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Traumatic War Experiences and Health
1
Archives of General Psychiatry, 63, 193-200.
Physical and Mental Health Costs of Traumatic War Experiences
Among Civil War Veterans
Judith Pizarro, M.A.
Roxane Cohen Silver, Ph.D.
JoAnn Prause, Ph.D.
Author Affiliation: Department of Psychology and Social Behavior (Ms. Pizarro, Dr. Silver and
Dr. Prause); Department of Medicine (Dr. Silver), University of California, Irvine
Corresponding Author: Roxane Cohen Silver, Ph.D., Department of Psychology and Social
Behavior, 3340 Social Ecology II, University of California, Irvine, CA 92697-7085.
Telephone: 949-824-2192; Fax: 949-824-3002; Email: rsilver@uci.edu
Running Head: Traumatic War Experiences and Health
Word Count: 4500
Keywords: combat exposure, Civil War Veterans, war trauma, physical health, mental health
Traumatic War Experiences and Health
2
ABSTRACT
Context: Hundreds of thousands of soldiers face exposure to combat during wars across the
globe. The health impact of traumatic war experiences has not been adequately assessed across
the lifetime of these veterans.
Objective: Identify the role of traumatic war experiences in predicting post-war 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 (POW experience, percentage of company killed,
being wounded, early age at enlistment), signs of lifetime physician-diagnosed disease, and age
at death were recorded.
Setting and Participants: US Pension board surgeons conducted standardized medical
examinations of Civil War veterans over their post-war lifetimes. Military records of 17,700
Civil War veterans were matched to post-war medical records.
Main Outcome Measures: Signs of physician-diagnosed disease including cardiac,
gastrointestinal (GI), and nervous disease, and number of unique ailments within each disease;
mortality.
Results: Military trauma was related to signs of disease and mortality. Greater percentage of
company killed was associated with signs of post-war cardiac and GI disease (IRR=1.34, p<.02),
co-morbid nervous and physical disease (IRR=1.51, p<.005), and greater number of unique
ailments within each disease (IRR=1.14, p<.01). Younger soldiers (≤18 years old), compared to
older enlistees (> 30 years old), showed higher mortality risk (HR=1.52, p<.005), signs of co-
morbid nervous and physical disease (IRR=1.93, p<.005), and a greater number of unique
Traumatic War Experiences and Health
3
ailments within each disease (IRR=1.32, p<.005), controlling for length of 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, GI and nervous
disease, and a greater number of unique disease ailments across the life of Civil War veterans.
Physiological mechanisms by which trauma might result in disease are discussed.
Traumatic War Experiences and Health
4
Physical and Mental Health Costs of Traumatic War Experiences
Among Civil War Veterans
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
them, and watching friends and comrades die.
1
Heavy combat exposure, seeing comrades
injured, witnessing death, and Prisoner of War (POW) experience are traumatic above and
beyond the amount of 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 of age 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 symptomatology is higher among
Vietnam veterans who entered military service at a younger age.
5
Many investigators have examined the mental health consequences of exposure to war
trauma and found substantial post-war psychiatric difficulties among veterans.
6-10
Research has
also linked war trauma and physical health outcomes,
11
including an increase in negative
physical symptom reporting,
12-15
chronic illness, and death.
12,16
Traumatic war exposure has also
been linked to specific self-reported and objective health problems such as cardiovascular
disease and hypertension
6, 17-20
and gastrointestinal (GI) disorders.
8, 21, 22
Nonetheless, although
literature detailing patterns of physical health problems among aging veterans has grown,
23
it has
suffered from a heavy reliance on self-report measures of either military trauma
8, 12, 14, 22, 24-26
or
health.
6, 12-15, 18-21, 24-26
While some researchers have examined military and medical records on a
small sample of servicemen,
27
their aim has been to examine clusters of post-war syndromes
rather than link multiple traumas with specific physical disease states. Up to this point there has
Traumatic War Experiences and Health
5
been no examination of the health effects of multiple war traumas using both well-documented
military service records and objective health data over veterans’ lifetimes.
Outlining specific combat experiences (e.g., being wounded, taken as a POW, 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,
28-30
and that exposure to
war atrocities may be more traumatic than the threat of personal death that accompanies
combat.
31
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 suffered substantial losses, survivors were left with
few remaining friends or male family members.
32
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.
32
Unlike in other documented wars, young adolescents and older
men were allowed entry into military service (ranging from under 10 to over 70 years).
32
Overall,
the Civil War qualifies as one of the bloodiest in American history, exposing thousands to
incomparable traumatic experiences.
32, 33
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, D.C.,
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 current study examines the relationship
Traumatic War Experiences and Health
6
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 (e.g., greater exposure to death, younger age at entry) would predict signs of three
physician-documented diseases that have been linked theoretically and empirically to traumatic
life experiences: cardiac, GI, and mental health disorders,
11
and a greater number of unique
ailments across a veteran’s post-war lifetime.
METHODS
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 (EI), is sponsored by the
National Institutes of Health and the National Science Foundation.
34
Out 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 was
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.
35
Pension files
contain post-war 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.
36
Those recruits who died during the war or deserted did
not generate a Surgeon’s Certificate.
36
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
Traumatic War Experiences and Health
7
(n=16,200). The majority of excluded cases (n=1,442) 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. Prior to 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 (phi
2
=.024, p<.005). Effect sizes (phi
2
)
for the remaining study variables, although statistically significant, were extremely small,
ranging from .03% for POW status to .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. A substantial number of volunteer servicemen were rejected from
military duty due to illness, physical disabilities, body size, and other unclassified problems,
suggesting a healthy baseline sample.
37
One might hypothesize that recruits who enlisted early in
the war were healthier, more robust volunteers than 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)
versus 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 EI project developed its 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
Traumatic War Experiences and Health
8
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 (i.e., Surgeon’s Certificates) after the recruit's military service
was complete, among other variables. These datasets 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 insure
quality information. Trained researchers transferred written records into a standardized
computer database utilizing automated controls, such as upper and lower bounds on fields,
acceptable coded values for fields with a list of possible predetermined values, two-field checks,
and dates had to make sense (i.e., no death before birth year). Medical and occupational
dictionaries from the 19
th
and 20
th
centuries were available for reference by the data coders. De
novo sampling was used as a quality control technique. A random sample of 5-10% of recruits
were drawn from each company and re-entered. Differences calculated between the original and
de novo sample were classified as follows: incorrect entries (misread word, 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 years - 71
years old. Because younger age at first enlistment was predicted to be more stressful and lead to
more negative health outcomes over the lifespan, this variable was categorized into five age-
ranged groups of approximately equal size to highlight the effect of younger ages: 9-17 years old
Traumatic War Experiences and Health
9
(n=3013); 18-20 years old (n=3694); 21-25 years old (n=3435); 26-30 years old (n=2225); and
over 31 years (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. Additionally, it was stratified (9-49
years=1; 50-64 years=2; 65-74 years=3; 75-104 years=4) in order 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
(SES) during the Civil War era. Six categories of professions were identified: farmers,
professionals, artisans, service workers, laborers and unproductive persons (e.g., those involved
in scholarly activities). SES was represented as a series of five 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 (i.e., 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,
prior to 1864, 1864 or later) due to more severe conditions in POW camps later in the war effort.
Traumatic War Experiences and Health
10
However, results in the latter two groups were the same, so they were combined for the sake of
parsimony.
Health Outcomes
Health history was gathered from the Pension files. In order to receive a military pension,
veterans were required to attend a physical examination for each illness or disease claim. Thus,
medical exams were not conducted annually but only when a new claim was presented or an
adjustment in an existing claim was necessary. Every veteran had at least 1 exam, with a
maximum of 30 exams and a median of 4 exams (79% of the veterans had 7 or fewer exams).
The government Pension Board required that each exam be conducted by three physicians who
were required to come to a consensus before a diagnosis was made.
36
The original medical
diagnoses were entered into the EI data collection software system within “disease screens.”
These screens were divided by organ systems and provided non-medical data inputters a
framework with which to transfer the medical data into a database. Medical doctors on the EI
project carefully re-coded 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.
Post-war Signs of Disease
A veteran was classified as having signs of cardiovascular, GI, or nervous disease if he
was ever diagnosed with one or more ailments from the categories below in his post-war
lifetime. Signs of physical or nervous disease, alone or in combination, diagnosed in any exam
Traumatic War Experiences and Health
11
over the recruit’s post-war lifetime, were coded into one six-level categorical variable: no
disease, cardiac only, GI only, both cardiac and GI, nervous 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, dyspnoea, and impaired circulation. Further
coding of these disease symptoms according to the International Classification of Diseases
Version 9 (ICD-9) places them within the general category of circulatory disorders.
38
GI disease ailments included diarrhea, dyspepsia, pain, ulcer, vomiting food or blood,
abdominal tenderness, dysphagia, and malassimiliation, among others. Further coding of these
disease symptoms according to the ICD-9 places them within the general category of digestive
disorders.
38
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 Diagnostic and Statistical Manual of Mental Disorders (DSM
IV)
39
criteria B, C, and D classification of 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, as well as physical ailments of the nervous system including trouble with balance,
incoordination, aphasia, paralysis, tremor, hyperaesthesia, 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 exams over the veteran’s post-war lifetime. Each unique
Traumatic War Experiences and Health
12
disease ailment was counted only once, when the veteran was first diagnosed with 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.
40,41
The post-war lifetime presence of disease (a six-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 (IRR) for the post-war 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).
Regression models include indicator variables representing SES, year of enlistment, and
age at death to ensure the key study variables (trauma exposure and age at enlistment) were
adjusted for these covariates. For the sake of parsimony, we use age of death as a continuous
covariate in the analyses in order to insure 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 (e.g., 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
Traumatic War Experiences and Health
13
significance are reported.
RESULTS
Analysis of Nonparticipants
Nonparticipants were defined as recruits who were in the total military sample and had
data on predictor variables (e.g., POW experience) but whose medical records could not be
linked during data collection (n=18,027). Previous analyses utilizing this data set has 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.
34
Table 1
provides a description of participants and nonparticipants using all study variables. Although
there were statistically significant differences between participants and nonparticipants, we note
that standardized effect sizes (Phi
2
) were small, ranging from .002% for POW status to 5.7% for
occupation. One exception was age at death, where only 8,623 of the nonparticipants had this
information available and this group died quite young (M=37.1 years) when compared to
participants (M=72.5 years), p<.005.
Signs of Post-war 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 with signs of
cardiovascular disease alone and in combination with signs of GI disease and were at greater risk
of presenting with signs of co-morbid physical and nervous disease. There was no association
between age at enlistment and the presence of nervous disease alone.
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 co-
Traumatic War Experiences and Health
14
morbid GI and cardiac disease. Veterans in all quartiles of company killed, relative to the
lowest, were at greater risk of developing signs of co-morbid 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 co-morbid physical and nervous disease. Being
wounded was associated with an increased risk of nervous disease alone, a decreased risk of
physical disease, and signs of co-morbid 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 (p<.05) and for signs of co-
morbid physical and nervous disease (p<.05). 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 in the war, those in the highest quartile of
company killed were at increased risk of physical disease diagnosis (IRR=1.33, p<.05) and were
at increased risk of signs of co-morbid physical and nervous disease (IRR=1.36, p<.05).
Number of Post-war Unique Ailments
The youngest veterans at enlistment were at risk of developing a greater number of
unique post-war ailments than their older peers. This pattern continues through age 30 years with
younger enlistees at greatest risk of being diagnosed with more unique disease ailments when
compared to older enlistees (Table 3). Relative to the lowest quartile of company killed, recruits
in the upper quartiles were diagnosed with more ailments. POW experience was not associated
with the number of unique disease ailments and being wounded was associated with fewer
unique disease ailments.
Traumatic War Experiences and Health
15
Mortality
Mortality risk was significantly associated with age at entry into service (Table 4).
Recruits who were youngest at enlistment (<18 years old) had the greatest risk for early death
(hazards ratio [HR]=1.52, p<.005). This pattern continued across each age category, with
younger enlistees at greater risk of early death compared to older enlistees. POW experience was
associated with an increased risk of early death (HR=1.07, p<.005). There were two significant
interactions involving age at enlistment and the percentage of company killed for both the third
(p<.03) and fourth (p<.05) quartiles relative to the first. Among recruits who were less than 18
years old at first enlistment, having a higher percentage of one’s company killed was associated
with an increased risk of early death (3
rd
quartile: HR=1.15, p<.05; 4
th
quartile: HR=1.11, p<.05;
see Figure 1). Among recruits who were 18 years or older at first enlistment, there was no
association between the percentage of company killed and mortality.
COMMENT
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
Traumatic War Experiences and Health
16
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
Traumatic War Experiences and Health
17
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 theory
47
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
Traumatic War Experiences and Health
18
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).
Traumatic War Experiences and Health
19
Conclusion
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 21
st
century, as recent studies have suggested.
9,15, 52
Traumatic War Experiences and Health
20
ACKNOWLEDGEMENT
Project funding provided by grant P01 AG10120 from the National Institutes on Aging as
a subgrant from the Center for Population Economics (CPE) at the University of Chicago and the
National Bureau of Economics. We thank Joey Burton, Dora Costa, Louis Nguyen, Sven
Wilson, Werner Troesken, and Chulhee Lee for providing assistance with the Union Army
archival data system.
Traumatic War Experiences and Health
21
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Table 1
Descriptive Statistics for all Study Variables by Participant Status
Participants
a
Nonparticipants
Covariates
b
M SD % M SD %
SES: Profession upon entry**
Farmer 64.7 43.9
Professional 10.3 10.1
Artisan 15.0 20.9
Service 2.9 5.5
Laborer 6.7 18.9
Unproductive 0 .2 0.5
Total 100.0 100.0 (n=17,633)
Age at death (years)*** 72.5 10.13 37.1 18.6 (n=8,623)
Categorical Age at death**
9-49 years 1.7 78.0
50-64 years 20.1 9.6
65-74 years 32.9 5.9
75-104 years 45.2 6.5
Total 100.0 100.0 (n=8,623)
Year of Enlistment***
1860-1861 62.3 58.1
1862-1865 37.7 42.0
Total 100.0 100.0 (n=17,978)
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28
Descriptive Statistics for all Study Variables by Participant Status (cont)
Participants
a
Nonparticipants
Exposure Variables M SD % M SD %
Age at enlistment (years)** 23.6 7.3 25.1 8.1 (n=17,978)
Categorical Age at enlistment***
9-17 years 20.1 15.7
18-20 years 24.6 22.0
21-25 years 22.7 24.6
25-30 years 14.8 14.5
31 years & older 17.7 23.3
Total 100.0 100.0 (n=17, 978)
Company Killed (percent)*** 9.8 6.7 10.3 6.9 (n=18,027)
Quartiles of Company Killed**
0 - 4.16% 25.5 23.6
4.17% - 9.19% 25.0 23.9
9.20% - 14.10% 24.7 25.0
14.20% - 30.96% 24.9 27.4
Total 100.0 100.0 (n=18,027)
Length of Service (months)** 26.2 18.5 27.4 15.2 (n=17,828)
% POW** 8.7 9.5 (n=18,027)
% Wounded** * 33.2 20.0 (n=18,027)
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29
Descriptive Statistics for all Study Variables by Participant Status (cont)
Participants
a
Nonparticipants
Health Outcomes M SD % M SD %
Postwar Lifetime Signs of Disease
No Disease 15.0
Signs of Physical Disease
GI ailments only 5.79
Cardiac ailments only 18.0
Cardiac and GI ailments 17.4
Signs of Mental Disease
Nervous ailments only 5.1
Co-Morbid Physical and Mental Ailments 38.8
Number of Unique Ailments
c
Median Min Max
4.3 0 28
Note: M=Mean; SD=Standard Deviation; Percent (%) = column percent
*p<.05; **p<.01;***p<.001
a
n= 15,027; the number of nonparticipants with data is indicated for each variable.
b
Chi Square analyses conducted on dichotomous and categorical variables; unpaired t-test performed on age at
enlistment, age at death, length of service, and percentage of company killed. Effect size estimates ranged from
.0013%-.6880% for the Point Biserial
2
correlations and ranged from .0002%-.0569% for the Phi
2
Coefficients.
c
The total number of unique cardiac, GI, and nervous ailments that a veteran was diagnosed with over his post-
war lifetime.
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30
Table 2
Relationship between Age at Enlistment, Traumatic War Exposure, and Signs of Cardiac, GI or Nervous Disease.
Relative to No Signs of Disease Condition
a
GI Only Cardio Only Cardio and GI Nervous Only Nervous & Cardio/GI
(n=870) (n=2,699) (n=2,615) (n=762) (n=5,835)
Predictor Variables
b
Age at Enlistment IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI
Age 9-17 years 1.07 0.82, 1.39 1.44*** 1.18, 1.77 1.60*** 1.29, 1.98 0.95 0.72, 1.25 1.93*** 1.61, 2.30
Age 18-20 years 1.21 0.95, 1.54 1.38** 1.15, 1.67 1.63*** 1.33, 2.01 1.00 0.77, 1.32 1.90*** 1.61, 2.24
Age 21-25 years 1.23 0.95, 1.59 1.35** 1.13, 1.60 1.55*** 1.27, 1,89 0.99 0.78, 1.26 1.77*** 1.50, 2.09
Age 26-30 years 1.42** 1.09, 1.86 1.43*** 1.18, 1.73 1.47*** 1.21, 1.78 1.04 0.77, 1.40 1.71*** 1.43, 2.04
Age ≥ 31 years ----- ----- ----- ----- -----
POW (1=yes) 0.92 0.67, 1.27 1.04 0.83, 1.32 1.06 0.85, 1.33 0.96 0.73, 1.27 1.23* 1.01, 1.51
Ever wounded 0.45*** 0.37, 0.54 0.63*** 0.56, 0.72 0.46*** 0.40, 0.52 1.64*** 1.39, 1.93 0.67*** 0.60, 0.75
(1=yes)
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31
Table 2
Relationship between Age at Enlistment, Traumatic War Exposure, and Signs of Cardiac, GI or Nervous Disease (cont).
Relative to No Signs of Disease Condition
a
GI Only Cardio Only Cardio and GI Nervous Only Nervous & Cardio/GI
(n=870) (n=2,699) (n=2,615) (n=762) (n=5,835)
% Company Killed IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI IRR 95% CI
1
st
quartile ----- ----- ------ ----- -----
2
nd
quartile 1.30* 1.02, 1.64 1.31** 1.08, 1.59 1.34* 1.07, 1.68 0.99 0.78, 1.26 1.51*** 1.25, 1.84
3
rd
quartile 1.20 0.94, 1.53 1.18† 0.98, 1.43 1.32** 1.07, 1.63 1.15 0.92, 1.44 1.39*** 1.16, 1.67
4
th
quartile 1.13 0.88, 1.43 1.04 0.87, 1.25 1.32* 1.05, 1.65 1.05 0.84, 1.30 1.33** 1.09, 1.62
-- reference group
N=15,027
†p<.10; * p<.05; **p<.01; ***p<.005
a
IRR for one or more lifetime disease sign relative to No Disease Signs (n=2,246)
b
Effect sizes for predictor variables are adjusted for effects of listed predictors, SES, age at death, and year of enlistment.
Traumatic War Experiences and Health
32
Traumatic War Experiences and Health
33
Table 3
Relationship between Age at Enlistment, Traumatic War Exposure, and Development of Unique
Cardiovascular, GI, and Nervous Ailments.
Predictor Variables
b
Age at Enlistment IRR
a
95% CI
9-17 years 1.32*** 1.25, 1.38
18-20 years 1.28*** 1.22, 1.35
21-25 years 1.28*** 1.22, 1.34
26-30 years 1.23*** 1.17, 1.38
≥ 31 years -----
POW (1=yes) 1.02 0.96, 1.09
Ever wounded (1=yes) 0.87*** 0.84, 0.89
% Company killed
1
st
quartile -----
2
nd
quartile 1.11** 1.04, 1.19
3
rd
quartile 1.12** 1.04, 1.20
4
th
quartile 1.14*** 1.06, 1.23
-- reference group
n=15027
* p<.05; **p<.01; ***p<.005
a
Incidence rate ratio predicting number of unique cardiac, GI and nervous ailments that a veteran developed
over his post-war lifetime.
b
Effect sizes for predictor variables are adjusted for effects of listed predictors, SES, age at
death, and year of enlistment.
Traumatic War Experiences and Health
34
Table 4
Relationship between Traumatic War Exposure and Mortality
Predictor Variables
b
Age at Enlistment Relative Hazard
a
95% Confidence Interval
Age 9-17 years 1.52*** 1.44, 1.60
Age 18-20 years 1.31*** 1.26, 1.37
Age 21-25 years 1.29*** 1.23, 1.35
Age 26-30 years 1.20*** 1.44, 1.26
Age ≥ 31 years -----
POW 1.07* 1.01, 1.12
(1=yes; 0=no)
Ever wounded 1.03† 0.99, 1.07
(1=yes; 0=no)
% Company killed
1
st
quartile -----
2
nd
quartile 1.02 0.97, 1.07
3
rd
quartile 1.02 0.97, 1.07
4
th
quartile 1.02 0.97, 1.06
-- reference group
(n=15,027)
†p<.08;*p<.05; **p<.01; ***p<.005
a
Hazard Ratios.
b
Effect sizes for predictor variables are adjusted for effects of listed predictors, SES, age at
death, and year of enlistment.
Traumatic War Experiences and Health
35
Figure 1: Mortality Risk: Interaction Between Age at Enlistment and Percentage of Company Killed
Mortality Risk
0.9
0.95
1
1.05
1.1
1.15
1.2
3rd Quartile 4th Quartile
Quartiles of Company Killed
Hazard Ratio
17 years or younger at
enlistment
18 years or older at enlistment
Age at Enlistment
*
*
(n=15,027)
*p<.05
Confidence Intervals: 3
rd
quartile for 17 years and younger 1.06 ≤ 1.15 ≤ 1.24
3
rd
quartile for 18 years and older .94 ≤ .99 ≤ 1.05
4
th
quartile for 17 years and younger 1.04 ≤ 1.11 ≤1.18
4
th
quartile for 18 years and older .95 ≤ .99 ≤ 1.05
