Book Review

The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology: The U.S. Civil War (1861) to World War I (1918)

N Engl J Med 2003; 348:1611-1612April 17, 2003

Article

The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology: The U.S. Civil War (1861) to World War I (1918)
(The History of Medicine in Context.) By Charles F. Wooley. 321 pp. Aldershot, Hampshire, England, Ashgate, 2002. $99.95. ISBN: 0-7546-0595-7

The American Civil War (1861 to 1865) was the first major conflict of the industrial age, and the progressive industrialization of warfare that occurred over the subsequent 100 years led to unprecedented loss of life. The loss of over 600,000 men in that war was almost more than the fledgling United States could bear, but it was trifling in comparison with what was to come in World War I (1914 to 1918). Of the 65 million men who took up arms during the “war to end all wars,” an estimated 10 million were killed and 20 million wounded. French and British men who were between the ages of 19 and 22 years in 1914 saw their numbers reduced by 40 percent during the course of the war. Many deaths were caused by disease, yet ironically, this book is concerned not with a life-threatening disease but with a condition that led instead to substantial disability and was therefore a cause of great alarm to military commanders. Wooley's monograph is a collection of previously published, somewhat disparate, and occasionally repetitive writings that are consolidated into chapters dealing with irritable heart in soldiers. Variously known as disordered action of the heart, effort syndrome, and neurocirculatory asthenia, this condition was the diagnosis given to a large number of men who, after enlistment, were deemed unfit to fight. Wooley, a professor emeritus of medicine at Ohio State University, comprehensively describes the emergence of this condition during the American Civil War, its evolution and scientific study during World War I, and its apparent disappearance during the mid-20th century.

The development of efficient killing machines such as machine guns and accurate artillery led to an insatiable appetite on the part of the military for healthy young soldiers. In addition to the enormous logistical challenges resulting from the huge numbers of dead and wounded that overwhelmed existing medical facilities during the American Civil War, there was a major need for clear definitions of health and fitness for service. Wooley discusses the rapid expansion of medical facilities and the establishment of sound medical criteria for the screening of recruits. The summaries of such screening in both wars provide a fascinating snapshot of the general health of the U.S. population in the 19th and early 20th centuries.

Symptoms such as shortness of breath, palpitations, dizziness, and inexplicable, profound fatigue were so frequently observed and so frequently required the removal of soldiers from the battlefield that military hospitals were established for further examination of such cases to distinguish malingering from organic or functional cardiovascular disease. Cardiac causes of disability were studied in the first organized center of cardiovascular research in the United States, at Turner's Lane Hospital in Philadelphia, founded in 1862. Responsible for one of the wards at Turner's Lane was Jacob Mendez Da Costa, a remarkable man who later became chairman of medicine at Jefferson Medical College. Reflecting the educational convention of the time, Da Costa had trained at the predominant centers of medicine in Paris, Prague, and Vienna and was fluent in German and French. He elegantly described an unusual functional cardiac disorder that caused substantial disability among young men in military service, and he believed that persistent symptoms would lead to organic heart disease over time. His publications on irritable heart were highly respected in Europe, and Da Costa's original description of this condition serves as Wooley's point of embarkation for a fascinating medical journey back and forth across the Atlantic Ocean over the subsequent century.

Military hospitals established in England during World War I were modeled on the Turner's Lane experience, and these hospitals cared for large numbers of men in a fashion that allowed for both effective research and organized medical education. It was at this time that laboratory techniques were beginning to supplement the clinical skills that for almost a century had relied on the stethoscope of Laënnec; blood-pressure measurement was becoming routine, Einthoven's electrocardiogram was superseding Mackenzie's polygraph and Ludwig's kymograph, and Roentgen's x-rays were seeing increasingly wide application. World War I military medicine afforded unique opportunities for British and American physicians to work side by side and to use scientific means to develop methods of clinical care that have stood the test of time and that are reflected in much of modern cardiology practice. These productive collaborations were based on individual relationships that were forged in the crucible of war and derived their strong postwar momentum from a shared knowledge of adversity. The description in 1930 by Louis Wolff (Boston), John Parkinson (London), and Paul Dudley White (Boston) of what became their eponymous syndrome may be one of the more concrete examples of these highly fruitful relationships. The introduction of graded physical exercise as a form of therapy also has its origins in wartime experience; prolonged bed rest for the treatment of heart disease had been the norm for many decades, but it was clear that the heavy manpower needs of modern warfare now precluded this luxury. Thomas Lewis and his colleagues at the military hospitals in England dramatically altered the approach to cardiac rehabilitation, inspiring Samuel Levine, when he returned to Boston, to shorten substantially the six-week period of mandatory bed rest after myocardial infarction.

This book will interest cardiologists on both sides of the Atlantic who are curious about the roots of current practice and the impressive, if often eccentric, people who were instrumental in laying the foundations of the profession. However, this book may disappoint historians who expect more social, cultural, and political context than the book provides. Indeed, a complete understanding of the historical development of cardiology as a medical specialty requires critical examination of the influence of the dramatic social and technological changes that were under way in early 20th-century Europe and North America. Wooley has provided an excellent framework on which this more comprehensive history may be built.

David Martin, M.D.
Lahey Clinic, Burlington, MA 01805
david_martin@hms.harvard.edu