WH2Sur46a.jpg Wars tend to lead to significant medical improvements. In both World Wars, plastic surgery made significant strides, pushed by the frequent and crippling severity of wounds, especially facial wounds. Surgeons, doctors, and dentists found themselves confronted with the destruction of modern warfare written in intimate detail on human flesh. The demands were stunning, as one pioneer remembered:

Writing in the 1950s, Sir Harold Gillies, a pioneer in the art of facial reconstruction and modern plastic surgery, recalled his war service: “Unlike the student of today, who is weaned on small scar excisions and graduates to harelips, we were suddenly asked to produce half a face.”

Doctors confronted with such wounds made at least a start during and after the war in reconstruction, “in the treatment of fractures of the jaws, and in the repair of destructive wounds of the maxillae, by bone grafting and by adequate and ingenious prostheses,” (1) and the military began to institutionalize the lessons and pass them down. During the First World War, the U.S. Army created special programs at Northwestern and Pennsylvania to train both army doctors and dentists in reconstructive surgery. The Army Surgeon General reported in 1918 that:

The medical officers were given special instruction in plastic surgery, blood transfusion, and bone transplantation, and the dental officers in bone fragment fixation by intro-oral splints, the systemic effects of focal infections, and surgical anatomy of the face, jaws, and neck.

The war in Iraq and Afghanistan have lead to their own medical improvements, as well as their own problems. The enormous improvements in body armor have meant that soldiers, sailors, and marines are surviving much more lethal situations. Coupled with an aggressive policy to get injured Americans care within the “golden hour,” the result has been a substantial drop in fatalities. In Iraq, one in seven American casualties have been fatalities, compared to ratios in World War II of about one in four.

One unwelcome effect of those survivals is the increasing number of lost limbs and devastating head injuries. IED explosions often result in “traumatic, compound bone fractures [that] are very difficult to treat on the battlefield, often requiring multiple surgeries with bone screws, plates, and rods to cobble together grafts with healthy bone.” Such fractures, Army doctors hope, might be treated with “fracture putty“:

‘Fracture putty’ is a biocompatible compound designed to be packed in and around non-union fractures. It provides a load-bearing, osteoconductive, bone-like structure to give regenerative growth a chance. Then, once the bone heals, the putty degrades into harmless, absorbable by-products.
“The fracture putty will serve as a bioactive scaffold and will be able to substitute for the damaged bone,” said principal researcher Mauro Ferrari. “At the same time, the putty will facilitate the formation of natural bone and self-healing in the surrounding soft tissue through the attraction of the patient’s own stem cells. The putty will have the texture of modeling clay so that it can be molded in any shape in order to be used in many different surgical applications, including the reconnection of separated bones and the replacement of missing bones.”

Along with this, unfortunately, has gone other, less savory things. The demand for medical progress creates monetary incentives even in the military:

A former surgeon at Walter Reed Army Medical Center, who is a paid consultant for a medical company, published a study that made false claims and overstated the benefits of the company’s product in treating soldiers severely injured in Iraq, the hospital’s commander said Tuesday.

The military has also had difficulty in making progress on recognizing and treating post-traumatic stress disorder, though the Obama administration seems to be speeding things up, if only a bit.

There is no likelihood of complete cures, of course. The treatment of mangled limbs may improve, but it is unlikely that it will ever be complete. Body armor will cover more and more, but the IEDs will get larger and larger to compensate. And, of course, war maims and kills those without body armor as well. Worse, wars continue their sanguinary harvest for years after their official ends. But we should not lose sight of the fact that wars, distressingly, have often created conditions ripe for medical advancement: plenty of patients and lots of resources. Practice makes, if not perfect, then, at least, better.

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(1) Quote from John Staige Davis, “Plastic Surgery in World War I and in World War II,” in Ann Surg. 1946 April; 123(4): 610–621