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Tuesday, March 28, 2017

Minds at War

By Jeffrey Allen Smith and B. Christopher Frueh, 3-20-13


Any attempt to calculate the carnage of the Civil War, the number of sick, wounded, dismembered and dead, leaves one numb in the struggle to make sense of it all. The conditions and horrors faced by those who fought the war exacted a horrific toll.

One would assume that the physical price paid by the men who fought in the war would have a rough equivalent in the mental price, that the experience of that terrible war would have left countless survivors with horrible psychological scars. But that may not actually be the case: according to official Union war records, adverse psychological reactions to combat across a variety of categories never matched, or even approached, the shocking physical losses from the war.

Serving as the official medical record of the Union Army, “The Medical and Surgical History of the War of Rebellion, 1861-65” was a groundbreaking effort to systematically record the medical impact of one of the first “modern” wars while it was happening. Undertaken by the Army Medical Department, and using exclusively military and governmental records, the six-volume publication contained thousands of pages of medical case studies, pictures, graphs and statistics. With more than 100 separate tables charting some 150 “diseases,” ranging from serpent bite to gunshot wounds and dysentery to suicide, the study provided one of the first medical tallies of the impact of warfare on its combatants.

Looking over the exhaustive array of medical data found in “The Medical and Surgical History,” a subtle trend lies beneath the jaw-dropping numbers of physical wounds and maladies suffered by those who fought the war. Across a variety of potential psychological categories, the number of cases and deaths for both white and black troops was often well below 1 percent, surprisingly low even after adjusting for the possibility of underreporting.

In a paper we published in a peer-reviewed psychiatric/psychological journal, the highest annual rate of cases reported for any year of the Civil War for Union troops was .017 percent for insanity, .032 percent for “nostalgia” (or depression), .005 percent for concussion of the brain, .045 percent for delirium tremens, .034 percent for inebriation and .06 percent for chronic alcoholism. The data also revealed there were a total of 278 documented suicides over the four years of the war, fewer than the 349 military personnel who died by suicide in 2012 alone.

The excessive use of alcohol has historically been a common coping mechanism for troops under the stressors of combat. Yet the annual rate of reported inebriation and chronic alcoholism remained below 1 percent throughout the duration of the war, save for two interesting spikes. First, Union troops in the “Pacific Region” had in excess of a tenfold increase in rates of inebriation relative to their Atlantic and Central counterparts – probably more a function of boredom than combat stress. Second, all regions and racial groups reported a discernible spike in reported inebriation in the year following Appomattox, a perhaps understandable surge given the ending of the war.

Likewise, chronic alcoholism and delirium tremens mirrored these patterns, but with significantly fewer reported cases. While these numbers reflect what was socially considered drunkenness by 1860s standards, they also highlight that most troops were not outside that intangible norm, and when low levels of delirium tremens are taken into account, it further underscores how relatively few men had to “sober up” for duty.

Union Surgeon General Joseph K. Barnes acknowledged in the “The Medical and Surgical History” that “obviously troops stationed in the neighborhood of large cities furnished the greater number” of alcoholism cases, and he credited “the government and discipline of the camps” for keeping rates from getting out of hand. Of course, the adverse effects of combat have the power to do more than simply drive a person to drink.

For some Union troops, military service became a mental burden too great to bear. The psychological stressors of combat began to physically manifest themselves in reported cases of nostalgia and insanity. Psychologically naïve by modern standards, Civil War combatants and medical personnel struggled to identify and understand psychiatric disorders and behavior health problems that resulted from combat. For example, the term nostalgia, described as “a temporary feeling of depression… on account of discomfort, hardships and exposures” in the “The Medical and Surgical History,” was treated as “a camp disease of war” that proved “dangerous to their efficiency.” Some current examinations of the “disease” ascribe to it symptoms comparable to post-traumatic stress disorder.

Nevertheless, regardless of terminology, official cases in the Union Army of nostalgia and insanity were quite rare and they peaked during the first two years of the Civil War, and then dropped markedly over the duration of the conflict in many regions, with some exhibiting declines by half or more. The trend of early, elevated levels of diagnosed cases of nostalgia and insanity that diminished as the war went on was also evident in segregated colored units, even with official military incorporation not until 1863.

To be sure, accusations of malingering and an evolving understanding of these psychological reactions to combat probably resulted in a degree of underreporting. As with nostalgia and insanity, Civil War health professionals’ understanding of suicide was limited by the paucity of research on the topic.

With the French sociologist Émile Durkheim’s groundbreaking book “Suicide” still 30 years in the future, most Civil War doctors and nurses had few tools with which to interpret Union Army suicides. During the war annual suicide rates for white Union troops fluctuated between 8.74 and 14.54 per 100,000, while surging to 30.4 for 1865-1866. Serving in segregated units, African-American troops’ suicide rate ranged from 17.7 per 100,000 in 1863, to 0 in 1864 and 1.8 for 1865-1866. These figures appear consistent with some of Durkheim’s conclusions about suicide, including that whites had higher rates of suicide than blacks during the 19th century.

Looking deeper into these numbers in his 2011 paper “Felo De Se,” R. Gregory Lande noted seasonal variations in Union suicides, with rates spiking reliably every spring. However, as with any of these psychological variants tracked in the “The Medical and Surgical History,” a certain amount of caution must be taken, as the data is 150 years old, and the study’s strict reliance on government medical records undoubtedly led to some undercounting.

These statistical limitations were not lost on the compilers of the “The Medical and Surgical History,” for as was noted in its introduction, the publication “cannot be regarded as complete,” but while “most imperfect,” the data “embrace so large a proportion of the troops concerned that they cannot fail to serve fairly as a reliable basis for deductions with regard to the health of the whole army.”

The men who fought in the Civil War participated in a brutal modern war, as soldiers’ letters, photographs and newspaper articles bear testament. Yet often obscured by the ghastly casualty figures and recounts of battles won and lost were the personal struggles that the troops fought on a daily basis – an internal conflict constantly waged against the self-evident, understandable mental and physiological pressures of military service and combat.

Nevertheless, what should be made of the relatively low-recorded instances of psychological casualties in the Civil War? Was it a result of flawed data collection or analysis? Did Victorian or religious social pressures result in under reporting or unwillingness to recognize these invisible wounds?

While considering diagnoses of modern psychiatric conditions extrapolated from records kept 150 years ago during the Civil War is problematic at several levels, perhaps the larger take away message is a heartening one of human resiliency. The data seem to demonstrate that exposure to combat alone does not weaken the human psychological condition. Instead, as with most things in life, there are a multiplicity of factors that result in psychosocial casualties. One of the real tragedies of the conflict was not the sheer number of men who fought to win the Civil War, but the few who lost the war within. On the other hand, these data remind us there is good reason to be optimistic that the psychological consequences of war are not inevitably devastating to all those who serve.

Jeffrey Allen Smith is an assistant professor of history at the University of Hawaii, Hilo.

B. Christopher Frueh, a clinical psychologist and a professor of psychology at the University of Hawaii, Hilo, is a McNair scholar and directs the research programs at the Menninger Clinic in Houston.

From: opinionator.blogs.nytimes.com

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