Younger soldiers who served in the U.S. Civil War and those who saw more of
their comrades die were at greater risk for heart, stomach, and nervous
illnesses decades after the war, reveals a study of individual and unit
records of more than 15,000 veterans.
Parallels with earlier wars and soldiers may offer insight into the
aftereffects of contemporary combat, co-author Roxane Cohen Silver, Ph.D., of
the Department of Psychology and Social Behavior at the University of
California, Irvine, told Psychiatric News in an interview."
There can be serious mental and physical health costs of traumatic war
exposure," she said. "While the specific forms of trauma may have
changed, the message is the
Portrait of Private Ira Fish, 150th New York Infantry, later wounded at
John H. Young / Library of Congress
She noted that these are "objective" data, not just
self-reports, and include military records and physicians' observations. The
Early Indicators of Later Work Levels, Disease, and Death project, sponsored
by the National Institutes of Health and the National Science Foundation,
spent 15 years and millions of dollars putting together the database.
"It's very exciting to gain access to data based on comprehensive
military and medical records," said Silver, whose research has
concentrated on the impacts of stressful experience over the life course."
The specific forms of trauma are not the same, but the physical and
mental effects are similar."
Silver and her co-authors, Judith Pizarro, M.A., and JoAnn Prause, Ph.D.,
sought to assess how the severity of wartime trauma would predict later
illness by randomly selecting 303 out of 20,000 Union Army companies whose
records are kept in the National Archives. Their study appeared in the
February Archives of General Psychiatry.
Of the possible 35,730 men who served in these companies, 15,027 lived
until at least 1890 and had complete medical records available. The medical
histories and diagnoses were drawn from pension files compiled by government
physicians to certify the veterans' health and disability status. Most of the
other soldiers not included in the study were dead or deserters, and so lacked
postwar medical records.
Veterans applying for service-connected disability pensions had to visit a
Pension Board, a panel of three doctors who had to agree before a diagnosis
was accepted. Three-fourths of the veterans had at least seven examinations;
the median number was four.
"The government went to great pains to eliminate malingering,"
she said. "They even sent investigators out to their homes."
"The first laws covering military pensions were passed in 1863, and
there have been arguments for the next 140 years," said anthropologist
Allen Young, Ph.D., of McGill University, in an interview. "Along with
self-reports comes malingering."
In the study exposure to traumatic events during service was determined by
the percentage of soldiers who died in the recruit's company, whether the
soldier was wounded or was a prisoner of war, and whether he was under age 17
"Percentage of company killed is likely a powerful variable because
it serves as a proxy for various traumatic stressors, such as witnessing death
or dismemberment, handling dead bodies, traumatic loss of comrades, realizing
one's own imminent death, killing others, and being helpless to prevent
others' deaths," wrote the authors.
Silver sees no difference in whether deaths in a given company were due to
battle casualties or to disease, which killed more soldiers than combat. Civil
War units were raised in towns or counties, consisting of local boys and men
who had known each other all their lives. "How they died didn't make any
difference," she said. "There was still bereavement, death, fear,
Cardiac, gastrointestinal, and nervous diseases are categories that map to
ICD-9 diagnoses and that reflect traumatic stress, said Silver. The
original diagnoses were recoded for the study by physicians participating in
the study to equate with modern disease categories.
Cardiac disease included irregular pulse, heart murmurs, arteriosclerosis,
heart enlargement, and other symptoms. Gastrointestinal illnesses included
diarrhea, dyspepsia, ulcer, vomiting, and malassimilation. The definition of"
nervous disease" at the time of the Civil War included symptoms
today separately allotted to psychiatry and neurology, from psychosis,
hallucinations, depression, mania, hysteria, suicidal ideation, and anxiety to
aphasia, headaches, paralysis, epilepsy, and vertigo.
"In addition, many symptoms that fit within the DSM-IV
criteria B, C, and D classification of posttraumatic stress disorder (PTSD)
were diagnosed as nervous disease during the Civil War era," the
The veterans were diagnosed with a median of 4.3 unique cardiac, GI, or
nervous disorders over the course of their lives. Recruits under age 18 and
those who had been taken prisoner had the greatest risk for early death.
Younger soldiers also faced a greater risk of cardiac disease alone, of
cardiac plus GI disease, and of combined physical and nervous disease.
Soldiers in companies that lost a higher percentage of men displayed more
comorbid cardiac and GI disease and more combined physical and nervous
Prisoner-of-war experience increased the risk of comorbid nervous and
physical disease. "In addition, veterans who were younger at enlistment
had a 93 percent increased risk of developing signs of comorbid physical and
nervous disease and experienced a 32 percent increased incidence of unique
However, there was no association between age at enlistment, POW status, or
percentage of company killed and the presence of nervous disease alone, they
wrote. Only among soldiers who were wounded was there a statistically
significant increased risk (risk ratio, 1.64) of nervous disease. Wounded
veterans had a decreased risk of physical disease and fewer signs of comorbid
physical and nervous disease, possibly because only the toughest soldiers
survived the era's grim medical standards and poor sanitation.
The absence of increased risk for nervous diseases alone may seem
surprising, given the present-day focus on posttraumatic stress disorder as a
"During the Civil War, doctors had primitive notions of mental
illness," commented R. Gregory Lande, D.O., a clinical consultant to the
U.S. Army Substance Abuse Program at Walter Reed Army Medical Center. Lande
has studied alcohol abuse in Civil War soldiers. "Psychiatry and
neurology were just being born around this time, and they have changed a lot
in 140 years. There was no agreed-upon nomenclature and no precision in
diagnoses. They were just beginning to recognize the mental effects of war on
For instance, said Lande, in the official military medical history of the
war, just one page is devoted to "homesickness," a diagnosis that
he said probably equates to major depression. Severe cases were termed"
nostalgia," characterized by disturbed sleep, poor eating, and
erratic behavior and that sometimes resulted in death. The only cure, said the
doctors, was to send the unfortunate soldier home.
While there were 2,000 cases of nostalgia, there were 48,000 cases of"
headache," which Lande suspects may represent some behavioral
response to the stresses of the military experience.
Official records say there were low levels of drunkenness, he said, but it
was actually a major problem.
Despite these indications, there were only 2,000 cases of"
insanity" and fewer than 500 suicides recorded among the 600,000
men who served in the Union Army.
Did the 19th-century vocabulary of war and medicine tilt diagnoses to one
disease category or another? Other researchers have noted that similar
syndromes observed from the Civil War to World War I referred to the heart as
the organ reacting to the stress of war. Prior to World War I, doctors argued
that the strain of carrying heavy packs led to "disordered action of the
heart." By World War II, the mind was considered the site of anguish for
"It's not just the language or the applicant, but the expectations of
the clinician and the kinds of questions being asked," said Young of
McGill University. "You find the doctor asking very precise questions
and the patient being silenced. One can assume that the diagnostic process was
highly directed by the doctors, so both idioms of distress and the doctors
guided the process."
Silver is not surprised by her findings. "This is another set of
results that add to a growing body of literature showing that traumatic life
experiences can have a detrimental effect on life and health," she said."
Postwar mental and physical health difficulties are not a sign of
individual coping failures or exaggeration on the part of the soldier but may
well be the result of exposure to traumatic experiences that are out of the
norm for most of us who have not gone to war."
Looking back a century or more at veterans' health might shed light on
present-day circumstances but must be approached with caution, said Lande."
If we study the past, we must make sure we understand what has changed
in the interim."
"Physical and Mental Health Costs of Traumatic War Experiences
Among Civil War Veterans" is posted
Arch Gen Psychiatry