From Shell Shock to Combat Stress: A Comparative History of Military Psychiatry (review)

Hans Binneveld. From Shell Shock to Combat Stress: A Comparative History of Military Psychiatry. Translated by John O'Kane. Amsterdam: Amsterdam University Press, 1997. xi + 220 pp. Ill. $34.50 (paperbound, 90-5356-270-2).

This book purports to be a study of mental health care in war, military psychiatry, and combat stress reaction. It is a weak and incomplete survey. The first five chapters review selected historical aspects of war, military operations, and psychiatry. Chapters 6 through 10 discuss military psychiatry. The changing nosology, therapy, and basic principles, the place of prevention and PTSD, are presented in nonchronological order. This thematic approach distorts the history, requires redundancy of comment and data, and will be confusing to most readers. Any sense of the real sequence of events, their interactions, and the real-world variables is largely lost.

The "shell shock" of World War I was variously diagnosed in all armies and variously treated--from painful electrical stimulation (Germany) to forward treatment with rest and reassurance (England, France, and the United States). These national differences persisted in World War II. The American development of "Proximity, Expectancy, Immediacy, and Centrality" in World War I became the model for all subsequent U.S. and British wars. The book describes events through the Gulf War, with limited discussion of the Korean War. The discussion is based almost exclusively on Anglo-American data and viewpoints, and on American and European wars and armies. Air force, navy, and marine topics have been excluded.

There are many obvious errors of fact. For examples, see Swiss pikemen (p. 10); first conscription in 1793 (p. 22); the Malmédy murders (p. 41); British troop strength in Malaya (p. 49); one million Vietnam veterans with PTSD (p. 58); the mislabeled photograph on p. 96, whose source says it is not combat exhaustion; the ability to treat mass casualties (p. 151); the date of the Korean War (p. 154); uniforms for medical officers (p. 159); and American popular opinion on the Vietnam War (p. 179).

The analysis of military psychiatry is weak or wrong. Heimweh (not "heimwee") and nostalgia are homesickness, not combat stress reactions (p. 3). It is ridiculous to speak of "military psychiatry" in the American Civil War (p. 4). The overemphasis on Yealland in Britain (pp. 111-14) and Kaufman in Germany (pp. 107-16) in World War I distorts the chapter on therapy, as do the incorrect assumptions about psychoanalysis in that war (pp. 118-19). The "old sergeant syndrome" diagnosis is wrongly assigned on several occasions (e.g., p. 97). There is no discussion of the harm done to patients if they are simply sent from the front to safe rear area hospitals where secondary gain and symptom fixation often led to permanent psychiatric illness. Nor is the danger of labeling the soldier as "neurotic"--interpreted as "crazy"--analyzed. In general the important issue of the development of nomenclature is not presented. Binneveld is surprised that psychiatrists in uniform often share the nationalistic and patriotic views of their fellow officers and countrymen; he appears to want them to be antiwar humanists. He does not understand armies, or he would not dismiss a 65-70 percent return-to-duty rate by saying "not really all that much can be claimed for the actual results of combat psychiatry" (p. 158). If he understood the consultative and supervisory roles of the military psychiatrist, he would not have wandered into the absurd pseudo-epidemiology of physician numbers to total force strength given on p. 181. And "mercenary armies" is ahistorical (p. 130).

The author has not really mastered the literature. For example, had he consulted the official medical history of Britain in World War I he would have discovered centrality. Had he read the 543-page U.S. World War I history, he would not have missed Salmon's unique contribution--the division...