Concussion and PTSD in the Ancient World

The Ludovisi Battle Sarcophagus depicting Roman conquest

of Barbarians, 2nd - 3rd century CE.  Photographed at the 

Palazzo Altemps, Museo Nazionale Romano, in Rome Italy

by Mary Harrsch.

After I suggested in my review of "Semper Fidelis"  that the antagonist in Ruth Downie's novel, a brutal Centurion named Geminus, may have been suffering from PTSD, Ruth sent me a link to a very thoughtful post by Dr. Dorothy King  entitled  "PTSD in Antiquity."  (Sadly, it is no longer online.)

In my review, I cited a post by Dr. Jonathan Eaton who had generally dismissed the probability that many ancient soldiers suffered from PTSD because modern research points to PTSD being most prevalent in soldiers experiencing explosive events (like IEDs, land mines or booby traps).  He theorizes that since gunpowder or other explosive material was generally not used in ancient warfare, such explosive events did not occur so the probability that PTSD could develop was quite low.  He also pointed to the death-filled environment of the ancient world as something that he felt would desensitize ancient peoples to the trauma of warfare.

Dr. Eaton's viewpoint may have reflected a study done in 2011 by C.W. Hoge. In it, the researchers followed 2,525 soldiers and questioned them three to four months after their return from a year-long deployment in Iraq.

"Of the majority of soldiers who suffered no combat injuries of any sort, 9.1 percent exhibited symptoms consistent with PTSD. This allows a baseline for susceptibility of roughly 10 per cent of the population.  A slightly higher number (16.2 per cent) of those who were injured in some way, but suffered no concussion, also experienced symptoms. As soon as concussive injuries were involved, however, the rates of PTSD climbed dramatically. Although only 4.9 percent of the troops suffered concussions that resulted in complete loss of consciousness, 43.9 percent of these soldiers noted on their questionnaires that they were experiencing a range of PTSD symptons.  Of the 10.3 per cent of the unit who suffered concussion resulting in confusion but retained consciousness, more than a quarter (27.3 per cent) suffered symptoms. This suggests a high correlation between head trauma and the occurrence of subsequent psychological problems." - Aislinn Melchior, Caesar in Vietnam: Did Roman Soldiers Suffer from Post-Traumatic Stress Disorder

 Melchior admits that concussion is not the only risk factor for PTSD but says it is so strongly correlated that it suggests the incidence of PTSD may have risen sharply with the arrival of gunpowder, shells, and plastic explosives.

"In Roman warfare, wounds were most often inflicted by edged weapons. Romans did of course experience head trauma, but the incidence of concussive injuries would have been limited both by the types of weapons they faced and by the use of helmets." - Aislinn Melchior, Caesar in Vietnam: Did Roman Soldiers Suffer from Post-Traumatic Stress Disorder

In his footnotes, Melchior speculates that the Romans designed their helmets with an eye to blunting the force of the blows they most often encountered.  Although Peter Connolly argued that the helmet design in the Republican period suggested a crouched fighting stance, Melchior disagrees suggesting the change in helmet design at that point may have signaled instead a shift in the role of troops from performing assaults on towns and fortifications when the empire was expanding and the blows would more often rain from above to the defense and guarding of the frontiers.

Melchior, like Eaton, also speculates that death was so common in the ancient world that it desensitized many of its residents to the prospect of unexpected death.

But in his 1999 paper entitled "The Cultural Politics of Public Spectacle in Rome and the Greek East in 167-166 BCE"  Jonathan C. Edmondson points out that when King Antiochus IV introduced Roman-style gladiatorial combats in Syria in 166 BCE, the Syrians were terrified rather than entertained.

"In time gladiatorial contests came to be accepted and even popular, but only after Antiochus had instituted a local variation whereby fights sometimes ended as soon as a gladiator was wounded."

This hardly sounds like people desensitized to death.

Dr. King also disagrees pointing to the fact that she, a diagnosed victim of PTSD, had never experienced an explosive event and she knew of a military general diagnosed with PTSD that had never been near explosive devices either.  She was particularly impressed with the research of Jonathan Shay summarized in his book " Achilles in Vietnam: Combat Trauma and the Undoing of Character . 

Shay's work has now been made into a poignant documentary entitled "Odysseus in America." 

In another of King's articles, "The Rage of Achilles and PTSD". King discusses what she feels (and I concur) are clear examples of PTSD in the ancient texts.  Her post opens with a moving passage from Homer:

Then said Achilles, "Son of Atreus, king of men Agamemnon, see to these matters at some other season, when there is breathing time and when I am calmer. Would you have men eat while the bodies of those whom Hector son of Priam slew are still lying mangled upon the plain? Let the sons of the Achaeans, say I, fight fasting and without food, till we have avenged them; afterwards at the going down of the sun let them eat their fill. As for me, Patroclus is lying dead in my tent, all hacked and hewn, with his feet to the door, and his comrades are mourning round him. Therefore I can think of nothing but slaughter and blood and the rattle in the throat of the dying."

Iliad 19.226

Then she goes on to examine descriptions of the behaviors of such ancient military men as a Greek warrior at Marathon, Leonidas at Thermopylae, Alexander the Great and Gaius Marius, all supported by quotes from the ancient sources.

So, I was gratified to find another scholar with personal experience with PTSD who also disagrees with Eaton and Melchior.   

Recently, scholars studying cuneiform medical texts left behind by ancient Mesopotamians point to passages describing mental disorders expressed by soldiers and even a king during the Assyrian Period (1300–609 BCE) when military activity was extremely frequent and brutal. The King of Elam is said to have had his mind changed.  Soldiers were described as suffering from periods where they were forgetful, their words were unintelligible, they would wander about, and suffer regular bouts of depression.

"If in the evening, he sees either a living person or a dead person or someone known to him or someone not known to him or anybody or anything and becomes afraid; he turns around but, like one who has [been hexed with?] rancid oil, his mouth is seized so that he is unable to cry out to one who sleeps next to him..." - Translation by Scurlock and Andersen, Diagnoses in Assyrian and Babylonian Medicine

"As seen in the cases of military casualties, the signs and symptoms of the victim were attributed by the ancient Mesopotamians to ghosts, as was the case with many mental and psychosomatic disorders seen during that period. It looks as if, in the case of military casualties, the responsible ghosts were usually assumed by the treating ašipu to be the ghosts of the enemies whom the patient had killed during military operations..."

"...Generally, the symptoms described fit the symptoms of post-traumatic stress disorder as we understand them now. The flashbacks of images of dead people, particularly those occurring at night (in the form of nightmares) and accompanied by fear, are an important symptom. The changes of mental state with fear, forgetfulness and depression are also symptoms that we see often in
clinical practice. - Walid Khalid Abdul-Hamid and Jamie Hacker Hughes, Nothing New under the Sun: Post-Traumatic Stress Disorders in the Ancient World (2015)

I would like to take all of their observations just a few steps further and point to even more recent findings that I feel call into question the "explosive events as the primary cause of PTSD" theory.

I think the results of the autopsy of one of the NFL players who recently committed suicide is particularly significant.  The news reported that the individual had significant brain damage from repeated concussions suffered not from explosive events but from the impacts experienced during a series of football games.  If you consider the repeated impacts ancient soldiers experienced in set piece battles where tight formations were used, such as Greek or Macedonian phalanxes or Roman maniples, the probability of the occurrence of repeated concussions similar to those experienced by modern football players is quite high.  The news program went on to interview the football player's family and they discussed how he had deteriorated mentally from an outgoing, very social individual to a sullen, withdrawn person who no longer found life fulfilling.  As the spouse of a war veteran who has been permanently disabled by severe PTSD, I found the symptoms described by the football player's family all too familiar.

I also think Eaton and Melchior dismiss too readily the psychological aspects of PTSD in the ancient world because of their observations that the ancient world was a far more brutal environment than we have now (outside of inner city ghettos).  They point out how people were surrounded by death because of disease, accidents without proper medical treatment, and entertainments that featured the orchestrated deaths of both people and animals.  I propose that observed deaths occurring in a venue where the observer and the participants are separated both by physical barriers and social hierarchy (most human victims were criminals, prisoners of war, "Others" so to speak, or slaves, those whose social status separated them from the vast number of citizens in the audience) are distinctly different when compared to violent deaths of friends, family members, and comrades, your "band of brothers," fighting right beside you in a person-to-person battle scenario.

Furthermore, ancient executions were designed to further distance the audience from the victim through the use of mythological reenactments or by placement outside the city.

"Crucifixions were usually carried out outside the city limits thus stressing the victims rejection from the civic community. Because of the absence of bloodshed out of an open and lethal wound, which evoked the glorious fate of warriors, this type of death was considered unclean, shameful, unmanly, and unworthy of a freeman. In addition the victim was usually naked. Essential, too, was the fact that the victim lost contact with the ground which was regarded as sacrilegious." - J.J. Aubert, "A Double Standard in Roman Criminal Law?" from "Speculum Juris: Roman Law as a Reflection of Social and Economic Life in Antiquity"

We also cannot forget the medical personnel either.  Following the Vietnam War, many veterans (both male and female) who served in a medical capacity were later found to be suffering from PTSD.  The medical environment of an ancient treatment facility following a major ancient battle was far worse than in a modern field hospital.  Ancient surgeons attempted to treat often thousands of wounded in a relatively short time compared to only handfuls at a time during the Vietnam conflict.  Ancient physicians were surprisingly quite skilled, especially Roman military surgeons, but they had little but herbal compounds (and honey if the Romans listened to the Egyptian physicians) to ward off infections.  Their patients' mortality rate was much higher than the relatively low mortality rate experienced in Vietnam.  So, how could they have escaped the effects of PTSD, often after years of service, not "just" 6 - 12 months - more than enough to trigger PTSD in modern warfare?

Psychotherapist Alan Greaves in his paper, "Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review" points out that identifying the characteristic behaviors associated with PTSD in an ancient culture is particularly problematic because of socio-cultural factors such as social taboos on men crying or the abrogation of suicide.

"...we do not know how common or acceptable somatisation or the outward expression of any of the other psychological symptoms of PTSD would have been in ancient Greece, which in itself was made up of many differing local cultures or communities."

Greaves does acknowledge, though, that there is enough description in historical sources to point to a recognizable human response to traumatic stress in earlier ages.

"...the fact that PTSD has been identified, to various degrees and variously expressed, across different ethnic and cultural groups does indicate that the human species is naturally predisposed towards reaction formation following episodes of traumatic stress. As discussed above, there would appear to be some evidence that Conversion Disorder was present in Greece in the 1st millennium BC, even if finding similar evidence for PTSD is a more complicated matter because of the nature of our sources and its symptoms and definition. The sheer  prevalence of PTSD across modern populations adds further weight to the argument that it has  been a feature of human experience for a considerable  period of our history, even if the precise form of its expression has varied across contemporary and historical cultures." - Alan Greaves, "Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review"

However, in a 1996 study of emotion, Fischer and Manstead argue: ‘there are both cross-cultural similarities and differences in emotion.’ There is, therefore, no universal human reaction that can be predicted in all circumstances of traumatic stress, but neither are our reactions entirely culturally determined. Bearing in mind the very different incidences and presenting symptoms in different cultures, can we  possibly ever know what PTSD, or any of the other post-traumatic conditions discussed above, would have looked like in ancient Greece?

Perhaps, not. I sometimes wonder, though, if modern scholars think that ancient people just didn't value their lives as much as we do, since they did not shrink from casualties as high as 50,000 in a single military engagement or investment of an enemy city.  But if you've ever looked at some of the poignant grave goods found in ancient burials or studied the reliefs and inscriptions on ancient funerary monuments, I think you will conclude that we are only separated by time, not by our shared human nature.

References:

Abdul-Hamid, W. K., & Hughes, J. H. (2014). Nothing New under the Sun: Post-Traumatic Stress Disorders in the Ancient World. Early Science and Medicine, 19(6), 549-557. doi:10.1163/15733823-00196p02

Aubert, J.-J, & Sirks, A. J. (2002). A double standard in Roman criminal law? In Specvlvm ivris: Roman law as a reflection of social and economic life in antiquity. Ann Arbor, MI: The University of Michigan Press.

Cook, J. (2012). Crucifixion as Spectacle in Roman Campania. Novum Testamentum, 54(1), 68-100. Retrieved from http://www.jstor.org.libproxy.uoregon.edu/stable/23253630

Edmonson, J. C. (1999). The cultural politics of public spectacle in Rome and the Greek East in 167-166 BCE. Studies in the History of Art, 56, 76-95.

Fischer, A. and Manstead, A. H. 1996. Emotions. In A. Kuper and J. Kuper (eds.), The Social Science  Encyclopaedia 2nd ed., 239-240. London, Routledge.


Greaves, A. M. (2008). Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review. Warfare and Society in the Ancient Eastern Mediterranean. Retrieved from https://www.academia.edu/6897230/Post-Traumatic_Stress_Disorder_PTSD_in_Ancient_Greece_A_Methodological_Review

A. Melchior (2011). Caesar In Vietnam: Did Roman Soldiers Suffer From Post-Traumatic Stress Disorder. Greece & Rome, 58(2), 209-223. Retrieved from http://www.jstor.org.libproxy.uoregon.edu/stable/41306157

JoAnn Scurlock and Burton Andersen, Diagnoses in Assyrian and Babylonian Medicine: Ancient Sources, Translations, and Modern Medical Analyses (Urbana and Chicago: University of Illinois Press, 2005), Pp. xxiii + 879.

Review: Semper Fidelis by Ruth Downie

A history resource article by Mary Harrsch © 2013

Assimilating conquered warriors into the vanquishing army has been a problem for military commanders for thousands of years.  When Alexander the Great attempted to form an elite cavalry unit composed of the sons of conquered Persian nobles, his own officer corps was so enraged it led to the tragic death of Cleitus the Black, a longtime loyal officer to both Phillip II and Alexander, who was slain by Alexander himself after heated words about Alexander's efforts to incorporate Persians into positions of authority within his army.

It is this issue that forms the foundation for the plot of Ruth Downie's latest novel "Semper Fedelis".  We find our heroic medicus, Gaius Petreus Ruso, trying to find out what is happening to native Briton recruits at the hands of an apparently sadistic much-decorated centurion in second century Eboracum (modern day York).

As is usually the case, his native-born wife, Tilla, tries to help by questioning some of the local townspeople but ends up causing Ruso even more trouble with the commanding tribune who happens to be related to the family-honored centurion.  Ruso is summarily ordered to keep his nose out of things that don't concern him and Tilla receives a less subtle warning in the form of a severed pig's head found between her bedsheets.

But a recruit shows up at the hospital with a nasty infected arm after the young man had attempted to carve off a tribal tattoo to avoid any more abuse.  Then Ruso is further appalled when the man's friend turns up asking Ruso if he could remove the tattoos that embellish his arms as well.

With Tilla's urging, Ruso takes matters into his own hands when the emperor Hadrian shows up to inspect the fort, and Ruso attempts to explain the problem directly to Hadrian.  After all, Hadrian and Ruso served together in Antioch where Ruso was instrumental in saving the life of the emperor Trajan, Hadrian's adopted uncle.  Meanwhile, Tilla is called into the presence of the empress Sabina who thinks conversing with a colorful local would be amusing and Tilla attempts to bring the recruits plight to the empress' attention.

Interesting image of Mars the God of War with the face
of the Roman Emperor Hadrian and a female companion
whose face was resculpted in 170-175 CE to resemble
the Empress Lucille (according to The Louvre), wife of
the Roman emperor Lucius Verus (???) Photographed at The Louvre in Paris, France by Mary Harrsch

Then things take an even more nasty turn and the centurion in question is found murdered.  The related tribune throws Ruso into chains, more out of outrage that Ruso went to the emperor over his head than truly believing Ruso had anything to do with the murder. So Ruso and Tilla must scramble to discover the truth before Ruso is marched off to Deva for what is believed will be a summary trial and execution on the orders of the legate there.

The exciting conclusion involves Praetorian guards, conspiratorial royal secretaries, Tilla's less expert use of one of Ruso's scalpels, near mutiny of the recruits of the 22nd Legion and an ultimate solution devised by a very wise man who happens to be the most powerful ruler of the known world.

Again Downie has given us a mystery with twists and turns that keep readers guessing until almost the very end.  The characterizations of Ruso and Tilla are consistent with previous novels and, as I mentioned in a recent post to the Roman History Reading Group on Facebook, Downie offers each character's thoughts to us to flesh out their personalities.  She also provides a little backstory for tribune Accius letting us imagine his rather lonely childhood and the social importance of having an uncle publicly decorated for valor.  We can then understand, at least partly, the rational for what would normally be seen as outrageous behavior towards a respected medical officer.

The only thing I didn't understand in the plot was why Hadrian, who remained at the fort for several days during the time that tribune Accius imprisoned Ruso, did not act to prevent the mistreatment and possible loss of a valued medical officer who had proven himself in the Antioch earthquake?  Of course, our hero is ultimately saved but Hadrian's apparent indifference earlier in the story does not seem consistent with his obvious longtime respect for Ruso expressed at the end.

Of course, we don't know when Hadrian's knowledge of all of the events that occurred was realized, but as astute as Hadrian was, I can't imagine him not knowing that the tribune was blaming Ruso before Hadrian had left Eboracum for his next port of call.  If the tribune had simply locked up the native deserter, Victor, and blamed him from the beginning, it would have been more understandable that Hadrian would have been reticent to get involved.  Hadrian was a soldier's soldier and would not have intervened in a matter that should have been handled by the existing chain of command in circumstances that did not involve a professional officer held in high esteem by the emperor.  Perhaps this was Downie's way of developing events that would lead up to Russo's offer to sacrifice his own life to preserve order on the frontier and the emperor's continued successful reign.  Such an offer would then justify the size of the favor Ruso requests at the end of the story.

As for the supporting history behind the abuse of native recruits to the legions in Britain, we can look to the Vindolanda Tablets that include correspondence from the professional  auxiliaries from the Tungri tribe of the Aardennes region (Belgium/France/Luxembourg).  Although these men were not originally Romans from the Empire's heartland, they still  used a disparaging nickname for their British hosts: Brittunculi.

"In Latin, the suffix -unculus is both diminutive and pejorative: the term translates as "pathetic little Brits" (Vindolanda Tablet 164). The author was probably not referring to the provincial population as a whole, but specifically to young trainee recruits to the regiment. - Roman auxiliaries in Britain, Wikipedia

The Vindolanda Tablets, dated from 85 - 122 CE, also reveal that the military was understrength at the time of Hadrian's visit in 122 CE. The I Tungrorum listed its strength at 752 instead of the official 800 men expected to fill its rolls.  So, it would have been a time that recruits would have been sought, even from the local tribes.

Originally, Rome did not deploy auxiliary units in their home country or region but this policy relaxed to some degree as military shortages became more acute in the second century.

Centurion abuse of young recruits, outside the demanding regimen of basic training, is also documented in the ancient sources, although the most prominent record involves the Germanic Batavians.  In the "Year of the Four Emperors" (69-70 CE), the governor of Germania Inferior was ordered to raise more troops.  The Batavians  were regarded by the Romans as the very best (fortissimi, validissimi) of their auxiliary so the governor attempted to conscript more Batavi than the maximum stipulated in their treaty.  This action was compounded by the brutality and corruption of Roman recruiting-centurions including reports of sexual  assault on Batavi young men.

A Batavian helmet with remnants of blonde wig,
Courtesy of the Nijmegen museum.

Then, Julius Civilis, himself a decorated veteran of 25-years service in Britain and prince of the Batavi people, led his people in open revolt.

"... the uprising soon became a bid for independence.  Civilis exploited the fact that some legions were absent from the Rhine area due to the civil war, and the rest under-strength. In addition, the Roman commanders and their rank-and-file soldiers were divided by loyalty to rival emperors. Civilis quickly won the support of the Batavi's neighbours and kinsmen, the Cananefates, who in turn won over the Frisii. First the rebel allies captured two Roman forts in their territory, and a cohort of Tungri defected to Civilis.  Then two legions sent against Civilis were defeated when their companion Batavi ala defected to his side. The Classis Germanica (Rhine flotilla), largely manned by Batavi, was seized by Civilis. Most importantly, the eight Batavi cohorts stationed at Mainz with XIV Gemina mutinied and joined him, defeating at Bonn a Roman force that attempted to block their return to their homeland. By now, Civilis commanded at least 12 regiments (6,000 men) of Roman-trained and equipped auxiliary troops, as well as a much larger number of tribal levies. A number of German tribes from beyond the Rhine joined his cause. Several other German and Gallic units sent against him deserted, as the revolt spread to the rest of Gallia Belgica, including the Tungri, Lingones and Treviri tribes. He was able to destroy the two remaining legions in Germania Inferior, (V Alaudae and XV Primigenia). 

By this stage Rome's entire position on the Rhine and even in Gaul was imperiled. Their civil war over, the Romans mustered a huge task force of eight legions (five dispatched from Italy, two from Spain and one from Britain) to deal with Civilis. Its commander Petillius Cerialis had to fight two difficult battles, at Trier and Xanten, before he could overrun the Batavi's homeland. Tacitus' surviving narrative breaks off as he describes a meeting on an island in the Rhine delta between Civilis and Cerialis to discuss peace terms. We do not know the outcome of this meeting or Civilis' ultimate fate. But in view of his former friendship with Vespasian, who had already offered him a pardon, and the fact that the Romans still needed the Batavi levies, it is likely that the terms were lenient by Roman standards." - Roman military Auxiliaries, Wikipedia

So, the situation described in the novel could have been equally disastrous for Hadrian, who would have been keenly aware of the outcome of the Batavian revolt just 50 years before.  Furthermore, by Hadrian's time auxiliaries outnumbered legionaries by 2.5 to 1 in Britain.  Unfortunately for Ruso, Tribune Accius was far more nearsighted, thinking only of his family's social standing and not the welfare of the empire.

I also though Downie accurately portrayed the relationship between Hadrian and his wife Vibia Sabina.  Downie's townspeople mention rumors that Hadrian preferred to spend more time with his mother-in-law than Sabina.  Although that sounds strange, Hadrian's mother-in-law was actually his second cousin and only eight years older than Hadrian.  Furthermore, they were raised together in Trajan's household.

Sabina, as portrayed in the novel, was known to be independent minded and by the time of the novel, she had already had an affair with the historian Suetonius, secretary to Hadrian.  So, it would be totally in character for her to admonish Tilla by saying "Don't pray too hard" when Tilla said she would pray for the empress to be fruitful.

As a war veteran's spouse, another issue I always ponder when I read about a character being particularly brutal to other characters is whether the brutal character may be suffering from post-traumatic stress disorder.  Geminus was described as a valorous, much-decorated veteran about to retire when he finishes training this particular batch of recruits.  Although scholars like Dr. Jonathan Eaton question a diagnosis of PTSD in members of the Roman Army because of a lack of explosive or concussive events in a typical Roman battle (PTSD and the Roman Army ), I would point out that heroic epics like those of Homer formed a foundation of source material used in the formation of the Roman heroic ideal.  In Chapter 3 of "From Melos to Mylai: War and Survival", Lawrence Tritle asserts that the heroes portrayed in Homer, Tyrtaeus, Archilochus, and Aeschylus share the characteristic of being someone who takes revenge for the death of his friends and strongly believing a good man is a brave man.

Not only may Geminus have been subconsciously seeking revenge for friends lost in past campaigns but as the recruits quaked from the centurion's actions, he may have dismissed the lot of them as not worthy since they apparently displayed no bravery in his eyes.

Tritle further points out that in war, officers are taught to instill in the troops an image of the enemy as foreign and different.  "[these] emotional factors... were greater inducements to carry out brutal acts of violence than racially or culturally based perceptions of the 'Other'."

So despite his horrendous behavior, perhaps we should reserve at least a little sympathy for Geminus just as Ruso expressed for Geminus' dog, Bella.  She may have attacked Ruso because of her training, but in the end she waited calmly beside the body of her beloved master, unaware that she, too, would be struck down for her learned behavior and share his funeral pyre.