War And The Surgeon
Together with the siren song of war that has sung so loud in the ears of leaders and armies and nations, a very different tune, sweeter than the Aeolian harp has called forth another breed of men and women to march in step with the bloody mayhem and madness of the battlefield.
Where armies have deployed battering rams, muskets, cannon smoke and laser guided bombs, surgeons have deployed the scalpel, the suture, the soothing splint, the urgent shot of morphine; where soldiers, airmen, sailors have engaged in deliberate acts of destruction, surgical teams have sprung into action setting up field hospitals and makeshift beds; and where the telegraphed report back from the battlefront has reckoned success in terms of pieces of armoury taken out and enemy lives lost, the surgeon’s success has always been measured by lives saved.
Nor does the surgeon set apart friend from foe. The wounded warrior - or civilian - from either side must be treated the same, however fierce the battle, however cruel or villainous the enemy’s reputation. And perhaps in this way the surgeon rebukes gently, the folly of war.
As a surgeon who has spent much of his career in trauma surgery, I know that my trauma team has always sought to put together, to heal, to bind and to salvage the shattered, the lacerated, the bruised and the broken. All the injured are equally deserving of treatment - and no moral judgments are ever made. During the covid pandemic for example, we would never have imagined treating the “vaccinated” any differently from the “unvaccinated.”
Epochal surgical advances have been made amidst the myriad, fast-moving challenges of the the battlefield. The vine does not produce good fruit unless stressed and pruned - and if this logic is applied to war surgery, the vines of war have produced some of the finest surgical wine.
The application of sutures to bleeding battlefield wounds by the ancient Indian school of surgery led by Susrutha and later by the French army surgeon Ambroise Pare presaged the modern, widespread use of the surgical tie.
The horse-drawn “flying ambulance” of another French surgeon Dominique Jean Larrey (1766-1842), is different only in speed and mode from the airborne evacuations now common in both peacetime and war. The tourniquet that first saved soldiers’ lives in war is now used to save the farmer’s life as well. And but for Florence Nightingale and the Crimean war, nursing as we know it would not exist.
Florence Nightingale (1820-1910) -the “Lady with The Lamp”, as soldiers affectionately called her. Modern nursing was born in the crucible of war - Nightingale transformed nursing and brought in far reaching reforms in hospital management. The “Nightingale Pledge,” taken by graduating classes of nurses, is the equivalent of the Hippocratic oath.
The military nurse is now an indispensable part of the surgical team that cares for the casualties of war.
Wounds inflicted with the sword were reconstructed with the forehead flap by ancient Indian surgeons. Several centuries later, wounds inflicted by exploding shell and shrapnel in the first and second world wars saw the birth of modern plastic surgery with the brilliant work of Sir Harold Gillies.
Susrutha’s school of surgery (about 600 BC) practiced forehead flap reconstruction of noses that had been sliced off as punishment of criminals or the King’s enemies. This painting, from the Parke-Davis “Great Moments in Medicine” collection, shows Susrutha fashioning the forehead flap - a technique that is used almost unchanged to this day.
Watercolour portraits showing a soldier before and after facial reconstruction surgery performed by Harold Gillies and his team in 1918. Sir Harold Gillies (1882-1960) was a New Zealand born surgeon, who worked mostly in England and transformed the field of plastic surgery during and after the first world war.
The Canadian surgeon Norman Bethune of Gravenhurst, Ontario, first introduced organized blood transfusion on a massive scale to the frontlines of the Spanish Civil War. His “Servicio Canadiense de Transfusion de Sangre” (Canadian Blood Transfusion Service) arrived in Spain in 1937 and within 5 months, the Canadians were supplying a 1000 km long war front with up to 100 transfusions a day, 4000 blood donors, and 5 mobile transfusion delivery trucks.
Canadian surgeon Norman Bethune (1890-1939) with one of his transfusion trucks, Spanish Civil War, 1937. Bethune brought blood transfusion to the battlefield and the "Servicio Canadiense de Transfusion de Sangre” deployed rapidly along a 1000 km long war front.
Surgeons and poets alike have lamented the futility of war. Those closest to its horrors have also been the most averse to its repetition. The poets of the first world war fought in the trenches, saw and felt suffering as never before and sent back poems that would later strike the consciences of nations. In the months before he was killed in action (one week before the armistice to end the first world war), Wilfred Owen wrote what would today be called several, “anti-war” poems. They could also be called “futility poems” … as in the poem that describes the death of a young French soldier:
Futility
by Wilfred Owen
Move him into the sun—
Gently its touch awoke him once,
At home, whispering of fields half-sown.
Always it woke him, even in France,
Until this morning and this snow.
If anything might rouse him now
The kind old sun will know.
Think how it wakes the seeds—
Woke once the clays of a cold star.
Are limbs, so dear-achieved, are sides
Full-nerved, still warm, too hard to stir?
Was it for this the clay grew tall?
—O what made fatuous sunbeams toil
To break earth's sleep at all?
Surgeons have joined other eminent physicians in opposing war and their effective activism has resulted in the coming together of such groups as the Medical Association for the Prevention of War (MAPW), International Physicians for the Prevention of Nuclear War (IPPNW) and Medical Action for Global Security. In 1985, the IPPNW received the Nobel Prize for Peace.
But if wars should come (as come they do), surgeons will once again answer the call to duty in the service of mankind. Once again will the scalpel challenge the sword and surgical teams race against time and against the odds … and once again will death and life march hand in hand together. When this happens, there is almost certainly no time to contemplate the relative merits of war and peace as surgeons, nurses, anesthesiologists start once again the charged, frenzied, often rewarding work of war surgery.
And yet, when the particular trial of the particular war is over, surgeons and poets must surely look forward together to a time when, in the words of the prophet Isaiah, “they shall beat their swords into plowshares, and their spears into pruning hooks. Nation shall not lift up sword against nation, neither shall they learn war any more.”