We demonstrate substantial long-term health effects of traumatic war experiences among Civil War soldiers. While war trauma was moderately associated with developing signs of GI, cardiac, or nervous disease alone, it was strongly associated with developing signs of nervous and physical disease in combination. One objective measure of intimate violence, percentage of company killed, predicted a 51% increased incidence in signs of physician-diagnosed cardiac, GI and nervous disease, and a 14% increased incidence of unique disease ailments. Percentage of company killed is likely a powerful variable because it serves as a proxy for a variety of traumatic stressors such as witnessing death or dismemberment, handling dead bodies, traumatic loss of comrades, one’s own imminent death, killing others, and being helpless to prevent others’ deaths. In addition, veterans who were younger at enlistment had a 93% increased risk of developing signs of co-morbid physical and nervous disease and experienced a 32% increased incidence of unique disease ailments. Young veterans (under 18 years at enlistment) were at increased risk of early death if they witnessed more death during the war. In all analyses, we controlled for age at death, ensuring that these results were not simply due to the fact that younger men lived longer and thus had more opportunity to develop disease. We did not find any interactions between age at enlistment and most war trauma variables, suggesting that the effect of age at enlistment on health outcomes was not exacerbated by being taken POW or being wounded. In addition, younger recruits were at greater risk of contracting unique disease ailments than older men. It is also possible that those healthy enough to enlist in the Civil War at an older age may have been hardier individuals, leading to their decreased morbidity and mortality.42
Before entering military service, all recruits in this sample were screened for health problems and deemed unfit for service if they were ill or disabled.37
This initial screening suggests that it was the military experience, rather than some pre-existing medical condition, that accounted for the health effects observed. The possibility of differential health screening over the course of the war was also accounted for in our analyses. When examining both mental and physical health outcomes after exposure to war trauma, we found different trauma profiles predicted each. For example, while being wounded increased the incidence of developing signs of nervous disease by 64%, wounded soldiers were significantly less likely to develop signs of GI or cardiac disease alone. The pattern of findings suggest that those veterans who survived being wounded may have been particularly hardy given the unsanitary conditions of the war.43
POW experience predicted signs of co-morbid physical and nervous disease and mortality. This likely reflects the traumatic psychological impact that spending time in war camps may have had on soldiers, and bolsters our conclusion that although physical hardiness may have acted as a buffer for physical disease, it did not protect against the ill effects of war on mental health.
Although self-reported disease is not the focus of this paper, it is noteworthy that veterans who experienced more traumatic wartime experiences were significantly more likely to report an increased number of disease ailments. For example, POW experience, being wounded, increased percentage of company killed, and younger age at enlistment were associated with greater numbers of self-reported disease ailments.
Many studies link emotional stress, such as combat, to mental health problems.1–3,7–10, 13, 14, 24–31, 44
Recent literature on the impact of trauma on health has suggested that psychological response, specifically PTSD, mediates the relationship between trauma exposure and physical health outcomes.11
Unfortunately we are unable to examine this relationship in this archival dataset because we do not have clear temporal information on the development of nervous, GI or cardiac ailments (e.g., veterans may have presented with all ailments simultaneously rather than sequentially). In addition, the Civil War era preceded the recognition of a PTSD diagnosis.
Researchers have also hypothesized mechanisms by which emotional stress is linked to physical disease.6,12,13,16–21,24,25, 45–50
Allostatic load theory47
postulates a neurochemical response via the activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis in response to acute stress. Although this may be adaptive when stressors are met and resolved quickly, over periods of chronic stress, these body systems can become either unable to mount an appropriate response or become overly sensitive,44
overloaded by the normal cascade of stress hormones. For example, over periods of chronic stress (i.e., battlefield events or witnessing death), there may be chronic cardiovascular activation that leads to elevated blood pressure and atherosclerotic development. Permanent changes in the structure and function of the stress regulatory systems are a likely mechanism leading to increased morbidity and mortality in individuals exposed to intimate violence.
Individuals who experience severe, prolonged stress may engage in compensatory negative health behaviors such as overeating, smoking, drug abuse or other harmful habits that may, in turn, lead to subsequent physical disease. Unfortunately, reliable information about drug use, smoking, and obesity is not available for the men in this study. However, Body Mass Index (BMI) was calculated as a predictor of mortality in a subsample of 377 Civil War veterans from this data set and BMI appears not to be as significant a predictor of cardiac disease during the Civil War era as in modern time.42
This study has some limitations. While these data have been carefully accumulated, coded and analyzed, it is recognized that archival medical data, by definition, is not interchangeable with modern medical diagnoses. Due to the lack of sophistication and medical equipment during the Civil War era, diagnoses of ailments cannot be assumed to coincide with modern diagnoses of physical and mental disease. Because not all signs and symptoms of cardiovascular heart disease or PTSD were assessed, veterans are not assumed to have had these diagnoses. Nonetheless, although we are unable construct current medical diagnoses as outcome variables using this dataset, Civil War era physicians were able to recognize and record signs of physical and mental disease that are indicative of modern diagnoses. Similar to recent studies that have found evidence of cardiovascular 6, 17–20
and GI disease 21,22
and PTSD 6–10
post-war, we found that combat exposure was related to increased self-reports of negative physical symptoms, and physician-diagnosed signs of cardiac (e.g., arteriosclerosis), GI disease (e.g., ulcer) and mental health problems (e.g., depression).
The current study brings us a step closer to understanding the long-term health consequences of traumatic war experiences. Not only was the Civil War the beginning of a recognition of mental health problems caused by war, labeled “irritable heart syndrome”, but many recognize the Civil War as laying the roots of modern cardiology.51
Our analysis is the first to use objective military and medical records to demonstrate the development of post-war disease ailments over the life course among veterans of any war. We found strong relations between traumatic exposure (e.g., witnessing a larger percentage of company death), co-morbid disease, mental health ailments, and early death. Despite the age of the dataset, there have been few other opportunities to examine standardized medical exams over a post-war period until all soldiers have died. In fact, modern data sets could not provide this kind of information. Unfortunately, it is likely that the deleterious health effects seen in a war conducted over 130 years ago are applicable to the health and well-being of soldiers fighting wars in the 21st
century, as recent studies have suggested.9,15, 52