquired the group cohesiveness which sustains the individual soldier against psychological breakdown in battle.

It is therefore evident that for future combat operations medical plans should include a psychiatric program designed to function at the outset of fighting. Such a conclusion may seem obvious, but warrants emphasis and repetition because all too often in the past there has been a wait and see attitude. Then the inevitable psychiatric casualties were either evacuated out of the combat zone and thus permanently lost to their units or hastily improvised salvage efforts gave only imperfect results.

Of special importance in the medical planning for combat operations is the inclusion of psychiatric treatment facilities at Army level in order to give the theater psychiatric program the necessary elasticity to function in unfavorable tactical situations. Normally, Army facilities receive psychiatric evacuees from the division psychiatric units and provide treatment and consultation for Army and corps troops. But, as in Korea, often intradivisional psychiatric treatment is not possible, particularly in the early difficult phase of major combat operations or when there is a rapid withdrawal type of action. Army facilities must then assume the function of division psychiatry and become the first level of psychiatric care. Such Army psychiatric support was lacking early in the Korean campaign. It is the writer's opinion that two psychiatrists provided with the simplest of administrative and housekeeping facilities, to operate either as a separate unit or attached to the one evacuation hospital in Pusan, could have salvaged at least 50 percent of the psychiatric patients that were evacuated to Japan during this period. Field psychiatry is perhaps the most


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economical and effective form of medical care, requiring only a few personnel and a minimum of supplies and equipment.

The large incidence of psychiatric casualties caused efforts to implement an organized psychiatric program for the theater. In late September 1950 a senior Regular Army psychiatrist, with previous experience in World War II, was assigned as psychiatric consultant to the Surgeon, Far East Command.

The next combat phase saw a great UN victory. The successful Inchon invasion by the 10th Corps coordinated with a break-through by the 8th Army perimeter defenders from the south destroyed, captured, and dispersed the bulk of the enemy forces. Psychiatric casualties were numerous during the initial severe fighting, but sharply declined with the collapse of enemy resistance. The 1st Marine Division, who bore the brunt of the fighting for Seoul, suffered heavy battle losses and consequently incurred a large number of psychiatric casualties.

Marine psychiatric patients were first evacuated to a Navy hospital ship in Inchon Harbor, since intradivisional psychiatric treatment was not available. Despite the excellent psychiatric staff and facilities aboard the hospital ship few psychiatric patients were salvaged for combat duty. This was in sharp contrast to the results obtained somewhat later in the more primitive environment of a field hospital, where 50 percent of Marine psychiatric casualties were recovered for combat duty by a 1- to 3-day period of rest, sedation, and superficial psychotherapy. Obviously, the comfort and safety of a hospital ship militates against the motivation of psychiatric patients to face again the rigors of combat.

It is not surprising that morale in October 1950 was high. The tables had been quickly and almost miraculously overturned and everyone expected that soon the fighting would be over with return to comfortable Japan. The psychiatric casualty rate for this month, the smallest in the Korean campaign, reflected the low incidence of battle casualties and the optimism that pervaded all ranks. But, in November 1950, enemy resistance steadily increased, the weather became quite cold, supplies were short, and the optimism of the previous month began to wane. During this phase of victory and tactical security, a reorganization of the psychiatric program in Korea was accomplished.

Reorganization of Psychiatric Program in Korea before 30 June 1951

Psychiatric services at Army level were implemented by the utilization of small psychiatric teams in evacuation or field hospitals that were strategically located to receive most of the casualties from the combat zone. Separate clearing companies and like facilities were not available for employment as provisional Army psychiatric units, such


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as were used in World War II. Considering the small number of available psychiatric personnel, dispersion of Army psychiatric facilities was perhaps the most effective method of their employment during the rapid movement warfare of the first year in Korea. This arrangement provided alternate treatment sites in the event forward hospital units were dislocated by serious battle reverses, thereby insuring a continuation of Army level psychiatry, especially needed in any large-scale withdrawal, when interdivisional treatment was not feasible.

Such a dispersion was also better adapted to the vagaries of air evacuation then commonly used within Korea, which made difficult, if not impossible, the triage of psychiatric patients to any one area. Whether patients were brought to this or that hospital from the combat zone depended on the state of the weather, the condition of landing strips, the number of bed vacancies and even mechanical difficulties in flight. It was necessary to provide psychiatric facilities wherever large numbers of casualties arrived from the forward area. At various times during the first year of the Korean conflict, psychiatric teams were present with the 121st Evacuation Hospital at Hamhung, Taejon and Yongdongpo, the 4th Field Hospital near Seoul and at Taegu, the 64th Field Hospital at Pongyang and the 8054th Evacuation Hospital at Pusan. They operated at the first or second level of psychiatric treatment, dependent upon the tactical situation. The number of psychiatric evacuees to Japan markedly decreased as patients were recovered for combat and noncombat duty within Korea.

The role of division psychiatry was also enlarged and clarified. In the initial phase of the Korean conflict, division psychiatrists remained at clearing station level and restricted their efforts to the evaluation and treatment of referred or evacuated patients. Their activity was gradually increased to include visits to aid stations, liaison with other members of the divisional staff and orientation discussions with line and medical officers of the division. It is a common observation that when the division psychiatrist visits forward areas and makes personal contacts, he and his ideas become more highly regarded by combat medical personnel. The division psychiatrist who remains in the rear is resented as one who fears to share their hardships, even briefly, and is therefore an impractical, theoretical person who does not belong in their world of deprivation and trauma. By visits to aid stations, the psychiatrist not only brings his professional knowledge and help to the forward area but obtains first-hand information of combat psychological problems. His recommendations then display a more practical appreciation of the difficulties involved in combat adaptation.


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In time, divisional medical officers were influenced to treat cases of mild combat exhaustion at the aid station level whenever the tactical situation permitted. Division psychiatrists came to be more and more consulted by line and administrative officers on matters of morale, mental health, and special personnel problems, thus assuming an important role in preventive psychiatry. Curiously enough, resistance to the comprehensive function of division psychiatry arose more from senior medical officers than from line commanders who generally rather welcomed aid and advice on the prevention and management of psychological problems. Moreover, it was evident at least initially that some division surgeons were ignorant of the division psychiatrist's function and in some instances insisted upon limiting his efforts to purely treatment activities at the clearing station. However, once division psychiatry was firmly established in its larger role, it came to be accepted and each new division psychiatrist was expected to perform a similar function.

A reorganization of the psychiatric facilities in Japan was begun in December 1950. The practice of concentrating the bulk of psychiatric evacuees from Korea at the 361st Station Hospital in Tokyo proved to have serious disadvantages from the standpoint of treatment and disposition. Many psychiatric patients were adversely affected by the environment of this fixed hospital either to maintain a stubborn persistence of symptoms or develop more severe manifestations than were previously noted. This resistance toward improvement and return to any type of duty is not surprising when the comfortable atmosphere of a fixed hospital situated in the midst of peaceful and pleasurable Tokyo is compared with the monotonous, primitive, and hazardous existence of Korea. In addition, they could readily observe and envy the frequent evacuation to the Zone of Interior of other psychiatric patients, who were seemingly being rewarded for persistent or severe mental symptoms by being sent home.

The psychiatric casualty evacuated to Japan was especially vulnerable to suggestion. Separated from the positive sustaining forces of his combat unit and often tortured by a sense of guilt for leaving it, he readily seized upon any support for his symptom defense, the only excuse for his patient status. The hospital patient group who had similar needs and problems offered him such support. Patients reinforced each other in justifying their complaints and contaminated the newcomer with stories of "nothing being done" for them. Thus it was that the psychic trauma and its manifestations brought about by realistic battle stress were displaced to a hospital setting which became the new battleground as the psychiatric patient with the support of his hospital fellows fought to maintain the dubious but definite gains of neurotic invalidism.


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Obviously, improvement of the psychiatric program in Japan involved the decrease of non-psychotic patient admissions to fixed medical installations. The first step in this direction had already been taken by the implementation of effective psychiatric treatment within Korea. The next step was to circumvent the transfer to the 361st Station Hospital of patients from other areas in Japan by creating local NP facilities. This was accomplished by adding personnel and equipment to the psychiatric section of the Osaka Army Hospital, thus increasing its function to that of a service capable of definitive psychiatric care. Similarly, personnel and facilities were added to the NP service of the newly arrived 141st General Hospital which was placed in operation near Fukuoka and became the neuropsychiatric center of southern Japan.

Further progress was fortunately expedited in December 1950 when two convalescent hospitals were established near the major Army hospitalization centers of Tokyo and Osaka, respectively. They were designed to relieve congestion in fixed hospitals by removing ill and injured patients who had recovered sufficiently to require only ambulatory convalescent care, thus making available hundreds of beds vitally needed for those requiring actual medical and surgical care. Convalescent hospitals provided a realistic environment for psychiatric treatment. Here patients, in fatigue uniform, instead of hospital garb, participated in an active daily program of calisthenics, supervised athletics, marches, and other training activities. Under this regimen, there was less benefit from clinging to symptoms and no suggestive evidence of possible evacuation to the Zone of Interior. A psychiatrist was assigned to each convalescent hospital. Neurotic or open-ward-type psychiatric patients evacuated from Korea or originating in Japan who arrived in the Tokyo or Osaka areas were admitted to the nearby convalescent hospital, by-passing the NP centers in fixed hospitals. Such patients were deliberately dispersed among those recovering from wounds and illness who gave little support to mere neurotic complaints. Less resistance to therapy was encountered in this milieu and psychiatric patients turned more readily to their therapist for help. Marching together and performing other group activities again stirred previous feelings of group identification. The far better results obtained by psychiatry in convalescent hospitals over those of fixed hospitals argues strongly for its similar use in future communications zone medical operations.

Further improvement of psychiatry in Japan was effected by emphasis of outpatient evaluation and treatment in place of hospitalization whenever feasible. Not only were enlarged outpatient services maintained at each of the three neuropsychiatric centers previously mentioned, but similar facilities were created at large


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dispensaries, such as in Yokohama or station hospitals that served large troop populations. In effect, the goal of psychiatry in Japan aimed at a decentralized approach to the handling of psychological problems. By this scheme psychiatric evacuees from Korea were placed under treatment at whatever area they arrived in Japan, preferably at convalescent hospitals, thus eliminating the previous multiple transfers within Japan. Patients from troops stationed in Japan who had psychiatric problems were treated and evaluated on an outpatient basis if possible, or hospitalized at the nearest convalescent hospital or NP center. Only seriously ill patients or those presenting diagnostic problems, who required special care and facilities, were sent to one of the three NP centers in fixed hospitals.

Experiences involving the utilization of psychiatric personnel in the Korean campaign may provide useful lessons for future combat operations. During the first year, psychiatrists were not only relatively scarce, but their frequent turnover for various reasons constituted a constant problem in maintaining effective psychiatric support. Beginning in October 1950, all psychiatric officer personnel arriving in the theater were temporarily assigned to the 361st Station Hospital in Tokyo for a 1- to 4-week period of indoctrination and practical work in the psychological illnesses of the Far East Command. Orientation of the new arrivals was supervised by the theater psychiatric consultant and the staff of the 361st Station Hospital, during which their competence for specific assignments could be evaluated. The fact that most of the newcomers were relatively young in age, training and experience in psychiatry, eager to learn, and willing to consider other viewpoints and methods of therapy, perhaps made the task of indoctrination easier than it would have been if older and more experienced psychiatrists had been involved. From this pool of psychiatric personnel, assignments were made to various positions in Korea, Japan, and Okinawa. To insure a continuance of experienced division psychiatrists, replacements for this position were selected from those psychiatrists who served at Army level and thus to some degree were familiar with psychological disorders of combat. Each incoming division psychiatrist worked jointly for 7 to 14 days with his predecessor and was thus personally orientated in his new assignment.

The changing attitude of the psychiatrist as he moved from a rear to a forward function was noteworthy. Initially and in rear assignments, the psychiatrist new to combat problems is quite impressed by the manifestations displayed by psychiatric casualties. He is prone to over-identify with the patients and accede to their symptomatic request for further evacuation or removal from combat. He, also, feels guilty when making recommendations for a more hazard-


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ous duty than he fortunately must endure. Patients are prone to place their wishes on a personal basis with the physician who by refusing their requests comes to believe that he is serving a harsh even though useful function. Therefore, while the new psychiatrist may accept the indoctrination of others as being correct he is far from comfortable in this role. But as he moves forward to the division, shares to some degree the hazards of battle and better understands the individual sustaining forces in combat, a reorientation in attitude occurs. This comes about through realization that it is best for the individual to overcome fear else there remain a phobic scaring and chronic sense of guilt for failure. Then the psychiatrist can feel he is aiding the individual as well as the group and thus relieved of doubt and guilt he steadily improves in effective performance of his mission.

Because of the limited number of psychiatric personnel available in the first year of the Korean campaign, economy in their utilization was necessary. The majority of the psychiatrists involved had approximately 1 to 2 years of professional training in their specialty, a few had less than 1 year, but a small minority had completed 3 years or more of training and experience. One psychiatrist was assigned to each division instead of two that were authorized by tables of organization. As in World War II, actual operations indicated that a single psychiatrist can effectively accomplish this mission provided that he is assigned to the office of the division surgeon and thus free to function freely throughout the division. On occasions early in the Korean conflict, when the only psychiatrist in a division was assigned to the medical battalion or clearing company, there was clearly demonstrated a restriction of his efforts to the purely passive role of receiving and training patients admitted to the clearing station. This severely curtailed the larger role of the division psychiatrist in stimulating the more forward treatment of psychiatric casualties in aid stations and blocked his efforts toward preventive measures.

Whenever assistance was needed by the division psychiatrist, volunteer help was always available from the medical officers assigned to the holding platoon. However, it is believed that a clinical psychologist and psychiatric social worker on either enlisted or officer status could broaden and facilitate the work of the psychiatrist by virtue of their specialized skills. When such personnel were inadvertently available to the division psychiatrist they were quite profitably employed.

In Japan, economy of psychiatric personnel was also practiced by the use of neuropsychiatric centers instead of permitting the operation of separate psychiatric sections of services in each general or station hospital. Inpatient psychiatric facilities for the Tokyo-


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Yokohama area were provided by the 361st Station Hospital. Similarly the Osaka Army Hospital was the NP center for its area, which permitted the deletion of psychiatric personnel from two general hospitals located in the vicinity. The 141st General Hospital was the third NP center and served southern Japan. The saving of professional personnel by such area employment of psychiatric services not only decreased the number required but allowed for the assignment of psychiatrists to provisional convalescent hospitals and dispensaries in which there were no authorized vacancies.

Officer psychologists and social workers were employed at the three NP centers in Japan. Initially it was difficult to insure their professional function in Korea, because as MSC officers they were vulnerable for field or administrative assignments. However, later in the Korean campaign, selective assignments were arranged which permitted their professional function at Army level.

The emphasis upon field psychiatry in Korea, and the employment of convalescent hospitals and outpatient facilities in Japan markedly decreased the theater requirement for psychiatric nurses because they could only be assigned to the three NP centers in Japan. As a result, many psychiatrically trained nurses were employed in the usual spheres of medicine and surgery, both in Japan and Korea. Thus while requisitions for psychiatric nurses for a wartime theater may be on the basis of table of organization requirements they may not represent an actual need for such specialists, although the overall number of nurses requested by the theater may be quite correct.

An important aspect of the economic employment of psychiatric personnel in the Far East was the close cooperation of the personnel sections of General Headquarters, Far East Command, Japan Logistical Command and 8th Army with the psychiatric consultant. This liaison made possible selective assignments based upon individual personality and professional qualifications that were best suited for the particular position vacancy.

Utilization of Limited-service Personnel

During the first year of the Korean conflict certain innovations were made in the employment of limited-type personnel that had a pertinent bearing on the theater psychiatric program. The utilization of marginal persons whose mental and physical handicaps preclude their function in battle has always represented a difficult medical problem in a combat theater of operations, as was illustrated in World War II. Their number steadily rises with active combat because of the addition of individuals who either have residuals of or are incompletely recovered from wounds, diseases such as frostbite, and psychological breakdown. As this category of personnel


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grows ever larger more and more difficulty is encountered in arranging their suitable noncombat assignment, especially since many of the persons concerned have no special skills or training for the technical rear positions that are available. Yet some solution to their placement is mandatory, otherwise sizable numbers of individuals capable of performing limited service type duty would require return to the U. S. A. for medical or administrative reasons.

A similar problem presented itself during the Korean campaign. Initially, however, service units in Japan were so depleted by personnel sent to Korea that many vacancies for noncombat positions were present. Existing Army regulations which permitted a temporary change of the physical profile were used as a basis for a theater directive, which stipulated that persons so profiled be marked for "non-combat duty in Japan only." This procedure operated satisfactorily until January 1951 when it became difficult to find noncombat assignments within Japan. A combined medical and administrative study resulted in the following changes:

    (1) The designation "for Japan only" was deleted from the assignment recommendations for limited-type personnel. Instead the specific task to be limited was to be stated in non-medical terms, such as the avoidance of "combat duty," "long marches," "lifting heavy weights," and the like. Opportunities were thus opened for assignment in Korea, at both Army and communications zone level, and Okinawa.

    (2) Re-examination within 90 days for all reprofilees was made mandatory. Persons found fit for full duty were removed from the limited service category and made available for combat assignment. Those found still incapacitated had their limitation continued for another 1- to 3-month period. This constant rescreening of limited personnel served to partially offset their ever-increasing number.

As a result of the above changes, all reprofilees in Japan were re-evaluated in February and March 1951. A surprising result was obtained from those in the psychiatric category, when from 30 to 50 percent were deemed fit for full duty. Although the criteria for return to full duty were not uniform, all psychiatrists had been instructed to consider such individuals able to perform combat function if free of overt anxiety or its somatic displacements and able to contemplate such a change without strong protestations or recurrence of disabling symptoms. Examiners reported that many welcomed a decision rendering them fit for full duty, expressing a desire to prove themselves and thus be free of feelings of guilt and inferiority that had been present since removal from combat. This formal reclaiming of psychiatric casualties after several months of non-combat duty


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was a new procedure in military psychiatry. Unfortunately, no follow-up studies are available to determine effectiveness of reclaimed individuals after return to combat duty. However, repeated questioning of division psychiatrists in later months failed to uncover persons with such a history among their patients. Perhaps this favorable result was due to the influence of rotation that became fully operational in May 1951 and gradually removed the reconverted combat personnel.

The Problem of Character and Behavior Disorders

From another standpoint, psychological difficulties of certain personnel constituted a special problem in the theater psychiatric program. This concerned individuals with character and behavior disorders who under ordinary circumstances are considered for administrative seperation from the Service under the provisions of AR 615-368 or AR 615-369. Experience in both World War II and early phases of the Korean campaign illustrated the impracticality of implementing AR 615-369 for the removal of personnel in a combat unit, first because there is little time for such administrative procedures under combat conditions, and second because such a discharge under honorable conditions would be regarded as a reward for failure with consequent undesirable effect upon the morale of the unit involved. In actual practice AR 615-369 can seldom be utilized in a wartime theater since it is not an appropriate disposition for the emotional climate of a combat environment.

In the Far East Command, persons in this category were employed in noncombat positions as their personality defects were not so severe as to preclude their function under less stressful conditions. It became unofficial theater policy for division psychiatrists to evacuate those with personality problems who could not be reassigned within the division. When received at Army level such persons were reprofiled and recommended for a rear assignment. It was demonstrated that the vast majority of this category could, and did, function in noncombat assignments at Army or communications zone levels, when disposition was firmly made and the individual concerned pointedly reminded of his good fortune. Cases of enuresis were handled by this method and such patients became useful soldiers when it was made clear to them that their problem mainly involved the availability of laundry facilities of which there was no dearth in Korea and Japan. The provisions of AR 615-369 were therefore rarely employed in the Far East Command and only in those seriously inadequate individuals who were literally incapable of being forced to perform effective work of any kind.


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Persons with pathological personalities, as defined under AR 615-368, were not evacuated through medical channels but handled by administrative or disciplinary measures. This group included narcotic and alcohol addicts, habitual shirkers, chronic petty disciplinary offenders, and the like. This policy was based on the assumption that individuals of this type could not be rehabilitated by reassignment. Actually, combat units had relatively few persons in this category, since there is little opportunity for antisocial behavior and AWOL is a serious offense in the combat zone, punishable by general courtmartial. Most individuals of this type were found in rear areas of Korea and Japan. The fact that discharge under AR 615-368 is of the undesirable type makes such a disposition acceptable in a combat theater.

The disposition of noneffective officers was also satisfactorily solved but only at 8th Army level in Korea. Previously, officers who had demonstrated their unsuitability as combat leaders by reason of poor motivation or personality defects were either evacuated through medical channels or referred to their units for administrative action. Neither course proved to be satisfactory. On the one hand combat units did not have the time or administrative machinery to cope successfully with the unwieldy procedure of AR 605-200. On the other hand medical evacuation was regarded as an obvious reward for poor performance.

As a result of these difficulties, 8th Army Headquarters established a permanent AR 605-200 Board, under the supervision and control of the 8th Army JAG, which handled all such cases that arose in Korea. This removed the administrative burden from the combat units, who were then more willing to recommend this type of action rather than pressure their medical officers to use medical evacuation. By virtue of more expert guidance and accumulated experience, the 8th Army Board was more effective in accomplishing the prescribed procedure. This method became a uniform practice for the elimination of non-effective officers and in the writer's experience, which included similar difficulties in World War II, has proved to be the best solution to this vexing problem. A major weakness in the procedure still remained, namely, the delay of usually 3 months to await final action from the Department of the Army, during which time the officer involved is of little use to himself or the Service. It would seem reasonable to allow Army or theater headquarters to take final action on such problems in a wartime situation, or permit the already boarded officer to return to the USA and there await a final decision.

Similar cases that arose in Japan were not handled by the above stated centralized method; consequently, there was no uniform procedure and not infrequently officers in this category, particularly


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those with alcohol problems, were repeatedly hospitalized despite recommendations for administrative disposition.

Developments after 30 June 1951

After 30 June 1951, the Korean conflict entered into a more static period which continued until the termination of active combat. While there was relatively little of the rapid movement warfare that characterized the previous era, it should not be inferred that the fighting was maintained at a low level of intensity. On the contrary, there were numerous limited offensives by both sides which included fierce struggles for stubbornly defended hill masses. Patrol actions were commonplace, along with frequent artillery barrages by the ever increasing enemy firepower. U. N. troops lived in and fought from deeply entrenched and dug-in positions. Successive lines of already prepared defenses were available in the event of a withdrawal due to an enemy break-through. The enemy was similarly prepared with defenses in depth.

As the battle lines stabilized, medical support for the U. N. Forces became more uniformly and systematically applied with less of the improvised procedures that were made necessary by the previous erratic tactical situations. Mobile Army Surgical Hospitals were moved even farther forward to better fulfill their mission of emergency surgery. Evacuation hospitals also were located in their usual forward place in the evacuation chain.

Division psychiatry operated with increased efficiency as stable defensive positions allowed a greater participation of aid and collecting stations in the treatment of mild psychiatric casualties. This more static period also permitted effective modifications in the operation of psychiatry at Army level. The previous system of utilizing psychiatric teams attached to evacuation or field hospitals was changed in favor of a separate provisional psychiatric unit. This unit, similar in organization, structure, and function to that of Army psychiatric centers of World War II, was located in Seoul and served 8th Army as a focal point for combat psychiatry. All psychiatric evacuees from the combat areas were funneled to this unit where greater resources facilitated the function of the psychiatric team. As a center for 8th Army psychiatry, it served to train psychiatric personnel for more forward assignments, such as replacements for division psychiatrists. It was also utilized for the instruction of ROK medical officers. Noteworthy was the innovation which directed that all possible psychiatric evacuees from Korea, even those originating from rear areas, such as Pusan and Taegu, be sent to the Army psychiatric unit at Seoul. This insured standard criteria for evacuation to Japan, which in actual operation served to decrease their number.


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The incidence of psychiatric casualties after 30 June 1951 was maintained at fairly constant low levels with slight elevations in rate from the increase of battle casualties during offensive engagements. Aside from the static type of combat, perhaps the principal cause for the continued diminished frequency of psychiatric breakdowns was the influence of rotation. For this reason there was minimal adverse psychological reaction to the long drawn out and pessimistic peace talks. Relief from combat had become an individual affair obtainable regardless of the outcome of negotiations, and rotation became the chief topic of conversation among troops in Korea. As practiced in the Korean campaign it was a new phenomenon for American combat troops. Undoubtedly it is a long step forward in preventive psychiatry and has proved its value. However, there are certain seemingly inevitable and undesirable by-products. The most pertinent defect of rotation, aside from its logistical problems, arises from the disruption of the sustaining power of group identification which occurs when the combat soldier is notified or becomes aware that soon he will go home. The increase of tension that follows as the "short-timer" shifts his feelings for the group to concern for himself often makes battle fear unbearable. In some cases there is inability to function, with temporary breakdown. For most individuals, anxiety is noticeably increased in the last days of combat, as if it were now more dangerous to tempt fate. Many stories, undoubtedly exaggerated, are circulated about the unlucky persons who were killed on the day of rotation. Often the other members of the group readily identify with the "short-timer" by their spontaneous efforts to spare the "rotatee" further hazardous duty. The "short-timer" is also bothered by ambivalent feelings toward leaving the group, as ties with his buddies do not loosen so readily.

There was no essential change in the organization and operation of psychiatry in Japan. Greater progress was made in implementing the policy of decentralization in the management and treatment of psychiatric patients. Fewer patients reached Japan from Korea, and emphasis upon outpatient treatment resulted in less need for hospitalization of psychiatric patients originating within Japan.