Book Review

A History of Military Medicine

N Engl J Med 1993; 328:1427-1428May 13, 1993

Article

A History of Military Medicine
(Contributions in Military Studies. No. 124.) by Richard A. Gabriel and Karen S. Metz. 551 pp. in two volumes, illustrated. New York, Greenwood Press, 1992. $115. ISBN: 0-313-27746-X

As urban civilization developed in the ancient world -- Sumer, Egypt, Assyria -- about 4000 B.C., so did the professional army. As the vastness of the armies grew and weapons improved, the care of the sick and wounded became increasingly complex. Military medicine evolved to provide more than a one-on-one encounter between the wounded and the dresser of wounds on the battlefield. In combat the casualties are now collected and brought to the rear. Supplies, equipment, and means of shelter are provided and brought forward. Medical officers and specialized soldiers are recruited and trained. Methods to promote healing are developed and taught. The disabled are disposed of., and there is more to war than combat. Epidemics in armies have killed more troops than have weapons, so treating disease and preventing disease are a part of military medicine. The epidemiology of injury and disease is a part of military medicine., and so is the recording of its history.

This perceptive and gracefully written book is divided into two parts: ancient times through the Middle Ages, and the period from the Renaissance until now. The authors designate the year 1453 as the end of the ancient period: “In that year the Byzantine Empire was finally overrun and destroyed by the forces of the Ottoman Turks. . . . [Thus] the last continuous cultural link with the empire of Rome was finally severed.”

The evolution of military medicine crested in the first two centuries of the Roman Empire, when the might of its professional armies spread across the known world. Augustus, the first emperor (27 B.C. through A.D. 14),

reduced the army to twenty-five battle-hardened legions distributed throughout the empire, reorganized their staff structures, created the first truly professional medical corps in Roman history. . . . The Roman army was able to attract to itself a sufficient number of physicians to care for the legions until the end of the empire. Roman military medical care began with ensuring that only the best (and most intelligent) specimens were recruited. . . . Once in service, the military medical corps strove to ensure the general health of the soldier by a continuous stress of hygiene. . . . A great deal of thought went into the design of legion forts precisely in order to ensure a healthy environment for the troops.

Cleanliness kept pestilence at bay. (Roman soldiers bathed regularly even when on campaign.) Cleanliness also reduced the incidence of wound infection, and no antiseptic “was more effective than the acetum [vinegar] of the Romans until the carbolic acid of Lister.”

When the Western Empire declined and fell, the army of the Eastern (Byzantine) Empire maintained these standards. With the destruction of the Eastern Empire, the Roman tradition perished. The mysticism-medicine of the Dark Ages supervened. The trend continued downward, even through Napoleon.

In discussing the period from the Renaissance to the present, Gabriel and Metz tell us that “the Crimean War was one of the great medical disasters of all time.” Among British wounded in the Scutari Hospital, for example, the mortality rate among amputees averaged nearly 30 percent. Of every 100 men in the French forces admitted to military hospitals, no fewer than 42 percent died -- a hospital mortality rate equivalent to that of the Middle Ages. The disease rate per 1000 per annum was 253.5 for the French, 161.3 for the British, and 119.3 for the Russian forces. This compares to a similar rate of 110 in the Mexican War, 65 in the Civil War, and 16 in World War I. According to the authors,

The arrival of Florence Nightingale, her trained nurses in November 1854 after the battle of Balaklava resulted in the introduction of basic standards of hygiene and sanitation in the British military hospitals. Upon her arrival, Nightingale reported a hospital mortality rate at Scutari of 44 percent. As a result of her efforts, the rate dropped to 2 percent by the end of the war.

My synopsis has focused on a single thread from the web of a superb history book. I have not discussed the impact of weaponry and armor on wounds, the means employed to care for the wounded, the interaction between military and civilian medicine, the methods of medical education, or the care of veterans. The book encompasses all of these facets of history, and more.

William H. Crosby, M.D.
Chapman Cancer Center, Joplin, MO 64803