Between Flesh and Steel (33 page)

With the cessation of hostilities, the Union Army and its military medical service were demobilized. By the end of 1866, the Union Army had been reduced to a force of only 30,000 men.
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The army and its skeleton medical corps were scattered among 239 military posts stretching from Alaska to the Rio Grande. By 1869, the entire medical service comprised no more than 161 medical officers, and the frontier posts were forced to rely on civilian contract surgeons, which increased to 282.
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Although a young doctor could make more money in military service than he could in the first few years of his own practice, the shortage of military doctors remained a chronic problem. One reason was that the army maintained much higher entrance and training requirements than were generally found for civilian physicians.
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In 1862, Surgeon General Hammond ordered the establishment of the Army Medical Museum in Washington, D.C., to collect and study artifacts and information relevant to military medical care. In 1865 when John Shaw Billings (1836–1913) became director of the Library of the Surgeon General's Office of the Army,
he soon built it into the largest military medical library in the world, and the collection remains so today.
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After the war, Congress established a pension system for disabled soldiers that was far more generous and comprehensive than anything seen in Europe.
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The pension system was chosen over an asylum system of permanent care because it provided the disabled soldier with more freedom and mobility.

A number of significant advances in military medicine resulted from the Civil War. For the first time an accurate medical record system was established that made it possible to track casualty records for every soldier. One consequence was the U.S. government's publication of the massive six-volume
Medical and Surgical History of the War of the Rebellion
(1870–1888), which remains the standard against which all such works are judged. The army also developed the first effective military medical system for mass casualties, complete with aid stations, field and general hospitals, ambulance and theater-level casualty transport, and the staff to coordinate it. It was the best military medical system ever deployed and remained a model for other countries for decades. The introduction of the pavilion hospital was so effective at reducing disease mortality that it became the standard design for military and civilian hospitals for the next seventy-five years. Wide use of anesthesia, primary amputation, the splint, and debridement of necrotic tissue were the first effective doctrines for wound management. Thousands of physicians learned these techniques through hard experience and carried them into their civilian practice, elevating the general level of medical care available to the nation. Effective sanitary measures, especially in hospitals, reduced disease and death. The advent of microphotography made the American military medical establishment receptive to the discoveries of Pasteur and Lister when they appeared a few years later. Nurses were used on a wide scale for the first time. The terrible slaughter of the Civil War ironically marked one of the most progressive periods in the development of military medicine until the twentieth century.

Fear and psychiatric debilitation are constant companions in war. Battle is one of the most threatening, stressful, and horrifying experiences that man is expected to endure. Even in relatively small engagements, the participants often suffer a wide range of psychiatric conditions that, if pressed by events, lead to mental collapse.
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Severe emotional response to battle is neither a rare nor an isolated event. One of the most outstanding medical developments of the Civil War was the emergence of
the neurological profession in America and, along with it, the beginning of military psychiatry as a major subdiscipline of military medicine.
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Military psychiatry dates from the Civil War when neurologists made a systematic attempt to link damage to the brain to emotional behavior, but it did not become a separate discipline until the Russo-Japanese War of 1905.

Psychiatry was still in its infancy at the time of the Civil War, but neurologists recognized that soldiers could become debilitated from purely emotional forces. At that time, the discipline focused on the physiology of the brain and attempted to link disruptions of that physiology to behavioral disorders. Fewer than a dozen mental hospitals existed in the United States, but none served patients who developed mental disorders in war. Care of the mentally ill rested with the handful of superintendents of these mental asylums. The movement for humane treatment of the mentally ill that began in France fifty years before was only beginning to take root in the United States.
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The military itself had no psychiatrists and continued to take the traditional view that soldiers who broke in battle were cowards or had “weak” characters. By 1860, American military psychiatry had not come very far since the Revolution, and the discipline was considerably behind developments in Europe.
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Almost immediately after the outbreak of the Civil War, medical officers had to deal with the problem of psychiatric casualties. The War Department had rejected the offer by a group of superintendents of insane asylums to treat the problem on the battlefields, and treatment of psychiatric casualties fell to army physicians and surgeons. Their experience gained with psychiatric cases led to the birth of neurology in the United States and hardened further the tendency of medical practitioners of the day to regard soldiers' mental problems as caused by damaged physiology of the brain. The Turner's Lane Hospital in Philadelphia treated what were called “nervous diseases” during the war, but even the neurologists had to admit that a range of disorders that afflicted the soldiers had no sound physiological explanation. At the doctors' urging, the Government Hospital for the Insane in Washington, D.C., admitted the psychiatric casualties to specific wings in 1863. The men preferred to call it St. Elizabeths Hospital, after the land on which it was built.

The most common psychiatric condition that military physicians had to confront was “nostalgia,” a cluster of symptoms resulting from emotional fatigue that made it impossible for the soldier to continue to fight. Nostalgia was marked by excessive physical fatigue, an inability to concentrate, an unwillingness to eat or drink that led at times to anorexia, feelings of isolation and frustration, and a general inability
to function in a military environment. Swiss armies first reported the condition in 1569, and Swiss military physicians described it again in 1678.
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German physicians of the same period called the condition
heimweh
(homesickness), French military doctors termed the same symptoms
mal du pays,
and the Spanish, who noted their soldiers' suffering an outbreak of nostalgia in Flanders during the Thirty Years' War, called it
estar roto
(literally, to be broken).
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Even then military doctors recognized that the source of the symptoms was emotional and not physical, noting that “imagination alone can cause all this.”
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Nostalgia again was recognized and widely reported during the eighteenth century among the armies of France, Italy, Germany, and Austria. In one instance, a unit of Scottish Highland troops in 1799 succumbed to the condition almost to a man. To trigger the onset of symptoms, the report noted, the Highlanders only needed to hear the sound of the bagpipes. Nostalgia was reported among Napoleon's troops at Waterloo, during the retreat from Moscow, and in the Egyptian campaign, where it became so serious among the officer corps that it threatened to cripple the army.
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During the Civil War, autopsies performed on nostalgia patients confirmed that besides producing emotional turbulence, nostalgia was capable of producing physiological symptoms of disease. Tragically, nostalgia itself was often fatal, especially if a wound or lack of nutrition weakened the soldier's general resistance. When it did not kill, nostalgia often drove the soldier insane. In the first year of the Civil War, military physicians diagnosed 5,213 cases of nostalgia, or 2.34 cases per thousand.
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By the end of the war, almost 10,000 cases had been diagnosed among Union soldiers. In addition, physicians diagnosed a range of illnesses that are now known to stem from emotional turbulence and included “exhausted hearts,” paralysis, severe palpitations (called “soldier's heart” at the time), war tremors, self-inflicted wounds, and various states of nostalgia.
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Military doctors diagnosed the more severe psychiatric conditions as “insanity”—today the condition is termed “psychosis”—and it accounted for 6 percent of all medical discharges granted by the Union Army.
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Physicians also identified a number of cases that they diagnosed as “feigned insanity,” a condition in which emotional turbulence produced severe symptoms for which a physiological cause could not be found. These conditions included lameness, blindness, deafness, local paralysis, and lower back pain.
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Today, military psychiatrists call these conditions “conversion reactions.” Psychiatric symptoms became so common among Union soldiers that field commanders pleaded with the War Department to provide some form of screening to eliminate recruits susceptible to psychiatric breakdown.
In 1863, the Union Army instituted the world's first military psychiatric screening program for recruits. It proved no more helpful than it would later in World War I, and the number of psychiatric cases continued to increase.

Meanwhile, only a handful of physicians in the country—the superintendents of civilian mental asylums—had any experience in dealing with psychiatric patients, but none of these doctors saw military service during the war. Accordingly, military physicians were often at a loss when treating cases of insanity. With a long historical precedent in the armies of Europe, their particularly cruel solution in the first three years of the war was simply to muster out those soldiers diagnosed as suffering from severe psychiatric problems. Union and Confederate soldiers with psychiatric symptoms were escorted out of the main gates of their respective army camps and turned loose to fend for themselves. Others were put on trains with no supervision, the name of their hometown or state pinned to their tunics. Others were left to wander about the countryside until they died from exposure or starvation or were arrested for committing crimes. By 1863, the number of insane or shocked soldiers wandering around the country was so large that the public demanded an end to the military's practice of expulsion. That same year, the military began sending psychiatric cases to the hospital for the insane in Washington.

As noted earlier, the Union Army had discharged nearly ten thousand soldiers suffering from nostalgia by the end of the war. The number suffering from “epilepsy” and forms of hysterical paralysis was probably twice as large, while those discharged for “general insanity” reached several thousand. Although the problem of psychiatric breakdown among soldiers reached major proportions by the war's end, not a single article or book on the subject was published in the postwar years.
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The General Hospital for the Insane closed its military psychiatric facilities, and the government made no effort to involve the doctors who treated civilians with mental illness in helping the psychiatrically wounded. The veterans' problems were conveniently forgotten, and except for the advances in neurology, battle shock and psychiatric debilitation were no longer of concern to the military. The failure to learn from this experience returned to haunt the American Army when it took the field again in World War I.

By the first quarter of the nineteenth century, surgery had attained the general status of a legitimate branch of medicine in the United States, France, and England. The old barber-surgeons' guilds had largely disappeared. In Russia and Germany, this
development did not occur until after mid-century; thus, in Russia, with some exceptions, surgery and military surgery remained largely in the hands of the feldshers. In Germany, surgery was still regarded as a low-status craft that barber-surgeons practiced in the military. The general status of medicine in the larger society was also low; however, surgery found a home in the universities, where it was practiced by medical researchers, academics, and scientists. The beneficial result of this situation was that as being researchers and academics first, surgeons in the universities tended to be more strongly grounded in the sciences, where the rigors of empirical proof and scientific investigations had long traditions. When the opportunity came to transfer these skills to military medicine, German surgeons were better prepared to assimilate and integrate new knowledge than were their counterparts in other countries.
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Until the 1830s, German medicine was mired in the Hegelian period of its development, and debates centered on the philosophy of science with little in the way of empirical emphasis. After 1848, German science and medicine began its transition toward systematic realism, with a strong emphasis upon data collection and observation. The old academic habits of rigorous method and proof moved German medicine rapidly in the direction of an exact science.
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As a consequence, German medicine was much more receptive to demonstrated evidence than were the medical professions in the rest of Europe. For instance, German physicians and surgeons were the first to accept Lister's practice of antiseptic surgery. Once the idea of antisepsis caught on, the Germans' thoroughness propelled them to be the first to introduce steam sterilization, to use surgical face masks and gowns, and to invent the sterile operating room.
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By 1870, German medicine had established itself among the foremost scientific medical establishments in the world. By the 1880s, the medical world had adopted German as its official scientific language because its linguistic precision lent itself perfectly to the new science.
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