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MEDICAL SCIENCE PUBLICATION NO. 4
RECENT
ADVANCES
IN
MEDICINE AND SURGERY (19-30 APRIL 1954)
BASED ON PROFESSIONAL MEDICAL
EXPERIENCES IN JAPAN AND KOREA
1950-1953
VOLUME II
U. S. ARMY MEDICAL SERVICE
GRADUATE SCHOOL
WALTER REED ARMY MEDICAL CENTER
WASHINGTON, D. C.
WALTER REED ARMY MEDICAL CENTER
MAJOR GENERAL LEONARD D. HEATON, MC
Commanding
ARMY MEDICAL SERVICE GRADUATE SCHOOL
COLONEL WILLIAM S. STONE, MC
Commandant
MEDICAL DIVISION
LIEUTENANT COLONEL FRANK L. BAUER, MC
Director
MEDICAL SCIENCE PUBLICATION No. 4
FRIDAY
MORNING SESSION
30 April 1954
MODERATOR
DAVID McK. RIOCH, M. D.
COMBAT
STRESS*
BRIGADIER
GENERAL S. L. A. MARSHALL, RETIRED
In a meeting of this kind, there is the initial difficulty that the audience
does not really know the speaker, his experience, his credentials and his
reliability, and the speaker may only guess what those whom he faces would be
most interested in hearing. That is especially the case when an amateur comes
before professionals not too well qualified to speak their language or to
relate what he has learned to the practices of a quite different field of
endeavor. With no effort at modesty, I would therefore plead my sense of
shortcoming for the task at hand, being encouraged to go on only by the
realization that it is a subject concerning which no man alive has a truly
competent knowledge. My approach to it is that of one who has learned a few
things from practice rather than acquired a general wisdom of a great many
things through prolonged exposure to theory. I am not a scientist or a soldier
though I have been a dabbler in both fields. I am a reporter and, as such, I
have always thought of the human race as the material of my workshop.
I have long been interested in the combat field in war because it is the
crucible of human experience; there is no better place to know man as he really
is, stripped of nearly all of his pretensions. Still, looking back over 50
years, I would say in the summing up that there are but three things I have
learned from this earthly journey: No. 1. Life is much too short; there is not
time to learn very much; just about the time we begin to scratch beneath the
surface of knowledge, fate jerks us shrieking to another stage. No. 2. It is
not necessary to learn very much to win an unmerited reputation for expertism
in a given field: gaining about 1 percent more knowledge and experience than
the competition, "you just can't miss." No. 3. Practically every new
truth one may develop which adds anything original or different to the
mainstream of human knowledge arrives by accident. Intelligence and logic have
little to do with the matter. The new idea has to rise out of earth and
"smack you about three times between the
*Presented 30 April 1954, to
the Course on Recent Advances in Medicine and Surgery, Army Medical Service
Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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eyes" before you see it. Truly, I have concluded that there is no such
thing as intelligence; there are merely varying degrees of ignorance.
The one exceptional note in my background is that I have gone 10 times to
war in a relatively short life, sometimes as a soldier, and part of the time as
a correspondent. In 15 American campaigns, I have been with infantry, operating
ahead of regimental headquarters, either as a commander or staff officer. There
is a type of lunacy in which the victim hits himself in the head because it
feels so good when he stops. But that is not my difficulty, I am sure, though
an initial curiosity had much to do with it. In my first go at the combat line
during World War I, I discovered to my utter astonishment and delight that its
normal dangers did not give me an abnormal concern. I did not dream at night
about whatever horror I had witnessed in daylight. Machine gun and artillery
fire did not give me the involuntary urge to duck or wince. Nothing was greatly
oppressive but the dugout smell and the loathing for having to live
underground. Being then 17, I wondered whether it was because, as the junior in
the company, I was not weighed down by responsibilities toward a wife and
children. It seemed an argument for not getting married. But I could not tell.
The wonder continued: "Was a man born or conditioned in a certain mold?"
If he could "take it," was this because of prior fortune, mainly? I
went back a sufficient number of times to find out. A man remains the same,
though years come and responsibilities change. Provided he remains favored by
good health, he will react in much the same way at 50 as he did at 20. Always
on going up, there is the same dreadful sweat of anticipation, as if one were
doing it for the first time, except for the inner voice saying: "You fool,
why did you let yourself in for this again? Will you never learn?" But
always on arrival the habit of applying one's self to necessary work takes
over. This is the essential, the one necessary adjustment. At the front no
other therapy helps more than marginally.
My subject is combat stress; I would like to state my thoughts about it as
simply as possible. The object of all training and disciplinary procedures
should be toward systematizing the doing of effective, collective work in the
danger area, so that the individual, finding a use for his hand and mind, is
recalled from a rising terror. The main difference between seasoned and green
troops is not that the former, having felt fire, come to discount its danger.
To the contrary, the longer one stays, the more superstition takes over. But
seasoned troops have learned to habituate themselves to duty as a personal
easement which in the end insures unit stability.
There is a point which may apply here: I have read somewhere that our
medical authority has set 265 days or some number of combat
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days as the ceiling for the American soldier, the idea being that if we
exceed it, the breakdown rate will become excessive. With this, I do not agree,
because I could not accept the validity of any set of statistics in support of
it. It is not a problem to be approached statistically; at least, that is my
conviction. The figures prove nothing because in our recent wars, there has
been too little flexibility, individually and collectively, in the
administration of the infantry commitment. The line commander, seeing a good subordinate
nearing the cracking point-and this is relatively easy to determine-has no
authority to rotate him briefly to rear area duty for recuperation. Because our
infantry reserve has been invariably less than the need in our more recent
efforts, there was small chance to apply common sense in affording the combat
unit rehabilitation respite from pressure. But had we ever been in position to
apply conservation to our vital fighting material, we would have saved much
wreckage, and we might have learned that the American soldier, rightly used,
can continue on for an indefinite number of combat days. Fear and its
degenerative effects are not, as I see it, cumulative. We continue to discount
the amazing regenerative capability of the human mechanism. This is not because
the specialists in that mechanism have been shortsighted or unimaginative but
because soldiers who make policies with slide rules are not prepared to listen.
We may be approaching the point where we will either do better or go down.
I recall July 1918, my regiment was making an 11-mile approach march to the
front line. It was a balmy evening, and clear. There should have been no sweat.
There was nothing particular prompting foreboding about that journey except the
vast pyrotechnical display forward, raising the presumption that if the lights
were that much needed, the action must be terrific.
As we arrived at the line, I was astonished to see my platoon in a state of
collapse; men dropped in their tracks and could hardly remove their packs. I could
not understand it. Three weeks later I was more surprised to see the same
men-those who survived-shoulder the same packs and march 35 miles rearward,
doing it "in a breeze." The contrast then spelled nothing more
important to me than that it is easier to march away from a fight than to march
into it.
Years passed and I still, in reflection, saw no more meaningful lesson. Then
at Makin Island during the Gilberts invasion, I was once again with infantry in
an attack at the line of the equator. Fourteen days earlier I had flown out of
Washington and therefore had had no chance to get acclimated. In the early
morning I landed with the First Battalion against Red Beach. They continued on
into the bush. Feeling quite myself, I returned to the transport to keep track
of the logistical movement. At noon, I landed with the Second Battalion
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against Yellow Beach. Their task was to cut through the heart of the Jap
citadel to the lagoon, a distance of less than 600 yards. I intended to go with
them. I got at least 100 yards. By then we were under mild sniper and machine
gun fire. Suddenly my physical strength was completely spent, and with it, my
nerve and my ability to think. I was a shattered wreck, much too old for the
wars. In my mental fog, I concluded I was a victim of combat fatigue, and I lay
down under a palm, awaiting a stretcher bearer. I intended to return to the
ship and have myself marked a casualty. But a solitary rifleman came along,
stopped in front of me and swallowed some pills. I asked what it was and he
said salt. I said: "Give me some; they can't make me feel worse than I
do." I bolted 10 of them. Within one-half hour I felt a whole man again. I
did not again make that mistake in the Pacific, though it caused me to wonder
how many men have been shot for cowardice on the field of battle who had needed
only that simple cure. But no one had ever told me that from neglect of this
elementary precaution could come not just heat stroke but the loss of that
essence which we call "manhood" in the human spirit. I had to learn
it the hard way though I paid no price.
Later on, during the Marshalls invasion, General Arch Arnold asked me to
determine why it was that an infantry line, checked three times by enemy fire
in a quite short movement, even though it took no losses, became spent and
could not renew the advance. It was a puzzling phenomenon. I found certain
things wrong with our tactical procedures. We were fighting through semi-jungle
country, much like the growth on the Florida Keys. When the line went flat
after being fired upon, the men could not see one another. They remained inert
and fearful; there were no devices for giving them quickly a sense of the
presence of others. So group collection stagnated and the individual spirit
withered. A technical solution was immediately possible. It was recommended
that at the onset of any such situation, it be made SOP for all junior leaders
to crawl along the deployed line, each calling to his men. In this way we could
partly overcome the greatest enemy of the rifleman-individual loneliness. Man
is a gregarious animal. His greatest steadying force is the touch of his
fellows. Under battle's pressure, he cannot long endure out of sight and voice
contact with them. It was so in the time of the Medes and Persians; it will be
so in the wars of undefined dimension in a terrible tomorrow. Such marvels as
radio and television do not change it. We need the touch of the hand, even as
we need the conviction that we are a useful part of something much larger and
more important than ourselves, whenever the pressures of life put inordinate
demands upon our frail persons. One of the most challenging military statements
I know is that in World War II more than 50 percent of our
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so-called combat fatigue cases failed their first time in battle, and that
the majority of these were men who had just arrived and were given no
opportunity to meet their unit.
Yet we still tolerate procedures which directly promote this rate of wastage,
and we even call it good. The condition in Korea under rotation was the
sorriest example I can call to mind. Replacements would arrive at a front-line
unit and be given a battle station. For maybe 6 weeks or more, they would
belong to a company without ever seeing it, though they were part of it in
combat. They knew only the men living in their own bunkers. When at last the
company went out of line, they began to feel an identity with it.
Dr. Rioch was with me for several weeks in Korea. My work at that time was
the setting up of a new system for the debriefing of patrols. Invariably I
dealt with shattered patrols which had been full-bodied and fresh the prior
evening. The cases were far too numerous in which men had been sent on patrol
deep into no-man's land or enemy country, and had failed to return from it,
before they had ever been given the chance to meet their own unit. In one
patrol, 7 of the 18 men who had not made it back had arrived in the line for
the first time on the same evening they were sent out. There was one greatly
encouraging thing about it-one only-the ability of the average young American
fighter to take this kind of mishandling by his nation and still remain loyal,
eager, and full of fight is a modern phenomenon. They are better than we know,
potentially far more willing and able than we have yet admitted to ourselves.
Some of the statistics seem to reflect that we are becoming a nation of
"weakies," that an alarming percentage of young Americans are
mentally or physically unfit for military service, and that among those who
qualify, the flesh, though full, is too often excessively soft. I would simply
bear witness that the American troops-combat-with whom I dealt during two tours
in Korea were perhaps the best all-out fighting men who have ever served the
country-certainly, the ablest within my experience.
The policy-rotation-which too often denied them the substance of that strong
uniting force which is supposed to be a combat soldier's right is defended on
the ground that by providing a terminal point, and giving them a hope for home,
it bulwarked morale in a difficult period. But it was the cheapest form of
rotation, arrived at to achieve a dollar saving, and in balance, it was a
greater load on command and to the rifleman than a help to the human spirit. It
signally bypassed the main principles of military organization. As one
artillery brigadier put it to me: "The trouble isn't that we can't get
along with it but that some chump in Washington will think it's good and we'll be
stuck with it from now on." Rotation is worth mentioning only
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because it is symptomatic of a national ailment. In the Twentieth century we
are supposed to have gained more light on the spirit, mind, nervous
organization and flesh of man, and to have arrived at clearer undertanding of
the balance coming of the relationship between these things than in any prior
period. Nonetheless, the trend of policy within the military establishment, as
I see it, is toward placating weakness rather than rallying strength. This was
not forced upon us; rather, we did not make any real effort to resist the
diverse and untoward pressures which brought it about. So today, coca-cola
works, lollipops, and R & R are falsely given a priority over the
re-invigorations of ideals and requirements which put the utmost claim upon the
manhood of the male individual. We say that the future will require us to get a
higher level of performance out of our average soldier than ever before; but we
are not doing the things which would make it possible.
One truth, I feel, has stood the test of the ages: The will to risk greatly,
and to fight when it becomes necessary, is the ultimate proof of masculinity.
This is said with all possible deference to the values of that other great
proving ground-the boudoir-which, like John Paul Jones, I would not despise.
There may be a common demnominator in the two undertakings. The main wheel in
the drive of the real fighting man is the feeling that he personally, and also
his company, are both a startling success. Give him that pulse, and he not only
wears well, but continues to improve. One of the main signs that the
Army-largely by a tug on its own bootstraps-had lifted itself in Korea was the
return of the competitive feeling between one combat unit and another. Able
wanted to believe that it did a better fighting job than Baker. King or Love
would ask the question where other line outfits had better fighting tricks
unknown to them. They took pride in what they represented as a company group.
In World War II, that spirit was signally missing. Questions about the relative
unit capability were never once raised by any unit-yet I dealt with more than
500 rifle companies.
This remark may seem aside from a discussion of combat stress. I believe it
has bearing. In the midst of terrible endeavor, when fear mounts and crisis
thickens, the rifleman-though it may not be a conscious thought-needs the
steadying awareness that his nation and its military system have done the best
possible to harden him toward his ordeal. No soundness in treatment at the time
can overcome the degenerative effects of policies which put less than an
exacting demand upon the loyalty, integrity, and will of the male individual.
Having made tribute to the strengths of young Americans in Korea as I found
them, I add that during the bitter hours of our retreat out
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of North Korea, our shattered rifle formations continued to ask me why the
Army had taught them so little about how to survive in combat though it had
found time for ample indoctrination on practically everything else. They
expected me to answer for the system; I did not know what to tell them. As the
Army's Chief of Orientation in 1942, I had witnessed the deplorable surrender
to the idea that schooling a man in the justice of his cause was the main thing
instead of assisting him to a feeling of personal achievement in a new, but
worthwhile environment. Man is a finite being. As to his personal adjustments,
his horizons are not far beyond his fingertips. He cannot enthuse about a world
cause if he is treated like a dog in his squad. But in the person of an
inspired company commander, he can catch the reflection of his noblest ideals,
his faith in the nation, his love for his people.
Could we all but believe in this until policy guides firmly upon it, far
less of your time would have to be spent in sweeping up the debris. I, too,
have dealt with it. In the ETO, I screened personally 353 line officers who had
failed in combat, looking for the number which could be salvaged and put to
useful work. Finally, I took 27 of them as replacements; no one of them ever
let me down. But as I remember them in mass, the outlasting impression is one
of a body of men who felt they had lost their man's estate and were looking for
any opening by which to reclaim it. They were intelligent, earnest Americans.
They were not cowards; but there were pressures to which they could not be
conditioned. Of those who came with me, I sent as many as seemed wise back to
the line on duties which took them at least within the sound of guns. It simply
seemed to me that this was part of the business of giving them more secure
personal foundations.
After this long detour, I return to the subject of the findings in the
Pacific. Though we had administered a tactical specific, the mystery still
remained: Why did the riflemen erode so rapidly under fire though the physical
stress undergone was relatively light?
No light came until months later when I dealt with the rifle companies which
landed on Omaha Beach. On that dreadful field, panic and hysteria, halfway
action and extreme intrepidity were co-mingled. Some companies were so
thoroughly beaten by the early fire that in mid-afternoon the men sat on the
sands staring into space, seemingly, seeing and hearing nothing. They did not even
stir to find cover. Such officers as remained mobile forced weapons into their
hands, instinctively feeling that any act would be the beginning of recovery.
But there were other companies which, under completely adverse conditions,
because of strong leadership, forged ahead with painful slowness. There had
been control in these units at all times. Some had arrived unscathed at the
sands; finally they had triumphed. Yet one
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and all, as they recounted the maneuver, they spoke of the sudden shock discovery
of their physical weakness. Resolute of will, they still could not carry the
loads or move the distance possible under training.
In this way, I began to see what I should have known a quarter century
earlier-that fear and fatigue are concomitant and reciprocal in their effects
on man on the combat field. There is no point here in attempting to become
technical by describing the body reaction, the increase of lactic acid in the
muscles, the diminution of glycogen and the gradual paralysis of that function
in the male individual which gives him his most celebrated-and
troublesome-distinction. In more recent years I have collected many learned
papers on this subject. I could have lifted their language. But it would not
have impressed you and it could have baffled me. All that is worth saying is
what it does to the fighter. The more heavily men are loaded, the farther they
move, the more susceptible they become to fear. The more intense becomes their
fear, the greater becomes the impairment of their physical power. Whether the
degradation come of work or of terror, recovery is a function of time and of
the extraordinary regenerative potential of the body mechanism.
What was 10 years ago simply a theory based upon data from the battlefield
which seemed mathematically to exclude other hypotheses has been in the years
since a subject for rather comprehensive battlefield experiment in addition to
repeated laboratory tests with varying degrees of relevance. Suffice to say
that the general conclusion has been substantiated, though scientific argument
about the particulars continues. The Army moved with astonishing speed. One of
its field boards picked up the subject: There was brought about a wholly new
concept of one-man logistics, which has resulted in a broad program modifying
all man-carried equipment and procedures, whereby what we expect of our average
man in battle conforms to common sense. Some of my scientist colleagues in
Korea ran combat tests to determine the changing chemistry of man under fire.
Perhaps science must proceed in this way. To me it seems like running for a
street car after you have caught it.
By then my attention was drawn in quite another direction. I felt that we
needed to know more about the recuperative factor, or interval, and I believed
that Korea was an excellent laboratory for learning. It is not enough to show
that a fighter can be knocked down by fear: One need ask, how soon, and by what
means, can he be expected to get up from the canvas, swinging? Had this line of
inquiry been seduously followed up in Korea, I feel confident that by now we
would have a set of radically surprising answers, some of which would alter
training methods and tactical procedures.
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Because my time was directed toward other lines of study, all I can give you
are a few definite impressions. The first is that relatively little sleep is
needed to re-invigorate and make combat-worthy a totally exhausted company.
While on that point, I would like to add that when fighting men are totally
exhausted, no amount of discipline can make them dig foxholes or use average
prudence. It becomes a physical impossibility. The time comes when inertia
overpowers reason and men would rather take a chance of death than make one
more move.
When first dealing with troops, I heard numerous reports of riflemen who had
become caught and killed while in their sleeping bags. The bag was described as
a "death trap." In all my searching, I did not find one provable case.
But I did find numerous examples where this happened: The company had
arrived late and exhausted at its ridgeline objective. The commander knew he
was supposed to remain at total alert because of the near presence of the
enemy. Looking his men over, he also saw they were in no shape to fight. So he
took a chance and told them to get into the sacks. Perhaps 20 minutes later
they were hit. The men were out, up and fighting with greater speed and more
fury than he had imagined possible. In other companies, alongside them, or at
least under the same conditions, the commander had followed the opposite
course, playing it safe, he thought, by keeping all hands "alert."
When hit, the command had no unity of action and rapidly dissolved. Nature
cries out against arbitrary orders in circumstances like these. Squad leaders
do lip service to it, then on returning to their positions, modify the order,
put one man on guard for a spell, and tell the others to keep one eye open. But
it is an unsatisfying compromise.
After an all-night defense in which from hard body blows and fear it had
been reduced to a state of paralysis, one company of the 27th Regiment was told
to sleep by its captain. One-half hour later came the word that it would
prepare an attack against the key enemy ridge blocking the withdrawal of the
division. It hit at 1100. As the assault started, its officers were shot down.
The uphill attack which followed, carrying right to the skyline under NCO
leadership against heavy fire, was one of the most thorough and courageous
charges in our history.
Studying both the Marine Corps and Army operations, I found also what
appeared to be a direct correlation between the duration of the period in which
the individuals had been under excessive emotional pressure and the time
required for complete rest, after which they would bound back to normal. If the
fear-and-fatigue exhaustion, or the panic shock, were consequent to a brief few
hours of excessive strain and terror, a quite brief rest, as I have indicated,
would restore their fighting mobility and response to order. But if the period
of
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stress was prolonged over some days-and here I speak of acute stress-it was
found necessary to give them 24 to 48 hours of almost uninterrupted rest. The
point is, however, that they did bound back to normal. When returned to
duty in the line, there was no noticeable carry-over from the experience; no
marked incidence of slacking, disobedience, physical or emotional collapse
among them. No troops in Korea knew a harder ordeal than those who were trapped
on the eastern side of the Chosin Reservoir. In 5 days these men of 7th
Division experienced defeat, loss of their commander, capture, starvation and
exposure in 30-degree-below-zero weather. But after the few still mobile
survivors-there were about 350-were given 48 hours rest, they fitted into the
Marine line, did their part and marched out with the column.
It would be unbecoming to reason from the particular to the general. The few
propositions which I have advanced here should be supported by several volumes
of proof. But while my collection of data is mountainous, I do not have time to
write all the books I would wish. I must make a living; writing military books
is not a good way to do it. But the mind, I hope, is still able to assimilate
much which the hand is not free to transmit. In strengthening the governing
military principle-conservation of force-prevention is still better than cure;
yet in what we do with men, we too often go against nature. The thoughts which
I have expressed are all pertinent to one central theme. Whether we are
thinking about doing that at sunset which will restore man for the engagement
of the night or so administering him over war's long term that he can be
returned as a more useful and believing citizen of the Republic, the rule of
action is that he not be pushed beyond his tolerance limits, but rather, that
he be afforded temporary relief in time. Dean Inge described man as a creature
half angelic, half satanic. Any father of a 3-year-old would certainly agree.
No matter whether it applies to men of combat age, it is only through an
understanding of the elementary truth that a fighter's clay has well-defined
mortal limits that we achieve that enlightened usage of him which lifts his
heart and exhalts his spirit. In this, soldiers are no different than
bookkeepers.
My World War I commander, General Summerall, once said that he won his
victories by making men march one mile beyond their possible limit. To that, I
would reply that no force on earth ever made a man extend one mile beyond his
possible limit, and when commanders try for it, they risk leaving their fight
on the road and condemning too many of their men to life in a mental
institution.
One observation which I made in Korea was that the physical capacity of the
average American for marching, and for effective fighting at the end of a
march, shows that in our time the book has
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exaggerated his powers by approximately half. We are becoming a half-legged
people. We are not rearing a generation of lusty, confident,
weather-conditioned sons and daughters of democracy. In fact, we are letting
our people forget how to walk. Thirty pounds on the back of the average young
man in this country will break him down. We think we are getting somewhere physically
because 100,000 people gather in the Philadelphia stadium to see 22 men
struggle around a ball. We forget that 65 percent of American boys reach
manhood without ever having taken part in a group game.
In Korea, the average country-bred porter could walk three times as far
under the same load, or walk an equal distance under a triple load, as the
average American soldier. I personally recommended the organization of the
Korean Service Corps because it was obvious that our troops were unequal to the
logistical requirement which, in the straitened circumstances, many of our
commanders were disposed to put upon them. For exercise, mature Americans
travel farther under cover and on the seats of their pants than any people the
world has ever known. But this does not help the troop leader who is ordered to
take a ridge far beyond leg-reach by his men, though it does contribute to
those group failures of which come personal defeat, frustration, and breakdown.
I do indeed believe that the well-regulated company, and above it, an
understanding by command of the endurance limits at the lower levels, are both
the open sesame to battle success and the main safeguard within an army against
those ills which, when too little regarded, make mountainous our problems.
As for my own view of why, in Korea, there was relatively less difficulty
with casualties of the noncombat type-and I am not speaking here of
freezing-though the subject is debatable, I would attribute progress to three
factors:
1. Revival of the spirit of the good company.
2. Improvement in evacuation of the battle
casualty.
3. The absence of a hospitable rear: Korea does not
look good anywhere.
Having no more than skirted the fringes of my subject in this discourse, I
feel this the proper point to call a halt. As Mark Clark writes in his latest
book, I have but sighted down the lines of my rifle, and the target cannot be
more than what I see. Of the little I have learned, I am not too sure. Of the
much I do not know, I am absolutely certain.
