Shellshock

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Since U.S. Army medical authorities were slow to recognize the problem that awaited them—the Surgeon General’s Office of the U.S. Army did not even appoint a psychiatric consultant until well after the war began—the troops were in effect defenseless against combat stress in the first years of the war. Field commanders once again adopted the rough-and-ready approach so prevalent in the Great War, and which Gen. George Patton’s celebrated slapping incident showed was still in vogue in some fighting units. On the besieged island of Malta in 1942, when air attacks were at their most intense, antiaircraft artillery crews were officially advised that “anxiety neurosis was the term employed by the medical profession to commercialize fear, that if a soldier was a man he would not permit his self-respect to admit an anxiety neurosis or to show fear.”

Wartime psychiatry’s objective was the prompt return to duty of wounded soldiers. A cure was hardly the point: perfectly welladjusted men were not required for combat.

Knowing very well that most physicians had little training in or understanding of psychiatric disorders in civil life, much less the special permutations that combat stress could produce, psychiatrists were anxious to find their way to the front lines, a journey whose difficulties were compounded by a less than warm reception from military authorities. One board-certified psychiatrist who was to accompany the Americans’ Western Task Force as it invaded North Africa in the summer of 1942 was assigned to latrine inspection duties before shipping out. After he landed in North Africa, he was given guard duty on medical-supply convoys.

The U.S. Army had its baptism of fire in North Africa at Kasserine and Paid passes in February 1943. Up to 34 percent of all casualties were “mental.” Worse yet, only 3 percent of these soldiers were ever returned to frontline duty. Despite the experience of World War I, when it was discovered that shell shock intensified if the patient was evacuated from the combat zones, neuropsychiatrie casualties were shuffled through an evacuation system that took them hundreds of miles to the rear. One American psychiatrist, working in the rear areas, reported that most of these cases presented a “bizarre clinical picture, which included dramatic syndromes of terror states with mutism, dissociative behavior, marked tremulousness and startle reaction, partial or complete amnesia, severe battle dreams, and even hallucinatory phenomena.” Unable to return to combat or even to noncombat duty, these soldiers could only be sent home. At one point the number of soldiers evacuated from North Africa as neuropsychiatrie casualties equaled the number of replacements arriving in that theater of operations.

The experiences of North Africa were repeated elsewhere, and during the entire war. Fighting in the South Pacific at New Georgia, the American 43d Infantry Division virtually disintegrated under fire. More than 40 percent of the 4,400 battle losses sustained by the soldiers of this division were diagnosed as psychiatric cases. During one forty-four-day period of fighting along the Gothic Line in Italy, the 1st Armored Division’s psychiatric casualties amounted to a startling 54 percent of all losses. Even toward the end of the war, the 6th Marine Division on Okinawa suffered 2,662 wounded in a ten-day period—as well as 1,289 psychiatric casualties. Nearly a half-million American soldiers were battle casualties during the fighting in Europe; by 1945 another 111,000 neuropsychiatrie cases—then usually called combat fatigue—had been treated. Worse yet, these statistics must be regarded as the minimum credible figures. Still more cases were no doubt masked by an imperfect medical accounting system, command resistance, actual wounds, susceptibility to disease, selfinflicted wounds, desertions, and even frostbite cases.

During the course of the war, frontline soldiers and medics alike had come to agree that everyone in combat had his breaking point if he fought long enough. As early as 1943 consulting psychiatrists in the Army’s II Corps had persuaded their commanding general, Omar Bradley, to order that all breakdowns in combat be initially diagnosed simply as exhaustion, putting to rest the notion that only the mentally weak were susceptible to the stresses of combat. Eventually a vast network of psychiatric care was constructed in the Army; each fighting division had its own psychiatrist, and some younger practitioners even found their way to the fighting battalions. Whether the enlightened view of combat fatigue and its real causes ever triumphed is a good deal more problematical.

The Second World War produced an unprecedented body of knowledge about human behavior in combat, knowledge that has for the most part been little studied outside professional medical circles. One compendium of medical literature, published in 1954, shows 1,166 articles on the subject of combat fatigue. There was, of course, a great diversity of interpretations regarding the cause, character, and treatment of the disorder, but in one respect all agreed that combat fatigue was “transient.” They may well have been wrong.