Fighting Fear

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This was an issue of tremendous significance. If normal men could break, it meant that the problem of military psychiatry involved not just a small segment of abnormal individuals but the whole Army. It meant further that it would not be sufficient for psychiatrists merely to treat men who had broken down; they would have to focus not on the soldiers but on the soldiers’ environment, identifying the stresses in it and attempting to reduce them. The method we developed is an epidemiological approach to preventive psychiatry that was effective in the Army and could be directly applicable elsewhere.

One of the main things I did, or helped to do, was take psychiatrists out of the hospitals and put them out in the field among normal soldiers who had not broken down. Orders were issued assigning psychiatrists as advisers to commanders in training, personnel, and other departments that controlled policies affecting soldiers.

The line commanders were somewhat startled to find psychiatrists being thrown at them, but they gradually discovered that the newcomers had interesting things to say. For example, in choosing soldiers to lead troops in combat, psychiatrists frequently selected the same individuals experienced line officers did, even though the doctors were hardly fighting men themselves and often came from backgrounds with zero leadership experience.

Meanwhile, we established an Armywide reporting system that showed that the largest number of men broke down where the most men were killed. In the Mediterranean theater of operations—North Africa and Italy—studies established that by the time a regiment had been in combat for 120 days, 50 percent of its original strength, on average, had been killed, wounded, captured, or was missing in action; by 200 combat days, 90 percent of the regiment was gone.

Casualty rates of 1,200 to 1,500 per thousand per year were not uncommon for short periods of intense combat in rifle battalions, whereas corresponding units in all other branches of the Army rarely suffered rates above 20 to 30, a little less than one-fiftieth as high. In the North African theater the average soldier had broken down by 88 aggregate combat days; practically every man in a rifle battalion who was not otherwise disabled ultimately became a psychiatric casualty.

These were startling findings, but they were based on statistics; they could be wrong. I decided I’d better go to the front and clinically examine the neuropsychiatrie (or NP) cases to see for myself if they indeed were normal men and the danger of being killed or wounded in combat was the abnormal stress that had done them in.

The rate of killed and wounded and consequent rate of NP breakdown were highest around Monte Cassino, where the 5th Army under Gen. Mark Clark had become stalled in its push up the boot of Italy. The life expectancy of a platoon leader there was 27 aggregate days of frontline duty, that of the infantryman not much more. This seemed a good place to start. I flew from Washington in May 1942.

I’d gotten myself ordered to the 601st Medical Clearing Company of the 5th Army, and I stayed there for six weeks. The company was located a few miles behind the front and handled all neuropsychiatrie patients evacuated from the 5th Army’s infantry divisions, the 3d, the 34th, the 36th, and the 45th. Here indeed were men suffering from “combat fatigue,” dazed, exhausted, shuddering, jumping at the slightest noise, and constantly talking about “them shells.” These were the shells from 88s, the devastatingly effective German field guns.

I was able to examine more than a hundred cases. They turned out to be ordinary Americans, truck drivers, clerks, married men, with families and friends in civilian life. Were they cowards? Well, they certainly were now too frightened to stand up to danger. Did that indicate cowardice? Perhaps they were brave men who had become “cowards.”

The division psychiatrists drew my attention to what they referred to as the oldsergeant syndrome. These men, bearing multiple stripes on their arms and medals for valor on their chests, had served in frontline combat for one or even two years, through the campaigns in North Africa and on up through Italy. They were strong men with excellent combat records. But following the Cassino and Rapido actions, there were more of them than of new men coming in as psychiatric patients. They said things like “I’m the last old man left in my platoon” and “There’s only two of us old men left, and they’re no better off than I am. You’ll be seeing them soon.”

A subsequent survey found that the medical and line officers were in unanimous agreement that by the time a man had served 200 to 240 aggregate days of combat he was ineffective. If he had not “cracked up,” he was so jittery under shell fire and so overly cautious that in addition to being ineffective as a soldier, he demoralized the newer men.

Everything pointed to the average infantryman’s having an effective combat life that depended largely on how continuously he was used in combat. The British estimated that their riflemen in Italy lasted about 400 combat days, twice as long as their American counterparts. They attributed the difference to their policy of pulling men out of the line at the end of 12 days or less, for 4-day rests. The American soldier, on the other hand, was usually kept without relief for 20 to 30 days, and occasionally for 80.