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The purpose of military medicine is to make sure troops are fit for battle. Medical staff assess the health of new recruits, tackle outbreaks of disease in camp and treat the wounded on the front line.

The purpose of military medicine is to make soldiers fit for battle. This starts before the battle begins, with the health of new recruits, And, in addition to treating war wounds, doctors have to deal with the risks for large numbers of troops exposed to outbreaks of disease and infection.

And, as fast as medics devise new methods of treatment, weapons manufacturers find new ways to inflict injury and destruction. 

Fighting fit

The task of ensuring troops are fighting fit starts before the battle has begun, with new recruits.

Finding men and women fit to fight has always been a problem for the military. In the South African War, 40% of volunteers were unfit, often with poverty-related conditions such as rickets, bronchitis and rotten teeth. The poor condition of conscripts prompted concerns about the health of the British people in general, and a Physical Deterioration Committee was set up in 1904 to investigate.

Medical tests for new recruits were introduced along with regular inspections and guidance for nutrition and exercise. Towards the end of the First World War, military physiologist Martin Flack developed a series of tests for pilots to assess their fitness and suitability for pilot training.

By the Second World War, a mature medical service was called upon to improve the efficiency of soldiers.

Physiologists designed military rations, and psychologists and psychiatrists assessed the limits of human endurance and suitability for combat, while social sciences were used for management systems.

As modern infantry was required to operate increasingly complex equipment, aptitude tests for intelligence, and personality traits such as initiative were introduced.

Chasing the arms race

Every major war seems to bring a new generation of lethal weapons to the battlefield. For the medical teams whose job it is to repair damaged bodies and save lives, each war brings a new set of challenges.

At first, military medicine focused on 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 gangrene and save a soldier's life.

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

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

The South African War (1899–1902) gave doctors experience of treating small-calibre rifle wounds, and they found that antiseptic surgical techniques reduced infection in gunshot wounds.

Bullets and shrapnel drove fragments of clothing and debris deep into the body to become the seats of infection. The best way to stop a wound getting infected was with debridement—the painful process of scrapping away the dead tissue and foreign matter that caused infections.

In the First World War, machine guns, rapid fire artillery shells and missiles introduced warfare on an industrial scale, Well over 50% of all battle injuries on the Western Front were the result of artillery fire. 

Added to these were chemical weapons—mustard gas and chlorine. Chemical weapons were a new and unpredictable threat that were difficult to control. One gas attack reportedly killed 5,000 and damaged another 10,000 for life. 

But even minor conditions such as trench foot, which was caused by prolonged exposure to damp conditions in the trenches, if left untreated, could go from sores and fungal infections to gangrene and possible amputation.

Firepower in the Second World War increased five-fold. It also saw the first use of chemicals such as napalm for flamethrowers and incendiary bombs, and ultimately the atomic bomb.

Recent engagements have seen a return to small-scale weapons. In the Vietnam War, injuries from small arms, mines and booby traps resulted in lots of burns injuries and explosions inside armoured vehicles and bunkers.

Most wounds in the First Iraq War were caused by improvised explosive devices (IEDs) that were difficult to detect until you were right on top of them. The development of kevlar body armour helped to protect the abdomen and chest, spine, head and groin and minimise damage.

In mechanised war, mobile surgical teams made a huge difference to treating wounds near the frontline. Small field units were capable of 100 operations without replenishment and specialist maxillo-facial and neurological units and transfusion units provided the rapid surgical treatment needed after blast injuries.

Plastic Surgery

Before the First World War there was little concern with what an injured soldier's face looked like. But the sheer scale of the war and the significant increase in head and facial injuries resulting from trench warfare saw the emergence of plastic surgery as a new medical specialism.

Maxillofacial surgery was developed originally from dentistry to repair damaged jaws. Surgeon Harold Gillies treated 2,000 soldiers during the First World War. He worked with a dental specialist, Charles Auguste Valadier, on reconstructing faces. Materials such as metal were used to reconstruct the jaws and teeth.

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 the growth of aerial combat meant that pilots trapped in cockpits suffered terrible burns from aviation fuel.

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

Archibald McIndoe, who was coincidentally Gillies' cousin, treated 4,000 men who had suffered burns from aviation fuel. Each patient had an average of 12 operations. His work gave them new hands and faces, and many 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 readjust to their new faces.

Infectious diseases

More soldiers died from disease than from injuries inflicted by the enemy in virtually every military campaign before the First World War. Keeping troops fighting fit also meant preventing and dealing with outbreaks of disease. And each theatre of war had its own problems with disease.

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. Diseases such as typhoid, dysentery and cholera could bring down an army as effectively as any weapon.

In one winter during the Crimean War, only 9,000 troops were fit to fight, with 23,000 reporting unfit due to sickness.

The strategic value of medical research

Having accepted that medicine had a strategic role to play in saving the lives of highly trained troops, the military began to recognise the strategic value of medical research.

One of the lessons from the Crimean War (1853–1856) was that good medical provision was essential for both morale and wartime propaganda at home.

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. And the Army Medical School made a valuable contribution to medical research. 

Before and during the First World War, it was instrumental in developing vaccines and bacterial antitoxins for typhoid and tetanus.

By the Second Iraq War, surgeons were able to save approximately 90% of all wounded service personnel despite horrendous injuries, but for many of these men and women, rehabilitation became a lifelong process.

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