Shephard conveys the grim realities of war in striking vignettes of service members and patients. He captures concisely the personae of the shapers and movers of military psychiatry, including the few, such as Dr. William Rivers of World War I fame, who are known to general readers through literature or films. The book provides a fascinating account of the interplay of competing ambitions, clinical styles and interests, personal and institutional prejudices, and public opinion. Shephard succeeds in linking the ``undoubted successes and numerous disasters'' of military psychiatry with wider societal expectations and military and medical practices as they changed during the 20th century.
One disaster was the U.S. screening program in the initial years of World War II. Shephard's account left me simultaneously laughing and appalled, and I remembered the sad patient I had seen as a resident in 1968 whose thick chart for ``inadequate personality disorder'' began when he was rejected for military service because he was unable to urinate if others were watching. Alas, Shephard does not cite later observations and studies indicating that soldiers with substantial psychopathology could function well and even heroically in units with good leadership and comradeship. One provocative theme is the cultural shift from the traditionally Victorian masculine virtues of courage and self-denial of emotional expression in the service of duty (what used to be meant by ``showing nerve'') to the traditionally female virtues of free emotional expression and the giving and seeking of sympathy and care (which could lead to a pathologic ``case of nerves'' or ``nervous breakdown''). This theme culminates in the chapters, ``From Post-Vietnam Syndrome to PTSD'' and ``The Culture of Trauma,'' which will arouse anger in some readers and will reinforce the blind prejudice of others but should be read carefully and thoughtfully by all.
Shephard acknowledges the real suffering of many veterans and the honorable intentions of those who created the diagnostic label and criteria for post-traumatic stress disorder and championed treatment and compensation programs for it. His sharp critique is founded on experience during and after the world wars. We have seen similar syndromes before, made similar mistakes, and have sometimes done better. We should also determine why many of the veterans with the worst histories of exposure do well without treatment.
Shephard disproves many persistent myths that I hope will be dispelled by widespread reading of his book. He presents hard-learned lessons that are in perpetual danger of being forgotten. Shephard illuminates the struggles of the ``tough realist'' clinicians, in whose path I respectfully follow. In World War I and then starting from scratch again in World War II, the realists worked increasingly close to the battle, trying different but simple techniques to return many overstressed soldiers to duty in a period of hours to days. Those soldiers would have become psychologically disabled if they had been evacuated. The best realist clinicians educated unit leaders, general medical personnel, and chaplains to reduce the psychological and physiologic causes of stress-induced breakdown and to restore many stressed soldiers in their units, not in medical cots. I wish Shephard had included more historical details of that endeavor.
The focus of 21st-century combat and operational behavioral health (``stress control'') is on primary and early secondary prevention at the unit and community levels. The same should be true of civilian programs of community mental health and management of psychological trauma, which grew out of the military experience. Better preventive interventions can greatly reduce the need for tertiary treatment of chronic cases far to the rear of combat or after the war. Shephard describes the many approaches to tertiary treatment masterfully, as he does numerous other topics of public interest.
I hope the public response to A War of Nerves will encourage Shephard to finish writing the saga of post-World War II military psychiatry (behavioral health). I know he can find more gold by panning deeper in streams he has just skimmed in this book, by exploring the well-studied Israeli experience, and by addressing the special problems of ``peace-keeping'' missions. Shephard's account of the first half of the saga is a masterpiece, but the second half remains to be told.
James W. Stokes, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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