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For centuries, military medicine has used the latest advances in medicine and science to treat the injuries inflicted by ever more destructive weapons.  

Before the arrival of gunpowder, military medicine focused on mending arms and legs, repairing the damage caused by swords and spears with sutures to close wounds and bone setting to mend broken limbs and torn muscles.

Blast wounds

The introduction of gunpowder saw a dramatic shift in the scale and nature of war wounds. Blast injuries from artillery shells and cannons shattered limbs, tore open bodies, and smashed skulls.

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. By Charles Bell, Battle of Waterloo.

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 Paré was one of the first to specialise in military wounds. He was particularly innovative in developing new surgical techniques and equipment.

Bullets and shrapnel added a new dimension to infection. They carried fragments of clothing and debris deep into the body to become the seats of infection—until the arrival of antibiotics, this was a major cause of death in military hospitals. 

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 the first '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 were transported around the world to fight on multiple fronts. New forms of mechanised weapons contributed to the huge numbers of casualties, with over 50% of all battle injuries on the Western Front resulting from artillery shells.

Experience taught surgeons that the best way to stop such wounds from getting infected was a technique called debridement—the 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 brought 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), mines and booby traps resulted in wounds to the limbs. And explosions inside armoured vehicles and bunkers caused burn injuries to troops, while the use of napalm resulted in multiple burns casualties among both civilians and soldiers.

In the Gulf War (1990–91) and in later conflicts in Iraq and Afghanistan, many soldiers were injured by improvised explosive devices (IEDs). These, 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 wound had to develop new surgical techniques. And fields such as plastic surgery and orthopoedics saw major advances as a result.

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 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 a support group called the Guinea Pig Club to help them readjust to their new faces.

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