The Spanish Civil War was fought between the elected Republican government of Spain and the insurgent Nationalist forces led by General Francisco Franco. It determined the future of Spain and also served as a test prelude to World War II, drawing foreign volunteers and professional armies from Germany, Italy, and the Soviet Union.

The roots of the conflict lay in the widespread poverty, political instability, and deep divisions within Spanish society. In 1931, King Alfonso XIII left the country, and a new republican government introduced reforms aimed at reducing the power of the military, the Catholic Church, and the large landowners while improving conditions for workers and peasants. These changes were welcomed by liberals, socialists, and republicans but were strongly opposed by conservatives, monarchists, and many military officers.

In July 1936, a group of military officers launched a rebellion that quickly escalated into a civil war between the Nationalists, led by General Francisco Franco, and the Republican defenders of the elected government, also supported by socialists, communists, anarchists, and liberals. Nazi Germany provided the nationalists with aircraft, tanks, and military advisers, while Italy sent troops. In 1937, the Germans bombed the Basque town of Guernica, an infamous act that later inspired the famous painting Guernica by Pablo Picasso.

The conflict was marked by brutal fighting and atrocities. Cities and villages were devastated. Between 500,000–1,000,000 people perished from battlefield wounds, starvation, and political executions. Numerous volunteer medical missions arrived from Britain, France, the United States, and Canada to establish relief organizations, operate field hospitals, ambulance services, and civilian relief programs. Women served as nurses, anesthesiologists, and, in some cases, as surgeons in humanitarian and medical units.

Diseases such as typhoid fever, dysentery, influenza, and malaria remained endemic during the war, as were scurvy and pellagra, gas gangrene and tetanus. Surgeons were confronted daily by a cascade of shattered bones, perforated organs, and shrapnel-riddled limbs caused by high-velocity rifles, bomb fragments, and aircraft, creating contaminated wounds with high rates of infection. Surgeons learned through painful experience that closing wounds immediately after injury often led to catastrophic anaerobic infections, and that delaying closure gave better results. They likewise refined techniques for managing penetrating abdominal wounds and bowel injuries, controlling hemorrhage from solid organs, resecting damaged tissue, and intervening promptly after abdominal injury.

Hemothorax and pneumothorax were managed by improved drainage techniques. The Catalan surgeon Josep Trueta emphasized the circulatory component of acute renal failure, and dramatically reduced infection and limb loss following compound fractures by advocating thorough debridement of bone wounds followed by immobilization in plaster without drainage or suturing.

The development of modern blood transfusion services is one of the most enduring medical legacies of the war. It was based on Norman Bethune’s mobile blood transfusion system, in which blood was systematically typed and tested, stored, and distributed through a logistical chain, recognizable as a direct ancestor of the modern blood bank.¹ The Nationalists, supported by German advisors, developed their own transfusion services along parallel lines.

The psychological dimensions of the war received unprecedented medical attention. Republican medical services established facilities for the treatment of soldiers exhibiting what would today be recognized as combat-related PTSD, and there were early efforts to provide rest, psychotherapy, and occupational rehabilitation rather than immediately returning traumatized men to the front.

By 1938, the Nationalists had gained the upper hand. Barcelona fell to the Nationalists in January 1939, and Franco officially declared the end of the war on April 1, 1939. Its consequences were profound. Spain was left economically devastated and politically isolated. Thousands of Republicans fled into exile, and many who remained faced imprisonment or execution. Franco’s regime suppressed political opposition, limited civil liberties, and established a dictatorship that would last for forty years until his death in 1975.

It took many years to recover and return to a democratic form of government. A new generation has different interests and has transcended those of the past. It is unfortunately, however, likely to repeat its errors.

End note

1. For more on Dr. Bethune, see Satish Saroshe, “Dr. Norman Bethune: A tale of military heroism,” Hektoen International War & Veterans, Winter 2016, https://hekint.org/2017/01/22/dr-norman-bethune-a-tale-of-military-heroism/ and Irving Rosen, “Norman Bethune’s mobile blood transfusions,” Hektoen International Blood, Fall 2019, https://hekint.org/2019/12/10/norman-bethunes-mobile-blood-transfusions/.