22 The New York Review
front lines, he encountered a recent ar-
rival with no apparent battle wounds.
He asked what was wrong, and the
soldier—feverish, exhausted, disori-
ented—replied, “I guess I can’t take it.”
Patton exploded, slapping the soldier’s
face with his gloves and violently toss-
ing him from the medical tent.
Still seething, he ordered his senior
officers to deny “such cases” medical
care. And a few days later, as if to show
he meant business, Patton assaulted
another hospitalized soldier—“It’s my
nerves,” the man told the general: “I
can hear the shells come over, but I
can’t hear them burst”—by punching
“the yellow son of a bitch” and waving a
pistol in his face. “You’re a disgrace to
the Army and you’re going right back
to the front to fight,” Patton raged. “In
fact, I ought to shoot you myself right
now, goddam you!”
A medical officer at the hospital
filed a report about these incidents,
which reached General Dwight D.
Eisenhower, the supreme Allied com-
mander. Disgusted—if not exactly sur-
prised—he sent Patton a note warning
him that such behavior raised “serious
doubts in my mind as to your future
usefulness” and ordering him to apolo-
gize to the soldiers he’d assaulted. The
complication, Eisenhower admitted,
was that Patton’s warrior code paid big
dividends in the field. “[He’s] the best
ground gainer developed so far by the
Allies,” Ike conceded. “Patton is indis-
pensable to the war effort—one of the
guarantors of our victory.”
Privately, Patton remained defi-
ant, insisting that a bunch of muddle-
headed pacifists had concocted a phony
illness to undermine military disci-
pline. “There’s no such thing as shell
shock,” he declared. “It’s an invention
of the Jews.”
Still, military psychiatry made some
notable strides. The enormous jump
in uniformed psychiatrists, from fewer
than a hundred in 1940 to several
thousand in 1945, produced a wealth
of studies and anecdotal information
pointing to the same conclusion: “con-
stant exposure” to “intense combat”
could turn any soldier temporarily in-
sane, and the “breaking point” came
at about 210 days. According to one
military report, the focus had shifted
“from problems of the abnormal mind
in normal times to problems of the nor-
mal mind in abnormal times.”
Among the more enduring portraits
of World War II is the relatively seam-
less reentry of American veterans into
civilian life. “They were mature beyond
their years, tempered by what they
had been through, disciplined by their
military training and sacrifices,” wrote
Tom Brokaw in The Greatest Genera-
tion. “They stayed true to their values
of personal responsibility, duty... and
faith.” It’s an honorable depiction with
some notable holes. In truth, the return
of 16 million veterans, more than half
of whom had seen combat, was a daunt-
ing prospect. Magazine stories asked,
“Will Your Boy Be a Killer When He
Returns?” A prominent Columbia
University sociologist warned that “un-
less and until he can be renaturalized
into his native land, the veteran is a
threat to society.” More common were
reports from mainstream publications
like Newsweek that tens of thousands
of returning soldiers had developed
“some kind of psychoneurotic disor-
der” overseas that required further
attention.
Military leaders preached a different
reality: American GIs had come home
stronger, fitter, more responsible, and
better disciplined as a result of their
service in a just and necessary war.
The army even enlisted the acclaimed
Hollywood director John Huston to
make a documentary, Let There Be
Light, about the fine work being done to
help the (supposedly few) veterans who
had returned with mental health issues.
But trouble arose when Huston, taking
his responsibility quite seriously, as-
serted in the film’s opening scroll that
“twenty percent of our army casualties
suffered psychoneurotic symptoms,”
including “a sense of impending disas-
ter, a feeling of hopelessness and utter
isolation”—before proceeding to show
exactly what that damage entailed.
Alarmed by the documentary, the
War Department banned it on grounds
of patient confidentiality, although
Huston claimed to have written per-
mission from everyone he filmed. De-
cades would pass before it was made
public. “They wanted to maintain
the ‘warrior’ myth,” Huston recalled.
“Only a few weaklings fell by the way-
side. Everyone [else] was a hero.”
It wasn’t just military hard-liners
who felt this way. Even the highly re-
spected General George C. Marshall,
who would go on to serve both as sec-
retary of state and secretary of defense
in the Truman administration, loathed
the thought of indulging veterans with
psychiatric illnesses he believed to be
fake or exaggerated—yet impossible
to disprove. “He wears the clothes of
an invalid,” said Marshall, and “he es-
capes from those duties which he seeks
to evade.... He enjoys a life of leisure
with one great goal ahead: to wit, a dis-
charge for physical disability, a com-
paratively highly paid job as a civilian,
and eventually a pension from the Vet-
erans Administration.”
Progress came grudgingly. Studies of
the mental health of soldiers in Viet-
nam noted important changes—some
gleaned from the lessons of previous
wars, others resulting from new com-
bat conditions. According to army phy-
sicians stationed there, “No one served
in the theatre of war for longer than a
year; there was plenty of rest and rec-
reation during the tour of duty; battles
were short; soldiers had to endure few
major artillery barrages.” As Kieran
sees it, the Rambo-like portrait of the
returning Vietnam veteran “as perma-
nently and debilitatingly traumatized”
is largely a fiction of Hollywood. “In
fact,” he writes, “only about 15 per-
cent...screened positive for PTSD,
and just over 5 percent had ever had
a ‘major depressive episode.’ The vast
majority of Vietnam veterans, that is,
went on to lead lives relatively unhin-
dered by their wartime experiences.”*
K iera n h a rd ly m i n i m i z e s t he f ac t t h at
15 percent remains a disturbing figure,
or that soldiers’ morale and disciplinefaltered badly in the war’s final years.
A good part of Signature Wounds is
devoted to the military’s analysis of its
strategic and cultural failures in Viet-
nam. What emerged, he notes, was the
blueprint for an all-volunteer fighting
force based on “garrison leadership,”
which preaches discipline, order, and
attention to the soldier’s well-being.
Behind this lay the assumption that
America’s future wars would be the op-
posite of Vietnam: short and decisive,
whether against the Communists in
Europe or lesser opponents elsewhere.
For a time, this held true: armed in-
tervention in Grenada, Panama, the
Balkans, and Kuwait (Desert Storm)
proved relatively quick and painless.
But one of the consequences, it ap-
pears, is that psychiatric issues became
easier to ignore. The few mental health
providers assigned to Grenada were left
standing on the tarmac because their
names hadn’t been included on the
flight manifest. And military psychia-
trists who took part in Desert Storm
were surprised to find that the soldiers
were more stressed by concerns about
the lack of material comforts than by
worries of Saddam’s “weapons of mass
destruction.” Then came September 11
and its dreadful aftermath in Afghani-
stan and Iraq.In 1951 General Omar Bradley fa-
mously described the proposal by
right-wing hawks to expand the Ko-
rean conflict into Communist China
as “the wrong war, at the wrong time,
in the wrong place, and with the wrong
enemy.” For America’s military, the
2003 invasion of Iraq was all that
and more. The astonishing failure of
the Bush-Cheney-Rumsfeld adminis-
tration to plan for an extended conflict
put unprecedented demands on the
all- volunteer force. “The soldiers and
marines.. .were perpetually at risk,”
Kieran writes, “required to fight longer,
with fewer breaks, and on more deploy-
ments than any previous fighting force
that the United States had fielded.”
The army’s post-Vietnam goal had
been to expand the “dwell time” be-
tween deployments. But the ideal
ratio—three years home for every
year in the field—proved insufficient
to sustain the 150,000-troop rotation
required for Iraq and Afghanistan. Be-
fore long, the ratio had fallen to two-
to-one, then one-to-one, and finally
(during the “surge” of 2007) to an
exhausting fifteen-month deployment
with just nine months in between.
Recruiting also slowed down signifi-
cantly as the war dragged on, leading
the army to lower its personnel stan-
dards, which in turn increased the
likelihood of soldiers with substance
abuse issues and behavioral problems
being deployed to Iraq. Meanwhile, the
burden of maintaining adequate troop
strength fell to National Guard and Re-
serve forces, few of whom signed up ex-
pecting to be sent to a combat zone. By
2005, these forces comprised about half
the units in Iraq; inadequately trained
yet given the dangerous duty of pro-
tecting convoys, they suffered higher
casualties than their counterparts.
The main reason was the “impro-
vised explosive devices” (IEDs) used by
insurgents to disable military vehicles.
With US forces employing better body
armor, the chances of surviving a shrap-
nel wound had dramatically increased.
The problem was that soldiers exposedto IEDs regularly experienced concus-
sive brain injuries—some severe, some
less so. How, exactly, did one measure
such injuries, or differentiate between
them and PTSD, since both presented
the same general symptoms? So little
research had been done that it became
a guessing game, with army doctors
mostly choosing the TBI diagnosis as a
way of protecting their patients. “It was
physical, and people could grasp that as
something that they were okay with,”
the surgeon general admitted. “Hav-
ing a psychological reaction to combat
didn’t have the merit or cachet.”
It was the old stigma in modern garb.
The difference this time was that it
didn’t go unchallenged. In 2008 four-
star General Carter Ham publicly ac-
knowledged his own struggles with
PTSD, which he attributed to seeing
soldiers blown apart in suicide bomb-
ings. “You need somebody to assure
you that it’s not abnormal,” Ham said
of the insomnia, depression, and mood
swings that he, and thousands more,
had faced in shame and silence.
Ham quickly found an ally in Gen-
eral George Casey, the newly appointed
commander of US forces in Iraq. “I
can’t say that I went [there] with the
notion that I needed to do something
about PTSD and TBI,” Casey recalled.
What changed his thinking were the
surveys that crossed his desk showing
an extreme reluctance among his troops
to admit to any psychological problem
for fear of losing respect, being passed
over for promotion, or even being dis-
missed from the service. One survey
put the figure of those who would avoid
getting psychiatric care at 90 percent,
and others showed the stigma to be
most pronounced among young officers
engaged in day-to-day combat—those
most dependent on keeping their men
in action. “Ninety percent. That’s a cul-
tural issue,” Casey said, “but the Army
didn’t want to hear it.”Changing that culture became a pri-
mary goal. There’s little doubt that
the “top-down” pronouncements of
Ham, Casey, and others made it more
acceptable for the average soldier to
seek professional help, or that such
pronouncements caught the Pentagon’s
eye. Kieran is superb in demonstrat-
ing how the military became a major
research center for the study of brain
injuries and stress-related disorders.
It was one thing to acknowledge that
concussions can result from a direct
blow to the head—slamming into a car
windshield or helmet-to-helmet con-
tact on the football field—and quite an-
other to attribute them to the damage
done by an explosion, often yards away,
that causes no visible injuries. Army
studies suggested (not unlike Burr in
1865) that the blast waves emanating
from an IED (Burr’s “wind of passing
shells”) were powerful enough to cause
brain damage at the cellular level—the
variables included the distance from
the explosion and the frequency of
exposure.
Also studied were “co-occurring fac-
tors” that worsened the post- concussion
symptoms for battlefield soldiers, as
opposed to, say, professional athletes.
Returning Iraq veterans who met the
criteria for mild TBI—about 15 percent
of those who served there—reported
more serious mental health problems
than other groups. As one researcher
explained:*A sizable number of memoirs and oral
histories support this contention. In
his book Stolen Va lor (1998), written
with Glenna Whitley, B.G. Burkett,
who won the Bronze Star in Vietnam,
writes, “The popular perception of
Vietnam veterans as victims tortured
by memories—drug-abusers, criminals,
homeless bums, or psychotic losers—
did not fit me or anybody I knew who
served in Vietnam.... Certainly their
lives were not always perfect, but most
of their problems could not be attrib-
uted to their experiences in Vietnam.”