War Neurology

War Neurology ed. Laurent Tatu and Julien Bogousslavsky. S. Karger AG, 2016, 243 pp.

           The editors of War Neurology, Laurent Tatu and Julien Bogousslavsky, begin the book by observing and lamenting the fact that “War and Neurology are two themes that are rarely linked, and War Neurology is not a subject in its own right” (p. vii). While this statement must be caveated since the neurological effects of war on humans and the history of such ailments and their treatment have not escaped consistent attention, the editors are correct that the unification of war and neurology under a single subfield of study has thus far not occurred.[1] As such, “this book intends to lay the foundation” for such a subfield (p. vii). Commensurate with the ambition of this goal, Tatu and Bogousslavsky have put together an expansive volume delving into the history and practice of war neurology from antiquity to today.

          The book begins with a chapter providing a general overview of the historical development of neurological practice during wartime. The ancient Egyptians were the first to record connections between battle wounds and neurological deficits approximately 5,000 years ago. “[I]t was recognized early that head wounds were especially dangerous” (p. 3), and in the close-quarter, direct combat of antiquity, “warriors tended to focus on striking their enemies’ heads in order to defeat them” (p. 1). Beyond the head, spinal cord and peripheral nerve damage suffered during combat were also given special attention. As far as mental disorders arising from battle experiences, however, mentions of “mental stress produced by warfare” are found in ancient literary works, but not more widely (p. 7).

          Building on this foundation, War Neurology proceeds through chapters focusing on various conflicts (the Napoleonic Wars, American Civil War, Franco-Prussian War, Russo-Japanese War, World War I, World War II, Vietnam War, and the modern conflict in Afghanistan), the most significant neurological advancements that emanated from them, and the individuals primarily responsible for these advancements. There is also a chapter presenting the modern history of neurotoxic weapons and detailing their individual characteristics.

          Broadly, War Neurology is an illustration of the intimate link between warfare and progress in medical science. It has been noted that “[i]t is paradoxical that through war, a concerted effort to annihilate man, we have learned more and better ways to preserve him” (p. 62). But such a relationship is in fact logical. This is because the devastation of human bodies wrought by war provides “[t]he opportunity of making uncomplicated clinical observations,” which “is rare in civil life” (p. 43). Accordingly, “[t]hroughout human history, war and the subsequent need for treatment of war wounds has provided a fecund environment for the development of medicine as a whole. The origin of surgery is particularly rooted in the treatment of injured participants of war and combat” (p. 22), and the subfield of neurosurgery emerged and rapidly developed as a result of twentieth-century wars. Thus, as noted fifteenth-century surgeon Hieronymous Brunschwig said, “I would remind you again how large and various [is] the experience of the battlefield and how fertile the blood of warriors in rearing good surgeons” (p. 22). Some medical professionals have even gone so far as to perversely relish war because of the opportunities it affords them and their field, such as when English surgeon George James Guthrie expressed his regret with regard to the Napoleonic Wars that “we had not had another battle in the south of France, to enable me to decide two or three points of surgery which were doubtful” (p. 13).

          Further cementing the link between war and medical advancement is the fact that personnel are arguably the most important weapons in the arsenal of a military force, and this makes their treatment a critical component of war fighting. Avenues of warrior degradation must be countered in order to most effectively maintain military strength and capability. And neurological impairments are some of the most pernicious harms suffered by fighting men and women. Sides that are better able to treat and recycle injured personnel gain a meaningful advantage over opponents. As such, “[w]hile war influenced the development of medicine, and neurology in particular, medicine also helped to shape the outcome[s] of . . .  war[s]” (p. 93).

          War Neurology provides two excellent examples of this phenomenon. The first is the American Civil War. On top of advantages in funding, equipment, and manpower, Union forces also employed a superior military medical complex to that fielded by the Confederacy. This meant that “a greater proportion of the Union army was healthier than of the opposing Confederate force,” and “[i]t can be argued that the advantages provided by medical science were a significant factor in determining the eventual victory of the Union” (p. 105). The second example is the German military (the Wehrmacht) in World War II. Its remarkable success at the beginning of the conflict was due in part to highly mobile forward-operating medical units and streamlined methods for moving and treating wounded, including specialized neurological units and procedures. These facilitated the Wehrmacht’s quick-strike blitzkrieg method of attack and “became . . . viewed as ‘indispensable’ for the war effort” (p. 126).

          As noted above, the close connection between war and neurology has resulted in numerous advances in the latter as a result of the former. Exhibitive of this association is the incredible progress made in understanding the brain’s visual pathways and the treatment of injuries these areas during the Russo-Japanese War and World War I. A constellation of developments in warfare facilitated these breakthroughs: the increased muzzle velocities of the rifles used; the use of smaller and less deformable bullets; the insufficient cranial protection afforded by helmets of the time (specifically their lack of coverage of the back of the head and the brain’s visual processing center: the occipital lobe); the expansive employment of trench warfare, whereby soldiers’ heads were often their main physical attribute exposed to enemy fire; and a greater survival rate for those suffering head wounds. Together, these circumstances produced a relatively large number of individuals with “fairly discrete [brain] lesions” that resulted in visual impairments (p. 34). Surgeons of the time could then “carefully correlate . . . visual field deficits with brain injuries localized to the occipital lobe” (p. 32).

          The aforementioned general process involving widespread combat injury, clinical observation, correlation, and treatment is the common avenue by which war has facilitated great headway in neurology. War Neurology’s expositions on advances in peripheral nerve injury knowledge during World War I and spinal cord rehabilitation during World War I and World War II show similar dynamics.[2]

          But wartime has influenced more than simply the direct practice and knowledge base of neurology. It has historically also had great impact on the organization and ethics of the field. War Neurology examines this through the poignant example of neuroscience in Germany and Europe under the Nazis.[3] Nazi rule saw the wholesale “de-Jewification” of the neuroscience profession in Germany and occupied territories, and the resulting opportunistic rise of many “Aryan” neuroscientists (p. 170–71). As such, the field became “Nazified,” and was heavily relied upon to undergird Nazi ideology and policies: “neuroscience was not merely a microcosm of Nazi medicine; it was the central specialty in planning, enforcing, and profiting from Nazi eugenics policies” (p. 170). Its “findings” supported Nazi racist attitudes, and those deemed unworthy by “science” suffered harms ranging from their removal from the workforce, sterilization, subjection to experimentation, and death. The specialty and its practice became a tool of subjugation and murder as it was warped to fit the goals of Nazi leadership.

          Finally, war and neurology are also connected through the use of neurological knowledge to devise weapons, enhance soldiers, and gain intelligence. War Neurology addresses the first of these areas in a chapter on neurotoxic substances and their effects. But the book provides no coverage of the latter two—like the contributions of neurology to research into techniques, substances, and devices intended to heighten soldier cognition or induce captives to speak to interrogators—nor the ethical implications of these pursuits.[4] A chapter considering these topics would have been a welcome addition.

          This quibble aside, however, War Neurology offers an engaging and far-reaching examination of its namesake that successfully lays a foundation for war neurology as a distinct subfield of study. While time will tell if this foundation is built upon, the volume is valuable in its own right and will find an appreciative audience in those interested in military medicine specifically or seeking to add depth to their understanding of the many facets of war.

Andreas Kuersten

University of Pennsylvania Law School

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