Medical Advancements in War

Militaries cause the advancement of medical knowledge because pursuing war leads to the creation of new weapons that cause new types of injuries. New injuries force doctors to develop new medical treatments; this pushes the field forward. War with its mass casualties also provides a large-scale testing ground for these new developments. Mass experimentation out of necessity and desperation leads to improvements in medicine for both soldiers and civilians.

War is tied to power in history. The drive towards power produces societal pressure for military innovation to increase an army’s chances of defeating their enemy. Technological advances produce a cycle in war as all sides seek to outpace the others to gain advantages: armour was developed in response to metal tipped spears; fortifications were built in response to mounted warriors; and other technologies fell out of use as they become obsolete like Roman road building techniques.1

Three primary innovations developed prior to 1800 are considered the most important technological shifts in warfare: the production and use of iron, the domestication of horses, and the use of gunpowder.2 Despite these military advances increasing causality rates when they were introduced, the primary cause of death during war has always been infection.3 Before Louis Pasteur and the modern understanding of germ theory emerged in the late nineteenth century, several theories of medicine existed, but none were able to address infection.4 Though we now have proof that substances like honey used on wounds have some antiseptic qualities, the knowledge about the root cause of infection was not known, allowing infections to fester in wounds causing significant injury and even death. This was especially bad in military campaigns where sanitary conditions were poor and wounds were large.

Many military advances affect civilian life, including modern technology like the internet or navigation services.5 Just as these technologies developed for military use have influenced civilian life, medical advancements developed for military injuries have changed civilian life. Much of our knowledge surrounding wound care, infections, and transmittable diseases comes from times of war. The high number of injured individuals combined with the chaos of treating the wounded on or near the battlefield has allowed doctors, medics, and nurses to innovate, leading to the acquisition of medical knowledge that has subsequently applied in civilian medicine. To this end, the knowledge gained during war continues to be used in times of peace.

Roman Surgical Scalpels, year unknown, Historical Collections at the Claude Moore Health Sciences Library, University of Virginia. Fair use.

Rome endured a fifteen-year civil war that ended in 30 BC. When Caesar Augustus consolidated his power in 27 BC after the fall of the Triumvirate with whom he had previously shared power, one of his first actions was to implement the first military medical corps in response to the large casualty rates in the preceding conflicts.6 Military physicians had different ranks based on their work, including camp physician, medici ordinarii, and legionary physicians, and were entitled to land and other benefits combat veterans received.7 Notably, once medical care was made free and available to all Roman soldiers their life spans increased to five years longer than their civilian counterparts.8

Romans had a strong history of surgical technique; over 200 instruments were recovered from Pompei and records show that tools were cleaned in hot water between uses.9 The mentors of many aspiring doctors encouraged them to enter the military because it was the best avenue for experience and honing their skills. Texts from Rome contain some of the earliest descriptions of amputation from the first century.10 These amputations were not the field amputations seen in later history and they were mostly in response to gangrene or another infection in a wound. Descriptions of the medical procedure for these amputations echoes the techniques used much later in history; in his writing about the subject, Aulus Cornelius Celsus stressed the importance of a clean wound and leaving enough flesh to create a good stump.11 The Roman physician, surgeon, and philosopher Galen wrote about the technique of tying arteries to reduce bleeding while working, much like modern surgeons do. This was time intensive though, so the practice of cauterizing a wound with hot irons or pitch remained popular.12 Eventually, following the trend of the rest of the empire, medical knowledge began to be lost in the western empire and an organized medical corps would not reappear in western civilization for over a millennium.

An oil painting showing the care of the wounded in Napoleon’s invasion of Russia. Charles Meynier, Rückkehr auf die Insel Lobau am 23. Mai 1809 Oil on canvas. Palace of Versailles. Fair use.

The Middle Ages were not a time of great medical advancements. Under the feudal system, lords levied a fee on their local populations for military engagements.13 The lord may have had a physician in their party but the peasant soldiers were left to either treat themselves or rely on their fellow warriors for care.14 Most historians agree that receiving a killing blow was kinder than being left wounded. Barbers, or barber surgeons, were typically the medical professionals that accompanied armies, though they were considered little more than skilled tradesmen. Of these barbers Ambrose Paré was likely the most successful, serving under five successive French kings.15 Paré was responsible for rediscovering several techniques lost from the Roman era including Galen’s technique for tying arteries and the use of turpentine for wound care.16 By the early modern period in the late 1700s, some more advancements appeared in the medical military field with three textbooks being written that laid the foundation for the work of the surgeons in the 1800s.

William Holl, “Portrait of Ambrose Paré” (1510-1590). Wikimedia Commons.

An oil painting showing the care of the wounded in Napoleon’s invasion of Russia. Charles Meynier, Napoleon’s Rückkehr auf die Insel Lobau am 23. Mai 1809. 1810-1820. Oil on canvas. Palace of Versailles. Fair use.

The French Revolution is considered the turning point for war, bringing it into what is called the modern age, making war a total mobilization of a nation. Levée en masse became the norm, and larger proportions of the population were now killed and wounded in battle. The 1800s witnessed several significant technological advances in weaponry including mobile artillery and more accurate firearms. These weapons left more severe wounds and higher casualties than previous generations of doctors had seen.17 The slow round projectiles used in the guns of the 1800s caused a lot of internal damage by ricocheting around inside the body.18 In response, medical personnel needed to develop new ways to treat the large number of wounded soldiers they were seeing. Infection and disease were still the major causes of death as germ theory was not yet understood.19 Turpentine, pressure sponges, and alcohol were all used on smaller wounds to help them stop bleeding and heal, while cauterizing larger wounds remained the norm.20 These techniques were not for cleaning wounds as modern observers might assume; many doctors believed that pus was necessary for the healing process because it was so common in wounds.21 The use of these substances was to encourage healing.

High infection rates made surgery the best course of treatment for major injuries.22 Surgery became a constant feature on the battlefield as enormous numbers of amputations were performed to cope with the difficult wounds caused by musket and artillery fire. Speed became a surgeon’s best skill for amputations to keep patients from bleeding out; this became much easier once Petit’s tourniquets became widely used.23 The tourniquet was tightened using a hand screw which made it easier and faster to use in the field than other tourniquets, variations on the device were used until the late 1900s.24

Napoleon’s Army was one of the first in the modern era to organize a system for removing the wounded from the battlefield. Dominique Jean Larrey was in charge of developing the medical organization in Napoleon’s Army as chief medical officer. He set up a system for removing the wounded from battle and getting them the best care possible. Stretcher bearers would be sent out onto the battlefield to collect wounded and bring them to the field hospital. The wounded would then be stabilized in the hospital, including amputation if necessary, then they would be loaded on to the carriage ambulances and taken to a more permanent hospital away from the fighting to recover. Despite the significant success of this organization method, few armies copied it until many years later. along with Larrey’s work in the Russian campaign to care for the ill and wounded turned him into a folk hero in France.

Anne-Louis Girodet de Roussy-Trioson,

Napoleon’s Army was one of the first in the modern era to organize a system for removing the wounded from the battlefield.25 Dominique Jean Larrey was in charge of developing the medical organization in Napoleon’s Army as chief medical officer. He set up a system for removing the wounded from battle and getting them the best care possible. Stretcher bearers would be sent out onto the battlefield to collect wounded and bring them to the field hospital. The wounded would then be stabilized in the hospital, including amputation if necessary, then they would be loaded on to the carriage ambulances and taken to a more permanent hospital away from the fighting to recover.26 The carriages used for this purpose has suspension to reduce the jostling for the comfort of the injured. Despite the significant success of this organization method, few armies copied it until many years later.27 The success of this system along with Larrey’s work in the Russian campaign to care for the ill and wounded turned him into a folk hero in France.

Anne-Louis Girodet de Roussy-Trioson, Portrait of Dominique-Jean Larrey, 1804, oil on canvas. Louvre Museum, France. Fair use.

A drawing showing what the ambulances in Napoleon’s army would have looked like. These light weight carts were colloquially known as ‘flying ambulances’. Edmond Lajoux, Ambulance Volante de Baron Larrey 1920. Engraved Plate. Fair use.

Caption: Amputation of the Thigh, 19th century, Charles Bell (1774–1842), Wellcome Collection Gallery, Wikimedia Commons.

The American Civil War marks a shift in military medical treatment from the past towards a modern system of medicine. During the Civil War, the weapons technology was ahead of the medical ability to deal with the wounds the weapons inflicted. Like the wars earlier in the century, doctors often used amputations, despite disagreement between them about how often amputations should occur. Older, conservative doctors typically favoured trying to save the limb, which usually led to a slow painful death by infection. The younger doctors tended to be more excited about the new techniques developing in amputations and favoured quick surgery.28 Initially, the US Department of Sanitation, whose recommendations were widely followed by doctors, only recommended amputation after a direct hit from a cannon. Later the recommendations were updated with new battlefield data to include bone splintering—regardless of the source—as a reason to amputate; this advocated more liberal use of amputation. quick surgery, while medically necessary, earned Union doctors a reputation for excessive use of amputation among the soldiers; there were reports of some soldiers threatening surgeons with a pistol in an effort to save their limb.30 Despite gaining a public reputation for being too quick to amputate, the Union Public Health Director stated that generally, there should have been more amputations. in amputation was called the flap method. Developed by William Cheselden, the flap method created a better stump which led to a better post-surgery life for the patient, but the procedure took longer than the circular method and left a larger wound.32 Time was difficult to come by in these hospitals making the procedure difficult to use, and the larger wound resulting from this technique did create a higher possibility of post-surgical infection. The result was that both the new flap method and the older circular method were both used during the Civil War. Another new development used during the Civil War was anesthesia. Though not developed for military use, the Civil War provided ample testing ground for the development of anesthesia. Ether was not widely used on the battlefield because it was time consuming to administer so chloroform became the preferred anesthetic. of overdoses.34 This means that the doctors using chloroform were very good at the technique of applying the chloroform to a towel and dropping it on the mouth and nose of the patient in the correct dosage. Modern studies now show that had ether been more widely used in the war there likely would have been more deaths because of ether’s tendency to worsen the effects of shock which harms surgical outcomes.

The American Civil War is also classified as one of the first modern wars because large quantities of data were collected in coordinated efforts. This collection of data about wounds, surgical methods, and patient outcomes was compiled into the Medical and Surgical History of the War of Rebellion published in 1870.36 this data which ultimately informed future practice of American doctors.37 Much of the American medical apparatus formed in the wake of the war was staffed by the 15,000 experienced veteran doctors returning to their communities.38

Amputation being performed in a hospital tent, Gettysburg. 1863. Photograph. #520203, The National Archives and Records Administration. Fair Use.

The American Civil War marks a shift in military medical treatment from the past towards a modern system of medicine. During the Civil War, the weapons technology was ahead of the medical ability to deal the century, doctors often used amputations, despite disagreement between them about how often amputations should occur. Older, conservative doctors typically favoured trying to save the limb, which usually led to a slow painful death by infection. The younger doctors tended to be more excited about the new techniques developing in amputations Initially, the US Department of Sanitation, whose recommendations were widely followed by doctors, only recommended amputation after a direct hit from a cannon. Later the recommendations were updated with new battlefield data to include bone splintering—regardless of the source—as a reason to amputate; this advocated more liberal use of amputation.29 This preference for quick surgery, while medically necessary, earned Union doctors a reputation for excessive use of amputation among the soldiers; there were reports of some soldiers threatening surgeons with a pistol in an effort Despite gaining a public reputation for being too quick to amputate, the Union Public Health Director stated that generally, there should have been more amputations.31 The newest technique in amputation was called the flap method. Developed by William Cheselden, the flap method created a better stump which led to a better post-surgery life for the patient, but the procedure took longer than the Time was difficult to come by in these hospitals making the procedure difficult to use, and the larger wound resulting from this technique did create a higher possibility of post-surgical infection. The result was that both the new flap method and the older circular method were both used during the Civil War. Another new development used during the Civil War was anesthesia. Though not developed for military use, the Civil War provided ample testing ground for the development of anesthesia. Ether was not widely ter so chloroform became the preferred anesthetic.33 It is easy to administer an overdose of chloroform, but records do not indicate high numbers This means that the doctors using chloroform were very good at the technique of applying the chloroform to a towel and dropping it on the mouth and nose of the patient in the correct dosage.35 Modern studies now show that had ether been more widely used in the war there likely would have been more deaths because of ether’s tendency to worsen the effects of shock which harms surgical outcomes.

The American Civil War is also classified as one of the first modern wars because large quantities of data were collected in coordinated efforts. This collection of data about wounds, surgical methods, and patient 36 The Enlightenment with its focus on the scientific method encouraged the collection and examination of Much of the American medical apparatus formed in the wake of the war was staffed by the 15,000 experienced veteran doctors returning

Medics helping injured soldier in France. 1944. Photograph. War and Conflict Number 909, The National Archives and Records Administration. Fair use.

The World Wars were yet another time in history where a large portion of the population mobilized for war, taking up actively dangerous roles. By the twentieth century, germ theory was understood and universally accepted. This meant that these were some of the first major conflicts where infection was not the main cause of death for soldiers due to the introduction of penicillin.39 Burn care was also improved by the introduction of antibiotics; infections are especially susceptible to inflection. During the First World War the modern procedure for burn care was established: deep burns required excision, pain management was prioritized, and skin grafting became possible with minimal complications.40

Technological improvements led to an increased range for artillery, which forced hospital construction at least 2000 feet behind the front lines.41 The distance between the fighting and the hospitals required ambulances to become motorized for the first time. Once the First World War started, many private vehicles were commandeered for the war effort.42 The use of cars and trucks continued in the Second World War alongside the added capacity to air lift those who were gravely injured on the wings of planes or in helicopters.43

American Red Cross WWI soldier facial reconstruction documentation photograph (Before) 1920. Archives of American Art, Smithsonian Institution. Fair use.

In combination with the improvements in artillery, the introduction of small firearms and the use of hand grenades, the military techniques used in the First World War contributed to the high number of facial injuries; peering over the top of trenches left the neck and faced visible and vulnerable to enemy fire.44 The surgical improvements of the era meant that more patients were surviving these injuries, but with visible facial disfigurement. The solution the Allied side employed was the use of facial masks or prosthetics Third London General Hospital in the First World War under the guidance of Francis Derwent Wood, a sculptor and orderly for the Royal Army Medical Corps.46 The prosthetic masks were made specifically for the patient with plaster molds of their faces used as the guide for sculpting the prosthetic with gutta-percha, a substance similar to rubber, then the prosthetic would be painted to match the rest of the face.

The concept of sacrifice dominates narratives of war. The same applies when discussing the medical advancements that developed out of conflict. However, considering sacrifice through the lens of medical care is difficult. These soldiers never consented to being experimented on by doctors. They were wounded and in desperate need of care. The physicians treating them were not in an easy position; known practices were not enough to save lives so experimentation became the only option. Doctors had to have become as desperate to save as many of their patie As Eric Weiss says, “this was an experimentation that was forced upon the medical community, not elected by it,” casualty rates, the doctors had no choice but to try any and every thing they could. Sometimes doctors’ attempts worked; often this forced arena of practice led to several theoretical ideas being tested, and it resulted many tangible benefits and advancements. This is the paradox of medical advancement. Like any experiment, there will be mistakes and losses, but in medicine the losses are human. To save many lives, a few will be lost. This is the principle behind many wars that is forgotten in the aftermath of peace. These advancements came at a high cost, like any gain from war, and should be acknowledged alongside the other sacrifices we venerate when we memorialize war. The unknowing sacrifice of countless soldiers has led to much of what gives moderns a high quality of life and this deserves to be remembered too.

American Red Cross WWI soldier facial reconstruction documentation photograph (After) 1920. Archives of American Art, Smithsonian Institution. Fair use.

In combination with the improvements in artillery, the introduction of small firearms and the use of hand grenades, the military techniques used in the First World War contributed to the high number of facial injuries; peering over the top of trenches left the neck and faced visible and vulnerable The surgical improvements of the era meant that more patients were surviving these injuries, but with visible facial disfigurement. The solution the Allied side employed was the use of facial masks or prosthetics45 The Masks for Facial Disfigurement Department opened in the Third London General Hospital in the First World War under the guidance of Francis Derwent Wood, a sculptor and orderly for the Royal Army The prosthetic masks were made specifically for the patient with plaster molds of their faces used as the guide for sculpting the prosthetic with gutta-percha, a substance similar to rubber, then the prosthetic would be painted to match the rest of the face.47

The concept of sacrifice dominates narratives of war. The same applies when discussing the medical advancements that developed out of conflict. However, considering sacrifice through the lens of medical care is difficult. These soldiers never consented to being experimented on by doctors. They were wounded and in desperate need of care. The physicians treating them were not in an easy position; known practices were not enough to save lives so experimentation became the only option. Doctors had to have become as desperate to save as many of their patients as possible. As Eric Weiss says, “this was an experimentation that was forced upon the medical community, not elected by it,”48 and when faced with the high casualty rates, the doctors had no choice but to try any and every thing they could. Sometimes doctors’ attempts worked; often they did not. But this forced arena of practice led to several theoretical ideas being tested, and it resulted many tangible benefits and advancements. This is the paradox of medical advancement. Like any experiment, there will be mistakes and losses, but in medicine the losses are human. To save many lives, a few will be lost. This is the principle behind many wars that is forgotten in the aftermath of peace. These advancements came at a high cost, like any gain from war, and should be acknowledged alongside the other sacrifices we venerate when we memorialize war. The unknowing sacrifice of countless soldiers has led to much of what gives moderns a high quality of life and this deserves to be remembered too.

Political Science major