Sunday, July 10, 2016

Civil War Medicine and Scientific Advances: Emergence of Neurology as a Specialty in the United States


As a new medical specialty, American neurology developed in the mid- and late-nineteenth century under the influence of three primary forces: European Medicine and Scientific Advances, the American Civil War and the particular American penchant for Medical Specialization or Specialism. Founded in European traditions, American neurology developed and expanded rapidly with the greatest concentration of activity in Philadelphia, Boston and New York. Whereas Americans interested in advanced specialty training originally traveled to Paris, Berlin, London, or Vienna, by 1900, important neurological hospitals, laboratories, and outpatient specialty services in the United States attracted American students and physicians to remain in this country for their training. Furthermore, the reverse flow of Europeans coming to study in the United States began.

European Training
The scientific and medical infrastructure of American neurology was European in origin, although Americans borrowed eclectically and modified the European traditions. The Bernardian concept of Experimental Medicine was crystallized in America by Brown-Séquard who visited the United States on multiple occasions and served briefly on the faculty at Harvard Medical School in 1866 and 1867. Medically, neurology in Europe grew from two distinct models, as an outgrowth and subdivision of internal medicine as seen prototypically in France, and as an ally and anatomically-based offspring of psychiatry, as typified by the Viennese school. J.M. Charcot, perhaps the most celebrated nineteenth century neurologist, was trained as an internist, and his early research and testing effort focused on rheumatological and geriatric medicine. Charcot's studies of rheumatoid arthritis and tabetic (Charcot) joints led him to investigate peripheral and central nervous system pathology. Meynert, on the other hand, entered neurological research from the primary vantage point of psychiatry, the field to which the Germanic and Prussian schools had heretofore designated the study of general paresis of the insane, epileptic fits, and most encephalopathies.

These two European traditions were simultaneously incorporated in the United States to form early neurological programs particular to America in the form of neurological professorships, teaching services, and research efforts. Working simultaneously from the two disciplines of internal medicine and psychiatry, American neurology sculpted itself with close links to both traditions, creating some neurological activities directly out of medical departments, and creating others out of psychiatric asylums and other institutes. The titles of early American neurological professorial chairs, the names of early journals and societies, and the background of physicians who eventually became known as neurologists are all clear testimony to the double-image, or Janus evolution, of American neurology in its early years.

American Civil War
The American Civil War was incontestably the primary local historical event pivotal to the development of neurology in the United States. The gamut of neurological injuries seen among soldiers on both sides and the coalescing of an identified group of US physicians interested in neurological studies provided the setting for distinctive American contributions to the developing field. Shortly after William A. Hammond was named US Surgeon General, he became acutely aware of the breadth of war-related peripheral and central nervous system injuries among Union soldiers. Administratively, Hammond contributed fundamentally to the institutionalization of neurology in the United States by establishing Turner's Lane Hospital in Philadelphia, the site of S. Weir Mitchell's, Keen's, and Morehouse's seminal work on various nervous system disorders during the war. In developing a hospital devoted specifically to neurological military injuries and their study, Hammond provided the first American site for focused neurological investigation. This war-time model was incorporated to post-war Philadelphia medicine in the form of the celebrated Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases. The Civil War provided American physicians with case material for journal and monograph publications on peripheral nerve injuries, post-traumatic epilepsy, neurasthenia, malingering, and many other areas of neurological study. These publications brought international attention to American neurologists in the post-war era. During the Reconstruction Era, Hammond and Mitchell carried their war-time organizational skills and commitment to neurology in other civilian settings and helped to develop new neurological services, educational programs, journals and textbooks that solidified American neurology in the international medical arena.

During the second half of the nineteenth century, two primary medical factors fostered the emergence of neurology as a separate clinical specialty. First, and largely due to European scientists, an unprecedented and exponential growth of neurological knowledge occurred during this period. Second, a general movement towards subdivisions of medical practice internationally was already in full development in France, Great Britain, and the Prussian states. Initially, many American general practitioners of the era resisted specialization, and specifically neurological specialization, as a challenge to the established practice of medicine. In a sarcastic 1881 editorial, Specialism on the Rampage, one such clinician stated:

  "We noticed the appointment of a very worthy physician in an eastern city as 'Neurologist of the Hospital' which title he assumes in writing as an author. Cannot some other specialties be created to give positions to other aspiring gentlemen? Why not have a Pneumatologist to attend to the lungs -- a Thermatologist to observe temperature -- a Narcotizer to see that the patients sleep well -- a Defecator to attend to the bowels?"

Despite this condemnation, select American medical institutions embraced the initiative to support specialists and established lectureships, specialty clinics, and services devoted specifically to neurology. The growing wealthy class of the Industrial Revolution willingly supported specialized treatment of their ailments and made specialization financially rewarding. Without accreditation mechanisms in place at the local or national level, however, marketing strategies, rather than in-depth education, created some American "specialists" of questionable qualifications. This dilemma led to substantial re-evaluation of specialization movements at the very end of the nineteenth century, and neurology, along with other new specialties, realigned themselves with general medicine or consolidated their specialties with alliances to other specialties. In the case of neurology, early efforts to separate from psychiatry were partially reversed by this concern of isolationism, and closer ties were established in the early years of the twentieth century, a movement that ultimately culminated in the unification of a single Board of Psychiatry and Neurology in the mid-1900's.

Image: Dr. Mitchell examining a Civil War veteran at the Clinic of the Orthopaedic Hospital,


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