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Military medicine aims to keep soldiers fit for battle, so medical teams have to tackle outbreaks of disease among the troops as well as treat the wounded on the front line.

Military medicine has had to go  from treating broken limbs and blade wounds to reconstructing faces in order to keep up with the relentless arms race. And medical science and technology have had to keep pace with weapons technology.

New weapons, new wounds

The military has always kept up with technology advances to develop ever more sophisticated weapons. Military surgeons, faced with the destructive results of these weapons, have had to draw on advances in medicine and science to keep up. 

Sketches of soldiers from Waterloo - one with sabre wounds, one with an arm blown off by cannon fire Wellcome Collection, CC-BY
On the left is an example of sabre wounds, on the right an arm blown off by cannon fire. Sketches by surgeon Charles Bell

Until the 18th century, military medicine focused on mending arms and legs, repairing the damage caused by swords and spears using sutures to close wounds and bone setting to mend broken bones and torn muscles.

When infection set in, which it often did with battle-soiled wounds, the surgeon could do little more than clean and drain the wound. Ultimately, amputation was the only way to halt the spread of life-threatening infections such as gangrene. The 16th century French military surgeon Ambroise Pare was particularly innovative in developing tourniquets and new surgical techniques.

The introduction of gunpowder saw a dramatic shift in the scale and nature of war wounds. At the Battle of Waterloo in 1815, blast injuries from artillery shells and cannons shattered limbs, tore open bodies, spewing innards and smashing open skulls.

Bullets and shrapnel drove fragments of clothing and debris deep into the body to become the seats of infection - a major cause of death in military hospitals. The introduction of antiseptic surgery made a noticeable difference to post-surgical infections in the war zone after if was first (sporadically) used in the South African War (1899-1902).

Industrial warfare

The First World War, as the name suggests, was the first global war: a demonstration of the strength and killing power of modern empires. It was a 'Total War', one in which all of the resources of society - industrial, economic, political, social and medical - were directed to the war effort.

Huge numbers of troops with mechanised weaponry were transported around the world to fight on multiple fronts. Well over 50% of all battle injuries on the Western Front were the result of machine guns, rapid-fire artillery shells and missiles.  

Experience taught surgeons that the best way to stop such wounds from getting infected was a technique called debridement—the sometimes painful process of cutting away the dead tissue and foreign matter that caused infections in the wound. And it's a technique that is still used today.

Chemical weapons such as chlorine and mustard gas were a new and unpredictable threat. If the wind changed direction, the gas could be blown back over an army's own troops and those that were not killed by the poisonous gases went home with serious long-term damage to their lungs and nervous systems. One gas attack reportedly killed 5,000 people and damaged another 10,000 for life. Gas masks were the best protective measure against gas attacks.

Six soldiers demonstrating putting a gas mask on over the face. 1914-1918 Wellcome Collection, CC-BY
Six soldiers demonstrating putting a gas mask on over the face. 1914-1918.

Each theatre of war brings its own challenges for medicine. The Second World War saw an increase in the numbers of burns from airline fuel. In the Vietnam War (1955–75), injuries from, mines and booby traps resulted in lots of injuries to the limbs. Explosions inside armoured vehicles and bunkers and from napalm resulted in multiple burns injuries for civilians as well as soldiers.

In the Gulf War (1990–91), many soldiers were injured by improvised explosive devices (IEDs). These, often improvised weapons, were difficult to detect until the victim was right on top of the device. Kevlar body armour, developed in the 1970s, helped to protect the abdomen and chest, spine, head and groin and minimise damage from such devices.

Cougar was hit in Al Anbar, Iraq by a directed charge IED Wikimedia Commons Image source
Cougar vehicle hit in Iraq by a directed charge IED approximately 300-500 lbs in size. All crew members survived. 2007

As well as technological innovation, surgeons faced with many instances of a particular type of injury have had to develop new surgical techniques and even new fields of surgery in response. Plastic surgery, for example, saw advances after both world wars.

Facial reconstructive surgery

The First World War saw a significant increase in head and facial injuries resulting from trench warfare. The experience surgeons gained from treating such injuries contributed to the emergence of plastic surgery as a new medical specialism.

Maxillofacial surgery developed from the dentistry used to repair damaged jaws. Surgeon Harold Gillies worked with a dental specialist, Charles Auguste Valadier, on reconstructing soldiers' faces, using materials such as metal to rebuild the jaws and teeth. They treated 2,000 soldiers during the First World War.

Pages from the book 'Plastic Surgery of the Face' by Harold Gillies Wellcome Collection, CC-BY
'Plastic Surgery of the Face' by Harold Gillies, London, 1920

By the Second World War, mobile maxillofacial units saved the lives of many soldiers with early surgery. But a new challenge arose with the growth of aerial combat, as pilots trapped in cockpits suffered terrible burns from aviation fuel.

Safety equipment such as gloves, helmets and goggles helped protect them to some extent, but new surgical techniques for treating extensive burns injuries were needed.

Archibald McIndoe, who was coincidentally Gillies' cousin, treated 4,000 men with burns from aviation fuel. Each patient had an average of 12 operations. The surgery rebuilt hands and faces, and many of the men went back to fly again.

His patients became known as 'McIndoe's guinea pigs' because of the experimental procedures he performed, and they formed the Guinea Pig Club to help them re-adjust to their new faces.

Troop sickness and disease

Keeping troops fighting fit also meant preventing and dealing with outbreaks of disease, and each theatre of war brought its own challenges.

Malnutrition and exhaustion played a part in making soldiers susceptible to illness, but poor sanitation and living in close quarters were responsible for the rapid spread of infectious diseases such as typhoid, dysentery and cholera, which could bring down an army as effectively as any weapon.

In one winter during the Crimean War (1853-1856) for example, only 9,000 troops were fit to fight, while 23,000 were reported unfit due to sickness.

Florence Nightingale and the Crimean War

When Florence Nightingale arrived at the military hospital in Scutari, near Istanbul, with 38 volunteer nurses, she found the hospital in a dreadful state.

Soldiers lay on the ground in the clothes in which they arrived. Many were malnourished and dehydrated because of water and food shortages. The wounded were mixed in with the infected and open latrines helped to spread infection. If a soldier didn’t have a disease when he arrived, he would surely catch one at the hospital.

The new barracks hospital at Scutari, Crimean War Wellcome Collection, CC-BY
The New Barracks Hospital at Scutari, base hospital for the Crimean War.

Nightingale believed that sickness among the wounded was largely the result of exhaustion and poor nutrition and set about feeding and tending the wounded. But military surgeon James Barry argued that poor sanitation and bad ventilation were responsible for deaths from infectious disease and criticised Nightingale for not addressing the problem of poor hygiene.

Medical staff had very little influence in the Crimean War, and lacked the authority or resources to run an effective service. But negative reports in newspapers back home on the plight of the injured, coupled with the ministerial and Royal support that Nightingale received, achieved what the doctors could not: it provoked the authorities into action.

In 1855 an official Sanitary Commission arrived in Crimea and, with Nightingale's cooperation, they ensured that toilets and washing facilities were upgraded, ventilation was improved and overcrowding reduced. The mortality rate at the military hospitals went from 41% when Nightingale arrived to 2% by the end of the war.

Influenced by her experience during the Crimean War, Nightingale campaigned for better sanitation in all hospitals when she returned to Britain.

Medical science in the military

One of the lessons from the Crimean War (1853–56) was that effective medical provision was not only essential for both morale and wartime propaganda at home, it also made good military sense.

In response to that war, the Royal Victoria military hospital was established at Netley, near Southampton. The hospital included an Army Medical School where army doctors were trained for the Army Medical Service and later the Royal Army Medical Corps (RAMC). From 1863 until its closure in 1966, the military hospital became the centre of treatment for troops returning from war.

Royal Victoria Hospital at Netley, 19th century. Wellcome Collection, CC-BY
The Victoria Hospital and the Army Medical School at Netley.

The Army Medical School made a valuable contribution to medical research into infectious diseases. Before and during the First World War, it was instrumental in developing vaccines and bacterial antitoxins for typhoid and tetanus.

Pharmaceuticals made a huge difference to military medicine, from mass vaccination in the First World War to antibiotics in the Second World War, they meant that fewer soldiers died from infection than from enemy fire for the first time in history.

War-time pharmaceuticals

In the Second World War, new pharmaceuticals such as sulphonamides revolutionised infection treatment. They were dusted into wounds as a powder and also used in tablet form for diseases such as pneumonia. 

Once penicillin was found to be an even more effective antibiotic, with fewer side effects, laboratory research on large scale production was prioritised in Britain. By 1940, researchers at Oxford university developed a method of mass production, which the took to several pharmaceutical companies in the United States. Once mass production began the US War Production Board drew up a plan for the mass distribution to Allied troops fighting in Europe. The first penicillin supplies were in the field by 1943.  

Wooden chest used by Major Scott Thomson, RAMC, to transport penicillin supplies to North Africa during the Second World War, 1939-1945 Science Museum, CC-BY 4.0
Wooden chest used by Major Scott Thomson, RAMC, to transport penicillin supplies to North Africa during the Second World War.

Antibiotic drugs reduced levels of sepsis and gangrene, and allowed more operations to be carried out in mobile surgical units in the field. They also made a huge difference to treating sexually transmitted infections (STIs) among the troops. STIs had a significant impact on the health and availability of soldiers in both World Wars.  

MIcrobiological and pharmaceutical research made a huge difference to military medicine, from mass vaccination in the First World War to antibiotics in the Second World War, they meant that fewer soldiers died from infection than from enemy fire for the first time in history.

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