Over the past twenty years, a solid body of research has emerged regarding Post-Traumatic Stress Disorder (PTSD) in the Civil War. Rather than looking at prevalence or debating the application of modern diagnostic criteria to the past, I think it’s useful to consider some of the following associated dynamics/concerns: How is PTSD different from combat stress reaction, why does it matter, and how did this impact the soldiers? How were women impacted by trauma? What were some of the traumas children experienced, and how were these different from those of adults? How did trauma shape the experience of returning veterans? The increased attention to and awareness of PTSD has resulted in most people having a basic understanding of it. In short, PTSD is a chronic, pervasive response to traumatic events. It can be marked by flashbacks or nightmares of the trauma, increased startle response to sounds, avoiding situations that remind a person of the traumatic event, and difficulty concentrating or thinking. The flashbacks aren’t simply remembering the event, they are a re-experiencing of it, where the individual feels she/he is there reliving that moment. Because of this, PTSD is thought of as a cyclical condition in which the brain is essentially trapped, repeatedly reliving the moment and trying to figure out a way to change the outcome. Often overlooked is the fact that a witness to traumatic events can be traumatized as well. This is similar to, but somewhat different from, a combat stress reaction (CSR) or sometimes known as “battle fatigue”. There can be a range of symptoms, including fatigue, irritability, slower response times, and trouble concentrating. Generally, these symptoms appear in combat soldiers and result in a general decrease in the mental and physical functioning of a soldier. These symptoms often don’t last for long, especially when they are treated effectively. CSR can develop in response to a distinct traumatic event, or from prolonged emotional/physical tension (e.g., occupying a forward position for an extended period without rest). With repeated trauma, CSR can develop into PTSD, but this isn’t always the case and depends on a number of individual and situational factors. During the Civil War, it’s likely that there were tens of thousands of men impacted by combat stress reactions. First-person accounts of the emotional and physical toll of battle are commonplace and unusually poignant. Letters, diaries, and memoirs give us a unique insight into a sudden explosion of combat stress that hadn’t been seen before. For example: “…And in my sleep I see nightly the gastly [sic] upturned faces of the dead and hear the groaning of the mangled and dying, the hissing of the shot and shell, the shouts and curses of the victorious and the shrill whistles of the musket ball, as it wings its flight of death.” John McGrath, 13th Louisiana “I never expect to be fully believed when I tell what I saw of the horrors of Spottsylvania, because I should be loth to believe it myself, were the case reversed…” Thomas Hyde, 6th Corps Other accounts hint at experiencing or witnessing things too horrible to recount, but it is clear that these events had a lasting impact on those that survived. A consideration of the effects of CSR sheds some light on a frequently posed question related to Civil War combat: why didn’t the victorious army pursue the defeated one? The question was posed with considerable frustration by President Lincoln during the War, and by generations of historians since. Considering that the traumatic impact of combat and witnessing combat can lead to increased heart rate, fatigue, and confusion (and add to those factors woolen uniforms and extended physical exertion), it makes more sense that soldiers were rarely in any condition – mental or physical – to pursue a beaten enemy. The impact of trauma on women during the war took different forms. For women who volunteered as nurses, the exposure to wounded and dying soldiers could have been a source of repeated trauma. On the home fronts, women, particularly in the Confederacy, were exposed to multiple forms of trauma, including combat (e.g., Siege of Vicksburg), robbery and economic losses during the 1864 Shenandoah Campaign and Sherman’s March, and rape (at least 335 documented cases are known). The extended deployment of men meant that women were often thrust into multiple highly demanding roles – breadwinner, sole parent, farmer, and others. While these are not necessarily traumatic, the sudden changes women faced could have placed them at risk for more severe stress reactions. Certainly the loss of husbands, fathers, brothers, and sons would only have heightened the stress for women, who were also challenging social, political, and economic norms of the 19th century. Reliable figures were hard to find, but common estimates indicate that approximately 20% of the combat soldiers in the Civil War were under 18 years of age. This does not include children who were allowed to enlist as musicians or in other noncombatant roles. While children and teenagers were exposed to the same traumatic events that adult soldiers were, it’s necessary to consider that children will experience and interpret these events differently from adults. Children are definitely resilient, meaning they can often “bounce back” from traumas more easily than some adults, even without treatment. Depending on the child, the severity of the trauma, and the frequency with which they are exposed, they may not recover easily. Children repeatedly exposed to severe traumatic events (including witnessing these events) can develop auditory hallucinations, have sleep difficulty, bowel/bladder problems, and mood swings. Their understanding of the trauma may be more limited, especially for younger children who tend to blame themselves for being traumatized. One can only imagine that children, separated from family and far from home, witnessing multiple battles, were impacted in ways that we may never know of. Civil War veterans returning to their homes had few, if any, resources available to help them process the ordeal they survived. While many veterans were able to resume their prewar lives, countless men were suffering from the long-term impact of PTSD and unable to cope. Flashbacks, nightmares, and difficulty thinking would have devastated surviving veterans, and without an understanding of these symptoms or outpatient treatment, alcohol abuse was a common method for keeping symptoms under some control. A striking testament to the increase in PTSD is in the number of individuals committed to mental institutions: in 1861, there were approximately 8,500 people institutionalized. By 1866 the number had doubled, and continued to double every ten years for the next fifty years. Hospitalization reportedly was effective in the short term, but apparently didn’t last long when men were discharged. Many veterans were hospitalized repeatedly or incarcerated, and were often perceived as dangerous. Fortunately, treatment options improved at the end of the 19th century, and for Union veterans, military pensions provided some measure of economic support for disabled men. No such support system was available for Confederate veterans, unfortunately, resulting in some men becoming homeless. What can we learn from all of this? One of the clear conclusions is that trauma left thousands of unseen casualties in its path. Men who were legitimately traumatized may have been seen as weak, cowards, or unpatriotic. Those exposed to repeated trauma, typically men who served for extended periods, often had the worst outcomes, or at least this is suggested by modern research and anecdotal data. Women and children were also exposed to multiple forms of trauma unrecognized by history’s focus on battles and leaders. Understanding how the War impacted soldiers and civilians requires us to consider the invisible, but very real, wounds inflicted by trauma.  Clarke, D. (1996). Post-Traumatic Stress Disorder and the American Civil War: A Reappraisal. Accessed March 9, 2017. http://www.academia.edu/5812575/Pos...rder_and_the_American_Civil_War_A_Reappraisal.  Talbott, J. (1996). Combat Trauma in the American Civil War. History Today, 46 (3).  Alexander, E. (2013). Life of the Civil War Soldier in Battle. Accessed March 9, 2017. http://www.civilwar.org/hallowed-gr...013/life-of-the-civil-war-soldier-battle.html  Ransom, R. (2001). Economics of the Civil War. Accessed March 9, 2017. URL http://eh.net/encyclopedia/the-economics-of-the-civil-war/  Stutzman, M. (2009). Rape in the American Civil War: Race, Class, and Gender in the Case of Harriet McKinley and Perry Pierson. Accessed March 9, 2017. http://www.albany.edu/womensstudies/journal/2009/stutzman.html.  Clarke, D. (1996)  Ibid.