Page 106 - JSOM Spring 2023

Hospital (MGH). He traveled to Europe in 1926 to study in many would require weeks to months of dressing changes two
Copenhagen, Denmark alongside pioneers in thoracic surgery. to three times daily. This strategy was the only means of com-
Churchill returned to the United States in 1927 and rapidly bating the otherwise lethal consequences of wounds becom-
gained an eminent reputation as a thoracic surgeon. In 1937, ing infected, necrotic, and gangrenous, subsequently leading
Churchill founded the American Board of Surgery, where he to life-threatening septic complications and often death. The
served as president for many years. 4 introduction of penicillin proved to be a powerful adjunct to
preventing wound sepsis and accelerated the ability to close
Churchill volunteered in 1943 to serve in the US military as traumatic combat wounds at the primary operation or much
the Consulting Surgeon for the North African and Mediter- sooner in the postoperative period. Penicillin was soon recog-
5
ranean Theaters of Operations. It was here that he gained nized as a “miracle drug” that clearly saved countless lives and
the experiences that led to the publication of the manuscript, accelerated recovery and function of the wounded Soldier.
“The Surgical Management of the Wounded in the Mediter-
ranean Theater at the Time of the Fall of Rome.” This paper The introduction of penicillin as the first clinically relevant an-
led to advances in many surgical topics, including the “policy tibiotic created a simultaneous advance in the realm of micro-
of adequate debridement and delayed primary closure of war biology. Standard techniques to grow bacteria and molds were
wounds, early use of whole blood transfusions, the establish- available as early as the mid-1800s, but now they evolved as
ment of regional blood banks, and the use of air evacuation in an important tool to assess whether the culprit bacteria would
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the transport of wounded Soldiers.” Churchill also described be effectively treated by a specific antibiotic. During WWII,
the use of “chemotherapy” (i.e., intravenous penicillin) as an Churchill acknowledged the possibility of culturing wounds to
1,4
important new addition to the care of combat wounds. The determine which bacteria were responsible for creating a spe-
reader is encouraged to remember that this article was written cific wound infection, but he also acknowledged the logistical
almost 75 years ago and yet details countless important points challenges of attempting to culture bacterial specimens in the
that are applicable for care of the wounded Soldier even today. austere forward setting. During the war, a pragmatic approach
of observation and clinical response (e.g., improvement in the
At the conclusion of WWII, Churchill joined another preem- appearance of tissue and a decrease in suppuration [purulent
inent Army surgeon—Dr. (COL) Michael Debakey—to con- drainage]) were the mainstay of treatment. Churchill carefully
vene a medical conference of the Allied medical corps of the documented more than 25,000 cases that were treated by this
European theater. That first meeting was held at the Excelsior technique and reported successful resolution in more than
1
Hotel in Rome, and the society of surgeons continued to meet 95% of treated cases. Fast-forward 75 years, and the modern
over the next decade. In 2014 , the Excelsior Surgical Soci- medic recognizes that oral penicillin agents are in their medical
ety was reconvened by the Military Health System. The three kit bags as a potent remedy for many commonly encountered
Medical Corps (Army, Navy, and Air Force) gather annually at gram-positive organisms (i.e., staphylococcal and streptococ-
the fall meeting of the American College of Surgeons to share cal organisms). 7
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lessons learned as well as research and future directions. The
Churchill lecture is given annually at the Excelsior Surgical Antibiotics Are Not Substitutes for
Society meeting in memory of this truly remarkable Surgeon Good Medical and Surgical Care of the Wounded
Soldier.
Following the introduction of penicillin across the African
Churchill returned to the United States and, after a brief stint and European theaters, some thought that antibiotics could be
trying to repair the Medical Corps for the Department of De- used to delay or eliminate the need for surgical management
fense, returned to his practice at MGH. Churchill concentrated of wounds in the operating room. Others suggested that a less
on revising the surgical residency program and research efforts aggressive excision of wounded tissues could be undertaken
at both a local and national level. He suffered a stroke in in the presence of penicillin. Yet other surgeons suggested that
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1953, which limited his surgical practice, but afterward spent the addition of penicillin permitted the surgeon to be more
the remainder of his career in medical education until his re- aggressive at the operating table and open previously clean
tirement in 1962. It was during this final decade that Churchill tissue planes to “extend the scope of surgery.” Churchill’s ex-
1
assembled his wartime memoirs, which would be published tensive experience and his almost obsessive attention to daily
under the title Surgeons to Soldiers. (Author’s note: It is per- examination of wounds led him to counter these claims. In this
haps the most important work in my library of military med- publication, Churchill wisely observes: “Just as plasma is not a
ical texts. JAJ) Ten years later, while walking on his and his substitute for whole blood in resuscitation, neither are sulfon-
wife’s farm, Churchill died of a heart attack. amides and penicillin substitutes for the surgical excision of
devitalized tissue.” He believed that chemotherapy (the word
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Churchill uses to describe antibiotic administration) had a sig-
Why Is This Article Relevant Today?
nificant role in wound management but additionally stressed
Antibiotic therapy directly increased the number of wounded the importance of good wound care regardless of antibiotic
Soldiers returning to duty and prevented “deformity, disability, usage. (Authors’ note: These important thoughts continue to
and death.” 1 be emphasized in today’s surgical training programs.) Current
combat guidelines and manuscripts focus on empiric therapy,
Churchill focused on what he referred to as “reparative sur- surgical debridement, and the presence of implanted material
gery.” Reparative surgery “is designed to prevent or cut short (e.g., orthopedic hardware, cranial implants). The authors
wound infection either before it is established or at the period chose this article for “Lest We Forget” to emphasize that the
of its inception.” Prior to the advent of antibiotic therapy, basic principles of wound care in the forward area are as crit-
1
wounds were left open to begin slowly healing in over time. ically important today as when Churchill stressed this in his
Some wounds would eventually be closed with suture, while manuscript. 7

104 | JSOM Volume 23, Edition 1 / Spring 2023