Battlefield Surgery

The fundamental principles of surgery we see today are in many instances attributable to the experiences of battlefield surgeons throughout time. Battlefield surgery is the father of modern day surgery.
The fact is that within a relatively short period, advances made in modern general anaesthesia had radically changed the whole course of medical science. Doors have been opened that have encouraged the surgeon to develop and perform the sophisticated surgical procedures that we see today.

It must not be forgotten that without the development of the modern anaesthetics, surgery would still be a rare occurrence confined to abscess drainage, stone removal and amputations.

Camp Bastion Operating Theatre
Camp Bastion Operating Theatre
To reinforce my point, during the five years prior to the introduction of anaesthetics in Boston, only 184 surgical operations were carried out; that works out at just 3 per month.1
The sad fact of the matter was that before the discovery of anaesthesia, people would rather die than be subjected to the surgeon’s knife. Those that did consent to amputation or other surgery, often suffered from severe shock and post-operative depression and then a good percentage of those died from wound infection.
The American nation, because of Morton’s achievement, would like us to believe that anaesthesia is an all-American invention, but the Europeans, Asians and Africans have played an important role in the "development" of anaesthesia.

Camp Bastion Operating equipment
Camp Bastion Operating Equipment
The principles of battlefield surgery are being employed today in hospitals in London, New York, Baghdad, Jerusalem, Afghanistan, and even here where I work at Northallerton in the UK.
It is to this end that I have produced this article, to make you more familiar with the roots of surgery and anaesthesia. Those who undertake theatre practise as an occupation will at some time in their career be asked where it all started. You can after reading this, answer some of those questions.
The understanding of the history of Surgery and Anaesthesia is not critical to your development as a theatre Nurse or Practitioner, but to know a little about your professions history is I believe a good thing.
Battlefield surgery has and will always be needed, whilst the world still insists on being at odds with each other.

Most of what has been written so far has its roots firmly in the military camp, for without military involvement, surgery would not have progressed as far as it has done up to now.
The first real use of anaesthesia in war came during the Mexican War(1846 - 1848). Ether was first administered in war to an accidentally injured soldier during the battle of Vera Cruz. Barton was the surgeon, and he successfully amputated a patient’s legs whilst under the influence of Ether. At first there was opposition from some surgeons to Ether as they complained of side effects, namely that the patient bled more profusely: it was also considered by some to be unnecessary. in the Crimean war as an example, the main surgeon there thought it better that the soldier felt the sharp end of the blade.

The problem with the use of Ether in the early days, especially in the USA around its southern borders, was that the concentration of Ether given, was unpredictable due to the heat so there was a tendency to overdo the vapour.
It can be said with confidence that the first use of anaesthetic in times of war was a great success. The work of the Physicians like John Snow helped these anaesthetic agents into being accepted as an alternative to suffering pain; this especially after the Queen gave it royal approval after the birth of her son.

A lot has been made of the "Cock ups" of the Crimean war, there was the charge of the Light Brigade which was in fact a complete an utter disaster, although us British are great at turning a defeat into a victory. Most think of the charge as a brave charge of British cavalry, that's British propaganda for you. Then you have the disaster at the hospitals, especially Scutari. What a mess, how many would have died if it was not for the Times Newspaper reporter.

Another great success for the British and French armies was the introduction of Chloroform, it saved many lives. Some would have you believe that they killed a lot of people with its overuse, I believe some died as a result of the wrong concentration, but more survived not dying in agony on the operating table as many used to.

Anaesthetic delivery systems are still being developed by the Military. Ivan Houghton a Military anaesthetist before, during and after my time has been uppermost in the development of the delivery systems. He developed one using a Laerdal Bag and the OMV vaporisers. Ivan also invented other pieces of equipment for field Anaesthesia. He was affectionately known as the bionic hamster to those who worked with him.

The British Military have changed the way it responds to war casualties depending on the threat. During the time of the cold war, a definite chain of evacuation was formulated from the front line till the patient was evacuated from a dressing station to a forward hospital and eventually to the British Base Hospital, depending on the strategic position at that time.

Field Surgical Teams were independent operating teams deployed to front line positions or to positions where it would be too dangerous for a forward hospital to deploy. Today the scenario has changed, in the wars of recent years the enemy is all around, so the Medical Support Troop has been re-configured to a self-contained surgical team with holding and evacuation assets.

In instances such as Afghanistan, Hospitals such as Camp Bastion are set up in a relatively safe position surrounded by troops.
The trauma surgery that is carried out today is a modified version that Pare carried out during the 15th century. Today we have extremely good antibiotics and surgical equipment as well as anaesthetics that are far advanced from Morton''s day. The wars of today inflict injuries that are horrendous, caused by modern explosive weaponry.
Today advanced evacuation procedures transport the sick or wounded quickly to hospital. Add to this the surgeon's skills, gained from studying the techniques that even Paré used to use, to the modifications of his techniques, with the aid of ultra-modern surgical equipment and ultra-modern post opt care facilities, more soldiers are surviving wounds that they would have died of just ten years ago let alone 100 years.

The First World War.

In 2014 to 2018 we will remember the 100th anniversaries of a war the likes of the world had never seen before, this war produced statistics that were at the time unheard of for a conflict, thousands of British soldiers had died during the Crimean war 60 years prior, thousands had perished in the Sudan and Boer conflicts, this war however was responsible not for thousands or even hundreds of thousands being killed or injured, the word millions were used for the first time.
The injuries were appalling, and disease was once again a greater killer than the initial injury.

We remember with sadness this conflict, the sadness and the madness of sending hundreds of thousands to their deaths in one day, with not a single yard gained in response to the slaughter.
We remember the jack ass politicians and power-hungry men who led the world into this slaughter of the innocents, may God have mercy on their souls.

It is true however that with these tragedies came some good, and the good which came from this war were the innovations to save lives by improving the surgical and medical techniques.
These innovations were founded on the long suffering of the wounded and the need to end this suffering. In ancient times, the physician would end the patients suffering by ending the wounded man’s life quickly.
It was during this world war however when the onus was to get the wounded quickly from the point of injury to the dressing station where they could receive life-saving treatment. This was achieved as a result of the bravery of the many doctors and medics who ventured onto the field of battle to retrieve these poor wretches. The lives of many of these brave medics were lost attempting to save the lives of the wounded.
The bravery of the medics matched and, in many cases, exceeded those of others, many medics both doctors and ordinary stretcher bearers won awards for bravery beyond the call of duty with hundreds being awarded the Military Medal or cross, several posthumously, and fewer but still several who were awarded the highest award of all, the Victoria Cross and of the three people throughout history to win a bar to the Victoria Cross, two were medics and both won their second during this horrific conflict.

Captain Noel Chevasse
Captain Noel Chevasse

It is also worth noting that all three winners of this award are connected in one way or the other. Captain Noel Chavasse died of his abdominal wounds in August 1917 and it is said at one stage he was tended by Lt Col Martin-Leake, who was the first person to be awarded the bar to his VC. Second Lieutenant Charles Upham, from New Zealand, was awarded his VC's for outstanding leadership and courage in the battle of Crete in May 1941 and then in North Africa in July 1942, he is related to Noel Chavasse on his mother’s side.

The First World War was to be called at the time, a war to end all wars or the Great War, how wrong they were. The politicians obviously had never learnt anything from that barbaric conflict, as they were back for more 20 years later with the outbreak of the Second World War.

The First World War brought with it several inventions that allowed man to kill man in greater numbers more efficiently. Machine gunś, long-range artillery, aircraft, mortar fire and the grenade all did their job with devastating efficiently.

The Second World War added to that the mass slaughter of civilians, the rocket and the ultimate weapon of mass destruction the Atomic bomb.

Lt Col Martin Leake
Lt Col Martin Leake
During the WW1 one of the biggest killers were of course were the Generals, who for example at the Battle of the Somme ordered the men to walk casually toward the enemy positions as opposed to charge. The result of this was thousands upon thousands were killed on the first day more being killed than were killed by the A-bomb on Hiroshima on the first day, with many more wounded, and this slaughter of young men continued throughout the campaign.
Injuries were horrific, in a lot of cases death was a merciful exit from the world of agony both physical and mental.

The loss of so many men to death and injury forced changes in the civil society they grew up in, women were recruited to undertake work that were previously male dominated.

Once these women established themselves they were allowed to continue post war if simply because they were paid a lot less than their male counterparts.
So, the war to end all wars caused such a change in society that was never to be reversed. However, with all major wars, comes inventions of new weapons and ways to kill and maim a human being, a typical example of the First World War was the use of the aircraft and the airship to strafe and bomb, also the use of chemical warfare that produced a new type of injury.

Lt Charles Upham
Lt Charles Upham
It is then in reaction to these new weapons of mass destruction that the medical services start to produce a range of different treatments and counter reactions.
With technology to destroy, comes also invention of new medical techniques and surgical techniques to deal with a different wound that are a result of this new modern warfare.

Most are aware of Harold Gillies and Henry Tonks, the team who charted using art, a series of surgical operations of disfigured faces of several First World War injured. The artists picture (Tonks) portrayed the treatment stages of the plastic surgeon (Gillies). This of course was at the time of innovation when the idea of reconstructing facial disfigurement was new.

This war also brought with it a new approach to wound control. It was common at the beginning to give each soldier their own bottle of iodine, however the strength of this iodine was eventually to cause problems as it was too strong and resulted in the destruction of the crucial white cells required for healing. Other substances were eventually utilised a typical example being EUSOL.
It was also a time for research, as the initial stages of Fleming's theories on antibiotics were formulated during this war, maggots were used to good effect on the wounded.
The ambulance service improved as did the nursing service. The building of a great many hospitals was undertaken, also specialist hospitals for plastics (Sidcup) and for those who had battle shock (Post Traumatic shock) Netley.

Innovations in surgery were preceded by innovations in anaesthetics with the likes of McGill and Rowbotham. New anaesthetic machines were being developed by Boyle to take the place of the mask and lint.
New designs of endotracheal tubes produced by McGill, increased their usage. Surgery was able to progress simply because of the elimination of the need to work expeditiously: the surgeon could now feel as though there are no time restraints put on him.
The war also showed that there is a need for a National Health Service, the work investigated by Bertram was the template for the Future NHS.

The country also was put to the test post war, as an outbreak of Spanish Flu killed more people worldwide (some say as high as 50 million) than the bullets and bombs of the entire war.

X-Rays were introduced by the french into medicine in 1918, although very crude, they were seen as useful by some doctors and useless by others.
The blood transfusion service was really set up during the Great War. This was accomplished by trial and error, but the idea and the practice were perfected between the wars.
It's also a fact that more people died as a result of disease and infection during the First World War than by bomb and bullet. However, it is also the case that health and hygiene took great steps forward during this war.

One of the biggest improvements in practice during the First World War was the development of the ambulance service. This service was mechanised, and patients were reaching hospital far quicker than they had in earlier wars. On occasions, it was only possible to use horse-drawn ambulances especially on tusage.he fields of Flanders as mud stopped any mechanised vehicle in its tracks. The boats and trains transported the battlefield wounded quickly to their allotted hospitals.
With the mud and with so many dead bodies and body parts littering the battlefield, rats and the vermin increased. The cases of gangrene increased with many losing life and limb to this deadly bacteria. Because there were no antibiotics at this time amputation was also common on the battlefield, however the other big killer was disease, which was as a result of the filth of the battlefield.
New methods were tried to eradicate this disease on open wounds, maggots for instance were seen to be extremely helpful in keeping wound clean.

So, the First World War was a cause of so much misery, heartache and grief.
It was a result of the First World War that so many forms of medical research were followed; for example:

1. Antibiotics
2. X-rays
3. The modernisation of health services
4. Better hospitals
5. Better techniques in anaesthesia and surgery especially plastic.

It also led to changes in the way hospitals are now staffed, with nurses taking the primary role for patient care;  prior to this the doctors ruled the roost and nurses were subject to their will and did not question in most cases what they were told to do.

In the operating theatres staff were being replaced with women who were trained as nurses. The only place effectively open for the men, was as an anaesthetic assistant, mainly because the strength of a male assistant was required to restrain the patient when being 'gassed down'; some tended to struggle before being anaesthetised.

War however is the result of an inability of some polititians to find agreement or compromise, and it is they who are to blame for war!
There are regimes throughout the world who do not deserve power, as they abuse that power to their own ends, often terrorising their own citizens. We have United Nations and organisations that can put these regimes under the severest pressure economically and diplomatically, this should be the main way to defeat an irresponsible leader, sending troops to destroy this organisation just creates more violent groups.
That however will happen in a perfect world, this world is far from perfect and will never be perfect. Until then we must maintain research funding into better treatment for the wounded on the battlefield which would then be passed over to the civilian populace for general use and benefit all mankind.

It is now being 100 years since the start of that senseless war which cost the lives of millions and affected the lives of millions more. After the war, there was unemployment and many, many soldiers returned to poverty. Most of their original jobs no longer existed, or were taken up by women and converted to the production of munitions.

Later on, in the 20s came the great depression in which thousands upon thousands lost their livelihoods.

10 years after that, the Second World War started and with it more death and destruction and debilitating injuries. And there were of course, modifications within the hospitals in surgery, medicine and in rehabilitation which advanced these specialities.

It is important for us never to forget all those who died or were injured during this war, the first of a new form of warfare, were in most cases they did not even see their enemy as the shells fired from the cannons were miles away or the bombs that fell from the sky, that rained the shrapnel of death, instead of the water of life.
Lest we forget.


1 The Peoples Journal Of London 1847 On Anaesthesia

Ken True ODP