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Colonel Frederick R. Hanson
Lieutenant Colonel Stephen W. Ranson
Although the difficulty in obtaining statistics on any medical problem in combat is nearly insurmountable at times, it is possible to obtain reliable data most of the time if a relatively simple uniform system is constantly used. To be of value any system adopted must (1) provide a continuous and current evaluation of the neuropsychiatric casualty rate for each unit down to and including battalions, (2) contain comparable figures on "Sick" and "WIA" (Wounded in Action) for each reporting period, (3) provide a uniform method of collection of data so as to permit a comparison between divisions and, within the division, between regiments and battalions, and (4) provide a continuous and current record of these statistics at the level of division, army, and theater. Higher headquarters must be informed without delay of any unexplained increase in neuropsychiatric casualty rates. In the Mediterranean Theater of Operations a practical system was developed by trial and error. It was used continuously by Fifth and later Seventh Army for a year and a half. The data were collected, compiled, and reported every 2 weeks by the division psychiatrist, on whom rested the sole responsibility for this duty. The casualty figures were obtained from the records of the division clearing station, and the "Operational" reports were usually obtained from the regimental S-1 and S-3. When possible, the explanation for any major fluctuation in rate was obtained from the surgeon of the battalion concerned. The routine collection of data was usually delegated by the division psychiatrist to a responsible enlisted man. The collected data were forwarded through the division surgeon on the 15th and last day of each month, and copies of the report were retained in the office of the division, army, and theater surgeon.
The reporting forms used were mimeographed, and a sample copy is illustrated in figure 10. It will be seen that the daily figures
by battalion form an effective means of discovering any unusual increase in neuropsychiatric casualties. When this increase is disproportionate to the number of wounded, the average ratio being 1 neuropsychiatric casualty to 4 WIA, it is a sure index of trouble in the battalion. This trouble may arise from a variety of sources, the most common of which are: unusually unfavorable environment, prolonged combat without rest, poor leadership, alteration in evacuation policy by the battalion surgeon, or mass breakdown in unit morale from any cause. Any one of these situations requires immediate investigation by the division psychiatrist and usually also by Command. It must be kept clearly in mind at all times that the psychiatric casualty rate in a unit is directly proportional to the feeling and efficiency of the unit, and that for every neuropsychiatric casualty there are several other borderline or incipient casualties. Constant attention to the comparative neuropsychiatric casualty rate of the various units is the most reliable means available of measuring the existing and potential state of well-being and efficiency of a unit. Through this means, it is possible to control and prevent mass loss of badly needed combat personnel.
The parallel between casualty rates in terms of wounded and psychiatric casualties is clearly demonstrated by figures 11, 12, and 13. These graphs were prepared from the reports of the various division psychiatrists in the Mediterranean Theater of Operations, and they cover the period from the invasion of Italy in September 1943 to the end of December 1944. They include such major actions as Cassino, Anzio, Garigliano, and the Gothic line. In these graphs, the fact that psychiatric casualties are as inherently combat casualties as are wounds is inescapable. The great majority of psychiatric disorders arising among combat troops may be classified under the heading of "Neurosis." Figure 14 shows that there is a wide fluctuation in the rate of occurrence of neurotic disorders among combat soldiers, whereas psychotic and neurologic disorders occur at a relatively fixed rate which does not appear to be influenced by the intensity of the fighting. Table XIV shows the relative frequency of the various types of psychiatric disorders. In this table it will be seen that anxiety reactions comprise about 85 percent of the total neurotic disorders. Disposition of the various types of neuropsychiatric disorders is given in this same table.
Total neuropsychiatric cases discharged from all of the hospitals of Mediterranean Theater, January to June 1944
L. S.-Limited service.
In figure 15 the results of treatment of psychiatric disorders within the combat zone are given in terms of disposition. All patients returned to duty from the divisional level were returned to full combat duty. Of the patients returned to duty from psychiatric treatment installations at the army level, some were returned to full combat duty ("A" duty) and some were returned to noncombat duty ("B" duty) with troops in the "combat zone." Clear distinction should be made between the technical term "combat zone" where actual combat occurs and the lay use of the term to include the entire theater of operations. Throughout this volume "combat originated" applies only to those cases which arise within actual range of enemy artillery. Many of the patients evacuated to the "communications zone" for further treatment were returned to duty within the theater but relatively few of them ever returned to duty within the "combat zone." When these disposition figures are studied the question "How effective are these former neuropsychiatric patients?" almost invariably arises. This is a hard question to answer. The answer can have meaning only in terms of performance of assigned duty. Glass made followup studies of 393 neuropsychiatric patients returned to combat in the 85th Infantry Division in the Italian Campaign. Their effectiveness was compared with the effectiveness of those who had been returned to combat after hospitalization for sickness, minor injury, or wounds.
Figure 16 indicates that there was no essential difference in the effectiveness of those previously treated for sickness, minor injury, or neuropsychiatric disorders. It is probable that psychiatric factors played a role in all of these cases. Although comparatively greater effectiveness of the WIA returnees has not been explained, it must be recalled that only 9 percent of all wounded are returned to combat. Figure 17 indicates that there was a marked difference in effectiveness, on return to combat, between the group of soldiers who were good soldiers prior to evacuation for neuropsychiatric disorders and those who were not good soldiers before evacuation. Brief psychotherapy rarely affected the basic personality traits of the soldier treated, and, therefore, it is to be expected that the maladjusted soldier will continue to perform his duties ineffectively when his maladjustment arises from long-standing personality disorders rather than from powerful environmental stresses.
The criteria of what constitutes "effectiveness" on the part of the soldiers studied were established by Glass who said:
"Either the soldier performed effective duty after returning to his unit or his performance was judged to be ineffective. In order to be scored as effective it was necessary for the returned soldier to participate in 30 days of offensive combat duty or 60 days of defensive combat duty. This duty had to be rated by members of his unit as average or above average. The 60 days of defensive combat duty were necessary as an alternate standard to score subjects who were returned to duty in the latter stages of the campaign, i. e., the Italian Campaign. Failure of the subject to participate in the required period of combat duty because of administrative transfer, disciplinary infractions, or hospitalization for disease and injury was arbitrarily ruled as evidence of ineffective performance. The inability to complete the required combat duty because of causes arising from battle (killed, missing, or wounded) was regarded as evidence of effective duty performance and scored as such. All subjects who were rated as poor or useless in combat were scored as ineffective, regardless of the length of time they remained with their units."
These criteria are stringent, and it is probable that noncasualties, rated under this system, would show an ineffective rate of about 25 percent.
Ludwig made a study of the comparative rate of return to combat of neuropsychiatric patients derived from inexperienced divisions in contrast to those originating from experienced divisions. The figures include all psychiatric casualties admitted to Seventh Army medical facilities (both division clearing stations and army centers) between 1 January and 15 May 1945. The statistical material from this investigation is contained in table XV. Ludwig says of these data:
"The factor of total combat experience of the parent divisions exercised a very marked effect upon the percent of psychiatric cases which hospitals were able to return to full combat duty. This operated in the following manner: (1) New and inexperienced divisions were prone to evacuate mild cases, as well as cases not suffering from true psychiatric disorders, i. e., those with normal fear reactions developing early in combat, and the unwilling and poorly motivated soldiers. This derived from the fact that medical officers as well as psychiatrists in such divisions had not yet learned to differentiate correctly between these cases and those with disabling combat neuroses. As divisions developed more combat experience, these deficiencies were remedied, and far fewer mild cases were evacuated from the division. (2) Divisions with long combat records tended to evacuate a high percentage of soldiers with from 6 to 12 months of total combat exposure. Most of these had developed fixed anxiety states, with or without reactive depressions, of varying degrees of severity. It was our impression that such soldiers, even though they might willingly return to combat when told to do so, were rarely of any further value to their units in combat. In consequence, the rate of returns to duty from army psychiatric centers tended to be high in new divisions, and low in old divisions."
Returns to full combat duty of psychiatric casualties after hospitalization, correlated with total combat exposure of parent division of these casualties. Eleven divisions in Seventh Army, 1 January to 15 May 1945
(ref 1) Combat time here is given as the total combat exposure of the division at the end of the war, subtracting rest and training periods.
It will be noted from this table that the rate of return of psychiatric casualties to full duty after hospitalization tended to decrease progressively as the total combat exposure of the parent division increased.
A study of 358 patients who had been evacuated from the Seventh Army Neuropsychiatric Center to hospitals in the communications zone was made by Ludwig and Ranson. Of these, 33 (9.2 percent) were transferred to the United States as patients, 15 (4.2 percent) were re-hospitalized before they reached a new assignment, and 310 (86.6 percent) were assigned to noncombat duties within the communications zone. A follow-up was made on the 310 patients assigned to duty in order to determine the manner in which they performed their new duties. It was found that only 4.8 percent were given ratings of "unsatisfactory" by their commanding officers, whereas 3.6 percent were rated "superior," 41.6 Percent "excellent," 21 percent "very satisfactory," and 26.8 percent "satisfactory." Thus 93 percent of them performed their new jobs in a manner which was satisfactory or better. Performance was not rated for 2.2 percent. This result must be contrasted with that of the earlier part of World War II, when as high as 80 percent of patients with combat precipitated neuroses were evacuated to the United States. This change is believed to be a direct result of the initiation of neuropsychiatric treatment far forward in the combat zone. This treatment organization came into being in an organized way only after nearly a year of active combat. It is quite probable that an increased knowledge about therapeutic methods contributed to the improved results. This group of patients was representative in all ways. Age, rank, combat duration, and types of disorder, were entirely comparable to an average group of patients with psychiatric disorders of combat origin.