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Chapter XXI

Contents

CHAPTER XXI

Psychosomatic Medicine

Colonel Albert J. Glass, MC, USA (Ret.)

Part I. During Selection for Military Service

THE PSYCHOSOMATIC APPROACH

Psychosomatic medicine, as the term is used in this chapter, is broadly defined as a professional approach to disease and disability conceived as a mind-body whole. This viewpoint, which is held by most workers in the field of psychosomatic medicine,1 is perhaps most clearly elucidated by H. Flanders Dunbar2 who comments: "The term 'psychosomatic' is descriptive rather of the observer in his endeavor to apprehend than of the organism involved. Psyche and soma merely represent two angles of observation." Such a concept views every disease as psychosomatic since in all forms of illness the defensive reaction of the individual against threats from within or without involves the interrelationship of the resources of both psyche and soma operating together as a unity. In effect, disease is but another form of organismal adaptation.

World War II began during a favorable period in the development of the psychosomatic approach. The previous several decades had seen a growing interest in the influence of emotions upon bodily changes. There were many contributions demonstrating that somatic symptoms arose from psychic causes, and vice versa, but more important were the increasing efforts to discover the mechanisms involved. The year 1935 saw the publication of the monumental work by Dunbar, which surveyed the literature on psychosomatic interrelationships for the years 1910-33. In various symposia and professional meetings, the phenomena of total reaction in disease were discussed. In 1939, a regularly issued quarterly journal, Psychosomatic Medicine, came into existence. Despite such progress, the semantic confusion and the dichotomy inherent in the term "psychosomatic" fostered in many a continuation of the traditional separation of mind and body and permitted others to assume the complacent overgeneralization that psychosomatic medicine only restated an old and well-known axiom of medical practice.

1(1) Weiss, Edward, and English, O. Spurgeon: Psychosomatic Medicine. Philadelphia: W. B. Saunders Co., 1943, pp. 1-15. (2) Menninger, W. C.: Psychosomatic Medicine on General Medical Wards. Bull. U.S. Army M. Dept. 4: 545-550, November 1945.
2Dunbar, H. Flanders: Emotions and Bodily Changes. 2d edition. New York: Columbia University Press, 1938.


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Mobilization and war with their severe and unusual stresses created exceptional conditions for the recognition and utilization of psychosomatic concepts. There were produced numerous and obvious manifestations of mind-body interrelationships that remain latent under ordinary circumstances. This greater opportunity to notice the effect of emotions upon bodily changes could not fail to influence the professional thinking of most physicians engaged in wartime military practice. Another favorable circumstance lay in the close working relationship of psychiatrists with their medical colleagues. Not only was psychiatric opinion more readily obtained than in civil practice but informal discussions, among physicians of various medical disciplines who shared common frustrations, helped to dispel the skepticism and mysticism that so often surround psychiatrists and their concepts.

On the other hand, certain aspects of World War II military medicine militated against acceptance of the psychosomatic viewpoint. One deterrent arose from the specialization which, as in civilian medicine, was practiced in most large army hospitals; that is, the various separate clinical services and sections had each its own approach, and medical officers could readily avoid psychosomatic considerations by the transfer of patients whose manifestations did not fall within their specialized sphere. This attitude was illustrated especially by the almost universal efforts of medical officers to transfer to the psychiatric wards all patients who failed to exhibit a sufficient degree of so-called organic disease. It should be stated, however, that the large patient load often carried by the individual ward officer made understandable attempts to lighten this burden by removing puzzling or annoying patients.

The administrative necessity of adhering to a standard diagnostic code also fostered a one-sided attitude toward disease and disability. Then, as today, diagnosis mainly indicated tissue pathology or pathophysiology rather than the total reaction involved in the disease process for which there is as yet no adequate terminology.

Another obstacle came from the emotional difficulties that arose in many of the newly created medical officers by their transition from civil to military life. Physicians, like other participants in war, were separated from their loved ones, suffered economic losses, and endured varying degrees of hardship and danger. But apparently, these vicissitudes were not the major cause for their mental unrest. This mental unrest was due rather to a change from a status in which there was a high degree of independence, activity, and gratification in professional work and community prestige to the relatively restricted role of a subordinate medical officer who was often blocked from promotion, through no fault of his own, and who was frustrated by periods of delay and inactivity and by administrative procedures and other restrictions that seemed to be an inevitable part of military medicine. The psychic unrest thus created made it difficult for some medical


677

officers to evaluate objectively the manifestations of disease unless undoubted structural changes were evident. Psychosomatic interrelationships were often either overlooked, owing to the close identification of the medical officer with the patient's psychological problems, or, if recognized, rejected as not being a legitimate reason for symptomatology.

In addition to these favorable and unfavorable influences, there were other factors that affected psychosomatic medicine in World War II. Various directives and regulations were issued that periodically altered the physical and mental standards for the utilization of manpower. Also, there were situational stresses of different types and intensity, from training to combat, which had a pertinent bearing upon the common clinical syndromes that were presented to the medical officer. In this chapter, consideration will be given to the development of psychosomatic concepts in relation to the following areas of the military effort; namely, (1) selection at induction or enlistment, (2) training and other service in the Zone of Interior, and (3) oversea duty and combat.

THE FIRST YEAR

The growth of psychosomatic insight during World War II is perhaps best illustrated by the change that occurred in medical thinking relative to the selection of men for military service. Here was a most difficult task, which not only involved the problem of choosing men capable of performing military duty from a physical, mental, and educational standpoint but which was further complicated by factors such as the motivation of the selectees concerned, the possibility of future compensation for disability, and the demands of a democratic society for equality in the distribution of deprivation and sacrifice. Rules of deferment for age, marital status, number of dependents, essential occupation, and the like could be sharply defined. But, except for the obviously handicapped, no such clear-cut delineation was possible by the known methods of medical selection. To meet this problem, MR (Mobilization Regulation) 1-9, War Department, 31 August 1940, was issued, prescribing physical and mental standards to be used as a guide for induction and enlistment. These regulations, however, soon came to be used mainly as a rigid directive because the civilian physicians and the new medical officers, who comprised the vast majority of medical examiners at local draft boards and Army induction stations, had little or no actual experience with the duties or conditions under which soldiers live and work. Moreover, they were strongly influenced by the unanimous opinion of prominent civilian and military medical authorities3 who, placing

3(1) Hillman, C. C.: Medical Problems Encountered in Military Service. Am. Int. Med. 13: 2205-2211, June 1940. (Also Army M. Bull. No. 53: 27-35, July 1940.) (2) Editorial: With Emphasis on the Word Selective. Mil. Surgeon 87: 265-266, September 1940. (3) Fox, L. A.: The Medical Officer's Responsibility in the Present Emergency. Army M. Bull. No. 55: 77-86, January 1941. (4) Bowman, K. M.: Psychiatric Examination in the Armed Forces. War Med. 1:  213-218, March 1941.


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much emphasis upon the experience and statistics of World War I, called upon the examining physicians to exclude persons of substandard mentality and physique, on the grounds that they were both useless to the military and quickly joined the ranks of the compensable. Apparently, expert opinion at this time considered every inductee as a future combat participant, and it was considered axiomatic that modern war required only those with superior mental and physical stamina. Particularly emphasized was the careful detection and elimination of unstable persons and mental misfits.4 Most of the psychiatric authorities held the optimistic belief that potential emotional breakdowns could be detected at induction by proper mental evaluation, and various outlines for such examination were suggested. Pratt,5 in urging a thorough attempt to rule out mental breakdowns, quoted the British medical publication Lancet as advocating that medical officers turn down all men with a nervous disability, a suggestive family history, or a bad work record, and individuals who seemed otherwise doubtful. Kardiner,6 however, was not at all certain that combat breakdowns could be predicted at induction and held that psychoneurosis was not in itself a contraindication to military service.

This emphasis upon elimination at induction in order to remove all possible failures and obtain the best of available manpower had its logical consequences. In October 1941, Selective Service Headquarters estimated that about 50 percent of selectees were disqualified for general military service because of physical, mental, and educational defects.7 Medical causes for the first 900,000 rejections for general military service are shown in table 105.

Results of the first year's experience with medical selection confirmed an increasing awareness that men were being rejected by an unrealistic, compartmentalized, assembly-line type of examination in which each physician saw only a part of the whole and thus placed undue emphasis upon minor local bodily dysfunction or pathology.8 Little consideration was given to the functioning of the individual as a whole person, and no attention was paid to superior motivation of special skills which might offset such unimportant defects as insufficient teeth or pilonidal sinus. The author, who served as examining physician to a local draft board during part of this period, could not adequately explain to himself nor to his layman colleagues the rejection, because of insufficient molar teeth or a small perforation of

4(1) Sutton, D. G.: Naval Psychiatric Problems. Am. J. Psychiat. 97: 255-275, September 1940. (2) Circular Letter No. 19, Office of The Surgeon General, U.S. Army, 12 Mar. 1941, subject: Neuropsychiatric Examination of Applicants for Voluntary Enlistment and Selectees for Induction. (3) Madigan, P. S.: Military Psychiatry. Army M. Bull. No. 56: 61-69, April 1941. (4) Campbell, J. D.: Psychiatry and Military Service. Kentucky M. J. 39: 110-115, March 1941. (5) Porter, W. C.: Military Psychiatry and Selective Service. War Med. 1: 364-371, May 1941. (6) Cutler, E. C.: What Physicians Expect From Psychiatry. War Med. 1: 352-357, May 1941. 
5Pratt, J. H.: Psychiatric Factors in Medical Examination. War Med. 1: 358-363, May 1941. 
6Kardiner, A.: Neuroses of War. War Med. 1: 219-226, March 1941. 
7Plans for Rehabilitation of Rejected Draftees. J.A.M.A. 117: 1364, 18 Oct. 1941.
8Menninger, W. C.: Condensed Neuropsychiatric Examination for Use by Selective Service Boards. War Med. 1: 843-853, November 1941.


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TABLE 105.-Estimated number of registrants found to be unqualified for general military service because of physical and mental defects



Defect or disease

Registrants unqualified for general military service

Number

Percent

Dental defects

188,000

20.9

Defective eyes

123,000

13.7

Cardiovascular diseases

96,000

10.6

Musculoskeletal defects

61,000

6.8

Venereal diseases

57,000

6.3

Mental and nervous defects

57,000

6.3

Hernia

56,000

6.2

Defective ears

41,000

4.6

Defective feet

36,000

4.0

Defective lungs (including tuberculosis)

26,000

2.9

Miscellaneous 

159,000

17.7


Total


900,000


100.0


an eardrum, of husky, alert, well-motivated men who were capable of performing strenuous activity and the acceptance of sickly, timid selectees whose entire sedentary life had been supervised carefully by an indulgent mother. As the causes for military rejection became common knowledge,9 artificial values of health became established in the community, creating guilt and embarrassment for those rejected (the so-called 4-F group) and permitting poorly motivated persons consciously and unconsciously to exploit minor defects and subjective symptoms in order to avoid military service.

REEVALUATION OF INDUCTION STANDARDS

The disclosure of the excessive rejection rates marked the beginning of a critical reevaluation of induction standards, and with increasing needs for manpower after the outbreak of hostilities, there was a gradual policy change in the direction of considering the individual as an integrated functioning being rather than as a collection of tissues and organs. As early as July 1941, when the first 6 months of selective service operations indicated the trend toward high rejection rates, Darnell10 made a plea for medical examiners to utilize MR 1-9 more as a guide rather than as a comprehensive directive. Also, at this time, Meehan11 pointed out that military induction standards were designed to obtain individuals of superior qualifications for

9Koontz, A. R.: Has Psychiatry Failed Us in World War II? Mil. Surgeon 101: 204-208, September 1947.
10Darnell, J. R.: Concerning Physical Standards for Selective Service. Army M. Bull. No. 57: 18-27, July 1941.
11Meehan, J. W.: Health of the Nation's Manpower. Army M. Bull. No. 57: 13-17, July 1941.


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1 year's service and that they should not be construed as an index of health. Meehan indicated the unrealistic nature of current dental standards by quoting from the medical statistics of the Provost Marshal General of 1875, which noted that the availability of breech-loading guns and metallic cartridges made unnecessary the biting and tearing of paper required with the old-fashioned cartridges, and thus obviated enlistment requirements for incisor teeth. In February 1942, War Department Circular No. 43 reduced the dental and visual requirements to conform more with the selectee's overall ability to function. Dental elimination rates promptly began to fall, followed somewhat later by a decline in rejections for defective vision.

The efficiency of selection from the psychiatric standpoint also came under critical scrutiny. Aita,12 Menninger and Greenwood,13 and Smith14 all strongly condemned the 2- to 5-minute psychiatric examination usually performed at induction stations as being superficial and of little practical value. They called for a more comprehensive survey of the background and the current status of the inductee. In July 1942, Porter,15 "taking stock" of the mounting psychiatric rejection rate, warned against overzealousness in psychiatric screening, seriously questioned the ability to predict psychological failure, and advocated measures such as reassignment and rehabilitation instead of rejection and discharge.

As the war progressed, it was apparent that the rejection of a high percentage of men at induction stations had failed to prevent the later appearance of numerous soldiers who were seemingly unable to perform even noncombat duties. Williams16 argued that the quality of men selected was proof of the adequacy of induction methods, which could accordingly be measured by the relative numbers of inductees subsequently discharged for reasons of physical and mental disability. A corps area (later service command) with a high rejection rate for all causes or for a particular cause should have given to the Army such a well-selected group or category that its respective discharge rate would be small, but in a survey of the nine corps areas in the United States, Williams found much inconsistency. Only two of the corps areas followed the expected rule. The best correlation of rejection and discharge rates was for visual defects; the poorest correlation, for hernia, for defects of the ear, nose, and throat, and for neuropsychiatric and musculoskeletal defects.

Consequent to the mounting evidence that induction methods were not producing the desired results, various suggestions and policy changes were

12Aita, J. A.: Problem of Neurologic and Psychiatric Examination During Military Mobilization; III. Consideration of Guides for Examination. Proc. Staff Meet. Mayo Clin. 16: 307-313, 14 May 1941.
13Menninger, W. C., and Greenwood, E. D.: The Psychiatrist in Relation to Examining Boards. Bull. Menninger Clin. 5: 134-138, September 1941.
14Smith, L. H.: Psychiatric Aspects of Military Medicine. M. Clin. North America 25: 1717-1759, November 1941.
15Porter, W. C.: Military Psychiatry. War Med. 2: 543-550, July 1942.
16Williams, G. D.: U.S. Army Induction Board Experience November 1940-September 1942. Army M. Bull. No. 65: 105-135, January 1943.


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proposed. Halloran and Farrell17 and Moersch18 called for more intensive efforts to weed out potential mental disorders at induction. Bloomberg and Hyde19 published figures indicating that rigorous prior elimination of neurological and psychiatric disorders reduced the discharge rate. The majority of observers, however, were inclined to doubt the predictive value of induction examinations and advocated liberalization of physical and mental standards to include the current effectiveness of the individual rather than the future possibility of disability. This attitude was also dictated by the growing shortage of manpower. Koontz20 caused all roentgenograms of registrants rejected for tuberculosis to be reviewed by a panel of experts. This procedure resulted in a 31-percent reclassification to full military service. Another 19 percent were considered borderline cases requiring further study, following which many were declared fit for induction.

Rowntree,21 Chief Medical Officer, Selective Service System, called for a reexamination of all previous rejectees. He cited one study in which 53 percent of those reexamined were found capable of military service. Rowntree also gave current selective service data which demonstrated the effect of age upon acceptance for military service, as follows:

Age

Percent accepted

45

15

36

30

21

70

20

74

19

82

18

84


Reynolds22 noted the benefits of obtaining objective information in medical histories from civilian sources and gave results of using such a method in Pennsylvania. He recommended this procedure as of special value with individuals previously hospitalized for tuberculosis or for neuropsychiatric disease. A routine procedure, operational in the State of Maryland since the beginning of Selective Service, checked the name of each selectee against a roster of prior State hospital admissions.23 A similar program had been instituted in New York, N.Y.24

17Halloran, R. D., and Farrell, M. J.: The Function of Neuropsychiatry in the Army. Am. J. Psychiat. 100: 14-20, July 1943.
18Moersch, F. P.: The Psychoneuroses of War. War Med. 4: 490-496, November 1943.
19Bloomberg, W., and Hyde, R. W.: Survey of Neuropsychiatric Work at Boston Induction Station. Am. J. Psychiat. 99: 23-28, July 1942.
20Koontz, A. R.: Cases Rejected for Army Service on the Basis of Chest Films Alone. Mil. Surgeon 91: 440-442, October 1942.
21Rowntree, L. G.: Wartime Problems of Selective Service. Mil. Surgeon 92: 149-162, February 1943.
22Reynolds, C. R.: The Medical and Epidemiological Management of Selective Service Men Rejected for Military Service. Mil. Surgeon 92: 140-148, February 1943.
23Koontz, A. R.: Keeping Men With Psychiatric Records Out of the Army. Mil. Surgeon 91: 313-314, September 1942.
24(1) Kopetsky, S. J.: Validity of Psychiatric Criteria for Rejection for Service With the Armed Forces: Study of Cases of 696 Registrants With Psychiatric Diagnoses From New York City Selective Service Area. War Med. 6: 357-368, December 1944. (2) McBee, M., and Stevenson, G. S.: Role of Psychiatric Social Worker in Selection of Men for the Armed Forces. Am. J. Psychiat. 99: 431-434, November 1942.


682 

Cardiovascular manifestations.-Also noted were many instances of mind-body relationships that were characteristic of the induction examination itself and that had a pertinent bearing upon acceptance or rejection. Of particular importance were various abnormal cardiovascular manifestations. Kilgore25 and Lowry26 found that examination excitement produced such variations of pulse rate and blood pressure in young men applying for military service that recordings were deemed to be of little value at any given time. Both of these observers recommended that, as a better guide to determining the cardiovascular status, examiners should consider general appearance, coordination, posture, color, and strength and endurance as judged by action in the present and the past. Lowry pointed out that similar abnormal cardiovascular findings may be present in men who have served successfully for many years. He explained the fluctuations as being due to the incomplete development of young men, causing them to be highly responsive to sympathetic stimulation.

Wilburne and Ceccolini27 reviewed blood pressure findings in 25,000 consecutive induction examinations. Using 150 mm. Hg systolic and 90 mm. Hg diastolic as the upper limit of normal, they found that even after rest periods hypertension occurred at the rate of 0.96 percent, as compared with 0.47 percent for insurance examinations and 1.6 percent for examinations of young college students. In this large series, they found that from 18 to 20 percent of selectees had elevated blood pressures on initial readings if the current standard of 140 mm. systolic was used. Rest periods from 15 to 30 minutes reduced the blood pressure of the vast majority of cases to normal levels. The most marked instance of lability was an initial blood pressure of 230/112 which, after 35 minutes of rest, decreased to 146/80. Orenstein,28 using a standard of 140/90, found hypertension without other cardiovascular or renal findings to be three times more common among Negro selectees than among their white counterparts. Rogers and Palmer29 discussed the relationship of transient, nervous hypertension to so-called essential hypertension. Examination of candidates in an officer procurement center indicated that 14 percent had mild, variable hypertension with no organic changes at the initial examination. These individuals frequently displayed signs of a nervous pressor reaction, such as tachycardia and sweating. Their reaction to the cold test was greater than normal but less than in early, mild, definite hypertension, and responses to exercise and position were not significant. Prognosis, as revealed by a followup of 25 cases, was excellent. Wilburne and Ceccolini concluded that even early signs of essential hypertension need not be disqualifying, and they recommended ac-

25Kilgore, E. S.: The Heart in Military Service. J.A.M.A. 117: 258-260, 26 July 1941.
26Lowry, E. F.: Evaluation of Heart Signs in Navy Recruiting. Mil. Surgeon 90: 37-44, January 1942.
27Wilburne, M., and Ceccolini, E. M.: Note on the Incidence of Arterial Hypertension in 25,000 Army Examinees. Army M. Bull. No. 68: 118-125, July 1943.
28Orenstein, L. L.: Hypertension in Young Negroes. War Med. 4: 422-424, October 1943.
29Rogers, W. F., and Palmer, R. S.: Transient Nervous Hypertension as a Military Risk; Its Relation to Essential Hypertension, New England J. Med. 230: 39-42, 13 Jan. 1944.


683

ceptance of applicants with variable hypertension above the standard limits under the following conditions: A negative family history of death from cardiovascular disease under 60, absence of pronounced tachycardia, normal fundi, an age of 40 years or younger, and a response to cold test of less than 20 systolic and 15 diastolic.

A reevaluation of rejectees for cardiovascular reasons30 resulted in 17.3 percent being resubmitted as fit for military service. From this reevaluation, Fenn and his associates found that cardiovascular disease accounted for 10 percent of rejectees between the ages of 18 and 38. The common categories were as follows: Rheumatic heart disease, 50 percent; hypertension, 21 percent; neurocirculatory asthenia, 5 percent; and sinus tachycardia, 4 percent. These observers recommended that blood pressure standards be raised to 160/90 in nervous persons and that the pulse limits be placed between 40 and 120. In regard to neurocirculatory asthenia, it has been noted by British observers that this phenomenon was far less frequent than in World War I.31 Similar observations were noted in the United States.32

Neurocirculatory asthenia.-Starr33 reported on a ballistocardiographic study of draftees who had been rejected for neurocirculatory asthenia. He found that abnormalities of the circulation could be demonstrated in 75 percent of the cases and recommended the use of the ballistocardiograph for the detection of malingerers who feigned symptoms of this type. Starr was of the opinion that neurocirculatory asthenia was in no sense a disease for it affects neither health nor duration of life. He considered that the syndrome constituted a maladjustment of the circulation, no doubt precipitated by emotion but primarily a predisposition which, like clumsy movement of muscles, usually dates from early life and may be hereditary. He noted that many of those studied had selected certain light occupations and avoided others because they were aware of being made worse by emotion and by physical stress, which explained why they "quit" or broke down when placed at heavy work in the service.

Albuminuria.-Another example of psychosomatic interrelationships was the frequent occurrence in the young inductees of albuminuria without apparent cause. This phenomenon had been observed for many years and was variously described as benign, orthostatic, or psychogenic. It posed a chronic and annoying problem in evaluation for military service. Kidney disease was often suspected, and many individuals were rejected. Young,

30Fenn, G. K., Kerr, W. J., Levy, R. L., Stroud, W. D., and White, P. D.: Reexamination of 4,994 Men Rejected for General Military Service Because of Diagnosis of Cardiovascular Defects. Am. Heart J. 27: 435-501, April 1944.
31Jones, M., and Scarisbrick, R.: Effort Intolerance in Soldiers: A Review of Five Hundred Cases. War Med. 2: 901-911, November 1942.
32Dunn, W. H.: Gastroduodenal Disorders; An Important Wartime Medical Problem. War Med. 2: 967-983, November 1942.
33Starr, I.: Ballistocardiographic Studies of Draftees Rejected for Neurocirculatory Asthenia. War Med. 5: 155-162, March 1944.


684

Haines, and Prince34 stated that in their experience one out of every four rejections by Army induction boards for albuminuria was established by careful clinical and laboratory tests to be of orthostatic origin, with no renal lesions present. They emphasized the value of obtaining urine specimens after subjects had been placed in an exaggerated lordotic position. From their studies, they were convinced that albuminuria of this origin is harmless and disappears with age. A careful study of this problem was also made by Ahronheim35 in the examination of air cadets. He found that 554 out of 1,000 men displayed albuminuria in one or both specimens taken before and after the routine intravenous withdrawal of blood. Of those who fainted during blood removal, 100 percent exhibited albuminuria in subsequent specimens. Ahronheim noted that similar observations had been made on college students36 and on frightened cats.37 He gave support for his thesis that this type of albuminuria was of psychogenic etiology by citing the following incidents: (1) a cadet fainted during blood withdrawal and fell, striking his head and causing a bloody laceration. Of the 17 onlooking candidates awaiting their turn, 15 exhibited albumin in the urine specimens collected at this time. (2) A pilot who emerged unharmed from a nerve-racking crashlanding had 3+ albuminuria, which cleared by the next morning. (3) Subjects with albuminuria were given a placebo of a bright color and bitter taste to drink and were told that it was a potent medicine. In over 50 percent of the cases, the albuminuria promptly cleared. Ahronheim also found that this phenomenon decreased with age and that higher age groups did not respond to emotional stimuli by albuminuria.

REVISED STANDARDS

Toward the latter part of 1943 and in early 1944, the increasing evidences of failure in medical selection had become crystallized into overt admissions of error in aims and methods. A semiofficial editorial38 pointed out that current neuropsychiatric incidence was three times that of World War I, despite the fact that neuropsychiatric rejections were three to four times greater than in World War I. Farrell and Appel,39 emphasizing the limitations of psychiatric screening, recognized that psychiatric breakdowns in combat could not be predicted at induction since the breakdowns were a complex resultant of failures in group relationships, in leadership, and in training, complicated by fatigue, hunger, and other physiological

34Young, H. H., Haines, J. S., and Prince, C. L.: Orthostatic Albuminuria: The Importance of Its Recognition by Medical Examining Boards. Mil. Surgeon 92: 353-365, April 1943.
35Ahronheim, J. H.: Emotional Albuminuria. War Med. 5: 267-270, May 1944.
36Diehl, H. S., and McKinlay, C. A.: Albuminuria in College Men. Arch. Int. Med. 49: 45-55, January 1932.
37Starr, I., Jr.: The Production of Albuminuria by Renal Vasoconstriction in Animals and Man. J. Exper. Med. 43: 31-51, January 1926.
38Neuropsychiatric Disease: Causes and Prevention. Bull. U.S. Army M. Dept. 1: 9-13, October 1943.
39Farrell, M. J., and Appel, J. W.: Current Trends in Military Neuropsychiatry. Bull. U.S. Army M. Dept. 2: 44-50, July 1944.


685

factors. These authors urged consideration of preventive measures rather than elimination. Policy changes were instituted that completely reversed the former concept of screening out all potential breakdowns. War Department Technical Bulletin (TB MED) 33, issued on 21 April 1944,40 pointed out that the acute need for manpower made imperative the induction of all men who had a reasonable chance of adjusting themselves to the service. This change was incorporated into MR 1-9, in June 1945. In several studies of successful combat and noncombat soldiers,41 individuals were found to have performed satisfactory or superior service despite a background of psychoneurotic predispositions.42 Doubts about the value of medical screening became widespread, and to some43 it now seemed best to induct all but the halt and the blind-the obviously incapable-and rely upon basic training as a practical test of fitness.

It was evident that a more sensible viewpoint was needed in the medical selection of men for military service. Steps were taken in that direction by borrowing methods employed by the Canadian Army, which had been reported on favorably by Meakins44 and by Kubie.45

The Canadian Army system, known as PULHEMS, was a survey of seven physical and mental qualities numerically graded from one to four, the higher numbers indicating increasing dysfunction in the particular category: P represented overall physical endurance and capacity; U referred to the upper extremities; L, lower extremities; H, hearing; E, eyes or vision; M, mental ability or intelligence; and S, emotional stability. This method embodied the psychosomatic viewpoint of considering the entire individual, yet paying attention to local defects. It had the advantage of considering in one spectrum the overall capabilities and incapabilities of the individual. It was introduced in the American Army on a small scale in the spring of 1942 and came to be more widely used in 1944 and 1945.46

40War Department Technical Bulletin (TB MED) 33, 21 Apr. 1944, subject: Induction Station Neuropsychiatric Examination.
41(1) Sheps, J. G.: A Psychiatric Study of Successful Soldiers. J.A.M.A. 126: 271-273, 30 Sept. 1944. (2) Needles, W.: The Successful Neurotic Soldier. Bull. U.S. Army M. Dept. 4: 673-682, December 1945.
42During the postwar period, there appeared various reviews and reflections upon the results of routine induction examinations, particularly the failures of psychiatric screening (see Menninger, William C.: Psychiatry in a Troubled World. New York: MacMillan Co., 1948, pp. 134-152). Fry (see Carmichael, L., and Mead, L. C. (editors): The Selection of Military Manpower, a Symposium. Washington, D.C., National Research Council, 1952. A Study of Special Groups by Clements C. Fry, pp. 133-148) found that 70 percent of individuals who had been psychiatric patients while in college had rendered satisfactory or better than average service during World War II, the majority as officers. J. R. Eagan, L. Jackson, and R. H. Eanes (A Study of Neuropsychiatric Rejectees. J.A.M.A. 145: 466-469, 17 Feb. 1951) found that, of men who had previously been rejected for psychiatric reasons, 79.4 percent performed their duties well, although the number of discharges for disability for the group as a whole was three times the Army's average. N. Q. Brill and G. W. Beebe (Follow-Up Study of Psychoneuroses; Preliminary Report. Am. J. Psychiat. 108: 417-425, December 1951) in followup studies of psychiatric breakdowns during military service concluded that 50 percent of them could not have been predicted by the most thorough psychiatric examination-A. J. G.
43Bloomberg, W.: Plan for Screening, Induction, and Utilization of Man Power. Am. J. Psychiat. 105: 462-465, December 1948.
44
Meakins, J. C.: "Pulhems" System of Medical Grading. Canad. M.A.J. 49: 349-354, November 1943.
45Kubie, L. S.: Special Aspects of Procedures and Organization for Induction and Discharge in the Canadian Army. War Med. 5: 373-377, June 1944.
46(1) Developments in Military Medicine. Bull. U.S. Army M. Dept. 7: 602, July 1947. (2) Supplement to Mobilization Regulations No. 1-9, Physical Profile System, 22 May 1944, revised June 1945.


686

Six categories (PULHES) were employed in the U.S. Army, in what became known as the Physical Profile Serial System.47

To summarize briefly, it may be said that the selection experiences of World War II induced an appreciation of the human being as a complex, integrated organism whose future performance could be assessed not by a narrow localized measure but only through recognition of somatic and psychic interrelationships as well as of sociological and cultural factors.

Part II. During Training and Service in the Zone of Interior

PSYCHOSOMATIC DISORDERS DURING TRAINING

A primary mission of the World War II military program was the difficult task of transforming raw selectees into an effective fighting force. For the majority of new soldiers, this process comprised several distinct phases; namely, basic training, advanced or specialized training, unit training with battle indoctrination, and often participation in large-scale maneuvers and preparation for oversea movement. Considerable variation of the training program was necessary during the later years of the war because urgent needs for infantry and other replacements often permitted time only for basic training and preparation for oversea shipment. In addition, large numbers of troops remained in the Zone of Interior to perform the various necessary logistic and support tasks.

Although each of the phases just mentioned had its distinctive physical and emotional stress with consequent characteristic adjustment problems, the initial or basic training produced the largest number of medical and behavioral disorders. Basic training constituted the critical period of transition from civilian to military life. Here, the trainee was required abruptly to accommodate himself to separation from home, to regimentation, to lack of privacy, to enforced competition, to new dietary habits, often to sexual deprivation, and to the use of firearms and explosives, in addition to unusual and strenuous physical exertion and exposure to a relatively primitive field environment.48 Other types of training also produced discomfort, frustration, and physiological strain which, when added to uncertain or defective

47In September 1950, the Physical Profile Serial System was adopted as a common standard for all branches of the armed services (Jacobs, E. C.: Medical Screening of Military Man Power: Utilization of the Physical Profile Serial System. Mil. Surgeon 112: 112-118, February 1953; also AR 40-115, 20 Aug. 1948, subject: Physical Standards and Physical Profiling for Enlistment and Induction), and its soundness was confirmed during the Korean War. With liberal induction standards and emphasis upon proper assignment, rejection and discharge rates were not excessive. Psychiatric breakdowns increased in number during the severe battle phases, but accent upon rehabilitation and return to duty reversed the World War II experience of disability. In fact, the discharge rate for neuropsychiatric disease declined during the Korean War.-A. J. G.
48Menninger, William C.: Psychiatry in a Troubled World. New York: Macmillan Co., 1948, pp. 56-80.


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motivation and complicated by the cultural acceptance of disease as an honorable reason for the avoidance of obligations, produced clinical syndromes that defied the usual diagnostic and treatment procedures. In general, such psychosomatic disorders were of three related types, all of which had in common a persistence of somatic complaints.

First, there was a purely psychogenic group in which little or no objective evidence of significant structural or functional pathology could be demonstrated. The patients of this group stubbornly clung to bodily symptoms and, as noted by Menninger,49 were found almost as often on the medical and gastroenterology wards as on the psychiatric wards. Indeed, the bulk of overt psychological disorders had one or more chief complaints of headache, stomach trouble, chest pain, weakness, palpitation, backache, dizziness, arthralgia, skin rash, or diarrhea.50

Second, there were those well-known clinical entities generally regarded as having an emotional component in either etiology or clinical course, such as peptic ulcer, hypertension, asthma, various dermatological syndromes, migraine, and rheumatoid arthritis, which responded relatively poorly to treatment or promptly recurred upon preparation for, or after return to, duty.51

The third and perhaps most numerous group included personnel who persistently voiced residual somatic complaints following subsidence of the acute phase of almost any injury, illness, surgical procedure, or even physical strain. Thus, there were syndromes of painful discomfort with or without limitation of function following mild lower back injury,52 minor head injury,53 foot strain,54 rheumatic fever,55 infectious hepatitis,56 surgery for

49Menninger, W. C.: Relationships of Neuropsychiatry to General Medicine and Surgery in the Army. Mil. Surgeon 96: 134-138, February 1945.
50(1) Brussel, J. A., and Wolpert, H. R.: The Psychoneuroses in Military Psychiatry. War Med. 3: 139-154, February 1943. (2) Altman, L. L.: Neuroses in Soldiers; Use of Sodium Amytal as an Aid to Psychotherapy. War Med. 3: 267-273, March 1943. (3) Pulsifer, L.: Psychiatric Aspects of Gastrointestinal Complaints of the Soldier in Training. Mil. Surgeon 95: 481-485, December 1944. (4) Casey, J. F.: Disciplinary Problems in a Military Neuropsychiatric Hospital. Mil. Surgeon 97: 312-317, October 1945. (5) Incidence of Somatization Reactions in Psychoneurotic Disorders. Bull. U. S. Army M. Dept. 5: 383-384, April 1946.
51(1) Study of Psychosomatic Dermatological Syndromes. Bull. U.S. Army M. Dept. 5: 18-20, January 1946. (2) Davis, D. B., and Bick, J. W., Jr.: The Diagnosis of Migraine in Flying Personnel. Mil. Surgeon 98: 17-20, January 1946. (3) Zanfagna, P. E.: Perennial Bronchial Asthma; Analysis of One Hundred Cases. Bull. U.S. Army M. Dept. 3: 100-103, April 1945. (4) McFarland, M. D.: Hypertension in an Army General Hospital. Mil. Surgeon 97: 209-215, September 1945. (5) Sweeney, J. S.: Gleanings From the Medical Service of a General Hospital. Mil. Surgeon 97: 7-13, July 1945.
52Weiss, I. I.: A Study of Camptocormia With Presentation of 3 Postspinal Cases. Mil. Surgeon 97: 462-474, December 1945.
53Denny-Brown, D.: Sequelae of War Head Injuries. New England J. Med. 227: 771-780, 19 Nov. 1942; 813-821, 26 Nov. 1942.
54(1) Cozen, L. N.: The Treatment of Painful Feet in the Army. Mil. Surgeon 91: 196-198, August 1942. (2) Burnham, W. H.: Army Foot Disabilities, Mil. Surgeon 95: 20-24, July 1944.
55Hench, P. S., and Boland, E. W.: The Army Rheumatism Centers. Bull. U.S. Army M. Dept. 5: 655-662, June 1946.
56Benjamin, J. E., and Hoyt, R. C.: Disability Following Postvaccinal (Yellow Fever) Hepatitis. J.A.M.A. 128: 319-324, 2 June 1945.


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pilonidal sinus,57 abdominal surgery,58 elective orthopedic surgery,59 removal of herniated nucleus pulposus,60 and even diagnostic lumbar puncture.61 In these cases, the persistent symptomatology could not be substantiated by clinical, X-ray, or laboratory findings, and one could only speculate regarding the probability of adhesions, scar tissue, or altered physiology as causative mechanisms.

Clearly, these complex medical problems required a total approach for proper diagnosis and treatment, but such a psychosomatic viewpoint was lacking in the early years of World War II. The newly commissioned medical officers had little practical knowledge of the military environment. It was difficult for them to appreciate that somatic symptoms could and frequently did represent the mental, physical, and cultural responses to the stress of a wartime military adaptation rather than the presence of structural or psychological disease. Also, there existed a general tendency to hospitalize military personnel for subjective complaints and relatively minor disorders. Large numbers of these ambulatory cases were admitted or retained in Army hospitals.62 The secondary gain to be derived from illness and hospitalization soon became a familiar feature of military medicine, fixating symptomatology, vexing medical officers, and creating hostile and resentful patients.63 The more thoroughly symptoms were investigated, the longer was the hospitalization and the more convinced became patients that they had valid medical reasons for relief from onerous duty or even for discharge from the service.

Under these circumstances of iatrogenic and hospitalistic trauma, an atmosphere was created that stimulated others in and out of the hospital to seek relief, via medical channels, for their unhappiness and discomfort. One observer, Eisendorfer,64 commented: "Neurosis is as contagious as a virulent infection. For every neurotic patient hospitalized there are ten more with potential neuroses who do not require much stimulation to react in a similar manner." Altman and his associates65 found:

Soldiers lack no opportunity and lose none in comparing notes while in the hospital. Enforced idleness, few recreational facilities, and prolonged hospitalization help to en-

57Rogers, H.: Pilonidal Sinus; The Indications for Treatment in the Military Service in Time of War. Mil. Surgeon 95: 454-457, December 1944.
58Bowers, W. F.: Observations in the First Six Months of the General Surgical Section of the 1,500 Bed Cantonment Type Station Hospital at Fort Leonard Wood, Missouri. Mil. Surgeon 91: 170-176, August 1942.
59(1) Pickett, J. C.: The Diagnosis and Treatment of Internal Derangements of the Knee Joint. Mil. Surgeon 97: 198-203, September 1945. (2) Cozen, L. N.: Malingering Among Soldiers: Orthopedic Aspects. Mil. Surgeon 92: 655-657, June 1943. (3) Willien, L. J.: Second-Year End Result of Arthrotomies of Knee. Bull. U.S. Army M. Dept. 4: 452-456, October 1945.
60Haynes, W. G.: Problem of Herniated Nucleus Pulposus in the Military Service. War Med. 3: 585-595, June 1943.
61Levin, M. J.: Lumbar Puncture Headaches. Bull. U.S. Army M. Dept. 2: 107-110, November 1944.
62Pignataro, F. P.: Experiences in Military Psychiatry. Mil. Surgeon 91: 439-460, October 1942.
63(1) Sarlin, C. N.: Psychiatric Consultations in the Army. Mil. Surgeon 97: 139-143, August 1945. (2) See footnote 49, p. 687.
64Eisendorfer, A.: Clinical Significance of Extramural Psychiatry in the Army. War Med. 5: 146-149, March 1944.
65Altman, L. L., Pillersdorf, L., and Ross, A.T.: Neuroses in Soldiers; Therapeutic Barriers. War Med. 2: 551-560, July 1942.


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courage this tendency. Procedures, results of treatment, death in a ward, disposition of other soldiers or almost any other occurrence in the hospital rarely escapes them.

Frustrated medical officers defended themselves by blaming their patients for having "neurotic predisposition" or "functional overlay" or by such castigations as "misfits," "chronic complainers," "neurotics," "hysterics," or "slackers." There was a general tendency to refer these cases to the psychiatrist, as illustrated by Eisendorfer's report that 48 percent of all patients admitted to Tilton General Hospital, Fort Dix, N. J., for the first 6 months of 1943 were examined by the neuropsychiatric service for the purpose of either consultation, treatment, or disposition. But the psychiatry wards were also congested. Psychiatrists were loath to accept, as transfer patients, those who had extensive hospitalization because of either prolonged clinical investigation or residual complaints following disease, injury, or surgery. According to Altman and his coworkers, such patients were not only resistant to psychiatric exploration and treatment but were overtly hostile toward any effort to remove their favorable status of hospitalization with its expectation of medical discharge. No one wanted these patients who, in turn, resented their doctors. Thus, an impasse was created.

MEDICAL DISCHARGE

The simple solution to this impasse was medical discharge. Indeed, medical separation was not only the easy way out for both patient and medical officer but had been recommended by prominent authorities on the grounds that modern war demanded individuals of "superior mental and physical stamina."66 Madigan,67 considering the recruit's first year, concludes:

There is no place in the Army for the physical and mental weakling. The Army should not be regarded as a gymnasium for the training and developing of the undernourished and underdeveloped, nor a psychiatric clinic for the proper adjustment of adolescents who need emotional support.

These sentiments were echoed officially by Circular Letter No. 1968 and supported by Billings,69 Porter (p. 680), Harrison,70 and other civil and military medical leaders. As a result, the medical discharge rate steadily mounted. It was further increased by the influence of War Department Circular No. 161, dated 14 July 1943,71 which required the reevaluation and discharge of limited service personnel. In September 1943, the medical dis-

66See footnote 3 (1), p. 677.
67See footnote 4 (3), p. 678.
68See footnote 4 (2), p. 678.
69Billings, E. G.: The Recognition, Prevention and Treatment of Personality Disorders in Soldiers. Army M. Bull. No. 58: 1-37, October 1941.
70Harrison, F. M.: Psychiatry in the Navy. War Med. 3: 113-138, February 1943.
71War Department Circular No. 161, 14 July 1943, sec. III, subject: Elimination of the Term Limited Service With Reference to Enlisted Men.


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charge rate approached 70,000 per month, which approximately equaled the induction rate.72

A typical picture of this problem in the early years of the war is given by Kinsey73 who analyzed 1,000 consecutive medical discharges from the Station Hospital, Camp Blanding, Fla., over a 6-month period in the latter part of 1942 and early 1943. The 12 leading causes for medical separation were as follows:

 

Percent

Psychoneurosis (all types)

40.2

Duodenal ulcer 

7.4

Psychoses (all types)

6.9

Arthritis

5.9

Asthma

3.8

Organic and central nervous system disease

3.6

Epilepsy

2.7

Rheumatic heart disease

2.6

Tuberculosis (pulmonary)

1.7

Deformities of extremities

1.5

Bronchitis (chronic)

1.3

Hernia (inguinal, indirect, reducible)

1.2


Similar findings were reported by Pignataro74 from the Station Hospital, Camp Livingston, La., for 1941 and 1942. Kinsey commented that almost all the psychoneurotics had symptoms referable to the gastrointestinal tract or to the cardiovascular system. In most of the so-called organic categories, neurotic predisposition, functional overlay, or poor motivation were considered the primary cause of discharge. Peptic ulcer promptly recurred when patients were returned to duty. Depression and lack of interest were noted in most cases discharged for arthritis. Asthmatics all admitted that their illness occurred before induction but insisted that they could not perform physical work in the service and if forced to do so would suffer severe impairment of health. It was impossible to attempt a trial of duty for patients with minimal rheumatic heart disease as they began to complain upon leaving the hospital. The low incidence of discharge for orthopedic conditions is accounted for by the number of instances in which associated psychoneurotic disease was regarded as the primary reason for their medical disability.

When these men were questioned just before discharge, 60 percent said they should not have been inducted and could not be adjusted in the Army under any circumstances; 25 percent said they could have been adjusted if given a job to which they were accustomed upon entry in the Army but "they were too nervous to do any good now." Fifteen percent felt that they could have been adjusted if given the right commanding officer or "had been

72Disability Discharges. Bull. U.S. Army M. Dept. 2: 52-55, December 1944.
73Kinsey, R. E,: Study of 1,000 Cases Separated From the Army on Certificate of Disability for Discharge. Bull. U.S. Army M. Dept. 1: 64-75. October 1943.
74See footnote 62, p. 688.


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given a break" or "if things had gone right at home." Paradoxically, the majority of these men planned to work soon after discharge in defense plants or on a farm. Kinsey came to the pertinent conclusion that the major problem in most of these individuals was one of adjustment to army life rather than incapacitating disease.

POLICY OF MAXIMUM UTILIZATION

As the foregoing reports indicate, medical officers, with time and experience, learned that the purely medical considerations of symptoms, diagnosis, clinical course, and treatment of illness or injury could not be disassociated from the physiological and psychological problems of military adjustment. Meanwhile, developing manpower shortages demanded the salvage of so-called weaklings and misfits, if only for limited duty. A reorientation of medical thinking began to make itself felt in late 1942 and early 1943 in a liberalization of standards for selection and induction. A policy of maximum utilization was officially adopted in November 1943 with the issuance of War Department Circular No. 293,75 stating that no man should be discharged so long as he could render adequate service in the Army. This trend was further elaborated by War Department Circular No. 81, 13 March 1945,76 which directed against medical discharge for minor conditions, such as flat feet, mild sacrolumbar strain, and mild psychoneurosis, when the primary cause was defective attitude, inadaptability, and so forth. It warned that the medical defect in itself was not a cause for discharge unless genuinely disabling and directed that such cases be returned to duty or be administratively separated. In the main, medical efforts to implement these changes toward maximum utilization of marginal personnel were developed in three major areas: (1) Prevention of hospitalization, (2) reconditioning, and (3) hospital practice.

Prevention of Hospitalization

As has been noted, there was early recognition of the adverse effects of hospitalization in creating or perpetuating an adverse adaptation to illness or disability. This deleterious effect was most pronounced in neurotic disorders or in patients with minor or purely subjective complaints. An obvious solution was the outpatient management and treatment of such cases. Quite early in the war, Army psychiatrists moved toward the development of such extramural management of adjustment problems among trainees. This concept and practice rapidly expanded to become the replace-

75War Department Circular No. 293, 11 Nov. 1943, subject: Enlisted Men-Utilization of Manpower Based on Physical Capacity.
76War Department Circular No. 81, 13 Mar. 1945, sec. III, subject: Personnel-Administrative and Medical Disposition of Noneffective Personnel.


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ment training center clinic system which achieved official recognition in 194377 and became a prominent feature of military psychiatry in World War II. Its origin, development, and methodology have been well documented by Perkins.78

The concepts and methods of outpatient military psychiatry were soon reflected in many other areas of military medical practice. Rogers79 argued against radical excision for pilonidal sinus disorders, pointing out that such procedure required prolonged hospitalization and convalescence during which activity was extremely limited, motivation was impaired, new symptoms developed, and return to duty became problematical. He favored conservative treatment with the patient on duty status.

For gastrointestinal and other complaints.-From an extensive experience (1,702 cases) at a large Army post, Loder and Kornblum80 found that most cases referred for gastrointestinal complaints were best handled on an outpatient basis with roentgenologic studies. After negative findings by X-ray, 78 percent did not return to the clinic. These workers held that such beneficial results were due not only to reassurance of the patient but also to the reassurance of the referring medical officer, who could then adopt a firm and realistic attitude toward the repeated complainer.

The treatment on duty status of acute gonorrhea was successfully accomplished by Atcheson,81 using sulfathiazole. Patients were evaluated periodically on an outpatient basis, and in 92 percent successful results were obtained with no increase in complications in comparison with patients hospitalized for gonorrhea. Similar excellent results were obtained by Campbell and Carpenter.82

An effective plan for avoiding the hospital atmosphere was developed in 1944 at O'Reilly General Hospital, Springfield, Mo., as reported by Josey.83 All ambulatory admissions were placed in a group of wards known as the disposition section, which avoided the usual hospital regimen of nursing care and medication. These cases were thoroughly worked up in a nearby clinic building. A decision was then made for hospitalization, reconditioning, return to duty, or discharge from the service. Of approximately 5,000 patients admitted to O'Reilly General Hospital during a 6-month period, 52 percent were evaluated in the disposition section and 23 percent received final disposition to duty or discharge without further hospitalization.

77Halloran, R. D., and Farrell, M. J.: Neuropsychiatrists in the U.S. Army; Their Functions in General and in Relation to Replacement Training Centers. Army M. Bull. No. 65: 151-156, January 1943.
78Medical Department, United States Army. Preventive Medicine in World War II. Volume III. Personal Health Measures and Immunization. Washington: U.S. Government Printing Office, 1955, pp. 171-232.
79See footnote 57, p. 688.
80Loder, H. B., and Kornblum, S. A.: Duodenal Ulcer in a Large Army Camp; Incidence and Statistical Analysis. Mil. Surgeon 96: 492-497, June 1945.
81Atcheson, D. W.: Duty Status Treatment of Acute Gonorrhea. Mil. Surgeon 96: 159-163, February 1945.
82Campbell, G., and Carpenter, G. R.: Treatment of Acute Gonorrhea in the Army. Am. J. Syph. 28: 406-412, July 1944.
83Josey, A. I.: Disposition Section for Ambulatory Patients. Bull. U.S. Army M. Dept. 5: 353-355, March 1946.


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In the common problem of foot complaints, Pemberton84 found that most of such cases could be cared for by the dispensary medical officer in order to avoid hospitalization and loss of time from training. Pemberton pointed out that recent inductees readily developed foot strain, particularly those who had led a sedentary life before service. However, these symptoms begin to subside in the fourth week of training, and at the end of 8 weeks the soldier can drill all day and hike from 15 to 20 miles without strain. Treatment is not required except for a hot footbath at night since continued use is part of the conditioning process. Placing such a patient off duty or on light duty only postpones the time of complete recovery. Pemberton also restated an obvious but important finding; namely, that flat feet are subject to strain in the same manner as other feet and may become painful, but relief depends upon treatment of the strain and not of the flat foot.

In staging areas.-Prevention of hospitalization was particularly important at staging areas before oversea shipment. Lipschutz85 noted that soldiers arrive at all hours and the incidence of acute illness is unpredictable. He found that from 40 to 50 percent of sick call cases were primarily psychological problems. He noted that sick call was particularly crowded when a unit was alerted for oversea shipment. Under these circumstances, hospitalization justifies complaints and strengthens the connotation of disability. On the other hand, neglect, ridicule, and denial serve the same attitude. This situation required the vigorous resources of an outpatient clinic where the medical officers adopted a psychosomatic approach and made prompt decisions for disposition.

Reconditioning

The development of organized programs of physical and mental activity for convalescent and ambulatory patients marked another important advance in psychosomatic medicine in World War II. These programs began in 1942 as a spontaneous attempt to prepare hospitalized patients for return to duty. Pioneer efforts in this sphere are generally credited to the Army Air Forces hospitals along with British military hospitals.86 The idea and the practice, in various forms, of active convalescent care were rapidly adopted by most American military hospitals both in the United States and overseas. Soon there appeared reports of these successful activities which now became known as reconditioning. Childress,87 in noting the results of an active convalescent program begun in 1942 by the orthopedic service of Stark General Hospital, Charleston, S.C., found that supervised drilling and field exercises

84Pemberton, P. A.: The Care of Soldier's Feet. Bull. U.S. Army M. Dept. 3: 110-117, January 1945.
85Lipschutz, L. S.: Symposium on Psychiatry in the Armed Forces; Neuropsychiatry in a Staging Area. Am. J. Psychiat. 100: 47-53, July 1943.
86(1) The Reconditioning Program. Bull. U.S. Army M. Dept. 1: 27-30, December 1943. (2) Rusk, H. A.: The Convalescent Training Program in the Army Air Forces. Tr. Am. Neurol. A. 70: 19-22, 1944.
87Childress, H. M.: Regulated Group Exercise for Convalescent Patients. Mil. Surgeon 91: 581-584, November 1942.


694

prevented anxiety neurosis, "jitters," and "hospitalitis." Thomas,88 also in 1942, stressed the importance of such a program in maintaining the morale of patients. Piazza,89 in discussing the benefits of reconditioning at Moore General Hospital, Swannanoa, N.C., in 1943, remarked that reconditioning was fast becoming as much a part of Army medicine as typhoid inoculation. To quote from this author:

No longer need the patient stare aimlessly at the bare ceiling hour after hour, no longer need the ambulatory patient pace the hard floor or hospital corridor uselessly or spend his time lounging in the post exchange or Red Cross building thinking about his illness or injury, magnifying it to unendurable proportions to the point of becoming useless to himself and the service.

Convalescent reconditioning was formally recognized in the summer of 1943. In August 1943, Maj. (later Lt. Col.) Walter E. Barton, MC, was appointed the first director of the newly created (June 1943) Reconditioning Division, Professional Service, Office of The Surgeon General, and in September 1943, Circular Letter No, 16890 provided for the establishment of convalescent reconditioning programs at all Army hospitals. The Surgeon General's Office laid down broad guidelines for the operation of reconditioning in hospitals, as follows:91

1. Reconditioning to be successful must begin the moment convalescence begins. This may be while the patient is still confined to bed.

2. The mental attitude of every member of the hospital staff toward reconditioning is extremely important. There must be at all times the expectancy that the patient will return to duty.

3. Transfer of the patient from the hospital atmosphere to the reconditioning section as soon as he is not dependent upon active medical treatment is of paramount importance in restoring health.

4. In reconditioning sections, men spend their mornings in calisthenics, ward fatigue, outdoor drills, and marches. Afternoons may be spent in games and sports adapted to the physical strength of patients. In the evenings, movies, camp shows, group singing, quiz programs, and other opportunities for free choice of recreational outlets should be provided, with a more liberal use of town and weekend pass privileges.

The typical operation of reconditioning procedures in Army hospitals in World War II is illustrated in the reports from Lawson General Hospital, Atlanta, Ga.,92 and Oliver General Hospital, Augusta, Ga.93 As suggested by the Surgeon General's Office, convalescent patients were divided into four classes, as follows:

88Thomas, H. M., Jr.: Convalescent Care and the Morale of Patients. Mil. Surgeon 93: 453-457. December 1943.
89Piazza, F.: The Reconditioning Program at Moore General Hospital. Mil. Surgeon 96: 81-84, January 1945.
90Circular Letter No. 168, Office of The Surgeon General, U.S. Army, 21 Sept. 1943, subject: Convalescent Reconditioning in Hospitals.
91
See footnote 86 (1), p. 693.
92Titus, N. E.: Rehabilitation Program at Lawson General Hospital. Bull. U.S. Army M. Dept. 1: 88-93, April 1944.
93Bilik, S. E.: Reconditioning Problem at Oliver General Hospital. Bull. U.S. Army M. Dept. 2: 81-93, July 1944.


695

Class I: Convalescents capable of being toughened by full physical activity.

Class II: Patients capable of limited physical activity requiring graded training to prepare for progression to Class I.

Class III: Ambulatory patients handicapped to varying degrees by residua of illness or injury.

Class IV: Bed patients.

Classes I and II patients were housed in the reconditioning sections, generally troop barracks or the back wards of the hospital, where the usual hospital atmosphere of nursing and medication was avoided. Patients were given uniforms and fatigue clothing instead of hospital garb; they were marched to meals and were responsible for policing their barracks or wards, which were inspected regularly. They were drilled and commanded by convalescent officer patients. A full day's program of activity was enforced. Failure to abide by the program brought denial of pass, restriction, and even confinement.

All observers agreed that convalescent training should be accomplished under medical supervision with one or more medical officers devoting full time to this work, one being in charge of the program. Patients were transferred to the reconditioning section with their completed clinical record. A final note was placed on the clinical record when convalescent training, which often culminated in a 15-mile hike, was completed. Most Class I and Class II patients required from 18 to 21 days of reconditioning. Candidates for medical discharge were moved early to a "CDD" (certificate of disability for discharge) barracks to avoid "contaminating" return-to-duty patients.

Further organization of the reconditioning program continued as the war proceeded. Not only were convalescent training facilities at existing general hospitals enlarged, but separate convalescent hospital centers were established.94 The concept was extended to the management of psychiatric patients and successful results were reported by Rosner95 at Dale Mabry Field, Tallahassee, Fla., and by Cotton96 at Mason General Hospital, Brentwood, N.Y. On 6 September 1944, the Surgeon General's Office announced that one hospital in each service command would be designated as a neuropsychiatric reconditioning center to which any patient who was considered as having a remote chance of performing military service would be sent for a trial of reconditioning.97

Also initiated by the Surgeon General's Office was the Reconditioning Newsletter for monthly distribution to all Army hospitals in order to dis-

94Convalescent Hospitals. Bull. U.S. Army M. Dept. 2: 19-20, October 1944.
95Rosner, A. A.: The Neuropsychiatrist and Convalescent Training Program of the Army Air Forces. Bull. U.S. Army M. Dept. 2: 93-97, July 1944.
96Cotton, H. A., Jr.: Reconditioning Neuropsychiatric Patients in the Army. Mil. Surgeon 97: 450-455, December 1945.
97Reconditioning Notes. Bull. U.S. Army M. Dept. 2: 30-31, October 1944.


696

seminate widely new ideas, practices, and procedures. Reconditioning programs were further elaborated and divided into three basic components; namely, educational, physical, and occupational therapy. In each of these areas, technical manuals and training films were produced and distributed.98

The extent to which the reconditioning program became integrated as part of the psychosomatic development of military medicine of World War II is indicated by an open letter to hospital commanders from Maj. Gen. Norman T. Kirk, The Surgeon General of the Army.99 In this letter, General Kirk points out: "If you treat only their bodies and forget their minds you will have accomplished less than your full duty." The letter urges greater efforts toward implementing the reconditioning program and comments further: "Treatment of the whole patient, watching closely his progress, encouraging him to participate, taking pride in his mental as well as physical progress, is an essential of good medical care."

Psychosomatic Concepts in Hospital Practice

Gastrointestinal disorders.-The evolution of the psychosomatic viewpoint in the management of inpatients is perhaps best illustrated by the experience with persistent disorders of the upper gastrointestinal tract, chiefly peptic ulcer, probably the most common cause of medical disability in World War II.

Before the United States entered the war, there appeared numerous reports of the unusual high rate of functional dyspepsia and peptic ulcer in the Armed Forces of England, Canada, and Germany.100 Willcox,101 Payne and Newman,102 and others found duodenal ulcer to be the major cause for medical invalidism in the British Forces. Curiously enough, it was noted that peptic ulcer was only a minor problem of World War I, while neurocirculatory asthenia was a prominent disorder. The reverse situation obtained in World War II. Jones and Scarisbrick,103 on the basis of extensive experience with cases of neurocirculatory asthenia, believed that the medical profession of World War II viewed "effort syndrome" as a psychiatric disorder. They thought this change of attitude was responsible for the decreased incidence and argued against retaining the diagnosis, since almost all cases of neurocirculatory asthenia could be readily placed in the psychiatric category.

98(1) Boeckman, F. P.: The Reconditioning Program; The Army's Answer to the Manpower Shortage. J.A.M.A. 125: 280-282, 27 May 1944. (2) Rankin, F. W., and Barton, W. E.: Present Status of Rehabilitation in the U.S. Army. J.A.M.A. 125: 256-258, 27 May 1944. (3) Reconditioning of Patients. Bull. U.S. Army M. Dept. 2: 23-24, August 1944.
99Kirk, N. T.: A Letter to Hospital Commanders. Bull. U.S. Army M. Dept. 3, February 1945.
100Pepper, O. H. P.: Disease Expectancy in the New Army. War Med. 1: 463-469, July 1941.
101Willcox, P. H.: Gastric Disorders in the Services. Brit. M.J. 1: 1008-1012, 22 June 1940.
102Payne, R. T., and Newman, C.: Interim Report on Dyspepsia in the Army. Brit. M.J. 2: 819-821, 14 Dec. 1940.
103
See footnote 31, p. 683.


697

All British reports agreed that most cases of peptic ulcer originated in civilian life and were only brought forth or exacerbated by military life. Hurst104 expressed a common viewpoint when he flatly blamed the increase of peptic ulcer upon "heavy Army food." With other observers, he advocated the rejection of individuals with peptic ulcer at induction and prompt medical discharge when found in the service except those military personnel who could obtain special food at regular hours. Hinds-Howell105 recommended that even cases of functional dyspepsia should be discharged, but Hurst insisted that such patients could be benefited by early treatment directed to restore their ability to eat army food and face army life. Hurst pointed out that if treatment is not given early in such cases the result is "disordered action of the stomach," which he believed had replaced the effort syndrome of World War I.

In sharp contrast was the German attitude as expressed by Stehr,106 who stated that only active peptic ulcer cases are unfit for work. Then, treatment is indicated, but such patients should not be kept too long away from physical activity because dietetic treatment was complemented by exercise and work. Stehr argued that the danger of recurrent ulcer or life-threatening hemorrhage is no greater during work than it is during rest. Schindler107 disagreed with Stehr's back-to-work regime, considering it to be neither practical nor humane. He also advocated the discharge of all patients with peptic ulcer unless manpower needs became critical.

As the American Army mobilized, particularly after Pearl Harbor, the frequency and importance of persistent disorders of the upper gastrointestinal tract soon paralleled the British experiences. Published reports indicated that from 30 to 40 percent of admissions to the gastrointestinal wards of Army hospitals were diagnosed as peptic ulcer, mainly of the duodenal type.108 American observers, like their British colleagues, believed that in the majority of their ulcer patients the illness had originated in civil life.

As in England, there arose conflicting opinions on the cause of the frequency of peptic ulcer under wartime conditions. One group insisted that cases came from predisposed persons who had been traumatized by the Army diet and that psychogenic factors played little or no causative role. Thus, Kirk109 reported that the concept of the emotional genesis of peptic ulcer was not suggested by his experience at Fort Sill, Okla. He found that

104Hurst, A.: Digestive Disorders in Soldiers. Am. J. Digest. Dis. 8: 321-323, September 1941.
105Hinds-Howell, C. A.: A Review of Dyspepsia in the Army. Brit. M.J. 2: 473-474, 4 Oct. 1941.
106Stehr, L.: Die Beurteilung der Wehrdienst und Arbeitsfähigkeit bein chronisch Magenkranken. München. med. Wchnschr. 87: 1317-1322, 29 Nov. 1940. (Abstract in War Med. 1: 730-732, September 1941.)
107Schindler, R.: Gastroenterology in the Army; Methods of Examination and Disposition of Cases. War Med. 2: 263-276, March 1942.
108(1) Chamberlin, D. T.: A Plan for Standardization of Diagnosis and Treatment of Peptic Ulcer. Mil. Surgeon 93: 157-164, August 1943. (2) Kirk, R. C.: Peptic Ulcer at Fort Sill. Am. J. Digest. Dis. 10: 411-413, November 1943. (3) Berk, J. E., and Frediani, A. W.: Peptic Ulcer Problem in the Army. Gastroenterology 3: 435-442, December 1944.
109See footnote 108 (2).


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the incidence of peptic ulcer in psychoneurotic patients was not increased and concluded that intolerance to greasy foods was the greatest obstacle to satisfactory military service. He was partially supported by Chamberlin,110 asserting: "It was not safe for a patient with ulcer to be on duty. He can do better in civilian life where he can regulate his hours and diet." However, Chamberlin also believed that contributing to ulcer breakdown were psychogenic factors which varied from simple dislike of the service, to difficult adjustment to army life, to toxic psychosis. Cheney,111 in a study of 418 cases at Hammond General Hospital, Modesto, Calif., also failed to find an association between psychoneurosis and peptic ulcer. However, except for 31 cases, he noted that special diets made no difference in treatment and that a liberal diet made no patient worse.

A majority of American observers ascribed to psychogenic factors, as their major cause, ulcer breakdowns in military personnel. Flood,112 on the basis of careful clinical studies at the Station Hospital, Fort George G. Meade, Md., concluded that the fundamental cause of chronicity of peptic ulcer in most cases was an associated anxiety state-in fact, an anxiety or fear reaction. Flood found that stable personalities responded well to treatment, whereas anxious patients did not. He advised psychiatric evaluation to rule out neurosis before considering return to duty of any patient with peptic ulcer. Morrison113 came to similar conclusions from his extensive experience as gastroenterology consultant at an Army general hospital. He noted that gastrointestinal referrals were most common from the neuropsychiatric service. Conversely, psychiatric consultations were most frequently requested from the gastrointestinal wards. A major complaint of both types of patient was an inability to tolerate the Army diet. On this subject, Morrison made the pertinent observation that, for the personnel stationed in the United States, nowhere is there better food than in the Army. Only occasional meals are not satisfactory. Soldiers are not required to eat all that is offered and can practically select their own diet. Like others, Morrison noted the disappearance of gastrointestinal symptoms when patients learned of their contemplated discharge or when declared unfit for oversea duty. He concluded that the inability to tolerate an army diet was symbolic of maladjustment to military service. Sweeney,114 in summarizing the lessons learned during his 2 years as chief of the Medical Service, Bushnell General Hospital, Brigham City, Utah, also found the underlying basis of peptic ulcer to be neurosis or anxiety state, remarking that relief from situational anxiety paralleled improvement in peptic ulcer. He cited the well-known phenomenon of the patient with a diagnosis of peptic ulcer

110See footnote 108 (1), p. 697.
111Cheney, G.: Peptic Ulcer and Nutrition. Mil. Surgeon 95: 446-454, December 1944.
112Flood, C. A.: Peptic Ulcer at Fort George G. Meade, Maryland. War Med. 3: 160-170, February 1943.
113Morrison, S.: Interservice Consultations in One Army General Hospital; Comments With Particular Reference to the Section on Gastroenterology. War Med. 7: 84-94, February 1945.
114See footnote 51 (5), p. 687.


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made overseas, supported by X-ray evidence, who becomes asymptomatic and negative roentgenographically after return to the Zone of Interior.

Berk and Frediani115 in 3 years of experience in gastroenterology at Tilton General Hospital found further evidence for the psychological causation of acute breakdown of peptic ulcer. They cited patients who were asymptomatic until the day before induction or until their first Army meal. They also noted a remarkable subsidence when discharge was assured, or recrudescence when soldiers were informed of their impending return to duty. These workers found that the aggressive, conscientious, or perfectionist personality types so commonly described in civilian patients with peptic ulcer were infrequent in their military subjects, who were more apt to be slovenly, placid, and slow-moving men. An editorial in the Military Surgeon,116 June 1943, perhaps best expressed the popular psychosomatic viewpoint relative to peptic ulcer in military personnel by commenting that some soldiers simply had no stomach for war.

Practically all observers agreed that, in general, treatment of peptic ulcer in military personnel gave unsatisfactory results and that discharge from the service was the preferable and, in fact, the inevitable disposition for most cases. Flood observed that in contrast with ulcer patients in civilian life, of whom two-thirds were relieved within 2 weeks of the usual conservative Sippy regimen, only one-third of military patients obtained relief and one-half continued to have symptoms even after 4 weeks of treatment. Followup X-ray studies confirmed that improvement occurred in only one-half of the cases. Best results were obtained in Regular Army personnel who were highly motivated for return to duty. Reeser and Guthrie117 reported that 81 percent of ulcer patients were discharged from the service. Chamberlin118 believed that patients with peptic ulcer were unfit for service, for "no matter how well peptic ulcer seems at induction or after operation, breakdown in the service is inevitable. For even when well such individuals can be expected to neglect therapy or diet." Berk and Frediani119 returned to duty only 25 percent of Regular Army personnel, mainly men with uncomplicated cases who had some special military skill. They were against the promiscuous employment of gastric resection since this procedure did not alter the basic personal patterns nor did it remedy the emotional disturbance.

This almost uniformly gloomy prognosis for military patients with peptic ulcer was formally acknowledged in War Department Circular No. 46, 7 February 1945,120 which directed that all enlisted men hospitalized for

115See footnote 108 (3), p. 697.
116Editorial: The Stomach in War. Mil. Surgeon 92: 663-665, June 1943.
117Reeser, R., Jr., and Guthrie, M. B.: The Management of Army Personnel With Peptic Ulcer; An Analysis of 200 Cases. Mil. Surgeon 98: 125-131, February 1946.
118See footnote 108 (1), p. 697.
119See footnote 108 (3), p. 697.
120War Department Circular No. 46, 7 Feb. 1945, sec. V, subject: Enlisted Men, Discharge for Chronic Peptic Ulcer.


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chronic symptomatic peptic ulcer be considered for separation except those who possessed unusual qualifications for military service.

In the latter phase of the war, because of manpower shortages, occasional efforts were made toward rehabilitation of ulcer patients for duty. One such attempt was reported by Goldbloom and Schildkrout,121 who were assigned to a staging area medical facility. They noted the high rate of medical discharges in 1943, including 10 percent for gastrointestinal disorders, mainly peptic ulcer. Stimulated by War Department Circular No. 293, 11 November 1943, which directed the retention of personnel who could render some type of effective service, they chose for study 100 cases of chronic disorders of the upper gastrointestinal tract. These patients originated mainly from units in the process of oversea movement, but some were from the station complement. They were given complete examination in the hospital, including roentgenographic and psychiatric evaluation. All were then assigned to duty on the post but were brought to the hospital messhall regularly for meals which were prepared under the supervision of the dietitian in cooperation with the gastrointestinal service. These patients were all followed by the outpatient service, and adjustments were made in duty assignments as required. Small group discussions were held to help the patients arrive at an understanding of their problems with respect to their digestive disorders, their adjustment in the service, and their personal difficulties. Of the 50 peptic ulcer cases, good results were obtained in 38 (76 percent). The 50 patients with chronic functional dyspepsia had poor morale and definite psychoneurotic background as contrasted with the ulcer group. Of these 50 patients, 30 (60 percent) seemed to function reasonably well on duty. Goldbloom and Schildkrout concluded that approximately 70 percent of the entire group could be salvaged for military service. A small number were maintained successfully on regular military rations, but in a majority of cases attempts at imposing a usual diet resulted in increasing pain and intolerance, forcing return to a special dietary regimen.

By the time the war ended, a good deal of understanding had been achieved insofar as mind-body relationships were concerned in peptic ulcer and chronic dyspepsia. (See pages 710-711.) Most patients in this category however, were found to be unusable on a duty status and were discharged from the service.122

121Goldbloom, A. A., and Schildkrout, H.: Dyspepsia Regimen; A Method of Rehabilitation. War Med. 6: 24-26, July 1944.
122
After the war, military gastroenterologists pursued the question of diet and the usability of personnel with peptic ulcer, who in other respects exhibited excellent military potential, since many such men had performed superior duty even under stressful conditions. Based on the work of E. D. Palmer, B. H. Sullivan, and E. L. Hamilton (Duodenal Ulcer in Military Personnel: Studies on Military Effectiveness of the Ulcer Patient. III. Review of 350 Cases of Recurrent Duodenal Ulcer. U.S. Armed Forces M.J. 3: 1123-1133, August 1952) and the later work of Sullivan and Hamilton (Peptic Ulcer in Military Personnel; Incidence and Management. U.S. Armed Forces M.J. 6: 1459-1468, October 1955), an entirely different approach was evolved, denying that army diet or any diet was a primary cause of ulcer breakdown and proposing that ulcer patients when improved could and should perform military service provided the psychological factors could be satisfactorily alleviated. This viewpoint prevailed during the Korean War and has now become current operating policy in the Army. In a study (Yessler, P., Reiser, M., and Rioch, D. McK.: Blood Pepsinogen and Peptic Ulcer in Inductees. (To be published.)) on predisposition to peptic ulcer, followup examination of 16 young draftees in whom ulcer had been diagnosed early in the course of their military career showed that 15 remained on duty status after treatment and satisfactorily completed 2 years of military service.-A. J. G.


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Elective surgery.-Another psychosomatic insight that gained wide recognition in World War II was an awareness that persistent symptomatology of neurotic type, similar to the well-known compensation neurosis, not infrequently may complicate the results of elective surgery. A typical sample is found in the report of Butsch and Harberson123 on the results of elective surgery for varicosities of the lower extremities. In this series, 98 cases were chosen for operation because of complaints referable to the legs, obvious varicose veins and a competent deep venous circulation. The usual ligation and section procedure was performed. A 3-month followup study involving 35 cases revealed that only 10 had achieved symptomatic relief; the remaining 25 individuals complained of more difficulty with their legs than before the operation. The multiplicity of their complaints seemed incredible since careful examination of each soldier found 31 of the 35 subjects to have perfect surgical results with no instance of postoperative swelling. A correlation between maladjustment and the persistence of complaints was evident on psychiatric evaluation which further elicited unrelated symptoms, such as nervousness, headache, dizziness, gastrointestinal discomfort, and hyperhydrosis. In these cases, varicosities represented only an unimportant part of the soldiers' difficulties upon which operation had crystallized and fixated a rational reason for medical disability. These observers concluded that, when considering operation for varicosities, one should regard with suspicion the young soldier with a multiplicity of complaints. The presence of varicose veins is not in itself an indication for surgical treatment. One must consider the entire person-his past and current adjustment. A similar caution was sounded by Haynes124 in advocating careful selection of cases for the surgical relief of lumbar herniated-disk syndromes. He warned against enthusiasm for the surgical approach in these cases and insisted that a "psychiatrically sound" soldier is a paramount prerequisite before considering operative intervention. Experience with elective surgery of the knee joint also exemplified the need for a careful selection of cases from the psychological standpoint.125

In contrast to this, Rosenbaum126 deliberately employed elective surgery in a psychosomatic approach to improve effectiveness. He noted that, of 44 soldiers with strabismus, 35 were on a limited-duty status mainly because of their physical appearance and consequent inferiority feelings.

123Butsch, W. L., and Harberson, J. C.: Importance of Careful Selection of Soldiers for Ligation of Varicose Veins. Bull. U.S. Army M. Dept. 4: 226-230, August 1945.
124See footnote 60, p. 688.
125Selection of Cases for Arthrotomy of the Knee. Bull. U.S. Army M. Dept. 4: 4-5, July 1945.
126Rosenbaum, H. D.: Strabismus in the Army. Mil. Surgeon 95: 48-52, July 1944.


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Surgical correction of the cosmetic defect produced increased self-esteem and self-confidence, and many were raised to a full-duty status. Indeed, two men volunteered and were accepted for Officer Candidate School.

Ocular disorders.-Psychosomatic considerations were also found to be prominent in other ocular disorders. Birge127 described individuals with symptoms of persistent headache, photophobia, lowered vision, with loss of visual acuity up to 50 percent, burning and watering of the eyes due to increased autonomic activity of the lachrymal glands, sweaty palms, tremor, and often a history of nervousness. Such cases were found in persons awaiting shipment overseas and in those who had recently suffered the loss of one eye because of disease or injury, the other eye being normal. These patients received little benefit from spectacles or eye medication but required reassurance in psychiatric treatment. Similarly, McAlpine128 noted the frequency of "functional" ocular disorders in military personnel. Common manifestations were blepharospasm, asthenopia, spasm of convergence and accommodation, and anomalies of conjugate deviation. Pupillary reactions were normal and amblyopia a relatively rare phenomenon. McAlpine found that such ocular difficulties arose as a result of the patient's inadequacy in coping with an unpleasant or difficult situation. Symptoms could be precipitated by a mild blow on the head or by a major situational problem.

Rheumatic fever.-In a few notable instances, a psychosomatic or total approach to illness was the basis initiating major changes in the overall management of complex disease entities. This is perhaps best illustrated by the report of Holbrook and van Ravenswaay129 on the treatment and management of rheumatic fever. This had become a major problem of World War II with 400 cases originating monthly from Army Air Forces personnel alone. Generally, 85 percent of patients with rheumatic fever were medically discharged, many with cardiac neurosis. A new comprehensive program was begun in 1944, including measures of prevention, treatment, convalescent activity, and selective assignment to duty. Prevention was accomplished by the administration of prophylactic doses of sulfathiazole to personnel in areas of high disease incidence. Treatment procedures included the transfer of patients in litters to hospitals located in geographic areas of low incidence as soon as acute symptoms subsided (usually after the first few weeks). By this move, the likelihood of recurrence of rheumatic fever was markedly reduced (no recurrence in 1,000 cases). The transfer of patients also concentrated their care in the hands of experienced personnel who avoided the error of undue attention to the cardiac aspects of the disease. This diminished the incidence of cardiac neuroses that had hitherto been almost as important a cause for discharge and disability as

127Birge, H. L.: Ocular War Neuroses. Arch. Ophth. 33: 440-448, June 1945. (Abstract in War Med. 8: 181-192, September 1945.)
128McAlpine, P. T.: Hysterical Visual Defects. War Med. 5: 129-132, March 1944.
129Holbrook, W. P., and van Ravenswaay, A. C.: The Military Aspects of Acute Rheumatic Fever. Mil. Surgeon 96: 388-391, May 1945.


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organic cardiac sequelae. In the new hospital, an active convalescence program was initiated with the quiescence of the rheumatic process. Objective tests of physical fitness were employed so that patients could measure their progress by a practical yardstick that they could see and understand. After convalescent activities, those with no sequelae were given a 12-day trial of simulated duty, including hikes, bivouacs, drill, and exercises, which demonstrated both to the patients and to their medical officers a realistic appraisal of physical ability to perform duty. Concurrent with this activity, job-assignment officers reviewed the patients' capabilities for the determination of a suitable military assignment. Then followed on-the-job training for such an assignment under medical supervision. After successful completion of the convalescent phase, patients with no demonstrable sequelae were returned to limited duty for 6 months in an area of the United States free of rheumatic fever. If found to be still without residua after this 6 months' assignment, they were returned to full duty. Patients found to have permanent cardiac damage but good cardiac reserve were given a permanent limited assignment in an area of low incidence in the Zone of Interior. Patients having in addition to permanent cardiac damage either impaired cardiac reserve or no useful assignment potential were medically discharged after maximum improvement. The overall results of this program demonstrated a decrease of medical separations in rheumatic fever patients from 85 to 25 percent, with a minimum of cardiac neuroses.

Peripheral nerve injuries.-Another striking example of the practical utilization of the psychosomatic viewpoint in the management of disease was furnished by the treatment regimen for peripheral nerve injuries established by Lewey and Bowles130 at Cushing General Hospital, Framingham, Mass. Known as the work-furlough program, it was introduced to provide a practical incentive, during the long convalescent period, to improve the use of an impaired extremity by exercise. These patients, while still in the service, were given a 90-day work furlough. With the cooperation of civilian and welfare agencies, a full-time position was found for them in nearby factories or businesses. After 90 days, patients were again evaluated, usually at weekend periods, in order to avoid loss of time from work. If maximum improvement was found, such patients were medically discharged and could promptly resume their work and continue their new civilian adjustment. If further improvement was possible, they were given another 90-day furlough and reevaluated at the end of this period. By this method, active convalescence was carried on in an atmosphere that permitted a gradual transition to civil life, provided the practical incentive of pay, and fostered the return of self-esteem and self-confidence in persons who had temporary or permanent disability.

130Lewey, F. H., and Bowles, G. K.: Work Furloughs for Patients With Peripheral Nerve Injuries. Bull, U.S. Army M. Dept. 4: 683-686, December 1945.


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Part III. During Oversea and Combat Duty

Oversea duty during World War II intensified the probability of exposure to a wide variety of frustrations, deprivations, and hazards. In addition to prolonged separation from home and family, there were encountered, either singly or collectively, such stressful circumstances as climatic extremes; monotonous diet, work, and recreation; isolated assignments in unusual geographic locations, such as tropical jungles or barren islands; threats of strange and ominous diseases, such as scrub typhus, schistosomiasis, malaria, and filariasis; and the intermittent terror and danger of combat. It may be assumed, however, that men who were sent overseas had achieved some degree of adjustability to military stress by virtue of their indoctrination and training experiences. Moreover, many of the weaker and presumably more vulnerable individuals had been eliminated from oversea duty by assignment limitation or discharge from the service for medical or administrative reasons.

Despite these qualifications, oversea service, particularly duty involving the cumulative effects of combat or isolated assignment, posed greater difficulties in adaptation than the transition from civil to military life or other vicissitudes of military service in the United States. Disturbances of adjustment under these circumstances were interwoven into the various clinical disorders that confronted each medical officer. The relationship of oversea stress to symptoms and disability was recognized by most medical personnel and facilitated acceptance of a holistic mind-body approach to the management of many disease and injury syndromes.

COMBAT FATIGUE

This growth of psychosomatic concepts in oversea medical practice is perhaps best exemplified by the evolution of understanding and methods of management in so-called combat exhaustion or combat fatigue. It will be recalled that this entity termed "shellshock" in World War I, was initially thought to be an organic brain disorder similar to, if not identical with, cerebral concussion. Later in World War I, it was commonly agreed that shellshock was the result of psychogenic trauma. Subsequently, the observation and treatment of veterans with chronic neurotic symptoms following shellshock gave further confirmation of its psychological origin, and the syndrome was designated as a traumatic neurosis. Thus, the pendulum has swung from a wholly organic to a completely psychological concept of causation. Early in World War II, the psychogenic viewpoint continued to prevail. But experience with combat psychiatric casualties soon made it evident that both psyche and soma were involved. It was found that most psychiatric casualties occurred when units were locked in heavy combat for several days in either offense or defense. Characteristic syndromes appeared


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in which it was apparent that physical strain played a prominent role in reducing the individual's resistance to the psychological trauma of combat. Indeed, the very terms that came to be applied in such cases, namely, "combat exhaustion" and "combat fatigue," arose from this common finding of physical strain. Hanson131 graphically described such casualties as follows:

Their faces were expressionless, their eyes blank and unseeing, and they tended to go to sleep wherever they were. The sick, injured, lightly wounded, and psychiatric cases were usually indistinguishable on the basis of their appearance. Even casual observation made it evident that these men were fatigued to the point of exhaustion. Most important of the factors that produced this marked fatigue was lack of sleep. Under almost all combat conditions the infantryman gets too little sleep. The conditions of his existence-the almost continuous shelling, the strange night noises, flares, sentry and patrol duties, rain, snow, cold, heat, insects, and the ever present threat of the enemy-conspire to make his sleep at best intermittent and scanty. In spite of this lack of sleep he must undergo long periods of severe exertion, more often than not on a diet that is at best deficient in calories. Often the food is there for him, but he either cannot carry enough of it with him or is too frightened to eat the proper amount. Sometimes the type available has become distasteful through monotony.

Combat troops who were not psychiatric casualties also displayed this characteristic battle weariness, as witness Ernie Pyle's132 moving account:

For four days and nights they have fought hard, eaten little, washed none, and slept hardly at all. Their nights have been violent with attack, fright, butchery, and their days sleepless and miserable with the crash of artillery. The men are walking * * *. Their walk is slow, for they are dead weary, as you can tell even when looking at them from behind. Every line and sag of their bodies speaks their inhuman exhaustion. On their shoulders and backs they carry heavy steel tripods, machine-gun barrels, leaden boxes of ammunition. Their feet seem to sink into the ground from the overload they are bearing. They don't slouch. It is the terrible deliberation of each step that spells out their appalling tiredness. Their faces are black and unshaven. They are young men, but the grime and whiskers and exhaustion make them look middle-aged. In their eyes as they pass is not hatred, not excitement, not despair, not the tonic of their victory-there is just the simple expression of being here as though they had been here doing this forever, and nothing else.

The somatic component of combat fatigue was further demonstrated by the not infrequent finding, in these cases, of intercurrent disease, such as infectious hepatitis, malaria, diarrhea, and the like.133 Here was evidence that so-called organic illness had undermined the ability of the individual to withstand the inroads of battle terror, since these patients had the usual symptoms of combat fatigue; namely, an inability to control their behavior in combat, overt manifestations of anxiety, startle reaction, and the almost invariable complaint of intolerance to the sounds and nearness of shellfire.

The fact that physical fatigue lowered the soldiers' ability to tolerate stress was also confirmed by the dramatic improvement of combat psychiatric casualties after 12 to 24 hours of sleep and food. With physical re-

131Hanson, F. R.: The Factor of Fatigue in the Neuroses of Combat. Army M. Bull. Supplement No. 9: 147-150, November 1949.
132Pyle, Ernie T.: Here Is Your War. New York: Henry Holt & Co., Inc., 1943, pp. 247-248.
133Glass, A. J.: Combat Exhaustion. U.S. Armed Forces M.J. 2: 1471-1478, October 1951.


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cuperation, overt signs of anxiety diminished or disappeared, confidence was restored, and the former psychiatric casualty was again capable of appropriate behavior in battle. This finding became the cornerstone of the successful forward management of combat psychiatric casualties, which returned to combat duty from 60 to 70 percent of patients after a 1- to 4-day treatment period.

It should be made clear that physical fatigue did not in itself produce psychiatric casualties. This fact was amply demonstrated by the many occasions in which units, advancing rapidly for days against slight enemy opposition and, therefore, enduring little emotional stress, had few or no psychiatric casualties even though conditions were such as to induce extreme physical fatigue. Conversely, a minority of psychiatric casualties occurred either immediately before battle or in the early stages of combat before any significant degree of physical strain was possible. Such patients were not considered to have genuine cases of combat exhaustion because the factor of physical fatigue was absent.

OTHER PROBLEMS

Combat fatigue represented an overt breakdown of adaptation to battle stress. Less obvious but more frequent manifestations of inability to endure the combat environment were a wide variety of symptomatic disorders presented to medical officers as evidence of incapacitating disease or injury. The following three major types of these clinical problems could be distinguished:

1. Persistent symptoms associated with negative findings of somatic disease.-This group included syndromes of constant headache; chronic lower back pain; recurrent digestive upset (dyspepsia); frequent episodes of weakness, giddiness, or faintness; painful feet; increased sweating, palpitation, or other manifestations of autonomic overactivity; and similar subjective disorders. Essentially, these complaints could be equated with some aspect of physical or mental discomfort suffered by most combat participants. Here, subjective discomfort was interpreted by the soldier concerned as indicating the presence of illness and, therefore, a legitimate reason for at least temporary removal from battle.

2. Persistent symptoms associated with minor objective findings of somatic disease or injury.-The important characteristic of this group was the disparity between the slight or moderate evidence of structural disease and the severity of the symptomatology. These cases posed diagnostic problems, for indeed there were findings such as scoliosis, shortening of one lower extremity, localized muscle atrophy, purulent discharge from a pilonidal sinus, deviation of the nasal septum with congested nasal mucous membrane and postnasal discharge, myopia, astigmatism or other visual refractive error, residua of an old knee injury, scars from trauma or sur-


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gery, hypertrophic arthritis, and minor bruises and sprains. The symptomatology was focused upon and systematized around the particular physical finding. Current difficulties were blamed upon a recurrence or exacerbation of the previous disorder by virtue of strenuous exercise, minor injury, adverse climate, or primitive living conditions in the field. In this group, also, the drive for medical attention stemmed from a failure of combat adjustment rather than from a minor limitation of bodily function.

3. Persistent symptoms during or following convalescence from an acute disease, injury, or battle wound.-These were a problem usually during hospitalization when it became evident that impending recovery would result in a return to combat duty. The symptoms of pain, discomfort, or limitation of function seemed to arise as residual complications of the acute illness. Thus, there were digestive disturbances and pain in the right upper quadrant following the subsidence of infectious hepatitis; painful scars or limitation of joint motion following wounds or indeed elective surgery; weakness, easy fatigability, and chills after recovery from a malarial attack; and headache, irritability, giddiness, and inability to concentrate after head injury, meningitis, or other acute cerebral syndromes. The gain through illness in these cases was substantial. It was apparent to patients and medical officers alike that continued incapacity was rewarded by evacuation to the United States or at least return to duty in a noncombat assignment.

The widespread prevalence of these psychosomatic problems and the difficulties that they presented in diagnosis, treatment, and disposition was a characteristic feature of military medicine in oversea theaters. Symptomatic disorders with negative or minor objective findings were mainly handled by the combat medical officer, particularly the battalion surgeon. Here, the physician was truly in a doctor's dilemma. It was easy to identify himself with the physical and mental strain of the soldier and his conscious or unconscious drive to obtain relief from battle. The field medical officer could readily convince himself that medical evacuation was justified in the interest of accurate diagnosis, which required laboratory and X-ray facilities available only in rear medical facilities. But to evacuate soldiers because of subjective complaints would only stimulate many others who were equally uncomfortable to attempt the medical escape route. Moreover, his line and medical superior officers would soon question a lenient evacuation policy that materially depleted the fighting strength. With time and experience, most combat medical officers came to adopt a realistic approach, with the objective findings of disease and the overall effectiveness of the individual their main consideration rather than the traditional reliance on symptoms and differential diagnosis. The fact that the combat medical officer shared to some extent the dangers and hardships of combat troops enhanced his ability to distinguish between discomfort and disease, lessened feelings of guilt for refusing medical evacuation, and facilitated an identification of


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himself with the needs of the unit rather than with the desires of the individual.

Not infrequently, however, medical officers yielded to the demand of subjective symptoms and evacuated persistent complainers. That this practice was not rare is indicated by an editorial134 which argued against evacuation from combat for slight wounds and subjective complaints. Medical officers were urged to ignore what the patient says and evaluate disability almost entirely on objective findings. A new concept, phrased "medical discipline," came into common usage. Loose medical discipline during an active battle period could readily deplete the combat command and overload medical evacuation channels at a time when hospitals were fully occupied with the wounded. These uninjured ambulatory patients were either neglected at forward hospitals or sent further along the evacuation chain to fixed hospitals at the rear. Return to combat duty from such distant medical facilities was not only difficult and time consuming but produced numbers of resentful, poorly motivated soldiers who had convinced themselves of the merit of their symptoms, were repeatedly on sick call, and, in general, rendered inadequate duty.

A similar but somewhat more complicated problem was produced by the symptomatic disorders that occurred during convalescence from acute injury and disease. Here, the hospital medical officer was mainly involved. These physicians had not shared the combat hazards of their patients and had developed positive relationships of varying degrees with patients during the acute phase of their illness. When these hospitalized patients complained of residual symptoms during convalescence or before expected return to duty and objective findings of disease or its complications were not elicited, further management and disposition became a difficult matter. Often, the medical officer recommended that the patient be given a noncombat assignment despite the absence of any physical limitations. Not infrequently, he would reassure the patient and himself by telling him to report to the battalion surgeon upon return to duty and request assignment to light tasks or further consideration of his symptomatology. This procedure almost invariably confirmed the patient's belief that he was not fully recovered from his illness or injury and created chronic sick call problems for the battalion surgeon. At times, the hospital medical officer, frustrated by the patient's unexplainable symptoms, responded with anger and accusations of malingering. Obviously, this approach helped neither the patient nor the physician. Many of these complaining patients were referred to the psychiatrist because of "functional overlay" or "neurotic predisposition." This discharge of responsibility was rightly regarded as a rejection by the patient, who insisted that his pain and discomfort were not "in my head" and remained resistant to any psychiatric insight or help. Maj. Gen. Morrison C. Stayer,135

134Abuse of Medical Disposition Channels. Bull. U.S. Army M. Dept. 3: 34-35, February 1945.
135Stayer, M. C.: The Necessity of Making Decisions. (Editorial) M. Bull. Mediterranean Theat. Op., January 1945. (Cited in Bull. U.S. Army M. Dept. 3: 28-29, April 1945.)


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Surgeon, Mediterranean Theater of Operations, U.S. Army, commented on this problem in an editorial aptly entitled "The Necessity of Making Decisions." He enjoined medical officers not to "pass the buck" to the battalion surgeons and insisted that they face up to their responsibility by informing patients that in view of negative disease findings they were considered fit for duty. As the deleterious effects of hospitalization became recognized, active convalescent programs were instituted, much like those that had been developed in the Zone of Interior. Kunkel136 described a reconditioning program in an oversea general hospital, where patients being returned to the Zone of Interior were physically separated from those being readied for return to duty. The latter were dressed in fatigue clothing, quartered in tents, and given physical exercise and military training under the command of line officers. Kunkel noted that the patients who had been transferred from other general hospitals and had been excused from all military discipline were surly and arrogant and had developed symptom patterns against their return to duty. Effective reconditioning programs in oversea hospitals were also reported by Rathauser and Ulfelder,137 and by Neu and Urban.138

SCRUB TYPHUS AND OTHER INFECTIONS

A special convalescent program for scrub typhus patients was described by Romeo,139 who detailed his experience with 312 cases in a hospital in New Guinea, from July 1942 to September 1944. Scrub typhus had been considered to warrant a prolonged period of rest in bed after the acute phase. However, Romeo found that bed rest beyond the febrile period was productive of flaccidity and loss of muscle tone and fostered a fear of the disease and its sequelae. Patients at bed rest during convalescence exhibited tachycardia (55 percent), tremor of the hands (60 percent), and vertigo (25 percent), along with constipation, insomnia, and headache. With the institution of a program of properly graduated activity, apprehension was allayed and most patients recovered completely for full duty in less than 9 weeks.

A similar experience was recorded in the management of relapsing (Plasmodium vivax) malaria by Gordon, Lippincott, and their coworkers.140 These authors treated 435 patients evacuated from the Southwest Pacific Area, a majority of whom had had repeated attacks of malaria. They dem-

136Kunkel, P.: Reconditioning Program in an Overseas General Hospital. Bull. U.S. Army M. Dept. 4: 586-590, November 1945.
137Rathauser, F., and Ulfelder, H.: Reconditioning Program in a Station Hospital. Bull. U.S. Army M. Dept. 5: 178-181, February 1946.
138Neu, H. N., and Urban, F. K.: Convalescence and Rehabilitation in a General Hospital in the Tropics. Mil. Surgeon 96: 377-385, May 1945.
139Romeo, B. J.: Convalescence From Scrub Typhus. Bull. U.S. Army M. Dept. 6: 167-173, August 1946.
140Gordon, H. H., Lippincott, S. W., and others: Clinical Features of Relapsing Plasmodium Vivax Malaria in Soldiers Evacuated From South Pacific Area. Arch. Int. Med. 75: 159-167, March 1945. (Abstract in War Med. 7: 414, June 1945.)


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onstrated the value of an active reconditioning program in dispelling a commonly held anxiety of most patients that repeated attacks seriously compromised present and future health. An active reconditioning program coupled with work assignments on the post increased physical stamina, restored self-confidence, and removed the dread of the disease.

A special psychological problem became evident in soldiers who contracted filariasis. Coggeshall141 described patients with filariasis in the Southwest Pacific Area who developed fear of permanent lymphedema from seeing natives with elephantiasis. Coggeshall developed the policy of explaining to each patient that the end result of filariasis was good, with eventual recovery. Patients were given a series of gradually increasing exercises and placed on full duty. The mental response was prompt and favorable. Men became less apprehensive even though an occasional flareup of edema or lymphangitis occurred. This observer concluded that soldiers with filariasis should not be permitted to deteriorate mentally and physically by prolonged hospitalization.

GASTROINTESTINAL DISORDERS

As in the Zone of Interior, disorders of the upper gastrointestinal tract were a conspicuous problem among oversea and combat troops. Peptic ulcer was apparently of minor importance in comparison with the more numerous cases of functional dyspepsia. Magnes142 reported on the operation of an outpatient gastrointestinal service in England. He noted that "preinvasion jitters" brought on functional disorders and lighted up cases of quiescent peptic ulcer. Vomiting was a common symptom. Magnes confirmed the value of outpatient management in lessening invalidism and persistence of symptomatology.

Because of the frequency of gastrointestinal disorders in the Mediterranean theater, a special field facility was created for the diagnosis and treatment of these conditions. This unit, a platoon of a field hospital, was located at the evacuation hospital level, with an experienced gastroenterologist, a psychiatrist, and a radiologist on the staff. Cases were carefully but rapidly evaluated by means of roentgenographic, gastroscopic, psychiatric, and clinical studies. In reporting the results of this specialized hospital, Halsted143 noted that, of 110 combat soldiers with chronic gastrointestinal complaints, 59 percent were found by gastroscopic examination to have normal mucosa while the remainder showed a mild superficial gastritis. No correlation was observed between the appearance of the gastric mucosa and

141Coggeshall, L. T.: The Problems of Filariasis. South. M.J. 38: 186-189, March 1945. (Abstract in War Med. 8: 61, July 1945.)
142Magnes, M.: A Gastro-Intestinal Outpatient Service. Bull. U.S. Army M. Dept. 3: 99-103, February 1945.
143Halsted, J. A.: Clearing Company for Gastro-Intestinal Disease. Bull. U.S. Army M. Dept. 3: 90-95, May 1945.


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the severity of symptomatology. In one 4-week period, 263 cases were processed with an average hospitalization of 8.7 days; 80 percent were returned to duty and only 7 percent evacuated to a general hospital. A vast majority of cases (84 percent) were considered to be primarily of psychological origin. It was the experience of the author and other division psychiatrists that peptic ulcer occurred rather infrequently during combat, whereas syndromes referable to the upper gastrointestinal tract, including nausea, anorexia, and vomiting, were common. It appeared that situations of acute danger were less apt to provoke peptic ulcer than the chronic deprivations and frustrations of noncombat situations.

Blumgart and Zetzel (ch. XII, p. 310) have emphasized that some 90 percent of all cases of peptic ulcer occurring in the Army originated during civilian life. On the other hand, there were men who had endured the stresses of civilian life and the strains of military training and transport and only then, during oversea service, developed ulcers. The inference was drawn that, although there may well have been a psychogenic component in such cases, more severe strains were required for their inception. Evidence, though scanty, supported the view that this group responded well to treatment; of 54 patients returned to appropriate duty following therapy, only 8 had to be rehospitalized.144

SUMMARY

Medical practice in the relatively slow tempo of peacetime generally focuses upon the biological difficulties of the patient and usually ignores the sociological and psychological aspects of adjustment. The physician sees the patient in an office, clinic, or hospital, and confines himself to symptoms and complaints referable to bodily dysfunction or defect. Ordinarily, the physician has little time or opportunity to become familiar with the environment or milieu of his patient or its effects upon the symptoms or clinical course of the disease. War, with its characteristic situational changes, dramatically brings to the forefront the environmental aspects of man's struggle for existence. Thus, a byproduct of modern war has been advances in medicine stemming from a better understanding of environmental dangers, such as the control of infectious disease, sanitation, and the surgical treatment of injuries. These benefits were also evident in World War II, and in addition military medicine learned to appreciate psychological and sociological influences upon disease and adjustment. It was this experience in military medicine that made possible the growth of the psychosomatic viewpoint. Although psychosomatic concepts originated before World War II, they received a major impetus during the war years, for here was a vast laboratory of stress where physicians could observe firsthand the effects of

144Report, Head, D. P., Wilen, C. J. W., and Fradkin, N. F., to Surgeon, MTOUSA, subject: Survey of the Peptic Ulcer Problem in MTOUSA, 1943-45.


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mind-body interrelationships upon symptoms, treatment, and disposition in almost any disease and injury. It can be stated that World War II produced no evidence that a psychological trauma caused specific somatic disease. Amply demonstrated, however, was the fact that in order to obtain good clinical results in disease and injury it was necessary to take into account various pertinent aspects of the patient's individual reaction to environment, such as motivation, group and cultural attitudes, the influence of the treatment milieu upon the effectiveness of improvement or recovery, and personality characteristics of the sick or injured person.

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