Time after time in this troubled century, our whole society has made itself forget about the terrible, invisible battle wounds once known as shell shock, later as combat fatigue, and now PTSD ( posttraumatic stress disorder).
Let’s call him Frank. "He was in the war" is how adults explained Frank's odd behavior a generation ago. As he walked through the small town then, his gait was clumsy, his clothes disheveled, and he seemed to go nowhere in particular. One could drive through any part of town and chance to see Frank on the corner, his face at once drawn and blank, as he was waiting to cross a street where the traffic never ceased. Sometimes he carried a paper bag, clutched as though it were filled with precious things. Frank was ghostly, but in an odd way, never threatening. After all, he wasn't quite there.
One day, in direct contravention of parental orders, a child approached Frank and asked him questions. Was he really in the war? Frank said yes. What did he do? He fought, he said, in the Pacific. Already a devotee of war movies, the child knew what that meant: jungle combat against the most fearsome of enemies, the Japanese. The child's eyes widened, and the questions came tumbling out.
Frank answered quietly. He described crawling through the jungle, looking for signs of enemy snipers. What signs? asked the child. Rice, Frank said, at the foot of tall jungle trees. Why? Because, Frank replied, rice down below meant a sniper in the tree above.
Then what did you do? asked the child. Then, Frank said almost inaudibly, then I went up and got him. And after that Frank's eyes seem to turn inward. Sensing that he had hurt Frank, the child clumsily did his best to turn the conversation to harmless matters.
I saw Frank's look again on television not so long ago, during one of several specials on those Vietnam veterans who suffer from what is now called PTSD, or posttraumatic stress disorder. I had been thinking a good deal lately about Frank and his kind, and then all of a sudden there was a man, roughly my own age, staring that look at me from the screen. Strangely, I remembered that I had always thought of Frank as being old.
The Veterans' Administration hospital in my hometown had many Franks; they all seemed old, but none could have been more than thirty at the time. The VA hospitals still have their Franks. They are the old ghosts of battle. They have been with us for years, perhaps even for centuries, inextricably linked by their suffering. PTSD's ancestors reach back at least to the American Civil War. Before this century Russian medical scholars were discussing "diseases of the soul" among their soldiery. Their American counterparts wrote at length about "neurasthenia," but not until the First World War did they apply their knowledge to the military world. During and after that war "neurasthenia" was overtaken by "shell shock" and then by the slightly more sophisticated "war neurosis." The "war neurosis" of World War I gave way in World War II to the even more imposing "neuropsychiatric casualty" or the slightly more understanding "combat fatigue." Indeed, the history of soldiering in the last century and a half can be illuminated by these terms and what they represent.
The man I saw on the television screen was telling the interviewer about his unsuccessful life. Not that he was unable to provide for his family; it was only that he often felt estranged, detached from everyone who cared about him. And when the dreams from the old days in Vietnam were so terrible he could not sleep for fear of having them again, he retreated to his own personal redoubt, a small, dimly lit room, filled with relics of his war, that he had cobbled together in his garage. There he spent the night with his demons. Exhausted at dawn, he would climb into his car and commute to work with the rest of us. None of his fellow workers ever knew of his torments. Had he not presented himself to a veterans' counselor, those torments would be private still.
There were other men on the television program, new Franks all. Several of them had withdrawn altogether from society. Unable to adjust to the civil rhythms of life after their wars in Southeast Asia, they had made their homes in the mountains of the Pacific Northwest, sometimes prowling armed and camouflaged through the night forests. Nearly all were combating a past scarred by drug and alcohol abuse and brushes with the law. They commuted nowhere.
Since the end of the war in Vietnam, Americans have been engaged in a subtle and long-standing negotiation with the memory of that divisive conflict. It was perhaps the most ambiguous of our wars, and its aftermath has been no less so. "Back in the world" after their tours in Vietnam, veterans encountered indifference and sometimes outright hostility.
Even during the war, warnings were being sounded that this conflict, apparently so different in other ways, could also be different in its mental after-effects. VA psychiatrists began to speak of PVS, a post-Vietnam syndrome, behavioral disorders that were supposed to have been created uniquely by the war. Robert Jay Lifton, a noted psychiatrist and a passionate critic of the war, told Congress in 1970 that the injustice and immorality of Vietnam were sure to stimulate rage, hate, and guilt among those who had been coerced into fighting it. No wonder veterans had difficulty adjusting, given the character of the war; in Lifton's view, these reactions were normal and appropriate. Lifton thought PVS was so elastic and widely abused as to be useless as a diagnosis. Nevertheless, when his own study of Vietnam veterans, Home from the War, was published in 1973, he had to admit that the term was "used by almost everyone."
What had happened was that the post-Vietnam syndrome had slipped out of its professional confines and into public usage, a transformation that mirrored American attitudes toward the conduct of the war itself. As the public definition of the syndrome evolved, the post-Vietnam syndrome became another means by which Americans tried to make sense of the war itself.
At first, of course, there was an orgy of forgetfulness. "Putting the war behind us" became a common refrain in the seventies, when the nation was beset with other domestic and international problems. If remembered at all, the conflict was seen as evidence of a kind of pathological international behavior; those who had fought in it were regarded in much the same way.
But intrusions upon our forgetfulness began as early as 1973, when a group of Vietnam veterans at Southern Illinois University conducted a self-study that found an "emotional malaise" common to all veterans of the war. A New York Times survey the following year showed higher patterns of drug abuse among veterans than the national average. By 1978 the VA was reporting that about 20 percent of all Vietnam veterans were "having difficulty adjusting" to civilian life. Less than a year later the U.S. Department of Justice released figures showing that a majority of the fifty-eight thousand men with service records then in prison had been in Vietnam, a statistic that was sure to make headlines but that alone proved little.
The daily news did not improve the Vietnam veteran's image. Across the country dramatic incidents were reported in which veterans of the war killed themselves, loved ones, and others, had shoot-outs with the police, took hostages, and were implicated in other criminal activities. What made these crimes different was the veterans' trial defense: Their wartime experiences absolved them of responsibility for their actions. The courts were often sympathetic. In widely publicized cases vets were acquitted on the ground that they were suffering "combat flashbacks" at the time of their crime, a modern military variant of "not guilty by reason of temporary insanity."
Meanwhile, the post-Vietnam syndrome was losing ground to a more sophisticated understanding of the problem. Increasingly, veterans' readjustment was made the subject of private and government-sponsored research. One of the earlier studies, published in 1979 by the Center for Policy Research, found that 40 percent of all Vietnam vets suffered some sort of emotional distress and that 75 percent struggled with recurrent nightmares and marital and job problems. Other terms-"delayed stress syndrome," "posttraumatic neurosis," and "traumatic war neurosis," to name a few-began to supplant PVS in both professional and public literature. The inevitable disintegration of the fragile public consensus about the war's effects on its soldiers hinted at a new stage in America's negotiations with its memories of the war. When Jan Scruggs launched his campaign for a Vietnam veterans' war memorial in the nation's capital in the spring of 1979, a good deal more was at stake than the eventual building of a monument. After six years of repressing the experiences of the Vietnam War, America began to face the public and private wounds that still cried out for healing.
In professional medical circles an accepted term of psychiatric reference for these postwar behavior disorders was established in 1980 with the publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, known as DSM-III for short. Having based their work for the past decade upon outmoded diagnostic guidance within a highly charged social atmosphere, analysts, clinicians, and psychological self-help groups could now turn to DSM-III's new definition of posttraumatic stress disorder.
In the hands of DSM-III's authors, the shock of combat was only one of several possible causes of PTSD. Posttraumatic stress disorder was now defined as a behavioral disorder that set in after "a person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone." Significantly, the new definition avoided suggesting that PTSD victims had personalities that made them especially susceptible. DSM-III merely referred to "several studies" that assigned a more important role to "preexisting psychopathological conditions," but it carefully emphasized that if the stress was sufficiently extreme, anyone could succumb to the disorder. Natural disasters, catastrophic accidents, victimization by criminal or state action, the death of a loved one, and, of course, combat-any of these experiences were regarded as capable of invoking PTSD in even the best-adjusted people.
Three symptomatic complexes composed the disorder: a tendency to relive the traumatic event through recollections, dreams, hallucinations, or symbols; a general feeling of disaffection in which the victim avoided any situation that threatened to recall the original events of the shock; and finally, what was called increased arousal, or a combination of sleep disturbances, irritability or anger, inability to concentrate, hyper-alertness, and what laymen would call jumpiness.
Even now the number of war veterans suffering from PTSD is difficult to gauge. Posttraumatic stress disorder or a milder variant less intractable to treatment, posttraumatic stress syndrome, is estimated by veterans' groups to have affected as many as 500,000, perhaps as many as 800,000, ex-combatants. A recent study by the Research Triangle Institute's William Schlenger found that PTSD sufferers now make up about one-third of the 38 percent of Vietnam veterans exposed to combat action. Translated into raw numbers, Schlenger's figures amount to about 470,000 PTSD casualties. And there are suggestions that the numbers are increasing as time goes by.
Moreover, PTSD casualties are in one sense new casualties of the war. Certain aspects of the war, such as the episodic tempo of fire base-oriented fighting, the one-year tour of duty, and the soldiers' access to alcohol and drugs -self-medication, in essence- meant that the fighting soldier could tough it out. Of course, a serious wound enabled a soldier to escape the fighting sooner, but physical wounds and stress disorders routinely coexist, and early evacuation clearly does not protect soldiers from the threat of PTSD. Most victims of the disorder fought their war without resorting to medical treatment for any but physical wounds, went home, and were discharged, only to find that while they had left the war, the war had not left them. Official figures show that during the war, "combat stress reactions," the term of choice at the time, amounted to only 1.2 percent of American casualties, far lower than comparable figures for World War II (23 percent) and the Korean War (12 percent). One wartime psychiatrist reported that only 5 percent of psychiatric admissions were legitimate combat fatigue, whereas 40 percent of all recorded cases were simply psychiatric disorders common to civil life. Earlier wars appear to have contained their psychiatric casualties, and anyway, the declaration of peace seemed a proper prescription for any discontent. But the most prominent feature of the Vietnam War's psychological history seems to have been its postponement.
The more common explanations of Vietnam's lingering psychological effect were born in our judgments on the war as it was being fought. Vietnam was conceived as somehow unique, an aberration of America's military experience, somehow un-American. Convenient as such a judgment might be, it cannot withstand scrutiny. Except insofar as any historical event is unique, our military experience in Vietnam was hardly unusual. The same is true of PTSD.
For most Americans the standard upon which Vietnam has been judged -and found wanting- has been the Second World War, a conflict that makes a much more compelling claim to uniqueness than Vietnam ever could. We have fought revolutionary wars, guerrilla wars, punitive wars, imperial wars, limited wars for the finer points of policy, wars marked by low and grudging social support, wars that consumed disproportionately younger men, wars whose supposed nobility was spoiled by atrocity, wars in which the rhythms of life at home were hardly interrupted, and wars in which the soldiers had only the most meager idea of why they were fighting. Indeed, the Vietnam War has been described in all these ways. By contrast, World War II's image is so gratifying that few of these descriptions have ever been applied to that conflict. Indeed, World War II's image is so appealing to the national memory that it has overshadowed the intervening war in Korea, a conflict that in some respects was at least as unsatisfying as Vietnam. If we are forced to remember any war fondly, World War II is always the conflict of choice.
Yet none of these traditional standards of judgment are at all likely to tell us what we need to know to understand PTSD. PTSD belongs to the soldier's history of war, a history that until recently has been hidden from view, seldom celebrated, poorly documented, hardly remembered, almost never studied. Because the soldier's history of war does not readily submit to the orderly requirements of history, and because, when uncovered, it often challenges the orderly traditions by which military history has shaped our understanding of warfare, the soldier's war has been the great secret of military history. And within this special, secret history of war, the darkest corner of all has had to do with war's essential, defining feature: combat-what it is like to have lived through it and to have lived with one's own combat history for the rest of one's life.
Throughout history the sustaining picture we have been given of the soldier in combat is his anonymity and his changelessness. Only a heroic act may elevate a soldier from the ranks; otherwise he never escapes from the great uniformed masses, turned this way and that, charging here, retreating there. Let a writer describe the career of an ordinary soldier at war and he will show us a man who, nervous at first, usually rises to the immediate occasion and does his duty. Purified by his baptism of fire, he attains a state of soldierly grace in which each succeeding combat experience hardens him and protects him from misfortune. If he survives his war, he disappears into manly retirement. Along the way some fail the test of combat. And because the way in which a society conducts war follows in some respects its most deeply held values, those who fail are outcasts.
Though in vogue for centuries, this simplistic view of the soldier at war was at last challenged by the Industrial Revolution. Mechanical advancements enabled combatants to fire their weapons faster, more accurately, and at greater ranges than ever before, forcing the once densely packed battle formations to disperse, to seek intermittent cover from enemy fire, and to adjust their methods of command.
What was a good deal less obvious, however, was that there had been a corresponding transformation during the nineteenth century in human relationships and sensibilities: a democratic as well as an industrial revolution had occurred. The modern ways of war sprang not only from deadly new machinery but from a new importance and appreciation of the individual man on the battlefield. If military technology now influenced the conduct of war with an unprecedented force, so, too, did the individual soldier's performance in combat. On the eve of his own death in the Franco-Prussian War, the French officer Ardant du Picq had concluded in his classic Etudes sur le combat that the human cost of combat was going up. "Man is capable of but a given quality of fear. Today one must swallow in five minutes the dose that one took in an hour in Turenne's day," he wrote.
Du Picq was precocious. At the time only a few observers perceived the higher human burdens of modern battle. Instead, military commanders and soldiers, very like the societies from which they emerged, saw warfare in Homeric terms, as a matter of valor, courage, manliness, sacrifice, and, on occasion, the intervention of the gods. At all events, whatever a soldier did or did not do on the field of battle was believed to be the result of his absolute and conscious control over his own actions. Men chose to be heroes, and they chose to be cowards.
The persistence of the romantic view of warfare is remarkable, to say the least, when it is cast against the military history of the last century. Certainly the experience of our own Civil War should have spelled the doom of romance, but as Gerald Linderman's recent study Embattled Courage has shown, the reality of combat was repressed by the war's veterans. Had soldiers of the Civil War suffered mental breakdowns because of their combat experiences, either during the war or afterward? If so -and there can be little doubt that they had- the terms upon which society and soldiers alike regarded warfare ensured that their experiences would remain hidden from notice, ignored or confused with other ailments.
Society was protected from these uncomfortable questions not only by its own beliefs but by the state of medical knowledge in the mid-nineteenth century. Psychological treatises of the time belonged more to the realm of philosophy than medicine. Medical practice aimed at the alleviation of obvious physical complaints, and upon the outbreak of the war, military surgeons, overwhelmed by the massive number of soldiers torn apart by shot and shell, would not have been sympathetic toward soldiers who complained of suffering invisible wounds. In any case, neither society nor medicine provided a means by which such soldiers' complaints could be understood.
Only two diagnoses of mental disorder were available to the field surgeon: If a soldier's behavior was sufficiently bizarre and dramatic, he could simply be classified as one of the 2,603 cases of insanity recorded in the Federal army during the war. But if a soldier was chronically morose, lost his appetite and physical stamina, and was unable to function as well as his comrades, he became a candidate for the more opaque diagnosis of "nostalgia." Described by surgeons as a particularly debilitating form of homesickness, nostalgia was regarded chiefly as a "camp disease," marked by lassitude of the spirit, complicated by the boredom of long bivouacs and the rigors of marching. But neither nostalgia nor any other mental ailment was ever attributed to the rigors of combat itself. On the contrary, T. J. Calhoun, an assistant surgeon with the Army of the Potomac, advised his colleagues that if the soldier could not be "laughed out of it by his comrades" or by "appeals to his manhood," then a good dose of battle was the best "curative."
At only one Federal hospital could a soldier suffering from what modern clinicians would diagnose as a stress disorder expect any sort of treatment. At Turner's Lane Hospital in Philadelphia Dr. S. Weir Mitchell investigated neurological traumas that were later recorded in his classic Gunshot Wounds and Other Injuries of Nerves. Several of Mitchell's case narratives portray wounded soldiers, suffering from a paralysis that Mitchell and his colleagues had difficulty understanding. Although these cases arrived because of their physical wounds-one patient had fallen from a tree, while another had had part of a tree fall on him-their paralysis seems to have had little connection to their wounds. Mitchell would eventually become a novelist as well as a pioneer neurologist; in his very first attempt at fiction, a short story in the Atlantic Monthly based upon his experiences at Turner's Lane, Mitchell wrote of a soldier, unwounded, who had been made "dumb by explosion."
Since neither society nor medicine could quite comprehend that the shock of combat caused mental as well as physical damage, soldiers took other measures to alleviate their complaints. An enormous number of them -about two hundred thousand on each side- simply deserted. During combat soldiers could always join the unofficial army of stragglers that attended active campaigning. In battle, units seemed to melt away, only to reconstitute themselves once the fighting had stopped. Hidden away among these numbers were no doubt men who in later wars would have been discovered, diagnosed, and treated for combat stress of one sort or another.
Yet the traditional conceptions of human behavior in combat were nothing if not persistent. Each war seemed to provide proof anew that how men acted in battle depended on heroic virtue. Very much in the manner that a star shines brightest before its extinction, the traditional conception of human conduct in battle took on an intense glow in the years between the Civil War and the First World War. At the very time when foundations were being laid for new psychological understanding of human behavior, there appeared within the world of military thought a set of beliefs that held that no matter what the weaponry, the spirit of the soldier, properly inspired and managed by his courageous officers, would inevitably triumph in battle.
Ironically, this crusade of self-deception was being mounted in those very nations where the greatest advances in psychology were being made. In Paris, where Jean-Martin Charcot's studies in hysteria at the Salpêtrière attracted the young Sigmund Freud, French military savants would argue before long that élan vital-indomitable will-was the key to victory in battle. While in Germany and Britain theoretical debates over psychology routinely appeared in the medical journals, army officers often spoke of the high casualties that would necessarily be purchased by direct assaults on enemy lines and the corresponding need for men of good breeding and character to lead them.
After the Civil War American clinicians found another diagnosis for mental disorders, one that reached a peak of social and medical popularity by the turn of the century. "Neurasthenia"-literally a loss of the finite amount of nervous energy supposed to be inherent in each person- was promoted by Dr. George Beard and found an especially receptive clientele among the upper classes of the industrial Northeast. Neurasthenia was marked by chronic physical weakness, fatigue, stomach disorders, and anxiety. In private practice after the war, Weir Mitchell himself routinely diagnosed neurasthenia in his wellborn Philadelphia patients and prescribed a "rest cure" that he had first tried on Civil War soldiers. But the compartmentalization of the medical and military worlds persisted; both Mitchell and Beard had been wartime surgeons, but neither ever seemed to look to combat as a causative factor in his patients' complaints. Nor, for that matter, did anyone else.
Only a few researchers had an inkling that psychology was an important new means of understanding combat. Before the turn of the century, articles in obscure medical journals in St. Petersburg and Moscow discussed what was called hysteria in soldiers on campaign. From the Sino-Japanese Naval War of 1894-95 came medical reports of "traumatic delirium" among Japanese troops who had been "wounded in the neighborhood of the places where enormous shells had exploded." Toward the end of 1900 Morgan Finucane, a British army contract surgeon at Aldershot, treating soldiers evacuated from the Boer War, speculated in a Lancet article that artillery fire might be responsible for the mental disorientation he found in some of his patients. And an American army medical officer, Capt. R. L. Richards, observing combat during the Russo-Japanese War, reported hospital wards and evacuation trains from the front filled with troops, physically untouched, who were mentally impaired and no longer any good for soldiering. None of these reports seem to have made the least impression upon either medical or military thought. The notion that normal men could be mentally as well as physically wounded by the stresses of modern combat could not, as yet, challenge society's long and dearly held misconceptions about what it was really like to be trapped inside a battle.
And then came August 1914. Playing the general too much, some writers have characterized the opening stages of the Great War as a period of free maneuver, and indeed, from the strategic to the tactical levels, the combatant armies did contend with one another in ways that corresponded to the fondest imaginings of any staff-college student contemplating paper victories. But this war was not the lark many anticipated. By the time the maneuvering was definitively finished in December 1914, the French Army alone had suffered more than 350,000 casualties, and on other parts of the front the numbers were sufficient to crush even the sturdiest optimism, save, of course, that of the high commands.
Apart from the vast numbers of troops engaged, the most immediately noticeable feature of this new war was the antagonists' relentlessly industrial delivery of fire upon their enemies. And as time passed, their skill at deploying stupendous, unprecedented quantities of shell improved by quantum leaps. Less than a year after the war began, more artillery shells were fired at the Battle of Neuve-Chapelle than had been fired in all of the Boer War.
The sheer magnitude of this shellfire early on produced rumors that men died from that effect alone. The Times History of the War reports that as early as the Battle of the Marne, "dead men had been found standing in the trenches ... [and] every normal attitude of life was imitated by these dead men" who had no signs of physical injury. Observers lucky enough to retain their wits thought it inconceivable that men could live through such experiences unaffected.
Soon enough, all the warring nations began to receive soldiers evacuated from the front who had become mentally disabled. In Germany the psychologist Karl Birnbaum drew a clinical picture from the first six months of the war in which nervous conditions arose from the fatigue and exhaustion of fighting that included "great weariness and profuse weeping, even in otherwise strong men." One of Birnbaum's colleagues reported soldiers who had lost their voices, who were unable to walk steadily, who were easily startled, and who had difficulty controlling their emotions.
An American psychiatrist, Clarence A. Neymann, who served with the German Red Cross in Heidelberg from the earliest days of the war, saw no cases at all until after the Battle of the Marne had halted the initial German Army offensive. Then, Neymann recognized, "Hardly a transport of sick and wounded... did not contain its quota of mental cases." At first such cases were regarded as nuisances by hard-pressed surgeons and were sent farther to the rear, where after a period of "stagnation" they were returned to the front lines. One immediately noticeable class of mental case, marked by tremors, difficulty in standing, and chronic indigestion, quickly acquired the informal diagnosis of Granatfieber, or grenade fever. To these were added a growing number of casualties who had suffered "especially trying experiences" at the front. Soon, Neymann reported, his wards became so crowded that the overflow of patients had to be shunted to base hospitals for warehousing.
The British Medical Journal for December 1914 carried an article by Dr. T. R. Elliott, then a lieutenant serving with the Royal Army Medical Corps, who reported several cases of "transient paraplegia from shell explosions." Elliott's patients had sustained no physical wounds, but their legs were temporarily paralyzed. He did not discount entirely the possibility that shellfire had created a hysterical condition in his patients, but like a good many of his colleagues, he saw in these cases a physical origin, and shellfire provided a fertile ground in which to look. Elliott thought many cases were misdiagnosed as hysterical when, in fact, these soldiers had suffered physical injuries from being concussed, buried, blown up. He also took note of a diagnostic trend that attributed these complaints to the carbon monoxide and nitric oxide released by high explosives, but he could find no evidence for this in conversations with returning soldiers. Only a month before, in the very same journal, another doctor had forecast, "I do not think that the psychologists will get many cases."
On the contrary, in the months and years of war that lay ahead, there was nothing short of what one scholar has called "a mass epidemic of mental disorders" along the fighting lines, disorders that inspired a huge body of literature on the psychology of combat. At the same time Elliott's article appeared, the British army received a report from lines at Boulogne that 7 to 10 percent of all officer patients and 3 to 4 percent of patients from the other ranks were suffering nervous breakdowns. By the end of 1914 more than nineteen hundred such cases had been reported in the British army alone. The next year that number increased tenfold. By the end of the war, the British army had treated more than eighty thousand frontline men for mental disorders, variously classified.
The classification, diagnosis, and treatment of the mental wreckage of combat posed unprecedented and, indeed, unanticipated problems for the medical profession in all the countries at war. Early in 1915 C. S. Myers, writing in The Lancet, introduced a classification for these disorders that was -as it happened- all too appropriate to the epidemic then overwhelming battalion surgeons: shell shock. Ironically, Myers thought that hysteria, not concussion, was responsible for shell shock. Another British neurologist, Sir Frederick Mott, quickly entered the debate to agree with Elliott. And so began a veritable flood of articles in the professional journals and in popular literature. For better or worse, shell shock was enshrined as a term of public usage.
Shell shock had a convoluted career both during the war and after. The diagnosis was so obligingly broad that it could be applied to any number of mental ailments, and before long shell shock aroused suspicion in medical as well as-not surprisingly-military circles. By 1916 physicians only reluctantly employed the popular term, preferring to rely instead on more conventional diagnoses such as neurasthenia and war neurosis, and most of the medical elite understood that whatever lay at the bottom of shell shock, the concussions of high explosives and their gases were entirely too simplistic an explanation.
While the medical debates progressed, however, a war was on, and commanding officers interpreted shell shock in accordance with their own unambiguous professional values. In the early days of the war soldiers found wandering about behind the combat lines were simply shot for cowardice. Others who funked their duty were court-martialed. One commander flatly "refused to allow" shell-shock cases in his battalion, while in one particular infantry division anyone who evinced
symptoms of shell shock was tied to the barbed-wire lines that protected the trenches.
This approach might have become more widespread but for the remarkable numbers of "all-round good sporting chaps" among the officer classes who broke down. Faced with mounting shellshock casualties, not to mention the terrifying realities of the carnage on the Western front, the armies in time conceded that mental stresses, however classified, could easily debilitate their soldiers. One official estimate showed more than two hundred thousand British soldiers discharged during the war because of shell shock.
One of the most public cases of shell shock was that of the poet Siegfried Sassoon. As a young officer in the Royal Welsh Fusiliers from 1915 on, Sassoon was a model soldier, well liked by his men and so avid a trench raider that he was nicknamed Mad Jack. Having already won the Military Cross, Sassoon was convalescing from his latest wound when in the summer of 1917 he wrote "A Soldier's Declaration," which protested the conduct of the war and announced that he would no longer contribute to the massacre. And just to make sure he was heard, he sent copies of the protest to his commanding officer and the House of Commons. "A Soldier's Declaration" was published in the Times of London at the end of July, but by then Sassoon had already met an army medical board and been packed off as a shellshock case to the Craiglockhart War Hospital near Edinburgh.
At Craiglockhart Sassoon was fortunate to be entrusted to Dr. W. H. R. Rivers, a young Freudian whose realistic understanding of shell shock was founded upon an unromantic view of the battlefield rather than on rarefied theories. Rivers soon decided that the young officer only needed rest, but he could have fallen into the clutches of other physicians who advocated a so-called disciplinary treatment for shell shock that included painful electrical shocks, isolation, and unsympathetic handling, all intended to encourage the reappearance of the soldier's "normal" self.
Sassoon was familiar with such rough-and-ready treatment, part of which encouraged shell-shocked soldiers to repress their memories of the trenches, shake themselves out of their depression, and carry on manfully. In "Repression of War Experience," a poem published after his experience at Craiglockhart, Sassoon made savage fun of "disciplinary treatment" and the outmoded social views that inspired it:
And it's been proved that soldiers
don't go mad
Unless they lose control of ugly
That drive them out to jabber
among the trees.
Eventually discharged by Rivers, Sassoon returned to the front, his views on the war unchanged. There he fought until July 1918, when he was wounded again and invalided home for good. But to say that Sassoon's war was over would be a mistake. In the form of restlessness, irritability, guilt over surviving, and, above all, battle dreams, Sassoon's war remained alive for years afterward. His memoirs recalled his time at Craiglockhart and his fellow patients there: "Shell shock. How many a brief bombardment had its long-delayed after-effect in the minds of these survivors, many of whom had looked at their companions and laughed while inferno did its best to destroy them. Not then was their evil hour; but now; now, in the sweating suffocation of nightmare, in paralysis of limbs, in the stammering of dislocated speech…”
Sassoon was right. The "long-delayed after-effect" of the war was to be an essential part of European postwar life. The war had blasted a great demographic hole in all the combatant nations. In Germany, where thirty-one per thousand of that nation's population were killed during the war, another 10 percent of the population-disabled veterans, widows, and dependent families-six million in all, were victimized by it. The French lost even more: thirty-four killed for every thousand citizens. Great Britain's war dead was less-sixteen per thousand of population-but that nation confronted the same problems of human reconstruction as the other Europeans. Ten years afterward more than two million British veterans were receiving some sort of government assistance. Sixty-five thousand of these were still in mental hospitals, suffering from what was then classified as "chronic neurasthenia.”
The fortunes of shell-shocked veterans depended more upon social views than medical advances. Even though some German psychiatrists advanced highly sophisticated explanations for war-related nervous disorders, German society at large resisted the idea that war alone caused nervous disability. Less than 2 percent of all German casualties treated during the war had been diagnosed as nervous disorders. Either a shell-shocked veteran was insane or his suffering had to do with heredity. That being so, the war bore no responsibility for his mental state. True to this form, six years after the war's end only 5,410 German veterans were drawing pensions on diagnoses of insanity as a result of their service.
While a highly conservative medical opinion held sway in Germany, in Britain the whole question of shell shock became a matter for heated public discussion. As early as 1915 members of Parliament, fearful that shell-shock victims returning from the front would be consigned to lunatic asylums, moved to prevent shell-shock cases from being confused with ordinary cases of insanity. Parliament's concerns were real enough: one doctor estimated that more than 20 percent of all the shellshock victims at one of the army's main hospitals were committed to asylums. Moreover, quite without regard to what the doctors or the army (whose medical service had forbidden use of shell shock as a diagnosis in 1917) thought, the British public readily accepted shell shock as a war-related nervous disorder that could afflict anyone at all. During the ten years immediately following the war, pension authorities examined 114,000 shell-shocked veterans. On the eve of World War II, the British Ministry of Pensions was still paying two million pounds a year to shell-shocked pensioners from the 1914-18 war.
The veterans of the Great War phrased their complaints in much the same way as Vietnam veterans more than half a century later. Front-line troops often resented all but their own kind, and especially their countrymen on the home front. When soldiers returned home to find scant appreciation or understanding of their wartime trials, their resentment could easily deepen into bitterness and outright alienation. A German veteran's lament, written in 1925, could pass for some veteran's complaint today: "The army returned home... after doing its duty and was shamefully received. There were no laurel wreaths; hate-filled words were hurled at the soldiers. Military decorations were torn from the soldiers' . . . uniforms. . .”
Weimar Germany struck no medals commemorating war service as in times past. Not until six years after the armistice was there an official memorial service for the war dead.
But these were public manifestations of much more private trials. Sassoon's Craiglockhart psychiatrist, Rivers, believed that society did no good at all by asking, "What's it really like?" and then insisting that soldiers "banish all thoughts of war from their minds." Torn between a conflicting desire to retrieve the past and to avoid its pain, the soldiers found their inchoate memories had become an essential part of their identities. Rivers thought that the best course of action lay somewhere between the outright repression of one's war experiences and an unhealthy fixation upon the past.
This was more easily said than done. Veterans who recorded their postwar experiences often mentioned nightmares, vivid battle dreams that persisted for years, sometimes for decades. Certain events unexpectedly called forth memories of the war. Armistice Day celebrations meant reliving a murderous chaos in Delville Wood for one veteran-"hand-to-hand fighting with knives and bayonets, cursing and brutality on both sides, mud and stench, dysentery and unattended wounds... unable to come to terms with a peaceful, indifferent society, another veteran escaped to the country: "I realized that this was what I needed. Silence. Isolation. Now that I could let go, I broke down, avoided strangers, cried easily and had terrible nightmares."
Steering a course between repression and fixation proved difficult for the armies as well, for when the Second World War began, much of what had been discovered in the Great War about the stresses of combat had been repressed all too well. Valuable insights into the management of combat stress, the diagnosis and treatment of soldiers suffering from nervous disorders, and the vast professional organization required to tend such cases, not to mention a substantial body of medical and military knowledge-all were seemingly forgotten by the outbreak of World War II. The United States had suffered only a glancing blow in the Great War when compared with other nations, yet in 1942 some 58 percent of all the patients in VA hospitals were World War I shell-shock cases, now twenty-four years older. Ignoring experience, knowledge, and memory, the U.S. Army followed a now familiar cycle of mystification, suspicion, diagnostic confusion, a competition between military and medical authorities for the power to determine how such cases fitted within the business of war, a grudging reconciliation with the unavoidable facts of combat fatigue, and, by war's end, a pragmatic approach to neuropsychiatric battle casualties.
In the period between the two world wars, medical authorities in the American army, confident that "proper psychiatric screening of the mentally unfit at induction was the basic solution for eliminating the psychiatric disorders of military service," managed to institute psychiatric exams of soldiers when they enlisted. Of 5.2 million American men called to the recruiting stations after Pearl Harbor, 1.6 million were prevented from enlisting because of various "mental deficiencies." But the widespread faith in psychiatric screening that one American army psychiatrist observed could only be "equated with the use of magic" was
again tested by combat. In the American army alone the enlistee rejection rate for this war was more than seven and a half times that of World War I, yet before the war was over, the psychiatric discharge rate soared to 250 percent of that earlier conflict.
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."
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 Faïd 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, neuropsychiatric 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 non-combat duty, these soldiers could only be sent home. At one point the number of soldiers evacuated from North Africa as neuropsychiatric 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 neuropsychiatric 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, self-inflicted 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.
Wartime psychiatry, no less than wartime medicine in general, had as its official objective the prompt treatment and return to duty of the wounded soldier. Psychiatrists in uniform took pride in turning in the highest "return to duty" rates they could manage, and indeed, wounded soldiers were often anxious to get back to their buddies on the fighting lines. Combat fatigue was meant to be transient; when a soldier's condition intensified, military psychiatry had failed its primary purpose of maintaining the fighting strength of the army in the field. A cure was hardly the point. Perfectly well-adjusted soldiers were not required for combat. The adjustments, if they occurred, were postponed until after the victory parades.
Anthony Paluszek, a Vietnam veteran, at Northampton (Mass.) Veterans' Hospital, one of sixteen VA hospitals having a PTSD unit.
The best known of all World War II's heroes and the quintessential infantryman, Audie Murphy, had a celebrated homecoming. But he was also lucky. When Murphy was invited to Hollywood by the actor James Cagney, his fatigued appearance so alarmed Cagney that he gave the young soldier the use of his pool house for a year. Despite his advantages, Murphy never really got over his war. Twenty-two years after his last combat experiences, Murphy slept with the lights on and a loaded .45 by his bed.
As the American memory commemorated the image of the Second World War, other veterans picked up their lives again and took on the comfortable identity that so characterizes them today: children of the Depression generation who went off to wage a victorious defense of freedom and humanity-tough, uncomplaining, irrepressible in their pursuit of the American Dream. If there were those, like my childhood friend Frank, who did not quite fit the image, they never seemed to interrupt the public consciousness. They lived on with their torments or in the clinical quiet of VA hospitals.
In 1951 two psychiatrists working at the Los Angeles VA Hospital's mental-hygiene clinic published a disturbing report in the American Journal of Psychiatry. For the preceding five years Samuel Futterman and Eugene Pumpian-Mindlin had been treating two hundred veterans who exhibited persistent symptoms of intense anxiety, battle dreams, tension, depression, guilt, and aggressive reactions and who were easily startled by minor noises. The psychiatrists' general impression of their patients was of a "well-adjusted individual who broke down in [the] face of an overwhelming trauma." More disturbing still, Futterman and Pumpian-Mindlin wrote, "even at this late date we still encounter fresh cases that have never sought treatment until the present time." And although some veterans responded to treatment, they added, for others "it is as if they live in the ever present repetition of the traumatic experience that so overwhelmed them."
Nearly fifteen years after the Los Angeles psychiatrists' report, another article appeared in the Archives of General Psychiatry. Working in a VA outpatient mental-health clinic near San Francisco, Herbert Archibald and Read Tuddenham had been "struck with the persistence and severity of the combat syndrome" in their patients. A systematic study of these cases revealed "a clear-cut picture of the combat veteran's chronic stress syndrome" consisting of precisely the same complaints as those identified in 1951. Nor, in the authors' judgment, were these mild cases; most were "severely disabling... chronic, highly persistent over long intervals and resistant to modification." As in the earlier investigation, some of the men who saw Archibald and Tuddenham had never before sought treatment. The article concluded on a forbidding note: "Perhaps the most disturbing in the latest reports is the suggestion that the incidence of the syndrome is increasing, as aging makes manifest the symptoms of traumatic stress which have been latent since the war."
Just two months before this report was published, President Lyndon Johnson ordered the U.S. Marines to South Vietnam. The cycle of war experience, and the repression of it, was about to begin anew. Maybe this is what Frank saw, so far away.*
Roger J. Spiller is a professor of military history at the U.S. Army Command and General Staff College, Fort Leavenworth, Kansas.
TO FIND OUT MORE
There is no overview of this problem, so far as I know, but the following touch on various aspects: John Keegan, The Face of Battle (Penguin, 1983); Gerald Linderman, Embattled Courage (Free Press, 1987); Denis Winter, Death's Men: Soldiers in the Great War (Penguin, 1985); Cols. William S. Mullins and Albert J. Glass, Neuropsychiatry in World War II (Government Printing Office, 1973); Peter Boume, Men, Stress and Vietnam (Little, Brown, and Co., 1970). The last two are medical works, and the Boume is mercifully short.