MEDICAL SCIENCE PUBLICATION NO. 4
MEDICINE AND SURGERY (19-30 APRIL 1954)
BASED ON PROFESSIONAL MEDICAL
EXPERIENCES IN JAPAN AND KOREA
U. S. ARMY MEDICAL SERVICE
WALTER REED ARMY MEDICAL CENTER
WASHINGTON, D. C.
WALTER REED ARMY MEDICAL CENTER
MAJOR GENERAL LEONARD D. HEATON, MC
ARMY MEDICAL SERVICE GRADUATE SCHOOL
COLONEL WILLIAM S. STONE, MC
LIEUTENANT COLONEL FRANK L. BAUER, MC
MEDICAL SCIENCE PUBLICATION No. 4
30 April 1954
DAVID McK. RIOCH, M. D.
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,
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
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
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
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
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
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
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.
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
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
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.