Medical Department #17 - Purple Hearts and Soldier's Hearts

A few weeks ago, a reporter asked Secretary of Defense Robert Gates if the Pentagon might consider awarding Purple Hearts to troops with combat-related Post-Traumatic Stress Disordser (PTSD). Gates's answer to that question: “It’s an interesting idea … I think it’s clearly something that needs to be looked at," has caused something of a firestorm in the armed services press and blogs. For an example, see the coverage in Army Times.

The reaction among some soldiers and Marines has been quite strong, with the Army Times article including the following quotes:

“It would lessen the meaning of the award”
“I’d be ashamed to wear it”
"It's an insult to those who have suffered real injury on the battlefield"

In any event, the discussion has brought back to the forefront the mental health consequences of combat. These consequences were no less severe for Civil War veterans. I described this in a "Medical Department" column a couple of years ago, when an article in Archives of General Psychiatry - "Physical and mental health costs of traumatic war experiences among Civil War veterans" - received widespread attention in both the scientific press and the mass media.

The lead author of the article - Judith Pizarro - was kind enough to answer some questions, that led to the column. I'm also pleased to announce that she has written a terrific chapter on the mental health of Civil War veterans for a forthcoming collection of essays on Civil War medicine being edited by Guy Hasegawa, Pharm. D., and myself.

The column - from April 2006 - is reprinted for your information and enjoyment:

SOLDIER’S HEART
By James M. Schmidt
The Civil War News – “Medical Department” – April 2006

“There is many a boy here today who looks on war as all glory, but, boys, it is all hell.” - William T. Sherman, Speech at Michigan Military Academy, 1879

There are probably readers of this column who, from personal experience, can attest to General Sherman’s oft-quoted aphorism. Perhaps other readers also know soldiers affected by war experiences – some who suffer in silence and others with more profound physical and emotional suffering that in turn affects their family and friends. Fortunately, our attitudes about “combat neuroses” have matured over time, so that we no longer see the victims as cowards. Indeed, we take for granted that psychiatric casualties are an inevitable feature of warfare.

Whatever we call the affliction - “shell shock,” “post traumatic stress syndrome,” or something more poetic, such as “soldier’s heart” - recent research suggests that this disease is not limited to modern warfare. The study, “Physical and mental health costs of traumatic war experiences among Civil War veterans,” was published in a recent issue of the Archives of General Psychiatry (Feb 2006, Vol. 63, No. 2, pp. 193-200, full text available here), and showed that the “hell” of war is hardest on the youngest and those who witness the most carnage. The study garnered wide attention in the mainstream media, including ABC, MSNBC, and newspapers from Australia to Atlanta.

“I think there are several reasons our paper was widely reviewed,” Judith Pizarro, M.A., one of the paper’s authors (along with Drs. Roxane C. Silver and JoAnn Prause), told me. “The National Archives in Washington, D.C., state that the American Civil War is the most researched war in history. Therefore we immediately had a greater audience than just health practitioners because of the historical link. I also think that because the U.S. is currently engaged in a war, people want to know about the soldier’s experience and life after war. What is going to happen to all those soldiers coming back from combat; how do we treat them, and what should we expect for their mental and physical health?”

Judith is in her fourth year of graduate studies in the University of California-Irvine’s (UCI) Department of Psychology and Social Behavior, and if all goes well she will earn her Ph.D. in Health Psychology next summer (at that writing). She has a special interest in traumatic stress and its impact on subsequent mental and physical health. She was kind enough to answer my questions about the paper, including the methods and conclusions used in the research.

While the traumatic effect of war is a research interest for all of the authors, none of the group had specific interest in or experience with the Civil War. “In fact, I was born and raised in Canada,” Judith said, “so I had to do quite a bit of reading about the Civil War in order to understand the conditions these soldiers endured.”

Judith told me that she has developed an interest in the Civil War over the course of the project, adding: “Based on some of the feedback I’ve been hearing from the paper, I’d like to pursue a line of research looking at the intergenerational effects of war trauma. We’ve had so many folks email us regarding family experiences in the Civil War and how they are still affected by them to this day. It seems that the effects of war are not only painful for the persons who experience it directly but generations thereafter.”

An excerpt from one of the e-mails Judith has received demonstrates the multi-generational effect of the Civil War:

“My great-grandfathers on both sides were both Union Veterans. My mother's grandfather was in a Confederate prison camp and my father's grandfather was a 17-year old soldier who participated in Sherman's march to the sea. My mother's grandfather was an alcoholic and set off three generations (so far) of alcoholism in that branch of the family. My father's grandfather deserted my great-grandmother as a result of his PTSD from Sherman's march. She was left to raise my grandmother and her sister on her own. She was very angry, and constantly told my grandmother how worthless her father was, and how untrustworthy men were in general. That whole experience brought about severe anxiety and migraine headaches in my grandmother, which affected all the children in the family, but most of all, my father.”

For their study, the researchers analyzed data from the “Early Indicators of Later Work Levels, Disease, and Death” database (EI). The EI is largest, most comprehensive collection of electronic Civil War files from the National Archives (NARA). Compilation of the EI, which took thousands of hours and millions of dollars over a 15-year period, was performed through the Center for Population Economics (CPE) at the University of Chicago and sponsored by the National Institutes of Health (NIH) and the National Science Foundation (NSF).

Records of veterans’ ailments, as diagnosed by period physicians, were transcribed by historians and economists. Using 19th- and 20th-century medical dictionaries to classify diseases within modern definitions of cardiac, gastrointestinal or nervous disorders, the handwritten military and pension records were coded and “cleaned” to create computerized records.

“Our work would not be possible without the EI,” Judith told me. “As a result, these very thorough, reliable and detailed records of a representative sample of over 30,000 Union Army soldiers allow us to examine outcomes that are based on objective measures.” Judith’s project began with a grant request, and once funded (by the NIH through the CPE), took two years to complete. Since so much data was used for the study, the Archives paper is (purposely) heavy on statistics and (purposely) light on anecdotes generally favored by Civil War enthusiasts. Indeed, lay readers (like myself) might be scared off at first glance---but don't be! The authors’ discussion of the study results makes for especially fascinating (and easy) reading.

Among the conclusions that Judith and her co-authors made is that nearly two in five Civil War veterans later developed both mental and physical ailments such as heart disease and gastrointestinal problems. An especially interesting finding is that soldiers who enlisted between the ages of 9 and 17 were nearly twice as likely, than their older peers (≥31 years) to suffer disorders. Percentage of company killed was also a significant variable, presumably because it serves as a marker for traumas such as witnessing death, handling dead bodies, and loss of comrades (often from the same community). Prisoners of war were also susceptible to postwar problems, although, interestingly, the researchers found that men who survived war wounds were less likely to develop lifetime physical disease but more likely to develop mental disease.

The work has attracted the attention of both health professionals and history enthusiasts, but as it was published in a professional journal, Judith and her co-authors expect that the intended audience will act on the data and results, perhaps even dramatically and controversially. “It is my hope that professionals as well as policy makers read this paper and take our findings seriously,” Judith told me. “For example, I would recommend that the age of entry into armed service and combat companies be revised. As Dr. Pittman of Harvard University has noted in an editorial accompanying our paper: ‘the nervous system and emotional regulatory centers of the brain do not fully develop until adulthood. Thus, exposing teens to the graphic details of combat will likely debilitate them for life.'"

Judith also thinks that mental health professionals currently treating veterans for post-traumatic disorders would be wise to check the status of the veteran’s physical health and incorporate disease prevention strategies and health-promoting behaviors into their overall treatment plan.

William Sherman was among the first military leaders to implement the concept of “total war” on the battlefield. We should never forget that soldiers also fight their own “total war” when they come home – one of mind, body, and spirit.