The terror that lingers

Post-traumatic stress disorder in war

June is post-traumatic stress disorder (PTSD) awareness month. Called by many other names down the centuries (and, in fact, millennia), PTSD has been tormenting soldiers and other trauma survivors since the dawn of history. Though serious research into it only began in the modern era, literary sources reveal that men have suffered from it for much longer. This article is a brief overview of how modern wars have shaped the perception of PTSD, and is dedicated to PTSD sufferers, military or civilian.

The effects of what would later be called PTSD were already observed and recorded in ancient times. Some of the earlies known records date back to ancient Assyria, during the period from 1,300 to 600 BC. The life of an Assyrian soldier was based on a yearly rotation: he would spend one year building roads, bridges and other infrastructure, then fight in campaigns for another year, then return home for a year of rest and relaxation with his family; the cycle would then begin anew. Written sources from the time refer to soldiers finding it difficult to fit in back home after a year of fighting, which is a common problem for modern military personnel suffering from PTSD.

Some scholars have suggested that the Bible also contains references to PTSD. The Old Testament names Saul as the first king of Israel. According to the Bible, “God’s spirit” left Saul early on in his reign, after his wars with hostile peoples, and he grew bothered by an evil spirit which changed his personality: he experienced negative emotions, panic attacks and paranoia. Now, whether or not the events of the Bible should be interpreted literally is not the point; what matters is that the culture the Old Testament is rooted in has already recognized that such things can happen to war veterans.

Another ancient example of PTSD, sometimes referred to as the first definitive description, dates back to the Battle of Marathon between the Persian Empire on one hand and the Greek city states of Athens and Plataea on the other in 490 BC. According to the Greek historian Herodotus, an Athenian soldier called Epizelus saw the death of a comrade and immediately went blind for the rest of his life, even though he himself wasn’t wounded. Losing some bodily functionality such as sight or speech is known as conversion disorder today and is a known symptom of PTSD. Frightening dreams of previous battles and a fear of the night have also been described by the physician Hippocrates and also appear in Icelandic Sagas and medieval descriptions from the Hundred Years’ War. Once psychologist also suggested that Shakespeare’s King Henry IV, Part 1 (more specifically Act II, Scene III, lines 40-62) are also an accurate description of a war veteran’s PTSD given poetic form.

In the modern era, PTSD was named nostalgia by 18th century Austrian physician Joseph Leopold, who described it as melancholy, incessant thinking of home, insomnia, weakness, loss of appetite, anxiety, cardiac palpitations, stupor, and fever. It was called vent du boulet, “cannonball wind," during the French Revolution and the Napoleonic wars of the early 19th century, as it was believed to be fright caused by the draft of a near-miss by a cannon shot. This theory starting the tenacious but long-held notion that PTSD is caused by some sort of physical effect or injury. The famous German writer Johann Wolfgang von Goethe (1749-1832) described his own experience with it: “Your eyes can still see with the same acuity and sharpness, but it is as if the world had put on a reddish-brown hue that makes the objects and the situation still more scary ... I had the impression that everything was being consumed by this fire ... this situation is one of the most unpleasant that you can experience.”

PTSD-like symptoms in civilian survivors of train accidents in the 19th century were dismissed by train companies as fake claims so they wouldn’t have to pay. The medical community was divided: one leading German neurologist proposed that such symptoms were caused by “railway spine,” microscopic injuries to the spine and the brain caused by the crash; other believed the survivors were suffering from a form of hysteria. 

The American Civil War and the Franco-Prussian War of 1870-71 saw the medical establishment’s first concerted effort to understand PTSD. Symptoms were considered to be signs of weakness and malingering at the time, and victims were treated as insane: they were often herded into cattle wagons and sent away with a note of their hometown or state on their clothes; at other times, they were allowed to wander away and succumb to the elements. 

The large number of shell-shocked soldiers forced doctors to concentrate on practical approaches to curing the men. The emerging treatment revolved around giving the patient a few days’ rest, but not too far from the front. Some medical officers noted that as long as the patient trusted his doctor, telling the man that there’s nothing wrong him, and showing an interest in him, were the best cure.  

This method proved effective, and formed the basis of PTSD treatment in World War I. At the Battle of the Somme in 1916, 40% of the casualties were shell-shocked. In late 1917, the terrible Battle of Passchendaele (also known as the Third Battle of Ypres) only saw 1% of the participating British force diagnosed with shell shock, and 75% of those could return to service without hospitalization.  

It’s been suggested that the nature of combat also had an effect on the prevalence of shell shock: cases were more common during the period of trench warfare, when all you could do was “sit and take it,” but decreased in the last phase of the war, which was characterized by more mobile combat. 

Despite the advancement of diagnosis and treatment, shell shock victims were still sometimes put on trial in the British Army on charges like desertion or cowardice. Out of 240,000 cases of court martial, 3,080 death sentences were handed down, 346 of which had been carried out. Long-term treatment of shell shock survivors after the war often involved electroshocks and other painful methods, none of which proved effective. While shell shock continued to carry of strong stigma, the civilian population of Europe also felt pity for victims who had visible manifestations, such as the German Kriegszilterer (“war shakers”). 

After World War I, militaries tried to combat PTSD in the ranks by screening emotionally weak individuals. When World War II rolled around, however, this proved ineffective, as 25% of all casualties were from PTSD, now called “combat exhaustion” or “battle fatigue.” It was this experience that led to the U.S. Army slogan “every man has his breaking point.” Many people still refused to accept battle fatigue as a legitimate health issue, and ascribed its effects to cowardice or weak personality. The best-known example of this attitude was General George S. Patton (Read our earlier article – The wars of George S. Patton), who infamously slapped two privates (in two separate incidents) who were hospitalized for combat exhaustion during the Sicily campaign. Patton’s actions earned him the ire of the press, the disapproval of his superiors, and a year of being sidelined from command. On the upside, the high-profile incidents also spurred the development of more effective treatment methods that could be instituted for the Italian campaign.  

Psychiatrist John W. Appel was head of the Mental Hygiene Branch of the Neuropsychiatry Division in the Surgeon General's Office. Appel found in his research that the average U.S. infantryman in Italy is worn out in 200 to 240 days. He believed that the American soldier "fights for his buddies or because his self respect won't let him quit." After that much time, however, the soldier would feel that he already proved his courage, so he would no longer be motivated by self-respect. He would also lose most of his original comrades, the ones he trained with, by that time, and would no longer have anything left to fight for.  Appel thought that British soldiers were more resilient against combat exhaustion because of their better rotation schedules, and also because they felt they were surviving for their country’s survival (which Americans didn’t really feel, since the U.S. was safely on the far side of the Atlantic and was not being bombarded by the Luftwaffe). 

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