As a surgeon, I resent the use of the word ‘surgical’ to describe punitive, retaliatory and deadly armed attacks that are designed to destroy property and kill humans. Over the last 40 years, I have performed surgical operations on thousands of patients but I have never performed a surgical strike. Surgery is used to cure and improve life and often to prevent death. The fact remains that when a surgeon operates on a patient, the patient is not an enemy and every operation attempts to limit the damage to body parts in the way or around the organ needing treatment.

Originally the term surgical strike was probably used in to describe an attempt to destroy a local ‘irritant’ within enemy territory without producing generalised destruction. However, in the context of modern warfare considering the destructive capability of weaponry, a difference exists between what is now called total war and limited war.

A surgical strike is an attack that attempts to limit the extent of death and destruction and possibly avoids a major retaliation that could lead to all-out war. More importantly world opinion is unlikely to get too upset about something that sounds as benign and possibly even beneficial as a ‘surgical strike’.

I am not too pleased at calling any attempt to kill or injure human beings as surgical but at the same time I must admit that surgery and war have a long and mutually beneficial relationship. Also there is much that is common at least in terminology between warfare and surgery. As a surgeon I operate in an operation theatre. In war the area where a battle is being waged is also referred to as a theatre of operation. The surgeon in the operating theatre is often referred to as the ‘captain of the ship’ meaning that the surgeon is the commanding officer in the operation theatre. And the surgeon has a team at his or her command that follows orders. Yes, instructions from the ‘surgeon’ to members of the team are called orders.

Another important similarity between surgeons and commanders in a battle field is that if the ‘operation’ goes wrong the surgeon as the commander in the operation theatre takes the blame. This is not just a matter of honour but has important consequences for a surgeon at least in a country like the United States. Medical malpractice is a major issue in the US and if a surgical operation goes wrong the surgeon as the ‘captain of the ship’ is held liable for the bad result. This of course means that the surgeon might have to pay monetary damages to the patient or the family. That is a sob story that I will leave for another day.

War has always been a major impetus for scientific progress in general. But development of surgery as a discipline has depended greatly on war. From the very beginning of history war has been a part of human civilisation and war means injury and injury means attempts to repair or limit it. So from the beginning war wounds had to be treated and treatment of such wounds was the responsibility of a certain type of person. This person in time developed into the war surgeon.

When we talk of the history of modern surgery, two names stand out. First is that of Ambroise Pare (1510-1590 CE) a French war surgeon who developed many of the less ‘barbaric’ methods of treating wounds. The other is John Hunter (1728-1793 CE) a Scottish/British surgeon and anatomist who also started his professional life as a war surgeon but went on to become a researcher and teacher of surgery. I am sure that there were many ‘surgeons’ in service of Muslim armies that probably did much to advance surgical treatment of wounds but their names and exploits are not available in present day medical literature.

In modern times, the presence of trained surgeons and surgical assistants is an extremely important part of any army fighting in a battle. Experience gained over the last century in many different wars has greatly improved the survival of soldiers injured on the battle field. Many experiences gained during war have had an important effect on improvements in the management of injuries in civilian life. This knowledge is useful now that many modern cities have become centres of the sort of violence that was once seen only in war.

Now to some of the areas in modern surgery that have benefited tremendously from experience during war. First is what seems so simple and obvious and that is ‘triage’. What this means is simply to take care of the urgent problems first and let the problems less significant wait their turn. This concept forms the basis of management of most major accidents and disasters in civilian life. And one of the most important parts of the training of surgeons as well as physicians working in emergency rooms is the ability to recognise severity of problems and then triage patients according to that assessment.

The second area where war taught surgeons a lot was in the management of ‘shock’. Shock basically means that a person’s blood pressure has become too low to maintain adequate supply of oxygen to vital organs. This situation is almost always a precursor to death if not treated urgently. The basic concept that emerged from treatment of this condition in injured patients was the aggressive and appropriate replacement of the blood being lost and of course an immediate attempt to prevent further blood loss. Here perhaps a bit of technical stuff. In an emergency, salt solution (saline) can provide early resuscitation and improvement while blood becomes available for transfusion.

The third area where battlefield experience helped greatly is in the treatment of major burns. Without going into details, I might just say that both in terms of survival as well as recovery both physical and in appearance have improved tremendously over the last 40 years. Most of these improvements first came out of army hospitals.

The fourth area is the ability to prevent limb loss in many injuries. One of the basic ideas that was made practical was that injured blood vessels could be repaired to keep a limb alive. This attempt at repairing blood vessels virtually created an entirely new surgical specialty of peripheral vascular surgery. Also latest development of ‘prosthetics’ or artificial limbs is being spurred to a great degree by war injuries that lead to limb loss. There was a recent report about an ‘arm transplant’ for a patient who had lost all four limbs.

Fifth then is the area of my specialisation. The first heart wound was successfully repaired in 1896. However, it had to wait until WWII before heart wound due to shrapnel or other penetrating injuries were treated frequently and successfully. Dwight Harken (1910-1993 CE), a US war surgeon, reported hundreds of cases of successful removal of shrapnel from the heart. This experience pushed forward heart surgery and Harken after the war was one of the surgeons that popularised closed heart surgery for diseases of the mitral valve. I have enumerated just a few areas where war has helped develop surgical techniques.