The Stress of Combat

On a particular day in World War 2, war correspondent Ernie Pyle sat on a hillside and watched "the Gosh-darned infantry march along on road below him.  "Every, line and sag of their bodies," he wrote, "spoke their inhuman exhaustion.... They didn't slouch. It was the terrible deliberation of each step that spelled out their appalling tiredness." Young as they were, they appeared middle-aged, and as they approached he saw nothing in their eyes but "the simple expression of being here as though they had been doing this forever, and nothing else."  It was too much weariness.  From his own experience, Pyle knew the lingering effects of being shelled, the initial rush of delight at escaping a blast alive, but also the later reaction that left him cringing at the sound of artillery. He knew of the re-occurring battlefield memories that could be recalled by the least thing,"a mere rustling curtain can paralyze a man with battlefield memories." The massive, long-lasting conflict that was World War 11 took the human system to its limits and beyond.

The stress that warfare inflicted on soldiers had been growing steadily. For a century or more, nations had been fielding more and more powerful weapons, designed to deliver the most lethal possible impact.  As armies grew larger, battlefields broadened because heavy enemy fire compelled the troop formations to spread out.  Small units became separated from the sight of their leaders, and individuals from the shoulder-to-shoulder contact with their comrades that had helped to sustain them during struggles in the past. Battles began to last for days, then for weeks or months, forcing men to spend seemingly endless time under fire. The body's fight-or-flight mechanisms, designed by God for use in brief emergencies, instead were evoked over long periods by the constantly impending danger of death.

In World War 11, the early fighting in the Pacific and Africa brought the effects of fatigue and stress home to Americans. On Guadalcanal and Papua the condition seemed closely linked to the jungle environment, its alienness, its stifling heat, and its tormenting diseases.  At night strange noises were continuous; on the front lines no man slept well unless he was exhausted.  Tension exaggerated small sounds; the fall of raindrops became hostile footsteps, the rubbing of leaves the movement of infiltrators.  Behind the illusion lay the reality of sudden and violent death.

In North Africa the landscape was absolutely different, In combat, "psychiatric reactions were responsible for 20 percent of all battlefield evacuations, and for days at a time the proportion ran as high as 34 percent."" Such losses were unacceptable; something had to be done.

To understand and control the conditions that resulted from combat stress was a key duty of psychiatrists in uniform. The problem was one of the most complex presented by war.  Patients in all theaters showed the same symptoms of intolerable weariness and baseless alarm.  Some were in a stupor and withdrawn; some tense and violent; some suffered from Parkinson-like tremors or from delusions that mimicked the symptoms of schizophrenia.  They were beyond self-control, and orders and threats meant nothing. Weeping, shaking, curling up in the fetal position, or merely numb and unresponsive, they had ceased to be soldiers for a time.

In the beginning, many psychiatrists diagnosed the problem the same way they did of new recruits.  Breakdown in combat was not a developing condition but rather the surfacing of an internal flaw; anyone who was susceptible ought to be excluded from the military.  Many commanders and medical officers gave this solution their enthusiastic support. Once a man broke, he was damaged goods and worthless from then on. But the shape-up-or-ship-out philosophy drained away military manpower. There was no way to fight a world war with this “solution”.  What was needed was a way of salvaging ordinary men.  Medical officers in the field began leaning towards a solution early in the war.  On Guadalcanal, the Marines evacuated their worst psychiatric cases but began to send the others to labor battalions in the rear. An army medical report from the same battle concluded "the majority of [psychiatric] cases are nothing but a direct result of ... mental and physical fatigue." Given rest, regular food, and a chance to bathe, "85% to 90% ... requested to be returned to their respective units.”

Colonel Martin A. Berezin, a psychiatrist, was for a time surgeon of the Americal Division.  Since his commander denounced psychiatric cases as cowards, he diagnosed their problem as blast concussion and gave a prescription of "P&S," meaning pick and shovel. Patients then worked out their fears digging trenches around the hospitals, while receiving nourishment, rest, and decent treatment they needed to recover.  As a result, many returned to combat without relapses, and even those who could fight no more served usefully behind the lines.  By sheer good luck, the army had found its first division psychiatrist.  On New Guinea the problem was the same as on Guadalcanal, but the solution was less innovative. Planes taking off from Port Moresby fields and droning south toward Queensland proved to temporarily solve the problem to commanders and doctors alike who wished to be rid of their "mental" cases. As a result, salvageable men received a ticket out.  Meanwhile, the fighting forces were denied their services at a time when they were needed most. During 1943, despite efforts at reform, almost 40 percent of the Southwest Pacific Area's evacuations to Hawaii or the United States were loosely classed as mental.

The most famous case exposing the of the old ways of viewing combat breakdowns occurred not in the Pacific but on Sicily. The Seventh Army commander, Lieutenant General George S. Patton, Jr., held views that were very similar to many high ranking commanders of the time. On August 3, 1943, Patton paid a visit to the 15th Evacuation Hospital near Nicosia.  On this day in the admitting tent he happened upon a Private who had recently arrived with a diagnosis of "psycho-neuroses anxiety moderate/severe." The diagnosis meant more or less the symptoms or his current condition. As a matter of fact, the diagnosis was wrong: The man was later found to be running a high fever, and the hospital's ultimate diagnosis would be chronic dysentery and malaria.  When Patton stopped and asked what was wrong with him, the private replied miserably, "I guess I can't take it." At this the general lost his own self-control. Patton berated the man, slapped his face with his gloves, seized him, and threw him out of the tent. An enlisted medic picked the patient up and took him to a ward.  Back at his headquarters, Patton noted in his diary, "I gave him the devil, slapped his face with my gloves and kicked him out of the hospital.... One sometimes slaps a baby to bring it to." He then issued a memorandum to his subordinate commanders, warning them that "a very small number of soldiers are going to the hospital on the pretext that they are nervously incapable of combat. Such men are cowards.... Those who are not 'willing to fight will be tried by Court-Martial for cowardice in the face of the enemy.

A week later Patton visited the 93d Evac on another mission to cheer the wounded.  In the receiving ward he found a patient shivering on his bunk with a diagnosis-in this case accurate-of severe shell shock.  When Patton questioned him the man began to sob, saying, "It's my nerves, I can hear the shells coming over, but I can't hear them burst."

"What is this man talking about?" Patton demanded. "What's wrong with him, if anything?" Then he called the patient "a coward." He slapped him hard and repeatedly, threatened to have him shot, and waved his pistol in the man's face.  The hospital commander, who had entered the tent, had to step between Patton and his victim before the attack ended.  These incidents reflected the traditional prejudices and lack of understanding of what is combat fatigue. Yet the problem of how to deal with psychiatric casualties remained. In the face of excessive losses caused by the evacuation of combat exhaustion cases, the old school of thought reluctantly changed, but only as a result of the need to conserve manpower. The army began to make serious efforts to save its psychiatric casualties as functioning soldiers.

In 1943 a School of Military Neuropsychiatry opened at Lawson General Hospital in Atlanta, and by the year's end division psychiatrists were listed on the army's tables of organization.'

The success of combat psychiatry can be traced to the efforts of one man, Capt. Frederick R. Hanson. Born in the United States and trained as a neurologist and neurosurgeon, Hanson had been working in Canada when the war broke out. He joined the Canadian Army and served in its psychiatric hospital in England, where he studied and learned from the experiences of the Allies.  When the United States entered the war, he transferred to the U.S. Army.  But he volunteered to accompany, the Canadians on their disastrous raid against Dieppe, and in the process found a first-rate opportunity to study the reactions of men under fire. His experiences in combat helped him to win the confidence of front-line surgeons and commanders alike. Posted to Africa and attached to 11 Corps, Hanson soon had many more victims of combat stress to observe.  In the aftermath of the Kasserine disaster, a nurse at the 48th Surgical Hospital watched him as he patiently questioned a hundred or so combat fatigue cases in his "low and calm" voice. Hanson found that the psychiatric casualties were indistinguishable from the combat wounded. "Their faces were expressionless," he wrote, "their eyes blank and unseeing, and they tended to go to sleep wherever they were." He concluded that the most critical factor in causing their condition was simply lack of sleep and instructed the nurses: "Put them to bed.  Give huge doses of barbiturates.  Awaken them only for meals and elimination (bathroom).  Nothing else. Don't talk to them-let them sleep."

Hanson's practical approach, emphasizing sedation and brief therapy, returned about 30 percent of the patients to combat duty in little more than a day, and more than 70 percent after forty-eight hours.   Another key to treating psychiatric casualties was provided by observing the course of those who were evacuated. The view that men with "mental" symptoms should be removed at once-not only for their own benefit but to avoid infecting others with their fears casualties were hauled hundreds of miles to the Atlantic coast for treatment.  By the time they arrived many presented "a changing and ... bizarre clinical picture.  Psychiatric casualties were unlike the wounded in that they became worse, not better, as they moved farther to the rear. Some were simply malingerers, conscious or unconscious, who discovered imaginary ailments, exaggerated the symptoms of real injuries, and developed psychosomatic disorders long before they came within sound of the enemies guns.  But even genuine casualties resulting from the most intense combat might refuse to recover once they entered the chain of evacuation, for they could get farther to the rear and closer-to safety only by continuing to be perceived as a bit mad.

By the opening of the battle for Tunisia, Hanson's ideas had matured.  Psychiatric casualties were to be held in a hospital close to the front and were to be diagnosed with the term exhaustion," borrowed from the British Eighth Army.  It described pretty well the way the patient actually felt, encouraged him to believe that he could recover with rest, and removed the stigma of mental illness. Some psychiatrists complained that the term had nothing to do with the accepted lingo of their specialty, but that was probably one of its advantages."  However, the psychiatrist still had to order evacuation for the most serious cases that resisted front-line treatment

n World War 2 military psychiatry, a psychotic was simply a patient with severe symptoms that persisted despite efforts to relieve them."  As the new method of treatment took form, the combat psychiatrist assumed a practical role.  His efforts at therapy did not involve probing deeply into the psyches of his patients. Instead, he conducted sessions in open ward-a kind of "modified group therapy." Patients were encouraged to relive the experiences that had shocked them, and their memories were assisted with injections of Pentathal (truth serum) if necessary.  Sometimes "dramatic scenes" occurred, with the therapist playing the roles of buddy, squad leader, medic, platoon sergeant, or company commander, while the patient, in a condition resembling chemical hypnosis, recovered memories lost to amnesia.  One might recall an episode of the TV show MASH in which a patient relived his combat experiences which under hypnosis. Patients were obliged to conform to ward routine, to wash and shave, and to walk to meals; none was allowed to remain more than three days. Any longer than that, the doctors found, hypochondria set in as the patient attempted to prolong a status he found infinitely more comfortable than combat, For most men, however, removal from the immediate stress of combat did wonders when combined with sleep, a bath, verbalizing their experiences, and receiving comforting words from an authority figure all in a forward location where air raids still occurred.

No single factor explained all cases of combat fatigue.  In the environment of war, fatigue, terrain, and weather interacted with fear, belief, the quality of leadership, and unit morale.  Sickness helped to exhaust a man, and exhaustion could help to make him sick.  Under so many pressures, a complete cure of the patient's symptoms might be impossible, but most patients could be returned to duty as effective, functioning soldiers. By the later phases of the African campaign, the proportion of cases that returned to full duty without evacuation from the combat zone was a fairly constant 58-63 percent. The command made division surgeons responsible for the initial treatment of psychiatric casualties, and psychiatrists were attached to all the forward evacuation hospitals.  The system's success did not result from any decline in the level of combat. On the contrary, casualties mounted steadily, and the last month's fighting in North Africa brought almost twice as many wounded to the hospitals as the period from New Year's Day to mid-March. The improvement was real, both in the return rate and in the understanding of psychological stress that had produced it.

In March 1944 an experiment was tried in the 3d Infantry Division at Anzio.  Psychiatric casualties were heavy after a winter of siege; the beachhead remained all front and no rear, so that even support troops were subjected to much the same dangers as riflemen and suffered breakdowns under the stress.  Captain Joseph Robert Campbell, a "decisive and firm" medical officer with much combat experience, set up a unit staffed by himself, a line officer, and seven enlisted medics to treat psychiatric casualties. The mood was entirely non-hospital; the unit was attached to the division's engineer battalion, and its program featured rest, physical work, and therapy.  Campbell returned 66 percent of his psychiatric cases to duty.  He also evaluated disciplinary cases from the stockade, returning about one-third of them to duty as well. So promising was the success rate that-in another step forward for combat psychiatry-treatment at division level later became the rule in the Italian campaign."

In conclusion, many studies were conducted to try and determine what was the allowable time while in combat. In the end it was determined that there was no firm way to determine what would be the breaking point.  For some, a single near miss would break a man yet others could endure the rigors of combat and field conditions for up to 200 days.

The only hope was prevention.  The British practice of systematic rotation, doubled the period of combat effectiveness to about four hundred days.  Rotation was essential to keep effective troops on the line in modern war.

 Attempts by the ground forces to rotate combat troops usually took the form of efforts to relieve individual soldiers with longest service, rather than to establish a definite tour of duty, as the Army Air Corp did.  In general, Americans underrated the importance of unit integrity. Perhaps the only solution was to have shorter wars, if wars there must be.