Psychiatry in the Korean War: Lessons for Community Psychiatry

Albert Julius Glass and Franklin D. Jones wrote extensively about psychiatry in the Korean War in Chapters 5 through 12 of the government-generated volume, Psychiatry in the U.S. Army: Lessons for Community Psychiatry.

Contents:

• Chapter 5 - An Introduction to Psychiatry in the Korean War
  • Background to the Korean War
    • US Army Strength and Deployment: June 1950
    • US Army Far East Command: June 1950
  • Psychiatry in the Korean War
  • "Combat Exhaustion" on the Eve of the Korean War
• Chapter 6 - The North Korean Invasion (25 June 1950-15 September 1950)
  • The Tactical Situation
  • Psychiatry at the Division Level: August 1950
  • Psychiatry at the Army Level
    • Korea: Rear Area
    • Necessity and Advantages
  • Base Section Psychiatry in Japan
    • Tokyo
    • Osaka
    • Fukuoka, Kyushu (Southern Japan)
    • 118th Station Hospital (Southern Japan)
      • The 361st Station Hospital (Tokyo)
      • Clinical Severity
      • Previous Combat in World War II
    • Visit by Karl Bowman, MD Psychiatric Consultant - In July 1950
  • FDJ: Summary
  • References - Chapter 6
• Chapter 7 - The United Nations Offensive (15 September-26 November 1950)
  • Tactical Considerations
    • Inchon Landing and Capture of Seoul, 15-30 September 1950
    • Operation Chromite - The Inchon Landings
      • The Assault in Readiness
      • Results
    • Breakout from the Pusan Perimeter: 16-27 September 1950
  • Psychiatry at the Division Level: Early Experiences
    • 7th Infantry Division
    • Psychiatric Casualties: September 1950
  • Psychiatry at the Division Level: Later Experiences
    • Psychiatric Casualties: October 1950
    • Changes in Division Psychiatry
    • Surveys of Divisional Psychiatric Programs
  • Psychiatry at the Army Level
  • Base Section Psychiatry
    • Additional Neuropsychiatric Personnel
    • Further Decentralization in Japan
    • Non-Convulsive Shock Therapy
    • Japanese B Encephalitis
  • References - Chapter 7
• Chapter 8 - The Chinese Communist Offensive (26 November 1950-15 January 1951)
  • Chinese Communist Intervention
  • Psychiatry at the Division Level
    • Case 8-1.  Intermittent Hysterical Paralysis
  • Self-Inflicted Wounds, Accidental Injury, and AWOL from Battle
  • Psychiatry at the Army Level
  • Base Section Psychiatry
  • References - Chapter 8
• Chapter 9 - The United Nations Winter Offensive (15 January-22 April 1951)
  • Cease-Fire Negotiations
  • Psychiatry at the Division Level
    • New Informal Theater Policy
    • Administrative Discharges
    • The Non-effective Combat Officer
  • Psychiatry at the Army Level
  • Base Section Psychiatry in Japan and Okinawa
    • Limited Duty Assignment
    • Arrival of Psychiatric Assets in Theater
      • 279th General Hospital
      • 382nd General Hospital
      • 118th Station Hospital
      • 141st General Hospital
      • Osaka Army Hospital
      • 361st Station Hospital
      • 40th and 45th Infantry Divisions (National Guard)
    • Psychiatric Problems on Okinawa
    • Discharge of Undesirable Personnel
  • References - Chapter 9
• Chapter 10 - The Spring Offensives (22 April-10 July 1951)
  • The Tactical Situation
    • The Chinese 5th Phase Offensive
    • The United Nations' Counteroffensive
  • Psychiatry at the Division Level
  • Psychiatry at the Army Level
    • The 121st Evacuation Hospital
    • The 11th Evacuation Hospital
    • Pusan Area 3rd Station Hospital and 10th Station Hospital
    • The Pusan Prisoner of War Hospital
  • Base Section Psychiatry
    • Staffing Issues
    • Visiting Consultant in Psychiatry
  • References - Chapter 10
• Chapter 11 - Truce Negotiations and Limited Offensives by the United Nations (10 July 1951-1 October 1951)
  • Limited United Nations' Offensive Actions
  • The Psychiatric Rate
  • Influence of Rotation
  • Misassignment of Limited Service Personnel
  • 2nd Infantry Division Psychiatry
  • Combat Psychiatry for Battalion Surgeons
  • Rotation of Psychiatrists
  • Psychiatry at the Army Level
    • 121st Evacuation Hospital
    • The Psychiatric Team
    • Professional Medical Consultants at the Army Level
    • 11th Evacuation Hospital
    • 4th Field Hospital
    • Pusan Area
    • Discharge by AR 615-368 Versus Courts-Martial
  • Base Section Psychiatry
    • Visit by Colonel Caldwell
    • Important Changes in Rotation
    • New Arrivals to the Theater
    • Changes of Assignment
    • Change of Theater Consultant in Psychiatry
• Chapter 12 - Military Psychiatry After the First Year of the Korean War
  • Stalemate and Negotiations
  • References - Chapter 12
• About the Authors

Chapter 5

An Introduction to Psychiatry in the Korean War

by Albert J. Glass, MD, FAPA

Background to the Korean War

The Soviet-sponsored government of North Korea, having failed to conquer its southern neighbor by less violent means, invaded South Korea (the Republic of Korea) on 25 June 1950. When the United States with other members of the United Nations came to the aid of the South Koreans, a war of over three years resulted that cost the Americans more than 110,000 battle casualties (19,353 KIA and 92,363 WIA) and over 365,000 non-battle admissions for disease and injury, including 13,565 psychiatric disorders. [Footnotes 1,2]

The campaigns set in motion by the invasion of South Korea came to be considered a “limited war.” The fighting was deliberately confined in geographic terms, political decisions placed restrictions upon military strategy and none of the belligerents with the exception of the two Korean governments used its full military potential. [Footnote 2, pp. 1-6] Thus, actual combat between Communist and South Korean-United Nations forces was contained within the Korean peninsula proper, including coastal waters. The United States and its allies did not extend hostilities across the borders of North Korea to attack bases from which came the Chinese Communist offensive or to interfere with the Soviet bases in the maritime provinces of Russia which sent armaments and other military supplies to the North Korean Army.

U.S. Army Strength and Deployment: June 1950

In June 1950 the active U.S. Army was about 591,000 and included 10 combat divisions. About 360,000 were within the Zone of the Interior. Another 231,000 were overseas, many performing occupation duties. The largest group, 108,500, was in the Far East. In Europe 80,000 were in Germany, 9,500 in Austria, and 4,800 in Trieste. Over 7,000 were assigned to the Pacific area, and about 7,500 to Alaska. In the Caribbean were about 12,200 troops. Several thousand troops were assigned to other military missions throughout the world.

The forces designated to carry out the U.S. Army’s emergency assignment were called the General Reserve. Except for one regimental combat team (RCT) in Hawaii, this force consisted of five combat divisions and small support units in the Zone of the Interior (ZI). The major General Reserve Units on 25 June 1950 were the 2nd Armored Division, 11th Airborne Division (minus one RCT), 3rd Armored Cavalry Regiment, 5th RCT (Hawaii), and the 14th RCT. [Footnote 2 – pp. 433-60]

U.S. Army Far East Command: June 1950

In June 1950 U.S. Army forces in the Far East Command comprised four under-strength infantry divisions and seven anti-aircraft artillery battalions in Japan and one infantry regiment and two anti-aircraft artillery battalions in Okinawa. Major combat units were the 1st Cavalry Division (actually infantry) in Central Honshu, Japan, the 7th Infantry Division in Northern Honshu and Hokkaido, Japan, the 24th Infantry Division in Kyushu, Southern Japan, the 25th Infantry Division in South Central Honshu, Japan, and the 9th anti-aircraft artillery group in Okinawa.

Eighth Army, the main combat force of the Far East Command, had 93 percent of its authorized strength on 25 June 1950. Each division had an authorized strength of 12,500 men as compared to its authorized war strength of 18,900. Each division was short of its war strength by nearly 7,000 men, 1,500 rifles and 100 90-mm antitank guns, three rifle battalions, six heavy tank companies, three 105-mm field artillery batteries, and three anti-aircraft artillery batteries.

Until 1949, the primary responsibility of military units in the Far East Command was to carry out occupation duties. No serious effort was made in these years to maintain combat efficiency at battalion or higher level. This changed markedly beginning in April 1949, when General MacArthur issued a policy directive in which combat divisions of the Eighth Army were progressively relieved of the majority of their purely occupational missions and directed to undertake, along with Far East Air Force (FEAF) and US Navy, Far East (NAVFE), an intensified program for the establishment of a cohesive and integrated naval, air, and ground fighting team. However, there still remained many administrative features of the occupation which constituted a barrier to the full development of the planned training program.

The readiness of combat units within the Far East Command (FEC) was not enhanced by the quality of enlisted personnel received from the ZI. Replacements arriving from the United States during 1949 had a high percentage of lower intelligence ratings. In April 1949, 43 percent of Army enlisted personnel in FEC, rated in class IV and class V (the two lowest classes) on the Army General Classification Test.

All units of Eighth Army had completed the battalion phase of their training by the target date of 15 May 1950. Reports on Eighth Army’s divisions in May 1950 showed estimates ranging from 84 percent to 65 percent of full combat efficiency for the four divisions in Japan.

Equipment for FEC troops was mostly of World War II vintage. Much of it had been through combat. Vehicles, particularly, had been serviced and maintained with difficulty during the years of occupation. There was unusual dependence upon Japanese workmen, in the absence of U.S. Army service units, to duties ranging from menial hall tasks to highly technical functions.

By mid-1950, the American forces in the Far East had begun a gradual shift away from occupational duties to acquiring combat skills. However, these forces were under-strength, inadequately armed, and sketchily trained as commanders sought to overcome the inertia of years of occupation and the prevailing uneasy peace. [Footnote 2 – pp. 43-60]

Psychiatry in the Korean War

Three separate, often different, but linked psychiatric programs of evaluation and treatment were simultaneously being operated in the several geographic areas of the Far East Command (FEC). In Korea, psychiatry at the division level (1st echelon, which included mainly the combat zone) would affect the numbers moved rearward and types of psychiatric cases evacuated to the army communication zone level (2nd echelon) psychiatric services which determined the numbers and types of mental disorders sent to neuropsychiatric services in Japan (3rd echelon). Psychiatric units in Japan or at the army level in Korea could return unfit individuals to combat duty and complicate the problems of division psychiatry. During the initial months of the Korean War, psychiatric facilities in Japan inappropriately evacuated many psychiatric cases to the ZI because “Limited Service” of World War II had been abolished in 1947. Also the neuropsychiatry (NP) staff during this early period were meager and lacked sophistication in combat psychiatry.

At the beginning of the Korean War on 25 June 1950, there were only nine psychiatrists and neurologists in the Far East Command (FEC). Eight of nine were residents with one or more years of training at Letterman, Fitzsimons, or Walter Reed General Hospitals who had been sent to the FEC with residents in other medical specialties in May 1950, for three months temporary duty to provide care for the occupation troops and their dependents. As American forces entered Korea in early July 1950, this small group of psychiatrists and neurologists were deployed in Korea, Japan, and Okinawa.

In response to urgent needs of the FEC for medical officer personnel, psychiatrists, neurologists, and other medical specialists began to arrive in Tokyo by airlift beginning in mid-July 1950. As additional increments of psychiatrists and neurologists arrived in succeeding months, it became necessary to indoctrinate the new arrivals with information relevant to combat psychiatry.

The orientation was conducted at the 361st Station Hospital in Tokyo, the “NP Center” of the FEC to which most incoming psychiatrists and neurologists were initially assigned. This preliminary assignment also made possible a coordination of the qualifications and desires of new arrivals with the needs of the Theater.

During this era, there was not the plethora of medical specialists available to the Army that existed in World War II. Even recall to active duty of many reserve medical officers and later the “doctor’s draft” brought into service mainly young medical officers with partial training and experience in the various medical specialties. Army Medical Service was therefore compelled to utilize its few career medical specialists as supervisors. In this regard, the author, a senior Regular Army specialist board-certified in psychiatry and neurology with extensive experience in World War II combat psychiatry, arrived in Tokyo during late September 1950 to assume the position of Theater Consultant in Neuropsychiatry. Soon he participated in the orientation and assignment of psychiatrists and neurologists new to the theatre. Fortunately, the Neuropsychiatric Consultant to the U.S. Army Surgeon General, Col. John Caldwell MC, had caused to be published a supplemental issue of the Bulletin of the U.S. Army Medical Department in November, 1949 entitled, “Combat Psychiatry.” The Supplemental Issue was entirely devoted to describing in some detail the establishment and operation of an echeloned system of combat psychiatry as developed in the Mediterranean Theater of World War II. “Combat Psychiatry” became the textbook for the orientation of neurosychiatric personnel in the Far East Command.

"Combat Exhaustion" on the Eve of the Korean War

Beginning during World War I (1914-1918), the manifestations and frequency of most psychiatric disorders in participants of modern warfare were found to be related to the battle casualty rate, i.e., killed-in-action (KIA), wounded-in-action (WIA), and various aspects of the prevailing tactical situation. These relationships were again demonstrated in World War II and noted early in the Korean War.

Such combat related psychiatric disorders became differentiated in World War I, and in World War II from the less frequent traditional peacetime mental illnesses in which causation apparently originated within the person rather than from stressful battle situations. [Footnote 3]

As previously stated in Chapter 1, the term “exhaustion” was created during the Tunisian campaign of the Mediterranean Theater in World War II to designate combat-induced psychiatric disorders. (FDJ: It may have been selected from review of World War I literature since the term was occasionally used then and Hanson may have been familiar with the Salmon lectures.) After World War II, this wartime designation was made permanent as “Combat Exhaustion” on 19 October 1950, by the U.S. Army, which terminology was adopted by the Veterans Administration and later by the American Psychiatric Association. [Footnote 4 – pp. 1-2, Footnote 5 – p. 756]

The treatment of “Combat Exhaustion” was understood during the Korean War; however, some difficulties were encountered in its implementation. Commonly such cases were regarded as psychiatric casualties. Because of the background circumstances described above, combat-inducted psychiatric disorders and their management including prevention and treatment during the Korean War will be described in successive time phases as related to battle casualties, existing tactical situations and associated combat conditions.

Chapter 6

The North Korean Invasion
(25 June 1950 - 15 September 1950)

by Albert J. Glass, MD, FAPA

The Tactical Situation

Initially, during this period, medical and psychiatric support for 24th Division troops was necessarily limited to emergency care and evacuation which in itself posed difficult problems because of frequent retrograde movement of divisional medical facilities. This tactical situation made impossible the holding of any type patients for intra-divisional treatment. [Footnote 1, pp. 3-20]

Cpt. James Hammill MC (1 ½ years Army neurology residency at Fitzsimons General Hospital) was assigned to the 24th Division. Because of need and the tactical situation, he was utilized as commander of a clearing platoon, a component of the divisional medical battalion. Captain Hammill demonstrated coolness and leadership under fire. His clearing platoon was the last medical facility to leave Taejon as enemy tanks entered the city. His behavior under combat conditions achieved the respect of both line and medical officers which facilitated his later function as 24th Infantry Division Psychiatrist.

Neither the 1st Cavalry Division that arrived in Korea on 18 July nor the 25th Infantry Division whose first elements reached Korea on 15 July had met the enemy until the 24th Division was relieved on 22 July. These fresh elements and ROK forces fought off the North Korean Army with stubborn determination, strengthened the weak United Nations position, and allowed for some semblance of a battle line. But more enemy troops were hurled into the attack, forcing a continuation of United Nations’ withdrawal and delaying tactics. It was still impossible to hold patients for any type of intra-divisional treatment because of enemy infiltration and the realistic fear of medical facilities being overrun. Therefore it was not a serious deficiency that neither the 1st Cavalry Division nor the 25th Infantry Division had an assigned psychiatrist at this time. [Footnote 1 – pp. 3-4, Footnote 2 – pp. 115-125]

Admissions for psychiatric disorders during July 1950 occurred at a rate of 209/1,000/year, the highest in the Koran War to which was associated the highest KIA rate (769.04), the second highest WIA rate (950.97), and a high incidence of MIA (some 2,400) from the 24th Division, many of whom were later declared dead or died of wounds or disease. [Footnote 3, pp. 108, 116] The large majority of American troops in Korea during July 1950 were divisional with only a minority less exposed to combat (28,817 divisional versus 3,793 non-divisional). [Footnote 3, pp. 15-18]

This was in keeping with the accumulated experiences of World War II which indicated that the highest rates of psychiatric casualties occur during the initial severe battle experiences of combat units new to battle before the acquisition of combat skills, the development of group cohesiveness, and the removal of less effective immediate combat leaders. Thus, in July 1950 the most favorable circumstances existed for the causation of psychiatric casualties, namely high battle casualties in units new to intense combat. [Footnote 4]\

Psychiatry at the Division Level: August 1950

The almost continuous intense defensive fighting of August was responsible for the third highest battle casualties (KIA and WIA) of the Korean War and the third highest rate of psychiatric admissions. As the battle lines stabilized, it became possible for division clearing stations to hold and treat mild non-battle casualties. This action was also dictated by a desperate need to rapidly conserve and rehabilitate all available manpower in order to hold the thinly-manned perimeter defense lines. Under these circumstances divisional psychiatric treatment (1st echelon) began in latter August 1950.

Cpt. James Hammill assumed full-time function as the 24th Division psychiatrist. Cpt. Paul Stimson (1 ½ years civilian psychiatry residency) arrived in the 1st Cavalry Division to initiate division psychiatry. Lieutenant Colonel (LTC) Philip Smith (completed three years Army psychiatry residency and Board eligible) was assigned to the 25th Infantry Division in early August and soon thereafter began intra-divisional psychiatric treatment.  Cpt. Martin John Schumacher (completed almost three years Army psychiatry residence) arrived with the 2nd Infantry Division in mid-August and began division psychiatry at the end of the month.

In early September, the enemy hurled their strongest assaults at various points of the Pusan Perimeter. As the fighting proceeded at this intensity, heavy casualties of all types were produced in United Nations troops. Intra-divisional psychiatric casualties were in full operation as 100 to 200 psychiatric casualties were receiving care in each of the division treatment centers. Three of the divisions utilized facilities and resources of holding platoons of division clearing companies as psychiatric centers. Additional cots, litters and other needed items, also personnel were somehow obtained by the respective division surgeons who quickly became aware of the project’s value; and, driven by the same need to salvage manpower, instituted similar programs for the intra-divisional treatment of patients wit mild organic illness or injury. Captain Schumacher of the 2nd Infantry Division improvised a separate unit for intra-divisional psychiatric treatment. The necessary equipment and personnel were obtained with the aid of the division chaplain.

Many psychiatric casualties were noted to have a large element of physical exhaustion, which was readily relieved by the two- to four-day period of sleep and rest provided in the treatment regimen. Other cases, less numerous, were more severe, exhibiting dissociative states and marked startle reaction. Gross hysteria such as blindness and extremity paralysis were stated by two division psychiatrists (Schumacher and Smith) to comprise ten percent of the case load. Individuals with somatic complaints were quite frequent, but showed relatively little overt anxiety.

All division psychiatrists explored the use of amytal or pentothal interviews in therapeutic endeavors. Schumacher claimed his results were quite successful, particularly with hysterical reactions, in restoring complete function. He returned such recovered patients promptly to combat duty and insisted that there were few recurrences.

The other division psychiatrists were not as impressed with the value of barbiturate interviews. All agreed that employment of the simple therapeutic technique of reassurance, explanation, and ventilation, when combined with a regimen of rest, sleep, food, and a short respite from battle stress accomplished miraculous improvement in haggard, apathetic, tremulous, weary, patients. Division psychiatrists learned that it was necessary to use a firm matter-of-fact approach to patients that indicated in the initial interview that they were not disabled, but temporarily worn out, that such a reaction was understandable and common, that recovery will occur after several days of rest and relief from battle following which return to the combat unit would be expected. In general, the principles of forward psychiatric treatment set forth in “Combat Psychiatry” as previously described were well-known to division psychiatrists and utilized in treatment programs.

The results of intra-divisional psychiatric treatment were uniformly 50 percent to 70 percent return to combat duty with relatively few recurrences. This success in salvaging needed combat personnel convinced division commanders, the Eighth Army Surgeon, and various division surgeons that division psychiatry was of practical value. The efforts of the four division psychiatrists, LTC Philip Smith, Captains James Hammill and Martin J. Schumacher, and 1LT (later Captain) Paul Stimson, firmly established division psychiatry in the Korean War. Thus it can be stated, that as a result of lessons learned in World War II, the reiteration of these principles in training memoranda and other Army publications, and the invaluable inclusion of psychiatrists in the Tables of Organization and Equipment (TOE) of combat divisions that in the Korean War, division psychiatry become operational within six to eight weeks after an unprepared onset of battle in contrast to the two-year delay in instituting a similar program in World War II. It is this achievement that spurs planning and efforts to further progress because it disproves that old adage that “men learn from history only that men learn nothing from history.” [Footnote 1, pp. 5-8, Footnote 2, pp. 125-137]

Psychiatry at the Army Level

Korea: Rear Area

In sharp contrast to the prompt application of psychiatry at the division level, psychiatric efforts at the Army level were meager and ineffective. It was evident that a need to support division psychiatry by a second echelon of psychiatry at the Army level was not recognized, although such a need was first demonstrated in World War I and in World War II. This lack of recognition was unfortunate since two qualified psychiatrists were available in Eighth Army to provide the professional nucleus for a second echelon army level psychiatric facility.

Captain (later Major) W. Krause (one year civilian psychiatry residency and one year Army psychiatry experience) arrived in Korea on 7 July 1950 as the assigned psychiatrist with the 8054th Evacuation Hospital. This unit soon became operational in Pusan as the major medical facility serving Eighth Army, receiving thousands of sick and wounded during July, August, and September 1950. Captain Krause, while in charge of the psychiatric section, had other duties because of medical officer shortage. It was impossible to establish a psychiatric treatment program as bed space was scarce. Only non-transportable sick and wounded were held for emergency treatment. Evacuation was considered the only means of providing beds to receive the daily flow of patients from the combat zone. Captain Krause stated that he returned about ten percent of psychiatric patients to duty during August and September 1950, and evacuated about 1800 others in Japan. Captain Krause was not even able to obtain a separate room or small wall tent for privacy in psychiatric evaluation or treatment.

Captain (later Major) F. Gentry Harris (two years Army psychiatry residency at Letterman General Hospital, San Francisco, California) was one of the residents sent to the Far East Command in May 1950 for three months temporary duty. When American troops entered Korea in early July 1590, Captain Harris was assigned to Eighth Army Headquarters, then at Taegu, where he operated a general dispensary.

Captain Harris had received considerable indoctrination in combat psychiatry during residency training, and he made repeated requests to serve as a psychiatrist. After some time he was placed in charge of a convalescent unit of the 8054th Evacuation Hospital. It is unclear as to the purpose or expectations of function for this convalescent facility. In mid-August 1950, Captain Harris found a suitable building and proposed that he and Captain Krause be permitted to function as a psychiatric unit; however, he was unable to obtain necessary support or supplies and personnel from the Commanding Officer of the 8054th Evacuation Hospital, the senior medical officer in Pusan, who did not believe the project to be practical. At this time, because of the tenuous tactical situation, senior medical officers in Pusan were not sympathetic to holding psychiatric patients for treatment who could be readily evacuated. Captain Harris stated that during this time there was never any explicit or formal recognition of need for a psychiatric facility at the Army level.

In latter September 1950, Captain Harris was transferred to the 64th Field Hospital, then temporarily providing care for North Korean prisoners of war near Pusan. Captain Harris did give psychiatric treatment to a small number of mainly psychotic patients despite a major language barrier. At this time, the author saw Captain Harris and planned for his utilization at the Army level.

Thus it was that the plans and efforts of Captains Harris and Krause were largely ineffective, although they clearly saw the need, understood their role, and desired to function, but were unable to obtain the necessary logistical support. It should be appreciated that this was a time of confusion and tension. Medical support was difficult to obtain with supplies and personnel in great shortage. The evacuation and care of wounded assumed first priority and a need to maintain open beds for this purpose was a major concern of responsible senior medical officers. Last but not least was the overall anxiety that defenses would be overrun and patients lost to the enemy.

Thus, it seemed reasonable to move every patient out of Korea as soon as possible to keep the medical resources free to handle the daily load of new casualties. It was not uncommon for adverse news of battle to create more apprehension in the rear than in forward areas where the situation was better known at first hand as witness the fact that in mid-August 1950 with the establishment of the Pusan Perimeter, combat divisions began the treatment of psychiatric casualties.

Information relative to the above situations during July, August, and September 1950 was obtained by the author in early October 1950, from the two psychiatrists, Captains Krause and Harris, the commanding officer and other medical officers of the 8054th Evacuation Hospital, the Eighth Army Surgeon, and other line and medical officers. It would be presumptuous to be critical of their efforts when everyone was so sorely pressed. The following comments are made in a constructive spirit in the hope that this early experience of the Korean War may provide a worthwhile lesson for the future.

Necessity and Advantages

The major problem in dealing adequately with psychiatric casualties has been failure to appreciate the effectiveness of combat psychiatry in the field. It has been a source of amazement to senior line and medical officer, even those with considerable experience and training in the field, that one or several psychiatrists with a minimum of equipment and personnel can return to effective combat duty so many of their patients. In practice more than one-half of acute psychiatric casualties can be rehabilitated for combat duty within two to four days. This technique has been demonstrated in World War I, World War II, and the Korean War where it was shown that a single psychiatrist can handle 50 to 100 patients at any one occasion. For the time, effort and logistics required, it is perhaps the most economical type of medical care.

It would have been only necessary in the Pusan area during this early period to have established a minimum field or fixed facility which included cots, a simple mess, a water source, some sedative drugs, shelter, and a small number of personnel. Patients wore their uniforms and did not require frequent changes of bed linen, but towels were needed. The two available psychiatrists would have been sufficient. At least 50 percent of acute psychiatric casualties who were evacuated from Korea in July and August 1950 could have been restored to combat duty. This is precisely what occurred when division psychiatry became operational in latter August 1950. For those cases evacuated from division psychiatry to psychiatry at the Army level, experience indicated that about 30 percent were returned to combat units with most of the remainder utilized for combat support and non-combat duties. This pertinent usage of field combat psychiatry should receive emphasis in the training of career army medical officers who should become thoroughly aware that acute psychiatric casualties can be readily salvaged with a small expenditure of equipment and personnel.

Even the admission and evacuation of psychiatric casualties as was performed at the 8054th Evacuation Hospital required one to two days with Captain Krause working without privacy sitting on cots of patients in crowded wards. Yet he managed to return ten percent of mainly directly received psychiatric casualties to combat duty. By doubling the time of one to two days to two to four days in an organized treatment program, it is likely that 50 percent of directly received psychiatric casualties could have been removed from the evacuation flow to Japan.

There are other benefits of psychiatry at the Army level. A unit of this type removes psychiatric patients from the stream of sick and wounded, thus decreasing the overload of evacuation channels and admissions to base hospitals in Japan. Also, psychiatry at the Army level (2nd echelon) supports combat forces in battle when withdrawal or other tactical circumstances makes it impossible to treat patients at the division level. As already indicated, an Army level psychiatric service could have salvaged psychiatric casualties in July and August 1950 when division psychiatry was “impractical.”

Army level psychiatric service should be included in medical planning of any battle campaign since commonly in its early phases problems in deployment and other tactical circumstances tend to nullify division psychiatry. Following World War II, it was proposed to include a platoon of a separate clearing company with the addition of psychiatrists and other professional personnel as needed to constitute an Army level psychiatric service. After much discussion, it was deleted on the basis that such a unit could be readily created when needed, and its inclusion would only increase the complexity of already large Army medical facilities. In 1946, the author was present at a War Department Medical Board meeting held at Brooke Army Medical Center, San Antonio, Texas, during a discussion of the subject. All psychiatrists at the meeting agreed that there would be inevitable delay and much time lost before some future Army Surgeon could be convinced that Army level psychiatric units were needed. The psychiatrists argued that it should be part of a finite organized plan, but others rebutted that this knowledge was well-known and mollified the objections of the psychiatrists by a decision that the use of Army level psychiatric centers would be made a part of teaching doctrine. Time has proved the accuracy of the psychiatrists’ predictions. Failure to provide Army level psychiatric services in the initial phase of the Korean conflict again points to the necessity of formally establishing psychiatric function as an integral component of medical services of a combat army. It should not be forgotten that the relatively rapid establishment of division psychiatry in the Korean War was largely due to the inclusion of psychiatrists and ancillary personnel in the Tables of Organization or every combat division. [Footnote 5, pp. 9-13]

Base Section Psychiatry in Japan

The sudden impact of war found medical facilities in Japan unprepared to receive the casualties that were evacuated from Korea in increasing numbers. Prior to hostilities, medical support barely met minimum requirements for the occupation troops and their dependents. These resources were now further reduced by the loss of medical personnel and provisional hospitals that were sent to Korea.

Psychiatric facilities and personnel shared in the professional shortage. As the psychiatric casualties entered Japan 3-5 July, the following facilities and personnel were present.

Tokyo

The Neuropsychiatry Service of the 361st Station Hospital, previously the Neuropsychiatry Center of the Far East Command (FEC).  Personnel were a psychiatrist, a neurologist and two psychologists as follows:

Psychiatrist:

Col. Eaton Bennett Mc USA (two years Army psychiatry residency)

Neurologist:

Maj. (later LTC) Roy Clausen (one year neurology residency plus five years experience)

Psychologists:

1Lt. (later CPT) James Hoc
1Lt Ann Laue

Also present were several enlisted psychological and social work assistants. Facilities included closed and open wards with a capacity of 200 inpatients, EEG machine and electroconvulsive (ECT) apparatus.

Osaka

Psychiatric Section of the Osaka Army Hospital.  Personnel were a psychiatrist, a psychologist and a social worker as follows:

Psychiatric:

LTC Weldon Ruth (one and a half years Army psychiatry residency)

Psychologist:

Master Sergeant (M/Sgt) David Kupfer (excellent training)

Social Worker:

CPT. Topfer MSC (some experience, no formal training)

Facilities included open and closed wards with a capacity of 80 patients. The psychiatrist became ill in early August 1950 and required medical evacuation to the ZI. He was replaced by a general medical officer with the 7th Infantry Division in Northern Japan. The new psychiatrist and the neuropsychiatry team developed an effective treatment program.

Fukuoka, Kyushu (Southern Japan)

Psychiatric Section of the 118th Station Hospital. Personnel was a psychiatrist:

Psychiatrist:

Maj. James Bailey (two years Army psychiatry residency)

Facilities included an open ward with a capacity of 60 patients. Closed facilities were available for transient care.

118th Station Hospital (Southern Japan)

A large majority of all patients evacuated from Korea in July 1950 arrived first at the 118th Station Hospital in southern Japan, a short distance from the Korean Strait, southeast from Pusan. This hospital rapidly expanded as it assumed the functions of major triage for the transfer of patients to other hospitals in Japan.

Major Bailey at the 118th Station Hospital was caught up in the increasing flow of incoming patients, as was his counterpart with the 8054th Evacuation Hospital in Pusan, Captain Krause. Also, he could do little in establishing a treatment program since beds were available only for non-transportable patients. Further, he was needed in the sorting and triage of evacuees from Korea as the small medical staff often worked around the clock to keep patients moving north so that incoming casualties could be processed. Major Bailey stated that he managed to return ten percent of psychiatric evacuees to combat duty but triaged the remainder to the 361st Station Hospital in Tokyo.

The 361st Station Hospital (Tokyo)

On 15 July 1950, LTC Arthur Hessin MC (completed psychiatric residency and board eligible) arrived to join the 361st Hospital as Chief of the Neuropsychiatry Service. He was followed soon thereafter by a second: LTC Oswald Weaver (completed three years of Army psychiatry residency, also board eligible). An internist, Captain Fancy, and a general medical officer, Cpt. Dermott Smith, who desired psychiatric training were added to the neuropsychiatry staff which also included two other psychiatrists, Col. Eaton Bennett and LTC Ray Clausen. Physical facilities were expanded to include the adjoining detachment barracks which became an annex mainly for the Neuropsychiatry Service whose census averaged between 500 and 600 for August and September 1950. Somewhat over 50 percent of psychiatric admissions to the 361st Station Hospital during this period were evacuated to the ZI as the lack of available bed space and other problems apparently forced this means of disposition. [Footnote 6, pp. 14-16]

An administrative problem soon arose when it became apparent that many psychiatric admissions could function on a non-combat status, but not in combat. However, such a designation was not permitted since the term “Limited Service” utilized for this purpose during World War I had been deleted from Army Regulations. G-1 (personnel), GHQ Far East Command (FEC) finally resolved the problem temporarily at least by the designation of “general service with waiver for duty in Japan” to be accompanied by an appropriate change of the physical profile (PULHES) under the S category (Stability). PULHES, borrowed from the Canadian Military, had been also introduced after World War II. The geographic limitation was not a medical recommendation but a G-1 stipulation to insure filling depleted service units in Japan. At the end of 30-60-90 days as so stipulated, they were reexamined by a psychiatrist. A surprising proportion of up to 50 percent were found fit for combat, often with approval of involved persons, and returned to the original combat unit, thus preventing accumulation of the category “For duty only in Japan.” When the examination indicated unfitness for combat the individual remained in Japan to be reexamined usually in 90 days.

Return to combat duty had advantages for the individual other than increased self-esteem, as those in combat units became more quickly eligible for rotation to the United States than persons in non-combat assignments in Japan. But difficulties arose later when replacements for service units in Japan were not needed in large numbers. By this time fewer psychiatric casualties were evacuated to Japan as the first and second echelons of psychiatric services became fully operational in Korea. [Footnote 6 – p. 16]

Clinical Severity

The clinical picture of psychiatric casualties observed at the 361st Station Hospital was described as severe with florid manifestations of “free floating anxiety” including startle reactions, gross tremors, battle dreams, dissociative reactions, hysteria and outbursts of irritability or aggressive behavior. Observers were impressed by the incidence of severe reactions; however, it is common for the early psychiatric casualties of a war to be regarded as more severe and more frequent than later reactions when combat units have acquired battle skills, developed group cohesiveness, and removed less effective leaders.

A further explanation lies in the time and place where psychiatric casualties are observed. In the Tunisian campaign after the North African invasion of World War II, early psychiatric casualties were evacuated hundreds of miles to Algiers, Constantine, Casablanca and Oran over several days where they were observed by psychiatrists in rear Army hospitals to exhibit severe clinical symptoms much like that described in psychiatric casualties evacuated from Korea to the 361st Hospital. [Footnote 7]

At the 361st Hospital, patients were described as more severe than noted in Korea. When observed early, many showed marked improvement. Thus Captain Krause at Pusan, Korea was able to return ten percent to duty after only an evaluation; similarly Major Bailey did so in southern Japan. After repeated evacuation over many days, psychiatric casualties exhibit increased severity of symptoms as if to justify their evacuation from combat. Another explanation for increased severity of symptoms at the 361st Hospital was the fact that large numbers of psychiatric patients were being evacuated to the Zone of the Interior (United States). Logically, they were selected on the basis of severity of symptoms. All of the above noted reasons may have played a role in producing the severe reactions observed at the 361st Hospital in the early phase of the Korean War; but, as the conflict continued these severe type cases became increasingly rare.

Previous Combat in World War II

Observers at the 361st Hospital were impressed by the seemingly large number of psychiatric casualties who claimed to have experienced combat in World War II. As explained by many of these individuals, they were more vulnerable to combat stress in Korea because dormant trauma in World War II had been revived. Most troops initially engaged in the Korean fighting were career army personnel with many World War II veterans.

In discussions of this issue by line officers during early October 1950, it was their consensus that men with previous combat experience were more effective than newcomers to battle. These officers placed emphasis upon the psychological and physiological un-preparedness of occupation troops for return to the rigors and hazards of war. This viewpoint was also expressed by many psychiatric casualties in discussing their inability to adapt to sudden change from the standpoint of training and state of mind.

A small but troublesome subcategory of psychiatric patients at the 361st Hospital during this period were career-commissioned and non-commissioned officers who had been classified as “Limited Service” during World War II because of partial mental or physical disability. After World War II some continued in the Army, while others reentered after a brief time in civil life. When “Limited Service” was abolished after World War II, they were placed on general service with their knowledge and consent.

These individuals functioned quite well in peacetime assignments and were promoted one or more times. The outbreak of hostilities found them in the occupation forces in Japan or assignments elsewhere, mainly the ZI. When ordered to Korea, many became prompt psychiatric casualties with anticipatory anxiety which caused hospitalization in Korea or in Japan en route to Korea. These individuals became part of the caseload of the NP Service at the 361st Hospital. They exhibited dependency intermixed with resentment, as they complained that an implied promise to them had been broken by the Army who should have known of their limitations and insured a continuation on non-combat duty. It would be paradoxical, however, to foster career non-combat personnel in an Army whose primary mission is combat.

Perhaps such personnel should seek positions in a civil governmental agency if the objective is security of employment. These patients were usually included in the group evacuated to the ZI for disability discharge, which could not readily be accomplished overseas. [Footnote 6, pp. 17-19]

Visit by Karl Bowman, MD, Psychiatric Consultant - In July 1950

The Far East Command was visited in mid-July 1950 by Dr. Karl Bowman, Psychiatric Consultant to the U.S. Army Surgeon General. He stayed in Japan for several weeks visiting US military psychiatric facilities. Dr. Bowman saw many incoming psychiatric casualties. He was impressed by the severity and frequency of psychiatric patients and recommended that a special psychiatric hospital be established in southern Japan with a capacity of 1,000 beds, although initially 200 beds would suffice. It was a logical suggestion because he saw so many patients with so few facilities. He also suggested instituting forward psychiatric treatment and that a Theater Consultant in Psychiatry be added to the Medical Section of GHQ (General Headquarters) Far East Command (FEC). The recommendation of Dr. Bowman to initiate forward psychiatric treatment was of great value. It provided the impetus toward implementing the assignment of psychiatrists to combat divisions in August 1950. [Footnote 6, pp. 19-20]

FDJ: Summary

After an initial retreat and surrender of territory to gain time for replacements, American forces created a firm perimeter around the southern part of Pusan by the end of July. The division psychiatrists after having a stable front were able to implement principles of forward treatment. The second echelon of evacuation at army level was still in disarray mainly due to the failure of commanders to recognize psychiatric casualties as replacement resources. Third echelon treatment in Japan was scarcely any better with continued evacuation of casualties to ZI.

References - Chapter 6

1. Glass, A.J. Psychiatry at the division level. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington DC. [Compilation of data obtained from Medical Corps, Medical Service Corps and line officer participants who were present in Korea during the period 25 June 1950 to 30 September 1951.]

2. Schnabel, J. United States Army in the Korean War: Policy and Direction: The First Year. Washington, DC: Office of the Chief of Military History, United States Army; 1972.

3. Reister, F.A. Battle Casualties and Medical Statistics: US Army Experience in the Korean War. [Appendix B]. Washington, DC: The Surgeon General, Department of the Army; 1973.

4. Glass, A.J. Lessons learned. In: Glass, A.J. (ed.). Medical Department, United States Army, Neuropsychiatry in World War II, Vol. II, Overseas Theaters. Washington, DC: US Government Printing Office; 1973: 989-1027.

5. Glass, A.J. Psychiatry at the Army level. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

6. Glass, A.J. Base section psychiatry. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

7. Drayer, C.S., Glass, A.J. Introduction. In: Glass, A.J. (ed). Medical Department, United States Army, Neuropsychiatry in World War II, Vol. II, Overseas Theaters. Washington, DC: US Government Printing Office; 1973; 1-23.

Chapter 7

The United Nations Offensive
(15 September-26 November 1950)

by Albert J. Glass, MD, FAPA

Tactical Considerations

Inchon Landing and Capture of Seoul, 15-30 September 1950

General MacArthur, foreseeing the enemy's vulnerable disposition early in the war even before the first clash between American and North Korean troops, had decided that a seaborne strike against the North Korean rear was a logical solution.  A chance to strike deep behind the enemy's mass to cut lines of supply, then attack front-line divisions from two directions was enticing to the general, who in World War II had proved so well the value of amphibious envelopment against the Japanese.  Before such a blow could be struck, General Walker had to halt the North Korean Army short of Pusan and General MacArthur had to build an amphibious force almost from the ground up.  By the opening of September 1950, both generals had progressed considerably in meeting these essentials. [Footnote 1, pp. 139-154]

Operation Chromite - The Inchon Landings

General MacArthur planned his bold amphibious venture at Inchon sustained only by hope and promises. At no time during planning did he have the men and guns he would need. The Joint Chiefs of Staff (JCS) frequently told MacArthur that with military resources of the United States at rock-bottom and with the short-fused target date (15 September 1950) on which General MacArthur adamantly insisted, the needed men and guns might not arrive on time.

Disagreements over time, place, and method of landing occurred. MacArthur knew that even with fullest support by Washington, he might not have by his chosen D-day enough men and equipment to breach the enemy’s defenses and exploit a penetration by X Corps. The nature and location of the planned landing dictated its direction by a tactical headquarters which was separate from Eighth Army. General Walker had his hands full with the Pusan Perimeter and could not easily divide his attention, effort, or staff. The size of the landing force, initially set at about two divisions, indicated a need for a corps command.

On 21 August 1950 General MacArthur requested permission to activate from sources available in the Theatre, a Headquarters X Corps. Department of the Army readily agreed and X Corps was formally established 26 August 1950. The Special Planning Staff, General Headquarters became Headquarters X Corps and Lieutenant General Edward M. Almond became its Commanding General in addition to duties as Chief of Staff and Deputy Commander, Far East command of United Nations Command. On 1 September 1950 MacArthur assigned the code name, Operation Chromite, to the planned landing at Inchon.

The Assault in Readiness

X Corps at embarkation numbered less than 70,000 men. Included as its major units were the First Marine Division, the 7th Infantry Division, the 92nd and 96th Field Artillery Battalions, the 56th Amphibious Tank and Tractor Battalion, the 19th Engineer Combat Group, and the 2nd Engineer Special Brigade. The 1st Marine Division had 25,040 men, including 2,760 Army troops and 2,786 Korean Marines; the 7th Marines, which arrived on 21 September 1950 added 4,000 men to the division strength. [Footnote 1, pp. 155-172]

Results

Events dramatically justified General MacArthur’s firm confidence. American Marines, backed by devastating naval and air bombardment, assaulted Inchon on 15 September 1950 and readily defeated the weak, stunned, North Korean defenders. By mid-day Marines had seized Wolmi-do, the fortress island dominating Inchon harbor. By nightfall more than a third of Inchon had fallen.

Operation Chromite stayed on schedule. In the wake of the Marines, the 7th Division landed and struck south toward Suwon. Kimpo Airfield fell to the Marines on 19 September 1950 and on 20 September General MacArthur could tell the Joint Chiefs of Staff that his forces were pounding at the gates of Seoul. So far American forces had suffered only light casualties, while the North Koreans had lost heavily. At Inchon, supplies were being unloaded at a rate of 4,000 tons daily. Kimpo Airfield had swung into round-the-clock operation. When General Almond took command at 1800 on 21 September, he had almost 6,000 vehicles, 25,000 tons of equipment and 50,000 troops. [Footnote 1, pp. 173-174]

Breakout From the Pusan Perimeter: 16-27 September 1950

On 16 September 1950, Eighth Army and ROK troops, the Pusan Perimeter defenders, reinforced by the 27th British Brigade, began an all-out offensive to coordinate with the Inchon invasion. Fortunately, the success of MacArthur’s plan did not depend upon a prompt juncture of Eighth Army and X Corps. The North Korean Army fought as fiercely on 16 September as on 14 September, and for nearly a week stood off all attempts by Eighth Army to punch through their defenses.

By 22 September, signs of enemy weakness had appeared; the next day the North Korean Army, at last feeling the effects of severed lines of communication and a formidable force in its rear, began a general withdrawal from the Pusan Perimeter. The withdrawal turned into a rout. During the next week Eighth Army pursued the fleeing enemy. On the morning of 26 September 1950, a task force from the 1st Cavalry Division of Eighth Army met elements of the 7th Infantry Division of X Corps near Osan to mark the juncture of the two forces.

Psychiatry at the Division Level: Early Experiences

Psychiatric admissions were elevated for several days with high battle casualties at the beginning of the Eighth Army offensive, then dropped precipitously, as to be expected when victorious troops are rapidly advancing with few battle casualties. The combat troops were far ahead of their clearing company facilities as they outran the slower support troops. In this happy tactical situation, division psychiatric centers could not operate effectively because they were dislocated from the combat troops and too far in the rear. It is fortunate that such occasions do not require psychiatric support as mental patients who may be produced are too few to be of practical importance.

Meanwhile, X Corps had enlarged its holdings in the Inchon-Seoul area. The reinforced enemy gave stubborn battle for Seoul which forced street-by-street and house-to-house fighting. Seoul was finally secured on 28 September with the aid of 7th Division elements who attacked from the south; however, Marines bore the brunt of the fighting and suffered heavy battle casualties.

Psychiatric casualties from the Marine division were also numerous, but neither a division psychiatrist or intra-divisional psychiatric treatment was present. Together with battle casualties, Marine psychiatric casualties were initially evacuated to the Navy hospital ship Consolation at Inchon harbor and later to army hospitals that became operational in the X Corps area. Lieutenant Commander (LCDR) Wade Boswell MC, psychiatrist with the hospital ship, reported to the author in early October 1950 that he had little success in returning Marine psychiatric casualties to combat duty. Apparently the superior living conditions of the hospital ship were not conducive to improvement and return to combat hardships despite proximity of the hospital to the battle action and prompt placement of psychiatric casualties under treatment. This was in sharp contrast to the somewhat later results obtained at the relatively primitive setting of an army field hospital, where it was possible to return about 50 percent of Marine psychiatric patients to combat duty within a one- to three-day period of rest and brief psychotherapy. [Footnote 1, pp. 74-177, Footnote 2, pp. 21-23]

7th Infantry Division

The 7th Infantry Division had relatively light battle casualties, and consequently had few psychiatric casualties. A psychiatric treatment section was included in the division clearing company facilities. It was headed by Captain David Markelz, who had a one-year Army residency in internal medicine and who was assigned as the assistant division psychiatrist because a psychiatrist was not available. Captain Markelz briefed himself on his new position by various readings, including Combat Psychiatry, a supplemental issue of the U.S. Army Medical Bulletin published November 1949. He saw about ten psychiatric patients from the relatively brief combat action of the 7th Infantry Division. These cases did not impress him as being severe and six were returned to duty after a short period of rest and sedation. [Footnote 2, p. 22]

Psychiatric Casualties: September 1950

For the month of September 1950, which included intense combat in both defense and offense mainly by Eighth army, there occurred the highest U.S. Army rate for WIA and the second highest for KIA. The rate of psychiatric admissions (includes cases only excused from duty) from U.S. Army personnel in September was also the second highest for the Korean War and the effect of tactical situations. [Footnote 3]

Psychiatry at the Division Level: Later Experiences

Psychiatric Casualties: October 1950

The psychiatric admission rate for October of 34.21/1,000/year, the lowest during the first 18 months of the Korean War, reflects the optimism that pervaded all ranks as well as light battle casualties for the month. [Footnote 3] It was not surprising that morale was high. The fortunes of war had been quickly and almost miraculously reversed and there was widespread expectations that soon the fighting would be over and return to comfortable Japan would be accomplished. [Footnote 2, p. 23]

Changes in Division Psychiatry

Early in October 1950, LTC Philip Smith, 25th Infantry Division Psychiatrist, was medically evacuated to Japan. He was replaced in late October by Captain W. Krause of the 8054th Evacuation Hospital who volunteered for a divisional assignment. Fortunately few psychiatric or battle casualties occurred in the division during October, as the division remained near Taejon to combat guerrillas and mop up bypassed enemy remnants.

X Corps forces were increased by the addition of the 3rd Infantry Division, the first elements of which disembarked at Wonsan in early November. This division was unique in arriving with two psychiatrists, Captain (later Major) Clarence Miller (three years Army psychiatry residency) assigned as the division psychiatrist and 1st Lieutenant (later Captain) Clay Barritt (one year civilian psychiatry residency under Army auspices) assigned as the assistant division psychiatrist.

In November 1950, further gains of Eighth army and X Corps became increasingly limited due to stiffening enemy resistance, difficulties of maintaining adequate logistical support to forward troops, and onset of the severe North Korean winter with its numbing effect. This month, with its increasing enemy activity, saw a moderate rise of battle casualties (KIA and WIA) with a corresponding rise in the psychiatric admission rate as optimism of the previous month began to wane. In addition, there were significant increased rates for disease and non-battle injury—frostbite. Eighth Army continued to advance above Pyongyang and X Corps expanded its control over much of northeast Korea including the Chosin Reservoir district. By 25 November 1950, the United Nations’ forces were ready for a final offensive to the Yalu River with Eighth Army 75 to 80 miles above Pyongyang and X Corps anchored at the Manchurian border on the east by elements of the 7th Infantry Division in readiness to wheel westward and coordinate with the northward push of Eighth Army. [Footnote 2, pp. 23-24]

Surveys of Divisional Psychiatric Programs

Surveys of divisional psychiatric programs by the author during October and November 1950 revealed some common problems. While all division surgeons appreciated the value and need for intra-divisional psychiatric treatment, they were unaware of or resistant to the function of the division psychiatrist in prevention. For this reason and because most division psychiatrists were unfamiliar with this aspect of their duties, they confined their efforts mainly to treatment and evaluation of referred or evaluated cases. This use of division psychiatrists was necessary during the Pusan Perimeter period when large numbers of psychiatric casualties focused attention upon treatment. This early role presumed that treatment was the major function which could be performed by a psychiatrist.

As a consequence, and consistent with the knowledge of division surgeons at this time, two divisions in Korea assigned their only psychiatrist as the assistant division psychiatrist. This designation insured restriction of preventive aspects in division psychiatric programs as assistant division psychiatrists were subordinate to division clearing and medical battalion commanders. Thus, the mission of the only psychiatrist could and was curtailed by the whims and ideas of clearing company commanders. These psychiatrists could not visit and make recommendations to combat units or in one instance obtain permission to discuss problems with the division surgeon, including policies and methods for treatment of psychiatric casualties. Also, the assistant division psychiatrist was subject to performing routine duties of the clearing company which in one division interfered with psychiatric treatment. [Footnote 2, pp. 24-25] Experiences with abuses which occur when the Table of Organization for a combat division permits two psychiatrists, when seldom can more than one be made available, leads the author to seriously question the value of this change from the Table of Organization in World War II combat divisions which contained a single psychiatrist specifically designated as the division psychiatrist and assigned to the office of the division surgeon. Even in the future, there will be too few psychiatrists available to assign two per division. In actual practice a general medical officer of the division clearing company can be readily trained to serve as assistant to the division psychiatrist when such help is needed. [Footnote 2, p. 25] After the Korean War a change was made replacing the assistant division psychiatrist with an officer psychiatric social worker or clinical psychologist as available. These officers became division social worker or division psychologist with the single division psychiatrist assigned to the office of the division surgeon.

In the course of the survey, an effort was made to orient psychiatrists assigned to divisions in assuming a role in preventive psychiatry to coordinate with efforts to remove obstacles to such a program. The young psychiatrists were receptive to such a function. It was agreed that division psychiatrists should regularly visit battalion and other divisional units when conditions permitted. In general a program of prevention was to be established as set forth in the November 1949 Supplemental Issue of the Bulletin U.S. Army Medical Department entitled Combat Psychiatry.

The administrative problems associated with division psychiatry were resolved in October 1950. The first concerned the Emergency Medical Tag (EMT) diagnoses of combat psychiatric casualties. All types of designations were used from “shell shock” to “psychosis,” including the ubiquitous “Psychoneurosis-anxiety state.” This practice caused a similar iatrogenic trauma to patients and semantic confusion to medical officers that occurred early in World War II. The Eighth Army Surgeon agreed to corrective action. An Eighth Army directive was issued implementing the use of “Combat Exhaustion” to designate all psychiatric casualties in combat troops, equivalently prescribed in current army regulations as “Combat Fatigue.”

The second problem was also resolved when the Eighth Army Surgeon agreed to issue a directive that all combat divisions submit periodic biweekly (semimonthly) reports giving data on battle casualties and psychiatric admissions, focused at the battalion level. The form used was identical with that utilized in World War II. From data in these reports division charts were constructed. The division psychiatric reports became a pertinent part of efforts to expand preventive aspects of psychiatric programs at this time, as they pinpoint differences of the various divisional elements and raise questions by command. As in World War II, during the Korean War, they became powerful levers for interest and research in preventive psychiatry. [Footnote 2, pp. 28-29]

A prompt result of efforts to establish preventive psychiatry programs within combat divisions occurred in the 24th Infantry Division. Here, Major Hammill enjoyed the full confidence of senior medical officers. He was properly assigned to the office of the division surgeon and had access to all divisional units. As a staff officer, he began the orientation of line and medical officers on pertinent psychiatric problems. Prior to leaving the division in November 1950 to complete residency training, he worked jointly with his replacement, Captain (later Major) William Hausman (two years civilian psychiatry residency under Army auspices) for a ten-day period. During this time there were visits to the various divisional elements where Captain Hausman was personally introduced to key line and medical officers. By this transition process, Major Hammill transferred his prestige, status, and gains for psychiatry in the division to Captain Hausman, who further developed the divisional program. This orientation of new incoming psychiatrists became a preferred procedure in the many changes of division psychiatrists that occurred in the Korean War. [Footnote 2, pp. 25-26]

The improper assignment of Cpt. Paul Stimson to the 1st Cavalry Division as the assistant division psychiatrist instead of division psychiatrist was corrected after discussion with the division surgeon. Captain Stimson assumed an increasing staff function as he developed a superior psychiatric program. Efforts to remedy a similar situation in the 2nd Infantry Division initially met failure after two attempts but was resolved several months later after the division surgeon and Captain Schumacher, the assigned only psychiatrist in the division, left Korea.

There was no problem in the assignment or function of Cpt. William Krause the assigned psychiatrist to the 25th Infantry Division. The only requirement was for a psychiatrist to implement an intra-divisional psychiatric program. The division surgeon recognized the necessity of both treatment and prevention in divisional psychiatry. He was happy to receive Captain Krause and gave him whole-hearted support.

The lack of a trained psychiatrist in the 7th Infantry Division was remedied in early November 1950. Captain (later Major) Wilmer Betts (one and a half years civilian psychiatry residency under Army auspices) was assigned to the 7th Infantry Division after prior discussion with the division surgeon on the comprehensive utilization of the division psychiatrist and a promise that Captain Betts would be correctly assigned and be permitted full function. The division surgeon not only kept the agreement, but his strong encouragement and support of Captain Betts facilitated the development of a superior divisional psychiatric program.

Efforts to persuade the 1st Marine Division to establish intra-divisional psychiatric treatment initially failed, but was later implemented. In November 1950, while at Hamhung, an important northeastern coastal port in North Korea, it became evident that a considerable number of Marine psychiatric casualties were being admitted to the 121st Evacuation Hospital at Hamhung, who provided medical support to the 1st Marine Division. It was suggested to the Marine Division Surgeon that he request a division psychiatrist who would conserve manpower by treatment and prevention. The Marine Division Surgeon was quite surprised to learn that so many psychiatric casualties were being produced in his division. After confirmation by his subordinates that Marine psychiatric casualties were indeed being sent to the 121st Evacuation Hospital, he agreed that the author could transmit to Navy Headquarters in Tokyo his willingness for the 1st Marine Division to receive a division psychiatrist. This was accomplished on the author’s next return to Tokyo, but a further delay occurred. In March 1951, a Navy psychiatrist was assigned to the 1st Marine Division. From all reports, a superior 1st Marine Division psychiatric program was developed. [Footnote 2, pp. 6-29]

Psychiatry at the Army Level

This period saw a marked improvement in Army level psychiatric facilities, the second echelon of psychiatric treatment, which took place in late October 1950. In the second half of September 1950, Captains Krause and Harris continued their efforts at Pusan, but the rapid forward movement of United Nations combat troops in late September and October 1950 negated the value of the Pusan area, which became too rear for useful function. Medical facilities that were tactically situated to better support the combat troops were the 121st Evacuation Hospital and the 4th Field Hospital, units of X Corps medical services which became operational in the Inchon-Seoul sector during latter September and early October 1950, respectively. Both hospitals were receiving psychiatric patients, mainly from the 1st Marine Division at the time of the author’s visit to this area in early October. The 121st Evacuation Hospital was preparing to cease operations in order to move with other X Corps elements south to Pusan to participate in the next amphibious invasion. The 4th Field Hospital was transferred to the control of Eighth Army and remained at the site of Ascom City between Inchon and Seoul. Currently the 121st Evacuation Hospital is at this location.

The 4th Field Hospital had no trained psychiatrist, but Cpt. James Gibbs who had been accepted for Army psychiatry residency training, was assigned to this duty at his request. The author saw about 20 psychiatric patients in treatment-evaluation interviews with Captain Gibbs during a most concentrated course of psychiatric training, as in 24 hours an attempt was made to indoctrinate him in both the socio-dynamic concepts and treatment methods pertinent to combat psychiatric casualties. Captain Gibbs was an apt student, but further supervision was required at least for a time.

The 121st Evacuation Hospital had admitted about 40 patients to the psychiatric section during the brief period of its operation at Yongdongpo near Seoul. The assigned psychiatrist, Cpt. Thomas Glasscock (one year psychiatry residency under Army auspices) also required instruction in combat psychiatry and was introduced to the techniques of hypnosis and barbiturate interviews. As noted with Captain Krause of the 8054th Evacuation Hospital, Captain Glasscock had not been given such facilities as a small wall tent to permit privacy in work with patients. This difficulty was not uncommon at this time as two division psychiatrists were similarly handicapped. The necessity for such privacy was repeatedly stated by various psychiatrists as essential for proper functioning; but, their contentions were not seriously considered. On the surface it would appear to be a minor matter; nevertheless, it required personal guarantees to respective hospital commanders and division surgeons that psychiatrists obtained their best results by listening and talking to patients in an atmosphere which was conducive to privacy. Later, however, these same senior medical officers came to regard their psychiatric services as effective and valuable and freely gave their support.

In early October 1950, a conference was held with the Eighth Army Surgeon and the author on improving psychiatric services at the Army level (2nd echelon). The author accepted his decision that a separate psychiatric unit to support divisional psychiatry patients was not feasible at this time for reasons of difficulties in maintaining security in unstable rear areas and because supplies and personnel for such a facility were scarce. We agreed that a psychiatric team could be made operational in an already functioning hospital. Not acceptable was his suggestion that a Pusan area military hospital was the logical site for the psychiatric team. It was over 300 miles to the rear of the combat zone and literally miles out of the “war.” The author suggested the 4th Field Hospital near Seoul, only 30 to 40 miles back of the forward troops. Here also there was assurance of support from Col. L.B. Hanson, the Commanding Officer of the 4th Field Hospital. Initially this proposal was rejected by the Eighth Army Surgeon, who insisted on Pusan. The author argued that Captain Harris should be moved from Pusan to join with Captain Gibbs in forming the nucleus of a psychiatric team at the 4th Field Hospital. The matter was left at this stage but, to the author’s pleasant surprise, the Eighth Army Surgeon moved Cpt. F. Gentry Harris three weeks later to the 4th Field Hospital where he and Captain Gibbs formed a harmonious team, trained the needed medical corpsmen, established a treatment program, and by the end of October 1950, demonstrated that 80 percent of psychiatric admissions were returned to combat or non-combat duty. In late November Captain Harris was returned to the ZI to complete psychiatry residency training. He was replaced by 1Lt (later Captain) Harold Kolansky (one and a half years civilian psychiatry residency).

The 171st Evacuation Hospital that arrived in Korea in mid-September 1950 became operational for the first time at Pyongyang about 1 November 1950. As the most forward large medical facility soon the hospital was receiving all types of casualties. The assigned psychiatrist, Cpt. Richard Cole (one year civilian psychiatry residency under Army auspices) lacked experience with military psychiatric patients. The author spent several days of supervision with Captain Cole which focused upon brief evaluation and treatment of combat psychiatric casualties. Cases were seen together with later discussion.

The 121st Evacuation Hospital was visited again in early November 1950 at a new location in the X Corps sector near Hamhung. Captain Glasscock had excellent facilities for privacy of patient interviews at this time. He had improved in confidence and competence as he developed an efficient treatment program. This psychiatric section became the Army level psychiatric center for X Corps.

The 8054th Evacuation Hospital was mainly utilized for support of non-combat troops based in Pusan and Taegu. Captain Hausman replaced Captain Krause in late October and remained for several weeks prior to assignment with the 24th Infantry Division. Latter November 1950 found psychiatric facilities at Army level expanded and functioning effectively. The 171st Evacuation Hospital and the 4th Field Hospital gave adequate support to Eighth Army combat forces. The 121st Evacuation Hospital supported X Corps troops.

At this time another conference was held with the Eighth Army Surgeon to decide on the best location for an Army level psychiatric center to support the forthcoming United Nations offensive. This attack was publicized as a drive to the Yalu River with the goal of ending the war by Christmas. It was agreed that the Pyongyang area offered the best location. For this reason it was planned to establish a psychiatric team at the 64th Field Hospital, then about to move to Pyongyang. The author agreed to personally supervise the project. Initially Captain Cole, to be detached from the 171st Evacuation Hospital and the author, would constitute the psychiatric team. If all went well, Captain Kolansky, at the 4th Field Hospital would be moved to the psychiatric center at Pyongyang.

From the author’s visits to hospitals at Eighth Army and X Corps, it became evident that large numbers of military personnel were evacuated from combat units for subjective somatic complaints or mild non-disabling physical defects. Many such patients were observed in the various Army level psychiatric services where the underlying problems were defects in motivation and group cohesiveness. Efforts to correct these problems were directed at line and medical officers in the Far East Command. The concepts utilized and general orientation to these problems were described by the author in the Surgeon’s Circular, Far East Command, entitled Medical Evacuation and the Gain in Illness, January 1951, which was reproduced in the Symposium on Military Medicine in the Far East Command Bulletin of the U.S. Army Medical Department, September 1951. Cases were more frequent as combat and the winter became more severe. As in the Mediterranean Theatre of World War II, a subgroup of this category were manifested in persons whose spectacles were lost or broken. It was necessary to evacuate such individuals to hospitals at Army level for refraction and the furnishing of glasses. While in the hospital, other complaints were common. An average of ten days per person was lost from duty. Later during the winter of 1951, optical units were established in each division which finally resolved the problem. [Footnote 5, pp. 30-34]

Base Section Psychiatry

During this period, a reorganization of psychiatric facilities in Japan was initiated. The current practice of concentrating most psychiatric evacuees from Korea at the 361st Station Hospital in Japan had serious disadvantages in treatment and disposition. Many psychiatric patients were seemingly adversely affected by the hospital setting, allowing them either to maintain a persistence of symptoms or to develop more severe manifestations than were previously noted. This resistance toward improvement and return to duty cannot be considered surprising when the comfortable atmosphere of a fixed hospital situated in the midst of peaceful urban Tokyo, where pleasures abound, is contrasted with the monotonous, primitive, and hazardous existence of Korea. In addition, patients at the 361st Hospital could readily observe and envy the evacuation to the United States of other psychiatric patients who were apparently being rewarded for persistent or severe manifestations of mental illness by being sent home.

It should not be assumed that reasons for continuing the gain in illness were in any large degree unconscious to individuals concerned since such matters were openly brought forward by them in treatment interviews and not infrequently were discussed among patients. In this connection, the concentration of patients at the 361st Hospital who had similar battle experiences, symptoms, conflicts, and desires fostered a negative group attitude toward return to duty even of a non-combat type. Patients reinforced each other in justifying complaints and contaminated new admissions with stories of “nothing being done for them” as they indoctrinated the newcomer on what the “score” was in this institution.

The psychiatric casualty when evacuated to Japan was especially vulnerable to group suggestion. Separated from the positive motivating forces of his combat unit, often troubled by guilt for leaving them, he was figuratively alone with his conflict and readily seized upon any support which would aid his symptom defense, the only excuse he had for patient status. The hospital patient group offered him such support by persons who had similar problems and needs. Their presence and numbers gave him justification for symptoms and facilitated the projection of painful self-directed criticism outward to hospital personnel and others who had not endured the hardships and hazards of combat and therefore could not appreciate or understand his problems.

A person rarely acts entirely upon his own wishes or needs. It is more usual to be part of some group since being alone is to be defenseless. Within the group the individual can solidify neurotic defenses or antisocial behavior. When the psychiatric patient was part of the 361st hospital group that sanctioned the use of symptoms for tangible benefits, he was encouraged to obtain further gain of illness. For this reason, many patients at the 361st Station Hospital had a recurrence or persistence of symptoms which related to combat stress, such as startle reaction, insomnia battle nightmares, and the like. In the hospital it seemed that psychiatric patients were fighting another battle, the battle to go home.

The adverse influence of large psychiatric patient groups in rear hospitals was a well known problem of base section psychiatry in World War II. Efforts were made to oppose this negative attitude including group therapy, a more rapid evaluation and disposition of less severe cases, a full program of physical activity, and finally successful program in forward zones (division and army levels) which limited the number evacuated to base sections. At this time therapeutic efforts of psychiatrists at the 361st Hospital were almost wholly occupied in contending with gain in illness. The 361st Hospital, located in a densely populated area of Tokyo, Japan, had little space for a physical reconditioning program. Instead, reliance was placed on indoor activities, mainly of a recreational nature including motion pictures, Red Cross and special services entertainment, occupational therapy, and evening passes to Tokyo. All of these activities made the thought of return even to non-combat duty an unpleasant prospect of resuming daily obligations and irksome tasks. In truth, it was difficult to establish positive rapport, for the therapist had little to offer the patient compared with the tangible benefits of remaining disabled.

Any efforts to minimize or correct the errors of current psychiatric treatment in Japan involved decreasing the admission of non-psychotic mental patients to fixed medical installations such as the 361st Station Hospital. Steps in this direction had already been taken by improvement of the psychiatric program in Korea at division and army levels which prevented evacuation of cases to Japan. The next phase was to limit the transfer of patients to the 361st Hospital from other areas in Japan, particularly the 118th Station Hospital in southern Japan which received most of the psychiatric evacuees from Korea. Finally, it was planned to establish psychiatric consultation and treatment at various locations in Japan to circumvent transfers to the 361st Station Hospital of any patient who showed no evidence of organic disease or psychosis. Thus, the total effort involved the decentralization of psychiatric facilities so that mental patients could be dealt with early and near the origin of situational difficulties. By this plan psychiatric evacuees from Korea would be evaluated and treated at whatever psychiatric center was first reached in Japan. Similarly psychiatric problems that arose from patients in Japanese hospitals or originated from nearby military units could also be treated locally, preferably on an outpatient basis. In effect the psychiatric program in Japan duplicated that of Korea where psychiatry at division and army levels represented a decentralized approach to evaluation and treatment near the origin of situational conflict. The 361st Station Hospital continued as a neuropsychiatric center but was utilized mainly for psychoses, severe neuroses, neurological disorders, or other problem cases who required full time inpatient services for care or diagnosis. [Footnote 6, pp. 35-39]

Additional Neuropsychiatric Personnel

Additional psychiatry, neurology, psychology, and social work personnel needed to implement such a decentralized program began to arrive in early October 1950, when a neuropsychiatric team was assigned to the Far East Command. Several of its members have been previously mentioned as replacements for various positions in Korea. The team included the following:

• Cpt. Stephen May – completed three years Army psychiatry residency

• Cpt. William Hausman – completed two years civilian psychiatry residency under Army auspices

• Cpt. Wilmer Betts – completed one and a half years civilian psychiatry residency under Army auspices

• Cpt. William Allerton – completed two years civilian psychiatry residency under Army auspices

• Cpt. Philip Dodge – completed two years civilian neurology residency under Army auspices

• Cpt. Ralph Morgan – Army psychiatric social worker, adequate training and experience under Army auspices

The new arrivals were temporarily assigned to the 361st Station Hospital in Tokyo for a seven- to ten-day period of orientation to the neuropsychiatric problems of the Far East Command (FEC) which gave the author an opportunity to evaluate the aptitude and competence of the recent arrivals. Patients were seen together in individual case conferences and also lectures were given. This pre-assignment orientation became a standard procedure for all incoming neuropsychiatric officer personnel to the FEC. It made possible a more appropriate assignment from the standpoint of individual preference and needs of the theatre. Such a policy made for uniformity in methods of treatment and criteria for disposition which facilitated transition from civil to military psychiatry. Because most of the new neuropsychiatric personnel were relatively young in age and experience, eager to learn, and willing to consider other viewpoints and methods of therapy, this made the task of indoctrination far easier than perhaps if older and more experienced neuropsychiatric personnel with fixed opinions and methodology had been involved. [Footnote 6, pp. 39-40]

Further Decentralization in Japan

As part of the decentralization of psychiatric facilities in Japan, a treatment section at the 118th Station Hospital in southern Japan was established in early November 1950. Previously this hospital served as the receiving facility for most casualties evacuated from Korea and also as a triage center for psychiatric evacuees. An arrangement was made with the Commanding Officer of this hospital to permit the psychiatric section to have a minimum of 30 beds for short term treatment. Major Bailey, the assigned psychiatrist, was returned to the ZI to complete psychiatric training in November 1950. He was replaced by Captain (later Major) William Allerton. The decreased psychiatric casualties in October and November 1950 enabled the psychiatric section to begin functioning with the understanding that Allerton would transfer all severe cases to the 361st Station Hospital and hold mild cases for treatment.

Further progress toward decentralization in Japan included the increase of psychiatric facilities in the Osaka area. LTC Philip Smith, previously medically evacuated to Japan from Korea replaced Cpt. John Black, psychiatrist of Osaka Army Hospital in early November 1950, who was returned to the ZI for completion of residency training. An additional psychiatrist, a neurologist, and a clinical psychologist were to be assigned with LTC Smith when available, with the ultimate goal of establishing a psychiatric service of 80 beds with closed and open wards, instead of the extant psychiatric section. An ECT machine already on order along with an existing EEG apparatus would enable the expanded neuropsychiatric service to render a similar level of treatment as at the 361st Hospital. The transfer of patients from the Osaka area to the 361st Hospital in Tokyo would be unnecessary, especially since evacuation to the ZI could be accomplished directly from Osaka. The lack of psychiatric facilities in the Yokohama area was remedied in early November 1950 by arrival of the 141st General Hospital and the utilization of its neuropsychiatric service as an outpatient consultation and treatment center. Adequate space and facilities were found in the outpatient building of the 155th Station Hospital in Yokohama. The professional staff of the Neuropsychiatry Service included the following:

• LTC Herman Wilkinson – Chief of NP Service, board certified in psychiatry, Regular Army

• Cpt. Kenneth Kooi – two years civilian training in electroencephalography

• Cpt. Philip Duffy – one years civilian neurology residency under Army auspices

• 1Lt Roger Pratt – experienced, adequately trained, Army psychiatric social worker

Subsequent operations of the Neuropsychiatry Service demonstrated that both consultation and treatment was provided for a large number of patients from local units and dependent families. Here, decentralization prevented a flow of both inpatients and consultations to the 361st Hospital in Tokyo. Prior services by the 361st Station Hospital was unsatisfactory because distance between Yokohama and Tokyo was sufficiently far as to make communication difficult with an inevitable delay in forwarding reports. The Yokohama center was able to render more meaningful advice and reports because unit commanders and other pertinent persons could be directly contacted either to elicit further information or give suggestions for assignment or disposition. Outpatient treatment was readily available for military persons or dependents with minimum time lost for work.

A visit to the 395th Station Hospital at Nagoya, Japan in mid-November 1950 by the author found that the hospital served as a medical facility for both nearby Air Force units and casualties evacuated from Korea. A trained psychiatrist was not present. It was decided to assign a trained psychiatrist to the hospital when available in order for the decentralized program to function, particularly with respect to frequently referred flying personnel. Cpt. Robert Yoder, MC (three years civilian psychiatry residency) was assigned to the 395th Station Hospital in December 1950. [Footnote 6, pp. 40-43]

Non-Convulsive Shock Therapy

Dr. Howard Fabing, M.D., Civilian Consultant to the U.S. Army Surgeon General in Neuropsychiatry, arrived in the FEC in early November 1950 for a 30-day tour. He was interested in determining if non-convulsive (also termed sub-convulsive) shock therapy was beneficial in the treatment of combat neuroses. He brought with him a new Reiter apparatus to instruct various Neuropsychiatry Service staff members of the 361st Station Hospital in the technique of non-convulsive treatment. Dr. Fabing’s preliminary results were encouraging. After completing his tour of psychiatric facilities in Japan and Korea, he obtained permission for an additional two-week stay at the 361st Hospital in order to personally supervise the treatment of acute combat neuroses by sub-convulsive shock therapy. The group selected for treatment consisted of twenty recently evacuated combat psychiatric casualties from Korea. They were given daily non-convulsive therapy for seven to ten days.

The results can be summarized as follows: approximately 50 percent of treated cases showed varying degrees of improvement. Neuropsychiatry staff members of the 361st Hospital were of the opinion that this type of therapy was only of limited value because similar or better results could be obtained with less inconvenience to both patients and hospital personnel. It should be noted, however, that cases available for selection by Dr. Fabing at this time were relatively fixed character disorders upon which battle stress had found fertile soil.

Such individuals were made even more refractory to treatment by the gain in illness incident to evacuation and hospitalization in Japan. Perhaps it was expecting too much for any rapid somatic therapy to alter basic personality particularly in an adverse therapeutic environment. More suitable cases were not available because of the lessened incidence of acute psychiatric casualties during October and November 1950 and that effective forward psychiatric treatment had been established in Korea beginning in latter August 1950. Psychiatric casualties who possessed relatively good motivation and a stable personality were returned to duty from treatment in Korea at division or army level. Persons with more disturbed personality substrate were evacuated to Japan. Because of current effective forward psychiatric treatment, it is doubtful whether non-convulsive shock therapy would be of benefit in the early phase of combat psychiatric breakdown. Moreover, time required for such treatment, namely seven to ten days, militates against its success since two or four days was the optimum period for best results of treatment at the division level. Even the more severe cases returned to Japan were later found to demonstrate more consistent improvement in a convalescent setting than the formal treatment of any type given in a comfortable fixed hospital atmosphere. Since time and place or setting has been demonstrated to be of major importance in the treatment of acute combat psychiatric casualties, perhaps Dr. Fabing should have determined the results of non-convulsive shock therapy in Korea at the Army level. [Footnote 6, pp. 44-45]

Japanese B Encephalitis

In early November 1950, a study of residual cerebral dysfunction from Japanese B encephalitis was initiated at the 361st Station Hospital. This was occasioned by an epidemic of some 300 cases from combat troops in Korea that occurred in the late summer and early fall of 1950. Clinically the victims ran the gamut from mild to severe with death in 100 of these cases. The more severely ill had an acute onset with headache, stiff neck, and fever, followed rapidly by an altered sensorium, confusion, delirium, and coma. The febrile phase was present for seven to ten days during which time constant nursing care, attention to nutrition, and adequate air passageways were crucial in sustaining life. In favorable cases the temperature returned to normal by lysis leaving the patient in a more or less vegetative mental state from which there was gradual but striking improvement in most cases.

Two hundred patients who had recently recovered from the febrile stage were gathered and studied at the 361st Station Hospital. Thirty of the group with the most severe loss of mentation were evacuated to the ZI. The remainder were thoroughly studied for residual train damage by neurological examination, serial EEG’s psychological test batteries, and psychiatric evaluation including a complete background history. The fast majority of the examined group were returned to limited duty status in the Tokyo area. The subjects were re-evaluated at three-month intervals over a period of six months. The common symptoms were headache, irritability, and tension feelings similar to the posttraumatic concussion syndrome. Very little organic residuals were demonstrated. After discharge to limited duty the persistence of symptoms largely depended upon adjustment to their assignments.

The clinical severity of the disease bore no relationship to the symptoms of headache or tension. Pre-illness personality and motivation for duty were apparently pertinent in determining the persistence of complaints. Outpatient psychotherapy and support was of value in facilitating adjustment to the resumption of duty. As with other organic disease, secondary gain in illness was strongly evident in complicating the rehabilitation of these patients. Pertinent in this respect was the semantic disadvantage inherent in the word “encephalitis.” A complete report of this project was prepared by LTC Oswald Weaver of the 361st Station Hospital. [Footnote 6, pp. 44-46]

References - Chapter 7

1. Schnable, J. United States Army in the Korean War: Policy and Direction: The First Year. Washington, DC: Office of the Chief of Military History, United States Army; 1972.

2. Glass, A.J. Psychiatry at the division level. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC. [Compilation of data obtained from Medical Corps, Medical Service Corps and line officer participants who were present in Korea during the period 25 June 1950 to 30 September 1951.]

3. Reister, F.A. Battle Casualties and Medical Statistics: US Army Experience in the Korean War [Appendix B]. Washington, DC: The Surgeon General, Department of the Army; 1973.

4. Appleman, R.E. United States Army in the Korean War: South to the Naktong, North to the Yalu (June-November 1950). Washington, DC: Office of the Chief of Military History, Department of the Army; 1961.

5. Glass, A.J. Psychiatry at the Army level. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

6. Glass, A.J. Base section psychiatry. In: Notes of the Theater Consultant, Section VI. Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

Chapter 8

The Chinese Communist Offensive
(26 November 1950 - 15 January 1951)

By Albert J. Glass, MD, FAPA

Chinese Communist Intervention

On 25 November 1950, Eighth Army began an all-out offensive in the western sector of the North Korean front to coordinate with the attack of X Corps on the east to reach the Yalu River (boundary between North Korea and Manchuria) and quickly end the Korean War. The Eighth Army attack proceeded unopposed for almost two days. On the night of 26-27 November, several fresh Chinese Communist armies counterattacked with a major thrust at the right flank, then held by ROK II Corps. The ROK troops collapsed exposing the 2nd Infantry Division, the Turkish Brigade and the 27th British Brigade to enemy onslaughts in the flank and rear. The position of other Eighth Army units was also untenable and they disengaged in an orderly withdrawal to the Pyongyang area to avoid entrapment. The 2nd Infantry Division and the Turkish Brigade were forced to fight their way out of entrapment during which enemy roadblocks and flank attacks caused heavy casualties. The Chinese broadened their offensive on 27 November 1950 with attacks against X Corps. On 28 November Chinese units slipped southeastward past the Marines and cut their supply route.

This wide display of Chinese strength swept away General MacArthur’s doubts. Instead of fighting fragments of the North Korean Army reinforced by token Chinese forces, Eighth Army and X corps now faced Chinese armies of about 300,000. MacArthur stated, “We face an entirely new war…which broadens the potentialities…beyond the sphere of decision by the Theater Commander.” MacArthur announced that for the time being he intended to pass from the offensive to the defensive making adjustments as the ground situation required. [Footnote 1, pp. 274-293; Footnote 2, p. 48]

Psychiatry at the Division Level

As initially in the Korean conflict, divisional medical support was limited to emergency care and evacuation because holding any type patient for treatment was impossible or hazardous. Even meager medical support was difficult to accomplish in the 2nd Infantry Division, which lost five medical officers (MIA) in the desperate retreat. Despite appreciable battle casualties (KIA and WIA) psychiatric admissions were not high in November (74.5/1,000/year) and December 1950 (59.8/1,000/year although definitely higher than October 1950 (34.51/1,000/year) when American forces were proceeding almost unopposed in pursuit and mopping up operations north of the 38th Parallel. As stated previously, this relatively low incidence of psychiatric casualties to battle casualties during rapid withdrawal was characteristic in World War II and the Korean War indicating lessened contact with the enemy, moving away from danger, and inability of division medical services during such times to detect or diagnose psychiatric problems. [Footnote 2, pp. 48-49)

Psychiatric admissions during this period were evacuated to medical facilities at the Army level since divisional psychiatric centers were dislocated and on the move. Intra-divisional psychiatric treatment did not become operative until December 1950 when the evacuation of Pyongyang was completed and stabilized defensive positions were established along the 38th Parallel. For several weeks enemy contact was slight and serious fighting not resumed until December 1950.

The battered 2nd Infantry Division was placed in Eighth Army reserve for rest, retraining, and absorption of replacements. The division personnel had been through a harrowing experience and were disheartened. Captain Schumacher, the division psychiatrist, was also adversely affected by his recent combat experience. However, his psychiatric unit with the 2nd Medical Battalion had suffered no battle casualties as, along with the 38th Infantry Regiment of the 2nd Infantry Division, they were enabled to withdraw along an alternate route, thereby avoiding enemy roadblocks and flank attacks that traumatized the other divisional units. Yet the experience contained elements of sustained anticipatory anxiety and tension from nearby combat. During this period when the 2nd Infantry Division was placed in army reserve, Brigadier General S.L.A. Marshall, using his debriefing techniques of combat units as utilized in World War II, again demonstrated that only 15-25 percent of riflemen fired their individual weapons in combat. Crew-served weapons such as machine guns, mortars, or artillery, however, were fired without such inhibition. [Footnote 3]

In early January 1951, Captain (later Major) Hyam Bolocan (three years civilian psychiatry residency and board eligible) replaced Captain Schumacher, 2nd Infantry Division Psychiatrist, who was returned to the ZI to complete professional training.

Similar massive Chinese Communist assaults in northeast Korea forced the withdrawal of X Corps. This was readily accomplished except in the mountainous Chosin Reservoir area where the 1st Marine Division and 7th Infantry Division elements were forced to fight their way out of encirclement. The story of their almost ten-day battle to reach safety, including air evacuating thousands of wounded and injured (also frostbite) from rapidly constructed improvised airfields, severe physical deprivations, intense cold, and the overwhelming numerical superiority of an enemy who attacked from all sides, was an epic in American military history. Despite the large number of wounds, injuries, and frostbite casualties, relatively few psychiatric casualties were diagnosed during this time. Here again was a situation with little or no gain in illness. Air evacuation was uncertain and mainly utilized for the obviously physically disabled; all others had to fight their way out.

Case 8-1. Intermittent Hysterical Paralysis

An illustration of the impact of reality upon mental mechanisms in such an environment was exemplified by a patient with hysterical paralysis of both lower extremities. His paralysis occurred during combat in early December 1950. During the fighting retreat he was transported in a 2 1/2–ton truck with other disabled patients as a litter case. When the convoy encountered enemy fire, the patient promptly recovered sufficient function to leave the defenseless vehicle and take cover. He repeated this temporary recovery several times until the convoy reached safety in the large airfield at Hungnam when the paralysis promptly recurred. By this time the patient’s repeated temporary recovery was apparent to others. Initially the patient had complete amnesia for these events, but they were vividly recalled as he relived battle experiences during a pentothal interview. In this session he portrayed dramatically how impossible it was for him to remain paralyzed in the vehicle and how he moved rapidly and instinctively to seek safety. [Footnote 2, pp. 49-51]

On 9 December 1950, relief troops mainly composed of 3rd Infantry Division and Marine elements reached the retreating column. By 11 December all United Nations troops had withdrawn to the coastal plain at Hungnam with the perimeter defenses of X Corps. Then followed a gradual evacuation by sea as the defensive perimeter, mainly manned by the 3rd Infantry Division strongly supported by the guns and planes of naval vessels standing off shore, was progressively narrowed. Total evacuation was completed on 24 December. X Corps troops were brought into southern Korea to become an integral component of Eighth Army. For the first time since September 1950 all United Nations troops in Korea had a single field commander, Lt. Gen. Matthew B. Ridgeway, who took command of Eighth Army on 27 December following the accidental death of Lt. Gen. Walton Walker.

The end of December saw a renewal of the communist offensive against the insecure defense lines of Eighth Army along the 38th Parallel. United Nations troops resumed an orderly withdrawal and by 4 January 1951 the enemy recaptured Seoul. By 7 January Eighth Army had withdrawn to a line along the general level of P’yongt’aek in the west, Wonju in the center, and Samshok on the east coast. Here stubborn resistance was offered to further enemy advances. At Wonju in early January, the 2nd Infantry Division with attached French and Dutch Battalions made a historic stand against severe enemy onslaughts. This successful defense marked the end of retreat for Eighth Army who consolidated a defense line across the waist of South Korea.

The period of December 1950 and early January 1951 found morale of United Nations troops at a low ebb. The expectations of an early victory in late November had turned to bitter defeat in December. There seemed to be no way of stopping the mass infantry tactics of the Chinese Communists who seemingly came on like hordes of locusts climbing over their own dead to move forward. The discouraging loss of hard-won territory, the bitter cold and uncomfortable field existence, and continued withdrawals produced a defeatist attitude with many rumors that Korea was to be evacuated. Indeed, for a time the decision as to continuance of the Korean War was uncertain. [Footnote 2, pp. 51-52]

The lowered morale of American troops was not reflected in psychiatric admissions, but rather in the rise of disease and non-combat injury, including self-inflicted wounds. It was true that inclement weather did cause increased respiratory and other infectious diseases including pneumonia, and no doubt the numbing cold and icy roads were responsible for such frostbite and accidental injury. Yet to the observer at this time, it was plainly evident that many psychiatric casualties were concealed among the numerous evacuees for subjective complaints and non-disabling conditions. In particular were cases of so-called frostbite who had no objective findings of cold injury, even after several days of observation. This ‘syndrome of the cold feet’ was compounded out of the usual numbing sensations of feet in intense cold weather, a conscious or unconscious wish for gain in illness and poor motivation. One can only speculate as to the greater vulnerability of psychiatric casualties to frostbite. It may well be that increased sympathetic stimulation, in such fear ridden persons, causes excessive vasoconstriction of the extremities and might account for lessened psychiatric cases noted at this time when frostbite casualties were so high. [Footnote 4] (FDJ: The complex interaction of physiological and psychological forces in frostbite is addressed elsewhere. – Footnote 5)

Self-Inflicted Wounds, Accidental Injury, and AWOL From Battle

The increase of self-inflicted wounds among American combat troops in North Korea during this winter period represented another source of manpower loss for psychological reasons. Almost invariably, it was explained by the involved person as a combination of numbed fingers and carelessness. Environmental conditions made it seem reasonable to expect many such unavoidable errors. Yet the relative innocuous nature of most current self-inflicted wounds and their occurrence in safe rear positions where there was no cause for haste, pointed to the purposeful nature of the accident. The increase of other accidental injuries tended to the belief that a dispirited, unhappy individual may become apathetic to an injury which could remove him from a traumatic environment. In this vein when rotation had been established in May 1951, serial signposts noted on a highway in North Korea were appropriate as follows: “Never fear….Rotation is here….Accidents unnecessary….Drive carefully.”

In further considering manpower loss from psychological causes it should be recognized that there were relatively few United Nations troops who were “AWOL” (absent without leave) from battle. This was in sharp contrast to numerous instances of such overt reactions to fear that occurred in the European and Mediterranean Theaters of Operations in World War II. In Korea, there was simply no safe place to which such an inclined person could go. It was dangerous to leave one’s unit and wander in rear areas from the standpoint of both guerrilla activity and the weather. The only escape from the hazards and discomforts was evacuation through medical channels. For this reason, in December 1950 and January 1951 a more accurate indication of manpower loss for psychological causes can be found in the increased incidence of disease and injury rather than the relatively low psychiatric rate that reflected lessened enemy contact during the period (See Table 9). [Footnote 2, pp. 53-54]

Psychiatry at the Army Level

Psychiatric facilities at the Army level were prepared at this time to support divisional psychiatric programs. The previously mentioned plan of establishing a psychiatric center at the 64th Field Hospital near the airfield in Pyongyang was implemented on 27 November 1950. Sufficient accommodations for 100 patients were made available in a building adjacent to the main hospital. Cpt. Richard Cole, detached from the 171st Evacuation Hospital and the author constituted the psychiatric team along with several corpsmen from the 64th Field Hospital. The psychiatric center at the 4th Field Hospital remained in operation headed by Captains Kolansky and Gibbs. The 8054th Evacuation Hospital in Pusan, the most rear hospitalization point in Eighth Army, had a small psychiatric unit headed by Captain (later Major) Stephen May who had replaced Captain Hausman in early December 1950. X Corps sector in northeast Korea was served by the psychiatric section of the 121st Evacuation Hospital at Hamhung headed by Cpt. Thomas Glasscock and supported by the psychiatric service of the Naval Hospital Ship Consolation under Lieutenant Commander (LCDR) Wade Boswell.

Neuropsychiatric personnel at the Army level were deliberately dispersed rather than concentrated in any area or unit by assigning one or two psychiatrists to various hospitals strategically located to receive the majority of psychiatric patients. This arrangement served a dual purpose; first, it provided alternative treatment services when divisional medical facilities were forced to dislocate due to battle reverses, thereby insuring continued psychiatric services at the Army level particularly needed in any large withdrawal action when intra-divisional psychiatric care was not feasible. Second, such dispersion made it possible for psychiatric facilities to adapt to air evacuation. At this time in Korea the majority of battle and other casualties from forward areas were evacuated by air. This rendered difficult if not impossible the triage of psychiatric cases to any one area or hospital. Whether patients were brought to this or that hospital depended upon weather, the condition of landing strips, the number of vacant beds, and even the needs of the flight crew. For this reason it was necessary that psychiatric services be situated wherever large numbers of all types of patients were brought for treatment.

As a result of the Communist offensive of late November 1950, thousands of sick and wounded poured into Pyongyang by plane, train, ambulance, and truck. All available medical facilities were soon overtaxed, forcing prompt re-evacuation to medical units in the Ascom City-Seoul area and Pusan.

All psychiatric cases were brought to the 64th Field Hospital as planned. Admissions did not exceed 20 per day, relatively few compared to the large number of wounded even though there was little prior screening by division psychiatrists who were on the move rearward with their divisions. Most psychiatric casualties were of the mild to moderate type, readily treated by physical restorative measures and brief psychotherapy. Patients who could not be returned to combat duty were evacuated to the 4th Field Hospital at Ascom City for prompt disposition to non-combat duty. The adverse tactical situation at Pyongyang made limited duty to this area impractical except for some patients placed on duty temporarily with the medical detachment of the 64th Field Hospital that was under-strength and needed all possible help. After five days of operation it became evident that Pyongyang was untenable and withdrawal of our forces from the city inevitable. When the 64th Field Hospital prepared to close, Captain Cole and the author moved to the 4th Field Hospital where they joined Captains Kolansky and Gibbs to become the major psychiatric service of Eighth Army. The 4th Field Hospital also became the principal hospitalization center in Korea as most other medical units were dislocated. The Commanding Officer, Col. L.B. Hanson, demonstrated characteristic energy and resourcefulness as he rapidly improvised added facilities to receive the large influx of casualties. In early December the 4th Field Hospital had about 2,000 beds in operation besides providing temporary quarters and meals for personnel of the 64th Field Hospital, 171st Evacuation Hospital, 10th Station Hospital, and nurses from three Mobile Army Surgical Hospitals (MASH). Many personnel of these hospitals participated in treatment of the large inpatient population. Colonel Hanson produced large stocks of food and reserve supplies; and, with his hospital warmed by steam heat and serving ice cream daily, it was a veritable oasis in the cold, dreary, and discouraging period that was the Korean War in December 1950.

The psychiatric service of the 4th Field Hospital had sufficient facilities and personnel to adequately deal with 20 to 40 daily psychiatric admissions. The effectiveness of treatment steadily improved. An account of this experience was reported. [Footnote 6] The rapid effective methods of the psychiatrists influenced their medical and surgical colleagues to adopt a similar management of mild illness and those persons with only subjective complaints. This emphasis upon prompt evaluation and treatment for return to duty rather than medical evacuation was also fostered by Colonel Hanson. As a result, 150 to 200 patients were daily returned to duty from the 4th Field Hospital during this time. [Footnote 7, pp. 55-58]

Base Section Psychiatry

The large influx of casualties caused by the Chinese counteroffensive again overflowed medical facilities in Japan. As before, most evacuees were flown to southern Japan where the 118th Station Hospital at Fukuoka functioned as an evacuation hospital, retaining non-transportable cases for treatment and transferring the remainder by plane and train to hospitals in the Tokyo and Osaka areas. For a brief period in late November and early December 1950, the 118th Station Hospital received over 1,000 patients daily. The Commanding Officer, Col. Lyman Duryea, enlarged the hospital to 1,600 beds and perfected a smoothly functioning medical and administrative team which received, fed, and triaged thousands of patients during this hectic period.

In early December 1950, the 141st General Hospital that was recently established in the Yokohama area was ordered to Camp Hakata (18 miles from Fukuoka) to increase medical facilities in southern Japan and lessen the burden of the 118th Station Hospital. The neuropsychiatric patients were made available in an area separated from the main hospital which had sufficient space for an outdoor recreational program. Arrangements were made for Cpt. William Allerton, psychiatrist of the 118th Station Hospital, to continue receiving all psychiatric evacuees from Korea who arrived in southern Japan. He was to maintain a census of 20 to 30 less-severe cases for treatment and return to duty, transferring the remainder to the 141st General Hospital; however, more severe except for psychiatric, neurological, and other problem patients would be sent to the 361st Hospital in Tokyo. The plan became operational in latter December 1950. By early January 1951 the psychiatric service of the 141st Hospital had over 100 patients. It became apparent that ECT apparatus, an EEG machine, and substantial closed ward facilities were needed for more complete coverage of psychiatry and neurology in this region. Steps were initiated to achieve this objective.

The 361st Station Hospital in Tokyo received most of the psychiatric casualties that arrived in Japan during late November and early December 1950. Many of these cases were prematurely evacuated to the ZI on the erroneous assumption that the large incoming patient load would continue and there would be insufficient beds at the 361st Station Hospital to receive them.

At this time a number of professional mental health personnel, recently arrived to the Far East Command, were receiving orientation at the 361st Station Hospital in Tokyo. They included six young naval medical officers with civilian residency training in psychiatry or neurology who were on loan to the Army for six to nine months. A list of the new arrivals in late November, December 1950 and early January 1951 follows:

• Maj. Henry Segal – completed three years Army psychiatry residency

• Cpt. Richard Turrell – one and a half years civilian neurology residency under Army auspices

• 1Lt. (later Captain) Richard Conde – one year civilian psychiatry residency

• Cpt. (later Major) Robert Yoder – three years civilian psychiatry residency

• 1Lt. (later Captain) Herbert Levy – one year civilian psychiatry residency

• 1Lt. Stonewall Stickney – one year civilian psychiatry residency

• 1Lt. (later Captain) James Corbett – two and a half years civilian psychiatry residency

• 1Lt. Francis Hoffman – one and a half years civilian psychiatry residency

• LTjg. Shane Mariner – one year civilian psychiatry residency

• LTjg. Richard Blacher – one and a half years civilian psychiatry residency

• LTjg. Haskell Shell – one and a half years civilian psychiatry residency

• LTjg. Simon Harris – one and a half years civilian psychiatry residency

• LTjg. James Allen – a half year civilian neurology residency

• LTjg. Norman Austin – one year civilian neurology residency

• 1Lt. (later Captain) Frank Hammer – MSC PhD. Experimental Psychology

Captain Turrell had a primary medical specialty (MOS) of Internal Medicine due to two years of residency in that specialty; however, he was mainly interested in Neurology and was assigned to this specialty at his request. Captain Turrell was sent to the 361st Station Hospital where he replaced Maj. Roy Clausen who was returned to the ZI for completion of neurology residency. Captain Turrell displayed superior professional competence in Neurology.

1Lieutenant Hammer was assigned to the 361st Station Hospital for on-the-job training (OJT) in clinical psychology under 1LT James Hoch and made rapid progress. The period of instruction given at the 361st Station Hospital for mental health specialists newly assigned to the Far East Command included the following orientation.

Psychiatric casualties or cases of “combat exhaustion” were not fixed neuroses but amorphous, transient, emotional breakdowns due to situational battle stress with lowering of resistance for fear stimuli, either because of continued intense combat or inability of involved individuals to obtain emotional support from their combat units (group cohesiveness) or combinations of both conditions. The newly-arrived specialists also received orientation in administrative procedures involved in military settings, medical-legal issues relative to courts-martial, manifestations and prevalence of gain in illness, brief directive methods of psychotherapy, and the use of hypnosis and barbiturate interviews as uncovering therapeutic techniques. In treatment, emphasis was placed on factors of time and distance from the traumatic episode, the environmental circumstances under which therapy was given, and the attitude of the therapist and the treatment team toward return to duty.

The availability of new psychiatrists, neurologists, and other professional mental health personnel made possible the implementation of decentralizing neuropsychiatric programs. By such a system psychiatric patients would receive evaluation and care near the source of situational disorders and prevent the evacuation of such cases to the 361st Hospital which would then continue to be utilized for more severely ill and diagnostic problems. To accomplish this objective the following assignments and change were made in December 1950 and January 1951.

LTjg. James Allen and LTjg. Simon Harris were assigned to Osaka Army Hospital as part of a team headed by LTC Philip Smith (board eligible psychiatrist), to operate a neuropsychiatric service for the Osaka area. A Reiter ECT apparatus was given to this center to provide more comprehensive services and negate the need for transfer of patients to the 361st Hospital in Tokyo. LTjg. Haskell Shell was assigned to the 141st General Hospital at Camp Hakata in southern Japan to bolster the neuropsychiatric service as only Lieutenant Col. H. Wilkinson (board certified psychiatrist) Chief of the Neuropsychiatry Service was trained in psychiatry. A new Reiter ECT apparatus was also sent to this unit.

Cpt. Robert Yoder moved to the 395th Station Hospital in Nagoya to insure the availability of psychiatric consultation in the special problems of flight personnel. For similar reasons 1LT. Stonewall Stickney was sent to the 376th Station Hospital at Tachikawa that served the Air Force in the Tokyo area.

Maj. Henry Segal was assigned as psychiatric consultant to Tokyo Army Hospital, where he was in position to render prompt psychiatric consultation and treatment to large numbers of medical and surgical inpatients. The assignment of psychiatrists and neurologists as set forth was soon reflected by lower admission rates to the 361st Station Hospital, which were further decremented by the utilization of convalescent hospitals.

Use of Convalescent Hospitals

Two convalescent hospitals were established in Japan during this period. These facilities at Omiya (25 miles from Tokyo), the other at Nara (25 miles from Osaka), began receiving patients 9 December 1950. The convalescent hospitals were designed to relieve congestion in major hospital centers by receiving organic illness, wounds, or injuries that required several weeks of convalescent care prior to return to duty. Thus, the use of convalescent hospitals made available hundreds of hospital beds in fixed hospitals that were vitally needed at this time to provide for the influx of new casualties who mainly required active surgical or medical treatment. From the psychiatric standpoint, the opening of convalescent hospitals was an event of the first magnitude. It made available a realistic environment for psychiatric treatment which offset the vexing gain in illness unwittingly fostered by the atmosphere of the usual fixed hospital. In contrast, the convalescent hospital put all patients in fatigue uniforms and had a full daily program of calisthenics, marches, training, and athletic activities. Psychiatric patients under this regimen found little benefit in clinging to symptoms and were not adversely affected by suggestive evidence that evacuation to the ZI was possible. Indeed, everyone was going to duty. Psychiatric patients were deliberately dispersed among individuals recovering from organic disease or injury who gave little support to somatic symptoms or complaints of nervousness. The single assigned psychiatrist found less resistance to treatment as psychiatric patients turned to the therapist for assistance. An account of psychiatric treatment in the convalescent hospital setting can be found in the Symposium of Military Medicine – Supplemental Issue of the Surgeon’s Circular Far East Command, September, 1951. 1LT. Francis Hoffman was assigned to the Nara Convalescent Hospital in early January 1951. LTjg. Shane Mariner was sent to the Omiya Convalescent Hospital in latter December 1950 but was replaced by LTjg. Richard Blacher in mid-January 1951. LTjg. Mariner moved back to the 155th Station Hospital and reopened the psychiatric outpatient and Consultation Service which had been dormant since the 141st General Hospital was transferred to southern Japan.

The end of this period found neuropsychiatric facilities in Japan staffed and distributed to implement a decentralized program aimed at the outpatient and convalescent treatment for largely non-psychotic patients and the inpatient care of psychotic and neurological patients in three neuropsychiatric centers strategically located in major hospitalization areas. [Footnote 8, pp. 59-65]

References - Chapter 8

1. Schnabel, J. United States Army in the Korean War: Policy and Direction: The First Year.  Washington, DC: Office of the Chief of Military History, United States Army; 1972.

2. Glass, A.J. Psychiatry at the division level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.  [Compilation of data obtained from Medical Corps, Medical Service Corps and line officer participants who were present in Korea during the period 25 June 1950 to 30 September 1951.]

3. Marshall, S.L.A.  Men Against Fire.  New York: William Morrow & Co.; 1947.

4. Ransom, S.W.  The normal battle reaction.  Combat psychiatry.  Bulletin US Army Medical Department, Supplemental Issue.  November 1949:3-11.

5. Sampson, J.B.  Anxiety as a factor in the incidence of combat cold injury: A review.  Military Medicine.  1984:149 (2)89-91.

6. Kolansky, A.H., Cole, R.K. Field hospital neuropsychiatric service.  US Armed Forces Medical Journal.  1951; 2:1539-1545.

7. Glass, A.J.  Psychiatry at the Army level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

8. Glass, A.J.  Base section psychiatry.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

Chapter 9

The United Nations Winter Offensive
(15 January - 22 April 1951)

by Albert J. Glass, MD, FAPA

Cease-Fire Negotiations

By late January 1951, local successes of United Nations' forces and a renewed offensive spirit within General Ridgeway's command had altered the combat scene and improved the outlook.  No longer was there a real threat of further evacuation.

Psychiatry at the Division Level

As indicated, by 15 January 1951 momentum of the Communist attack had reduced considerably and United Nations forces turned to aggressive patrolling. On 21 January began the United Nations tactics (Operation Killer) of employing armored counterattacks supported by infantry air, and artillery, designed to inflict a maximum of enemy casualties with minimum self losses. By the end of January our limited offensive reached north of Suwon and Inchon. In February 1951 the United Nations offensive continued scoring gains against stubborn resistance and by 14 February United Nations troops had seized Inchon, Kimpo Air Field, and secured a line along the south bank of the Han River. Then followed vicious enemy delaying actions. The Communist used road mines and dug-in positions, destroyed bridges, and demonstrated their ability to hold hill masses by repeated counterattacks. By mid-March 1951 resistance diminished. The enemy withdrew, fighting only rear guard actions as United Nations troops recaptured Seoul and pushed north toward the 38th Parallel. It was known that the Communists were building up a powerful reserve striking force. Yet they offered only sporadic resistance and by 8 April 1951 all enemy east of the Imjin River withdrew from South Korea. Bitter opposition occurred thereafter, particularly against United Nations offensive moves in the central and eastern sectors.

The winter offensive caused increased battle casualties and a consequent rise of the psychiatric casualty rate which remained at higher levels through February, March, and April 1951 paralleling aggressive United Nations tactics. However, the psychiatric incidence never reached levels that could be expected from uphill combat in such a bleak, desolate environment with living and fighting in sub-zero weather. There were many reasons for relatively low neuropsychiatric rates during this period. The battle line was more secure as United Nations combat units were placed tightly across the waist of the Korean Peninsula with none of the rear infiltration and confusion that plagued United Nations forces in previous periods of the Korean War. Enemy positions and territory were methodically and carefully taken with an obvious regard for sparing the lives of infantrymen. Operation Killer was well named and publicized as a procedure calculated to destroy the enemy with less emphasis upon capturing ground.

The resurgence of morale under this leadership and by this method of fighting was a remarkable phenomenon as defeatism was turned to grim determination and finally aggressive confidence when it became apparent that concentrated firepower and carefully planned assaults could overcome the previously feared human wave tactics of the Chinese Communist Armies. An added factor that maintained psychiatric admissions at reasonable levels was improved medical discipline. The now experienced divisional medical officers had learned to realistically appraise subjective complaints and firmly close the door of medical evacuation except for those disabled from mental or physical causes. Last but not least was the promise of rotation in March 1951. This most pertinent morale stimulus gave hope that relief was possible. Indeed, the first rotates left Korea on 18 April 1951.

During this period psychiatrists consolidated and organized functioning within divisions. Aid stations were visited regularly and battalion surgeons indoctrinated in techniques of psychiatric evaluation and treatment. Division psychiatrists were consulted by medical and line officers on morale, mental health, and personnel problems as they gradually became emancipated from a restricted role of mainly treatment and evaluation of referred cases.

In early January 1951, Cpt. Hyam Bolocan (three years civilian psychiatry residency and board eligible) was assigned as the 2nd Infantry Division Psychiatrist replacing Cpt. M.J. Schumacher, who was returned to the ZI to complete professional training. In April 1951, Captain Bolocan received a well-deserved promotion to major. As soon as Major Bolocan became a staff officer, he began to visit all divisional units and was thus available for consultations and discussions with line and medical officers. [Footnote 2, pp. 67-69]

It was commonly observed that when the division psychiatrist visits forward areas, he becomes highly regarded by combat personnel. His presence demonstrates that he shares their interest and viewpoint. By such visits the psychiatrist gains firsthand knowledge of combat problems. His recommendations display understanding of battle situations. Basically, visits by division psychiatrists evoke mechanisms of identification that on the one hand includes sharing by psychiatrists, even briefly, in the trials and tribulations of combat troops while on the other hand there was participation of combat line and medical officers with efforts of psychiatrists at prevention and treatment. The division psychiatrist who remains in the rear becomes resented as one who fears to share hardships and danger, even for a short period, and therefore does not belong in their world of anxiety and deprivation. This viewpoint of combat personnel was valid though based on an emotional bias for the psychiatrist can best understand mental processes by having had similar actual experiences, thus being enabled to objectively evaluate the symptoms and feelings of referred patients. [Footnote 2, pp. 60-70]

As in World War II, semimonthly division psychiatric reports were important instruments by which combat commanders became acquainted with the principles of preventive psychiatry. The comparison of psychiatric rates with the incidence of battle casualties (KIA, WIA, MIA), diseases and non-battle injury including frostbite and self-inflicted wounds aroused interest as to reasons for difference among various large divisional components. The Commanding General, 24th Infantry Division, instructed Maj. W. Hausman (division psychiatrist) to visit the three regimental commanders to discuss conditions which could explain variations of psychiatric rates in the three regiments. Major Hausman was impressed by the regimental commander with the lowest neuropsychiatric rate who personally screened and observed the functioning of assigned offices. [Footnote 2, pp. 70-71]

Major Clarence Miller, 3rd Infantry Division Psychiatrist, was returned to the ZI in February 1951. He was replaced by Cpt. Clay Barritt, the assistant division psychiatrist (one year civilian psychiatry residency under Army auspices). Captain Barritt demonstrated an ability to motivate and work with line and medical officers which made him a popular figure in his division.

Major Wilmer Betts, 7th Infantry Division Psychiatrist, studied self-inflicted wounds (SIW’s). He found that about 50 percent of cases came from new divisional replacements. This survey, supported by the division surgeon, influenced the Division Commander to establish battle indoctrination for infantry replacements. The investigation by Major Betts made it logical to conclude that relative unfamiliarity with weapons plus numbing cold permits some persons to accede to more or less unconscious wishes for accidental injury and medical evacuation. The institution of a seven to ten-day training period in the 7th Infantry Division produced decreases of SIW's. It proved to have further beneficial effects of giving the newcomer more self-confidence as battle tactics were learned under experienced combat personnel. Under these training conditions insecure replacements were especially motivated to absorb imparted knowledge when frankly told that the instruction was akin to life insurance. In the process of battle indoctrination the new infantryman came to appreciate group identification when taught that one could best survive as a team member.

The training period also demonstrated that combat leaders were concerned with health and safety of personnel. All in all the preliminary instruction for the newcomer was a pertinent and valuable morale factor and represented a major improvement over placing new and tremulous recruits into battle with no alleviation of inevitable anxiety. The success of the training program as publicized in a Sunday Supplement of the Stars and Stripes, Far East Command edition, spurred other divisions to adopt similar training. [Footnote 2, pp. 71-72]

From both Captain Stimson, 1st Cavalry Division Psychiatrist, and Major Krause, 25th Infantry Division Psychiatrist came information that over half of their psychiatric casualties had eight to nine months of combat beginning with the early fighting in July and August 1950. These patients were designated the “Old Sergeant Syndrome” as their manifestations seemed identical with the syndrome described in World War II. One can argue whether there were sufficient combat days in number and severity endured in Korea as in World War II; yet, there was the same clinical picture of the previously excellent soldier often becoming promoted to a noncommissioned officer who gradually became ineffective in battle with or without accompanying guilt. However, with the beginning of rotation in April 1951 such cases were removed from Korea. [Footnote 2, pp. 72, 3]

In all combat divisions the division psychiatrist made the holding platoon of the clearing company the permanent base of operations. Psychiatric cases were sent to this platoon for evaluation or treatment. The holding platoon was located in a rear position relative to the other two clearing platoons which moved according to the needs of the tactical situation. Patients with mild organic diseases were also treated at the holding platoon to which two general medical officers were assigned. The presence of other medical officers in the treatment platoon obviated the need for a professionally trained assistant division psychiatrist. In actual practice it was not difficult to orient one or more of these young medical officers in utilizing the relatively simple physical and psychological measures employed at this level for psychiatric casualties. The division psychiatrist was seldom absent for more than a 24-hour period so that all evaluations and major decisions were made by the division psychiatrist. The “assistant division psychiatrist” was mainly concerned with initiating or continuing routine treatment.

Each division psychiatrist had several enlisted assistants with more or less psychiatric experience. Their services were invaluable in the management and observation of patients. They were also useful in obtaining history data and gathering information for routine reports. The chief enlisted assistant of Captain Barritt (3rd Infantry Division Psychiatrist) was a former bartender with no psychiatric experience, but who possessed a keen intuitive ability in understanding and managing mental disorders. Rarely were there available trained social workers or clinical psychologists who were utilized mainly by psychiatry at the Army level.

A frequent complaint of division psychiatrists involved difficulties in obtaining transportation for trips to visit divisional units. This was a chronic problem in combat areas where it seemed that every staff officer needed a personal vehicle. Actually, necessary visits by division psychiatrists were only delayed rather than blocked; and, although it required pleading, ingenuity, and cooperation, visits by division psychiatrists were accomplished. Naturally, it would have been more convenient and would have facilitated the work of the division psychiatrist to have a jeep similar to the transportation advantages of division chaplains. [Footnote 2, pp. 73-74]

New Informal Theater Policy

During March 1951, an informal Far East Command Theater policy was gradually established that gave the division psychiatrist control over decisions for return to combat duty of psychiatric casualties who originated from combat personnel of his division. The policy was based upon experience that the division psychiatrist could more correctly estimate the potential of such casualties to perform combat duties than rear colleagues. When the division psychiatrist determined that a psychiatric casualty was temporarily disabled for combat, the initials DSB (Don’t Send Back) were added to the diagnosis of “Combat Exhaustion” on the Emergency Medical Tag. This decision was honored by psychiatrists at the Army level. Division psychiatrists were enjoined never to predicate the decision of the receiving psychiatrist as to fitness for non-combat duty in Korea or Japan by avoiding such a recommendation either directly to the patient or on the medical record. In such cases decisions for combat duty avoided iatrogenic trauma to patients who were not promised duty in Japan or evacuation to the ZI, thus allowing receiving psychiatrists to make their own disposition.

Division psychiatrists did not abuse their control over criteria for assignment to combat duty as uniformly they were motivated to maintain as many personnel as practicable on duty within the division. To further this goal, division psychiatrists were active in obtaining reassignment within the division for battle-weary riflemen or other neurotically handicapped persons who could be effectively utilized at less strenuous positions in regimental and division headquarters or the service units of quartermaster, ordinance, and the like. The author has a distinct recollection that Major Hausman, 24th Infantry Division Psychiatrist, initiated the DSB technique. [Footnote 2, pp. 74-75]
 

Administrative Discharges

Another aspect of formal psychiatric disposition involved personnel with so-called personality or behavior disorders who in peacetime received administrative discharges under AR 615-369 [Footnote 4] and AR 615-368 [Footnote 5].  Experiences in World War II and the Korean War indicated that few cases could be discharged under AR 615-369 in a combat unit because first, there was little time for administrative procedures and second, such a general discharge under honorable conditions would in the combat environment be construed as a reward for ineffectiveness with a consequent negative impact upon morale.  Moreover, in wartime with increased situational needs, persons who fall under AR 615-369 can be profitably employed in non-combat assignments since their personality defects were not so severe as to preclude functioning under less stressful conditions.

It was agreed that the division psychiatrist was to medically evacuate mild personality problems who could not be reassigned within the division.  The next psychiatric echelon would then re-profile the evacuee and recommend a rear assignment.  By this procedure, it was demonstrated that the bulk of such cases could and did function effectively.  Even enuretics became useful rear soldiers when it was made clear that the problem was laundry facilities of which there was no dearth in Korea or Japan.  Generally the enuretic was considerably less bothered by his uncomfortable habit when reassigned out of combat.  In time discharge by AR 615-369 became rare in the entire Far East Command.  Such a gain producing reward was impractical in an overseas wartime theatre.  AR 615-369 was only utilized in severe instances of inadequate personality where it was clearly evident that marked ineffectiveness in military service duplicated a borderline civilian adjustment and the person was literally incapable of being motivated toward effective work of any kind.

Individuals with pathological personalities who belonged in the category of AR 615-368 for undesirable discharge were not evacuated through medical channels, but were handled by administrative and disciplinary measures within the division.  Such cases included narcotic and alcohol addicts, habitual shirkers, antisocial personalities, and chronic disciplinary problems.  This policy was based on the assumption that such persons cannot be rehabilitated by reassignment.  In actual practice, infantry divisions had few cases when in the combat zone.  There was little opportunity for usual disciplinary disorders and AWOL was a serious offense at this time.  Alcohol and drugs were scarce and addiction much less of a problem.  In one infantry division (25th Infantry Division) only 12 AR 615-368 dispositions were made during one year of combat.

The Non-effective Combat Officer

The disposition of non-effective combat officers was resolved during March 1951.  Previously, officers who demonstrated unsuitability as combat leaders at the company or battalion level, for whatever reason, were either evacuated through medical channels or referred for administrative action under AR 605-200. [Footnote 6]  Neither method proved to be effective.  On the one hand combat units did not have the time or administrative ability to cope successfully with the unwieldy process of AR 605-200.  On the other hand medical evacuation was an obvious gain for poor duty performance.  As a result, Eighth Army in early March 1951 established a permanent 605-200 Board at the main Army headquarters under direct supervision of the Eighth Army Judge Advocate General to process all cases that arose in Eighth Army.  This action promptly removed the administrative burden from combat units who were then more willing to recommend this procedure rather than press medical officers to use medical evacuation.  Because of more expert guidance and accumulated experience, the permanent 605-200 Board was able to readily accomplish the procedure assisted by prompt medical or psychiatric consultation as needed.

The utilization of the permanent Board proved to be an effective solution to this difficult problem.  After six months of operation, 45 cases had been processed under AR 605-200 with 13 cases pending approval from Washington, DC.  In this regard was demonstrated a major problem as final action from Department of the Army required about three months during which the individual concerned was useless to himself or others.  During wartime it seems advisable to permit final action by the overseas Army or Theater Headquarters involved or allow return of the already boarded officer to the ZI to await final decision of Department of the Army. [Footnote 2, pp. 74-78]

Psychiatry at the Army Level

In the early phase of this period, the 4th Field Hospital at Taegu with the psychiatric team of Captains Kolansky and Cole continued to be the major psychiatric center of Eighth Army.  There were no special changes in the clinical syndromes of psychiatric casualties at this time except a proportional decrease of patients with free floating anxiety in favor of those with somatic complaints.  Headache was most common, followed by backache, fatigability, urinary frequency, and gastrointestinal disorders.  Physical hardships from cold and inclement weather coupled with monotonous diet seemed almost as stressful to the soldier as combat trauma.  Indeed, battle casualties (KIA and admissions for WIA) during this period (January-April 1951) were decreased whereas admissions for disease and non-battle injury including frostbite were increased; also psychiatric casualties slowly decreased.

Thus mild injuries, disease and diagnostic problems comprised a high proportion of evacuees from combat areas.  The trend toward treatment and disposition of such cases at the Army level (2nd echelon) rather than evacuation to Japan was especially fostered during this period.  Colonel Hanson, the commanding officer (CO) of the 4th Field Hospital, strongly encouraged the professional staff toward treatment.  He constantly improved and expanded the facilities of the hospital toward this end.  It was his characteristic boast that the 4th Field Hospital had "beds unlimited" so that space requirements did not deter the hospital from holding patients for treatment.  The salvage of men for duty was also stimulated by a directive from General Ridgeway, who enjoined the Army Medical Service to make all possible efforts toward prompt rehabilitation and prevention of unnecessary hospitalization or evacuation. [Footnote 7, p. 79]  In addition to the treatment of psychiatric casualties, Captains Kolansky and Cole received a number of inpatients and outpatients from the many service units of Eighth Army.  The main Eighth Army Headquarters was also located in Taegu, thus placing the psychiatric center of the 4th Field Hospital in a strategic position to give advice and consultation to the various administrative and medico-legal problems commonly encountered in a large headquarters.

From the beginning, Captain Kolansky established an excellent relationship with Colonel Silvers, the Judge Advocate General of Eighth Army.  Colonel Silvers was pleased with the comprehensive reports that he received relative to referred disciplinary problems.  He came to appreciate the psychiatric position which insisted on administrative handling of ineffective officers and men rather than abusing medical evacuation channels.

In contrast to the policy of Eighth Army Headquarters was the stubborn refusal of 2nd Logistical Command (Pusan, Korea) to alter their stand that courts-martial was the proper method of elimination for the behavioral problems of enlisted personnel rather than administrative discharge.  It was their fear that employment of administrative discharge would result in a wholesale loss of manpower.  At best they agreed to consider a limited number of cases referred by local psychiatrists.  1LT (later Captain) Richard Conde (one year civilian psychiatry residency) arrived at the 10th Station Hospital in February 1951 to initiate another psychiatric unit in Pusan.  This was a welcome relief to overworked Captain Steve May whose psychiatric section of the 3rd Station Hospital (previously the 8054th Evacuation Hospital) was kept busy with consultations and referred patients from local organizations.  1st Lieutenant Conde received the strong support of Col. John Baxter, the CO of the 10th Station Hospital, who, like Colonel Hanson, was convinced of the need to hold patients for treatment and return to duty, rather than accenting the number of patients passing through the hospital.  1st Lieutenant Conde combined forces with the orthopedic section in the treatment and evaluation of patients with backache and, by the use of hypnosis or pentothal interviews, demonstrated psychological causation in most cases with improvement. [Footnote 7, pp. 80-81]

In the Prisoner of War Hospital for captured North Korean prisoners, Dr. Jun Doo Nahm lived up to expectations as he steadily enlarged the scope of the psychiatric section and demonstrated rare tact and ability to work with Korean psychiatric cases.  All of his cases were carefully evaluated.  Because Dr. Jun's professional training was mainly in descriptive psychiatry, considerable attention was paid to diagnosis and prognosis.  But his approach to patients was one of concern and help.  An ECT machine was obtained to be used mainly for psychotic disorders.

The 121s Evacuation Hospital, after withdrawal from northeast Korea in late December 1950, was placed near Pusan for staging.  In late January 1951, the hospital became operational at Toxond-dong, about twenty miles from Taegu.  Their site was a frozen rice paddy.  Rarely has the author seen hospital personnel in such poor spirits.  They were cold, miserable, living in tents, and off the main channels of evacuation.  There was not even the stimulus of hard work, which usually acts as a tonic to medical personnel.  In late February 1951 the hospital was moved to Taejon.  Morale promptly improved as all became occupied in establishing and operating a winterized hospital using the existing station hospital buildings as a nucleus.  Captain Glasscock, the psychiatrist, maintained the psychiatric section at a high peak of interest.  Initially, he received few patients in this location because conditions of the airfield at Taejon did not permit its frequent utilization and mainly mild surgical and medical cases evacuated by train were received.  In late March 1951, the hospital moved to Yongdongpo near Seoul and in early April 1951 it was established in Seoul.  Here, the 121st Evacuation Hospital was in the most favorable location to receive casualties from the combat area.  The psychiatric section soon became quite active and at the close of this period an addition of another psychiatrist was contemplated. [Footnote 7, pp. 81-83]

Base Section Psychiatry in Japan and Okinawa

This phase saw further progress in the organization and development of psychiatry in Japan.  One change was in the air evacuation of patients from Korea.  The usual policy had been to evacuate the majority of cases by air to southern Japan from which most patients were transhipped by air or rail to hospital centers around Tokyo and Osaka.  This method involved considerable duplication of handling and hospitalization in Japan which required additional personnel and delayed definitive treatment.

For sometime Brigadier General S. Hays, Surgeon, Japan Logistical Command, had endeavored to have air evacuation from Korea routed directly to the various hospital centers in Japan, but apparently there were insufficient planes for this purpose.  But in January 1951 direct evacuation as proposed was placed in operation.  Each of the hospital centers in the Tokyo and Osaka areas were to receive 40 percent of the casualties from Korea with 20 percent sent to medical facilities in south Japan (Fukuoka area).  Thus was created the then well known "40-40-20" distribution of evacuees from Korea based upon the number and types of hospital facilities in various areas of Japan. [Footnote 8, p. 84]

From a psychiatric standpoint, the changes in air evacuation was fortunate because the three psychiatric centers were strategically located along the 40-40-20 axis, thus completely obviating the transfer of psychiatric patients within Japan.  The location of the two convalescent hospitals near Tokyo and Osaka allowed for the triage of non-psychotic psychiatric casualties directly to the convalescent hospital, thus bypassing fixed hospitals in Tokyo and Osaka for a more realistic treatment environment.  However, psychotic, neurological, or mother severely-ill neuropsychiatric patients were sent to fixed hospital facilities. [Footnote 8, pp. 84-85]

The greater effectiveness of a convalescent hospital type environment over that of a fixed general hospital, in the treatment of non-psychotic psychiatric patients became quite evident in the early part of this period.  As time passed, convalescent psychiatry was steadily exploited as indicated by accumulated evidence to insure a growing belief that only severe mental reactions, as psychoses or neurological disabilities required the facilities of a fixed hospital.  The minor mental reactions (combat psychiatric casualties), not only did not need to be in the "good beds" of a general hospital, but such accommodations served as a deterrent to recovery by increasing gain in illness through providing an artificial and suggestible atmosphere that militated against return to even non-hazardous daily tasks.  Fortunately the two assigned psychiatrists, 1LT Francis Hoffman, at Nara Convalescent Hospital (near Osaka) and LTjg Richard Blacher, his U.S. Navy counterpart at Omiya Convalescent Hospital (near Tokyo), were enthusiastic young therapists.  Both developed objective methods of brief treatment, learned to deal realistically with gain in illness complications, used abreactive techniques of hypnosis and barbiturate interviews, and fully utilized the daily activities of the convalescent hospital to discourage tendencies toward neurotic helplessness.

At Omiya, Dr. Blacher treated about 350 patients during this period and performed 75 hypnotic and barbiturate interviews.  The great majority of this caseload was returned to non-combat duty (90 percent).  The remainder were transferred to the 361st Station Hospital because of psychotic manifestations or organic neurological disabilities.  Similar results were obtained a the Nara Convalescent Hospital except that a larger percentage was returned to combat duty.  The author believed that the reason for the difference was that the Osaka triage was more successful in sending patients directly to Nara Convalescent Hospital; whereas, in Tokyo it seemed almost impossible to prevent similar patients from being first sent to the 361st Station Hospital where 3.5 days were required to effect their transfer to Omiya Convalescent Hospital.  Apparently even this brief period at a general type hospital was sufficient to produce a fixation of symptoms. [Footnote 8, pp. 85-86]

Limited Duty Assignment

The many difficulties inherent in the reassignment of reprofiled (Limited Service) personnel were clarified during this period, also through the efforts of Brigadier General S. Hays, Surgeon, Japan Logistical Command.  It will be recalled that in the early months of the Korean War (July, August, September 1950), there was an improvised theater (FEC) policy that covered the return to duty of patients whose physical or mental defects permitted only a limited type service.  But "Limited Service" had been deleted by Army Regulations following World War II.  Because hospitals in Japan were still under the control of Eighth Army during this time, the Eighth Army Surgeon gave verbal permission to return suitable cases to limited type duty.  The G-1 (Personnel) Section of GHQ FEC promptly changed this designation to "general service with waiver for duty in Japan only" to be accompanied by an appropriate change of the physical profile on a temporary basis not to exceed 90 days.  The geographical limitation to Japan was not a medical recommendation but a G-1 stipulation for the purpose of filling depleted service requirements in Japan.  The need for a limited service category is a virtual necessity in a wartime overseas theatre, otherwise large numbers of individuals would be medically returned to the ZI who were capable of performing service but not combat type duty.  This procedure operated satisfactorily so long as there were sufficient vacancies in Japan.  However, in January 1951, it became increasingly difficult to find non-combat assignments in Japan. [Footnote 8, pp. 16, 86]

The entire problem of limited assignment was brought to a head by the following circumstances.  In latter January 1951 GHQ FEC ordered the 34th Regimental Combat Team (RCF) reconstituted and put in combat readiness.  This unit, previously a part of the 24th Infantry Division, had been withdrawn from Korea after severe losses in July and August 1950.  There were no "pipeline" replacements for the project.  The G-1 Section of GHQ FEC directed the utilization of recently re-profiled hospital returnees waiting at the Japan Replacement Training Center (JRTC) for limited assignment.

Due to an apparent misunderstanding the JRTC officials assigned all re-profiled persons to the 34th RCT, regardless of physical or mental defect.  Replacements numbered about 1500, and included mainly individuals improved from frostbite, wounds, injuries, and disease.  Former psychiatric casualties were about 1/6 (250) of the total group.  The CO of the 34th RCT was informed that his training mission should be construed as a "sense of urgency."  Accordingly he began a vigorous program designed to reach efficiency in several weeks.  Curiously in none of the above arrangements was medical advice sought or obtained from either the medical section of GHQ FEC or the Surgeon, Japan Logistical Command.

The effects of strenuous battle training upon recent reprofilees was immediate, as sick call became inundated by hundreds of complaining and bitterly protesting soldiers who felt that promises made to them were broken and their mainly physical condition made it impossible to perform such duty.  Brigadier General Hays as made promptly aware of the problem from dispensaries and hospitals near Zama, the training area of the 34th RCT.  He called for a general conference to reach a reasonable solution of the Zama situation.  The meeting was attended by theatre medical consultants to the Far East Command (medical section of GHQ) including the author, representatives from G-1 and G-3 (operations) GHQ, General Hays and members of his staff and ranking officers of the 34th RCT.  In the ensuing discussion it became obvious that there was confusion in use of the term non-combat duty, doubt as to accuracy of medical recommendations, and difficulties in finding suitable assignments for non-combat personnel in Japan.  It was decided that a team of medical specialists would review all re-profiled assignments to the 34th RCT.  It was also agreed to reexamine existing directives to prevent similar future difficulties. [Footnote 8, pp. 86-88]

The medical team found that three-fourths of the reprofiled members of the 34th RCT were unfit for continuation of battle training.  The remainder were permitted to continue with the unit, but with a decreased intensity of training.  A medical and administrative group under the supervision of Brigadier General Hays brought forth the following changes in the utilization of limited duty personnel that were in the main, accepted and incorporated in directives of GHQ and Japan Logistical Command:

1. The limitation "for Japan only" was deleted from recommendations for assignment.  This increased opportunities in the use of non-combat personnel for vacancies in rear Korea and Okinawa.

2. Reexamination was made mandatory for all reprofilees at the expiration of temporary disability.  It should be realized that raising physical profiles of hospital returnees was necessarily temporary (up to 90 days) since Army regulations did not provide authority for permanent limited service except under special circumstances.  Individuals found fit for full duty were made eligible for combat assignment.  Those still unable to perform full duty had their status continued for another period of one to three months.  This procedure served to offset the ever increasing number of limited personnel.  All previous reprofilees in Japan were reevaluated during February and March 1951.  A surprising result was obtained from those in the psychiatric category when 30 percent to 50 percent were judged to be fit for full duty by many examiners in various areas of Japan.  Although criteria employed for the determination of full duty were not uniform, psychiatrists were instructed to consider individuals fit for combat when free of overt anxiety or its somatic displacements, nightmares and insomnia, and when capable of considering return to combat duty without a recurrence of disabling symptoms.  Examiners reported that many psychiatric reprofiles welcomed a full duty decision, expressing a desire to prove themselves and avoid feelings of inferiority that had been present since removal from combat.  This formal process of reclaiming psychiatric casualties after several months of non-combat duty was a new practice in military psychiatry.  Unfortunately, no follow-up studies were performed to determine effectiveness after restoration to combat duty.  However, on repeated questioning of division psychiatrists in later months, the author found it was rare to find a history of restoration to combat duty among their cases.  Perhaps this apparent favorable result was due to rotation that became fully operational in May 1951 and gradually removed the personnel restored to combat duty.  Despite the absence of more exact information as to effectiveness, there is sufficient data to indicate that such a reclaiming process as so stated is of much benefit and should be given further trials in future wars. [FDJ: Israeli experience with psychiatric casualties of the 1973 war who were returned to combat duty in the 1982 Lebanon War showed this same lack of increased psychiatric breakdown.]  There are powerful forces which impel psychiatric casualties to return to combat.  They are discernible in battle dreams and irritability of the psychiatric casualty who constantly returns to the traumatic situation that he was unable to master.  When forward psychiatry operates effectively, salvageable psychiatric casualties were usually returned to duty at division or army level.  But when circumstances did not permit efficient combat psychiatry as occurred early in the Korean War, many reclaimable psychiatric cases were rapidly evacuated and placed in non-combat assignments.

3. Hospitals were enjoined to give special consideration to accuracy in reprofiling and required to create a special board of senior medical officers (Chiefs of Service) to review and approve all profile changes made by members of the medical staff.  It was further stipulated that the physical or mental limitations stated on the individual disposition form be in understandable lay terminology in order that proper placement was facilitated. [Footnote 8, pp. 88-90]

Arrival of Psychiatric Assets in Theater

279th General Hospital

A major event during this period, was the arrival in Japan of three numbered general hospitals.  The 279th General Hospital became operational in early March 1951 at Camp Sakai near Osaka; the 382nd General Hospital was established also near Osaka at Konoka Barracks and began receiving patients in latter March 1951.  The 343rd General Hospital was placed on a standby basis at Camp Drew, 50 miles from Tokyo, and did not become operational until 1 October 1951.  The pre-existing psychiatric facilities in Japan were adequate for current and future foreseeable needs.  Accordingly it was proposed and accepted by Brigadier General Hays that the three new general hospitals delete their planned psychiatric services except for consultative functions.  The personnel thus made available would be absorbed in other psychiatric assignments as needed.

The 279th General Hospital arrived with a complete complement of psychiatric personnel as follows:

• Maj. Marvin Lathrum - board certified psychiatrist, civilian psychiatric training

• Cpt. James Reilly - 2 1/2 years civilian neurology residency under Army auspices

• 1Lt. Otto Thaler - six months civilian psychiatry residency

• Maj. Susan Stimson - psychiatric social worker

• 1Lt. George Humiston - clinical psychologist

A full quota of enlisted neuropsychiatric ward technicians, psychological assistants, and social work assistants, including six nurses with special psychiatric training, was available.

Arrangements were made to utilize the psychiatric staff of the 279th as follows: Their major function was to provide psychiatric consultative services for the entire Osaka-Kobe-Kyoto region.  More specifically Major Lathrum and his staff became responsible for consultations from the 8th Section Hospital at Kobe and the 35th Section Hospital at Kyoto besides referrals from his own hospital and the 382nd General Hospital.  It was agreed that Major Lathrum was to maintain an open neuropsychiatry ward for the diagnosis and treatment of referred patients considered to warrant further study or recoverable by brief psychotherapy.  All closed ward patients were to be transferred to Osaka Army Hospital that had closed ward facilities and ECT apparatus.  Major Lathrum found it convenient to visit one day each at Kobe and Kyoto on a regularly scheduled basis.  This avoided travel by patients, enabled Major Lathrum to become familiar with local problems, and allowed him to furnish written reports as well as to be available to discuss findings in appropriate cases with referring line or medical officers.  Generally he was accompanied by Major Stimson on these visits.  The 279th General Hospital received no patients directly from Korea as they were triaged directly to Nara Convalescent or Osaka Army Hospitals.  These various functions allowed for the effective utilization of Major Lathrum and some specialized personnel.  The remainder were absorbed by other psychiatric units, mostly in Japan.

382nd General Hospital

The following officer personnel were included in the psychiatric service:

• Cpt. Avrohm Jacobson - completed civilian psychiatry residency and board certified

• Cpt. Pust - two years experience with chronic mental patients in a VA Hospital

• Cpt. Dunaef - two years civilian psychiatry residency under Army auspices

• 1Lt. Gordon McKay - psychiatric social worker

• 1Lt. Philip Barenberg - clinical psychologist

Captain Jacobson was delayed, arriving in the theater in late April 1951.  He was sent to the Nara Convalescent Hospital to aid 1st Lieutenant Hoffman and become familiar with this type of treatment.  Captain Dunaef and 1st Lieutenant Barenberg were sent to the Neuropsychiatry Service of the 141st General Hospital in early April 1951.  Captain Pust was permitted to continue his work as an anesthetist on the surgical service of the 382nd General Hospital.  He was not particularly interested in psychiatry.  1st Lieutenant McKay was eventually transferred to the 361st Station Hospital in Tokyo.

118th Station Hospital

With decrease of the casualty flow through southern Japan after implementing the 40-40-20 ratio of patient distribution from Korea to Japan, the 118th Station Hospital and the 141st General Hospital received relatively few psychiatric admissions; but, the 118th Station Hospital, steadily increased its outpatient function.  Captain Allerton of the 118th Station Hospital assisted by 1Lt. Pamella Robertson (psychiatric social worker) continued to maintain a small number of inpatients, but most of Captain Allerton's caseload comprised evaluation and treatment of referred outpatients.  In the course of time, Captain Allerton could not fail to note the relative frequency of referrals from nearby units.  This led to a discussion with Brigadier General Hays, Surgeon, Japan Logistical Command to determine what channels, if any, could be used to transmit such information.  It was evident that while the frequency of disciplinary and psychiatric disorders fall in the realm of preventive psychiatry, any remedial action was the very essence of command.  Brigadier General Hays informally transmitted information gathered on one organization which was investigated by General Clark, the Commanding General of the Southwest Base Command that included southern Japan, who found evidences of poor leadership with mismanagement and lowered unit morale.  Thus Brigadier General Hays demonstrated that the channels required should be comparable to those employed with the bimonthly division psychiatric reports which are routinely sent to the Commanding Officer of each combat Division through the Division Surgeon.

141st General Hospital

In early March 1951 Lieutenant Commander H. Wilkinson, Chief of the Neuropsychiatry Service, was medically evacuated to the ZI.  He was replaced by Major Henry Segal from Tokyo Army Hospital who reorganized and further developed the Neuropsychiatry Service.  Plans were made and approved to rebuild the closed facilities.  ECT apparatus was obtained and placed in operation.

Osaka Army Hospital

The Neuropsychiatry Service of Osaka Army Hospital became a smoothly functioning team under LTC Philip Smith.  It was further strengthened by the addition of 1st Lieutenant F. Hammer, clinical psychologist.  A study of self-inflicted wounds (SIW's) was begun at this time to determine if any specific personality traits of dynamic mechanisms could be demonstrated.

361st Station Hospital

The Neuropsychiatry Service of the 361st Station Hospital continued to function as the major center for psychiatry and neurology in the Tokyo-Yokohama area.  However, the policy of decentralization had steadily decreased the inpatient census until it remained fairly constant at about 150 psychiatric and neurological patients of all types including prisoners for pre-trial examination.  More than half the patients came from local sources.  New arrivals to the Neuropsychiatry Service, 361st Station Hospital included:

• 1Lt. L. Laufer - two years civilian psychiatry residency

• Cpt. James Rafferty - one year civilian psychiatry residency under Army auspices

• Maj. Philip Steckler - board certified psychiatrist, completed three years civilian psychiatry residence and necessary professional experience

• LTjg. Mariner - enlarged the scope of the psychiatric outpatient and consultation service at the 155th Station Hospital Yokohama

In February 1951, he was joined by Ltjg. Austin (one year civilian neurology residency) who, soon became fully occupied with neurological referrals both inpatient and outpatient.  An account of their experience can be found in the Symposium of Military Medicine in the Far East Command (FEC) published as a Supplemental Issue of the Surgeon's Circular FEC, September 1951.

Cpt. James Corbett (two and a half years civilian psychiatry residency) replaced Major Segal as psychiatric consultant at Tokyo Army Hospital.  Also at Tokyo Army Hospital, Cpt. Philip Dodge (one year civilian neurology residency under Army auspices) worked with both the neurosurgical and medical services as neurology consultant.  He organized weekly evening seminars on neurological topics which was given strong support by LTC William Caveness (board certified neurologist), Chief of Neurology US Naval Hospital at Yokosuka near Tokyo.  The evening seminars were well attended by neuropsychiatry specialists from the Tokyo-Yokohama area. [Footnote 8, pp. 90-94]

40th and 45th Infantry Divisions (National Guard)

The 40th and 45th Infantry Divisions (National Guard) arrived in Japan during March and April 1951.  The 45th Infantry Division from Oklahoma was sent to Hokkaido, the northern island of Japan, and the 40th Infantry Division from California to the northern area of Honshu, the main Japanese island.  Both divisions had as their mission the defense of Japan, and both began active training programs calculated to reach combat readiness as soon as possible.  Each division arrived with a psychiatrist.  In the 45th Infantry Division Major H. Witten (three years civilian psychiatry residency and board eligible) was properly assigned as the division psychiatrist and prepared to function as such.  It was arranged that Major Witten would also act as psychiatric consultant to the 161st Station Hospital in Sapporo, Hokkaido, the hospital support for the division.  The 40th Infantry Division refused to assign Captain Bramwell (two years civilian psychiatry residency) as division psychiatrist because of a shortage of medical officers and their insistence that he was needed as the clearing company commander.  It was agreed that Captain Bramwell would be released to serve as the division psychiatrist when additional medical officers were assigned to the division; but, this did not occur until August 1951.

Here was another instance of the misuse of division psychiatrists either due to ignorance of their functions or an inability to appreciate the need for all efforts to prevent loss of manpower.  The contention of the 40th Infantry Division Surgeon that he lacked sufficient medical officers was technically correct.  But of the 15 medical officers in the division that were available, four (the division surgeon, the medical inspector, the CO of the Medical Battalion, and the clearing company commander) were utilized in mainly administrative duties.  Yet the largest loss from the division at this time came from persons hospitalized for anxiety or vague somatic complaints; thus, it seemed unrealistic at such a time to be without a division psychiatrist while four medical officers were not professionally utilized.  The author's suggestion that the CO of the Medical Battalion who had few professional duties also act as the clearing company commander fell on deaf ears. [Footnote 8, pp. 94-95]

Psychiatric Problems on Okinawa

Psychiatric problems on Okinawa increased to troublesome proportions during this period.  The early phase of the Korean War saw a depletion of the Okinawan garrison for services in Korea and a subsequent decrease in the psychiatric caseload.  1LT. Daniel Casriel (eight months civilian psychiatry residency), replaced Captain Clements (one and a half years Army psychiatry residency) who was returned to the ZI in November 1950 to complete residency training.  Psychiatric consultations during this time were less than 100 per month with a small inpatient census of 10-15 per month.  1st Lieutenant Casriel was assisted by a civilian clinical psychologist and several enlisted social workers.

In December 1950 and January 1951 there began a rise in psychiatric consultations as the strength in Okinawa was increased in both ground and air elements.  As the winter months brought its discouraging tide of battle and continuation of the lengthened tour of duty in Okinawa, there ensued inevitable loss of morale that occurs when military personnel stationed on an island do not have an obvious mission or stated length of time to serve.  The result was a sharp upswing in disciplinary problems, psychiatric referrals, and suicidal attempts.

A visit to Okinawa by the author in early April 1951 confirmed the impression of typical irritability and low morale common in an island setting with little effort made to utilize recreational, social, and other outlets that were available.  Despite the increase of suicidal attempts, there had been no fatalities from this source since the onset of the Korean War.  In the author's opinion, this fact demonstrated such attempts were not the result of serious intrapsychic conflict, but rather represented anger against the environment with an effort to influence the outside world.  The attitude of many on Okinawa that they were neglected, unappreciated, and not given due consideration, as even shared by senior officers.  Any attempt to make favorable comparisons of their situation with those fighting or living in Korea, brought forth angry outbursts that displayed an oversensitivity toward any argument that seemed to be against their right to complain and feel unhappy.  It was clear that while living conditions on Okinawa were not elegant and there were decreased opportunities for recreational and social outlets, the major difficulty was the need for a definitely stated tour of duty.

1st Lieutenant Laufer (two years civilian psychiatry residency) was sent to Okinawa to join with 1st Lieutenant Casriel, so as to enlarge the psychiatric facilities required for the increased patient load.  An enlisted psychologist was transferred to Okinawa from the 361st Station Hospital to replace the civilian psychologist who had returned to the ZI.  It was recommended that certain behavior and disciplinary problems characterized by restlessness and aggression in persons with a relatively good military record prior to Okinawa be transferred to the replacement center in Japan for shipment to combat units in Korea.  This procedure, which became known as "Operation Vital," functioned quite effectively to salvage worthwhile soldiers who found it difficult to tolerate monotony and welcomed a change that gave an opportunity to externalize aggression.

It is believed that morale in Okinawa was certain to improve in the future as the reestablishment of a stated length of a tour of duty was expected.  Dependent travel had resumed in April 1951 and was to continue in larger increments since considerable housing construction was nearing completion.  In general the building program was making good progress with a reasonable expectation of providing better barracks, roads, and recreational projects. [Footnote 8, pp. 96-97]

Discharge of Undesirable Personnel

The elimination of undesirable personnel by the provision of AR 615-368 came up for considerable discussion during this period.  There were many inconsistencies in the use of this regulation in Japan as various local headquarters utilized individual interpretations relative to what constituted proper criteria for administrative discharge from the service.  In some instances, as in the 2nd Logistical Command in Korea, no cases were approved for discharge; court-martial was deemed the logical method of elimination.  They feared that undesirable discharge by AR 615-368 would result in a wholesale loss of manpower.  In other instances, AR 615-368 was used freely as a punitive measure.  The entire question was taken up with Brigadier General Hays, who submitted a more uniform procedural data to MG Walter Weibel, the Commanding General (CG) of Japan Logistical Command.  This resulted in a well-written directive on the subject by Japan Logistical Command Headquarters, to its subsidiary branches.  In time, there was definite improvement as indicated by a decrease of referrals for alcohol addition, chronic behavior disorders, and various other pathological personalities who were a burden to their units and not amenable to any type of punishment or treatment. [Footnote 8, pp. 97-98]

In the above connection, the question of narcotic addiction will be mentioned.  Before the Korean War, narcotic addicts were well-known to be relatively common, particularly among American troops based in port cities of Kobe and Yokohama in Japan, and also Pusan, Korea.  As in civilian life, this problem was difficult to control, especially so in the Far East where opiate drugs were cheap and easy to obtain.  Previous attempts to solve narcotic addition by lectures to the troops, unannounced inspections for drugs, and undercover investigations by the Central Intelligence Division (CID) had not been successful.  At this time it was stated that there had been no increase in narcotic addition since the onset of hostilities in Korea.  This statement was later found to be erroneous.

Also, at this time, it seemed logical to conclude that the prompt removal of confirmed narcotic addicts by AR 615-368 would decrease the extent of the problem and prevent to some degree the contamination of susceptible soldiers.  Further, it was argued that action should be taken whenever the diagnosis of narcotic addition could be made by the psychiatrist on the basis of withdrawal symptoms, the presence of typical venous puncture marks, and a characteristic history in an effort to present evidence to warrant trial by court-martial.

However, later experiences and investigations indicated that most of the above stated characteristic manifestations of narcotic addition were found to be incorrect as follows:

1. The well known withdrawal symptoms seldom occurred when confirmed users were held in locked wards of a psychiatric service.  Also, the lack of withdrawal symptoms was found related to the relative youth of subjects and the low dosage of opiates involved.  Civilian experience with teenage addicts demonstrated that little or no distress was exhibited during drug withdrawal.

2. Moreover there was some evidence that the withdrawal syndrome was a learned process compounded out of physical discomfort from physiological dependence and anxiety from psychological dependence.  Thus, teenage users at the Federal Narcotic Hospital in Lexington, Kentucky had severe withdrawal symptoms in contrast to the mild or no distress displayed by similar youthful offenders incarcerated in hospitals such as Bellevue in New York City.  Presumably association with confirmed and older offenders at the federal institution may have influenced the newcomers to exhibit a heightened response to drug withdrawal.

3. Experience with physical inspections indicated that needle scars must be looked for not only in the forearms, but also in the feet, legs, buttocks, neck and abdomen.  Random and well distributed needle scars could readily be explained away by suspects who rarely exhibited weight loss or physical stigmata that characterizes confirmed and older addicts. [FDJ: Furthermore, a habit can be maintained by nasal inhalation (snorting) heroin, the preferred route during the subsequent Vietnam War.]

In general, psychiatry in the Far East Command did not foster or favor punitive discharges either by AR 615-368 or by courts-martial.  Such a discharge only further handicapped the antisocial or disciplinary problem in civilian life.  Various efforts were made, including transfer of narcotic addicts from port cities to remove them from supply sources after complete withdrawal was accomplished.

It was further proposed that senior noncommissioned officers of port companies serve as "vigilantes" in protecting their men against known suppliers of narcotic drugs to their organizations.  Also proposed was the selective reassignment of completely withdrawn addicts to combat units where opiate supplies were as yet unknown.  However, none of the above noted later proposals were placed into operation during the author's tour of duty in the Far East Command, which ended 13 September 1951. [Footnote 8, pp. 98-99]

References - Chapter 9

1. Schnabel, J. United States Army in the Korean War: Policy and Direction: The First Year.  Washington, DC: Office of the Chief of Military History, United States Army; 1972: 331.

2. Glass, A.J.  Psychiatry at the division level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.  [Compilation of data obtained from Medical Corps, Medical Service Corps and line officer participants who were present in Korea during the period 25 June 1950 to 30 September 1951.]

3. Sobel, R.  Anxiety-depressive reactions after prolonged combat experience: The "old sergeant syndrome."  Combat Psychiatry.  Bulletin US Army Medical Department.  1949; 9:137-146.

4. AR 615-369

5. AR 615-368

6. AR 605-200

7. Glass, A.J.  Psychiatry at the Army level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

8. Glass, A.J.  Base section psychiatry.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

9. Not provided.

Chapter 10

[KWE NOTE: Unclassified copies of
Psychiatry in the U.S. Army: Lessons for Community Psychiatry
do not have the text for Chapter 10.]

References - Chapter 10

1.  Glass, A.J.  Psychiatry at the division level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.  [Compilation of data obtained from Medical Corps, Medical Service Corps and line officer participants who were present in Korea during the period 25 June 1950 to 30 September 1951.]

2.  Glass, A.J.  Psychiatry at the Army level.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

3.  Glass, A.J.  Base section psychiatry.  In: Notes of the Theater Consultant, Section VI.  Unpublished manuscript held by The Medical Division, Office of the Chief of Military History, US Army, Washington, DC.

Chapter 11

Truce Negotiations and Limited Offensives By the United Nations
(10 July 1951 - 1 October 1951)

By Albert J. Glass, MD, FAPA

The beginning of truce talks in July 1951 continued for several weeks the lull in ground activity that began in latter June 1951.  Soon it became apparent that optimism regarding an early end to the Korean fighting was not warranted.

Limited United Nations Offensive Actions

Offensive moves by United Nations forces began in latter July 1951 and were periodically renewed in August and September 1951, when severe combat produced a large number of battle casualties.  The attacks were aimed toward improvement of United Nations positions, particularly in the east central sector in Order to obtain a shorter and more defensible battle line.  These efforts were largely successful, but the capture of stubbornly-defended hill masses was a slow and painful process.  Although patrol actions and limited engagements took place in the western area, the units in the east central zone, particularly the 2nd Infantry Division, the 1st Marine Division, and to a lesser extent, the 7th Infantry Division, and the 24th Infantry Division, bore the brunt of offensive combat during the period.

The Psychiatric Rate

The psychiatric rate was only slightly elevated in response to increased battle casualties.  This was especially true in September 1951 when he psychiatric rate rose to 36/1,000/year from the August 1951 rate of 32/1,000/year despite an increase of battle casualties from 68/1,000/year in August to 227/1,000/year in September.

Influence of Rotation

Perhaps the principal reason for the continued relatively low incidence of psychiatric admissions was the influence of rotation.  For this reason any adverse reaction from the pessimistic progress of the peace talks was not evident.  Relief from combat had become an individual affair obtainable by the person regardless of the outcome of negotiations.  Rotation became the chief topic of conversation among troops in Korea; for, upon it depended their hopes and dreams.  As practiced in the Korean War, it was a new phenomenon for American combat forces.

While rotation was a mighty step forward in preventive psychiatry and already has proved its value, there were inevitable and undesirable by-products.  The most pertinent defect of rotation, aside from logistical problems inherent in such a mass replacement of personnel, lies in the disruption of the sustaining power of group identification that occurred when the combat veteran was notified or became aware that soon he will rotate home.  The increase of tension that followed was well known.  Such a person has been aptly named the "short-timer."

The "short-timer" has shifted his thoughts and feelings away from the group; and, often for the first time, battle fear became unbearable as now all of his love was returned to the self.  Emotionally at least the "short-timer" was disengaged from his buddies and only concerned about himself.  The subsequent rise in anxiety produced in some an inability to function and mental breakdown.  In most, tension noticeably increased in the last few days of combat as if it were now dangerous to tempt fate.  One could often hear stories, undoubtedly exaggerated, of the unlucky person who was killed the day before being scheduled to leave on rotation.

Others of the group readily identified with the "short-timer" as demonstrated by spontaneous actions of units in sending rotatees to rear safe positions or insuring relief from patrol or similar hazardous duties.  The "short-timer" often had mixed feelings about leaving as ties to buddies did not loosen so easily.  However, it was rare for one to give up the rotation opportunity as such behavior would be regarded as queer or unusual by the group.  An excellent description of combat rotation problems by the 25th Infantry Division psychiatrist, Major Krause, can be found in Appendix I.  (Here the "short-timer" was labeled the "short-timer's attitude.")

Perhaps the most effective form of rotation would be removal of entire combat units or at least its older or original members.  However, such a process would be most difficult to accomplish from a logistical standpoint.

Misassignment of Limited Service Personnel

The misassignment of reprofiled (limited service) personnel to combat units was satisfactorily corrected in late July 1951.  An Eighth Army circular (see Appendix II), clearly set forth the utilization of limited type personnel by service units and enjoined against return to their original combat unit.  This directive also made official in Korea a policy of mandatory periodic reevaluations of personnel classified as "general service with waiver," identical with the procedure in Japan.  Individuals found fit for full duty were available for reassignment to combat units.  Subsequent follow-up surveys with division surgeons and psychiatrists in August and September 1951 confirmed that the policies laid down in the Eighth Army directive were being carried out.

2nd Infantry Division Psychiatry

The 2nd Infantry Division had taken a major share of the uphill offensive fighting.  As a result, Major Bolocan was perhaps the most busy of the division psychiatrists during this period.  He collaborated with Brigadier General (BG) Bootner, the assistant division commander, in establishing an intra-divisional training program for replacements that was probably the most comprehensive effort of this type.  A copy of the 2nd Infantry Division training memorandum is included as Appendix III.  The report of Major Bolocan that led to the adoption of the replacement training program is listed as Appendix IV.

Combat Psychiatry for Battalion Surgeons

Periodic visits by division psychiatrists to Battalion Aid Stations strongly encouraged and influenced battalion surgeons to participate in the evaluation and treatment of combat exhaustion.  More and more the first echelon of psychiatric treatment became the battalion aid station and the collecting station in suitable cases, particularly in secure tactical situations.  To further this program Captain Glasscock, the 3rd Infantry Division Psychiatrist, distributed a divisional memorandum, a copy of which is included as Appendix V.

Rotation of Psychiatrists

In latter July 1951 among the first medical officers rotated to the ZI were the following two division psychiatrists: Captain Paul Stimson, veteran psychiatrist of the 1st Cavalry Division, had served continuously with his division since latter August 1950.  He was one of the pioneers of combat psychiatry in the Korean War.  His well-deserved promotion to major was approved while he was in Japan awaiting shipment home.  Captain R. Cole became the 1st Cavalry Division Psychiatrist by volunteering for this position from Japan.  Major W. Krause was the second division psychiatrist to earn rotation.  He had been in Korea since 7 July 1950, but with the 25th Infantry Division since October 1950.  He was replaced by Captain (later Major) Robert Yoder (three years civilian psychiatry residency), formerly assigned to the United States Air Force Hospital at Nagoya, Japan.  Both incoming division psychiatrists were oriented by their predecessors and had no difficulties in maintaining the high level of the two psychiatric programs.

In mid-September 1951, Major T. Glasscock (one year civilian psychiatry residency), 3rd Infantry Division Psychiatrist, was returned to the ZI to resume residency training.  He was replaced by Captain Dermott Smith who also volunteered for a divisional post from Japan. [Footnote 1]

Psychiatry at the Army Level

121st Evacuation Hospital

The 121st Evacuation Hospital continued to serve as the principal psychiatric center of Eighth Army throughout this period.  The psychiatric service had developed excellent physical facilities sufficient to care for 100 patients.  Major Segal, head of the service who replaced 1st Lieutenant Jensen, began reorganizing the Neuropsychiatric Service.  He was given invaluable support by Major Ralph Morgan, psychiatric social worker, who arrived in early August 1951.  His assignment was facilitated by Colonel Page, the new Eighth Army Surgeon.  Major Morgan took over most administrative details, assisted in consultations, oriented new admissions, began group therapy sessions, and supervised the recreational program.  An enlisted clinical psychologist joined the service in late August 1951, and another psychiatrist, 1Lt. Alan Clarke (one year civilian psychiatry residency) was added in September 1951.  The gradual shift of Eighth Army Headquarters from Taegu to Seoul brought the psychiatric staff in greater contact with administrative and medico-legal problems that required psychiatric consultation.

The Psychiatric Team

Experiences in the utilization of psychiatrists at Army level in Korea had consistently demonstrated the value of the psychiatric team.  Such a professional team functions in a similar manner to a surgical team.  The small group of trained personnel could be moved to any medical facility that was strategically located to receive casualties, be it a separate clearing company, field hospital, or evacuation hospital.  When thee was continued static warfare as in World War I or a large production of psychiatric casualties as occurred in the European Theater of Operations (ETO) of World War II, a separate psychiatric unit may be preferable.  In Korea, with its many tactical reverses, difficult transportation problems, and at times dangerous rear areas, especially in the first year of the Korean War, it was necessary to have alternate or reserve treatment capabilities.  The psychiatric team could begin functioning almost immediately in any unit that provided housekeeping facilities.  Eighth Army accepted the elastic use of psychiatric personnel and agreed to utilize Major Morgan and a psychiatrist of the 121st Evacuation Hospital as the psychiatric team that would be moved in the event the 121st Evacuation Hospital was dislocated or psychiatric casualties became large at another hospital.

Professional Medical Consultants at the Army Level

Colonel Paige, Surgeon Eighth Army, appeared to be more receptive than his predecessor to the acceptance of professional consultants on his staff.  In September 1951 he agreed to an Eighth Army Surgical Consultant and indicated that perhaps consultants in medicine and psychiatry would be included in the near future.

11th Evacuation Hospital

In mid-September 1951 the 11th Evacuation Hospital moved forward from Chungju to above Wonju.  The new site was conveniently located for air and rail transportation so that the hospital was in position to play a more active role by receiving casualties directly from forward units.  Captain Levy, the assigned psychiatrist, had previously only a small caseload but the future might make this unit of larger importance as a psychiatric center.

4th Field Hospital

The 4th Field Hospital in Taegu had become a relatively minor medical facility with a low patient census.  Thus the psychiatric section headed by Captain Corbett was relatively inactive.

Pusan Area

The Pusan area remained important as a major communication zone, a port facility, and a reserve hospital center for battle casualties.  In September 1951 Colonel Paige, Surgeon Eighth Army, agreed to a consolidation of the psychiatric section of the 3rd and 10th Station Hospitals.

Discharge by AR 615-368 Versus Courts-Martial

A final effort was made in September 1951 to influence 2nd Logistical Command (Pusan area) to alter their opposition toward discharge by AR 615-368 [Footnote 2] in appropriate cases rather than discharge by courts-martial.  A conference was held with Brigadier General (BG) Young, the Commanding General, 2nd Logistical Command.  In this meeting the author was supported by five senior medical officers from the Pusan area and the Medical Section, GQ, FEC.  A thorough airing of conflicting viewpoints occurred between the Chief of Staff 2nd Logistical Command and the author.  The conference ended with Brigadier General Yount's decision that undesirable individuals in the 2nd Logistical Command would be eliminated by AR 615-368.

It was further arranged that copies of the psychiatrist's recommendations for such a discharge be sent directly to Brigadier General Yount's headquarters to insure that action would be taken.  Apparently this meeting brought results as follow-up information by reliable sources found that by early December 1951 13 cases had been processed and discharged by AR 615-368 in the Pusan area. [Footnote 3]

Base Section Psychiatry

There was no essential change in the organization and operational procedures of psychiatry in Japan during this period.  The decentralization policy for psychiatric patients along with an emphasis on outpatient and convalescent type therapy for minor reactions was by this time a well established development.  Major mental disorders, neurological cases, and diagnostic problems were hospitalized at one of three well-staffed neuropsychiatric centers, each equipped with closed ward facilities, ECT apparatus and an EEG machine.

Visit by Colonel Caldwell

Col. John Caldwell, Chief of the Psychiatry and Neurology Consultant Division, Office of the US Surgeon General, visited the theater in latter July 1951.  He made a comprehensive tour of psychiatric units in Korea and Japan.  Colonel Caldwell offered valuable suggestions on psychiatric policies, personnel, and organization.

Important Changes in Rotation

Two important improvements were made in the reassignment of limited duty personnel in late July 1951.  The first and most important change was brought about by a GHQ FEC request for an extra rotation quota in order that some of the combat personnel reprofiled to non-combat duty, because of wounds or disease, could be returned home.  The request was granted in part.  Authority was given for a rotation quota of up to 200 reprofiled Korean veterans per month, who could not be effectively utilized in the Far East Command (FEC).  A conference with the G-1 and AG sections of GHQ produced agreement that selections for the additional quota be made at the Japan Replacement Training Center that served as the funnel through which all hospital returnees designated "general service with waiver" were concentrated.  It was further agreed that Lieutenant Commander Buhrig, the capable surgeon of the Japan Replacement Training Center, would make the actual selections based upon length of combat service in Korea, the number and severity of battle wounds incurred, and the total length of service in the FEC that must include combat.  Only the most deserving Korean combat veterans would be chosen for return to the ZI under this additional quota.  The rotation of limited service personnel began 1 August 1951.  Two months of operation proved that the above criteria for selection could be carried out in a practical manner.  It operated to prevent return to Korea of non-combat personnel who were sufficiently high in rotation eligibility so that a new assignment would have been only temporary.  At the same time it lessened the assignment problems in Korea for non-combat positions.

The second and relatively minor change arose out of the need to assign certain limited personnel specifically in Japan rather than Korea.  Individuals in this category included epilepsy controlled by medication, tension states in persons of marked passive personality, and injuries or organic disease that were improved but required routine treatment or evaluation.  Arrangements were made with the AG (Adjutant General) of GHQ to permit up to 25 so-called convalescent assignments per month.  The selection of cases would again be determined by Lieutenant Commander Buhrig at the Japan Replacement Training Center upon the request of the particular professional service in which the individual was hospitalized.  The procedure also operated successfully in that greater elasticity in assignment for special cases was provided.

New Arrivals to the Theater

New arrivals to the Far East Command in later July and August 1951 were:

• 1Lt. T. Sclhaug - seven months civilian psychiatry residency

• Cpt. William Lorton - one and a half years civilian psychiatry residency

• 1LT. Frank Norbury - one year civilian psychiatry residency

In September 1951, the following professional neuropsychiatric personnel arrived in the theater:

• Cpt. Samuel Bullock - three years civilian psychiatry residency

• Cpt. Rhead - two years civilian psychiatry residency

• 1LT. Thorndike Troop - one year civilian psychiatry residency

• 1LT. Walter Easterling - one year civilian psychiatry residency

• 1LT. Bernard Hanson - one year civilian psychiatry residency

• 1LT. Francis Vazuka - one year civilian neurology residency

In addition, Cpt. Harold Collings MC (Medical Corps) RA (Regular Army) was transferred to the 361st Station Hospital both to initiate training in neurology, that he requested, and to aid Captain Reilly in the large neurological caseload at the 361st Station Hospital.

The usual indoctrination lectures by the author and other senior medical officers were held with both groups of incoming psychiatrists and neurologists at the 361st Hospital in Tokyo.  With addition of the September 1951 arrivals the theater was in an excellent position insofar as the availability of psychiatrists was concerned.

Changes of Assignment

Assignment changes of neuropsychiatry personnel in Japan during this period were as follows:

In July 1951 1Lt. Gordon McKay, psychiatric social worker, was transferred from the 382nd GH to the 361st Hospital to replace Major Morgan.

In August 1951 1LT. George Humiston, clinical psychologist, was transferred from the 279th General Hospital to Okinawa.  1Lt. Pamella Robertson, psychiatric social worker, from the 118th Station Hospital, was assigned to the 361st Hospital in Tokyo.  Also in August 1951 Captain Lorton was sent to Nara Convalescent Hospital to understudy 1st Lieutenant Hoffman and perhaps serve as his replacement in the event 1st Lieutenant Hoffman was transferred to Korea.  At the same time 1st Lieutenant Schlhaug was assigned to Omiya Convalescent Hospital for training with Cpt. Dermott Smith.  Maj. Lucinda DeAguiar was given a 30-day compassionate leave in August 1951.

In September 1951 1st Lieutenant Schlaug replaced Captain Smith, who became the 3rd Infantry Division Psychiatrist.  Also in September 1951, 1st Lieutenant Vazuka was assigned as neurologist to the Neuropsychiatric Service of Osaka Army Hospital, a position that had been vacant since July 1951.  In this month also Captain Rhead was sent to the Neuropsychiatric Service of the 141st General Hospital.

Change of Theater Consultant in Psychiatry

On 19 August 1951 Col. Donald Peterson arrived in the FEC to assume the position of Theater Consultant in Psychiatry.  Colonel Peterson and the author made a complete tour of psychiatric facilities in Korea so that he could obtain a first hand acquaintance with the various psychiatrists and their special situations.  A similar tour was made of most psychiatric facilities in Japan.  Colonel Peterson also collaborated in the indoctrination talks for incoming personnel at the 361st Station Hospital.  In general it was the author's belief that Colonel Peterson became well oriented on the various neuropsychiatric problems in the Far East Command.  The author left the FEC on 10 October 1951.

This concludes the history of psychiatry in the Korean War up to this author's departure.  An integral part of this review not previously mentioned was the splendid cooperation and strong support given the psychiatric program by various members of the medical sections of GHQ FEC, Japan Logistical Command, and Eighth Army. [P. 314]

FDJ:

This ends Col. Albert Glass's contribution to this volume except for appendiceal material.  When Colonel Glass arrived at Far East Command, psychiatry was in disarray with combat stress casualties erroneously being evacuated out of country and often back to CONUS.  This is reminiscent of the disastrous policies in the beginning of World War II in North Africa in which stress casualties became psychiatric cripples by being evacuated out of combat to languish in VA hospitals in the United States.

Colonel Glass quickly established correct policies for treating stress casualties with steadily increasing numbers of casualties being returned to combat or non-combat duty reaching 80-90 percent in the latter months of Colonel Glass's tour.  Following Colonel Glass's rotation, Col. Donald Peterson was theater Neuropsychiatry Consultant until the war ended.  Both he and Colonel Glass were later Psychiatry and Neurology Consultant to the Army Surgeon General.  Major (later Colonel) Ralph Morgan became the Social Work Consultant to the Army Surgeon General and Captain (later Colonel) William Hamill specialized in neurology and as a reservist served as Neurology Consultant to the Army Surgeon General.

Colonel Glass achieved fame in the military and civilian psychiatric community.  He edited the two-volume definitive history of military psychiatry in World War II and was working on this history of military psychiatry in the Korean War when he died suddenly at his desk.

Chapter 12

Military Psychiatry After the First Year of the Korean War

by Franklin D. Jones, MD, FAPA

The United States had been engaging in a massive demobilization at the end of World War II.  The Army was reduced from 89 divisions and eight million men in 1945 to ten divisions and 591,000 men in 1950. {Footnote 1, p. 540]  When the North Koreans crossed the 38th parallel to invade South Korea on Sunday, 25 June 1950, the United States had only a small advisory group in the entire country.  The United States had only a small advisory group in the entire country.  The United States was able to gain support from the United Nations to counter the North Korean aggression since the Soviet Union had refused to participate in the United Nations because of its refusal to seat Communist China in place of the defeated Nationalist Chinese.

Chartered in San Francisco in 1950 with 50 member states, the United Nations had been unable to take action against communist aggression previously because of the veto power accorded to the Soviet Union (as well as the United States, the United Kingdom, France, and China).  This absence allowed the United Nations to pass a resolution supporting military action in Korea.

In early battles the Republic of Korea (ROK) forces were crushed followed by the defeat and retreat of a hastily assembled and under-supported group of 540 Americans (Task Force Smith) dispatched from elements of the 24th Infantry Division in Japan.  Three later American delaying actions with larger forces failed and by August 1950 United Nations forces were reduced to a small foothold in the southernmost part of Korea (Pusan Perimeter).  General MacArthur placed ground troops in the Eighth Army under the command of General Walton Walker.  On 15 September 1950 General MacArthur counterattacked at the Incho'on harbour in an amphibious maneuver that ultimately cut off most of the North Korean forces in the South and resulted in their deaths or capture.  About 30,000 North Korean troops were able, however, to escape to the north.

The United Nations forces then drove north until the North Koreans eventually took refuge in Manchuria.  On 25 October 1950, United Nations forces found themselves fighting Chinese forces at the town of Ch'osan.  By 24 November 1950 it was known that United Nations forces were facing 300,000 well-armed Chinese troops.  A retreat was ordered to avoid envelopment and eventually the Chinese drove the United Nations forces back once again to south of the 38th parallel.  The floating bridges over the nearly frozen Han River were blown and Seoul was left to the advancing Chinese forces.  Not only Seoul, with a third of the South Korean population, but also the important Kimpo Airport and Inchon harbor were lost.  Ridgeway established a firm defensive line in mid-January running due east from Pyongtaek 75 miles south of the 38th parallel to the coast about 40 miles south of the parallel.

By mid-January 1951 United Nation forces under command of General Matthew Ridgway (General Walton Walker had been killed two days before Christmas in a motor vehicle accident) began a cautious drive north and recaptured Seoul by mid-March 1951.  During this time there had been a great deal of political maneuvering in the United Nations and a call for a ceasefire and the removal of all foreign troops from Korea.  This was rejected by China.

MacArthur continued to demand a policy of victory in Korea and unification of the country.  He called for blockading the Chinese mainland and opening a second front with the Chinese Nationalists.  Finally he made these suggestions in a public setting despite President Truman's patient explanation to him of the risks of Soviet intervention in Europe if such a policy were initiated.  President Truman had little recourse but to recall General MacArthur, which he did on 11 April 1951 and named General Ridgway as his successor.  Ridgway's forces included units from 15 nations, all less than brigade size, except American, ROK, British and Turkish units.  Lin Piao, the Chinese commander, had 485,000 men in 21 Chinese and 12 North Korean divisions.

When Ridgway stabilized his line in mid-January, he had 365,000 men in three American and three ROK corps.  The air situation had improved with the arrival of F104 Sabres which quickly established superiority over the Russian Mig15's flown by the Chinese (and probably by some Soviet volunteers).

Stalemate and Negotiations

The war entered a period of stalemate with small exchanges of territory between opposing forces.  In the ensuing year each side advanced and retreated but with little improvement in tactical situation for either.  By the end of 1941, General Peng, who had replaced Lin Piao, had 1,200,000 men of which 270,000 were deployed in the front line.  General Mark Clark, who replaced Ridgway in May 1952, had 768,000 men in Korea.

Two years after the North Korean invasion, peace negotiations began but the fighting continued.  Negotiations and fighting dragged on for another year until 27 July 1953 when an armistice was signed.  In May 1953 an initial exchange of prisoners (Operation Little Switch) had occurred and after the armistice a large number of prisoners of war (POWs) were exchanged (Operation Big Switch).  In general the first ones released had been those who cooperated most and in some cases collaborated with the enemy. [Footnote 2]  Following Col. Albert Glass, Col. Donald Peterson was FEC Neuropsychiatry Consultant from September 1951 until the end of the war in 1953.  Neuropsychiatry Consultants to the 8th Army in Korea were, in order: Col. Harold D. Whitten (1951-July 1952), Col. Paul Yessler (July 1952-July 1953) and Col. James Green (July 1953-July 1954).  Colonel Green replaced Colonel Yessler three days before the Armistice (27 July 1953).  The replacement for an outgoing physician was called his "turtle" for obvious reasons.

Paul Yessler and Henry Segal had examined the released POWs at Operation Little Switch and after the armistice they examined the POWs from Operation Big Switch.  Colonel Yessler did some of these interviews in Japan and on a two-week voyage to California.

Dr. William Mayer was also on a ship transporting the POWs and he gained a great deal of attention by reporting on the degree to which some soldiers collaborated.  Dr. Mayer felt that the American soldiers lacked willpower due to overindulgent mothering.  He felt that this caused them to collaborate but also made them prone to die more readily in harsh circumstances due to "giveupitis."  A U.S. Army White Paper rebutted Mayer's assertions and revealed that most of the communist propaganda was accepted by only a small number of POWs, mainly among minority groups who had experienced discrimination due to their race or ethnicity.

The 37 months of fighting had produced 550,000 United Nations casualties including almost 95,000 dead.  American losses numbered 142,091 of whom 33,629 were killed, 103,284 wounded and 5,178 missing or captured.  The bulk of casualties occurred during the first year of the war.  The estimate of enemy casualties, including prisoners, exceeded 1,500,000, of which 900,000, almost two thirds, were Chinese.

In the Korean War, three fairly distinct phases are reflected in the varying types of casualties reported.  The mid- to high-intensity combat from June 1950 until November 1951 was reflected in traditional anxiety-fatigue casualties and in the highest rate of combat stress casualties of the war, 209/1,000/year in July 1950. [Footnote 4]  Most of the troops were divisional with only a small number being less exposed to combat.  This was followed by a period of static warfare with maintenance of defensive lines until July 1953 when an armistice was signed.  The graduate but progressive build-up of rear area support troops was associated with increasing numbers of characterological problems.

Norbury [Footnote 5] reported that during active combat periods anxiety and panic cases were seen, while during quiescent periods with less artillery fire the cases were predominantly characterological.  Following the armistice obviously few acute combat stress casualties were seen.  The major difference in overall casualties other than surgical before and after the armistice was a 50 percent increase in the rate of venereal disease among divisional troops.

Commenting on the observation that psychiatric casualties continued to be present in significant numbers following the June 1953 Armistice of the Korean War, Marren [Footnote 6] gives a clear picture of the reasons:

The terrors of battle are obvious in their potentialities for producing psychic trauma, but troops removed from the rigors and stresses of actual combat by the Korean armistice, and their replacements, continued to have psychiatric disabilities, sometimes approximating the rate sustained in combat, as in the psychoses.  Other stresses relegated to the background or ignored in combat are reinforced in the post-combat period when time for meditation, rumination, and fantasy increases the cathexis caused by such stresses, thereby producing symptoms.  Absence of gratifications, boredom, segregation from the opposite sex, monotony, apparently meaningless activity, lack of purpose, lessened chances for promotion, fears of renewal of combat, and concern about one's chances in and fitness for combat are psychologic stresses that tend to recrudesce and to receive inappropriate emphasis in an Army in a position of stalemate... Sympathy of the home folks with their men in battle often spares the soldier from the problems at home.  The soldier in an occupation Army has no such immunity... Domestic problems at home are often reflected in behavior problems in soldiers, particularly those of immature personality or with character defects. [Footnote 6, pp. 719-720]

The main result of the Korean War was that NATO was greatly strengthened.  In June 1950 NATO was virtually without power but in 1953 NATO could call on 50 divisions and strong air and naval contingents.  Also both the United States and the Soviet Union had become thermonuclear powers, the United States having exploded a hydrogen bomb in 1952 and the Soviet Union in August 1953.  Furthermore, the despot, Stalin, was dead and there was some thawing of East-West relations.

Psychiatric Lessons of the Korean War

Just as in the initial battles of World War II, provisions had not been made for psychiatric casualties in the early months of the Korean War.  As a result they were evacuated from the combat zone.  Due largely to the efforts of Col. Albert J. Glass, a veteran of World War II, who was assigned as Theater Neuropsychiatry Consultant, the U.S. Army combat psychiatric treatment program was soon in effect and generally functioning well [Footnote 7].  Since only five years had elapsed, the lessons of World War II were still well known and the principles learned during that war were applied appropriately.  Combat stress casualties were treated forward, usually by battalion surgeons and sometimes by an experienced aid man or even the soldiers' "buddies," and returned to duty.  Psychiatric casualties accounted for only about five percent of medical out-of-country evacuations, and some of these (treated in Japan) were returned to the combat zone.  To prevent the "old sergeant syndrome," a rotation system was in effect (nine months in combat or 13 months in support units).  In addition, attempts were made to rest individuals ("R and R" or rest and recreation) and, if tactically possible, whole units.  Marshall warned of the dangers to unit cohesion of rotating individuals, but this lesson was not to be learned until the Vietnam War.

These procedures appear to have been quite effective with two possible exceptions.  One was the development of frostbite as an evacuation syndrome.  This condition, which was the first psychiatric condition described in the British literature during World War I [Footnote 9], was almost complete preventable, yet accounted for significant numbers of ineffectives.

The other problem was an unrecognized portent of the psychiatric problems of rear-area support troops.  As the war progressed, American support troops increased in number until they greatly outnumbered combat troops.  These support troops were seldom in life-endangering situations.  Their psychological stresses were related more to separation from home and friends, social and sometimes physical deprivations, and boredom.  Paradoxically, support troops who may have avoided the stress of combat, according to a combat veteran and military historian, were deprived of the enhancement of self-esteem provided by such exposure [Footnote 10].  To an extent the situation resembled that of the nostalgic soldiers of prior centuries.  In these circumstances the soldier sough relief in alcohol abuse (and, in coastal areas, in drug abuse) [Footnote 11] and sexual stimulation.  These often resulted in disciplinary infractions.  Except for attempts to prevent venereal diseases, these problems were scarcely noticed at the time, a lesson not learned.

The Korean War revealed that the appropriate use of the principles of combat psychiatry could result in the return to battle of up to 90 percent of combat psychiatric casualties; however, there was a failure to recognize the types of casualties that can occur among rear-echelon soldiers.  These "garrison casualties" later became the predominant psychiatric casualties of the Vietnam War [Footnote 12]. Vietnam and the Arab-Israeli wars revealed limitations to the traditional principles of combat psychiatry.

References - Chapter 12

1.  Matloff, M.  American Military History.  Washington, DC, Office of the Chief of Military History: US Government Printing Office; 1969.

2.  Yessler, P.  Personal Communication, 11 March 1987.

3.  Mayer, W.E.  Why did many G.I. captives cave in?  US News and World Report.  24 February 1956: 56-72.

4.  Reister, F.A.  Battle Casualties and Medical Statistics: U.S. Army Experience in the Korean War.  Washington, DC: US Government Printing Office; 1973.

5.  Norbury, F.B.  Psychiatric admissions in a combat division in 1952.  US Army Medical Bulletin Far East.  1953; July: 130-133.

6.  Marren, J.J.  Psychiatric problems in troops in Korea during and following combat.  Military Medicine.  1956; 7(5): 715-726.

7.  Glass, A.J.  Psychiatry in the Korean Campaign (Installment I).  US Armed Forces Medical Journal.  1953; 4:1387-1401.

8.  Marshal, S.L.A.  Pork Chop Hill.  New York: William Morrow Company; 1958.

9.  Fearnsides, E.G., Culpin, M.  Frost-Bite.  British Medical Journal.  January 1915;1:84.

10. Kirkland, F.  Personal Communication, July 1991.

11. Glass, A.J.  Personal Communication, January 1982.

12. Jones, F.D., Johnson, A.W.  Medical and psychiatric treatment policy and practice in Vietnam.  Journal of Social Issues.  1975;31(4):49-65.

About the Authors

Glass, Albert Julius, M.D., F.A.P.A., Col. (Ret), U.S. Army

Formerly Division Psychiatrist, 85th Infantry Division (World War II); formerly Chief Psychiatric Consultant to the Far East Command (Korean War); formerly Psychiatry and Neurology Consultant, Office of The Surgeon General, U.S. Army; formerly Director, Oklahoma Department of Mental Health; formerly Director, Illinois Department of Mental Health.

Jones, Franklin D., M.D., F.A.P.A., Col. (Ret.), U.S. Army

Clinical Professor, Uniformed Services University of the Health Sciences; Past President and Secretary and Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and Neurology Consultant, Office of The Surgeon General, U.S. Army