The terror that lingers

Thanks to COL Jim Littig/Ranger (USA, ret), one of the truly good men.

Recall that we as a country are no further along with non-pharmacological “treatments” for PTSD than we were decades ago, with a few exceptions.  We don’t have even close to an accurate count of service members suffering from PTSD; the VA has been all over the map. Current VA estimates are that 7% of Veterans have PTSD:  1.33M

Left out of the VA’s discussion of PTSD is any mention of TBI and the relationship of TBI — diagnosed, undiagnosed,  or misdiagnosed — to PTSD. While the suicide rate continues its upward trend, significant increases in “suicide prevention” spending continue to reward the usual suspects, along with the contingent of researchers working with the new/old lineup:  ** ketamine, psilocybin, MDMA/ecstasy, LSD, CBD, SSRIs and SNRIs, Ibogaine, DMT

Nothing for healing brain wounds.

This series bears watching:

The terror that lingers


An American soldier comforting a comrade during World War II
(Photo: National Archives)

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.

Ancient mural of Assyrians flaying their enemies alive
(Photo: public domain)

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.

1878 painting of Saul (right) with David
(Painting: Ernst Josephson)

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.

1900 artist’s depiction of the Battle of Marathon
(Painting: John Steeple Davis)

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.”

Artist’s depiction of Napoleonic artillery, the assumed cause of “vent du boulet” at the time
(Painting: Keith Rocco)

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. 

Corporal Calvin Bates. During the Civil War, PTSD could be triggered not only by combat, but also exposure to nightmarish conditions such as at Andersonville Prison in Georgia, where Bates lost his feet. 
(Photo: Library of Congress)
American cardiologist Jacob Mendes Da Costa noticed that many veterans had heart-related symptoms such as high heart rate, palpitations, chest pain and exhaustion. This set of symptoms was called “soldier’s heart” or “irritable heart,” and another doctor tried it explained it as a result of military foot drills, where the overexpansion of the chest caused a dilatation of the heart. 
Jacob Mendes Da Costa 
(Photo: public domain) 
PTSD unsurprisingly became a massive problem in World War I. It was called “shell shock” at the time, and believed to be caused either by concussion from shell bursts, or carbon monoxide released by explosions. Some doctors were quick to point out that many patients had not been near artillery strikes, and proposed “battle hypnosis” or “war strain” as alternate classifications. Nevertheless, the British Army continued to differentiate between patients who had been exposed to artillery, and those who had not. The former were categorized as “wounded” and were entitled to wound stripes and extra pensions; the latter were classified as “sick” and denied the above. 
A soldier, possibly suffering from “shell shock,” in World War I 
(Photo: Ivor Castle) 

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.  

Australian wounded during the Battle of Passchendaele 
(Photo: Frank Hurley)

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”). 

A German victim of PTSD in World War II being comforted by a comrade 
(Photo: Bundesarchiv) 

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). 

Private Theodore James Miller exhibiting signs of combat stress in the Marshall Islands. Combat stress is a less severe condition than PTSD, and easier to recover from. 
(Photo: National Archives and Records Administration) 

Appel suggested that U.S. soldiers should be limited to 180 days of active combat, and that the war should be made to feel more “real” to them, with an emphasis on how the Axis powers intended to invade America, or by having them observe the destruction of war in the areas they were liberating. Other psychologists also suggested that families writing letters to servicemen were also partially responsible for combat fatigue, as they increased nostalgia and burdened the men with news of problems at home they could do nothing about. One psychiatrist even suggested that a nation-wide course on letter-writing to soldiers would have been a good idea, though it was too late for that. 

A War Department Official Training film for U.S. medical officers about combat exhaustion. (Source: YouTube)

The medical establishment finally came to accept by the end of World War II that nobody was immune to mental illness, and started instructing medical officers in the diagnosis of battle fatigue and various treatments such as drug-assisted suggestive therapy. The evolving practice of PTSD treatment became known as PIE: Proximity, Immediacy, Expectancy. Proximity meant that the sufferer must be treated close to the front and within nearing distance of the fighting. Immediacy refers to the notion that victims must be treated immediately, rather than having them wait for their turn after the “real” wounded. Finally, expectancy refers to ensuring that the victim expects to return to combat after some rest. The actual effectiveness of the PIE system has been called into question since, and the U.S. presently uses a more modern system called BICEPS: Brevity, Immediacy, Centrality, Expectancy, Proximity, Simplicity. 

A scene from the HBO miniseries Band of Brothers, depicting a case of conversion disorder (Source: YouTube)

If you know or live in the same neighborhood as a veteran suffering from PTSD, you can do your small part to help them. For example, not setting off fireworks in their area can help. You can also make them aware of the Veterans Crisis Line, whose contact details can be found at to receive confidential support 24/7. You may just save a life. 
An Independence Day-related propaganda poster from 1943
(Photo: Office of War Information)