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Psychic Injury From Bull Run To Fallujah

In July 1864 Captain Oliver Wendell Holmes, Jr., left the Union Army, still locked in a struggle to the death with the Confederacy, and returned home to Boston. The Civil War had nine months to run, but Holmes's war was over. He wrote his parents to explain why he would not be reenlisting when his three-year obligation expired: "Many a man has gone crazy since this campaign begun from the terrible pressures on mind and body. Doubt demoralizes me as it does any nervous man ... I cannot now endure the labors and hardships of the line."

In the summer of 2003 Captain Nathaniel Fick returned home from Iraq, where he had commanded a platoon in a Marine reconnaissance battalion that raced toward Baghdad ahead of the main invasion force. The war followed him home in nightmares and apparitions. "I thought I was losing my mind," Fick later wrote. "The only way I knew I was still sane was that I thought I might be going crazy. Surely, that awareness meant I was sane ... I was reduced to taking comfort in a tautology."

Nearly a century and a half apart, Holmes and Fick discovered that war inflicts wounds on the mind as well as the body. They characterized their bouts of combat stress in virtually identical terms. Between the Civil War and the wars in Iraq and Afghanistan, however, the labels affixed to this ancient malady changed many times. "Soldier's Heart" described the heart-attack-mimicking symptoms of patients in a Civil War military hospital. World War I's label emphasized a presumed cause: "Shell Shock." World War II retreated to euphemisms like "combat fatigue." Following the Vietnam War "Post-traumatic Stress Disorder," or PSTD, came to characterize all manner of responses to stress - from flashbacks through emotional numbing and beyond.

Holmes and Fick, like most combat veterans, recovered from their sense of "going crazy." Their mind wounds proved to be comparatively mild -- or at least not life-inhibiting. Holmes went on to become a Supreme Court Justice and Fick is well launched on a career in public service. But others emerged from their wars disabled by chronic combat stress. Unlike physical wounds, mind wounds are invisible. They appear only as mysterious alterations in character, personality, and behavior. They can make warriors return home as strangers.

Peeling back the labels affixed to mind wounds between the Civil War and our own day reveals perceptions and conceptions shaped by time, place, and culture. The more remote in time these are, the more they resemble guessing games. Perplexed Civil War surgeons thumbed their medical handbooks for Latinate terms like "Melancholia" and "Dementia." Weir Mitchell, the pioneer neurologist, tended to see combat stress as malingering and recommended scaring the shirker into his senses. Combat-stress-as-malingering was a robust and long-lived theme, exemplified in General George Patton's slapping of a soldier during World War II, a notion that persists in some quarters today. Jacob da Costa's Civil War diagnosis of Soldier's Heart, however, rested on physical evidence drawn from hundreds of cases. Noting that its symptoms resembled a heart attack without actually being one, he inferred a condition that today would be called panic disorder.

A lone physician also devised the label "Shell Shock," the most vivid term in the history of combat stress. Like Da Costa, Charles Myers inferred his diagnosis not only from what he saw, but also from what he did not see. In early 1915 he published an article on symptoms he had observed in infantrymen seeking treatment in the opening months of World War I. Trembling, convulsive, sometimes struck dumb, occasionally paralyzed in one or more limbs, these casualties bore no physical wounds. Noting they had all been near exploding artillery shells, he ascribed their symptoms to the concussive effect of explosions. Nearly a century later, Myers's inference echoes in Traumatic Brain Injury (TBI), "the signature wound" of today's American wars. Casualties, whose brains are concussed by the ubiquitous Improvised Explosive Device (IED), also exhibit symptoms of PTSD.

Myers regretted his inference, for he began observing the same symptoms in combat troops who had been nowhere near exploding ordnance. But the Shell-Shock label stuck.

The armies of all the World War I belligerents produced cases of combat stress in seemingly epidemic proportions. Treatment fell into the broad categories of punitive or sympathetic. Some medical staffs tried electric shock, on the theory that under stimulus the brain and nervous system would rearrange themselves, restoring patients to health. Behind this approach lay a suspicion of malingerers and an urge to punish them. Other physicians tried the sympathetic practice of various talking cures. The British delayed treating combat-stress casualties until they could get them back across the Channel; the French, fighting on their own soil, acted as quickly as possible. In Iraq and Afghanistan, the Americans have followed the French practice of the forward treatment of stress casualties. Experience has shown that the closer medical personnel get to the battlefield environment where combat stress arises, the more successful they are likely to be at heading off permanent damage.

The relationship between the battlefield environment and the incidence of combat stress has been variously explained. The outbreak of shell shock in World War I, for instance, has been ascribed to the industrialization of warfare, which made of soldiers cogs in a largely stationary killing machine. World War II, a war of movement, liberated armies from trenches, but not from combat stress. Vietnam, Iraq and Afghanistan followed as frontless, asymmetrical wars, where the enemy seemed everywhere at once, as did the risk of psychic injury. It could be that environments have changed but combat soldiers havent. Throughout the history of warfare they have endured, hardy yet vulnerable. Some have brought their demons to the battlefield; many have seen and done things they find hard to live with; a few have found these things unbearable .

World War II Army psychiatrists discovered that the longer a soldier was in combat, the more susceptible he grew to combat fatigue. Some said a man would reach his breaking point within 30 days of continuous fighting. The implication was clear: Every combatant, regardless of character, training, or experience, was at risk. Lessons learned in World War II were forgotten when it came to Vietnam, where an absence of small-unit cohesionserving a long time with buddies you knew and trustedmay have contributed to the incidence of combat stress. In Iraq, increases in the number, frequency and length of deployments, combined with shorter stays at home, have once again led to a high incidence of PTSD.

Created in 1980 at the confluence of science and politics, where the concerns of reformist psychiatrists met the interests of veterans' groups, PTSD became part of the psychiatric lexicon. Like all entries in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, post-traumatic stress disorder appears as a list of symptoms, including flashbacks, exaggerated startle response, emotional numbing, insomnia, and so on. But a full-blown case of chronic PTSD is far grimmer than the items on such a list can convey.

The wars in Iraq and Afghanistan have produced more PTSD cases than an overburdened military medical system can accommodate. Yet the armed forces of the United States have never made better-informed efforts to address combat stress than they are making today. Even so, there remain vast differences in approach among the services. Among the most skeptical observers of these practices are service members themselves, who have a hard time shaking the stubbornly persistent notion that to be identified as a combat-stress casualty is to be stigmatized. Marines, for instance, shrink away from psychiatrists  "wizards," they call them -- who can end their career prospects with the wave of a magic diagnosis.

In the long arc of history from the Civil War to the wars of our time, the interpretation of mind wounds changed from moral failing to injury. In Holmes's army, combat stress could be confused with cowardice, punishable by hanging. Myers's army hauled several hundred shell-shock casualties before firing squads. In Fick's armed forces , combat stress is palpable. Like a physical wound it manifests itself in all degrees of severity. You can't see it, but you can try to heal it.

John E.Talbott is Professor of History at the University of California, Santa Barbara. His work includes 'The War Without a Name; France in Algeria, 1954-1962' and 'The Pen-and-Ink Sailor, Charles Middleton and the King's Navy, 1778-1812,' and "Soldiers, Psychiatrists, and Combat Trauma," The Journal of Interdisciplinary History, Vol. 27, No. 3 (Winter, 1997), 437-454. He is working on a book to be called 'Mind Wounds; War and Psychic Injury from Bull Run to Fallujah.'

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Wartorn 1861-2010