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Original Article |

Physical and Mental Health Costs of Traumatic War Experiences Among Civil War Veterans FREE

Judith Pizarro, MA; Roxane Cohen Silver, PhD; JoAnn Prause, PhD
[+] Author Affiliations

Author Affiliations: Departments of Psychology and Social Behavior (Ms Pizarro and Drs Silver and Prause) and Medicine (Dr Silver), University of California, Irvine.


Arch Gen Psychiatry. 2006;63(2):193-200. doi:10.1001/archpsyc.63.2.193.
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Background  Hundreds of thousands of soldiers face exposure to combat during wars across the globe. The health effects of traumatic war experiences have not been adequately assessed across the lifetime of these veterans.

Objective  To identify the role of traumatic war experiences in predicting postwar nervous and physical disease and mortality using archival data from military and medical records of veterans from the Civil War.

Design  An archival examination of military and medical records of Civil War veterans was conducted. Degree of trauma experienced (prisoner-of-war experience, percentage of company killed, being wounded, and early age at enlistment), signs of lifetime physician-diagnosed disease, and age at death were recorded.

Setting and Participants  The US Pension Board surgeons conducted standardized medical examinations of Civil War veterans over their postwar lifetimes. Military records of 17 700 Civil War veterans were matched to postwar medical records.

Main Outcome Measures  Signs of physician-diagnosed disease, including cardiac, gastrointestinal, and nervous disease; number of unique ailments within each disease; and mortality.

Results  Military trauma was related to signs of disease and mortality. A greater percentage of company killed was associated with signs of postwar cardiac and gastrointestinal disease (incidence risk ratio [IRR], 1.34; < .02), comorbid nervous and physical disease (IRR, 1.51; < .005), and more unique ailments within each disease (IRR, 1.14; < .005). Younger soldiers (<18 years), compared with older enlistees (>30 years), showed a higher mortality risk (hazard ratio, 1.52), signs of comorbid nervous and physical disease (IRR, 1.93), and more unique ailments within each disease (IRR, 1.32) (< .005 for all), controlling for time lived and other covariates.

Conclusions  Greater exposure to death of military comrades and younger exposure to war trauma were associated with increased signs of physician-diagnosed cardiac, gastrointestinal, and nervous disease and more unique disease ailments across the life of Civil War veterans. Physiological mechanisms by which trauma might result in disease are discussed.

Figures in this Article

War is particularly traumatic for soldiers because it often involves intimate violence, including witnessing death through direct combat, viewing the enemy before or after killing him, and watching friends and comrades die.1 Heavy combat exposure, seeing comrades injured, witnessing death, and prisoner-of-war (POW) experience are traumatic beyond the time spent in military service or other military events.2,3 Young adults exposed to military combat may also be at greater risk than their older peers. Vietnam veterans who were 19 years or younger during the war were significantly more likely to have substance abuse problems, criminal activity, employment difficulties, and problems with social relationships after discharge,4 and long-term distress and mental health symptoms are higher among Vietnam veterans who entered military service at a younger age (R.C.S., E. A. Holman, FNP, PhD, N. A. Hawkins, PhD, and J. M. Butler, PhD, unpublished data, 2005).

Many investigators59 have examined the mental health consequences of exposure to war trauma and found substantial postwar psychiatric difficulties among veterans. Research has also linked war trauma and physical health outcomes,10 including an increase in negative physical symptom reporting,1114 chronic illness, and death.11,15 Traumatic war exposure has also been linked to specific self-reported and objective health problems, such as cardiovascular disease and hypertension5,1619 and gastrointestinal (GI) disorders.7,20,21 Nevertheless, although literature detailing patterns of physical health problems among aging veterans has grown,22 there has been a heavy reliance on self-report measures of either military trauma7,11,13,21,2325 or health.5,1114,1720,2325 While some researchers26 have examined military and medical records on a small sample of servicemen, their aim has been to examine clusters of postwar syndromes rather than link multiple traumas with specific physical disease states. To this point, there has been no examination of the health effects of multiple war traumas using well-documented military service records and objective health data over veterans' lifetimes.

Outlining specific combat experiences (eg, being wounded, being a POW, and witnessing death) is critical in determining what part of the traumatic experience is particularly detrimental to health. Some have theorized, based on self-reports of intense or prolonged combat, that intimate violence may be the most devastating mentally and physically,2729 and that exposure to war atrocities may be more traumatic than the threat of personal death that accompanies combat.30

During the Civil War, soldiers were particularly vulnerable to intimate violence. Family members and friends were often assigned to the same company of around 100 men, who were not replaced as they died. When companies experienced substantial losses, survivors were left with few remaining friends or male family members.31 Soldiers readily identified with the enemy (who were sometimes from the same state or county), making the sight of mutilated corpses even more gruesome.1 Although guns and cannons were used, frontal assault was common, and hand-to-hand combat, with no trenches or barriers, resulted in row after row of dead bodies and the sight of comrades blown apart.31 Unlike in other documented wars, young adolescents and older men were allowed entry into military service (ranging from those <10 years to those >70 years).31 Overall, the Civil War qualifies as one of the bloodiest in US history, exposing thousands to incomparable traumatic experiences.31,32 If intimate violence is particularly detrimental, increased exposure to such violence should consistently predict negative health outcomes.

There is great interest in the Civil War. The National Archives in Washington, DC, which house the original military and medical records, report that the Civil War is the most researched and written about war in all of history. The present study examines the relationship between traumatic war exposure and health outcomes directly using objective health and trauma data collected from a sample of Union Army Civil War veterans with the goal of parsing the effects of various war experiences on health. We hypothesized that severity of traumatic war exposure (eg, greater exposure to death and younger age at entry) would predict signs of 3 physician-documented diseases that have been linked theoretically and empirically to traumatic life experiences (cardiac, GI, and mental health disorders)10 and more unique ailments across a veteran's postwar lifetime.

SAMPLE SELECTION AND DATA SOURCES

Data were collected as part of an effort to amass the largest, most comprehensive collection of electronic Civil War data files transcribed from their original written records. This project, Early Indicators of Later Work Levels, Disease, and Death, is sponsored by the National Institutes of Health and the National Science Foundation.33 Of 20 000 possible companies from the Descriptive Roll books at the National Archives, 303 companies of Union Army recruits were randomly selected. Military service records and pension file information were sought on every recruit in each company, resulting in a final sample of 35 730. The government went to great lengths to ensure the validity and precision of military records.34 Pension files contain postwar medical records and standardized physical examinations until the recruit's death (called Surgeon's Certificates), completed by government physicians certifying the veteran's health and disability status.35 Those recruits who died during the war or deserted did not generate a Surgeon's Certificate.35 Thus, not all recruits' military files could be linked to their medical records. Of the sample of 35 730 recruits, 17 700 participants were linked, and among these, veterans with complete data on key study variables were selected for analyses (n = 16 200). Most excluded cases (n = 1442) were missing age at death, a crucial study variable that necessitated their exclusion. Consistent with pension law, the sample is further restricted to the 15 027 recruits who lived until 1890 or later, when physicians could diagnose non–service-connected disease. Before 1890, physicians only diagnosed service-connected illness and wounds to avoid paying pensions for conditions unrelated to military service. Recruits who died before 1890 were slightly older at enlistment (φ2 = 0.02, < .005). Effect sizes (φ2) for the remaining study variables, although statistically significant, were extremely small, ranging from 0.03% for POW status to 0.8% for enlistment year. Statistical models fit to the full (16 200) and reduced (15 027) samples were comparable, and inferential conclusions remain unchanged.

All recruits were examined by physicians and screened for health problems before entering military service. Many volunteer servicemen were rejected from military duty because of illness, physical disabilities, body size, and other unclassified problems, suggesting a healthy baseline sample (S. E. Wilson, PhD, unpublished data, 1993). One hypothesis might be that recruits who enlisted early in the war were healthier, more robust volunteers than those who enlisted later in the war effort. Also, early volunteers may have faced more rigorous health screening than recruits who entered during later years, when the draft made service unavoidable. An indicator variable reflecting early (1860-1861) vs later (1862-1864) enlistment was created as a rough proxy for baseline health status and to control for the possibility of differential health screening over time.

DATA COLLECTION

The Early Indicators of Later Work Levels, Disease, and Death project researchers developed their own data collection software designed for entering information available from data sources housed at the National Archives. The sources of data included military records, which contained detailed accounts of military service, including enlistment and discharge dates, age at enlistment, geographic location of company, and many other variables; and pension files, which contained birth information, number of self-reported disease claims, and health records (ie, Surgeon's Certificates) after the recruit's military service was complete, among other variables. These data sets were transcribed, cleaned, and cross-referenced with each other so that the accuracy and completeness of a recruit's file would be at the highest possible level. Careful data standardization and controls were instituted to ensure quality information. Trained researchers transferred written records into a standardized computer database using automated controls, such as upper and lower bounds on fields, acceptable coded values for fields with a list of possible predetermined values, and 2-field checks; dates had to make sense (ie, no death before birth year). Medical and occupational dictionaries from the 19th and 20th centuries were available for reference by the data coders. De novo sampling was used as a quality control technique. A random sample of 5% to 10% of recruits was drawn from each company and reentered. Differences calculated between the original and de novo sample were classified as follows: incorrect entries (misread word or data entered in the wrong screen, 2.3%), omission errors (random inadvertent skipping of information, 4.0%), numerical errors (0.2%), and rating errors (skipped or misread rating when coding disease categories, 0.3%).

PREDICTOR VARIABLES
Age at Enlistment

Age at first enlistment was obtained from military records, and ranged from 9 to 71 years. Because younger age at first enlistment was predicted to be more stressful and to lead to more negative health outcomes over the lifespan, this variable was categorized into 5 age groups of approximately equal size to highlight the effect of younger ages: 9 to 17 years (n = 3013), 18 to 20 years (n = 3694), 21 to 25 years (n = 3435), 26 to 30 years (n = 2225), and 31 years and older (n = 2660). The oldest group of recruits (≥31 years) was used as the reference group in all analyses.

Age at Death

Age at death was obtained primarily from death certificates in the veteran's file. If no death certificate was present, death date was gleaned from pension records, military notice of death records, or other correspondence. Age at death was used in continuous form as a covariate in some analyses and as an outcome in other analyses. In addition, it was stratified (9-49 years, 1; 50-64 years, 2; 65-74 years, 3; and 75-104 years, 4) to compare signs of disease across individuals in the same age cohort.

Socioeconomic Status

The profession a recruit claimed gives a rough estimate of his socioeconomic status during the Civil War era. Six categories of professions were identified: farmers, professionals, artisans, service workers, laborers, and unproductive persons (eg, those involved in scholarly activities). Socioeconomic status was represented as a series of 5 indicator variables, with farmer serving as the reference group.

Trauma History

History of traumatic events experienced by each recruit was gathered from military records. Traumatic exposure was operationalized as POW experience, being wounded, early age at enlistment, and the percentage of soldiers who died in a recruit's company (ie, percentage of company killed). Percentage of company killed was divided into quartiles; the lowest quartile served as the reference group. POW experience was originally cast as a 3-level variable (never, before 1864, and in 1864 or later) because of more severe conditions in POW camps later in the war effort. However, results in the latter 2 groups were the same, so they were combined for parsimony.

HEALTH OUTCOMES

Health history was gathered from the pension files. To receive a military pension, veterans were required to undergo a physical examination for each illness or disease claim. Thus, medical examinations were not conducted annually, but only when a new claim was presented or an adjustment in an existing claim was necessary. Every veteran underwent at least 1 examination, with a maximum of 30 examinations and a median of 4 examinations (77.6% of the veterans had ≤7 examinations). The government Pension Board required that each examination be conducted by 3 physicians who were required to come to a consensus before a diagnosis was made.36 The original medical diagnoses were entered into the Early Indicators of Later Work Levels, Disease, and Death data collection software system within disease screens. These screens were divided by organ systems and provided nonmedical data inputters a framework with which to transfer the medical data into a database. Physicians on the Early Indicators of Later Work Levels, Disease, and Death project carefully recoded the data into a classification system that corresponds to current medical diagnoses so the data can be equated to modern-day ailments. Diagnoses that were recorded include only medically reliable data. At no time in the process of data entry did the data inputters or cleaners make medical judgments. Only diagnoses representing signs of disease were examined in this study, and were selected based on indicators of abnormal chronic conditions.

Postwar Signs of Disease

A veteran was classified as having signs of cardiovascular, GI, or nervous disease if he was ever diagnosed as having 1 or more ailments from the upcoming categories in his postwar lifetime. Signs of physical or nervous disease, alone or in combination, diagnosed during any examination over the recruit's postwar lifetime were coded into one 6-level categorical variable: no disease, cardiac disease only, GI disease only, cardiac and GI disease, nervous disease only, and nervous disease with cardiac and/or GI disease.

Cardiac disease ailments included irregular pulse, regurgitant or stenotic murmurs, heart enlargement, arteriosclerosis, edema, cyanosis, dyspnea, and impaired circulation. Further coding of these disease symptoms according to the International Classification of Diseases, Ninth Revision, places them within the general category of circulatory disorders.36

Gastrointestinal disease ailments included diarrhea, dyspepsia, pain, ulcer, vomiting food or blood, abdominal tenderness, dysphagia, and malassimilation, among others. Further coding of these disease symptoms according to the International Classification of Diseases, Ninth Revision, places them within the general category of digestive disorders.36

Nervous disease ailments included paranoia, psychosis, hallucinations, illusions, insomnia, confusion, hysteria, memory problems, delusions, and violent behavior. In addition, many symptoms that fit within the DSM-IV37 criteria B, C, and D classification of posttraumatic stress disorder (PTSD) were diagnosed as nervous disease during the Civil War era. Nervous ailments also included other mental health problems, such as anxiety, depression, neurosis, suicidal ideation, antisocial behavior, attention deficits, hysteria, insanity, and mania, and physical ailments of the nervous system, including trouble with balance, incoordination, aphasia, paralysis, tremor, hyperesthesia, vertigo, headaches, epilepsy, and memory loss.

Number of Unique Disease Ailments

The number of disease ailments is a count of the number of unique cardiac, GI, and nervous ailments across all medical examinations over the veteran's postwar lifetime. Each unique disease ailment was counted only once, when the veteran was first diagnosed as having the condition.

DATA ANALYSIS

Although companies were randomly sampled, individual-level data were used in this report. As such, men were considered to be clustered within companies and regression models were estimated using methods allowing for dependence among observations within clusters.38,39 The postwar lifetime presence of disease (a 6-level categorical variable) was analyzed using a maximum likelihood multinomial logistic regression; the number of unique disease ailments was analyzed using a negative binomial regression (a Poisson with overdispersion), and mortality risk was assessed using a Cox proportional hazards model. This analysis provides estimates of the risk of mortality for veterans with and without traumatic war exposure. Effect sizes (and 95% confidence intervals) are estimated using incidence risk ratios for the postwar signs of disease and the number of unique disease ailments and hazard ratios for mortality risk. All analyses were performed using Stata, version 8.0 (Stata Corp, College Station, Tex).

Regression models include indicator variables representing socioeconomic status, year of enlistment, and age at death to ensure that the key study variables (trauma exposure and age at enlistment) were adjusted for these covariates. For parsimony, we use age of death as a continuous covariate in the analyses to ensure that greater health problems were not simply a result of living longer (and, thus, having a greater chance of developing health problems).

Theoretically relevant interactions were screened for inclusion in the multivariable models. Specifically, interactions among key study variables were evaluated to determine whether the effect of trauma on signs of disease depended on other exposures (eg, the effect of age at enlistment might be magnified by exposure to trauma as measured by POW status, percentage of company killed, or being wounded). Interaction terms reaching the P = .05 level of significance are reported.

ANALYSIS OF NONPARTICIPANTS

Nonparticipants were defined as recruits who were in the total military sample and had data on predictor variables (eg, POW experience) but whose medical records could not be linked during data collection (n = 18 027). Previous analyses using this data set have established that nonparticipants were significantly more likely to be dead or deserters, so that a link between their military service and medical records after the war could not be established.33Table 1 provides a description of participants and nonparticipants using all study variables. Although there were statistically significant differences between participants and nonparticipants, standardized effect sizes (φ2) were small, ranging from .0002 for POW status to .057 for occupation. One exception was age at death; only 8623 of the nonparticipants had this information available, and this group died quite young when compared with participants (< .005). Postwar lifetime signs of disease were available only for participants (n = 15 027). Among this sample, 5.79% had GI ailments only, 18.0% had cardiac ailments only, and 17.4% had both cardiac and GI ailments. In addition 5.1% had signs of mental disease including nervous ailments only, and 38.8% had comorbid physical and mental ailments; no signs of disease were present in 15.0% of the participants. The median number of unique cardiac, GI, and nervous ailments that a veteran was diagnosed as having over his postwar lifetime was 4.3 (minimum, 0; and maximum, 28).

Table Graphic Jump LocationTable 1. Descriptive Statistics for All Study Variables by Participant Status*
SIGNS OF POSTWAR DISEASE

Table 2 describes the association between disease outcomes and the key study variables. Relative to the oldest enlistees, the youngest were more likely to be diagnosed as having signs of cardiovascular disease alone and in combination with signs of GI disease and were at greater risk of presenting with signs of comorbid physical and nervous disease. There was no association between age at enlistment and the presence of nervous disease alone.

Table Graphic Jump LocationTable 2. Relationship Between Age at Enlistment, Traumatic War Exposure, and Signs of Cardiac, GI, or Nervous Disease for 15 027 Subjects*

Relative to the lowest quartile of the percentage of company killed, veterans in the second quartile were at increased risk of signs of GI and cardiac disease alone. Veterans in all quartiles of company killed, relative to the lowest, were at greater risk of developing signs of comorbid GI and cardiac disease. Veterans in all quartiles of company killed, relative to the lowest, were at greater risk of developing signs of comorbid physical and nervous disease. There was no association between percentage of company killed and signs of nervous disease alone.

POW experience was not associated with signs of physical or nervous disease alone, but was associated with an increased risk of comorbid physical and nervous disease. Being wounded was associated with an increased risk of nervous disease alone, a decreased risk of physical disease, and decreased signs of comorbid physical and nervous disease.

There was an interaction between percentage of company killed (highest quartile relative to the lowest) and being wounded for signs of physical disease and for signs of comorbid physical and nervous disease. Among recruits who were wounded during the war, there was no association between percentage of company killed and signs of disease. In contrast, among recruits who were not wounded during the war, those in the highest quartile of company killed were at increased risk of physical disease diagnosis (incidence risk ratio, 1.33) and were at increased risk of signs of comorbid physical and nervous disease (incidence risk ratio, 1.36) (< .03 for both).

NUMBER OF POSTWAR UNIQUE AILMENTS

The youngest veterans at enlistment were at risk of developing more unique postwar ailments than their older peers. This pattern continues through the age of 30 years, with younger enlistees at greatest risk of being diagnosed as having more unique disease ailments when compared with older enlistees (Table 3). Relative to the lowest quartile of company killed, recruits in the upper quartiles were diagnosed as having more ailments. A POW experience was not associated with the number of unique disease ailments, and being wounded was associated with fewer unique disease ailments.

Table Graphic Jump LocationTable 3. Relationship Between Age at Enlistment, Traumatic War Exposure, and Development of Unique Cardiovascular, GI, and Nervous Ailments for 15 027 Subjects
MORTALITY

Mortality risk was significantly associated with age at entry into service (Table 4). Recruits who were youngest at enlistment (<18 years) had the greatest risk for early death. This pattern continued across each age category, with younger enlistees at greater risk of early death compared with older enlistees. POW experience was associated with an increased risk of early death. There were 2 significant interactions involving age at enlistment and the percentage of company killed for the third and fourth quartiles relative to the first quartile. Among recruits who were younger than 18 years at first enlistment, having more of one's company killed was associated with an increased risk of early death (third quartile: hazard ratio, 1.15 [< .05]; and fourth quartile: hazard ratio, 1.11 [< .05]) (Figure). Among recruits who were 18 years or older at first enlistment, there was no association between the percentage of company killed and mortality.

Place holder to copy figure label and caption
Figure.

Mortality risk for 15 027 subjects: interaction between age at enlistment and percentage of company killed. The 95% confidence interval for the third quartile for those 17 years and younger was 1.06 ≤ 1.15 ≤ 1.24; and for those 18 years and older, 0.94 ≤ 0.99 ≤ 1.05. The 95% confidence interval for the fourth quartile for those 17 years and younger was 1.04 ≤ 1.11 ≤ 1.18; and for those 18 years and older, 0.95 ≤ 0.99 ≤ 1.05. The asterisk indicates P < .05.

Graphic Jump Location
Table Graphic Jump LocationTable 4. Relationship Between Traumatic War Exposure and Mortality for 15 027 Subjects

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 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. In addition, veterans who were younger at enlistment had a 93% increased risk of developing signs of comorbid physical and nervous disease and experienced a 32% increased incidence of unique disease ailments. Young veterans (<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 because of 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 recruits. 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.40

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 (S. E. Wilson, PhD, unpublished data, 1993). This initial screening suggests that it was the military experience, rather than some preexisting medical condition, that accounted for the health effects observed. The possibility of differential health screening during the war was also accounted for in our analyses. When examining 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 suggests that those veterans who survived being wounded may have been particularly hardy given the unsanitary conditions of the war.41

POW experience predicted signs of comorbid physical and nervous disease and mortality. This likely reflects the traumatic psychological effect 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 article, veterans who experienced more traumatic wartime experiences were significantly more likely to report more disease ailments. For example, POW experience, being wounded, increased percentage of company killed, and younger age at enlistment were associated with more self-reported disease ailments.

Many studies13,69,12,13,2330,42 link emotional stress, such as combat, to mental health problems. Recent literature10 on the effect of trauma on health has suggested that psychological response, specifically PTSD, mediates the relationship between trauma exposure and physical health outcomes. Unfortunately, we are unable to examine this relationship in this archival data set because we do not have clear temporal information on the development of nervous, GI, or cardiac ailments (eg, veterans may have presented with all ailments simultaneously rather than sequentially). In addition, the Civil War era preceded the recognition of a PTSD diagnosis.

Researchers5,11,12,1520,23,24,4348 have also hypothesized mechanisms by which emotional stress is linked to physical disease. Allostatic load theory45 postulates a neurochemical response via the activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal 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 overly sensitive,42 overloaded by the normal cascade of stress hormones. For example, over periods of chronic stress (ie, battlefield events or witnessing death), there may be long-term 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 was calculated as a predictor of mortality in a subsample of 377 Civil War veterans from this data set, and seems not to be as significant a predictor of cardiac disease during the Civil War era as in modern time.40

This study has some limitations. While these data have been carefully accumulated, coded, and analyzed, it is recognized that archival medical data, by definition, are not interchangeable with modern medical diagnoses. Because of 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. Nevertheless, although we are unable to construct current medical diagnoses as outcome variables using this data set, 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 cardiovascular5,1619 and GI20,21 disease and PTSD59 post war, we found that combat exposure was related to increased self-reports of negative physical symptoms and physician-diagnosed signs of cardiac disease (eg, arteriosclerosis), GI disease (eg, ulcer), and mental health problems (eg, depression).

In conclusion, the present 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.49

Our analysis is the first to use objective military and medical records to demonstrate the development of postwar disease ailments over the life course among veterans of any war. We found strong relations between traumatic exposure (eg, witnessing a larger percentage of company death), comorbid disease, mental health ailments, and early death. Despite the age of the data set, there have been few other opportunities to examine standardized medical examinations over a postwar 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 more than 130 years ago are applicable to the health and well-being of soldiers fighting wars in the 21st century, as recent studies8,14,50 have suggested.

Correspondence: Roxane Cohen Silver, PhD, Department of Psychology and Social Behavior, 3340 Social Ecology II, University of California, Irvine, CA 92697-7085 (rsilver@uci.edu).

Submitted for Publication: October 6, 2004; final revision received July 3, 2005; accepted July 27, 2005.

Funding/Support: This study was supported by grant P01 AG10120 from the National Institutes on Aging, Bethesda, Md, as a subgrant from the Center for Population Economics at the University of Chicago, Chicago, Ill, and the National Bureau of Economics, Boston, Mass.

Acknowledgment: We thank Joey Burton, MA; Dora Costa, PhD; Louis Nguyen, MD, MBA; Sven Wilson, PhD; Werner Troesken, PhD; and Chulhee Lee, PhD, for providing assistance with the Union Army archival data system.

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King  DWKing  LAFoy  DWKeane  JMFairbank  JA Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables. J Abnorm Psychol 1999;108164- 170
PubMed Link to Article
Simmons  RMaconochie  NDoyle  P Self-reported ill health in male UK Gulf War veterans: a retrospective cohort study. BMC Public Health 2004;427
PubMed Link to Article
Creasey  HSulway  MRDent  OBroe  GAJorm  ATennant  C Is experience as a prisoner of war a risk factor for accelerated age-related illness and disability? J Am Geriatr Soc 1999;4760- 64
PubMed
Blanchard  EB Elevated basal levels of cardiovascular responses in Vietnam veterans with PTSD: a health problem in the making? J Anxiety Disord 1990;4233- 237
Link to Article
Ullman  SESiegel  JM Traumatic events and physical health in a community sample. J Trauma Stress 1996;9703- 720
PubMed Link to Article
Folkow  B Psychosocial and central nervous influences in primary hypertension. Circulation 1987;76 ((1, pt 2)) I10- I19
Litz  BTKeane  TMFisher  LMarx  BMonaco  V Physical complaints in combat-related post-traumatic stress disorder: a preliminary report. J Trauma Stress 1992;5131- 141
Link to Article
Goulston  KJDent  OFChapuis  PHChapman  GSmith  CITait  ADTennant  CC Gastrointestinal morbidity among World War II prisoners of war: 40 years on. Med J Aust 1985;1436- 10
PubMed
Schnurr  PPSpiro  A  IIIParis  AH Physician-diagnosed medical disorders in relation to PTSD symptoms in older military veterans. Health Psychol 2000;1991- 97
PubMed Link to Article
Hyams  KCWignall  SRoswell  R War syndromes and their evaluations: from the US Civil War to the Persian Gulf War. Ann Intern Med 1996;125398- 405
PubMed Link to Article
Schnurr  PPSpiro  A Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. J Nerv Ment Dis 1999;187353- 359
PubMed Link to Article
Boscarino  JA Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med 1997;59605- 614
PubMed Link to Article
Schnurr  PPFriedman  MJSengupta  AJankowski  MKHolmes  T PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis 2000;188496- 504
PubMed Link to Article
Jones  EHodgins-Vermaas  RMcCartney  HEveritt  BBeech  CPoynter  DPalmer  IHyams  KWessely  S Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution. BMJ 2002;324321- 324[published correction appears in BMJ.2002;324:397]
Link to Article
Elder  GH  JrClipp  EC Combat experience and emotional health: impairment and resilience in later life. J Pers 1989;57311- 341
Link to Article
Adler  ABVaitkus  MAMartin  JA Combat exposure and posttraumatic stress symptomatology among US soldiers deployed to the Gulf war. Mil Psychol 1993;81- 14
Link to Article
Fontana  ARosenheck  R A model of war zone stressors and posttraumatic stress disorder. J Trauma Stress 1999;12111- 126
PubMed Link to Article
Yehuda  RSouthwick  SMGiller  EL Exposure to atrocities and severity of chronic posttraumatic stress disorder in Vietnam combat veterans. Am J Psychiatry 1992;149333- 336
PubMed
Bailey  RHClark  CDunbar  DGoolrick  WWalker  BSWiencek  H Brother Against Brother.  New York, NY Prentice Hall Press1990;
Dean  ET “We will all be lost and destroyed”: post-traumatic stress disorder and the Civil War. Civ War Hist 1991;37138- 153
Link to Article
Fogel  RW Public Use Tape on the Aging of Veterans of the Union Army: Military, Pension, and Medical Records, 1860-1940, Version M-5.  Chicago, Ill Center for Population Economics, University of Chicago Graduate School of Business; and Provo, Utah: Dept of Economics, Brigham Young University2000;
Deutrich  M Struggle for Supremacy: The Career of General Fred C. Ainsworth.  Washington, DC Public Affairs Press1962;
Fogel  RW Public Use Tape on the Aging of Veterans of the Union Army: Surgeon's Certificates, 1862-1940, Version S-1 Standardized.  Chicago, Ill Center for Population Economics, University of Chicago Graduate School of Business; and Provo, Utah: Dept of Economics, Brigham Young University2001;
World Health Organization, International Classification of Diseases, 9th Revision: Clinical Modification. 5th Los Angeles, Calif Practice Management Information Corp1999;
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Davis  CS Statistical Methods for the Analysis of Repeated Measurements.  New York Springer-Verlag NY Inc2002;
Kleinbaum  DGKlein  M Logistic Regression: A Self-learning Test. 2nd New York Springer-Verlag NY Inc2002;
Costa  DL Height, weight, wartime stress, and older age mortality: evidence from the Union Army records. Explor Econ Hist 1993;30424- 449
Link to Article
Rutkow  IM Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine.  New York, NY Random House Inc2005;
McEwen  BS The neurobiology and neuroendocrinology of stress: implications for post-traumatic stress disorder from a basic science perspective. Psychiatr Clin North Am 2002;25469- 494
Link to Article
Henry  JPWang  S Effects of early stress on adult affiliative behavior. Psychoneuroendocrinology 1998;23863- 875
PubMed Link to Article
Pavlides  CNivon  LGMcEwen  BS Effects of chronic stress on hippocampal long-term potentiation. Hippocampus 2002;12245- 257
Link to Article
McEwen  BS Protective and damaging effects of stress mediators. N Engl J Med 1998;338171- 179
PubMed Link to Article
Krantz  DSSheps  DCarney  RMNatelson  BH Effects of mental stress in patients with coronary artery disease: evidence and clinical implications. JAMA 2000;2831800- 1802
PubMed Link to Article
Tsigos  CChrousos  GP Stress, endocrine manifestations, and diseases. In:Handbook of Stress, Medicine and Health Boca Raton, Fla CRC Press1996;61- 83
Segerstrom  SCMiller  GE Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull 2004;130601- 630
Link to Article
Wooley  CF The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology: The US Civil War (1861) to World War I (1918): The History of Medicine in Context.  Aldershot, England Ashgate2002;
Kang  HKHyams  KC Mental health care needs among recent war veterans. N Engl J Med 2005;3521289
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Mortality risk for 15 027 subjects: interaction between age at enlistment and percentage of company killed. The 95% confidence interval for the third quartile for those 17 years and younger was 1.06 ≤ 1.15 ≤ 1.24; and for those 18 years and older, 0.94 ≤ 0.99 ≤ 1.05. The 95% confidence interval for the fourth quartile for those 17 years and younger was 1.04 ≤ 1.11 ≤ 1.18; and for those 18 years and older, 0.95 ≤ 0.99 ≤ 1.05. The asterisk indicates P < .05.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Descriptive Statistics for All Study Variables by Participant Status*
Table Graphic Jump LocationTable 2. Relationship Between Age at Enlistment, Traumatic War Exposure, and Signs of Cardiac, GI, or Nervous Disease for 15 027 Subjects*
Table Graphic Jump LocationTable 3. Relationship Between Age at Enlistment, Traumatic War Exposure, and Development of Unique Cardiovascular, GI, and Nervous Ailments for 15 027 Subjects
Table Graphic Jump LocationTable 4. Relationship Between Traumatic War Exposure and Mortality for 15 027 Subjects

References

Hendin  HHaas  A Posttraumatic stress disorders in veterans of early American wars. Psychohist Rev 1984;1225- 30
PubMed
Escobar  JIRandolph  ETPuente  GSpiwak  FAsamen  JKHill  MHough  RL Post-traumatic stress disorder in Hispanic Vietnam veterans: clinical phenomenology and sociocultural characteristics. J Nerv Ment Dis 1983;171585- 596
PubMed Link to Article
Kulka  RASchlenger  WEFairbank  JAHough  RLJordan  BKMarmar  CRWeiss  DS Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study.  New York, NY Brunner/Mazel1990;
Harmless  A Developmental impact of combat exposure: comparison of adolescent and adult Vietnam veterans. Smith Coll Stud Soc Work 1990;60185- 195
Link to Article
Falger  PROp den Velde  WHovens  JESchouten  EGDe Groen  JHVan Duijn  H Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch Resistance veterans from World War II. Psychother Psychosom 1992;57164- 171
PubMed Link to Article
Ursano  RJ Post-traumatic stress disorder. N Engl J Med 2002;346130- 132
PubMed Link to Article
Ford  JDCampbell  KAStorzbach  DBinder  LMAnger  WKRohlman  DS Posttraumatic stress symptomatology is associated with unexplained illness attributed to Persian Gulf War military service. Psychosom Med 2001;63842- 849
PubMed Link to Article
Hoge  CWCastro  CAMesser  SCMcGurk  DCotting  DIKoffman  RL Combat duty in Iraq and Afghanistan: mental health problems, and barriers to care. N Engl J Med 2004;35113- 22
PubMed Link to Article
Koren  DNorman  DCohen  ABerman  JKlein  EM Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry 2005;162276- 282
PubMed Link to Article
Schnurr  PPGreen  BL Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress.  Washington, DC American Psychological Association2004;
Elder  GH  JrShanahan  MJClipp  EC Linking combat and physical health: the legacy of World War II in men's lives. Am J Psychiatry 1997;154330- 336
PubMed
Wagner  AWWolfe  JRotnitsky  AProctor  SPErickson  DJ An investigation of the impact of posttraumatic stress disorder on physical health. J Trauma Stress 2000;1341- 55
PubMed Link to Article
King  DWKing  LAFoy  DWKeane  JMFairbank  JA Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables. J Abnorm Psychol 1999;108164- 170
PubMed Link to Article
Simmons  RMaconochie  NDoyle  P Self-reported ill health in male UK Gulf War veterans: a retrospective cohort study. BMC Public Health 2004;427
PubMed Link to Article
Creasey  HSulway  MRDent  OBroe  GAJorm  ATennant  C Is experience as a prisoner of war a risk factor for accelerated age-related illness and disability? J Am Geriatr Soc 1999;4760- 64
PubMed
Blanchard  EB Elevated basal levels of cardiovascular responses in Vietnam veterans with PTSD: a health problem in the making? J Anxiety Disord 1990;4233- 237
Link to Article
Ullman  SESiegel  JM Traumatic events and physical health in a community sample. J Trauma Stress 1996;9703- 720
PubMed Link to Article
Folkow  B Psychosocial and central nervous influences in primary hypertension. Circulation 1987;76 ((1, pt 2)) I10- I19
Litz  BTKeane  TMFisher  LMarx  BMonaco  V Physical complaints in combat-related post-traumatic stress disorder: a preliminary report. J Trauma Stress 1992;5131- 141
Link to Article
Goulston  KJDent  OFChapuis  PHChapman  GSmith  CITait  ADTennant  CC Gastrointestinal morbidity among World War II prisoners of war: 40 years on. Med J Aust 1985;1436- 10
PubMed
Schnurr  PPSpiro  A  IIIParis  AH Physician-diagnosed medical disorders in relation to PTSD symptoms in older military veterans. Health Psychol 2000;1991- 97
PubMed Link to Article
Hyams  KCWignall  SRoswell  R War syndromes and their evaluations: from the US Civil War to the Persian Gulf War. Ann Intern Med 1996;125398- 405
PubMed Link to Article
Schnurr  PPSpiro  A Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. J Nerv Ment Dis 1999;187353- 359
PubMed Link to Article
Boscarino  JA Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med 1997;59605- 614
PubMed Link to Article
Schnurr  PPFriedman  MJSengupta  AJankowski  MKHolmes  T PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis 2000;188496- 504
PubMed Link to Article
Jones  EHodgins-Vermaas  RMcCartney  HEveritt  BBeech  CPoynter  DPalmer  IHyams  KWessely  S Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution. BMJ 2002;324321- 324[published correction appears in BMJ.2002;324:397]
Link to Article
Elder  GH  JrClipp  EC Combat experience and emotional health: impairment and resilience in later life. J Pers 1989;57311- 341
Link to Article
Adler  ABVaitkus  MAMartin  JA Combat exposure and posttraumatic stress symptomatology among US soldiers deployed to the Gulf war. Mil Psychol 1993;81- 14
Link to Article
Fontana  ARosenheck  R A model of war zone stressors and posttraumatic stress disorder. J Trauma Stress 1999;12111- 126
PubMed Link to Article
Yehuda  RSouthwick  SMGiller  EL Exposure to atrocities and severity of chronic posttraumatic stress disorder in Vietnam combat veterans. Am J Psychiatry 1992;149333- 336
PubMed
Bailey  RHClark  CDunbar  DGoolrick  WWalker  BSWiencek  H Brother Against Brother.  New York, NY Prentice Hall Press1990;
Dean  ET “We will all be lost and destroyed”: post-traumatic stress disorder and the Civil War. Civ War Hist 1991;37138- 153
Link to Article
Fogel  RW Public Use Tape on the Aging of Veterans of the Union Army: Military, Pension, and Medical Records, 1860-1940, Version M-5.  Chicago, Ill Center for Population Economics, University of Chicago Graduate School of Business; and Provo, Utah: Dept of Economics, Brigham Young University2000;
Deutrich  M Struggle for Supremacy: The Career of General Fred C. Ainsworth.  Washington, DC Public Affairs Press1962;
Fogel  RW Public Use Tape on the Aging of Veterans of the Union Army: Surgeon's Certificates, 1862-1940, Version S-1 Standardized.  Chicago, Ill Center for Population Economics, University of Chicago Graduate School of Business; and Provo, Utah: Dept of Economics, Brigham Young University2001;
World Health Organization, International Classification of Diseases, 9th Revision: Clinical Modification. 5th Los Angeles, Calif Practice Management Information Corp1999;
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Davis  CS Statistical Methods for the Analysis of Repeated Measurements.  New York Springer-Verlag NY Inc2002;
Kleinbaum  DGKlein  M Logistic Regression: A Self-learning Test. 2nd New York Springer-Verlag NY Inc2002;
Costa  DL Height, weight, wartime stress, and older age mortality: evidence from the Union Army records. Explor Econ Hist 1993;30424- 449
Link to Article
Rutkow  IM Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine.  New York, NY Random House Inc2005;
McEwen  BS The neurobiology and neuroendocrinology of stress: implications for post-traumatic stress disorder from a basic science perspective. Psychiatr Clin North Am 2002;25469- 494
Link to Article
Henry  JPWang  S Effects of early stress on adult affiliative behavior. Psychoneuroendocrinology 1998;23863- 875
PubMed Link to Article
Pavlides  CNivon  LGMcEwen  BS Effects of chronic stress on hippocampal long-term potentiation. Hippocampus 2002;12245- 257
Link to Article
McEwen  BS Protective and damaging effects of stress mediators. N Engl J Med 1998;338171- 179
PubMed Link to Article
Krantz  DSSheps  DCarney  RMNatelson  BH Effects of mental stress in patients with coronary artery disease: evidence and clinical implications. JAMA 2000;2831800- 1802
PubMed Link to Article
Tsigos  CChrousos  GP Stress, endocrine manifestations, and diseases. In:Handbook of Stress, Medicine and Health Boca Raton, Fla CRC Press1996;61- 83
Segerstrom  SCMiller  GE Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull 2004;130601- 630
Link to Article
Wooley  CF The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology: The US Civil War (1861) to World War I (1918): The History of Medicine in Context.  Aldershot, England Ashgate2002;
Kang  HKHyams  KC Mental health care needs among recent war veterans. N Engl J Med 2005;3521289
PubMed Link to Article

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