Tracheostomy and the Spanish Civil War

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As a Catalan and having a special interest in the subject, I agree with Dr Coni (March 2002 JRSM1) that most of the medical advances were made by the Republicans rather than the Nationalists. As he says, this was partly because of the more liberal atmosphere of the big Republican cities. Also the looser organization of their Medical Corps may have been more conducive to the development of new ideas. One topic not specifically mentioned by Dr Coni is management of the compromised airway and the performance of emergency tracheostomies. Last summer, I got hold of an excellent book entitled Memories d'un Cirurgia (Memoirs of a Surgeon)2, written by the retired Catalan surgeon Moises Broggi who served in the International Brigades in one of the mobile hospitals. Before the Civil War he was one of the most promising young surgeons in Catalunya; afterwards he decided to stay in Spain but was denied all privileges in one of the university hospitals in Barcelona and could only practise privately for the rest of his professional career. His book, written in a very plain and simple style, became one of the best-sellers in the Catalan language in 2001. In it he describes his experience as a surgeon from 1936 to 1939 with the International Brigades from Brunete to Guadarrama, Belchite, Teruel and finally to the Battle of the Ebro. During the Battle of Belchite they noticed that casualties with severe facial injuries and fractures were dying shortly after triage, whilst waiting on the stretcher for definitive treatment. The deaths were usually due to aspiration of blood into the airway, so they decided to change their practice and perform emergency tracheostomies as initial action. This gave them the opportunity to suction the airway contents and rapidly restore respiration. After that, they stopped the haemorrhage and stabilized the patient, who could then wait to have his fractures reduced and debridement performed. This simple management sequence, resembling current methods of resuscitation, saved many lives during the subsequent battles of the Civil War and was adopted by Allied surgeons during the Second World War. It is said that, for various reasons, we had to wait more than 60 years before the medical heroes in Spain received proper recognition.