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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.

Specialization

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.

Recommended Reading: Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine (Hardcover) (416 pages) (Random House). Description: A landmark chronicle of Civil War medicine, Bleeding Blue and Gray is a major contribution to our understanding of America’s bloodiest conflict. Indeed, eminent surgeon and medical historian Ira M. Rutkow argues that it is impossible to grasp the harsh realities of the Civil War without an awareness of the state of American medicine at the time. At the outset of the war, the use of ether and chloroform remained crude, and they were often unavailable in the hellish conditions at the front lines. As a result, many surgical procedures were performed without anesthesia in the compromised setting of a battleground or a field hospital. This meant that “clinical concerns were often of less consequence,” writes Rutkow, “than the swiftness of the surgeon’s knife.” Continued below...

Also, in the 1860s, the existence of pathogenic microorganisms was still unknown–many still blamed “malodorous gasses” for deadly outbreaks of respiratory influenza. As the great Civil War surgeon William Williams Keen wrote, “we used undisinfected instruments from undisinfected plush-lined cases, and still worse, used marine sponges which had been used in prior pus cases and had been only washed in tap water.” Besides the substandard quality of wartime medical supplies and techniques, the combatants’ utter lack of preparation greatly impaired treatment. In 1861, the Union’s medical corps, mostly ill-qualified and poorly trained, even lacked an ambulance system. Fortunately, some of these difficulties were ameliorated by the work of numerous relief agencies, especially the United States Sanitary Commission, led by Frederick Law Olmsted, and tens of thousands of volunteers, among them Louisa May Alcott and Walt Whitman. From the soldiers who endured the ravages of combat to the government officials who directed the war machine, from the good Samaritans who organized aid commissions to the nurses who cared for the wounded, Bleeding Blue and Gray presents a story of suffering, politics, character, and, ultimately, healing. About the Author: Ira M. Rutkow is a clinical professor of surgery at the University of Medicine and Dentistry of New Jersey. He also holds a doctorate of public health from Johns Hopkins University. Dr. Rutkow’s Surgery: An Illustrated History was a New York Times Notable Book of the Year. He and his wife divide their time between New York City and the Catskills.

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Related Reading:

 
Recommended Reading: Civil War Medicine: Challenges and Triumphs (Hardcover) (475 pages). Description: Nothing is left unstudied! Alfred Jay Bollet covers a multitude of areas in the world of the medical care/treatment featuring early war ill-preparation, being overwhelmed, medical science, surgery, amputations, wounds, hospitals, drugs, diseases, prison camps and notable individuals of the era. Every chapter offers added insight via biographies on individuals that had influence on the subject discussed—thus adding more intrigue to this book. Continued below...
This book is considered very comprehensive and fair to all parties involved…often bringing to light the importance of doctors and nurses through out the entire war and its aftermath. Numerous sidebar articles appear throughout the text to embellish points of interest and a nice appendix is provided, as well as countless charts offering statistical data. Bollet's style is very reader friendly - you don't have to be that “med student” to enjoy it!
 
Recommended Reading: The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. Inside Flap: For both clinicians and their clients there is tremendous value in understanding the psychophysiology of trauma and knowing what to do about its manifestations. This book illuminates that physiology, shining a bright light on the impact of trauma on the body and the phenomenon of somatic memory. It is now thought that people who have been traumatized hold an implicit memory of traumatic events in their brains and bodies. That memory is often expressed in the symptomatology of post-traumatic stress disorder--nightmares, flashbacks, startle responses, and dissociative behaviors. Continued below...
 In essence, the body of the traumatized individual refuses to be ignored. While reducing the chasm between scientific theory and clinical practice and bridging the gap between talk therapy and body therapy, Rothschild presents principles and non-touch techniques for giving the body its due. With an eye to its relevance for clinicians, she consolidates current knowledge about the psychobiology of the stress response both in normally challenging situations and during extreme and prolonged trauma. This gives clinicians from all disciplines a foundation for speculating about the origins of their clients' symptoms and incorporating regard for the body into their practice. The somatic techniques are chosen with an eye to making trauma therapy safer while increasing mind-body integration. Packed with engaging case studies, The Body Remembers integrates body and mind in the treatment of post-traumatic stress disorder. It will appeal to clinicians, researchers, students, and general readers.
About the Author: Babette Rothschild, MSW, LCSW, has been a practicing psychotherapist since 1976. Author of 8 Keys to Safe Trauma Recovery and the best-selling The Body Remembers, and member of the International Society for Traumatic Stress Studies, she gives lectures and professional trainings around the world. She lives in Los Angeles.
 
Recommended Reading: When the Air Hits Your Brain: Tales from Neurosurgery. Description: "Dramatic, moving, and utterly fascinating." —New York Times Book Review. With poignant insight and humor, When the Air Hits Your Brain chronicles one man’s evolution from naïve and ambitious young intern to world-class neurosurgeon. In electrifying detail, Frank Vertosick Jr. describes some of the greatest challenges of his career, including a six-week-old infant with a tumor in her brain, a young man struck down in his prime by paraplegia, and a minister with a .22-caliber bullet lodged in his skull. Continued below...
Told through intimate portraits of Vertosick’s patients and unsparing yet fascinatingly detailed descriptions of surgical procedures, When the Air Hits Your Brain—the culmination of decades spent struggling to learn an unforgiving craft—illuminates both the mysteries of the mind and the realities of the operating room.
Inside Flap: "This book should be read by every medical student, doctor and present or potential patient. In other words, by all of us."
--Dr. Bernie Siegel, author of Love, Medicine and Miracles
Rule One for the neurologist in residence: "You ain't never the same when the air hits your brain." In this fascinating book, Dr. Frank Vertosick brings that fact to life through intimate portraits of patients and unsparing yet gripping descriptions of brain surgery.
With insight, humor, and poignancy, Dr. Vertosick chronicles his remarkable evolution from naive young intern to world-class neurosurgeon, where he faced, among other challenges, a six week-old infant with a tumor in her brain, a young man struck down in his prime by paraplegia, and a minister with a .22 caliber bullet lodged in his skull. In candid detail, WHEN THE AIR HITS YOUR BRAIN illuminates both the mysteries of the mind and the realities of the operating room.
About the Author: Frank Vertosick Jr., MD, is the author of Why We Hurt and The Genius Within. He retired from surgery due to Parkinson’s disease in 2002, but he still treats office patients in Washington, Pennsylvania.

 

Recommended Reading: Doctors in Gray: The Confederate Medical Service (339 pages) (Louisiana State University Press). Description: Horace Herndon Cunningham has created a comprehensive history of the "Confederate medical services in the Civil War." Cunningham explains in great detail the many afflictions and circumstances that befell Confederate soldiers and ultimately resulted in medical treatment by the Confederate doctor. Ironically, his research reflects that the majority of the ill and wounded soldiers who died had expired due to a burgeoning and developing medical system. Continued below...

Medical advancements, however, had progressed from primitive to slightly better by the end of the conflict. Cunningham further explains that while the Confederate doctors did the best that they could with their resources and shortcomings, there were some exceptional doctors who aided in the advancement of both medicine and medical treatment.

 

Recommended Reading: Gangrene and Glory: Medical Care during the American Civil War (University of Illinois Press). Description: Gangrene and Glory covers practically every aspect of the 'medical related issues' in the Civil War and it illuminates the key players in the development and advancement of medicine and medical treatment. Regarding the numerous diseases and surgical procedures, Author Frank Freemon discusses what transpired both on and off the battlefield. The Journal of the American Medical Association states: “In Freemon's vivid account, one almost sees the pus, putrefaction, blood, and maggots and . . . the unbearable pain and suffering.” Continued below...

Interesting historical accounts, statistical data, and pictures enhance this book. This research is not limited to the Civil War buff, it is a must read for the individual interested in medicine, medical procedures and surgery, as well as some of the pioneers--the surgeons that foreshadowed our modern medicine.
 
Recommended Reading: This Republic of Suffering: Death and the American Civil War. Editorial Review from Publishers Weekly: Battle is the dramatic centerpiece of Civil War history; this penetrating study looks instead at the somber aftermath. Historian Faust (Mothers of Invention) notes that the Civil War introduced America to death on an unprecedented scale and of an unnatural kind—grisly, random and often ending in an unmarked grave far from home. Continued below...
She surveys the many ways the Civil War generation coped with the trauma: the concept of the Good Death—conscious, composed and at peace with God; the rise of the embalming industry; the sad attempts of the bereaved to get confirmation of a soldier's death, sometimes years after war's end; the swelling national movement to recover soldiers' remains and give them decent burials; the intellectual quest to find meaning—or its absence—in the war's carnage. In the process, she contends, the nation invented the modern culture of reverence for military death and used the fallen to elaborate its new concern for individual rights. Faust exhumes a wealth of material—condolence letters, funeral sermons, ads for mourning dresses, poems and stories from Civil War–era writers—to flesh out her lucid account. The result is an insightful, often moving portrait of a people torn by grief. 

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