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PREVENTION OF LOSS OF MANPOWER FROM PSYCHIATRIC DISORDERS - SURGEON GENERAL’S REPORT |
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"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. Published by 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. INCENTIVES NECESSARY
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. Tactical
Orientation 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. Strategic Orientation 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. Group
Replacements 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 Saipan Campaign 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. |
