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Civil War Trauma Led to Combination Of Nervous and Physical Disease

The health sequelae of war are nothing new. Civil War soldiers were more likely to be diagnosed with an illness if more of their comrades died.

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 same."

Portrait of Private Ira Fish, 150th New York Infantry, later wounded at Gettysburg. 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 at enlistment.

"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, and loss."

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 researchers noted.

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 ailments.

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 disease ailments."

"Nervous" Disease Risk Assessed

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 combat outcome.

"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 soldiers."

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.

Can Syndromes Be Equated?

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 combat-traumatized soldiers.

"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 at<http://archpsyc.ama-assn.org/cgi/content/abstract/63/2/193>.

Arch Gen Psychiatry 2005 63 193

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