Long after the fighting stops, war continues to impact on the health of soldiers, civilians and the environment.
For some people, the physical and mental damage caused by war lasts a lifetime. Medical teams have had to develop methods to help them adjust to living with disability and illness.
But sometimes innovations in military medicine result in better ways to treat an injury or advance fields of medicine, such as plastic surgery, psychiatry and emergency medicine.
The wartime experience of surgeons who dealt with numerous limb injuries contributed to the grown of orthopaedic surgery (the branch of surgery concerned with the musculoskeletal system) in the first decades of the 20th century.
In the past, most soldiers with serious wounds would have died, if not from their wounds then from infections. As military medicine improved, more and more soldiers survived. But many war veterans were left to cope with long-term physical and mental medical conditions.
The loss of a limb was one of the earliest and most visible disabilities for war veterans. Although rates of amputation declined with improved surgical techniques and the introduction of antisepsis in the 19th century, the sheer scale of industrial warfare in the First World War (1914–18) resulted in large numbers of amputees.
Specialist rehabilitation centres such as Queen Mary's Hospital in Roehampton were set up to fit veterans with prosthetic limbs and help them with physical rehabilitation and social support.
Prosthetic limbs and rehabilitation
Military surgeons have always been involved in the rehabilitation of war veterans, designing prosthetic limbs, and developing expertise in fields such as plastic surgery, neurology and psychiatry.
After the Second World War (1939–45), faster and better treatment meant that more soldiers with serious neck and spinal injuries survived. But irreparably damaged nerves left many permanently paralysed with paraplegia (impairment in the legs) or quadriplegia (impairment in all four limbs).
In September 1943, the government asked the spinal injuries specialist Dr Ludwig Guttmann to establish the National Spinal Injuries Centre at Stoke Mandeville Hospital, the UK's first specialist unit for treating spinal injuries. It became a leading centre for neurosurgery.
After surgery, the long process of rehabilitation began. Guttmann believed that sport was a major part of rehabilitation. Sport helped veterans build up physical strength and self-confidence.
Ludwig Guttmann organised the first Stoke Mandeville Games for disabled patients on 28 July 1948, the same day as the start of the London 1948 Summer Olympics. His Games are often regarded as the forerunners to the modern Paralympic Games.
War and mental health
Veterans with mental health conditions resulting from their wartime experience often needed continuing treatment and support after the war.
Both World Wars impacted the fields of psychology and psychiatry, as specialists were called upon to treat soldiers suffering from debilitating stress and trauma. Special units were set up to receive soldiers experiencing mental trauma, some centres were near the war zone so soldiers could return to the front once they recovered. More serious cases were sent back to military hospitals in the UK.
Successive wars have had their own ways of describing and dealing with mental health conditions resulting from war:
Shell shock: 'blame the soldier not the situation'
The term 'shell shock' was coined in the First World War. At first, doctors thought that it was a physical illness resulting from the effects of sustained shelling. Many soldiers who survived an explosion had no visible injuries but exhibited symptoms that could be attributed to spinal or nerve damage.
The range of symptoms ascribed to shell shock included tinnitus, amnesia, headaches, dizziness, tremors and hypersensitivity to noise. Shell shock could also manifest as a helplessness, panic, fear, flight or an inability to reason, sleep, walk or talk.
The young men who signed up to fight in 1914 had little preparation or support for dealing with the stress and trauma of modern warfare. Some refused to fight and were mistakenly accused of cowardice. During the First World War, 309 British soldiers were executed, many of whom are now believed to have had mental health conditions at the time.
When soldiers who had never been exposed to shelling began to develop the symptoms of shell shock, the phenomenon was re-characterised as a range of mental rather than physical conditions and collectively called war neuroses.
The specific diagnosis often depended on who you were. The walking wounded and officers tended to be diagnosed with neurasthenia or nervous breakdown. Other cases of debilitating nervous symptoms were regarded as a consequence of inherited weakness or degeneration. The soldier was blamed, not the situation.
Shell shock was poorly understood, medically and psychologically, and the official response was often unsympathetic. Soldiers were suspected of feigning symptoms and accused of mallingering to avoid fighting.
For those who were discharged or returned after the war, some treatments were available. For example, neurologists at the Royal Army Medical Corps hospitals at Netley and Seale Hayne tried a range of therapies such as hypnosis, electrotherapy and psychotherapy.
Those that failed to respond or receive adequate help could end up in general asylums hospitals after the war, while many others returned to their homes to suffer in isolation.
Private Meek's Recovery
This short video was filmed at the military hospital at Netley during the First World War. It shows Private Meek, a 28 year old soldier during his two-and- a-half-year journey to recovery from shell shock. [1 min. 42 secs.]
This is an extract from a longer promotional film directed by neurologist Major Arthur Hurst. Patients such as Private Meek participated in reconstructions in order to demonstrate the results of their treatment.
Battle fatigue: 'every man has his breaking point'
Battle fatigue or combat stress reaction (CSR) was a term used in the Second World War to describe a range of behaviours resulting from the stress of battle. The most common symptoms were fatigue, slower reaction times, indecision, disconnection from one's surroundings and the inability to prioritize.
Battle fatigue was usually a short-term condition but could develop into something more serious.
Men and women diagnosed with battle fatigue were removed from the front line for rest and recovery. Treatment was not very effective, and 40% of medical discharges from the military during the war were for psychiatric reasons.
Military psychiatrists were more sympathetic towards troops in the Second World War than the First World War. The slogan 'every man has his breaking point' was used to warn people about the danger of stress.
The idea that anyone could succumb to stress reduced the stigma surrounding battle fatigue, and helped traumatised soldiers to be accepted when they returned home. The focus shifted from the ‘weak or inadequate’ soldier to the traumatic situation.
Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) was the term developed soon after the Vietnam War and codified by the American Psychiatric Association in 1980 to explain the mental and psychological effects of war on soldiers.
PTSD is a mental health disorder that can develop after the experience of either a single traumatic event or recurring traumatic experiences.
It can affect a person's social interactions, their ability to work, or other important areas of their lives. Symptoms may include disturbing thoughts, feelings, mental or physical distress, unexpected changes in behaviour and an increase in the fight-or-flight response.
The diagnosis of PTSD now covers a wide range of traumatic events such as accidents, assault, natural disasters and exposure to violence. The risk of developing PTSD after a traumatic event varies by trauma type, but military service and becoming a war refugee both increase the risk of developing PTSD.
Not all wounds are visible
This film was produced in collaboration with a small group of British military veterans from recent conflicts, who have all been diagnosed with post-traumatic stress disorder (PTSD). They hope to give an insight into the experience of living with this condition, which they believe is poorly understood.
It seems that every combat situation has its own particular mental pressures: shell shock, war neuroses, battle fatigue, combat stress reaction and PTSD are all time-specific terms for a variety of psychological symptoms that can result from war. Some are short-term, while others are more long-lasting and need continuing therapeutic support.
Wartime medical innovation
There is a lot of debate about how much war and medicine have influenced each other. Sometimes war adds to medical knowledge by drawing attention to a particular injury, such as the loss of a limb.
Military medicine has also influenced how medicine is done. Triage, the system of prioritising multiple casualties, has been adopted for all emergency medicine ever since the First World War.
War has also created new roles and opportunities in medicine. The First World War saw a huge increase in the number of female nurses and male orderlies working in field hospitals near the front line. And with most men sent to fight, the War Office called on women to drive ambulances and female surgeons to perform surgery both in the war zone and at home, giving them a chance to prove their competence.
Military medicine has also influenced society in unexpected ways. The military was one of the first organisations to use physical and phychological assessment tests on new recruits.
Concerns about the poor performance of troops in the South African War prompted questions about the national efficiency and 'racial health' of the population. This eventually led to medical inspections for new recruits in the First World War.
Towards the end of the war, a physiologist working for the military, Group Captain Martin Flack, used his knowledge of respiratory and circulatory physiology to create tests for Royal Air Force recruits. His tests were designed to select the recruits that were most suitable for training as pilots.
Psychological evaluation was added to the assessment process in the Second World War. The idea of assessing and evaluating applicants gradually filtered into civilian recruitment and is now used for all kinds of jobs.
Suggestions for further research
- M R Howard, 'British medical services at the Battle of Waterloo' in British Medical Journal, 24 December 1988 (pdf ejournal)
- H Graeme Anderson, 'The medical and surgical aspects of aviation' [with chapters on applied physiology of aviation, by Martin Flack], Hodder & Stoughton, 1919. [ebook]
- J Laffin, 'Combat Surgeons'; Wiltshire: Sutton, 1999.
- J Scruton, 'Stoke Mandeville: Road to the Paralympics'; Aylesbury: The Peterhouse Press, 1998.