The noise of war is in the air. Fortunately, almost every sane person wants peace. That said, surgery as a discipline owes much to war for its advances over the millennia. The comparisons between surgery and warfare are still quite prevalent.

We have ‘surgical strikes’, the surgeon is the ‘captain of the ship’ in the operation theatre or if you will, the ‘theatre of operation’. But most importantly, surgery has evolved by treating war wounds and once a war is over the lessons learnt in combat are transferred to civilian practice. A good example of this transfer of experience was seen in ‘emergency rooms’ in the inner cities of the United States where guns violence was and is still very prevalent.

Interestingly, during my own training in surgery in the US, one of the surgeons that taught me some of the basics of surgery on different blood vessels told me that he had earlier on served as an army doctor at the Badaber Airbase near Peshawar that once served as a US facility. It was from this airbase that the infamous U-2 spy aircraft flew over the then Union of Soviet Socialist Republics (USSR) in May of 1960 and was brought down and its pilot, Gary Powers, was captured.

After the U-2 affair, emphasis was put on development of spy satellites and unmanned spy planes (drones). The impact of war and preparation for war has always helped in development of many scientific disciplines including medicine in general and surgery in particular.

Today I want to primarily discuss the influence that war has on the development of medicine and surgery. Medical treatment of disease as we know it today is the product of scientific developments of the last century but surgery and war have a long history. Ambrose Pare, a French war surgeon of the sixteenth century, is often considered the father of modern surgery. His statue in France carries a statement attributed to him that says, "I bandaged him and God healed him".

The first major contribution of war to general surgical practice today is the concept of ‘triage’ during emergencies. Triage means the treatment of patients based on the urgency of their problems rather than when they arrive in an emergency room. And with that is a concept of rapid transport of the very sick to a place where they can receive appropriate care.

The second important contribution is to the treatment of ‘shock’ after an injury. The treatment established was rapid replacement with intravenous fluids of blood loss to prevent damage to body organs due to low blood pressure. This need for replacement ‘fluids’ was a major impetus for the development of modern systems of blood banks and blood transfusion.

Another area of surgical treatment that owes a lot to war is the treatment of burns, both in the immediate phase after injury and the long term treatment after the patient survives the initial injury. An advanced area of surgical treatment for these patients led to the development of the field of ‘reconstruction surgery or plastic surgery beyond the basic ‘nip and tuck’ of cosmetic surgery.

As far as the treatment of gunshot wounds is concerned, I have alluded to it earlier. However the war experience taught us that modern bullets are a lot more destructive than they seem to be from the external sites of injury. Today in civilian practice it is almost mandatory that somebody with a bullet wound to the abdomen or the chest must be opened up to repair what can be extended damage to different internal organs.

When talking of gunshot wounds it is also now imperative for a practicing trauma surgeon to have an idea about the different types of bullets and guns to understand the sort of damage that can occur after these injuries.

Another area where war experience has made important contributions is the area of limb loss and amputations. During much of the history of war surgery, amputation of limbs was one of the major procedures performed on the battlefields. Even after the Afghan engagements a few decades ago a large number of ‘amputees’ were seen in Pakistan. As a result the need for prosthesis (false limbs) and their production developed considerably.

This is one area where science of applied ‘bio-mechanics’ is making major advances and is producing prosthesis that can actually function like the real thing. This is important not only for victims of limb loss due to any reason but this technology can also help in the rehabilitation of people that have suffered from limb paralysis due to strokes and other neurological problems.

Another area that was helped along by war was the need to salvage limbs where the blood supply had been damaged. This need helped develop the field of vascular surgery (surgery of the blood vessels) where arteries could be repaired or ‘plastic’ tubes (vascular grafts) are used to replace irreparably damaged arteries.

In the field of surgery of the heart and other organs in the chest, during WWII the work of Dwight Harken, an American surgeon working in London, essentially founded modern Cardio-Thoracic surgery. Harken successfully removed more than a hundred pieces of bullets and shrapnel from the chest area and even from within the human heart.

The ability to work on a beating heart without killing the patient led to major cardiac operations done in the late forties and the early fifties and in Mayo Hospital, Lahore even in the late sixties and the early seventies before the heart lung machines became generally available.

During almost a year I spent as a house surgeon in the Department of Cardiac Surgery in Mayo Hospital in 1971, I participated in almost a hundred closed heart valve operations (closed mitral commissurotomies). This operation was popularised in the US by Harken in the post-WWII period, though it had first been performed successfully by Sir Henry Souttar in London in 1925.

Even though the advent of the heart lung machine essentially made closed heart operations obsolete but over the last few decades there has been revived interest in doing heart operations especially bypass operations on heart arteries without using the heart lung machine. These operations are now called ‘beating heart’ operations.

Modern warfare especially between countries that possess nuclear weapons will create such massive destruction that saving individuals, combatants as well as civilians is going to be the last thing that will be possible. In consideration of this fact, physicians from the US and the USSR in 1980 formed an organisation called the International Physicians for the Prevention of Nuclear War (IPPNW). IPPNW won the Nobel Peace Prize in 1985.

I left my house job that I mentioned above in October of 1971 to go to the US for further training. The main reason for that timing was to avoid being conscripted by the Pakistan army and being forced to participate in the India-Pakistan war of 1971. Pakistan always had a fully volunteer army except for 1971-72 when recently graduating doctors were being forcefully conscripted because the army medical corps AMC) ran out of doctors after ‘reportedly’ grounding all Bengali officers including doctors serving in the AMC.