Every soldier is affected by the strain and violence of combat. Most learn to cope or even adapt, some become stronger and tougher, but others develop immediate or delayed reactions that can be psychologically disabling. Historically these have been labelled shell shock, combat fatigue, battle exhaustion, combat stress reaction, post-traumatic stress disorder and most recently operational stress injury. Psychological problems related to experiences in war and other stressful situations are universal, but doctors, patients, governments and the military are constantly changing their ideas about causation, prevention and treatment.

During the Second World War the Canadian Army initially refused to employ so-called intelligence tests or other methods of personnel selection, preferring to leave it to medical officers to cull “obvious misfits” defined as those “with a history of nervous breakdown, residence in a mental institution, drug addiction, etc.” A specialized hospital combining neurosurgery with neuropsychiatry was created and established at Basingstoke in southern England.

The neurosurgeons found steady work because the army allowed large numbers of young Canadians to ride motorcycles on the “wrong side of narrow English roads.” The resulting head injuries led German propaganda broadcasts to suggest that every Canadian soldier be given a motorcycle.

Gradually patients with nervous disorders flooded the hospital which soldiers began to call “No I Nuts.” The neuropsychiatrists at Basingstoke paid close attention to each patient while trying to decide on the best treatment. One particularly difficult case, a major from the Seaforth Highlanders of Canada, responded well to a frank discussion of his problems, but after several months back in his unit he was forced to return to hospital. Normally this would mean an immediate discharge and return to Canada, but something about this young, intelligent officer led the psychiatrists to offer him another chance. The major, Bert Hoffmeister, returned to the Seaforths, and commanded them in action until he was promoted to brigadier and then major-general commanding 5th Armoured Division.

The Hoffmeister case and other similar examples helped Canadian doctors avoid rigid ideas about the range of neurotic disorders they treated at Basingstoke and the army’s senior psychiatrists, Colonel F.H. Van Nostrand and Lieutenant-Colonel J.C. Richardson, advocated a pragmatic treatment system for use in combat. Third Canadian Div., training with I British Corps for D-Day, got its own psychiatrist, a dynamic young New Brunswick doctor, Maj. Bob Gregory, who won the confidence of medical and military commanders. When large numbers of combat stress cases occurred during the fighting in Normandy for Carpiquet and Caen, Gregory and the field dressing stations were well prepared to provide treatment based on the principles of proximity (to the battlefield), immediacy and expectation (of relief of symptoms and return to unit). When it became apparent that many patients could not be returned to combat, jobs were found in the rear areas.

The situation was very different in II Canadian Corps where medical and military officers rejected the advice of the psychiatrists, insisting that exhaustion casualties would not be a significant problem. Following the British model, they relied on a single corps exhaustion unit with an establishment of two psychiatrists and eight other ranks. No I Canadian Exhaustion Unit (CEU) was to be attached to whichever field dressing station had room for them. No. 1 CEU was commanded by an exceptionally able physician, Maj. Burdett McNeel, who tried to educate rather than challenge his fellow officers. No one, including McNeel, anticipated the scale of the challenge. During the six-day period before 2nd Div. began its first battle, 160 cases of acute stress reactions—with tremours, weeping, startle reactions and withdrawal as the main symptoms—arrived at McNeel’s unit. Treatment plans; immediate sedation for 24 hours, followed by two days of rest and “psychotherapeutic talks,” soon had to be abandoned as numbers grew and supplies of sodium amatyl—the sedative—ran out.

McNeel’s war diary entry for July 18 notes that “We were awakened by a terrific roar of gunfire…rumour is that ‘This is it’ and that the show should soon be over…” So much for rumours, Operation Atlantic, the Canadian part of Operation Goodwood, cost 2nd Div. 249 fatal casualties and 900 men with physical wounds. More than 300 battle exhaustion cases were evacuated to the CEU. The entry for July 22 reads: “One hundred and one cases of exhaustion admitted…our ward and the “morgues” are filled. Those in the morgues have had to sleep on blankets spread on the ground. The rain has been pouring down and the majority of men are wet and muddy.” Fortunately, 2,000 capsules of sodium amatyl arrived and full sedation was possible.

As McNeel and his small staff tried to cope, the corps’s senior medical officer who had opposed all preparations for psychiatric casualties arrived to apologize and find out what was needed. He warned McNeel that a new and potentially difficult night operation was planned for July 25 with the code name Operation Spring. “The Unit,” he warned, “should expect another increase in admissions.”

On July 25, one of the blackest days in the history of the Canadian Army, a disaster of near-Dieppe proportions struck 2nd Div. By nightfall, 450 men were dead and more than 1,000 wounded, missing or taken prisoner. Battle exhaustion, during and immediately after this trauma, added several hundred more casualties. The division, after only 12 days in battle, had produced almost as many serious exhaustion cases as the 3rd Div. had suffered in six weeks. Between July 21, when Operation Goodwood ended, and Aug. 30, the Canadians suffered 3,000 killed and 7,000 wounded. More than 1,500 exhaustion cases were evacuated beyond the regimental aid posts. Operation Spring was a costly defeat, seen as having destroyed the self-confidence of much of the 2nd Div. Asked to examine the circumstances which had led to the apparent vulnerability of the division, McNeel conducted an investigation that included visits to the divisional field ambulances and dressing stations, as well as conversations with medical officers, battalion commanders, and the men at the sharp end.

He soon began to grasp the complexity of the problem, and his report included this important statement: “The sources of error in the compilation of statistics and in the use of such a figure as an Exhaustion ratio are so numerous as to make any conclusion based on statistics alone of very doubtful value. The incidence of Exhaustion in any unit is only a part of the picture of that unit’s efficiency and may be outweighed in a positive direction by a generally high standard of performance and in a negative direction by large numbers of AWL, PoW, and trivial illnesses… The Exhaustion ratio will also be altered by the wholesale evacuation of trivial sick or wounded… For these reasons the thoughtful appraisal of the unit’s overall performance by responsible officers who know all the factors is of more value than any set of statistics or ratio can hope to be…”

On the other side of the battlefield, the German army was attempting to cope with its own exhaustion crisis by tightening the disciplinary screws. German military psychiatrists had long insisted that stress breakdowns were a leadership problem, not a medical one. In the early years of the war, with the Germans everywhere victorious, such casualties were few. It was satisfying to attribute this to the army’s emphasis on group cohesion and the responsibility of junior officers and especially NCOs for the welfare of their men. But even in the days of triumph, the new Nazi-inspired code of military law was dealing out death sentences and long terms of penal servitude for disciplinary infractions, profoundly influencing military behaviour.

Battle exhaustion became a significant problem after the German army was forced to the defensive. Some psychiatrists tried to intervene, urging recognition of the nature of stress reactions in battle. A film script about treating such casualties was completed and a statement advocating early forward treatment issued. No doubt many German army units were already using short rest periods and “comradely comfort” for stress casualties. The alternative was to allow soldiers to be caught up in a legal system that was “underpinned by compliance with Nazi war aims and ideology.” With new crimes added almost monthly in 1944-45, “death sentences rained down faster and faster each year.”

By March 31, 1943, more than 1,500 death sentences had been carried out in the German army, most of them for crimes of desertion and “subverting the will of the people to fight.” (Only 48 German soldiers were executed in the First World War). By mid-1944, 107,000 German soldiers had been tried for absence without leave, 49,000 for disobedience, and 46,000 for contraventions against guard duty. The most serious crimes of desertion and subversion had led to between 13,000 and 15,000 cases each. More than 7,000 German soldiers had been executed for these crimes by June 1944.

The Allied armies took more than 200,000 prisoners of war in Normandy. Many of them had surrendered in a condition suggesting complete physical exhaustion and serious nervous fatigue. McNeel, who saw many such prisoners in late July and August, was convinced many German soldiers were battle exhaustion cases by the end of the battle of the Falaise Gap. In the Allied armies, desertion and other crimes against discipline and good order were dealt with by prison sentences. There were no executions of soldiers or punishment of any kind for acute stress reactions.

The Canadians, because of their relatively small numbers and their insistence on a completely Canadian medical system, were able to analyze medical events closely. By the fall of 1944, in both Italy and Northwest Europe, Canadian neuropsychiatrists had persuaded senior commanders that battle exhaustion was inevitable and reasonably predictable. Rapid treatment as far forward as possible was the best way of preserving manpower for battle, but it did not always work. A high return to unit rate was probably worth pursuing in military terms, but many individuals would break down again.

No one was confident that the ones who did not turn up again at exhaustion centres were still effective with their units. Col. Van Nostrand, the senior Canadian psychiatrist overseas, offered his view of the problem: “I am not convinced that psychiatry will ever solve the vast problem of the psychiatric breakdown of soldiers during war. It is my opinion that the methods now employed in the British, American and Canadian armies will not materially lower the incidence of psychiatric casualties in a fighting force. There are various reasons for these opinions, but two of them are fundamental. First, there is direct conflict between the needs of the service and the needs of the individual soldier as assessed by his physician. Secondly, the attitudes and behavior of the successful soldier are contrary to most of his previous teaching. He must not allow death or mutilation of his comrades to prevent him from reaching his objective, and finally, he must pretend that he is glad to risk or lose his life for that cause.”

He went on to note that “the basic conflicts will always exist in armies such as ours which are composed largely of civilians who become soldiers, either voluntarily or by compulsion for a short period. It is right that this should be so.

“This is not a plea for sympathy for the inadequate soldier who is unable to stand the stresses of prolonged combat, nor is there any wish that discipline be relaxed or that any of the defections which fall under the heading of cowardice in the face of the enemy should be condoned. It is a plea for the adoption of realistic attitudes toward the reactions of normal men and women to the stresses of war.

“We who formulate the medical policy should keep constantly before us certain premises which we believe to be true, but which we have ignored in practice: 1) An army’s killing power is not necessarily proportionate to its numerical strength. 2) We fight our wars with human material we have and not with what we think we would like. 3) Although there are wide variations in the capacities of normal soldiers to withstand stress, every soldier has his breaking point, and if this is reached, he becomes a liability to his unit.”

His summary of the Allied experience with personnel selection and forward psychiatry in the war offers a comprehensive statement of what was known by 1945. Unfortunately, the lessons were soon forgotten.

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