Peter Graeme Hobbins | 'Living in Hell But Still Smiling': Australian Psychiatric Casualties of War During the Malaya-Singapore Campaign, 1941–42 | Health and History, 9.1

'Living in Hell But Still Smiling'¹: Australian Psychiatric Casualties of War During the Malaya-Singapore Campaign, 1941–42

Psychological casualties rarely feature in the historiography of Australians at war. This paper utilises both military and medical sources to characterise the incidence and significance of 'war neuroses' during the 1941–42 retreat from Malaya and Singapore. In the context of this harrowing withdrawal, psychological casualties apparently formed only a minor part of the medical burden and—with notable exceptions—had little effect on the operational effectiveness of Australian military forces during the campaign.

Data from World War II suggest that 'war neuroses' affected only 2.6–5.0 percent of the Australian Army population—a rate far lower than for most other belligerents.² In recent years, however, this assumption has been called into question. In particular, it has been suggested that wartime military and medical policies led to artificially low reporting of psychiatric casualties and that the true scope of the problem emerged only months or years after the tribulations of military service.³ While the previously taboo issue of psychiatric casualties among World War I 'diggers' has recently been addressed,⁴ relatively few sources discuss the scope or management of such cases during World War II. This study seeks to evaluate the medical and military impact of 'war neuroses' on Australian service personnel during World War II, focusing specifically on the Malayan campaign of 8 December 1941 to 14 February 1942.

The battle for Malaya, culminating in the surrender of Singapore, occupies a central place in Australia's experience of World War II. Both temporally and geographically, it fell between the earlier battles fought largely for British ends—in the Middle East and Mediterranean—and the later actions to defend Australia and liberate the Southwest Pacific from Japanese occupation. Labelled by the British Prime Minister Winston Churchill as the 'greatest disaster and capitulation' in its history, the fall of Singapore cost the Empire 11,000 wounded and 7,500 dead.⁵ Amongst these, approximately 1,300 Australians were wounded and 1,800 died during the campaign, while a further 15,000 passed into years of appalling captivity.⁶

The defeat at Singapore has been richly documented and analysed in, among other sources, academic and popular historiography, individual and unit memoirs, and as-yet unpublished personal narratives and documents.⁷ Indeed, reevaluations of the campaign began almost immediately the garrison fell and the survivors themselves were among the most avid discussants— especially those incarcerated by the Japanese.⁸ However, despite the difficult and unfamiliar jungle environment, the shocking effectiveness of Japanese military forces, and the wearying series of retreats leading to the final surrender, Australian accounts of the campaign rarely describe psychological casualties.⁹ This is apparent in both contemporary reports and subsequent materials, and can in part be explained by the wartime desire to minimise depictions of 'weakness' in the armed forces, the difficulty of maintaining accurate records during the confusion of retreat, and the destruction of documents through the bombing of Singapore and subsequent years of Japanese occupation.¹⁰ In her narrative history of the Australian Imperial Force (AIF) in Malaya, Janet Uhr also suggests that the very ubiquity of fear led participants to minimise references to psychological reactions in their accounts.¹¹

The psychological consequences of active service are nevertheless apparent in a variety of reports from Malaya and Singapore.¹² In some cases these were understandable fear responses and may rapidly have passed: 'In one of the early bombings the ground trembled when a bomb exploded a clear hilltop away. One man went on smiling, but developed a stammer as he went on with his job.'¹³ Other reports point to more sustained and incapacitating reactions: 'he was a great big strapping fellow ... [but] as soon as there was a bit of shellfire he'd run. Run for cover, anywhere—in any direction at all. He just couldn't stand it.'¹⁴ For some—including my grandfather, who served with 8 Squadron Royal Australian Air Force (RAAF) throughout the campaign— incapacitating psychological sequelae persisted well beyond the war and into civilian life.¹⁵

Medical management of 'neurotics' in Malaya and Singapore

Across both civilian and military medicine during World War II, Australian doctors generally lacked any interest or training in psychiatry,¹⁶ which was 'regarded as the mysterious and inalienable preserve of the psychiatric specialist.'¹⁷ The Australian Army Medical Corps (AAMC) thus began the war without an official policy on mental cases,¹⁸ although in 1940 a conference on 'war neuroses' led to the promulgation of a memorandum on prevention, treatment and terminology.¹⁹ An additional medical Technical Instruction on the treatment of neuroses and a brochure on psychiatric casualties were distributed within the AAMC in 1941, and lectures on the topic were given to medical staff throughout this period.²⁰ Lieutenant-Colonel William Harvey of the 10 Australian General Hospital (AGH) in Singapore noted in his diary on 14 January 1942 that he had received minutes from 'the meeting on "war" neuroses ... from early bombings, esp. Kluang.'²¹ The only Australian wartime textbook on the topic was not published until at least a year after Singapore fell.²²

Despite the hurried introduction of guidelines on psychological casualties, there was a clear management and evacuation protocol in place during the Malayan campaign. While such systems are always subject to the exigencies of combat, the general process is borne out by accounts of both medical staff and forward units. The lessons of World War I were rapidly relearned. Official documents and—in particular—early 1941 experience from the 9^th Division AIF in Tobruk reiterated that 'The most important place in the treatment of war neuroses is the front line area.'²³ Thus, affected individuals may have received support from comrades or noncommissioned officers—even if it took the form of 'a firm open-handed left and right slap to the face.'²⁴ Reflecting the focus on forward treatment, the Regimental Medical officer (RMO) was intended to be the gatekeeper of psychological health for his unit. Indeed, contemporary sources frequently describe the RMO as a general practitioner for his troops.²⁵ In this role he was intended to detect early signs of fatigue or fear, reallocate those at risk of breakdown to duties away from the front, counsel affected individuals and also to maintain morale within the remainder of the unit.²⁶ While on the whole RMOs were considered more sympathetic than commanding officers to their men's psychological plight,²⁷ they received no systematic training in psychiatry²⁸ and in crude terms they were informed that their role was to 'detect the malingerer and bash back the neurotic.'²⁹

Problems of increasing severity or persistence were dealt with progressively through the regimental aid post or main dressing station, then by the Field Ambulance, Casualty Clearing Station (CCS), General Hospital and finally a Convalescent Depot. Instructions focused on the value of rest, sedation, food and reassurance—even basic psychotherapy³⁰—with the nexus of care being the Field Ambulance units, who were directed to keep the men in forward areas if at all possible.³¹ Casualties with persistent symptoms then moved on to the CCS, which 'During this short campaign [was] the key to the Australian Imperial Force medical dispositions.'³² If no improvement was observed after three days, patients were then transferred to an AGH,³³ although it was well recognised that 'neuroses' tended to become more fixed with increasing time and distance from the combat zone.³⁴ Cases considered intractable by the General Hospital or Convalescent Depot were then sent before the local Medical Board and—if deemed unfit for further duty—eventually repatriated to Australia.³⁵ Throughout the process, medical staff were encouraged to minimise in patients' minds the possibility of evacuation or repatriation, in order to avoid encouraging an 'escape into neurosis.'³⁶

Despite the presence of such a clear management path for psychological casualties, descriptions or references to 'neurotics' or 'mental cases' are notably absent in accounts from AAMC and nursing staff throughout the Malayan campaign. This includes an RMO from the 2/15 Field Regiment,³⁷ a Captain from 72 Light Aid Detachment,³⁸ various staff from the 2/9 and 2/10 Field Ambulance,³⁹ a nurse attached to 2/4 CCS,⁴⁰ and officers, orderlies and nurses at both 2/10 and 2/13 AGH.⁴¹ Indeed, the occasional references only illustrate how unusual such cases appeared to be within the medical system. For instance, despite his role as RMO for an artillery unit in action throughout the campaign, Captain Rowley Richards' only mention of a psychiatric case came right on the verge of Singapore's surrender: 'I can still picture one poor lad; he'd gone bonkers—that was what we called it at the time—as a result of shell shock. He tried to claw his way bare-handed through a bitumen road.'⁴² Lieutenant Colonel William Harvey from 10 AGH was even more laconic: the only case his diary mentions also occurred late in the campaign: 'Mac brings in his "shocked" Major at 10.'⁴³ The only detailed accounts of psychiatric casualties come at the final stages of evacuation: the 2/2 Convalescent Depot and the ensuing Medical Boards, as outlined in the following section.⁴⁴ The lack of reference to psychological casualties does not of course imply that there were no such cases; rather, the point is that they did not comprise a significant or alarming proportion of troops seen by medical personnel.

Image 1: Battle casualties—such as this wounded soldier in January 1942—imposed a significant medical and logistical burden throughout the Malayan campaign. (Source: Australian War Memorial Negative Number 011305.)

There are, of course, many reasons why medical staff might not heed psychologically disturbed soldiers.⁴⁵ Given the low standards of awareness of psychological medicine, it is unlikely that doctors or orderlies specifically sought out cases or identified less obvious presentations. Moreover, several accounts refer to the overwhelming numbers of wounded, especially serious surgical cases, that rapidly overtook most medical detachments once Australian troops joined combat in early January 1942.⁴⁶ Throughout the campaign, at least 10 percent of the 8^th Division AIF were wounded; 'its 2/19 [Battalion], in just 22 days of fighting, suffered more dead, missing and wounded than any AIF unit in World War II.'⁴⁷ However, the number of deaths and serious wounds sustained by a unit both have a deleterious effect on nonbattle injury rates (including battlefield stress),⁴⁸ which would tend to have heightened the likelihood of 'neuroses' developing.

The predominantly somatic presentations of many 'neurosis' cases—particularly as headaches or dyspepsia—may also have mitigated against an accurate diagnosis.⁴⁹ It is well documented that gastric complaints comprised a major medical burden for most combatants during World War II, with the suggestion that physical symptoms were more acceptable outlets for 'neurosis' than the frank 'hysterical' symptoms or conversion disorders noted in World War I.⁵⁰ However, a physician at 2/2 Convalescent Depot was quite clear that dyspepsia and headaches were well-known manifestations of psychological disturbance,⁵¹ and Medical Boards conducted throughout the campaign discerned between 'ulcer' and 'gastric neurosis,' or between 'migraine' and 'neurosis with headache.'⁵² In fact, an AIF medical Administrative Instruction issued some months prior to the Japanese attack warned that 'A considerable number of cases suffering from Organic Disease have been labelled "Anxiety Neurosis,"' suggesting that a thorough physical examination should be made prior to labelling a man as 'neurotic.'⁵³

The scope of the problem

There are no firm statistics on the overall incidence of Australian psychiatric casualties during this campaign.⁵⁴ The most detailed account was published after the war by Dr. C.R. Boyce, who served both before and during hostilities as a Captain with the 2/2 Australian Convalescent Depot in Singapore.⁵⁵ In line with the forward treatment policy, Boyce noted that many cases were either retained in their units or adequately treated prior to reaching the Depot, which was the final referral centre prior to repatriation of intractable cases. Of the eighty-nine 'neurotics' he examined during the two months of the campaign, thirty-eight were recorded during the final days when his facility was packed with approximately 1,100 convalescents.⁵⁶ Assuming Boyce saw all such cases in the Depot, a crude calculation suggests that psychiatric casualties comprised 3.5% of all convalescents during this climactic period. This is broadly in line with both a mid-1941 series from a Tobruk war neurosis clinic (3.0% of all patients admitted to hospital),⁵⁷ a mid-1941 AGH series from Palestine (1.4% of hospitalisations)⁵⁸ and a 1942–43 AGH series from New Guinea (2.1%).⁵⁹As these data pertain to individuals with a primarily psychiatric diagnosis, it must be assumed that a cross-sectional survey of all hospitalisations— including surgical and infectious disease casualties—would have returned a much higher percentage of psychological comorbidities.⁶⁰ Indeed, in August 1941 at 1 Australian Convalescent Depot at Kefar Vitken (Palestine), 'psychoneurosis' cases comprised 12% of the convalescents.⁶¹ It therefore appears from contemporary data that psychiatric cases represented 2–12% of all army hospitalisations during the campaign.⁶²

This suggestion is borne out by a review of the outcomes of Australian Army Medical Boards held in Singapore. During the period 7 December 1941—10 February 1942, exactly 400 officers and men were referred to Boards: ninety-one (22.8%) were diagnosed with a mental or neurological disorder, of whom fifty–two (13.0% of the total) were classed as unfit for further service.⁶³ Presentations of 'neurosis'—including 'anxiety neurosis,' 'emotional shock,' 'mental exhaustion,' 'neurasthenia' and 'effort syndrome' accounted for seventy-five cases (18.8% of the total): of these, forty-five were considered unfit for further service (i.e. 11.3% of the total).⁶⁴ While the 'wastage' due to psychiatric casualties is thus considerably higher than might be deduced from the proportion of hospitalisations, the rate is still relatively low. For instance, in a contemporary sample of AIF recruits who came before medical boards in 1940–41, 'mental and nervous disorders' represented the single largest reason for 'boarding' men out of the service: at 26.7% this was twice the rate noted under operational conditions in Singapore.⁶⁵ It is certainly much lower than the British Army rate for 1943–45, where psychiatric casualties accounted for 35–41% of all medical discharges.⁶⁶

A third indicator may come via the absence of self-inflicted injuries during the campaign. The only recorded suicides during the fall of Singapore were among civilians;⁶⁷ indeed, only ninety-seven suicides were reported for the Australian armed forces throughout the period 1939–43.⁶⁸ Likewise, no mention of self-inflicted wounds during the campaign has been located in memoirs of military or medical staff. All such cases had to come before local medical boards,⁶⁹ yet there are only two mentions of 'accidental gunshot wounds' in the medical board records for the Malayan campaign—neither of which was listed as self-inflicted.⁷⁰ Given that only sixty-two self-inflicted wounds were recorded for the Australian Army over the entire duration of the war,⁷¹ it seems likely that official figures significantly underestimated the true incidence of self-harming behaviour. Nevertheless, it was clearly not a serious medical or operational issue in Malaya.

Among troops who did suffer a persistent psychological reaction, the likelihood of being returned to active duty was compromised at all stages by the dire military situation. The constant retreats and early loss of air superiority meant that ideal forward treatment was rarely achievable for Australian RMOs,⁷² while medical units close to the front line 'were left in their successive positions until the last possible minute.'⁷³ Yet the effectiveness of the RMOs, Field Ambulances and CCS in managing early cases is apparent in the low proportion of casualties reaching the Convalescent Depot and the Medical Boards. There was, however, no safe haven: according to Boyce, patients 'commonly stated that the conditions at the [convalescent] depot, whence they had been sent for treatment, were worse than those that had produced the neurosis.'⁷⁴

The regimen of rest, reassurance and basic psychotherapy provided at the Convalescent Depot did ensure that 'a number of patients were returnedfit to units and to action.'⁷⁵ Within a series of eighty-nine patients, this statement suggests a fairly low return-to–duty rate during the Malayan campaign—certainly less than 10%. While it was considered satisfactory in a postwar commentary,⁷⁶ the proportion of casualties returned to active frontline duty—achieving an 'A' classification—is much lower than other Australian series published during hostilities, including 61% at a war neurosis clinic in Tobruk, 48% from an AGH in New Guinea, or 20–50% from a Convalescent Depot in Palestine.⁷⁷ However, these optimistic wartime reports are likely to have significantly overstated the success rates of treatment; indeed, it has been noted elsewhere that two-thirds of Australian troops returned to 'A' status broke down a second time.⁷⁸ British experiences in the 1940–41 period confirm that much lower return to active duty rates were the norm—in the range of 11–16%—with further relapses documented once men had returned to their units.⁷⁹

It has been suggested that many wartime psychiatrists overstated the effectiveness of their treatment of 'neurotics,' both for morale reasons and to justify their own professional standing.⁸⁰ Owing to his incarceration, Boyce did not publish his series until 1946; in the postwar world, priorities had reverted from manpower deficits to pension burdens.⁸¹ As a staunch believer in individual predisposition to breakdown,⁸² Boyce apparently saw little reason to overstate the effectiveness of treatment, especially as he so clearly believed that most patients had developed 'neuroses' as a means to escape odious military duties—a moot point for a nation rapidly demobilising its armed forces. Indeed, he noted that almost all of his 'neurotic' patients at the depot 'were cured immediately upon the capitulation and the removal of danger stimuli,' and that only eleven new cases appeared during the first fifteen months of Japanese captivity (approximately 0.1% of Australian prisoners of war).⁸³

Factors contributing to the low apparent prevalence

Given that Japanese aerial superiority and rapid advances on the ground exposed all Australian personnel in the Malaya-Singapore theatre to combat stress, why were the apparent rates for psychiatric morbidity so low?

Training and esprit de corps are important factors in preventing service-related psychological problems.⁸⁴ Australian Army recruits underwent minimal psychological screening at this early stage of the war, although numerous cases of breakdown were detected during training.⁸⁵ Most of the troops who served in Malaya, however, had been in the army for over a year and were thus well trained, including exercises in the local jungle where possible.⁸⁶ Breakdowns seemed to be more common among the 1800 hastily trained reinforcements who arrived just days before the Japanese invasion of Singapore and 'were so raw they didn't even know how to load a rifle properly.'⁸⁷ The value of extensive training was also shown in unit cohesion and the belief among troops that they could rely on their comrades when wounded or surrounded, which helped alleviate fears prior to entering combat.⁸⁸ Attitudes toward officers also tend to reflect general unit morale;⁸⁹ apart from some adverse comments directed at senior commanders, Australian officers were generally respected by their men, and on the whole they effectively maintained discipline and morale.⁹⁰ 'There were occasionally instances of lack of example to the men by noncommissioned officers and by officers,'⁹¹ and some broke down during combat,⁹² but such cases seemed rare and were often attributed to inadequate training or experience.

Image 2: Cameraderie is readily apparent between these members of A Company, 2/18 Battalion, Australian Imperial Force in Malaya, 1941. Of the sixteen men in the photograph, at least ten ended up as prisoners of war and two were killed during the campaign. (Source: Australian War Memorial Negative Number P04154.003.)

The role of 'ideology' in the motivation and morale of Australian troops in this theatre is problematic and poorly documented. Few members of the 8^th Division expressed strong commitments to fighting or dying for the British Empire or for democracy,⁹³ but very rapidly they came to a stark realisation: 'We had seen the Japanese military and air strength and knew that the Japanese navy ruled the waves in that area, so we worried that if they got past us they would push on to Australia.'⁹⁴ The World War I ANZAC legend may have held some value during recruiting and the first exposure to battle, but its influence on Australian troops waned quickly thereafter.⁹⁵ More relevant was the recent defiant stand by the 'rats of Tobruk': their phrase 'we can take it' seems to have also become a ubiquitous rallying cry for Australians flghting the Japanese.⁹⁶ Indeed, Australian morale was considered to be higher than in many other armies of the period,⁹⁷ and the behaviour of troops in Malaya was no exception.⁹⁸ While formations with high morale tend to suffer lower nonbattle casualty rates,⁹⁹ both personal and organisational strength inevitably suffered when units disintegrated, as frequently occurred during the retreats through the Malayan jungle.¹⁰⁰ Similarly, the severe rates of death and wounding suffered by the 8^th Division following its deployment in January 1942 are also likely to have increased nonbattlefield casualties, including psychiatric cases.¹⁰¹

Among troops fighting in Malaya or Singapore, the two most frequently cited causes of fear states or prolonged psychological reactions were aerial attack—both strafing and bombing¹⁰²—and artillery barrages.¹⁰³ Both were constant throughout the Japanese advance, heightening the siege mentality—with constant artillery and aircraft attacks—that was also associated with 'neuroses' in Tobruk.¹⁰⁴ 'Near bomb-burst' was listed as the most frequent reason for breakdown during the Malayan withdrawal,¹⁰⁵ although a later report from the New Guinea campaign noted that 'the soldier claimed blast as a causal factor in his illness in a much larger percentage of instances [than were warranted by the facts].'¹⁰⁶ This attribution to a 'near miss' may have been seen as an honourable way of admitting to breakdown after a history of increasing anxiety:¹⁰⁷ even though Australian troops were only in action for a month, the campaign was largely one wearying fighting retreats amid a demoralising sense of being overwhelmed by the Japanese.¹⁰⁸

While desertions from the front line were rare in the Australian Army during World War II,¹⁰⁹ morale sagged noticeably when men withdrawing onto Singapore Island realised that it was in no way the impregnable citadel they had been promised.¹¹⁰ Indeed, the most pronounced breakdown in discipline among the troops occurred once the Japanese had landed on the Island. In the final days of the campaign some units or small groups began to make their own decisions regarding when to withdraw.¹¹¹ Numerous accounts mention Australian (and other Commonwealth) soldiers skulking around the city, often without weapons, during the final week of fighting. As the defensive perimeter dwindled and evacuation of civilians and technical personnel accelerated, a variety of observers were appalled to find Australian troops panicking and forcing their way onto refugee ships.¹¹² Given the lack of records from these final days, the extent of the problem—and to what degree it was the result of psychological breakdown or 'contagious neuroses'—can never be quantified.¹¹³

As this was the first campaign in which AIF troops fought the Japanese, most Australians had not yet developed an exaggerated fear of their enemy, although some believed that they would be massacred after they surrendered.¹¹⁴ Fear symptoms among combat troops appear to be most pronounced among those who have witnessed enemy atrocities,¹¹⁵ but news of Japanese ill-treatment of prisoners and wounded—including the massacre at the Alexandria Military Hospital on Singapore itself—generally did not reach the troops until after the general cessation of hostilities.¹¹⁶ Rather, many accounts refer to personnel simply collapsing into sleep or entering a trance-like state after the cease-.re, being 'so shocked they could hardly speak.'¹¹⁷

The strains of fighting in Malaya also entailed the tropical climate, jungle warfare and physical exertion that were later considered important psychological factors in the New Guinea arena.¹¹⁸ Fatigue and sleep deprivation were constant problems— especially during the final withdrawal onto Singapore¹¹⁹—and physical exhaustion was considered a more important factor in psychological breakdown during the Malayan campaign than in many other Australian deployments.¹²⁰ However, physical illness— particularly infectious disease rather than combat wounds—was more closely associated with the development of psychiatric comorbidity.¹²¹ Again, it is clear that the medical guidelines focusing on forward treatment—comprising rest, food, sedation and reassurance—were of considerable value in minimising the psychological sequelae arising from the physical environment.¹²²

While fear was considered by physicians to be the overriding contributor to the development of neurosis amongst Australian personnel,¹²³ contemporary explanations were careful to avoid attributing the problem to actual combat conditions. Reflecting then-current concerns with constitutional weakness and a desire to reduce post-war pension burdens, the character and history of the individual soldier was believed by medical staff to be the major contributor in 35–50 percent of psychological breakdowns.¹²⁴ This was certainly true of Boyce, who considered many of his 'neurotic' patients in Malaya to either have had a predisposition or family history of 'mental weakness,' or to be of poor character on account of the decadence of the 1920s, the hardships of the Depression, and 'the demoralizing influence of "talkies" and gangster pictures, undermining discipline and authority'!¹²⁵

This focus on avoiding attribution of psychological breakdown to active service is also clear in the military and medical terminology of the day. Use of 'shell shock' and 'bomb happy' were officially forbidden early in the war¹²⁶—a call reiterated by Boyce in 1946¹²⁷—but these terms remained in use with soldiers and medical staff during the campaign.¹²⁸ 'Neurasthenia' was generally avoided while 'effort syndrome' and 'disordered action of the heart' were considered redundant by 1942.¹²⁹ The former two phrases did appear in medical board diagnoses early in the Malayan campaign but were generally superseded by variations on 'anxiety neurosis.'¹³⁰ However, there is no evidence from contemporary records or subsequent accounts that changes in terminology were deliberately introduced in order to downplay the problem of psychiatric casualties. Ignorance of psychology or diversion of medical staff onto more pressing medical or surgical casualties are more likely to explain any underestimations of the true in-theatre prevalence of psychiatric cases.

The RAAF and LMF

The majority of records for military service and psychological casualties during the Malaya-Singapore campaign focus on the Australian Army. However, the RAAF was in combat within hours of the first Japanese attack, and in fact many units carried on fighting from Java and Sumatra for several weeks after Singapore fell, an almost unbroken three-month span.¹³¹ During this period, units of the RAAF were twice accused of panic or cowardice. Given the fine line between cowardice, fatigue and psychological incapacity—especially within the Air Force culture of the time¹³²— both episodes are deserving of review.

While RAAF attitudes toward psychological problems were similar to those in the Australian Army, there were differences in aetiology, diagnosis and treatment. There was little emphasis on psychological testing for aircrew in the early part of the war,¹³³ but when men did break down it was generally attributed to prior mental problems.¹³⁴ Cumulative flying fatigue and repeated exposure to combat or dangerous flying conditions were considered the major environmental factors leading to breakdown—with fighter pilots particularly at risk owing to their isolation in combat—and the likelihood was heightened under poor living conditions and in situations of low morale.¹³⁵ These factors match the description of the unceasing round of missions in unpredictable tropical weather or against Japanese aerial superiority over Malaya and Singapore, where

pilots, who were ill and weary ... maintained a constant state of stand-by, sitting in their aircraft all day long in the hot sun, without any breakfast or lunch ... when they were not at stand-by they were in the air or on the ground dodging bombs or machine-gun bullets or cannon shells.¹³⁶

During 1940 the Royal Air Force (RAF) created the administrative term 'lacking in moral fibre' (LMF), a deliberately stigmatising label which incorporated elements of fatigue, 'neurosis' and cowardice.¹³⁷ It was introduced in order to minimise psychiatric diagnoses among aircrew who could not—or would not—face further operational flying.¹³⁸ This policy was intended to be administered by the squadron medical officer, with a requirement that all suspected cases should be reported to the Air Officer Commanding (AOC).¹³⁹ The RAF and RAAF high command were both quite concerned with the possibility of 'infectious' LMF,¹⁴⁰ but at a squadron level most station commanders and medical officers were reluctant to create pariahs of men who had shown at least some commitment to their missions.¹⁴¹ Nevertheless, like the Army, both the RAF and RAAF were keen to ensure that their personnel did not view 'mental weakness' as a means to escape duty.¹⁴²

The first instance during which the RAAF came under suspicion occurred on 9 December 1941, when the bomber airfield at Kuantan was subject to an unauthorised evacuation following a Japanese raid. A RAAF officer on the base recalled: 'In half an hour that little flame of panic spread like wildfire. I looked out on a deserted station ... For the first time I felt ashamed to be an Australian.'¹⁴³ Indeed, a Royal Navy officer who witnessed this withdrawal, Lieutenant Commander H. Austin, scathingly stated that 'This defection of the RAAF on the East Coast of Malaya is surely one of the most shameful episodes in the history of the British Empire.'¹⁴⁴ Austin's report prompted the British AOC—Air Vice-Marshal Conway Pulford, RAF—to institute a Court of Inquiry into the evacuations. All copies of the report were lost during the retreat but in 1946 the British Air Ministry asked the President of the Court, Group Captain John McCauley (RAAF), to recollect his findings. McCauley's 1946 report, marked 'secret,' found that the 'disorderly and uncoordinated' evacuation was largely the fault of the station commander, who did not have any prepared emergency plans and did not take charge of the evacuation.¹⁴⁵ Poor leadership within the RAAF—especially in training for crisis situations—was also the main conclusion of the Lowe Commission into the panic that accompanied the first Japanese air raid on the RAAF station at Darwin on 19 February 1942.¹⁴⁶ Thus, while the evacuation of the northern Malayan airfields early in the campaign left the morale of the RAAF under a cloud, there is little to suggest that a significant proportion of psychological casualties was a contributing factor.

As the campaign wore on, however, the psychological strain did begin to tell among the air and ground crew. The RAAF lost many of its aircraft and facilities within the first few weeks which, coupled with overwhelming numbers of superior Japanese aircraft, soon reduced the effectiveness of the Air Force.¹⁴⁷ One of the ground crew from 453 Squadron noted in his diary on 23 January 1942: 'Nerves going to hell. Just wondering how much more I can stand ...'¹⁴⁸ A bomber pilot from 1 Squadron observed at the same time that he and his colleagues were 'pale and shaking. Our voices were quiet and high-pitched in our anxiety.'¹⁴⁹ Fighter pilots in particular were under enormous strain: the commanding officer of 453 Squadron, Squadron Leader W.J. Harper, noted later that at least two of his pilots who were found away from their base without permission 'were individuals who were mentally unbalanced and had been under observation by the Station Medical Officer for some time.'¹⁵⁰ The situation in this squadron reached a head in early February, when Harper asked Air Vice-Marshall Pulford to address his unit. Squadron records indicate that Pulford '"spoke strongly" on the subject of discipline and morale. Members of the squadron incensed. Only two aircraft left to fly.'¹⁵¹ Other Squadron members were more blunt: the AOC had called them 'yellow.'¹⁵² This accusation was all that much harder for the Squadron to bear as they themselves believed Harper to be nervous to the point of cowardice—most likely a psychiatric casualty himself from his service during the Battle of Britain¹⁵³—and Pulford also finally broke under the strain.¹⁵⁴

Important factors contributing to morale within the Air Force include strong leadership—particularly within the squadron—and confidence in one's specific aircraft type.¹⁵⁵ Within 453 Squadron, accounts of Harper's effectiveness as a leader vary, but there was frequently ill-feeling between the commander and his Australian pilots—he expressed severe reservations regarding their readiness for combat, while many aircrew in turn questioned his willingness to undertake combat missions.¹⁵⁶ His invitation to the AOC to berate the Squadron at the height of Japanese aerial superiority is unlikely to have raised flagging spirits, but it may have been prompted by his growing fears of 'infectious LMF.'¹⁵⁷ Similarly, attitudes toward their Brewster Buffalo fighter aircraft were ambivalent at best, but the type's performance was clearly inferior to Japanese fighters and, in some cases, to the enemy bombers that the squadron was frequently tasked to intercept.¹⁵⁸

Nevertheless, sick rates for the RAAF remained low during the campaign—although whether this included psychiatric casualties is not clear.¹⁵⁹ Despite the drop in spirits following the early defeats in Malaya—and the fact that most RAAF personnel were continuously in action for three months—morale remained high in most squadrons and psychological casualties did not appear to affect operational matters to any significant degree.¹⁶⁰ Indeed, notwithstanding the concerns of some senior officers regarding morale, many instances of courage and endurance under harrowing conditions were noted both in flying and support personnel,¹⁶¹ such as one bomber pilot who 'was so overwrought that he actually vomited on the tarmac as he went to climb into his Hudson. But he vomited, shook his head, climbed aboard and took off.'¹⁶²

Comparisons and conclusions

While Australian military units certainly sustained psychological casualties during the Malaya-Singapore campaign, the prevalence was relatively low and did not significantly affect military operations, or lead to dramatic revisions in medical policy. This is despite the fact that many troops—and particularly Air Force personnel—spent considerably longer than the optimum period of a week in front-line duty.¹⁶³ Added to this were the physical hardships, concurrent tropical illnesses and increasing exposure to aerial and artillery attacks as the Japanese advanced down the Malayan peninsula before invading the once-vaunted 'fortress' of Singapore. There were certainly those who did break down under these circumstances, and there is no doubt that many more suffered from longer-term sequelae of their service, as John Raftery found among survivors of the later Kokoda Trail campaign.¹⁶⁴ Nevertheless, Australian personnel in the field seemed to cope well with what in many cases was their first exposure to combat. It seems that sound training, strong esprit de corps, reliable leadership and a determination not to crack—'we can take it'—played important roles within Army units. In contrast, the lack of effective leadership, training and morale within the RAAF may explain the greater degree of concern expressed about the reliability of Air Force personnel during the campaign.

Was the Singapore environment unique? There is no doubt that other Allied campaigns—including Guadalcanal in 1942, Burma in 1942–43, Tunisia in 1943 and Italy in 1944—all returned higher 'psychoneurosis' rates that alarmed senior commanders.¹⁶⁵ Arguably, the Australian campaign in New Guinea of 1942–43 also produced a high rate of psychiatric morbidity,¹⁶⁶ although this was not reflected in the official reports at the time.¹⁶⁷ The Anglo-French retreat before the Germans at Dunkirk in May 1940 parallels in many ways the later experience of the Australians in Singapore.¹⁶⁸ In the aftermath of Dunkirk, it was estimated that 10–15 percent of British casualties were psychiatric in nature; while not severe by later standards, this prevalence was alarming enough to instigate significant policy changes.¹⁶⁹ The Australians in Malaya fought for longer and withdrew over greater distances than the British during the Battle of France, and while some 'essential' personnel were evacuated before the surrender, most Australians knew that 'Singapore was no Dunkirk. There were no little ships to ferry us away to fight another day.'¹⁷⁰ Nevertheless, at 2–12 percent of hospitalisations, the Australian psychiatric casualty rates in Malaya-Singapore are broadly comparable to those observed after Dunkirk. A more immediate parallel was the siege of Tobruk, whose defenders—the 9^th Division AIF—were cultural and demographic contemporaries of the 8^th Division on Singapore. In this case, however, exposure to the two most frightening enemy weapons—dive bombers and artillery—was sustained almost daily over eight months, and there was almost no possibility of evacuation for psychiatric casualties. While the reported prevalence of 'war neuroses' at the clinic in Tobruk was 3 percent of hospitalisations—toward the lower end suggested for Malaya-Singapore—this wartime statistic is open to more rigorous evaluation.¹⁷¹

It is obvious that despite an indifference to psychology across the Australian military and medical cultures of the time, many of the lessons from the First World War were rapidly reapplied in the Second. In particular, instructions focusing on proximity, immediacy and expectancy were soon promulgated and appeared to be effective. By keeping affected troops close to the front, allowing them some respite when possible, encouraging them to see their fear as normal but temporary, and reminding them of their duty as soldiers, many were retained in forward units and avoided evacuation and hospitalisation. While never ideal, it is clear that these medical policies—and the ministrations of medical staff—contributed greatly to the general psychological health of personnel serving in this campaign.¹⁷² It is unfortunate that the same policy process ultimately denied adequate long-term care or recompense to many who did suffer mental illness following their active service.¹⁷³

University of Sydney

Notes

^1. Diary entry of Australian private soldier during the retreat from Malaya. Quoted in Mark Johnston, At the Front Line: Experiences of Australian Soldiers in World War II (Cambridge: Cambridge University Press, 1996), 69.

^2. Kristy Muir, "The Hidden Cost of War: The Psychological Effects of the Second World War and the Indonesian Confrontation on Australian Veterans and Their Families" (PhD thesis, University of Wollongong, 2003), 51–6; A.J.M. Sinclair, "Psychiatric Aspects of the Present War," Medical Journal of Australia 1 (1944): 501–14, 502.

^3. It is suggested that these policies were driven by desires to uphold the ANZAC legend of stoic bravery during the conflict, and also to minimise the postwar pension burden. See Ann-Marie Conde, "'The Ordeal of Adjustment': Australian Psychiatric Casualties of the Second World War," War & Society 15 (1997): 61–74; Stephen Garton, The Cost of War: Australians Return (Melbourne: Oxford University Press, 1996); Muir, "The Hidden Cost of War"; Kristy Muir, "'Idiots, Imbeciles and Moral Defectives': Military and Government Treatment of Mentally Ill Service Personnel and Veterans," Journal of Australian Studies no. 73 (2002): 41–7 and 225–7; John Raftery, Marks of War: War Neurosis and the Legacy of Kokoda (Adelaide: Lythrum Press, 2003).

^4. Michael Tyquin, Madness and the Military: Australia's Experience of the Great War (Loftus: Australian Military History Publications, 2006).

^5. Peter Thompson, The Battle for Singapore: The True Story of the Greatest Catastrophe of World War Two (London: Portrait, 2005), 424.

^6. George Odgers, Diggers: The Australian Army, Navy and Air Force in Eleven Wars (Sydney: Lansdowne Publishing, 1995), 197.

^7. The Australian War Memorial alone contains well over a hundred personal records, memoirs and correspondence files of relevance to the campaign.

^8. Peter Stanley, "'The Men Who Did the Fighting Are Now Busy Writing': Australian Post-Mortems on Defeat in Malaya and Singapore, 1942–45," in Sixty Years On: The Fall of Singapore Revisited, edited by Brian Farrell and Sandy Hunter (Singapore: Eastern Universities Press, 2003), Chapter 14.

^9. For instance, see Michael Tyquin, Little by Little (Canberra: Army History Unit, 2003), 395–401; Russell Braddon, The Naked Island (London: Pan Books, 1956); K.J. Browne, "'Mudflat' (Memoir)," (undated), PR00531, Folder 1 of 6, Australian War Memorial (hereafter AWM), Canberra; Brian Cull, Paul Sortehaug, and Mark Haselden, Buffaloes over Singapore: RAF, RAAF, RNZAF and Dutch Brewster Fighters in Action over Malaya and the East Indies 1941–42 (London: Grub Street, 2003); Lloyd Ellerman, "Memoirs of Lloyd Ellerman, J Section, 8 Division Signals," (undated), PR86/369 (item 419/3/55), AWM, Canberra; Stanley Field, Singapore Tragedy (Sydney Angus & Robertson, 1943); Iain Finlay, Savage Jungle: An Epic Struggle for Survival (East Roseville: Simon & Schuster, 1991); Ray Wheeler, "Transcript of Interview [with Ina Bertrand]," Victorians at War—Oral History Project, 11 December 2000, State Library of Victoria and Australian Government Department of Veterans'Affairs, Melbourne. Interestingly, one soldier believed that he actually recovered from depression because of his service conditions (David Ralph Boardman, "Manuscript," (undated), MSS1617, AWM, Canberra, 2); he also noted a soldier who adapted remarkably well to combat: 'At first he seemed quite calm, but as he chatted his eyes lit up. He had just experienced the high point of this life: he had shot seven Japanese this morning.' (page 4).

^10. Noel Barber, Sinister Twilight: the Fall of Singapore (London: Fontana, 1971), 214; David Vincent, The RAAF Hudson Story, vol. 1 (Highbury: David Vincent, 1999), 83. Indeed, the only medical record of psychiatric casualties published from the campaign had to survive several years of captivity in Singapore and Japan, two earth tremors and firebombing by US aircraft! (C.R. Boyce, "A Report on the Psychopathic States of the Australian Imperial Force in the Malayan Campaign," Medical Journal of Australia 2 (1946): 339–45, 339).

^11. Janet Uhr, Against the Sun: The AIF in Malaya, 1941–42 (St Leonards: Allen & Unwin, 1998), 99–100.

^12. A.C. Arthurson, "The Story of the 13^th Australian General Hospital, 8^th Division, 2^nd A.I.F., 1941–1945," 1990, MSS1377, AWM, Canberra, 39; Osmar Julius Blau, "Papers of Captain Osmar Julius Blau, 72 Light Aid Detachment, 22 Brigade, 8 Division AIF," (undated), PR01047, AWM, Canberra, 3, 6; Ray Connolly and Bob Wilson, eds, Medical Soldiers: 2/10 Australian Field Ambulance 8 Div. 1940–45 (Kingsgrove: 2/10 Australian Field Ambulance Association, 1985), 62; Erwin Heckendorf, "2/30^th Battalion [interview with Hank Nelson]," 29 January 1990, ID500763, Keith Murdoch Sound Archive of Australia in the War of 1939–45, AWM, Canberra, 22, 25–6; Hank Nelson, POW: Prisoners of War. Australians Under Nippon (Sydney, Australian Broadcasting Corporation, 1985), 18; Donald Smith, And All the Trumpets (London: Panther, 1968), 17; Eugene Sullivan, "Malaya, Singapore and Changi, 1940–42," in Brother Digger: The Sullivans 2^nd AIF, edited by Patricia Shaw (Elwood: Esplanade Publications, 1989), 40–72, 56; Gerald L. Veitch, "Personal Record," (undated), PR 89/178, AWM, Canberra, 78–9, 86, 88; Don Wall, ed., Singapore & Beyond: the Story of the Men of the 2/20 Battalion Told by the Survivors (East Hills, 2/20 Battalion Association, 1985), 63–4, 86; Cliff Whitelocke and George O'Brien, Gunners in the Jungle: a Story of the 2/15 Field Regiment, Royal Australian Artillery, 8 Division, Australian Imperial Force (Eastwood: The 2/15 Field Regiment Association, 1983), 62. The low prevalence of psychotic disorders was noted among personnel serving in Malaya (Boyce, 342), but as both wartime and current thought do not consider military service to be an aetiological factor, psychoses have been excluded from this analysis.

^13.13. Whitelocke and O'Brien, 62.

^14. Heckendorf, 25.

^15. Lionel George Thomas Hobbins, "Personal Service Record," (undated), Folder Series A9301, Item 3455, National Archives of Australia, Canberra. See also Uhr, 211; Vincent, John Raftery has explored in detail the longer-term psychological sequelae of front-line service during the 1942–43 Kokoda Trail campaign, suggesting that many problems did not manifest until months or years after combat (Raftery).

^16. E.L. Cooper and A.J.M. Sinclair, "War Neuroses in Tobruk: A Report on 207 Patients from the Australian Imperial Force Units in Tobruk," Medical Journal of Australia 2 (1942): 73–76, 74; Allan S. Walker, Clinical Problems of War, vol. I, Australia in the War of 1939–1945, Series Five: Medical (Canberra: Australian War Memorial, 1952), 675.

^17. H.R. Love, "Neurotic Casualties in the Field," Medical Journal of Australia 2 (1942): 137–43, 137. Only twenty to thirty Australian doctors or psychologists showed any interest in 'war neuroses' during the conflict; some of these had only cursory training (Conde, 64).

^18. Raftery, 28. The Army Psychology Service was not established until October 1942 (Muir, "The Hidden Cost of War," 87).

^19. Walker, Clinical Problems of War, 676. Australian guidelines were developed with reference to a British report to the Ministry of Pensions, chaired by Lord Horder and dated 3 November 1939 ("Psychiatry in the Australian Army. Case Histories and Reports 1939–1945," (undated), AWM 54 (item 804/1/4), Folder 2 of 2, AWM, Canberra, Appendix C, "Report to the Minister of Pensions"). This document certainly set the tone for British responses to psychiatric casualties during World War II, as detailed by Ben Shephard, "'Pitiless Psychology': the Role of Prevention in British Military Psychiatry in the Second World War," History of Psychiatry 10 (1999): 491–524, 510–14.

^20. Walker, Clinical Problems of War, 684. Technical Instruction No. 10 (41/73/850), 'Recommendations for treatment of neurosis,' was authored by Colonel John Adey, a consultant psychiatrist, based on his experiences in the Middle East (John K. Adey, "Adviser in Psychiatry Middle East" 1941, AWM 52 (item 11/1/7), June–July 1941, AWM, Canberra). The Instruction was dated 18 June 1941 and distributed to all Australian Army regimental medical officers at this time—6 months prior to the Japanese attack on Malaya ("War Neurosis—Advisory Committee. Minutes of a Meeting Held in the Office of the D.G.M.S. on Friday, 18^th July, 1941, at 4 O'Clock p.m.," AMW 54 (item 804/1/4), AWM, Canberra, 1).

^21. William Cotter Burnell Harvey, "Papers of Lt Col William Cotter Burnell Harvey, 10 AGH," (undated), PR02072, AWM, Canberra, 3. Note that the inverted commas for 'war' neurosis appear in the original. Kluang was the base for 2/4 Casualty Clearing Station, which played a central role in management of Australian casualties through the Malayan campaign (Tyquin, Little by Little, 396).

^22. Raftery, 30.

^23. "Note on the Prophylaxis of Psychogenic Disorders in the Army and the Treatment and Disposal of Cases of War Neurosis Occurring Amongst Soldiers," undated (circa 1941), AWM 54 (item 804/1/4), AWM, Canberra, "Treatment and Disposal". See also Anonymous, "The Royal Australasian College of Physicians Annual Meeting," Medical Journal of Australia 2 (1942): 50–1, 51; Cooper and Sinclair, "War Neuroses in Tobruk," 73; Love, 142; C.C. Minty, "War Neuroses," Medical Journal of Australia 2 (1940): 386–7, 387; "Summary of Prevention and Treatment of War Neuroses," 10 July 1941, AWM 54 (item 804/1/4), AWM, Canberra; Walker, Clinical Problems of War, 677. The Australian experience of employing PIE (proximity, immediacy, expectancy) principles during the siege of Tobruk has been credited with revising the subsequent treatment of psychiatric casualties throughout the Commonwealth forces (Edgar Jones and Simon Wessely, Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War (Hove: Psychology Press, 2005), 78). However, while the Tobruk experience also highlighted the value of dedicated war neurosis clinics near the front line—another lesson from the Great War—this concept was only adopted slowly, at least in part out of fear that grouping affected individuals together might further reinforce their 'neuroses' (W.D. Curtis, "Pages from a Military Psychiatric Notebook," Medical Journal of Australia 2 (1946): 76–80, 78; Love, 140; Minty, 387). The US Army did not return to the principles of forward treatment until after the disastrous neuropsychiatric consequences of the 1943 Tunisian campaign (Hans Pols, "War and Military Mental Health: The U.S. Psychiatric Response in the Twentieth Century," American Journal of Public Health (2007), in press).

^24. Johnston, At the Front Line, 48.

^25. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 50–1; W.S. Dawson, "Prevention of War Neuroses," Medical Journal of Australia 2 (1941): 375–8, 377; C.H. Fitts, "The Effort Syndrome," Medical Journal of Australia 2 (1942): 41–3, 42; Love, 137, 142; Sinclair, "Psychiatric Aspects of the Present War," 502.

^26. Cooper and Sinclair, "War Neuroses in Tobruk," 77; Love, 142; "Technical Instruction No. 10 (41/73/850), 'Recommendations for treatment of neurosis,'" 18 June 1941, AWM 54 (item 804/1/4), AWM, Canberra.

^27. Johnston, At the Front Line, 51.

^28. Raftery, 32.

^29. Walker, Clinical Problems of War, 705.

^30. Johnston, At the Front Line, 48; Love, 140–2; 'Recommendations for treatment of neurosis,' AWM; Sinclair, "Psychiatric Aspects of the Present War," 502, 504.

^31. Veitch, 78; Walker, Clinical Problems of War, 684.

^32. A.P. Derham, "Singapore and After: A Brief Historical Survey of the Activities of the Australian Army Medical Corps in Malaya," Medical Journal of Australia 2 (1946): 397–403, 401.

^33. 'Recommendations for treatment of neurosis,'AWM.

^34. Cooper and Sinclair, "War Neuroses in Tobruk," 73; Love, 137; Minty, 387; Sinclair, "Psychiatric Aspects of the Present War," 504; A.J.M. Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," Medical Journal of Australia 2 (1943): 453–60, 456. Conversely, exposure to comrades in their unit who had 'cracked up' was more likely to lower morale and to foster additional breakdowns among US troops (Samuel A. Stouffer et al., Studies in Social Psychology in World War II. vol. II. The American Soldier: Combat and Its Aftermath (Princeton: Princeton University Press, 1949), 209), so removal of psychiatric casualties from the front line may have benefited the remaining members of the unit more than the affected individual.

^35. Raftery, 33; Walker, Clinical Problems of War, 676.

^36. Cooper and Sinclair, "War Neuroses in Tobruk," 75; Sinclair, "Psychiatric Aspects of the Present War," 505; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 456. Interestingly, Argentinean data from the Falklands/Malvinas conflict of 1982 suggest that psychiatric casualties comprised less than 5 percent of the total, possibly because there was no hope of evacuation from the islands (Edgar Jones and Simon Wessely, "Psychiatric Battle Casualties: An Intra- and Interwar Comparison," British Journal of Psychiatry 178 (2001): 242–7, 245).

^37. Rowley Richards, A Doctor's War (Sydney, HarperCollins, 2005).

^38. Blau.

^39. Boardman; Connolly and Wilson.

^40. Barbara Angell, A Woman's War: The Exceptional Life of Wilma Oram Young, AM (Sydney: New Holland, 2005); Wilma Young, "Transcript of Interview [with Ina Bertrand]," Victorians at War—Oral History Project, 4 December 2000, State Library of Victoria and Australian Government Department of Veterans' Affairs, Melbourne.

^41. Angell; Arthurson; Harvey; Charles Huxtable, From the Somme to Singapore: a Medical officer in Two World Wars (Kenthurst: Kangaroo Press, 1995); Veronica Turner, "Manuscript," (undated), MSS1086 (item 419/106/16), Folder 2 of 4, AWM, Canberra.

^42. Richards, 66. This is not to say that there were no psychological casualties in his unit: during the campaign, five men from the 2/15 Field Regiment appeared before medical boards on account of 'anxiety neurosis,' 'neurasthenia' or 'effort syndrome' and were classed as unfit for further service. ("Record of Medical Boards, 8^th Australian Division Malaya. Maintained by Lt-Col J.G.G. White," 1942, AWM 54 (item 277/8/6), AWM, Canberra).

^43. Harvey, diary entry, 4 February 1942. It is not necessarily clear whether Harvey is referring to circulatory or psychological 'shock'; however, as an Australian Army Major from the 2/10 Field Ambulance was 'boarded' for 'Anxiety state. Emotional shock. Depression' at 10 AGH on the following day, it is likely that Harvey is noting a 'neurotic' case (AWM 54 (item 277/8/6), 5 February 1942).

^44. Boyce; AWM 54 (item 277/8/6).

^45. Muir, "The Hidden Cost of War," 50,52.

^46. Angell, 43–4; Arthurson, 40; Betty Jeffrey, White Coolies (London: Panther, 1963), 8; Sullivan, 46. One solider who later collapsed with malaria noted on 11 February that he 'was told the doctors were no longer able to attend the sick, only the wounded' (Sullivan, 56). Technical Instruction No. 10 on neurosis concludes, for instance, that 'There is always a tendency, amidst a rush of severely wounded to have little time to devote to these cases of exhaustion, but if the above measures be adopted many men will be returned to their Units who otherwise would have been sent to the Base' ('Recommendations for treatment of neurosis', AWM).

^47. Uhr, xii. The actual numbers for the 2/19 were 335 killed and ninety-seven wounded (Thompson, 424), yet only two members of this unit came before medical boards for 'anxiety neurosis' (AWM 54 (item 277/8/6)).

^48. Jones and Wessely, "Psychiatric Battle Casualties," 246. This conclusion includes data from the US Marine Corps during the 1945 Okinawa campaign and the Korean War (Christopher G. Blood and Eleanor D. Gauker, "The Relationship between Battle Intensity and Disease Rates among Marine Corps Infantry Units," Military Medicine 158 (1993): 340–4, 342), plus the 1^st Canadian Division fighting the Germans in Italy in 1944 (Jones and Wessely, "Psychiatric Battle Casualties," 244).

^49. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 50; Fitts, 42; Walker, Clinical Problems of War, 678.

^50. Edgar Jones, "Historical Approaches to Post-Combat Disorders," Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences 361 (2006): 533–42, 538; Edgar Jones et al., "Post-Combat Syndromes from the Boer War to the Gulf War: a Cluster Analysis of Their Nature and Attribution," BMJ 324 (2002): 1–7, 2, 5, 6. This problem was well recognised within Commonwealth military forces by 1941, and 17% of all medical discharges from the British Army and Royal Air Force in 1942 were on account of digestive disorders (Jones and Wessely, Shell Shock to PTSD, 197). Based on his cluster analysis of postcombat symptoms, Edgar Jones has questioned whether dyspepsia should be as strongly associated with World War II as has previously been accepted (Jones, "Historical Approaches to Post-Combat Disorders," 540).

^51. Boyce, 340.

^52. AWM 54 (item 277/8/6).

^53. Adey, "Administrative Instruction, No. 30 (41/73/127)," issued 19 August 1941, section 79: "Mental cases—diagnosis of". This instruction could be seen as a means to downplay the incidence of 'neurosis,' but it appears to have been intended to secure a correct primary diagnosis in cases where a physical complaint was also present.

^54. Indeed, Kristy Muir has found significant discrepancies in the reported incidence of Australian psychiatric casualties throughout and after World War II (Muir, "The Hidden Cost of War," 51–4).

^55. Boyce.

^56. The total number in the depot is of interest; official figures suggest only 1306 Australians were wounded during the Malayan campaign. It is extremely unlikely that 84% of all Australian casualties for the entire campaign passed through the convalescent depot during the last days before the surrender. It therefore seems that the actual number of wounded personnel was considerably higher than officially reported, or that the depot was accepting civilians or casualties from other Commonwealth armies.

^57. Sinclair, "Psychiatric Aspects of the Present War," 504.

^58. Adey, "War Diary," 8 August 1941.

^59. Sinclair, "Psychiatric Aspects of the Present War," 508; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 453. In Tobruk, the incidence of 'war neurosis' was believed to be in the order of one case per 800 combatants (~0.1%): Sinclair, "Psychiatric Aspects of the Present War," 504.

^60. More recent data suggest that individuals with wounds are at higher risk of psychiatric disorders than those without physical harm (Simon Wessely, "Twentieth-Century Theories on Combat Motivation and Breakdown," Journal of Contemporary History 41 (2006): 269–86, 272).

^61. Adey, "War Diary," 6 August 1941.

^62. Kristy Muir suggests that psychiatric cases represented 39% of Australian World War II casualties, but her assumptions and calculations are open to question, especially the calculation of the denominator and the inclusion of psychosis as a service-related psychiatric condition (Muir, "The Hidden Cost of War," 58). Even in the intense fighting faced by the British 21^st Army Group following the Normandy invasion in 1944, the overall proportion of psychiatric casualties to all wounded was 14.6%, peaking at 21%, with considerable variation between units (Jones and Wessely, "Psychiatric Battle Casualties," 244). Psychiatric casualty rates in the US military—which were staggeringly high for some World War II campaigns—ultimately comprised 6% of all hospital admissions (Pols).

^63. This tallies with 1941 totals across the Middle and Far East theatres, where 386 of the total 2678 personnel with 'psychoneurotic' conditions (14.4%) were repatriated to Australia (Muir, "The Hidden Cost of War," 53).

^64. AWM 54 (item 277/8/6). The diagnoses are based on those written in the records, not on modern (re-) interpretations. While a variety of diagnoses were listed in the board records, 'anxiety neurosis' was by far the most frequent term for psychiatric casualties. Among the non-neurotic mental and neurological disorders also listed were 'psychosis,' 'delusional insanity,' 'feeblemindedness,' 'psychopathic personality' and 'idiopathic epilepsy.'

^65. Johnston, At the Front Line, 49.

^66. Shephard, "'Pitiless Psychology,'" 512.

^67. Barber, 216–17.

^68. Muir, "The Hidden Cost of War," 51.

^69. This was certainly the case in Tobruk in 1941, where some self-inflicted wounds were reported among Australian troops (Walker, Clinical Problems of War, 684).

^70. No other common presentations of self-inflicted wounds—such as gunshots to the feet or hands—were found among the 400 cases that were forwarded to boards between 7 December 1941 and the cessation of hostilities (AWM 54 (item 277/8/6)). This is despite the promulgation during 1941 of a booklet compiled by Colonel G.W.B. James, consultant psychiatrist to the British Forces in the Middle East, which described not only neurotic and hysterical states, but also paid particular attention to epilepsy and self-inflicted wounds (Walker, Clinical Problems of War, 684).

^71. Johnston, At the Front Line, 56.

^72. Boyce, 340.

^73. Derham, 403.

^74. Boyce, 340. A similar problem hampered efforts at treating patients at the war neurosis clinic in Tobruk.

^75.Ibid. The commanding officer of the depot was expected to have some skills in mental reconditioning in order to avoid 'scrimshanking and loss of manpower on one hand or to genuine distress and even suicide on the other.' ("Medical Administration Instructions, Malaya Command 1941–1942," 1942, AWM 54 (item 481/13/16), AWM, Canberra, Paragraph 3, "Instructions Regarding the Policy Governing the Organization and Administration of Convalescent Depots," Fort Canning, Singapore, 12 August 1941).

^76. Walker, Clinical Problems of War, 693.

^77. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 50; Muir, "The Hidden Cost of War," 113; Sinclair, "Psychiatric Aspects of the Present War," 506

^78. Muir, "'Idiots, Imbeciles and Moral Defectives,'" 42.

^79. Jones and Wessely, Shell Shock to PTSD, 71, 75. Even by 1944, British success rates (returning men to duty in the same medical class) remained generally under 20% (Jones and Wessely, "Psychiatric Battle Casualties," 245). US psychiatrists also claimed 40–50% return-to-duty rates during the war, but substantially revised these claims after the end of hostilities (Pols).

^80. Jones and Wessely, Shell Shock to PTSD, 79.

^81. Garton, 169–70.

^82. The predisposition theory was only beginning to be challenged within Australian medical circles by the end of the Second World War (Muir, "The Hidden Cost of War," 15).

^83. Boyce, 340, 342. The prevalence calculation is based on eleven cases among 15,000 Australians who passed into captivity in February 1942. Even if a decrease in the denominator by 5,000 personnel is allowed for to account for deaths and transfers out of the camp over the fifteen months, the incidence remains approximately 0.1%—at least an order of magnitude lower than during active service. This finding of lower rates of psychiatric problems among prisoners of war was echoed in other contemporary reports (Muir, "The Hidden Cost of War," 54). However, Simon Wessely has recently noted that almost all longitudinal studies of former prisoners of war—including those in the Far East theatre— indicate significant psychiatric morbidity rates were the norm (Wessely, 272).

^84. Jones and Wessely, "Psychiatric Battle Casualties," 244.

^85. J.V. Ashburner, "Psychology in the Australian Army," Medical Journal of Australia 2 (1946): 86–92, 86–7; Dawson, 376; Garton, 163; Muir, "The Hidden Cost of War," 82; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 454; N.V. Youngman, "The Psychiatric Examination of Recruits," Medical Journal of Australia 1 (1942): 283–7, 284. Boyce echoed the call for more stringent screening of recruits following his experience of 'neurotics' in Malaya (342), even though the US military had abolished screening in 1944 (Pols).

^86. Most men in the 8^th Division AIF had joined up following the fall of France in May 1940 (Uhr, 16, 18–19). Boyce, however, believed that inadequate training—especially in local conditions—did contribute to the breakdown rate (Boyce, 340). Morale of US servicemen during World War II was observed to be lower among those posted overseas as opposed to those remaining within the USA, and also declined after more than six to twelve months in the army (Samuel A. Stouffer et al., Studies in Social Psychology in World War II. vol. I. The American Soldier: Adjustment During Army Life (Princeton: Princeton University Press, 1949), 157, 203–4).

^87. Mark Clisby, Guilty or Innocent? The Gordon Bennett Case (North Sydney, Allen & Unwin, 1992), 15; Heckendorf, 22; Richards, 66; Sullivan, 54–5; Tyquin, Little by Little, 399–400. American studies of this period also suggested that 'psychiatric breakdowns tended to occur disproportionately among the newest combat men' (Stouffer et al., Combat and Its Aftermath, 452).

^88. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 50–1; Heckendorf, 23, 25; Johnston, At the Front Line, 80, 84; Love, 142; Sinclair, "Psychiatric Aspects of the Present War," 508; A.J.M. Sinclair, "The Psychological Reactions of Soldiers," Medical Journal of Australia 2 (1945): 233.

^89. Stouffer et al., Adjustment During Army Life, 403–4.

^90. Connolly and Wilson, 66; Johnston, At the Front Line, 70–1; Sullivan, 53–54.

^91. Boyce, 340.

^92. Heckendorf, 26.

^93. Data from other soldiers of democratic nations, including World War II US forces and Israeli soldiers fighting in the Yom Kippur War, suggest that nationalistic or political convictions played very little part in motivation or morale (Pols; Stouffer et al., Combat and Its Aftermath, 75; Wessely, 277).

^94. Sullivan, 53.

^95. Johnston, At the Front Line, 76. Michael Tyquin, however, suggests that the valorisation of First World War 'diggers'—especially by the official historians C.E.W. Bean and A.G. Butler—allowed little room for sympathy for psychiatric casualties within the armed forces during World War II (Tyquin, Madness and the Military, 157, 159).

^96. Stan Arneil, One Man's War (South Melbourne: Sun Books, 1980), 9; Johnston, At the Front Line, 69.

^97. Garton, 166.

^98. Sullivan, 50. Michael Tyquin suggests that Army morale was quite low early in the campaign, after news spread of the Pearl Harbor attack and loss of the British capital ships HMS Repulse and Prince of Wales (Tyquin, Little by Little, 396).

^99. Stouffer et al., Combat and Its Aftermath, 15.

^100. Uhr, 145. The concept of small-group solidarity became an important dictum for many combatants during World War II (Wessely, 278), but was not espoused in Australian military guidelines or psychiatric literature of the period. However, numerous memoirs of the campaign document personal distress and loss of combat effectiveness once detachments were separated or incapacitated via casualties.

^101. Blood and Gauker, 342.

^102. James Burfitt, Against All Odds: the History of the 2/18 Battalion AIF (Frenchs Forest: 2/18^th Battalion (AIF) Association, 1991), 54; Johnston, At the Front Line, 29–30; Richards, 65; Uhr, 99.

^103. Heckendorf, 25; Johnston, At the Front Line, 195; Nelson, 17; Sullivan, 51; Thompson, 353; Uhr, 179–80; Roy Whitecross, Slaves of the Son of Heaven (East Roseville, Kangaroo Press, 2000), 3. The intensity of the Japanese barrage of Singapore Island immediately prior to the invasion was indeed fearsome, and borne largely by the Australian 2/18, 2/19 and 2/20 Battalions. Lieutenant-Colonel Varley, the commanding officer of the 2/18, remarked that 'During my four years of service from 1914 to 1918 I never experienced such concentrated shell fire over such a period.' (Whitelocke and O'Brien, 125).

^104. Love, 141; Sinclair, "Psychiatric Aspects of the Present War," 503–4. German 88 mm anti-tank guns and dive bombers were rated by US troops in North Africa as the most feared enemy weapons, although the correlation between the psychological impact of a weapon and the actual danger it posed was not strong (Stouffer et al., Combat and Its Aftermath, 232–4). US data also suggested that the fear of aerial attack was most intense during the first week of combat, falling away after five to ten days, while fear of artillery rose with increasing exposure to shellfire (Stouffer et al., Combat and Its Aftermath, 236).

^105. Boyce, 340.

^106. Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 455.

^107. Sinclair, "Psychiatric Aspects of the Present War," 504.

^108. Leslie Bell, Destined Meeting (London, Readers Book Club, 1960), 34; Connolly and Wilson, 39–40; Johnston, At the Front Line, 11, 45; Uhr, 45. The wartime research of US psychiatrists Roy Grinker and John Spiegel suggested that troops were more likely to reach their 'breaking point' following at least 100 days of combat—much longer than the Australians were in the front line (Pols). Factors such as battle intensity and casualty rates appear to have been the predominant drivers for breakdown among the AIF (see, for instance, Jones and Wessely, "Psychiatric Battle Casualties," 244).

^109. Johnston, At the Front Line, 55.

^110. Bur.tt, 58; Heckendorf, 23; Sullivan, 52–3. The retreat onto Singapore also heightened the burden on medical personnel: 'Commanders faced an uncertain water supply, a deteriorating hygiene situation, no defensive cover and an increasing incidence of malaria' (Tyquin, Little by Little, 399).

^111. Heckendorf, 22–3; Sullivan, 56.

^112. Barber, 203–4; Joan Beaumont, "Australia's War: Asia and the Pacific," in Australia's War 1939–45, edited by Joan Beaumont (St Leonards: Allen & Unwin, 2000), 26–53, 29; Bell, 34–5; Clisby, 15–16; Nelson, 18; Thompson, 321,352–3.

^113. The most famous case was the commanding officer of the 8^th Division AIF, Major-General H Gordon Bennett, who was tried by a military court after the end of the war and found guilty of deserting his post, although there was no suggestion that he was psychologically disturbed at the time (Clisby).

^114. Angell, 57; Johnston, At the Front Line, 37, 44, 69; Richards, 63; Veitch, 88.

^115. Stouffer et al., Combat and Its Aftermath, 81.

^116. Arthurson, 45; Mark Johnston, Fighting the Enemy: Australian Soldiers and Their Adversaries in World War II (Cambridge: Cambridge University Press, 2000), 97. However, it has been suggested that news of the recent massacre of Commonwealth military hospital staff in Hong Kong—including rape and murder of the female nurses—may have been a factor in the decision to evacuate all female nurses from Singapore prior to the surrender (Mark Harrison, Medicine and Victory: British Military Medicine in the Second World War (Oxford: Oxford University Press, 2004), 72).

^117. Arneil, 9. See also Angell, 57; Heckendorf, 24; Richards, 70.

^118. Sinclair, "Psychiatric Aspects of the Present War," 507–8; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 453–4. This was also noted among US personnel serving in the Pacific theatre (Stouffer et al., Combat and Its Aftermath, 70).

^119. Arneil, 9; Muir, "'Idiots, Imbeciles and Moral Defectives,'" 14; Richards, 63, 70; Smith, 17; Uhr, 129.

^120. Boyce, 340; Cooper and Sinclair, "War Neuroses in Tobruk," 76; Garton, 166; Minty, 386; Sinclair, "Psychiatric Aspects of the Present War," 508; Sinclair, "The Psychological Reactions of Soldiers," 233.

^121. Boyce, 341; Cooper and Sinclair, "War Neuroses in Tobruk," 74; Sinclair, "Psychiatric Aspects of the Present War," 508; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 454; Sinclair, "The Psychological Reactions of Soldiers," 233; Wall, 63–4. The overall sick rate for troops—especially skin infections— was considered 'exceptionally high' prior to the Japanese attack (Tyquin, Little by Little, 396). In Tobruk there was a trend for medical or surgical cases to develop super-added neuroses (Cooper and Sinclair, "War Neuroses in Tobruk," 73), but Boyce observed only one such case in Malaya (Boyce, 341).

^122. US neurologist Frederick Hanson provided much the same treatment in 1943 and published favourable return-to-duty rates (Pols).

^123. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 51; Boyce, 339; Cooper and Sinclair, "War Neuroses in Tobruk," 74; Love, 142; Sinclair, "The Psychological Reactions of Soldiers," 234. The term 'fear state' suggested by Cooper and Sinclair following their experiences in Tobruk—to distinguish an understandable but transient reaction to combat stress—does not appear to have been used in Malaya.

^124. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 50; J. Bostock, "Nervousness: a Negligible and Not Pensionable Disability," Medical Journal of Australia 1 (1942): 133–5, 135; Conde, 66; Cooper and Sinclair, "War Neuroses in Tobruk," 74; Curtis, 77–8; Garton, 158, 170; Love, 138; Minty, 386; Muir, "'Idiots, Imbeciles and Moral Defectives,'" 45–6; Sinclair, "Psychiatric Aspects of the Present War," 507, 508, 514; Sinclair, "Psychiatric Casualties in an Operational Zone in New Guinea," 457; Sinclair, "The Psychological Reactions of Soldiers," 230; Walker, Clinical Problems of War, 705–6; Youngman, 284.

^125. Boyce, 340–1.

^126. Anonymous, "The Royal Australasian College of Physicians Annual Meeting," 51; Bostock, 135; Johnston, At the Front Line, 46; Muir, "'Idiots, Imbeciles and Moral Defectives,'" 45; AWM 54 (item 804/1/4); Raftery, 5; F.M. Richardson, Fighting Spirit: A Study of Psychological Factors in War (London: Leo Cooper, 1978), 72–3; Shephard, "'Pitiless Psychology,'" 511; Walker, Clinical Problems of War, 676–7.

^127. Boyce, 341.

^128. Richards, 66; Wall, 64. Australian army psychiatrists were still lamenting the frequency of soldiers reporting with the label of 'shell shock' as late as 1943 (Tyquin, Madness and the Military, 153).

^129. Fitts, 41. The abbreviation NYDN (not yet diagnosed—neurological) has not been observed in any official or unofficial records from the campaign, suggesting it was also considered archaic by World War II, although it was apparently used by Australian medical staff at El Alamein in 1942 (Walker, Clinical Problems of War, 687).

^130. AWM 54 (item 277/8/6).

^131. R.H. Davis, "Personal Record," (undated), 3DRL/2398(A), AWM, Canberra.

^132. Edgar Jones, " 'LMF': the Use of Psychiatric Stigma in the Royal Air Force During the Second World War," Journal of Military History 70 (2006): 439–58, 443–4.

^133. Garton, 163; John McCarthy, "Aircrew and 'Lack of Moral Fibre' in the Second World War," War & Society 2 (1984): 87–101, 90.

^134. Conde, 67; Allan D. English, "A Predisposition to Cowardice? Aviation Psychology and the Genesis of 'Lack of Moral Fibre,'" War & Society 13 (1995): 15–34, 19; Muir, The Hidden Cost of War, 82. RAF data from this period found that only half of the aircrew who broke down had a history of—or 'predisposition' to—mental problems (Jones, "'LMF,'" 450).

^135. English, 17; Jones, "'LMF,'" 449; Stouffer et al., Combat and Its Aftermath, 379–80; Allan S. Walker, Medical Services of the R.A.N. and R.A.A.F., vol. IV, Australia in the War of 1939–1945, Series Five: Medical (Canberra: Australian War Memorial, 1961), 208. Many of these factors were not formally iterated until later in the war or after the cessation of hostilities.

^136. Joseph John Shanahan, "Personal Record," (undated), 3DRL/6601 (item 419/93/18), Folders 1 and 2 of 6, AWM, Canberra, "Account of operations and other historical matters of 453 Squadron from December 7^th, 1941 to December 31^st," 7.

^137. English, 23; Jones, "'LMF,'" 440; Jones and Wessely, Shell Shock to PTSD, 97–8; McCarthy, 88. The RAAF had essentially adopted the RAF's LMF policies by September 1941, several months prior to the Japanese attack on Malaya; in any case overall operational command in the theatre lay with the RAF (Muir, "The Hidden Cost of War," 81–2).

^138. Jones, "'LMF,'" 443.

^139. Jones and Wessely, Shell Shock to PTSD, 98; McCarthy, 88.

^140. Jones, "'LMF,'" 457; McCarthy, 94–5.

^141. Jones, "'LMF,'" 447.

^142. McCarthy, 94–5.

^143. Quote by Flight Lieutenant R.P. Bulcock of 8 Squadron in John Balfe, War Without Glory: Australians in the Air War with Japan 1941–45 (Melbourne: Macmillan, 1984), 58. Personnel from both 1 and 8 Squadrons RAAF were present on the station at the time, along with RAF personnel. The removal of some aircraft was authorised, but in the confusion this was taken by many staff to mean that the entire aerodrome should be evacuated.

^144. Vincent, 83. See also Balfe, 114–15.

^145. "Report by Air Commodore J.P.J. McCauley, C.B.E., on the findings of the Court of Inquiry: Evacuation of R.A.F. aerodromes Malaya: December, 1941," dated 28 May 1946. Reproduced in Vincent, 375–7. The report also noted that during the inquiry, Lieut