October 1999 | Volume 50, Issue 6
“If you gotta go, you gotta go” is what they replied when I asked, “Do you want to go into military service?” In 1940 tanks were rolling I across Kurope, bombs were exploding, blackness was descending. The United States was in clanger. Did these young men leap to our defense? No. They were not volunteering; they had been drafted. “If you gotta go, you gotta go,” they said.
I was a civilian psychiatrist at an induction station examining these draftees to determine if they were mentally fit for military duty. Their resigned, apathetic reply to my question hardly seemed conducive to effective performance, let alone to their mental health.
Later studies determined that that single question, asked at induction, “Do you want to be in the service?,” predicted actual emotional breakdown better than any other. Negative responses heralded subsequent mental disorder.
Pearl Harbor, of course, turned the threat of war to reality. Although physicians were not being drafted into the service at that time, I decided I shouldn’t wait. But how could I help most effectively? Not by doing what psychiatrists did ordinarily—that is, treat patients, which takes months or even years and involves only one person at a time.
It came to me that perhaps I could help prevent soldiers from breaking down, rather than try to treat them after they had done so. I reasoned that the apathy I had seen in the inductees was due primarily to their failure to comprehend that they and their families were actually threatened by the enemy. They still thought, “Well, if you’re drafted, you gotta go.” My plan was to use mass media to show Hitler’s and Japan’s intent—and ability—to conquer the United States along with the rest of the world. I reasoned that if this were done effectively, it would make the troops angry and eager—in short, motivated.
My father-in-law, Rear Adm. Alan G. Kirk, who later commanded American naval forces during the Normandy landings, was close friends with Harvey Bundy, special assistant to Secretary of War Henry Stimson, and Bundy gave me personal contacts. I got an appointment to see Gen. Frederick Henry Osborn, head of the Information and Education (I&E) Division, which was responsible for maintaining Army morale. I told him my proposal. He was receptive, even enthusiastic. I then saw Col. Roy D. Halloran, director of neuropsychiatry in the Surgeon General’s Office. He agreed to institute a section for preventive psychiatry, which I would head while also serving as liaison with General Osborn’s division. I enlisted and was given the rank of first lieutenant. My assignment was to prevent the seven million men in the Army from having nervous breakdowns.
I was ordered to the Office of the Surgeon General, U.S. Army, Psychiatry Division, and given my desk as chief of the Preventive Psychiatry Branch. Shortly thereafter Colonel Halloran was replaced as head of the Psychiatry Division by Gen. William C. Menninger, M.D., of Topeka, Kansas.
I remember entering General Menninger’s office, standing smartly to attention, saluting, and saying, “Lieutenant Appel reporting for duty, sir.” General Menninger looked at me with a friendly smile and said, “Oh, come off it, Jack. Call me Bill.” Merely “Bill”? How could I regard him with appropriate awe? I soon learned, however, experiencing the immense competence with which he performed, that “Bill” could be a term of the highest respect.
As psychiatric liaison to the I&E Division, I took on my first project—helping make five movies in a series entitled Why We Fight , to be shown to recruits. I recall discussing id, superego, and ego with the experts making the films: a Harvard professor of sociology, a professor of psychology from Yale—and Ted Geisel, or “Dr. Seuss.” I said that the soldier’s superego would tell him it was his duty to fight; his ego would convince him fighting was a good idea; and his id would arouse his emotions, his fear, and his anger. Thus did Sigmund Freud enter the fray on the American side. We enlisted the help of Hollywood, and the films were made and shown throughout the Army.
One of the problems the Psychiatry Division faced was that the military wisdom of the day held that normal soldiers did not break down, that only neurotics did. This belief had led to the policy of screening “weaklings” out of the Army. The policy soon proved a failure. Psychiatric cases accounted for more than a third of all casualties being shipped home from overseas, despite the fact that 12 percent of all men rejected at induction stations had been turned down for psychiatric reasons. Already a substantial winnowing had occurred, and those taken into the armed forces were the psychological cream of the civilian population.
So if screening was not the answer, what was? Edward A. Strecker, who had served as a frontline psychiatrist in World War I, said a lesson learned there was that whereas in peacetime abnormal men break down from normal stress, in wartime normal men break down from abnormal stress. The question: Was this true in World War II?
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.
Individuals developing psychiatric disorders after fewer than 200 days could successfully be returned to combat by the excellent frontline treatment developed in North Africa. But a man who was “worn out” was through as a fighting soldier. (Years later studies showed these ex-soldiers functioning at normal levels in civilian life.)
What was combat stress really like? I needed to go see for myself. I had myself ordered to a battalion aid station in the front lines. Under fire—from some small arms, bombs from airplanes, and, worse, “them shells”—I quickly learned that if the sound of an incoming round went from higher to lower, it had passed by to explode elsewhere. But if the sound kept rising, you’d better duck; it was coming your way. I learned to dive for cover with some enthusiasm.
The sense of danger hit me at once, and in my report I said that the experience of frontline combat duty could no more be comprehended by one who had not had it than could the experience of sexual intercourse. Constant fear of death accompanied a feeling of immediate deep bonding with the other men in the unit. Today, more than fifty years later, the faces of the men in my outfit are still vivid in my mind. If, for example, Blackie, a sergeant, should show up at my front door in Radnor, Pennsylvania, I would recognize him immediately, embrace him, and invite him to stay for as long as he wished. This is true despite the fact that I was with the unit for only three days. I noticed, too, that once I received orders to return to the rear, the feeling of bonding disappeared immediately. I became a stranger in their midst.
Once out of the line, seeking remedies, I consulted with various division psychiatrists who had been diagnosing and treating NP cases for many months. All cited the poor morale, the hopelessness of the infantryman; he saw himself as underappreciated, as the low man on the totem pole, the sucker. One way to attack this was by publicly recognizing the frontline soldier’s importance. I proposed establishing a large combat badge, bright blue, to be worn by every fighting infantryman, and also providing extra pay for days spent in action.
But most important, we had to offer a ray of hope. Army regulations assigned soldiers to frontline duty —period. The only way out was death, injury, or war’s end.
The only remedy would be to change regulations so as to offer a foreseeable end to combat duty and honorable escape. My next step was to return to Washington as rapidly as possible to try to get such a measure adopted. I was concerned that my written report, which I carried with me, might be deemed critical of theater operations—as indeed it was—and seized by censors at the airport. I managed to have myself made a military “courier.” This meant I was given a locked and sealed briefcase, chained to my wrist, immune to censorship. It contained confidential documents, among them my report, and I passed into the States without incident.
Back in Washington I began my chief task: to determine the optimum length of the tour—short enough to offer hope for the soldier, long enough to keep the loss of manpower to a minimum. The War Department would have to be assured that the loss was acceptable before it would seriously consider the proposal. I joined forces with Gilbert Beebe, a highly competent statistician in the Surgeon General’s Office, and we set to work determining and analyzing the casualty rates in the Mediterranean theater. By 214 aggregate days of combat duty, all men had broken down psychologically—that is, if they had not been wounded, killed, or lost to physical sickness. The number who had survived that long was so small that the loss of manpower involved in releasing them would be acceptably slight. We finally decided to recommend a tour of 180 aggregate days.
Now to compose that report and the proposal. I had been told that Gen. George Marshall, the Army Chief of Staff, would not read anything longer than a single paragraph on a single page. I distilled what I had to say into that space and bulwarked it with appendices and supporting data, along with the comments of various reviewing officers. Of course I never got a direct response from the general, but the limited tour of duty for infantrymen was adopted and became an Armywide policy, applied in both Europe and the Pacific during the final campaigns of the war—and in Korea and Vietnam as well.
Also adopted were those blue combat badges—plain for infantrymen who had not yet fought and embellished with a silver wreath once the wearer had seen action. They were worn proudly, I believe, and did raise the morale and status of the infantryman. (Soldiers in other combat units—artillery, for instance—who protested could be offered transfers into the infantry, whose casualty rates were invariably far higher.)
My final contribution to the war effort took place after the fighting had ended, but if the psychological matters it addressed were no longer the stark ones of life and death, they were urgent enough to the soldiers they affected. Logistically it was easiest to release troops stationed in the United States, and this is what Washington headquarters blithely commenced to do. The effect of this on troops overseas may be imagined. They had done the actual fighting, yet who was being rewarded? The men who had cushy, safe assignments close to home. When the injustice of this was drawn to Washington’s attention, the policy quickly changed: Combat troops were to be discharged first, noncombatant overseas troops next, and soldiers on stateside duty would have to wait their turn. We accomplished this by establishing a point system, in which credit was given for number of days in combat, number of days overseas, and number of days in the Army.
And so the troops came home. Millions of soldiers melted back into civilian life, as did I. There was a relief in taking off my uniform—it was a lieutenant colonel’s by then—but I admit to feeling a pang at surrendering the kind of authority the Surgeon General’s Office had conferred upon me. Harry Truman had warned General Eisenhower: “Things are different for a President than for a general. When a general gives an order things happen: thousands of men move, guns go off, bombs drop. When I, as President, sitting here at my desk in the Oval Office, give an order, nothing happens.” It had been exciting for me to have so much power, to be able to think up an idea and then have the whole Army adopt it. It was rather heady to be able to conduct Army-wide questionnaires on any topic I chose, asking questions such as “Do you bite your fingernails?” (17 percent did, as I remember) or how many prayed when going into battle (72 percent).
From a medical viewpoint, the most exciting event had been that discovery that every man has a breaking point. This had not been known previously to psychiatry or to anyone, I believe. Dr. Strecker had come to that conclusion during the First World War but had based it on anecdotal rather than scientific evidence. It is now accepted in the military but is still hardly common knowledge. That it is true has enormous implications for understanding social structure and human nature.