in the museum…

Posted on Sunday 20 October 2013

Well, I’m on the road checking out some of those Civil War sites in the North I’ve never visited. Yesterday, we were in Frederick Maryland, a town that was turned into a hospital when the big battles in that War were fought nearby – Antietem [Sharpsburg] in particular, where 22,000+ died in a single day [America’s bloodiest day]. There’s a small museum, The National Museum of Civil War Medicine in Frederick filled with unknown facts. Here are a few:
  • Of the 620,000 soldiers that died in our Civil War, only 1/3 died from combat. The rest died from disease. Number one? Dysentery.
  • Before the Civil War, the were almost no hospitals in the US. There were created by necessity during the War.
  • Some of the innovations during the War were the concept of Triage, the use of Field Stations, the coming of Ambulances.
  • 95% of the amputations were done under anesthesia.
  • The ubiquity of field amputations was because they’d learned that the miniball injuries lead to sure sepsis and death.
The volunteer greeter at the museum was an aged bearded man [it wouldn’t have taken much to make you believe he actually fought in that War himself]. He rolled off his practiced spiel in the elevator. He said something like: "This is a trip back to a time when it was the Art and Practice of Medicine that mattered. It was a time before Science came to Medicine." And the museum bore that out. With the exception of Opium and anesthetics, the few medications they used were toxic heavy metals and odd potions, none of which would have made it through the FDA [or even to the FDA]. Forget efficacy – they would’ve flunked Adverse Effects. Our guide went on to say, "Forget about diseases – and treating diseases. This was a time for treating symptoms." My mind added "badly."

One little section of the museum was devoted to Clara Barton, founder of the American Red Cross. She got her start delivering supplies to the hospitals [at Antietem, her supply wagons followed the cannon fire]. But she did more than that, offering personal support and personal attention to the wounded soldiers [on both sides]. After the War, she directed the Missing Soldiers Office, for example, identifying all but a few hundred of the thousands that died at Andersonville Prison – helping the grieving families come to closure. Her section of the museum was but a small testimonial to Clara Barton’s legacy – apparent today in every disaster. Her American Red Cross has become synonymous with the better side of the human enterprise.

The next stop was Harper’s Ferry, site of John Brown’s attempt to end slavery by capturing the US Armory and distributing the guns and ammo there to slaves for a violent uprising. He had 21 men and he held the Armory for just 36 hours. Even that’s an exaggeration. It was 36 hours before he was captured after being holed up in a small building. It may have been the spark that ignited the Civil War, but, to be honest, it was a mighty small spark seen in person. I’m thinking if something of value came from that ill-fated war, we’d put Clara Barton on the front page and John Brown in the footnotes. The real freeing of the slaves in the South took another century, and it wasn’t violence that made it happen. At least that’s how it looks to me.

So back to our greeter at the museum:
"This is a trip back to a time when it was the Art and Practice of Medicine that mattered."
"It was a time before Science came to Medicine."
"Forget about diseases – and treating diseases."
"This was a time for treating symptoms."
My thoughts were predictable. After a pretty hearty romp on the side of treating diseases, I gravitated to what I considered the more humanitarian side of things and became a psychotherapist. I was at my best in the years I taught medical students, where I leaned the Behavioral Science course into a course about the psychological consequences of "being sick," something I’d learned about in an Internal Medicine practice formalized some by psychiatric training. I was more suited for the Clara Barton side of Medicine than as a Field Surgeon, though I enjoyed both. The Civil War surgeons are still seen as "butchers" because there were so many amputations, but they were following science – and they were right. There was no treatment for infection. The germ theory of diseases was still "germinating" in the mind of Louis Pasteur across the pond at the time of our Civil War. Those surgeons saved lives by desperate measures, but it was solid science for that day. Clara Barton saved something else, something equally important.

I wanted to say to our greeter, "You know, there’s nothing wrong with treating symptoms. After all, it’s what people want first and foremost anyway. But those chemicals in those ancient vials in your museum aren’t very good for that – too toxic. Mercury doesn’t do much for people that’s good for them. We have this rule – Do No Harm." But what I thought about later was that this whole business of Clinical Trials in psychopharmacology that I write about is right in the center of this 150 year ago discussion. These are symptomatic medications we’re talking about. As much as many try to turn this into a discussion of treating disease [as listed in the DSM-5], it’s the symptoms of psychosis, depression, mania, anxiety, inattentiveness that are measured in a clinical trial – not diseases. I suppose that’s a point Dr. Szasz might make, though I’m not sure that he would be altogether justified in his claim that there are no diseases proper in psychiatry, but in terms of treatment, we might agree. We’re primarily treating symptoms. Again, there’s nothing wrong with that, if we do it right.

There are two rules in the symptomatic treatment of disease:
  • Don’t mask underlying disease. Don’t give someone with acute right lower quadrant abdominal pain a shot of Morphine. The diagnosis of Appendicitis is made by the course of the symptoms. Once you give a pain shot, you end up having to operate and will do a lot of unnecessary operating on people who have a virus or an inconsequential painful ovulation.
  • Do no harm. Don’t treat symptoms if the consequence is disastrous like putting someone with rheumatoid arthritis on maintenance steroids and giving them another long-term illnesses unnecessarily.
I suppose there’s a third rule
  • Don’t lie about the Efficacy or Adverse Effects of medications – like happened with the psychopharmacological agents in the era from 1987 to the present. There’s nothing wrong with the drugs. They are what they are. But they’ve been used as if they’re what we want them to be [and they aren’t].
So my comrades in travel are off hiking at Gettysburg this morning. I’m joining them for a bus tour of the Battlefield this afternoon. Two spinal fusions and 71 years have put an end to my hiking days. The surgeries were a big help, but hardly a cure. Some symptomatic medications helped and I’m glad for the help, but adapting to infirmity and learning to live with that adaptation has been the key to success [along with one on those handicapped stickers that gets me closer to the doors of the bus]. Other symptomatic medications, more powerful, might help even more with the symptoms, but they carry a very loud "uh-oh." In psychiatry, the very loud "uh-oh" of our drugs was suppressed far too long, and we’ve been ignoring the Clara Barton side of things. That’s what I thought about at the The National Museum of Civil War Medicine
    October 20, 2013 | 4:44 PM

    I visited Harper’s Ferry when I was a kid. Not really understanding its significance I felt kind of gypped. It might as well have been a barn. The Shenandoah Caverns, however, were grand; though I really wished they had not spoken the word “bacon” before we saw those gorgeous formations, because I thought that had made me see bacon before I actually saw them.

    On one hand, it may be better to treat symptoms in a careful and limited way, than to label people with mental illnesses as if there really were homogeneous and discrete biological brain diseases that a person could suffer regardless of their lot in life and burdens they bear.

    I’ve been reading sporadically about reactive psychosis, “hysterical” psychosis”, Janet, and Jaspers. It seems that the pressure to label someone as schizophrenic or manic depressive precludes a thoughtful consideration of what a person may be suffering from such that reification is the rule.

    October 20, 2013 | 5:53 PM

    I think this is one of the very helpful aspects of Joanna Moncrieff’s books: the distinction between a drug centered approach vs. disease centered approach to thinking about and studying the drugs we use. She argues in favor of using a drug centered approach. She also argues that our use of a disease-centered approach has contributed to our failure to recognize the many limitations of the drugs we use. I think it is a compelling and important argument and I will probably blog about this at some point..

    October 20, 2013 | 6:27 PM

    … it may be better to treat symptoms in a careful and limited way, than to label people with mental illnesses

    … the distinction between a drug centered approach vs. disease centered approach to thinking about and studying the drugs we use

    … our use of a disease centered approach has contributed to our failure to recognize the many limitations of the drugs we use


    October 20, 2013 | 7:43 PM

    Sorry this is a tad off-topic but I thought you might be interested in this “Book of Lamentations” piece reviewing DSM5 as a “new dystopian novel”.
    I think it’s very good.

    October 20, 2013 | 10:26 PM

    It was very good, Paul. The document is more pathos than a catalog of pathological diseases and disorders of the brain.

    On the lighter side, start at 6:59.

    October 21, 2013 | 7:43 PM

    For what it is worth, you are close by to me in you Civil War Tours. Hope the weather has been nice, it will get colder by the middle of the week. At least colder to what you know in Georgia.

    Civil Wars, is there a theme to this within psychiatry. I think I know who are the equivalent to the Confederates in this one, ’cause for some it is about slavery and money. But, not the road I think we want to take.

    I advise all track down the segment 60 Minutes did last night about politicians and their lovely agendas with skirting the laws. Makes you wonder why the slimdown lasted 2 weeks. Didn’t happen around an election though, eh???

    the link:

    have fun on your travels. Joel H

    Nick Stuart
    October 23, 2013 | 1:49 AM

    ‘We’re primarily treating symptoms.’ I think possibly Dr Szasz would have said ‘We’re primarily treating unwanted behaviours.’ But I do not know. I am enjoying your writings on the civil war Mickey. Thanks. Being a UK boy, there is a lot I am unaware of in US history.

    October 23, 2013 | 12:29 PM

    NEJM Calls for Release of Trial Data
    Published: Oct 22, 2013
    By John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today

    The international push to get drug companies to share patient-level data from their clinical trials got another shot in the arm Monday with the publishing of two papers in the New England Journal of Medicine.

    For years, pharmaceutical industry reformers have said that drug companies should be required to release individual patient data — with protections to preserve privacy — as means to ensure more transparency about the true safety and effectiveness of treatments.

    From Vioxx to Avandia to Infuse, they point to a growing number of controversies in which concealed clinical trial data prevented the true safety of products to become known until years after they got onto the market.

    At the same time, they cite research showing that up to half of all clinical trial are not published.

    Today, two online perspectives in the New England Journal of Medicine added to the chorus of calls for more information sharing as medicine enters the new world of “big data.”….

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