WATERLOO - That soldiers suffer hardly ranks as a new development in warfare. That they endure mental hardship surprises few.

But despite what modern psychiatry considers an obvious and common condition, experts labeled post-traumatic stress disorder only relatively recently.

Experts maintain the mental state as it relates to armed conflict likely began when the first human picked up the first stick or stone. Only the name has changed.

During the Civil War, soldiers who lost their will or capacity to fight were afflicted with nostalgia, later diagnosed as soldier's heart. The affliction for a time also carried the name Swiss disease, a tribute to soldiers from that country forced into military units.

Society later introduced the concept of railway spine, which evolved from numerous and horrific railroad accidents. The diagnosis was popularized in lawsuits in the 1870s.

As the theory evolved, doctors reached a general view that intense fear disturbed a person's nervous system. By the end of the 19th century, traumatic hysteria and traumatic neurasthenia were the accepted terms.

Then came World War I. The global cataclysm advanced the idea of subconscious mental processes, a theory gaining acceptance.

During that war, physicians described soldiers as shell shocked. They assigned the diagnosis to those with neurological symptoms but no physical injuries. The term came from the idea exploding shells changed atmospheric pressure near soldiers, harming their nervous systems. Researchers later determined relatively few cases involved exploding ordnance, which only added to the mystery.

World War II provided the concept of combat fatigue. Statistics show one in four casualties in World War II resulted from the mental disorder. In Europe, the U.S. military recorded one combat stress casualty for every three soldiers wounded in action, according to Field Manual FM 6-22.5, which is used and distributed by the U.S. Marine Corps.

The American Psychiatric Association in 1980 included the term post-traumatic stress disorder in "Diagnostic and Statistical Manual of Mental Disorders."

The U.S. Department of Defense issued a directive in February 1999 mandating use of the term combat stress reaction. Top officials with the Navy, Air Force and Marines objected, based on the fact combat is not required to produce trauma. The term combat-operational stress reaction was coined as a compromise.

Stigma

Part of the disorder's history includes society's reaction to it. Whether diagnosed with nostalgia, railway spine or shell shock, afflicted soldiers over the years were labeled as malingerers.

When he admitted problems about midway through a tour in Iraq, Army veteran Ron DeVoll Jr. of Cedar Falls says supervisors' attitudes changed.

"They talked down to me, called me a coward. 'You're supposed to be tough. You're supposed to be a man.' I thought I was," he says.

In the course of seeking help, DeVoll told superiors he was having nightmares.

"They said, 'That's normal. You'll get over it.'"

The response DeVoll received in 2003 echoes that from earlier eras.

During World War I, Thomas Salmon, a U.S. medical officer, defined the condition as merely an "escape" from intolerable circumstances.

At the same time, Fredrick Parsons, commanding officer at a U.S. military hospital, said "a war neurosis which persists is not a creditable disease to have … as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies."

He added "no one should be permitted to glorify himself as a case of 'shell shock.'"

During World War I, the British military reportedly executed more than 300 of its own soldiers for cowardice, desertion or insubordination. In today's terms, at least some likely were only demonstrating effects of combat-stress reaction. In World War II, the British military described some of its soldiers as lacking moral fiber.

On the American side, Gen. George Patton severely tarnished his distinguished military career after slapping and yelling at two soldiers. The privates were recuperating in a military hospital in Sicily alongside others with more visible wounds.

"Don't admit this yellow bastard," Patton reportedly yelled at a medical officer. "There's nothing the matter with him. I won't have the hospitals cluttered up with these sons of bitches who haven't got the guts to fight."

President Franklin Roosevelt received hundreds of letters about the incident. The majority supported Patton and his actions; some even suggested a promotion was in order.

Ultimately, though, Patton was reprimanded, ordered to apologize and relieved of command of the Seventh Army.

The perception soldiers might face reprisals for admitting issues related to post-traumatic stress disorder persists, according to a study published in the New England Journal of Medicine. Researchers discovered more than 60 percent of veterans who fought in Iraq and Afghanistan - and who displayed symptoms - said they would not seek help.

Those in the study stated primary concerns: Fear of the stigma attached to mental health issues and concern for their jobs or military careers.

"My experience since being back here has been negative. And that's unfortunate," DeVoll says.

He is diagnosed with post-traumatic stress disorder and visits regularly with therapists and counselors in Cedar Falls and Iowa City.

Urged by his wife, Jill, who threatened divorce and began court proceedings, DeVoll began getting help. He is certain others are not.

"I'm sure there are a lot of vets of Iraq who are doing what I did and bottling it up."

Contact Dennis Magee at (319) 291-1451 or dennis.magee@wcfcourier.com.