Voices from the past: Mental and physical outcomes described by American Civil War amputees.

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Voices from the Past: Mental and Physical Outcomes Described by American Civil War Amputees a

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Jess Bonnan-White Ph.D. , Jewelry Yep M.S. & Melanie D. Hetzel-Riggin Ph.D. a

The Richard Stockton College of New Jersey, 08205, Galloway, NJ.

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School of Health Sciences, The Richard Stockton College of New Jersey, Galloway, NJ 08205 c

School of Humanities and Social Sciences, Penn State Erie, The Behrend College, Erie, PA 16563 Accepted author version posted online: 09 Jul 2015.

Click for updates To cite this article: Jess Bonnan-White Ph.D., Jewelry Yep M.S. & Melanie D. Hetzel-Riggin Ph.D. (2015): Voices from the Past: Mental and Physical Outcomes Described by American Civil War Amputees, Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2015.1041070 To link to this article: http://dx.doi.org/10.1080/15299732.2015.1041070

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Voices from the past: Mental and physical outcomes described by American Civil War amputees Jess Bonnan-White, Ph.D.1,4, Jewelry Yep, M.S.2, and Melanie D. Hetzel-Riggin, Ph.D.3 The Richard Stockton College of New Jersey, 08205, Galloway, NJ.

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School of Health Sciences, The Richard Stockton College of New Jersey, Galloway, NJ 08205.

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Corresponding author: School of Social and Behavioral Sciences, The Richard Stockton College of New Jersey, Galloway, NJ, 08205. Phone: 609-652-4453. Fax: 609-626-5559. Email: [email protected] Keywords: phantom limb pain, war trauma, archives, Abstract

Studies of trauma commonly concentrate on the psychological and physiological effects of recent

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violent events. Although today connections are becoming more explicitly drawn, early studies of the aftermath of amputation serve to shed light on our modern understanding of the interaction of

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the physical and emotional. The study of combat amputation, dissociation, and related

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posttraumatic stress largely began with the work of 19th-Century Philadelphia physician Silas Weir Mitchell, who brought attention to the phenomenon of "phantom limb pain." Less known, however, are the data he and his son, John K. Mitchell, also collected on the mental outcomes of

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Downloaded by [University of Otago] at 04:01 14 July 2015

School of Humanities and Social Sciences, Penn State Erie, The Behrend College, Erie, PA 16563

trauma. Using an archived collection of original surveys of double-amputee patients dating

largely from 1893 housed at the Historical Medical Library at the College of Physicians of Philadelphia, an interdisciplinary team explored the historical, anthropological, and psychological background of the study of combat trauma. Almost 30 years following the end of

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hostilities, the majority of the sample of U.S. Civil War veterans indicated that their general disposition, general health, and sleeping or eating patterns had changed following limb amputation. More telling, possibly, are the written comments on the surveys and letters that

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indicate frustration with continuous suffering and the knowledge of their mental and physical changes. These data illustrate the value of historical archives in documenting the development of

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Keywords: phantom limb pain, veteran, archives, war trauma, injury

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“My mind at times is stronger and active, then it is heavy and not so active. What is the cause I know not.” (E.W.)

Psychological and physiological effects of violent bodily injury have been the subject of extensive study, particularly focusing on experiences of veterans of combat (Stansbury et al.,

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2007). A review of recent literature demonstrates great concern for issues related to violent

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physical injury. Physiological concerns include, but are not limited to, assessing functional postamputation outcomes and use of prosthetic devices (Dillingham, Pezzin, MacKenzie, & Burgess,

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2001; Esquenazi, 2004; MacKenzie et al., 2004; Penn-Barwell, 2011), comparison of physical outcomes following amputation or salvage of damaged limbs (Doukas et al., 2013), changes in the rate of amputation within military contexts (Islinger, Kuklo, & McHale, 2000; Stansbury,

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the study of trauma and modern concepts of combat experiences.

Lalliss, Branstetter, Bagg, & Holcomb, 2008), and the phenomenon and treatment of “phantom limb pain” (Russell, 2008). Mental health outcomes, however, are also a primary concern when considering violent physical trauma, particularly as they interact with processes of rehabilitation and post-amputation reintegration into community settings (Melcer, Walker, Galarneau, Belnap,

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& Konoske, 2010; Phelps, Williams, Raichle, & Turner, 2008). In addition, empirical studies have suggested differences in mental health outcomes between patients recovering from amputations and those from limb reconstruction (Doukas et al., 2013; Ferguson, Richie, &

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Gomez, 2004), between patients experiencing upper, rather than lower, limb amputation (Cheung, Alvaro, & Colotla, 2003), and those coping with amputation following planned surgical amputation rather than accidental injury (Cavanagh, Shin, Karamouz, & Rauch, 2006;

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The interaction between injury event, functionality assessment, and mental health outcomes is

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not a new line of inquiry. Although the original posttraumatic stress disorder (PTSD) diagnosis was only introduced in the DSM-III (1980), the roots of observing and investigating outcomes that are now diagnostically categories are centuries old (Birmes, Hatton, Brunet, & Schmitt,

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2003). Additionally, we are introduced to the intellectual, academic, and research roots of the modern field of traumatology, as new research suggests that American Civil War veterans may

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have experienced symptoms consistent with our current understanding of PTSD (Horowitz, 2015). The time period surrounding and following the American Civil War began the first foray

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into the scientific study of traumatic stress due to the catastrophic effects of improved warfare technology (Bentley, 2005) and a more rigorous adoption of the scientific method in the field of medicine (Cervetti, 2012). In his discussion of “railroad spines” or the emotional and physical

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Kratz et al., 2010).

distress due to severe railway accidents, John Eric Erichsen (1866) ascribed the psychological distress experienced by victims purely to physical injury of the nervous system. In contrast, Herbert W. Page (1885) attributed the symptoms to psychological origins. Jacob M. Da Costa (1871; Paul, 1987) described traumatic stress symptoms occurring in both men and women

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(including symptoms of breathlessness, racing heart, chest pain, and nervousness) as “soldier’s irritable heart” and “Da Costa’s effort syndrome”. In France, the neurologist Jean-Martin Charcot (1887) began his taxonomist research into posttraumatic and dissociative experiences in

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“hysteria”. Charcot rejected the notion that hysteria was a disease of the female reproductive system and used his clinical methods to describe and define it as a nervous system disorder. His work with three French women who were patients at the Salpêtrière Hospital in Paris showed

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associated with dissociative and hysterical symptoms (Hustvedt, 2011). Charcot’s work would

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eventually influence Pierre Janet (1887) and Josef Breuer and Sigmund Freud (1896/2000), his efforts and consultation on these and other cases guiding them in developing psychoanalytical theories on the hysteria and other mental health issues. Much of our current understanding of

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traumatic stress and dissociation dates back to these early pioneers.

Somewhat lost to history is the contribution of Silas Weir Mitchell, a physician working in

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Philadelphia, Pennsylvania during the American Civil War through the turn of the 20th century. A colleague and friend of Da Costa’s at Turner’s Lane Hospital during the 1860s (as well as an

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influential force for Charcot [Goetz, 1997]), Weir Mitchell was a prominent physician, physiologist, and researcher during and after the war (Cervetti, 2012). Well-known for his research of the effects of rattlesnake venom, in 1871 Weir Mitchell coined the term “phantom

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how physical and sexual abuse, violence, abandonment, and loss experienced early in life were

limbs” and published extensively on the effect of the pain of amputation on soldiers and other accident victims (J. K. Mitchell, 1895; S. W. Mitchell, 1871; S. W. Mitchell, 1872; S. W. Mitchell, Morehouse, & Keen, 1864; Wartan, Hamann, Wedley, & McColl, 1997). His interest in dissociative processes of the mind extended beyond his experience treating phantom limbs, as

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evidenced by his publication of a very comprehensive case study of Mary Reynolds, a Pennsylvania woman who experienced a long-standing and severe case of dissociative identity disorder (S.W. Mitchell, 1889). Less well-known was Weir Mitchell’s labeling of soldiers’

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anxiety and irritability in response to physical injury, amputation, and other illness as “hysteria” and “neurasthenia” (Cervetti, 2012). He was one of the first physicians to consider both physical and emotional trauma as the cause of symptoms; and records from his time on staff at

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scientific study of medicine increased the diagnosis of “hysteria”, “neurasthenia”, and other

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traumatic stress symptoms exponentially during the 1870s through 1890s.

Following his experiences treating wounded soldiers, Weir Mitchell developed an early understanding of the physical effects of nerve pain and degeneration following injury. In these

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early studies, he also alludes, periodically, to changes in patients’ mental states that accompanied such pain. Weir Mitchell and his co-authors noted in Gunshot Wounds and Other Injuries of the

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Nerves (1864) isolated instances of negative post-injury behaviors in a select number of patients. Memory loss, alcohol use, and changes in mood were identified, although Weir Mitchell and his

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colleagues did not necessarily make a direct association between mental outcomes and pain. Interestingly, Weir Mitchell and his colleagues do chide physicians who doubt the experiences of the injured patients. In one circumstance, a soldier was assessed by a U.S. Army inspector and

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Philadelphia’s Orthopedic Hospital showed that his detail to psychosocial history and the

was suspected of falsifying pain and nervousness. In response, Weir Mitchell and his co-authors state,

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“We prefer to believe that, like many such cases which we have seen, he was rendered nervous by the presence of others from the fear of being hurt; and hence arose the fact, that when along he was so much more free from the exhibition of nervousness” (1864,p. 118).

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In the 1872 Injuries of Nerves and Their Consequences, he notes the case of a solider wounded at

Gettysburg (J.C.) who was shot through the neck and upper shoulder. Of this case, Mitchell

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memory being impaired and his temper excessively irritable” (p. 65). Similar negative mental outcomes – including “melancholy” and “bad” memory – were also noted for a second case.

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(S.W. Mitchell, 1872, p. 66). Although certainly not sympathetic in many cases, these early testimonies by Weir Mitchell document a growing awareness that combat injury might be related to deterioration of mental function.

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In the 1890s, Weir Mitchell (joined by his son, John K. Mitchell) conducted a survey study of survivors of limb amputation following violent trauma (Civil War artillery injury, exposure

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injuries, and locomotive accidents, for example; Mitchell, 1863-1906). Many of their patients,

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including all of the participants of the survey described here, were double amputees. Until this time, the majority of the writing on traumatic stress, “hysteria”, and “neurasthenia” consisted of theoretical texts and extensive case studies (e.g., DaCosta, 1871; Erichsen, 1866). And while the

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(1872) writes, “…he showed very plainly that the mind as well as the body had suffered,- his

majority of the questions on the survey focused on phantom limb pain, some of the questions address psychological symptoms of traumatic stress and may be the first scientific survey of traumatic stress symptoms undertaken in the United States.

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The present study illustrates the value of using primary resources to more fully understand the development of trauma as an area of inquiry. The Weir Mitchell surveys have been available for a number of years at the Historical Medical Library at the College of Physicians of Philadelphia

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(Mitchell, 1863-1906), but remained largely unused (A. Brogan, personal communication, February 19, 2014). Scholars of many disciplines, including traumatology, can benefit from awareness and use of historical archives. Historians, with the goal of recapturing event details,

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Katifori, Vassilakis, Lepouras, & Halatsis, 2010). Recent studies (Bernstein, 2007; Biber, 2013;

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Fealy, McNamara, & Geraghty, 2010), have explored the role, treatment, and use of archives in academic disciplines such as criminology, nursing, and the study of trauma. The purpose of this study is to present archival information in such a manner as to enrich our modern understanding

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Method

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of combat trauma and post-traumatic stress.

The dataset consists of two components: 14 physical surveys completed by Union

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veterans, in addition to nine letters written by participants and non-surveyed participants. The survey was composed of a 3-page instrument with a total of 66 questions ranging in subject from

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often use a combination of intuition and scientific approach to find archived material (Elena,

nature of wound and pain, symptoms of physical and behavioral changes, and experiences with artificial limbs and mobility appliances. In the case of three participants (H.K., C.R., E.W.), letters accompanied the surveys; the 6 additional letters were written by individuals who appeared to have been informed of study recruitment or were aware of Weir Mitchell’s interest in veteran amputees. Statistics presented here represent the frequency of answers in the 14

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surveys; additional qualitative information is presented from the letters to supplement survey answers. Surveys and additional material collected by Weir Mitchell are now curated in the Historical Medical Library at the College of Physicians of Philadelphia (Mitchell, 1863-1906).

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Material relating to Weir Mitchell’s study of amputees was provided to us as high-resolution digitally-scanned reproductions produced by Historical Medical Library staff. Details of the Weir Mitchell archives can be found on the Philadelphia Area Consortium of Special Collections

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website:

http://dla.library.upenn.edu/dla/pacscl/detail.html?id=PACSCL_CPP_CPPMSS2024103.

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Measures

The data presented herein represent a subset of survey questions related to symptoms and behaviors that have the potential of being related to behavioral and experiential criteria of PTSD

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as presented in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). Weir Mitchell did not include direct questions

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that measure the current PTSD criteria (such as intrusive symptoms, avoidance of trauma-related

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stimuli, negative changes in mood and thought, or increased arousal and hyperreactivity), nor was the primary concern of Weir Mitchell signs of war-related mental trauma. Instead, the surveys focus on documenting the existence of dissociative phantom limb sensation and pain

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Libraries

following a traumatic wound. A subset of questions, however, document a growing recognition following the American Civil War that physical, mental, and behavioral changes might be associated with traumatic injury. The following 11 survey questions are the focus of the present discussion (see Table 1):

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1. Character of wound; 2. Symptoms during this period: (at time of injury)

4. Symptoms following operation - pain - character?

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6. Have there been alterations of…disposition? 7. Have there been alterations of…habits?

8. Is there any alteration in the amount of sleep or of solid or liquid nourishment required?

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9. Was the amputation followed by any marked change in your ability for mental or bodily exertion?

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10. Do you still feel the lost part?

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11. How much of the limb do you feel now, and how does the feeling differ from what it would be if the member were present?

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5. Has the loss of your member altered the general health?

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3. Symptoms following operation - shock?

Data Analysis For each of the identified focus questions, codes were assigned for the responses to give a general impression of the nature of answers (see Tables 1 and 2). Given the small number of

respondents and the nature of the survey questions, only simple frequencies were calculated to

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indicate trends of answers. Quantitative trends are supported with sample qualitative data to illustrate severity of symptoms or self-evaluation of conditions by the participants.

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Results All 14 survey respondents were double-amputees, with 6 (42.9%) living with double arm

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time of the survey (1893), the veterans had spent an average of 28.6 years (SD = 3.01; range 19 –

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32 years) as amputees. The average age at injury in the sample was 26.9 years (SD = 6.73; range 17 – 39 years). The specific nature of the injury was indicated in eight of the surveys and letters. Two veterans (H.H., H.K.) were wounded by “minié balls,” conical soft lead bullets that were particularly destructive to muscle and bone tissue due to flattening upon impact (Bourke, 2009;

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Herschbach, 1997). One (D.F.) was injured by the explosion of a shell. Another (F.M.) lost both arms to premature cannon discharge. A final four veterans provided details of their injury, with

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two (S.P., C.R.) suffering crushing injuries in locomotive accidents and two (H.V., E.W.) losing limbs to combinations of frostbite and gangrene. The remaining twelve survey participants and

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letter authors did not specify the nature of their wounds. A final letter included in the sample (L.B.) was included in qualitative analysis as it detailed recovery from a torso and spinal injury.

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amputations, 5 (35.7%) double leg amputations, and 3 (21.4%) arm and leg amputations. At the

All of these individuals would currently meet the DSM-V (APA, 2013) Criterion A.1, direct exposure to a stressor, due to the nature of their injuries. The majority of survey respondents indicated pain at the time of the injury and following the operation (8 [57.1%] and 10 [71.4%], respectively), and provided supplemental comments

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recounting their experiences. R.D. characterizes his pain as “extraordinary” whereas F.M. indicates that he “suffered intensely” following the operation. In relaying his experience, H.V. indicated that he suffered a “terrible shock to my nervous sistem [sic]” and explains in other

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areas of the survey that he lost his speech for a time following the amputation of his feet after a 17-day treatment of frostbitten feet in 1874. Finally, in a separate area of the survey, C.G. further describes his experience writing, “The pain was sharp and lacerating in the bones after each

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could be understood as dissociative reactions consistent with both acute and posttraumatic stress

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responses.

Seven of the 14 survey respondents (50%) indicated that their general health suffered following the loss of their limbs. Eight (57.1%) responded that their disposition changed in some

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way, with four of the veterans clearly indicating negative outcomes in regard to changes in “disposition”. For example, phrases like “cranky” (R.D.), “nervous” (D.F.), “irritable” (L.H.,

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F.M.), and “quick temper” (H.K.) were utilized. One veteran, D.F., who lost both arms to a shell explosion, stated he “had a nervous dyspopsion [sic] for [the] past 12 years.” These symptoms

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are consistent with current PTSD symptoms of Criterion E: alterations in arousal and reactivity (APA, 2013). Only one respondent, C.G. detailed a more positive change in outcomes (“less irritable”). Upon closer examination, this may be explained by the 14-year gap between injury to

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operation until after the shock or reaction, then suffered no pain.” These latter two responses

his right leg, which was characterized by necrosis and treatment by calomel. Following amputation of the leg in 1879, other indicators on the survey suggest a general improvement of health.

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Changes in eating and sleeping habits were noted by 7 of the respondents (50%), consistent with the sleep disturbance symptoms of PTSD. Nine (64.3%) indicated changes to their ability cope with physical or mental exertion. While many of the positive answers were

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related to loss of mobility or physical exhaustion, changes to the ability to perform mental tasks was also mentioned – similar to the problems in concentration symptom of PTSD. S.P., who lost both feet due to a railroad incident in 1865, explained, “mental study is painful and I cannot

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Finally, all of the surveyed veterans indicated retention of sensation in the missing limb. Five

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(35.7%) and 2 (14.3%) of the 14 characterized the sensations as either pain or numbness, respectively. D.F., the veteran who had previously identified a 12-year struggle with nervousness wrote that he “can feel the whole of both limbs, [has a] hot sensation in both. This is

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continuous.” L.H., a veteran who also lost both arms to a shell blast and who was rescued after being thrown into water, describes, “the hands, pain in the fingers and thumbs all the time, it

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gives me no pease [sic].” H.K., who suffered a gunshot to the elbow, characterizes the pain in his hands and fingers as resembling “holding a pretty hot iron.” S.P., who lost both feet in a railroad

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accident stated, “It feels like feet were at the end of stumps, but terribly cramped.” E.D., who also lost both feet and eventually additional leg tissue in 1865 and 1866 explained, “It feels as if the foot was in the place where amputated, can feel the toes…seems as tied or bandaged.” Not all

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move…”

of the veterans who reported phantom limb sensation felt the limb in its entirety. For example, W.J., who lost both hands above the wrist in 1865 wrote, “I feel the hand but it feels like the fingers grew out at the wrist.” The phantom limb sensations, considered by Weir Mitchell to be partially dissociative in nature, can also be interpreted as a type of intrusive symptom. In some

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ways, the pain and phantom limb sensations keep the veteran in a constant state of reliving the memory of the experience and can also lead to intense and prolonged distress, as described by these veterans.

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Letters written to the original study team by the veterans also chronicle their experiences at the time of injury, during the recovery period, and in the decades that had lapsed since the end of the

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perspective that combines historical chronology with a sense of cynicism and defiance. This letter is so poignant that the majority of it is copied here so that readers can hear the patient, who

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was shot by minié balls in both the arm and leg in 1863: “Gentlemen:

Should you really find any interest as to how we criples [sic] get along can say that I think my

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general health has not suffered an [ounce] of my wounds. Still the inconvenience and being

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deprived of free bodily actions of course I constantly feel and therefore have to live accordingly. Should you want any particular description of my wounds would refer you to [Dr. Joseph] who

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at the time amputated both limbs for me, and thank him for his knowledge, kind heart, and my sound constitution all of which combined brought me through all right.”

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war. One soldier in particular, H.K. provided a statement that illustrates a multi-layered

In his letter, H.K. expresses knowledge of social judgment against “criples” [sic] as well as the

self-awareness of his own loss of freedom and a pressure to adapt to a world largely lacking in support. In some ways, his words echo a sense of separation and alienation from others (PTSD

Criterion D.6). He describes a keen appreciation for those who saved his life, as well as for his

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own ability to cope with the amputation. He does, however, demonstrate a separation of mind from the body, acknowledging a loss of freedom and change of lifestyle while remaining assertive in the state of his good health.

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Another of Weir Mitchell’s participants, C.R., lost both feet to a crushing accident by a

locomotive in 1865. C.R. describes post-operative sickness caused by morphine and “shock,” but

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been good.”). In a letter accompanying his survey, however, he further describes the pain he

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feels in the missing feet:

“My suffering has been severe at times in my feet that are gone…I call it double-geared lightning it is so severe.”

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He later provides a comment that illuminates some reasoning for participating in the study: “I shall hope you will find the causes and also be able to furnish…some relief.”

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C.R. clearly describes an on-going challenge with excruciating pain (using a colloquialism of the

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time, “double-geared lightning”), and anticipation that participating in research may provide him with resources for treatment.

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indicates neither his general health nor disposition changed after the event (he writes, “always

A similar note attached to a survey by E.W. also requests assistance in determining the cause of physical and mental distress: “If you will send me…what [doctors] …think of the caus [sic] of so much suffering.”

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In this short comment, E.W. reveals a desire to be given further information about his wounds – we assume his questions have not been previously answered to his satisfaction. In 1892, Weir Mitchell also received a letter from L.B., a veteran who had not suffered an

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amputation, but had instead been shot through the lungs and suffered from a spinal injury. His letter, though, provides some perspective on the medical establishment’s interest in nervous

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the point that he has sought treatment. It is unclear, however, if the author of the letter was referring to diseases of the nerves or in mental outcomes; the text, however, provides some

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weight to the latter: “Dear Sir,

Learning that you take somewhat of an interest in soldiers I write you regarding myself. I

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understand you have paid considerable attention to nervous disease…My greatest trouble

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however is nervousness and insomnia from which I have suffered extremely for the past 17 years. I have been treated by [several specialists]…and although I am much better than formerly,

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I am far from well.”

Of final note, in 1906 a two-page letter was addressed to Weir Mitchell, entitled “In matter of

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diseases. He describes struggling with nervousness and sleeplessness consistent with PTSD to

loss of limb.” In this letter, H.H., describes his experience as an amputee of the right arm as a

result of minié ball shot in 1863. In his narrative, he compares his physical limitations with the feelings and motion possible to him while dreaming. He writes,

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“…I drove every day while regaining strength. When a gust of wind would make…my straw hat…blow off, an attempt was involuntarily made to catch my hat with my right hand. This feeling…gradually grew less, until it entirely disappeared. And now, I never think of my right

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hand with any thought of using it. …Now for the curious part. Almost two-thirds of my life has passed [without the use of right

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dreamt that I was holding a paper up with my two hands. When I ride or drive, or cling to limb on the trees, or write, in my dreams, I always have the use of both my hands…Thus, in my

than a one-handed being.”

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dreams, I remain a man with a perfect frame, but while awake, I never think of myself otherwise

As H.K. above, H.H. expresses a separation of his bodily condition with his own cognitive

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perception of his reality, at least while sleeping. H.K., however, reports surprise at the fact that decades after his amputation, he cognitively maintains “a perfect frame” in his dreams, while

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noting that during waking hours, he has accepted the limitations of his situation.

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Discussion

Although small in number, the surveys and letters described here highlight the challenges Civil

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arm], and yet never have I dreamed once, that I was not without two arms, and only last night I

War veterans struggled with decades after their initial injuries. Taken together, many of the participants in the Weir Mitchell surveys seem to suffer from symptoms consistent with a diagnosis of PTSD (APA, 2013). They all have experienced an injury consistent with criterion A, and many report both intrusive symptoms (such as involuntary memories, dissociative reactions,

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and prolonged distress) and alterations in arousal and reactivity (irritability, hypervigilance, problems in concentration, and sleep disturbance). It is unclear from the data gathered by Weir Mitchell if the participants specifically engaged in effortful avoidance; the surveys did not

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specifically ask about these particular symptoms. However, the narratives of many of the participants do suggest the presence of negative alterations of cognitions and mood, especially feelings of estrangement from others. If we look at the recently proposed National Institute of

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PTSD, many of the domains listed in the criteria (such as negative valence systems, perception,

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effortful cognitive control, and arousal) are addressed in the self-reports of these veterans. Modern structured studies on mental and physical outcomes exhibited by veteran amputees provide a comparative context for the Weir Mitchell survey participants. The Civil War era

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sample struggled with sleep interruption and fatigue, in addition to reporting changes in their mood. Of the approximately 66% of OEF/OIF veterans reporting a negative mental health

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outcome, 20.4% demonstrated mood disorders and 25.4% report anxiety. An additional 6.8% also reported non-organic sleep disorders in the first months following amputation. Half of the

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Weir Mitchell survey respondents reported sleep pattern disruptions. Nine of the 14 reported mental and physical fatigue, with at least one (S.P.) linking pain with mental fatigue. Several of the respondents also indicated a nervousness related to ongoing pain or the sensations of the

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Mental Health’s (NIMH) Research Domain Criteria (RDoC; NIMH, 2014) as they relate to

missing limb (recalling the aforementioned 1872 cases of J.C. and L.P.). Although rare in the surveys, some (H.V., for example) did mention the “shock” of the event (injury and amputation) as an element that has added to their struggles.

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Introduced by Weir Mitchell, phantom limb sensation (PLS) and pain continue to be studied by modern neurologists as a condition commonly reported by upper- and lower-limb amputees as somewhat dissociative in its nature. PLS is not associated with one particular form of physical

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trauma that results in limb amputation; indeed, it appears to be more frequently reported than not. Given potential differences for coping mechanisms and psycho-social resources following a particular context of injury (civilian versus military), veteran populations provide a similarity of

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spontaneity of injury and immediacy of amputation (Melcer et al., 2010). Although no less

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extreme an experience, this context differs, for example, from amputee populations whose limbs were removed as part of treatment to degenerative nerve or circulatory disease. The surveys included here illustrate how historical archives can be used to gain a full appreciation for the experiences of combat veterans (and others suffering with severe physical trauma) over time and

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across eras of psychological study. While limited in scope, we believe these data illustrate a history of veteran experience with physical trauma, medical treatment, coping mechanisms,

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posttraumatic stress, dissociation, and negotiating social stigma.

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The Weir Mitchell survey participants extend our historical understanding combat trauma and the effects of amputation in a way that is consistent with what current veterans report. In a survey of 526 British veterans (Falklands War, World War II, and World War I) who all had at least one

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comparison for type of injury (resulting from artillery shot or explosive devices) as well as

limb amputated following a traumatic injury (89% during military service), almost 68% of the sample reported phantom sensations, with 56.6% specifying some form of PLS (Wartan et al., 1997). Most commonly the pain was described as “stabbing” (24.3%) or as “pins and needles” (20.5%). In 44% of the British sample, the phantom pain was reported to maintain its severity

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over time, whereas an additional 3% reported it increased. The Weir Mitchell survey participants also report a range of sensations related to their lost limb, including stabbing pain, numbness, or the sensation of heat. The British combat sample population is of particular comparative value to

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the Weir Mitchell sample as 87% of the surveyed veterans had been living as an amputee for at least 30 years (Wartan et al., 1997). With this, a linkage can demonstrated with the Weir Mitchell respondents of long-standing pain and PLS symptoms. Interestingly, 8% of the British sample

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respondents requested assistance with treatment, at least one (D.F.) described a terrible

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experience with current treatment, finding relief only with a later amputation of the injured limb. In a more recent investigation of American veterans active in hostilities in Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF), 55.5% of 382

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respondents reported phantom limb pain (Melcer et al., 2010). The OEF/OIF veterans reported a general decrease in PLS complications within the first 12 months post-injury, although some of

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the initial sample were lost to discharge (85.3% of the sample was available for 12-month review). At 12 months post-injury, 8.9% of the responding sample reported PLS symptoms.

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Significant differences were not found in PLS rates between upper and lower amputees. The difference in rates of PLS between the British sample (Wartan et al., 1997) and OEF/OIF veterans (Melcer et al., 2010) certainly deserves greater scrutiny. It is possible that with new

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avoided new treatments from fear of added complications. Whereas several Weir Mitchell survey

surgical techniques and treatment options (including medications), more recent veterans with traumatic amputation develop negative mental health outcomes (including PTSD) in a somewhat different context than earlier veterans.

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More recent medical studies have attempted to identify potential differences in mental and physical outcomes between patients who had limbs amputated and those whose limbs were largely salvaged or reconstructed. Bosse et al. (2002) found little functional difference between

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the two groups, although poor outcomes were associated with socioeconomic factors (including education level, insurance status, racial identification, and involvement in injury-related litigation). A second team of researchers found that amputees had lower rates of PTSD and a

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been salvaged. On the other hand, there were no differences between these groups in regard to

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depression, employment or school participation, or experience of pain that interfered with daily activities (Doukas et al., 2013). The Weir Mitchell surveys also include questions regarding evaluation of the utility of prosthetic limbs and complications experienced by the users. The respondents commonly listed several different “makes” and “models” of prosthetic equipment,

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commenting on their frustrations or success with each. Broadly, the Weir Mitchell participants reported mixed frustration levels with prosthetic devices and many refused or ceased usage.

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However, the depth of information on specific prosthetic devices and their relationship to

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recovery is limited and is therefore beyond the scope of our current investigation. Nonetheless, as similar questions have been asked of more recent combat veterans (e.g., McFarland et al., 2010; Reiber et al., 2010), an in-depth historical comparison with the Civil War survey

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higher likelihood of participating in sports activities in comparison to patients whose limbs had

participants would certainly be illuminating and provide further context to the historical discussion of the evolution of prosthetic use and its association with mental health outcomes and

phantom limb syndromes (Herschbach, 1997).

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Historical Perspectives on Socio-Political Issues The timing of these surveys in the broader socio-political context of the United States should

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also be mentioned in reference to understanding these voices from the past. As today, Civil War

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veterans faced increasing public scrutiny, as well as the burden to adapt to a changing post-war society. Peter Blanck (2001; 2002) provides a detailed background to the development of federal

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Union Army, Congress introduced the Civil War pension system in 1861, providing pensions for

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disabled soldiers, as well as widows and minor children of soldiers. In 1862, the General Law System was passed, providing soldiers with benefits with the documentation of several categories of war-related disabilities. The Pension Bureau required veterans to be examined by physicians and to provide “surgeon’s certificates”. The Arrears Act was passed in 1879, allowing

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veterans who had yet to file a claim to receive back payments to their service in the Civil War. Under pressure from significant political factions (primarily supporters of the Republican party),

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the 1890 Disability Pension Act was passed by Congress, expanding the pension system benefits

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to reflect terms of military service and additional disabilities. With the Disability Pension Act, veterans were not required to demonstrate that disabilities were war-related (Blanck, 2001). By 1893, the year most of the surveys discussed here were completed, veterans were aware of

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support to veterans during and following the end of the Civil War. To recruit soldiers for the

the deep social and political divide resulting from debates concerning the pensions system. At this point, 42% of federal income was accounted for by pension benefits and there was deep suspicion in the media of the veteran claims (Blanck, 2001). Critics accused claimants of being undesirable of the benefits and defrauding the American government. These critiques were also

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attached to public perceptions of the moral characters of the aging veterans. Moral, upright veterans were represented as individuals who would have no need (or would even be ashamed) to claim benefits; even the patriotism of those who filed claims, therefore, was suspect (Blanck,

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2001). Union and Confederate veterans, alike, were pressured to put the violence in the past in favor of a new unified American narrative. In some cases, veterans were asked to view their

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New evidence, in the form of photographs, was also being used as evidence submission to review boards and for memorializing the effects of the Civil War (Connor & Rhode, 2003).

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Nineteenth-century veterans found their claims for mental disabilities publically scrutinized and denied at higher frequency by doctors (Blanck, 2001). The medical establishment also passed judgment regarding the moral character of those struggling with dissociation and traumatic

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stress. Janet suggested that dissociation and traumatic stress were a sign of psychological weakness (Herman, 1997), and “hysteria” symptoms were often considered the domain of weak,

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malingering women (Cervetti, 2012). Mitchell himself described behavior accompanied by nerve pain in a similar manner in 1872, stating, “…owing as much to the horrible pain…some of these

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cases become what in a woman we should call hysterical, and by turns bewail their condition” (p. 62). In the same description, he continues they might also, “pitifully apologize for their want of manly endurance” (Mitchell, 1872, p. 62). The belief that psychological distress associated with

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injuries and experiences as a sacrifice to greater political or religious meanings (Fahs, 1999).

war experiences were due to a failure of a soldier’s willpower would continue through the Great War (World War I) and not be challenged until World War II (Fischer-Homberger, 1975).

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Civil War veterans faced increasing public scrutiny, as well as the burden to adapt to a changing post-war society. In the post-war years, public interest in the experiences of soldiers decreased to be replaced by a greater concern for national reconciliation (Fahs, 1999). Even well over 150

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years after the Civil War, we continue to see debates within the field of traumatology regarding the nature of named syndromes, such as dissociative identify disorder (DID) and PTSD. In the past century, different perspectives are presented both by medical professionals (as demonstrated

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(for example, the analysis of the 1946 “The Best Years of our Lives” by Gerber [1994]) – these

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debates illustrate our continued concern for those who experience traumatic events, understanding results of treatment and access to support resources, and deciphering the language of experience in the context of varied cultural lenses.

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Veterans of more recent conflicts are experiencing similar socio-political issues as the veterans of the Civil War. Grossman (1995) discussed the experience of unwelcoming

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condemnation many Vietnam veterans experienced when they returned, as social movements of the times were distinctly anti-war. Remnants of this condemnation remain, often characterized by

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the phrase “Support the troops but not the war” where citizens seek to find a balance between rejecting the financial and personnel costs of war while helping those who have risked their lives to fight them (Rieckhoff, 2011). More recently, the VA health system is under investigation

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by the comparative samples discussed in Jones et al. [2003]), as well as by the popular media

because backlogged cases, overcrowding, exorbitant wait times, and poor medical care (Zucchino, Carcamo, & Zarembo, 2014). Evidence is mounting that numerous veterans were discharged in other-than-honorable fashion when they were likely suffering from PTSD, making it difficult for them to receive medical and mental health benefits (Dao, 2012). Veteran

23

unemployment is twice the national average (Plumer, 2013), and between one fourth and one fifth of all homeless people in the United States are veterans (National Coalition for the Homeless, 2009). While the general public has been more accepting of the fact that veterans

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often struggle with PTSD and other mental health concerns after returning from service, media and news portrayals of veterans as dangerous, uncontrolled, “time bombs” are not only a misrepresentation of the majority of veterans but also damaging to their ability to reintegrate into

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and significant loss—we hope that by providing a richer understanding of the experience of

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veterans throughout time will mitigate these issues for future veterans.

Historical archives in trauma studies: an underutilized resource As demonstrated by the present study, the value of library archives is evident in the historical

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study of PTSD, dissociation, and combat-related trauma. The process for identifying and accessing archived materials, however, is not. Our somewhat serendipitous introduction to the

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existence of the surveys occurred as a result of one of them being put on public display at the

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Historical Medical Library of The College of Physicians of Philadelphia. Sorensen (1988) discusses, within a nursing context, avoidance of archives as a result of frustration stemming from a lack of archive use training and miscommunication with librarians. Sorensen (1988)

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civilian life (Howell, 2012). Even 150 years later, veterans continue to experience public scrutiny

warns, “This reluctance to seek archival resources may prevent the discovery of potentially valuable data by the nurse who has a promising interest in history but who lacks an awareness of archival procedures” (p. 667). This sentiment is echoed throughout the literature (Benjamin, 2005; Gao, 2014; Sorensen, 1988). Berenbak et al. (2010) surveyed Association of Research

24

Libraries members and found that 95% of respondents are actively participating in special collections engagement by staging exhibits and holding events similar to the one that facilitated the current use of the Weir Mitchell materials. Not only are libraries promoting their archives

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with traditional outreach approaches, many are taking advantage of virtual opportunities through blogs, social media, and other Web 2.0 technologies (Berenbak et al., 2010). There is also a widespread effort for libraries to digitize archived collections, which further enables the

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aids effective for researchers who lack archive use training. Resources such as Europeana,

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OAIster, and Texas Archival Resources Online [TARO] allow researchers to search collections from multiple libraries, but items are cataloged in such a way that popular keyword searching is often ineffective. Furthermore, institutions organize collection with various schemes, further complicating the retrieval process (Peake, 2012). At this point, it is advisable for researchers

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unfamiliar with accessing archives to build relationships with librarians who can assist with the research process and the use of controlled vocabulary, which is advantageous over keyword

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searching when using library catalogs.

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Conclusion

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dissemination of collections. However, one problem that persists is the issue of creating finding

Although Silas Weir Mitchell’s amputee sample is oft cited in reference to the history of phantom limb pain diagnosis (Wartan et al., 1997), there has been little discussion of the respondents as one of the first American veteran population surveyed following combat in service. Weir Mitchell himself later wrote extensively about the experience of the veteran and war-time physician in medical reports and in non-fiction pieces written for a larger American

25

audience (Bourke, 2009; Canale, 2002). Included in the survey are questions that provide tantalizing clues to the traumatic healing process of the respondents almost 30 years following their injury and amputation. These questions probe respondents’ perceptions of sleep and mood

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alterations, as well as their experience with prosthetic devices and lingering pain. Their voices illustrate the complexity of recovery at the dawn of federal recognition of veteran’s experiences during combat. The 19th century patients report sleeping difficulty, negative changes to mood

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about their conditions. Many of these symptoms are the foci of modern psychological analyses as

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we work to understand post-combat stress and PTSD. To our knowledge, ours is the first indepth analysis of the combined Weir Mitchell surveys with the goal of describing self-reported mental distress and traumatic response. Whereas surveys like these are often translated and condensed into quantified values appropriate for statistical testing, it behooves traumatologists

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and related practitioners to take a moment to “hear” these voices amplified only by fountain pen scratched upon 150-year old paper. Practitioners in other social services fields (i.e., disaster

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management or conflict resolution) would also benefit from a historical perspective on the

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cultural barriers to presenting and coping with trauma. These surveys also highlight observations on post-amputation and traumatic injury coping that were made apparent in a period pre-dating the medical recognition of post-traumatic stress symptoms. As the current paper started with

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and memory, increased anxiety, and a frustration at not being provided sufficient information

words representing the concerns of soldiers, so it will end. In a letter dated October 2, 1893, A.Q. begins a request for more information from the study team with words noting the worthiness of a study on veteran experiences with pain:

26

“Please allow me to congratulate you on your original thoughts and reasons. I assure you it will meet the hearty and admired approval of all wounded veterans.”

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Russell, M.C. (2008). Treating traumatic amputation-related phantom limb pain: A case study

among British veteran amputees. British Journal of Anaesthesia, 78(6), 652-659. doi: 10.1093/bja/78.6.652

35

Zucchino, D., Carcamo, C., & Zarembo, A. (2014, May 18). Growing evidence points to systemic troubles in VA healthcare system. The Los Angeles Times. Retrieved from

cr ip us M an ed pt ce Ac


t

http://www.latimes.com/nation/la-na-va-delays-20140518-story.html#page=1

36

Assigned Codes

Q1: Character of wound

AEA – Above Elbow Amputation

cr ip

Question

t

Table 1. Question and response code identification.

us

AKA – Above Knee Amputation

M an

BKA – Below Knee Amputation L – Left

ed

R- Right

ce

pt

Q2: Symptoms during this period

Ac


BEA – Below Elbow Amputation

1 = pain mentioned 2 = state of consciousness mentioned 3 = “shock” mentioned 4 = unspecified “suffering” or other condition 5 = loss of blood mentioned 6 = lack of pain described

37

7 = indicates being “rational”

Q3: Symptoms following operation – 0 = no shock?

2 = not answered

cr ip

t

1 = yes

us

M an

Q4: Symptoms following operation – 0 = no pain – character?

1 = yes (general affirmative)

ed

2 = yes (participant indicates great severity)

pt

cont.

ce

Table 1 (cont.)

Question

Assigned Codes

Ac


3 = participant indicates lack of knowledge

Q5: Has the loss of your member 0 = no altered the general health? 1 = yes (general affirmative answer)

38

2 = yes, positive (answer indicates positive change) 3 = yes, negative (answer indicates negative

there

been

alterations 0 = no

us

of…disposition?

cr ip

Have

1 = yes (general affirmative answer)

M an

2 = yes, positive (answer indicates positive change)

3 = yes, negative (answer indicates negative

Have

been

ce

of…habits?

there

alterations 0 = no

pt

Q7:

ed

change)

Ac


Q6:

t

change)

1 = yes (general affirmative answer) 2 = yes, positive (answer indicates positive change) 3 = yes, negative (answer indicates negative change)

39

4 = unanswered

Q8: Is there any alteration in the 0 = no

cr ip

1 = yes (general affirmative answer) nourishment required?

t

amount of sleep or of solid or liquid

2 = yes, negative (answer indicates more sleep

us

3 = yes, negative (answer indicates sleeplessness

M an

and/or inability to rest)

4 = yes, negative (answer indicates loss of appetite

ed

or interest in food)

pt

(cont.)

ce

Table 1 (cont).

Question

Assigned Codes

Ac


required or fatigued)

Q9: Was the amputation followed by 0 = no any marked change in your ability for 1 = yes (general affirmative answer) mental or bodily exertion 2 = yes, positive (answer indicates positive

40

change) 3 = yes, negative (answer indicates negative

Q10: Do you still feel the lost part?

cr ip

t

change)

0 = no

us

M an

Q11: How much of the limb do you 0 = no sensation feel now, and how does the feeling

1 = yes, part(s) of lost limb

differ from what it would be if the member were present?

2 = yes, entire limb

ed

3 = unable to describe

5 = numbness indicated

ce

pt

4 = pain indicated

Ac


1 = yes (general affirmative)

41

Table 2. Code assignment for 14 survey responses. Case Year

50

R.D.

1864

52

D.F.

1862

61

C.G.

1864

4,

RBEA

5

LAEA; RAEA

1

LBEA; RAEA

4

0

3

LBEA; RBEA

AEA; AKA

t 3

1

1, 5

3

0

0

1

1

2, 4

1

2

0

2

0

0

0

1

3

0

2

3

3

0

4

3

1

1, 4

1

0

2

1

0

0

0

1

1

1

1

1

2

0

0

0

0

0

1

2

ed 67

2

3

1

5

1864

1

0

3

RAEA

C.L.

0

3

1,

61

1

Q9 Q10 Q11

4

LAEA;

1865

2

Q8

3

4

W.J.

2

Q7

3

RAKA

51

Q6

2

1,

1863

Q5

3

LAEA;

54

ce

L.H.

LBEA;

Q4

cr ip

1864

Q2 Q3

pt

J.D.

Q1

us

Injury Age

Ac


Initial)

of

M an

(First, Last

42

C.R.

1865

59

H.K.

1863

52

L.S.

1863

51

H.V.

1874

1865

2

0

3

3

0

0

1

2, 5

1

2

1

1

1

2, 4

3

1

2, 4

6

1

0

0

0

2

0

1

LBKA;

1,

RBKA

5

LBKA; RBKA

AEA, AKA

LBKA;

2,

RBKA

7

LBKA; RBKA

pt

58

58

ce

E.W.

1

0

LBKA; RBKA

t

45

3

cr ip

1865

RBEA

0

2

us

S.P.

LAEA;

3

M an

58

0

1

2, 4

0

2

1

1

1, 4

0

0

0

0

0

0

0

1

2

1

3

2

1

0

0

0

1

1

2

1

1

2

1

1

1

2

3

1

1

ed

1861

Ac


F.M.

43

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Comments by the American Civil Liberties Union on "demagogues and mental health".

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Leaders: Privilege, Sacrifice, Opportunity, and Personnel Economics in the American Civil War.

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Anesthesia advances during the Civil War.

Youth mental health after civil war: the importance of daily stressors.

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The "forgotten man" of the Civil War: the Southern experience.

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The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers.

New North American Chrysauginae (Pyralidae) described by E.D. Cashatt.

Epigenetics and the war on mental illness.

Physical and mental health outcomes following housing improvements: evidence from the GoWell study.

Parity of esteem for mental and physical healthcare in England: a hundred years war?

Launching the 'war on mental illness'.

'Inner voices': the cerebral representation of emotional voice cues described in literary texts.

Combat and the Medical Mindset--The Enduring Effect of Civil War Medical Innovation.