BRITISH JOURNAL OF PSYCHIATRY 2001), 178, 178, 242^247 242^247

Psychiatric battle casualties: muscular system amounting to paralysis more or less pronounced .Bowlby et aletal,1901:129)., 19 01: 129). an intra- and interwar comparison Excluding the 14pensions awarded for psy- chosis and 22 for depression, our survey of 6200 cases of soldiers medically discharged EDGAR JONES and SIMON WESSELY after the Boer War found only 11 examples where a psychological cause was diagnosed. These comprised six cases of nervous de- bility, three of neurasthenia, one of hysteria and one of nervous shock &Anon., various years). The last was Private John Lyons of the Royal West Surrey Regiment, who had Background Psychiatric casualties are Psychiatric battle casualties are a significant been concussed but not wounded by a shell recognised as ananimportant important andandinevitable inevitable feature of modern warfare. However, the explosion at the battle of Colenso in exact magnitude of the problem, and its featureofmodernwarfare.Atthebeginning December 1899. Returning to duty after a relationship to the experience of combat, hospital admission, he continued to experi- of the 20th century they were scarcely has been a cause for debate. In 1900 the ence fatigue and weakness with a functional acknowledged and stillless treated.Today, as idea that soldiers could suffer psychological paralysis of his right arm and leg, tremor, a result of lessons learned in the First and damage in action was barely acknowledged dizziness and free-floating anxiety. Lyons Second World Wars, numbers can be and yet 40 years later psychiatrists were was discharged from the Army in November routinely deployed to fighting units. This 1900 with a war pension &Anon., various predicted on the basis of battle intensity and paper is based on original sources from years; PIN71/3959). In time, his paresis re- effective clinical interventions applied. the Royal Army Medical Corps &RAMC) mitted and he died in 1950 at the age of collection and the archives of the Wellcome 82. This was, perhaps, one of earliest docu- Aims ToTodiscover discovermore more aboutthe Institute for the History of Medicine, sup- mented cases of what would later be called factorsthatcausepsychiatriccasualtiesfactorsthatcausepsychiatriccasualtiesand and plemented by contemporary literature. It shell-shock. It appears, therefore, that unam- their relationship to total battle casualties. is primarily concerned with combat stress biguous cases of combat fatigue were rarely and acute psychiatric casualties of battle identified in the Victorian period and that MethodMethod AsurveyofhistoricalWar treated in the field rather than at base hos- soldiers traumatised by the stress of battle Office reports and the papers of Royal pitals. We will not consider the relatively appear to have somatised their fears often Army Medical Corps psychiatrists has recent phenomenon of delayed psychiatric in the form of disordered action of the heart disorder, exemplified by the modern condi- &DAH) or psychogenic rheumatism. provided both statistics and treatment tion of post-traumatic stress disorder strategies.strategies. &PTSD).&PTSD). First World War Results Reported psychiatric casualties Military psychiatry was in its infancy Earlier wars were low in the Boer War, influenced, in during the First World War, as physicians Few reliable casualty statistics are available gradually appreciated that shell-shock, cer- part, by the misdiagnosis of psychosomatic for wars fought in the late 19th century tain forms of trench fever and DAH were disorders.Their incidence rose appreciably and, given the inconsistent nature of diag- functional disorders related to the stress of in the First World War with the nosis, at best these figures remain estimates. combat, whether actual or envisaged. The identification of shell-shock and Although the concept of combat stress did collection of data about soldiers suffering neurasthenia.The Second World War saw not then exist, it was recognised that from psychological breakdown was hap- soldiers could become debilitated by the hazard and inconsistent. The statistical ap- the collection of accurate data, and combat accumulated effects of active service &Jones pendix to the official medical history of the stress was treated efficiently, although few & Wessely, 1999). Having treated the sick war, based on hospital admission cards, soldiers returned to fighting units. and wounded of the Boer War, Anthony provides an approximate guide to the inci- Bowlby &1855±1929) concluded that ``the dence of psychiatric casualties &Table 1). Conclusions A constant relationship excitement of battle often following pro- The analysis was only performed for the exists betweenthebetween the incidence oftheof the total longed mental strain and bodily fatigue'' first 2 years of the hostilities and showed killed and wounded and the number of could produce a form of neurasthenia char- that psychological disorders accounted for acterised by ``the appearance of functional 2.5% and 3.8% of all admissions in 1914 psychiatric casualties, mediated by the nervous symptoms'' &Bowlby et aletal, 1901:,1901: and 1915 respectively &Mitchell & Smith, nature of the fighting and quality of the 129). He detected no clinical difference be- 1931: 115). These percentages greatly un- troopsinvolved. tween cases of military and civilian neur- derstate the true figures as they do not asthenia, adding that include functional somatic cases. Declaration of interest E.J. is Among the symptoms we find prominentlyinprominently in the supported by a grant from the US foreground pain, inthein the form of headache, gener- Treatment of combat fatigue DepartmentDepartmentof of Defense. ally posterior, pains in the neck, pains in the back and limbs, so that these cases are generally sent At first, cases of combat fatigue were in- back as rheumatism; general feebleness of the valided to hospitals in the UK. In July

242

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use. PPSYCHIATRIC SYCHIATRIC BATBATTLE TLE CASUALTIES

TaTable b l e 1 British psychiatric casualties and return to duty RTD) rates in France and Belgium 1914^1915) ThereisThere is datatodata to show thateven by the time these cases are received at base hospitals additions have beenmadetotheinitialneurologicalbeen made to the initial neurological disabil- DisorderAugust^December 19141915 ity and a colouring of invalidism given which fre- quently influences the prospects of recovery'' Admissionsper 1000RTD %)Admissions per 1000RTD %) .Salmon,1917: 539^540).

VDH 444 2.342.3474.3 3476 5.88 77.277.2 Salmon also embarked on a major study of DAH 508 2.672.67 95.595.54485 7.59 95.4 psychiatric disorders in the US Army. The incidence in 1918, he reported, was about `Nervous disorders'1906 10.0410.04 90.990.920 32734.39 90.2 twice that of the adult male population of Debility 10805.68 99.699.614 81025.06 99.099.0 the US and ``no higher than in the armies VDH, valvular disease of the heart; DAH, disordered action of the heart. of our Allies'' &Salmon, 1918: 1). Further Source: Mitchell & Smith, 1931: 130 ^131, 14 4 ^14 5). work demonstrated that combat or the threat of combat doubled the incidence of psychological disorders in officers but had 1916, Lieutenant Colonel Charles Myers, combat stress. Andre Le Leri,Âri, working in the little effect for enlisted men &Table 2). consulting psychologist to the British centre attached to the French Second Army, However, the latter showed an increased Expeditionary Force, persuaded the medi- reported that 91% of admissions between incidence of somatoform disorders such as cal authorities to treat them at base hospi- July and October 1916 were returned to neurocirculatory asthenia. For several diag- tals in France. However, the proximity to the fighting line &Salmon, 1917: 521). A re- noses deployment to the Continent appeared England and the expectation of evacuation view by G. Roussy and J. Boisseau in LaLa to have little effect, although shell-shock home tended to reinforce symptoms. At Presse MeMedicaleÂdicale for 1916 concluded that was markedly greater for officers and the end of the year, Myers set up four spe- these centres avoided: men, as was psychoneurosis. The figures cial centres at the rear of `Army Areas' for ``...sojourns.moredangerousthemoretheyare supported Mott's hypothesis that officers the reception of shell-shock cases, with the prolonged) in the hospitals at the rear where were more likely to exhibit the symptoms result that the return to duty rate rose from these patients are generally lost. It allows of the of neurasthenia, although his associated 50% to 90% &Myers, 1940: 92). Captain treatment of other nervous and mental cases claim that other ranks had more conversion William Brown, working at a casualty that are quickly curable and the direct evacua- tion to the special centres in the interior of those disorders was not confirmed &Mott, 1919: clearing station in December 1916 recorded more seriously affected'' .quoted by Salmon, 131). Yet this study did not represent a that of 200 psychiatric admissions, 34% 1917: 521). straight comparison between men exposed were transferred to base hospitals and Drawing on the French example and to war and those deployed in home defence, 66% returned to front-line units after an against considerable opposition, Myers as the European cohort includes troops average of 7 days' treatment &Salmon, opened an Advanced Sorting Centre close with 13 months of occupation and peace- 1917: 521). Lieutenant Colonel Gordon to the front early in 1917 where soldiers keeping duties. Holmes, consulting neurologist, confirmed could be rapidly treated. Captain F. Dillon Although it had now become clear that these figures, writing that 80% of men re- was apparently the officer responsible for psychiatric casualties were a major feature turned to duty within 2±3 weeks, whereas implementing ``the method of sedation, of modern warfare, military authorities if sent to a base hospital in France the pro- rest, occupation and return to duty carried continued to underestimate their incidence portion fell to 30±40% and as low as 5% if out at a hospital centre close to the lines and a range of conflicting conclusions were invalided to the UK &1939: 12). However, of trenches occupied by the Third Army'' drawn about their nature. Psychologically neither Myers nor Holmes recorded what &Phillips, 1944: 8). However, Sir Arthur minded physicians, like Myers, believed proportion returned to combat and of these Sloggett, Director-General of the Medical that they were inevitable and that the solu- how many relapsed. In the year ending 30 Services of the British Forces in the Field, tion lay in rapid and effective treatment, June 1917, the military psychiatric hospital soon ordered the unit's closure, arguing while many senior officers argued that with for other ranks at Maghull succeeded in re- that ``we can't be encumbered with lunatics effective training and good leadership they turning only 20.9% of itspatients to duty in Army Areas!'' &Myers, 1940: 90). were avoidable. Lord Gort, giving evidence and, in the opinion ofR. G. Rows, its to the Southborough Committee in 1921, senior medical officer, few were fit for argued that shell-shock would have been combat &Salmon, 1917: 525). Similarly, Salmon and US forces practically non-existent ``in the face of Thomas Lewis recorded that of 249 cases Through the work of Major Thomas Sal- strong morale and esprit de corps'' &South-''&South- of functional heart disease discharged from mon, the US Army had the opportunity to borough, 1922: 50). specialist cardiac hospitals in Hampstead study the incidence and treatment of psy- and Colchester between May and October chiatric disorders before it entered the 1917, only 23 &9.2%) went back to fighting War. Salmon recommended the setting up Second World War units overseas &cc. 1919: 1). The rates re- of `Advanced Section Lines of Communica- A retrospective War Office report esti- ported by physicians, therefore, were no- tion' with 30-bed wards for the emergency mated that between 5% and 30% of all ticeably lower than those presented in the treatment of mental and nervous cases, con- sick and wounded evacuated from battle official history &Table 1). cluding that: areas in all theatres during the Second The French military pioneered specialist ``much can be done in dealing with [shell-shock] World War were psychiatric casualties neuropsychiatric centres situated close to cases if they can be treated within a few hours and that this figure depended largely on the front line for the rapid treatment of after the onset of severe nervous symptoms. the type of warfare fought. In the retreat

243

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use. JONES & WESSELY

Ta b l e 22Tab Psychiatric disorders for the US Army in Europe between1April1917 and 31December1919 rates to adopt a severe disciplinary attitude to per1000 per annum) psychiatric casualties in the belief that they were due to laxness and weakness. Yet the overall percentages for the two battles were DisorderOfficers Enlisted menTotal similar &22.1% and 23.2%). Psychiatric ad- Neurasthenia 4.82 4.04) 4.04)4.82 1.41 2.6) 2.6)1.41 1.56 2.68) 2.68)1.56 missions were found to be closely corre- Neurosis 0.28 0.14) 0.14)0.28 0.15 0.26) 0.26)0.15 0.15 0.25) 0.25)0.15 lated with total battle casualties for both Neurocirculatory asthenia 0.68 0.13) 0.13)0.68 1.02 1.27) 1.27)1.02 1.0 1.01 1 1.21) engagements &Spearman's rrˆ0.8,0.8, PPˆ0.0050.005 and 0.8,and0.8, PPˆ0.005, respectively). During Shell-shock 2.98 0.14) 2.24 0.04) 0.04)2.24 2.27 0.05) 0.05)2.27 this campaign, the German 6-inch mortar Hysteria 1.3 0.44) 0.44)1.3 1.24 1.89) 1.89)1.24 1.24 1.89) 1.89)1.24 and the six-barrelled mortar were feared Psychasthenia 0.53 0.53) 0.53)0.53 0.13 0.22) 0.22)0.13 0.15 0.24) 0.24)0.15 beyond their actual capacity to inflict harm. Psychoneurosis 4.18 0.73) 2.41 1.72) 1.72)2.41 2.49 1.66) 1.66)2.49 ``Officers and mortar specialists'', recorded Total 14.77 6.15) 8.33 8.00) 8.87 7.98) 7.98)8.87 an Eighth Army morale report in 1944, ``appear to be generally of the opinion that Figures in parentheses are equivalent rates for the US Army in the US over the same period. their destructive effect is not sufficient to SourceSource: Bailey,WilliamsBailey, Williams & Komora 1929: 154). justify their introduction to the British Army. The morale effect of these weapons, to Dunkirk, it was calculated that combat 1 Canadian Division in Italy however, in particular of the Nebelwerfer is stress accounted for 10% of admissions to A comparison between the various units so great that the introduction of a similar regimental aid posts &Phillips, 1944: 6). In that made up 1 Canadian Division fighting weapon might well be considered on this view of the large numbers of servicemen in Italy during 1944 showed that great dif- ground alone'' &Anon., 1944: 1±2). admitted to psychiatric wards once they ferences could arise not only between en- had returned to the UK, this figure may gagements but also between battalions The Normandy offensive understate the true incidence of psycholo- &Doyle, n.d.: 8). In the first battle, for ex- In the Normandy campaign, the 21st Army gical disorders &Sargent & Slater, 1940). ample, Unit 1, which was in action for only Group encountered such intense German It was argued that the fluid campaign in 1 of the 10 days' fighting, recorded low resistance during July 1944 that it tested the Western Desert in 1940±1941 pro- psychiatric casualties &Table 4). Unit 6, the endurance of even seasoned troops. duced low rates &sometimes only 2%), however, which saw more intense combat, Planners had anticipated psychiatric casual- while fighting in north-west Europe, akin had an even lower figure, attributed to the ties of the order of 10±30% and, although to trench warfare, led to far higher figures quality and training of its troops. Having the recorded rate fell within this range, it &War Office, 1951: 1). In fact, detailed re- had high psychiatric casualties in the first caused ``considerable anxiety amongst cer- ports from the Western Desert reveal that battle, Unit 7 was thought to have im- tain officers, some of whom believed that the percentages were considerably higher proved its fighting qualities by the time of the psychiatric problem would be negligi- than claimed &Table 3). Between July the second engagement, when it had one ble'' &Main, 1944: 2). During the first 16 and September 1943 psychiatric casualties of the lowest percentages. Hence, psychi- days of the campaign, psychiatric casualties and total battle casualties were correlated atric casualties are not simply an indicator in 8 Corps varied considerably. The overall at a significant level &Spearman's rrˆ1.0,1.0, of the severity of combat but are also a re- rate was 14.6%, while the three divisions PPˆ550.001). In part, these variations can flection of the experience and preparedness recorded rates of 21%, 11.6% and 14.7% be explained by the different phases of of soldiers. Interestingly, the division had &Phillips, 1944: 12±13). The second battle, battle, as Major Craigie had observed that been instructed before the second action a fast-moving armoured thrust lasting only the incidence of psychiatric casualties in the desert during 1942 depended ``to some extent on the nature of the action itself ± Ta b l e 4 Canadian Division in Italy: battle casualties for instance, it is likely to be higher during unsuccessful, purely defensive or unduly Unit First engagement Second engagement prolonged actions'' &Craigie, n.d.: 1). Total casualtiesPsychiatric casualtiesTotal casualtiesPsychiatric casualties TaTable b l e 3 UK forces in the Western Desert: 121 2303040 17.4) 83 14 16.9) casualty rates 232 3171790 28.4)90 28.4) 107 25 23.4) 33 289289 74 25.6) 25.6)74 152 39 25.7) Month 1943)Total casualtiesPsychiatric 424 2414156 23.2)56 23.2) 211 45 21.4) casualties 525 2616159 22.6) 22.6)59 181 31 17.1)

July 2461161 6.5) 626 2242438 16.9)38 16.9) 178 26 14.6) August 1245154 12.4) 77 285285 62 21.8) 21.8)62 210 66 31.4) September 609 127 20.9) 20.9)127 88 266266 21 19.2) 19.2)21 217 65 30.0) 939 32828100 30.5) 252 58 23.4)58 23.4) Figures in parentheses indicate psychiatric casualties as a percentage of the total. Figures in parentheses indicate psychiatric casualties as a percentage of the total. Source:Barbour 1943:12). Source: Doyle n.d.: 8).

244

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use. PPSYCHIATRIC SYCHIATRIC BATBATTLE TLE CASUALTIES

5 days, led to a greatly reduced the Corps' base unit at Assisi sent only 19% of men correlated. As the fighting became more rate of 11.6%. The third battle, in which back in the same medical category &Sandi- intense, so there was a concomitant rise in British troops encountered severe opposi- ford, 1944: 45±46). the DNBI rate &Blood & Gauker, 1993: tion, saw an increase to 18%, although 342). They found a similar correlation great variations occurred between units. between the two measures in a study of These high percentages were also a function US forces Marine units in Korea from February to of widespread battle fatigue in soldiers who Although individual psychiatrists collected June 1951.June1951. had already fought in North Africa, Sicily statistics as campaigns were fought and Using the data collected by Beebe & and Italy, and, as a War Office report con- these guided decisions about treatment, sys- Apple, Noy &1987) hypothesised that the cluded, ``a number of men who broke down tematic studies were not undertaken until intensity of battle accounted not only for were experienced veterans with excellent the postwar period. A retrospective study the rate of psychiatric casualties but also past records'' &War Office, 1951: 7). by Beebe & DeBakey &1952) analysed ca- for their general presentation. Comparing Although some planners believed that the sualties for units engaged in combat, com- different types of departure from the battle- battle exhaustion crisis had passed, heavy paring the wounded with all other field, he found that psychiatric cases had fighting involving the 1 Canadian Army admissions. They calculated correlation experienced greater combat intensity than north of Falaise during August produced coefficients for two theatres in 1944, the medical &excluding wounded in action) even higher rates of psychiatric casualties south-west Pacific and the Mediterranean, and disciplinary cases &Noy, 1987: 604). &Copp, 1997: 150). It became clear that and for the 34and 45Divisions in Most psychiatric casualties were of the dra- the only effective way to reduce battle ex- October±November 1943. Admissions to matic, but transient, combat reaction type, haustion levels was to lower the intensity neuropsychiatric units were closely corre- while the medical and disciplinary cases ap- and duration of combat. lated with the total wounded, with the ex- peared to be a response to sporadic stress. ception of the south-west Pacific &Beebe & DeBakey, 1952: 28). Incomplete data and Korean War Return to duty rates a failure to recognise the nature and im- Total psychiatric casualties were recorded The main justification for deploying army portance of psychiatric casualties were pro- as 37 per 1000 among US servicemen psychiatrists to forward areas was to facili- posed as reasons for the anomaly. Three of &Dean, 1997: 40). However, the Korean tate the treatment of battle-fatigued troops the four examples showed that battle inten- War can be divided into two distinct phases so that they could be returned to their units sity was the crucial variable. A further with markedly different rates of psychiatric as quickly as possible. Although both study by Beebe & Apple &1958) involved casualties. During the first year, charac- Myers and Holmes suggested that over a representative sample of 2419 soldiers terised by movement, an exceptionally cold 80% of soldiers treated in specialist centres drawn from 150 companies that fought in winter saw battle injuries and wounds to in the First World War returned to duty, the Mediterranean and European theatres. US forces rise to 460 per 1000 &Jones, they did not record how many went to Unit losses and the arrival of replacements 19951995bb: 41). From mid-1951, it became a fighting units. The experience of the Second were recorded during periods of combat static war of attrition, although troops were World War suggests that most servicemen and showed a correlation between the num- better equipped and trained for the harsh returned to non-combatant activity, ber of killed and wounded and the inci- winters. Battle injuries and wounds to US although the percentage varied consider- dence of combat stress reactions. The forces fell to 170 per 1000 in 1951 and ably according to the intensity of battle average breaking point for a rifleman in 57 per 1000 in 1952. No statistics survive and provision of psychiatric services the Mediterranean theatre of operations, for UK units in the early phase of the war &Table 5). Major Doyle of 1 Canadian Di- for example, was 88 days of company com- but by December 1952 the proportion of vision concluded that ``less than 20% of bat ± days in which the unit sustained at battle exhaustion to battle casualty cases psychiatric casualties can be returned to full least one casualty &Beebe & Apple, 1958). for 1 Commonwealth Division was 21 per combat duty after treatment'' &Doyle, n.d.: Blood & Gauker &1993) examined the re- 1000 and from May 1952 to the end of 11). These figures were confirmed by Briga- lationship between the wounded in actionaction the war it fell to 18 per 1000 &Jones & dier Sandiford, who visited Corps' psychi- rate &WIA) and disease and non-battlenon- in-battlein- Palmer, 2000: 258). Battle exhaustion cases atric teams in Italy after the battle of jury rate &DNBI) for the 1 and 6 Divisions were found to be closely correlated with Casino. Between May and November of the US Marine Corps during their as- battle casualties &Spearman's rrˆ0.8,0.8, 1944, the return to duty rate fluctuated be- sault on Okinawa between April and June PPˆ0.001).0.001). tween 32% and 16%, while the specialist 1945. The two rates were significantly

Ta b l e 55Tab Return to duty rates Recent wars The Vietnam War is often taken as an ex- ample of low-intensity combat and US Unit Campaign Returned to combat troops suffered relatively minor rates of 88Army Army Italy 1944) 1944)Italy 25^30%25^30% battle injuries and wounds &from 62 per 21 Army Normandy July 1944) 50% with 10% relapsing 1000 in 1965 to 120 per 1000 in 1968). 88Corps Corps Normandy July 1944) 49% with 10% relapsing Psychiatric casualties were low: 12 per 1000 &Dean, 1997: 40). The prolonged 1 Canadian DivisionItaly July 1943^April 1945)22% reduced to 15% after relapses campaign also gave rise to a new term, SourcesSources: Hunter 1944: 4); Main 1944: 2); Phillips 1944: 12^14); Doyle n.d.: 3). post-Vietnam syndrome, which referred to

245245

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use. JONES & WESSELY

servicemen suffering from chronic psychi- evacuating casualties from the island helped concentrated shelling is said to have raised atric symptoms or to those who appeared to keep these figures down, in the same way psychiatric casualties to 54% in the US 2 well when demobilised but later developed that a firm regimental medical officer in the Armoured Division &Holmes, 1997: 218). an enduring psychological disorder. The First World War could discourage cases of diagnosis of PTSD was developed as a shell-shock &Jones, 1995aa: 23).:23). TraumaTrauma consequence of, or some might say as a The relationship between physical and stimulus to, these observations, but it lies DISCUSSION psychological trauma is a complex one. Ad- outside the scope of this paper. vances in medical science have progres- The Yom Kippur War in 1973, by con- The relationship sively reduced the proportion of troops trast, was a high-intensity campaign. At Today there is a consensus that a constant who die from their injuries, the rate falling first, Israeli combat stress rates were re- relationship exists between the incidence from 20% in the Crimean War to 6.1% in ported as only 10% of total casualties but of the total killed and wounded and the the First World War, 4.5% in the Second later were revised upwards to between number of psychiatric casualties. Several World War and 2.5% in Korea &Beebe & 30% and 50% &Jones, 1995aa: 21). Initial factors, however, act as mediators or effect DeBakey, 1952: 77). Improved survival reports had failed to include servicemen modifiers between these two variables: the rates may have increased the number of po- who had been treated at forward medical physical nature of the fighting; the state of tential psychiatric casualties and allowed units and returned to duty, men with light morale and preparedness of the troops; the focus of attention to move towards wounds who also suffered from psychologi- and the quality of leadership. These may re- psychological issues. Alternatively, wounds cal stress, and psychiatric casualties that duce the size of the association but not the could serve as a protector against post- arose 2 days after the cease-fire. Figures association itself. combat syndromes. Physicians during the from this war showed that the peak inci- First World War commented that soldiers dence of combat fatigue was in the first injured in battle were less likely to suffer few days, when physical casualties were at Cultural factors from shell shock and that many men with their greatest &Abraham, 1982: 21±2). The Military and health beliefs of the society this disorder had not been wounded. Lebanon War of 1982 had a short period from which the soldiers were drawn also Psychiatric casualties may continue to of high-intensity combat followed by pro- need to be considered. In particular, ideas be underreported. As the causes of combat longed low-intensity fighting, when snipers about acceptable levels of casualties and fatigue have become better understood, it and booby traps accounted for many the general level of psychological under- has been suggested that commanders may casualties. Although the war generated a standing are pertinent. In the decade before be reluctant to refer cases for treatment as moderate overall rate of 23% for psychi- the Boer War, when life expectancy for UK they will be considered a sign of poor mor- atric casualties, 90% of these fell within a males was only 44 years and knowledge ale or indifferent leadership. Today, when 3-month period &Noy, 1987: 602). about combat syndromes was embryonic, adults expect to survive most diseases and The Falklands War of 1982 lasted only observed psychiatric casualty rates were when great emphasis is placed on the elim- 74days, including a 25-day campaign from low, almost non-existent. But this hides, ination of risk, Western society has little the landing at San Carlos Water to the re- as we have shown, psychiatric morbidity tolerance of death and wounding. It ap- capture of Stanley. British troops lost 237 in the shape of DAH, rheumatism and cases pears that this fundamental cultural change killed and 777 wounded, with 446 requir- of sunstroke. The First World War saw a is reflected in the incidence of psychological ing significant hospital treatment. Psychi- greater appreciation of the stress of war- disorders both during combat and as a atric casualties were reported as 2% of all fare, such that doctors became increasingly delayed effect. wounded, with 16 declared cases evacuated alert to psychiatric symptoms and soldiers from the hospital ship UgandaUganda &Price, 1984: were better able to interpret their own 109). Further research by Abraham sug- responses to traumatic situations. Such REFERENCES gested that somatic presentations, such as understanding remained at an early stage Abraham, P. 1982) Training for battleshock. Journal of functional deafness, concealed the true rate, and judgements continued to be clouded the Royal Army Medical Corps,, 128,18^27. which was about 8% ± a figure well below by Edwardian notions of courage and duty. Bailey, P.,Williams,P., Williams, F. E. & Komora, P.O.P. O. 1929) TheThe that of many of the battles fought during By the Second World War, suggestions Medical Department of the United States Army in the the Second World War &Abraham, 1982: that psychiatric breakdown was due to a World WarWarWorld ,Vol.X,,Vol.X, Neuropsychiatry.Washington, DC: US 113). Explanations have included the fact failure of personal morality or social degen- Government Printing Office. that British troops were considered the eeliteÂlite eration had largely been abandoned. In Beebe, G.W. & Apple, J.W. 1958) Psychological of the army, with high morale. In addition, their place, psychiatrists and military strate- breakdown in relation to stress and other factors. In Variation in Psychological Tolerance to Ground Combat in the 2-week transatlantic voyage gave them gists sought measurable causes such as World War II, Final Report, pp. 88^131.Washington, DC: DC: time to prepare for the conflict ahead, while quality of training. In addition, Western National Academy of Sciences.

they were also able to practise amphibious society was less tolerant of the high __ &DeBakey,M.E.1952)& DeBakey, M. E. 1952) Battle Casualties: Incidence, assault landings on St George's Island, casualty levels that had been incurred Morality, and Logistic Considerations..Springfield,Ill: Springf ield, Ill: which remained under British control between 1914and 1918, and offensives Charles C. Thomas. &O'Connell, 1985). For the Argentine were planned so as to minimise losses. Blood, C. G. & Gauker, E. D. 1993) The relationship between battle intensity and disease rates among forces, psychiatric casualties also appear Nevertheless, some battles saw high rates Marine Corps infantry units. Military Medicine,, 158,, to have been surprisingly low and were re- of killed and wounded, notably the early 340^344.340^344.

ported as 4±5% &Jones, 1995aa: 23). It has stages of the Normandy campaign and the Bowlby, A. A., Tooth, H. H.,Wallace, et aletal 19 01)1901) AA been suggested that the impossibility of Monte Casino offensive in Italy, where Civilian War Hospital,BeingHospital, Being an account of the work of

246

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use. PPSYCHIATRIC SYCHIATRIC BATBATTLE TLE CASUALTIES

the Portland Hospital and of experience of wounds and sickness in South Africa, 1900190 0. London: John Murray. CLINICAL IMPLICATIONS Copp, T. 1997) `If`Ifthiswarisn'tover...'FirstCanadian this war isn'tover . . .'First Canadian Army, February ^ March 1945. In Time to Kill,The Soldier's Experience of the War in the West 1939^1945 .eds P. && Psychiatric battle casualties are an enduring and significant feature of modern Addison & A. Calder), pp. 147^158. London: Pimlico. warfare and their incidence is largely but not solely determined by the intensity of Dean, E. T. 1997) Shook over Hell, Post-traumatic stress, battle.battle. Vietnam, and the Civil War.Cambridge, Ma: Harvard University Press. && If treated rapidly by psychological means, most servicemen can be returned to Holmes, R. 19 97) The Italian job: five armies in Italy, duty, although fewer than half go back to combat units. 1943^45. InIn1943^45. Time to KillKillTime , .eds P. Addison & A. Calder), pp. 206^220. London: Pimlico. && There has been a tendency to misdiagnose soldiers suffering from functional Jones, E. & Palmer, I. P.2000) Army psychiatry in the somatic disorders, thereby understating the true incidence of psychiatric battle Korean War: the experience of 1Commonwealth Division. Military Medicine,, 165, 256^260.,256^260. casualties.

& Wessely, S. 1999) Case of chronic fatigue __ LIMITATIONS syndrome after Crimean war and Indian mutiny. British Medical Journal,, 22,1645^1647. && Although data appear to have been collected accurately from the Second World Jones, F. D. 1995aa)) Psychiatric lessons of war.Inwar. In Textbook of Military Medicine, Part 1 ^ War Psychiatry War onwards, there are few standardised measures and studies often rely on the .eds F.D. Jones, L. R. Sparacino,V.L.Wilcox, et al),), judgement of clinicians. pp. 3^33.Washington, DC: Office of the Surgeon General,US Army. && The statistics for psychiatric disorders in the First World War and the calculations

__ 19 95 bb)) Traditional warfare combat stress of return to duty rates have been shown to be inaccurate. casualties. InTextbook of Military Medicine, Part 1 ^ War Psychiatry .eds F.F.D. D. Jones, L. R. Sparacino,V.L.Wilcox, && Among military clinicians there has not always been agreement about the nature et al), pp. 35^61.Washington, DC: Office of the Surgeon General,US Army. of psychiatric casualties, as they often present with both psychological and physical

Mitchell,T. J. & Smith, G. M. 1931) Medical Services, symptoms.symptoms. Casualties and Medical Statistics of the Great War. London: HMSO.

Mott, F. 1919) Neuroses and Shell Shock.London: Henry Froude and Hodder & Stoughton.

Myers, C. S. 1940)194 0) Shell Shock in France 1914^18, Based EDGAR JONES, PhD, SIMON WESSELY,MD,Department of Psychological Medicine,King's College Medical on a War Diary. Cambridge: Cambridge University Press. School, London. Noy, S. 191987) 87) Battle intensity and the length of stay on the battlefield as determinants of the type of evacuation. CorrespCorrespondence:Drondence:Dr Edgar Jones,Department of Psychological Medicine,King's College Medical School, Military Medicine,, 153, 601^607.,601^607. 103 Denmark Hill,London SE5 8RT; e-mail: E.Jones@@hogarth7.demon.co.uk O'Connell, M. R.19 1985) 8 5) Psychiatrist with the task force. In Psychiatry:The State of the Art,Vol.6 .eds P. .First receivedreceived10 10 March 2000, final revision 27 July 2000, acceptedaccepted14 14 August 2000) Pichot, P. Berner, R.Wolf, et aletal), pp. 511^513. New York: Plenum Press.

Price, H. H. 1984) The Falklands: rate of British psychiatry combat casualties compared to recent American wars. Journal of the Royal Army Medical Corps,, Barbour, R. F. 1943) Forward psychiatric unit. London: Wellcome Institute for the History of Medicine .PP/ 130130,109^113. Wellcome Institute for the History of Medicine .GC/ LEW/C1/1). 135/ B1/2 6). Salmon,T.W. 1917) The care and treatment of mental diseases and war neuroses .`Shell Shock') in the British Craigie, H. B. n.d.) Notes on the early recognition and Main, T. F. 1944) Quarterly report by the adviser in Army. Mental Hygiene,, 11,509^547. treatment of psychiatric battle casualties. London: psychiatry.London: Wellcome Institute for the History of Sargent,W. & Slater, E. 1940) Acute war neuroses. Wellcome Institute for History of Medicine .PP/ Medicine .GC/135/B1/109). Lancet,, 22,1^2.,1^2. WWWS/E2/12).

Southborough, Lord 1922) Report of the War Office Doyle, A. M. n.d.) Psychiatry in the Canadian Army in Phillips, R. J. 1944) Psychiatry at corps level. London: Committee of Enquiry into `Shell-Shock'. London: HMSO. action. London: Wellcome Institute for the History of Wellcome Institute for the History of Medicine .GC/ Medicine .GC/135/B1/114). War Office 1951) Psychiatric Disorders of Battle.. 135/ B1/112). London: War Office. Holmes, G. 1939) Report on the conference on `neuroses'.London: Public Record Office .PIN15, 24-2/ Salmon,T.W. 1918) A preventable type of mental 15B).15B). disease in the American Expeditionary Force. London: Manuscript sources Hunter, H. D. 1944)194 4) Eighth Army psychiatric Wellcome Institute for the History of Medicine .GC/ Anon. various dates) War pension files of the Royal memorandum No.1.London: Wellcome Institute for the 135/ B1/41). Hospital,Chelsea. London: Public Record Office .PIN71). History of Medicine .GC/135/B1/91).

Anon. 1944) Eighth Army morale report. London: Lewis, T. Lewis, c. 1919) Memorandum on after-histories of Sandiford, H. A. 1944) Report on visit to CMF by Wellcome Institute for the History of Medicine .GC/ expeditionary force`DAH' [disordered action of the Director of Army Psychiatry.London: Wellcome 135/ B1/87).B1/87).135/ heart] cases recently discharged from hospital. London: Institute for the History of Medicine .GC/135/B2/30).

247

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 13:05:30, subject to the Cambridge Core terms of use.