When 1st Canadian Division veterans recall the Italian campaign, memories of Ortona and the winter that followed are never far from the surface. The battles of December 1943 produced casualties on a scale that reminded men of the western front in 1916. One month of combat cost 1st Div. 176 officers and 2,163 other ranks killed, wounded or missing. A further 1,617 all ranks were admitted to hospitals as sick, including more than 500 men diagnosed as suffering from battle exhaustion. These losses were concentrated in the rifle companies of the nine infantry battalions and as 1944 began most companies operated at half-strength.There was little that Major-General Chris Vokes and his staff could do about the physically sick or wounded men in the care of the Royal Cdn. Army Medical Corps. And although it accounted for more than one in four non-fatal casualties, few people understood what “battle exhaustion” was.

In 1943 most people were still using the WW I term “shell shock” to describe men who broke under the stress of combat and ceased to function as soldiers. British army psychiatrists insisted that a new label, which encouraged men to believe the condition was temporary and treatable, had to be devised. At first the term “Not yet diagnosed (nervous)” was used, but during the retreat to El Alamein, Egypt, cases were described as suffering from “exhaustion.” In their medical notes doctors still distinguish between simple fear states, anxiety neuroses and campaign neuroses that hit soldiers who had served in combat for several years, but battle exhaustion became the term of choice.

The staff of Gen. Bernard Montgomery’s 8th Army, including its medical officers, were reluctant to introduce forward psychiatry, using specially designated casualty clearing stations. They believed it would encourage men to give in to their fears. The Australians disagreed. Their experience during the siege at the Libyan port of Tobruk in 1941 convinced them that early treatment within sound of guns was highly effective. Rest, sedation and frank discussion of the need to discipline fear encouraged many soldiers to resume duty.

In 1942, 9th Australian Div. used a casualty clearing station to treat men with battle exhaustion. It required that patients contribute a pint of blood as part of the treatment process “to atone for the breakdown” and “to feel that he remained a useful member of the group.” The Royal Army Medical Corps was not impressed.

The United States Army arrived in North Africa completely unprepared for combat stress casualties. American psychiatrists had convinced themselves that personnel selection would eliminate men predisposed to “anxiety neurosis.” The shock of combat at Kasserine Pass and the battles for Tunis shattered this illusion producing hundreds of psychiatric cases. Colonel Fred Hanson was brought to North Africa to organize treatment of what the U.S. Army decided to call combat exhaustion. Hanson, who was studying with the famous neurosurgeon Wilder Penfield at the Montreal Neurological Institute when war broke out, had joined the Canadian Army serving as a neuropsychiatrist at No. 1 Neurological Hospital in Basingstoke, England.

The hospital, which was also known as “No. 1 Nuts”, expanded to include plastic surgery, but the bulk of its patients were admitted for mental problems. Hanson and most of the Canadian psychiatrists who worked at Basingstoke were convinced that intense combat would produce large numbers of acute psychiatric casualties.

They believed that while such casualties would occur among men who had previous histories of nervousness and instability many normal men would also suffer breakdowns. Every man had a limited store of courage to draw from and some would use up their reserves quickly. During the Dunkirk evacuation hundreds of men broke under an accumulation of physical and mental strain developing the classic symptoms of war neurosis; listless apathy, terrifying nightmares, depression and a pronounced startle reaction to the least noise. Few of those who were hospitalized would ever be fit to return to combat.

Many psychiatrists were convinced that more men could be returned to combat if treatment was provided before the symptoms became fixed. This approach came to be summed up in three words: proximity, immediacy and expectancy. Exhaustion should be dealt close to the action, as quickly as possible and in an atmosphere that encouraged the soldier to see his condition as temporary.

This was the official Canadian view when 1st Cdn. Div. left for the Mediterranean as the only unit to have its own divisional psychiatrist. Major Arthur Manning Doyle had trained at Basingstoke and was well prepared to practise the principles of forward psychiatry advocated there. He found little to do in Sicily where the exhaustion cases, following British practice, were quickly evacuated. Doyle did not hear about the notorious incident when Gen. George Patton slapped a hospitalized soldier who said he “just couldn’t take it”. He only heard about it when a story appeared in the press and Patton was forced to apologize. But Doyle was well aware that many Canadian officers also believed that discipline not medical treatment was the answer to soldiers suffering from combat exhaustion.

As the Canadians began their advance to the Moro River, Doyle established his treatment unit in the ruins of the village of Rocca, north of the Sangro River. “It was surrounded by our batteries,” he wrote, “and a day-long barrage was going on almost constantly.” This settled the question of proximity, but events were soon to overwhelm hopes of immediacy or expectancy. The reality of intense combat over a prolonged period produced 226 psychiatric casualties in a single week and on one memorable day Doyle “examined 57 patients and still could not keep abreast of the deluge.” He quickly decided to evacuate all but the most hopeful cases to a British hospital well behind the lines.

The flood of battle exhaustion cases at Ortona transformed Doyle’s ideas about psychiatric casualties. Brief interviews with scores of frightened and shaky men persuaded him that “84 per cent of all cases…were suffering from some form of psychiatric disorder prior to military service.” When the corps commander visited Doyle to ask about the high number of psychiatric casualties he was assured that “the division had now had a good and overdue house cleaning and the morale of the troops in general was good.”

Doyle’s sudden reversal of Canadian doctrine on combat stress had a significant effect on manpower policy in Italy. After Ortona, divisional medical and staff officers accepted Doyle’s view that large numbers of battle exhaustion casualties were inevitable given the quality of the replacements sent to Italy. In 1944, while the division was in a defensive role north of Ortona, Doyle treated 30 to 35 psychiatric casualties a week. He assigned most of them to non-combat duties. By April 1944, 1,234 battle exhaustion cases had been evacuated and less than one third had been returned to their units. The rest were assigned to tasks in the rear areas, and Special Employment companies were created to administer them.

Vokes took a very different view of the crisis in morale that was affecting his division. He argued that its “infantry units will not be in fit condition to undertake further intensive operations until they have had a period of rest free of operational commitments, during which they can carry out intensive training.” Instead of rest and retraining, the rifle companies were required to undertake aggressive patrolling and spend days in the frozen ground under mortar fire. Some men–67 were identified–decided to inflict wounds on themselves, others went absent without leave, the vast majority groused and endured, and found strength in friendships and youthful optimism.

The arrival of 5th Armored Div. And 1st Cdn. Corps Headquarters did little to alter this situation. The new division’s infantry battalions were needed in the line and the “spit and polish” directives sent out by corps headquarters made Gen. Harry Crerar and his successor, Lieutenant-Gen. E.L.M. Burns, less than popular with the veterans. Fifth Div.’s first operation north of Ortona–the “Arielli Show”–was a costly failure and patrols proved equally fruitless. No one seemed able to explain the purpose of such battles and morale plummeted.

The Allied attempt to end the stalemate in Italy with a “left hook” amphibious assault at Anzio failed to achieve its primary purpose because the enemy used its reserves to seal off the beachhead. In the larger scheme of things, where all aspects of the Italian campaign were judged for their impact on the forthcoming invasion of France, Anzio was a success. German units could not be withdrawn from Italy. For the men fighting in Italy the crisis at Anzio meant the 8th Army would launch a major offensive in the Liri Valley.

Operation Diadem began on May 11, 1944 with 4th British and 8th Indian divisions cracking through the Gustav Line. The lead Indian Army brigades were supported by Canadian armored regiments and were on their objectives in four days. 1st Cdn. Div. took over the lead advancing rapidly to the Hitler Line. Here the fighting reached Ortona levels of intensity. The Germans had prepared their main defensive positions with care employing thousands of anti-personnel mines, especially S mines that did not explode at foot level, but were catapulted up to chest height before exploding. Sown amongst the barb wire defenses they helped to slow down all attempts to attack German positions on the higher ground. On May 23, 2nd Bde., which thought it had seen it all at Ortona, lost 543 men. One hundred and sixty two killed, 306 wounded and 75 taken prisoner. Historian Shaun Brown has noted that this was the worst single day of the war for any Canadian brigade in Italy.

The preparations for the assault on the Hitler Line had included new policies on psychiatric matters. Burns and his medical advisers rejected Doyle’s assumptions about the causes of exhaustion casualties and “banished him to corps maintenance area well away from the front.” Corps believed that tighter discipline and a restoration of forward psychiatry using regimental medical officers would minimize the problem. In one sense they were right, significant numbers of mild cases were treated well forward and were able to return to their units, but as the battle continued more and more men had to be sedated and evacuated. By the end of June, 1st Div. had suffered 1,601 casualties and 23 per cent were due to battle exhaustion. While fighting its first sustained action, 5th Div. lost 785 men during May. Thirteen per cent of them were psychiatric casualties.

It ought to have been apparent to all that battle exhaustion ratios rose and fell with the intensity and duration of combat. Discipline, good leadership and high unit morale could help to limit the consequences of prolonged stress, but factors such as the loss of a close friend could precipitate a breakdown in the bravest of men.

Back in Britain, 1st Cdn. Army was preparing for Operation Overlord and trying to draw lessons from the Italian experience. The senior Canadian psychiatrist, Col. F.H. Van Nostrand, was a WW I veteran known for his blunt language and common sense. He had visited the Italian front and knew that the fighting in Normandy might produce similar levels of exhaustion casualties. He believed that men who had shown signs of instability in training should be “weeded out” but doubted that this would make much difference. Bob Gregory, the psychiatrist he assigned to 3rd Cdn. Div. was quite willing to weed people out, but during three months of screening units he was able to identify only 127 men in a division of 20,000 who “were apt to give trouble in action.”

He reported that the morale in 3rd Div. was excellent. “The troops are relaxed and in the highest spirits.” They had complete confidence in their ability to breach the Atlantic Wall. “They feel,” he wrote, “they have the firepower, the naval support and air superiority.” The achievements of the division on D-Day and the advance inland suggest that their confidence was justified and despite setbacks morale remained high and battle exhaustion casualties low.

The situation changed dramatically by the third week in June 1944. The Canadians and their D-Day partners, 3rd and 50th British divisions, occupied positions north of Caen that were under continuous mortar and artillery fire. At Hell’s Corners and at a dozen other places, front-line battalions suffered a steady stream of casualties including men suffering from battle exhaustion. While the men waited, the Germans constructed evermore elaborate defensive positions, turning villages like Buron, St. Contest and Authie into fortified strongpoints. On July 4th at Carpiquet, 8th Bde, reinforced by the Royal Winnipeg Rifles, advanced across open ground to seize the village and airfield. Major J.E. Anderson of the North Shore (New Brunswick) Regiment spoke for everyone when he wrote: “I am sure that at some time during the attack every man felt he could not go on. Men were being killed or wounded on all sides and the advance seemed pointless as well as hopeless. I never realized until the attack at Carpiquet how far discipline, pride of unit, and above all, pride in oneself and family, can carry a man even when each step forward meant possible death.”

But not everyone could endure battles like Carpiquet and when the main attack on Caen was launched four days later, medical officers described battle exhaustion as the outstanding problem facing the division.

By the standards of Italy the exhaustion ratios were still very low, more like one in eight than one in four, but by the end of July the crisis reached Ortona proportions.

After eight weeks of combat, 3rd Div. had lost the equivalent of its total strength in riflemen and 3/4 of the casualties were concentrated in the rifle companies.

Under these conditions battle exhaustion was bound to be a major problem and the senior medical officer, Col. M.C. Watson, reported that without a rest period and time to re-organize the rifle companies, the division would face a major collapse of morale.

Gregory and Major Burdett McNeel, who commanded the corps exhaustion unit, were sensible men who understood that intense and prolonged combat could traumatize anyone. They did their best to reassure their patients and only those who were both willing and able were returned to combat. The British and U.S. armies experienced similar problems and implemented comparable treatment programs.

The German army took another route. The Nazi-inspired code of military law demanded the death sentence or long prison terms for offences that included battle exhaustion. By June 1944 more than 7,000 German soldiers had been executed for such crimes and the toll would grow throughout the last months of the war.