PREVENTION OF LOSS OF MANPOWER FROM PSYCHIATRIC DISORDERS -
SURGEON GENERAL’S REPORT
"Just as an average truck wears out after a certain number of miles it appears that the doughboy wore out, either developing an acute incapacitating neurosis or else becoming hypersensitive to shell fire, so overly cautious and jittery, that he was ineffective and demoralizing to the newer men. The average point at which this occurred appears to have been in the region of 200 to 240 regimental combat days."
This page contains two reports on the prevention of manpower loss in rifle battalions during World War II.
The first report (dated 16 September 1944) is from Norman T. Kirk, Surgeon General. The "attachments" and "tabs" referred to in this report is no longer with the report in the National Archives.
The second report is a summary of the Surgeon's findings and recommendations, published by the Army in December 1944.
16 September 1944
MEMORANDUM for: The Assistant Chief of Staff for G-1, Room 2E928, Pentagon Building.
Subject: Prevention of Loss From Psychiatric Disorders.
1. In an effort to discover specific measures by which the loss of manpower from psychiatric disorders could be reduced an intensive study of the psychiatric problem in the North African Theater was made during 17 May through 29 July 1944. (See attachment No. 1)
2. The recommendations and findings of this study submitted below are believed to pertain to United States troops in all combat theaters. Certain of them apply particularly to the psychiatric problem which will arise when large numbers of troops are shifted to the Pacific theaters upon cessation of hostilities in Germany.
3. Summary of findings:
a. General. The key to an understanding of the psychiatric problem is that in combat the danger of being killed imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are just as inevitable as gun shot and shrapnel wounds in warfare. Prevention can be thought of only in terms of preventing needless waste of manpower.
b. Extent of Manpower Loss From Psychiatric Disorders. Of all branches, the infantry is most effected by danger. Battle casualty rates in no other branch even approach the same levels. For this reason loss of manpower from psychiatric cases is greatest in infantry units.
(1) In general 15-25% of the total nonfatal battle casualties are neuropsychiatric.
(2) Of more significance, however, is that in the North African theater practically all men in rifle battalions, not otherwise disabled, ultimately became psychiatric casualties. Just as a 2 1/2 ton truck becomes worn out after 14-15000 miles, it appears that the doughboy became worn out. The point at which this occurred appears to have been in the region of 200-240 aggregate combat days. The number of men on duty after this is small and their value to the unit negligible. (See Tab A)
c. Incentive. Infantrymen would be much more effective and last longer in combat if they were provided with some incentive to do so. Under the present policy nobody is removed from combat until he has become completely worthless. The infantryman considers this a bitter injustice. It seems to him he is expected to do 10 times, or 1000 times as much to win the war as anybody else, yet, all he can look forward to is being killed, wounded, or completely broken down nervously. He feels nobody back home has the slightest conception of the danger his job entails, nor of the courage and guts required to do one hour of it. He feels that the command makes no distinction between him and base area troops and actually is even less concerned for his welfare. The command has failed to make the broader issues of the war meaningful to him. He is willing to do what he considers his share, but after that he sees no reason to keep on. All he wants is to get out of combat duty. Became of this a wound or sickness is regarded not as a misfortune, but a blessing. Under these circumstances it is easy for him to become convinced in all sincerity that he is sick or unable to go on. This in turn leads to the premature development of genuine psychiatric disability and needless loss of manpower (See Tab B)
d. Leaks in Evacuation Screening. There is a widespread tendency for unit commanders to abuse medical channels of evacuation by attempting to use them as a means of getting rid of men who are noneffective through inadequate leadership rather than sickness. Medical evacuation is an honor means of getting out of combat. If an inexperienced battalion surgeon or an overly sympathetic psychiatrist permits goldbricks, cowards, and poorly motivated soldiers to escape through this channel the morale of the entire unit is undermined and genuine psychiatric disorders develop. (See Tab C)
e. Replacement System. The strongest force which keeps a man effective in combat is his self respect and pride. This in turn is dependent on the strength of the bond existing between himself and his fellow soldiers. In this regard there is a marked disadvantage in coming overseas and going into combat as an individual replacement. (See Tab D)
f. Training. (See Tab E)
g. Leadership. The majority of company grade and higher commanders have not regarded themselves as having direct responsibility for the attitudes and beliefs of the men under them (See Tab F)
4. Recommendations. To decrease loss of manpower from psychiatric disorders it is recommended that:
a. The following measures be taken to provide incentive for the infantryman to keep fighting:
(1) Upon completion of 200 (or 240) aggregate days of combat an infantryman be relieved from combat duty for a period of six months and given the option of serving this period in the United States.
(a) This policy should apply only to enlisted personnel of rifle battalions.
(b) The loss of manpower involved would be insignificant since the number of men in rifle battalions who attain the aggregate combat days is small and their subsequent value to the unit negligible. (See Attachment No. 2)
(c) Complaints which might arise from other personnel could be simply met by offering then the option of transfer to the infantry.
(d) Operation of the policy is administratively feasible. (See Tab G)
(2) Infantry troops should be constituted as a special type of soldier with special privileges. These should include more assiduous applications of priorities on supplies and equipment; provision of desirable articles not available for base area troops; recreation and entertainment facilities available for base troops never be put off limits for infantrymen in the vicinity on pass or furlough.
(3) Unit commanders again be reminded of their responsibility for insuring that subordinates at every level understand their place in each tactical plan and the reason for taking each objective.
(4) The following information be collected in readily available form and presented to troops through all available media:
(a) Evidence that the enemy intended to subjugate the United States and became very close to being powerful enough to do so.
(b) Evidence that if not now defeated unconditionally they soon will be powerful enough to try again.
b. The criteria and channels for disposing of medical and disciplinary noneffectives be clarified and the serious results of an overbalance either towards harshness or towards leniency be brought to the attention of unit commanders.
c. Infantry replacements be requisitioned and assigned by units of 3 to 9 men who have been trained and kept together from the beginning of their basic training.
d. Unit commanders again be reminded of their direct responsibility for the attitude and beliefs of the men under them and that effective methods and facilities available for their assistance in meeting this responsibility be further publicized.
NORMAN T. KIRK
This Memorandum was
sent to the following:
Special Technical Intelligence Bulletin No. 3
PREVENTION OF LOSS OF MANPOWER FROM PSYCHIATRIC DISORDERS
A REPORT OF THE SURGEON GENERAL
This publication is issued solely to give proper and speedy dissemination to timely, useful information concerning pertinent trends and developments. Nothing herein is to be construed as necessarily coinciding with United States Army doctrine. Changes in official doctrine, as they become necessary, will be officially published as such by the War Department.
PREVENTION OF LOSS OF MANPOWER FROM PSYCHIATRIC DISORDERS
A more adequate command recognition of the factors responsible for high troop losses from psychiatric disorders among front line combat ground troops, and the command applications of measure for reducing the loss of manpower from this source has been recommended by the Surgeon General.
The recommendations are the result of studies of the cause of psychiatric disorders, their effect on troop strength, and possible preventive measures made in the North African Theater of Operations in the heavily used Fifth Army Infantry Divisions in Italy.
ROLE OF DANGER
Cause of breakdown
The key to an understanding of the psychiatric problem is the simple fact that the danger of being killed or maimed imposes a strain so great that it causes men to break down. There is no such thing as ‘getting used to combat’. Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.
Greatest danger in infantry
Of all arms, the Infantry is exposed to the greatest danger. Precisely for this reason, it also suffers the greatest loss of manpower from psychiatric disorders. In the North African Theater neuropsychiatric casualty rates of 1200 to 1500 per 1000 strength per year were not uncommon in rifle battalions, whereas corresponding units of all other branches rarely suffered rates above 20 to 50. In general 15 to 20 percent of the total nonfatal combat casualties (N-P plus WIA) were neuropsychiatric.
Extent of loss in North African Theater
Of more significance, however, is the fact that in the North African Theater practically all men in rifle battalions who were not otherwise disabled ultimately became psychiatric casualties. Although only one to three percent of the combat strength was lost from this cause during any single offensive, apparently the intensity and duration of the continued campaigns surpassed the limit of endurance of the average soldier. Just as an average truck wears out after a certain number of miles it appears that the doughboy wore out, either developing an acute incapacitating neurosis or else becoming hypersensitive to shell fire, so overly cautious and jittery, that he was ineffective and demoralizing to the newer men. The average point at which this occurred appears to have been in the region of 200 to 240 regimental combat days.
Individuals developing psychiatric disorders after less than 200 combat days are frequently returned to full combat duty. The worn out soldier, on the other hand, is through. At least six months would be required to make him effective again for combat, although he still may be useful in noncombat assignment.
Effective Combat Life of Infantrymen
The effective combat life of the average infantryman appears to depend largely upon how continuously he is used in combat. The British, for example, estimate that their riflemen in Italy will last about 400 regimental combat days, about twice as long as U.S. riflemen in the heavily used U.S. divisions in Italy. They attribute this difference to their policy of pulling infantrymen out of the line at the end of 12 days or less for a rest of four days. The American soldier in Italy, on the other hand, was usually kept in the line without relief for 20 to 30 days, frequently for 30 to 40, and occasionally for 80 days.
Incentive to Fight
Although tactical requirements may have required this policy, the fact that a man wears out in combat has apparently been insufficiently recognized by command.
It is believed that infantrymen would be much more effective and would last longer in combat if they were provided with more incentive to do so. It is rudimentary knowledge that behavior is determined by motivation, but it is a fact which appears not to have been applied to the infantryman.
Under present policy no man is removed from combat duty until he has become worthless. The infantryman considers this a bitter injustice. He feels that he is expected to do ten, or even 100 times as much to win the war as anyone else, but he can look forward only to death, mutilation, or psychiatric breakdown. He feels that no one at home has the slightest conception of the danger his job entails or of the courage and guts required to do one hour of it. He feels that the command does not distinguish between him and the base area soldier, and is actually less concerned for his welfare.
Base area troops occupy safe jobs and live in comfortable barracks but they receive practically the same pay, rank, promotions, and priority on furloughs to the States, and they receive a great deal more in the way of passes, entertainment, recreation, chocolate bars, cigarette-lighters, and so, on.
Incentive to to Win
It would be convenient if the soldier were more concerned with winning the war. However, the command has failed to make the broader issues of the war meaningful for him.
In itself, winning the war is unimportant to the American soldier. The realization has never dawned on him that there might be danger to him or to his family if he did not continue fighting.
Winning the war is important only as the time when he can be relieved from combat, but that time to him is in some vague and distant future, too remote to have any real meaning. The Russians are fighting to avenge the death of their loved ones and to drive the enemy from their soil; the British fight for survival; and the French are fighting their way back to France. The doughboy fights because he has to. He fights for his buddies and because his self-respect will not let him quit. For a period this is a very strong incentive, but the time comes when it loses its effectiveness. After a man has been in combat for several months, and has fought well through several campaigns, he has proved to himself and others that he is neither a weakling nor a quitter. How he behaves after this point cannot disprove this. Moreover, after several months of combat he looks around to find that most of his buddies are gone. He is one of the "old" men. For whom can he fight now? What incentive has he to go on?
The doughboy is willing to do what he considers ‘his share’, but after that he sees no reason to keep on. If he deliberately shirks his duty or runs away, of course he will be court-martialed. But if he becomes unable to fight further, then he gets out of combat on an honorable status. Thus a wound or injury is regarded, not as a misfortune, but a blessing. Under these circumstances it is easy for a man to become sincerely convinced that he is sick or unable to go on. This in turn leads to the premature development of genuine psychiatric disability and to needless loss of manpower. It also leads to self-inflicted wounds and to misbehavior before the enemy.
MEANS OF REDUCING MANPOWER LOSS
There are specific measures which would provide incentive to the infantryman to keep fighting and which would thus decrease his tendency to become a psychiatric casualty.
Tour of Combat Duty
The first is the one most strongly and desperately pleaded for by all combat men, namely "a break". To be effective a goal must constitute something a man wants and what a combat man wants above everything else except his self-respect is to get out of combat. Thus the most effective goal which can be supplied is the promise of an honorable release from combat duty at a definite time.
The chief argument offered against such a policy is the claim that it would entail too great a loss of effective manpower. This argument can be met, however, by relieving individuals rather than entire units and also by the fact that after 200 to 240 regimental combat days the military value of the average man is negligible. He will soon break in any event.
The left-hand panel of the chart below gives an approximate picture of the proportion of original rifle battalion strength remaining on duty any number of regimental combat days after the battalion first entered combat, the data being based upon a recent statistical study of battle and nonbattle casualties made in the headquarters of the Fifth Army. On any day the number of men who have as individuals experienced that many combat days is slightly smaller, some men having lost time in hospital. Experience factors have been applied to allow for return to combat duty on the part of both sick and wounded personnel and for non-battle attrition when the unit was not in combat. The right-hand panel, which is based upon the same observations provides estimates of the additional cost of various policies under which men would be relieved of combat duty after having as individuals experienced the stated number of regimental combat days.
A tour of 240 days would increase replacement costs only by 5 percent. Although policies can be set so as to minimize the added cost, and so as to reflect the experience of the particular theater, it is important that the goal not be too remote to affect incentive. These estimates represent a stable condition and do not reflect the immediate costs of instituting such a policy, which would be somewhat higher.
Approximate computations suggest that the initial cost of instituting a 210 day policy would be in the neighborhood of 2,500 men for the entire North African Theater.
The justification for restricting the policy to infantry battalions is that no other unit suffers comparable attrition rates. Complaints which might arise from other personnel could be amply met by offering them the option of transfer to the combat infantry.
Rewards for Achievement
A second measure to increase incentive is to establish more appropriate rewards for achievement. The infantryman should be officially recognized as a special type of soldier with special privileges. Recognition of his importance should be reflected in the more assiduous application of priorities on supplies and equipment, the provision of coveted articles sow available primarily for base area troops, and, when on leave, unrestricted access to all recreation and entertainment enjoyed by base area troops.
It is recognized that there are the competing claims of paratroopers, airborne infantry, tank men, members of demolition units, etc., but the infantryman is at present the least appropriately rewarded specialist in the Army.
A third approach to the problem places greater emphasis upon what may be designated as tactical orientation. Incentive for taking an objective can be markedly increased by knowledge of the tactical situation with particular attention to the reason why the objective must be taken. Briefing of infantry troops is currently practiced according to the interest of the individual commander. It is believed that a definite War Department policy to this effect would be of great value.
A fourth approach attempts to make the goal of winning the war a more meaningful one to the combat soldier. This might be designated as strategic orientation and logically combined with the tactical briefing.
There is little doubt that lack of conviction as to the necessity or fighting is playing a major role in the performance of combat troops. It is believed that a great improvement could be made in this direction. Granted that the most important time to present data on why we fight is during training back in the States, and that at first glance it might appear ridiculous to tell veterans of two and one-half years what they are fighting for, nevertheless, men in combat need desperately to be reminded of what they are fighting for. The need to be reassured constantly that what they are doing is worthwhile and appreciated.
The data on why we fight which would make most sense to the combat infantryman is the evidence that the enemy intended to subjugate the U.S. that he very nearly acquired the power to realize this ambition, and that he will again threaten the U.S. if not now driven to the ground. The soldier in Europe has seen occupied and war-torn countries. If he could be made to understand the threat to himself and his family he could believe that, were he not fighting abroad, he would be defending U.S. soil. The evidence of the intent and ability of the enemy to harm the U.S. may not have been compiled in readily available form, for no more than a small portion of it has ever been presented to U.S. military personnel. Many officers, particularly higher commanders, have not regarded themselves responsible for the attitudes and beliefs of personnel under their command. Their concept of leadership has not extended to the realm of ideas and beliefs. Many have realized that indifference toward the issues of the war resentment over strikes in the States, and lack of tactical briefing, were all causing morale problems in their commands, but few have realized that they should or could act to counteract these attitudes. Few of them exhibit any knowledge of the orientation program, news services, informational materiel, or other facilities available to assist them in this problem.
Leaks in Evacuation Screening
There is a widespread tendency for unit commanders to abuse medical channels of evacuation by attempting to use them as a means of getting rid of men who are non-effective through inadequate leadership rather than sickness. Medical evacuation is an honorable means of getting out of combat. If an inexperienced battalion surgeon or an overly sympathetic psychiatrist permits goldbricks, cowards, and poorly motivated soldiers to escape through this channel, the morale of the entire unit is undermined and genuine psychiatric disorders develop.
The medico-legal aspect of the problem further complicates the picture. It is currently stated in Italy that there is no longer any such thing as cowardice in the U.S. Army, for any man who runs away from the enemy falls into the hands of a psychiatrist before he can be court-martialed and is thereupon declared not responsible for his acts on the grounds of psychoneurosis. Many line officers are very bitter about this and accuse psychiatrists of undermining the discipline of combat forces. On the other hand, the same line officers are naturally very disturbed at the possibility of punishing a man who was truly out of his head at the time of the of the offense. Also these same line officers often are the worst offenders in attempting to abuse medical channels in order to get rid of disciplinary noneffectives.
It is believed that there is an urgent need to clarify the categories and channels of evacuation in the minds of both line officers and medical officers.
The strongest force which keeps a man going in combat is his self-respect and pride. His strength depends upon the bond between himself and his fellow soldiers. In this regard there is a marked disadvantage in going overseas and into combat as an individual. It is believed that combat infantry replacements would be more effective if they were requisitioned and assigned in small units of three to nine men who had been trained and kept together from the start of basic training.
PSYCHONEUROSIS IN AN INFANTRY DIVISION
Methods employed in the handling of psychiatric cases during the Saipan campaign are described in a report by the psychiatrist of an infantry division.
Of the total number of psychiatric casualties admitted to the field hospital during the campaign from this division, 75 percent were returned to duty either in combat or service areas. The remainder were evacuated. The high percentage of cases returned to duty was achieved, at least in part, through the new methods developed for handling them.
Psychiatric casualties were routed through the usual channels to the clearing station and then to the field hospital. Despite the severity of the condition, all neuropsychiatric disorders were tagged as “exhaustion” in the field. Such tagging served a dual purpose; first, the term “exhaustion” suggested to the soldier a temporary condition; second, he was spared the stigma of a neuropsychiatric diagnosis. It was noted that those with true fatigue responded promptly (within three or four days) to rest, sleep, diet, and sedation when required. More acute cases, however, responded slowly to treatment and often required evacuation.
The division psychiatrist expressed the belief that in future operations such treatment could take place in the clearing station which should be located in its conventional site, namely three to seven miles from the front and outside the range of small arms fire. In such a location, its function can be carried on where a reasonable amount of safety is provided the patient and where he remains a part of the combat picture, which he would lose if he were evacuated to rear hospital facilities. This has a psychological advantage in that he does not feel that he is a patient but that he is physically exhausted and with a short period of rest will be on his feet again.
Experience proved that the further a patient was removed from the scene of mental injury, the more prone he was to remain such a casualty, and the less desire he had for returning. Therapy was materially assisted if instituted prior to fixation of such mental injury, i.e., the point at which he begins to feel sorry for himself. Also, if he sees that he is being treated by people subject to the same hazards as himself (vicinity of clearing station), he remains a part of their world subjectively, rather than becoming objective to the scene (a bystander).
The division psychiatrist recommended that a convalescent area should be made available for those who respond more slowly to the treatment given. This area should be used only for those who need segregation and who are not ill enough to occupy a hospital bed, yet not fit for full duty.
In order to assist in the prevention of psychiatric casualties the necessity for mental hygiene in its non-technical phases should be appreciated by the line, and every effort should be made to indoctrinate all commanders, from squad to regiment, with the absolute necessity for a healthy mental outlook in their personnel. In this respect the unit psychiatrist should stand ready to teach the basic principles of mental hygiene and to counsel and advise those requiring his technical assistance. Such a program, with intelligent screening on the part of commanders and surgeons, will do much to reduce the number of neuropsychiatric casualties usually attendant on such an operation.