DOI: 10.1097/01.sla.0000220038.66466.b5

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PMID: 16772775

Issn Print: 0003-4932

Publication Date: 2006/06/01


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Combat Casualty Care and Surgical Progress

Basil A. Pruitt

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The book of Revelation describes the 4 horsemen of the Apocalypse, conquest, death, famine, and war as the hardships that human kind must endure before the end of the world.1 The hardships of war have been evident throughout history and are now illustrated for us at least twice a day on the morning and evening news. Not so obvious have been the benefits derived from surgical experience during war, or the benefits derived from the application of new knowledge and new technology to the treatment of combat casualties. These benefits have been most conspicuous in the realm of wound care, the recorded history of which begins by best estimate 3605 years ago.
The Edwin Smith (1600 B.C.) and the Ebers (1550 B.C.) papyri, which are 2 of Egypt's most important medical documents, both describe treatments for injured patients. The former describes 48 surgical cases, including the treatment of head wounds, and the latter recommends application of goat dung in fermenting yeast or a frog warmed in oil as topical therapies for burns and raw meat for crocodile bites.2 The frog may represent the earliest example of the therapeutic use of biologic membranes.
Western surgery was simultaneously developing in Greece, as reported in the Homeric poems The Iliad and The Odyssey, composed in the 700s B.C., describing events that occurred 5 or 6 centuries earlier. The Iliad provides what some consider to be the first written description of the treatment of battle wounds. Specifically, Makaon, the son of Asklepios, removed an arrow from the side of Menelaus, the former husband of Helen over whom the Trojan War was fought, sucked out the blood, and applied a healing salve originally given to Asklepios by Cheiron, the centaur who had raised Asklepios and taught him the healing arts.3 Menelaus’ survival may be the first illustration of the importance of adequate debridement and the gentle handling of tissue. Such treatments were depicted on Greek pottery as in Figure 1 showing Achilles bandaging a wound on Patroclus, his cousin and best friend.
Three centuries later Hippocrates, 460–377 B.C., authored at least some of the 72 medical books collectively titled some years later, by order of the Pharaoh Ptolemaios Soter, Corpus Hippocraticum. His writings on surgery recommended using only wine to moisten a wound, giving little food and no drink but water for all injured patients including those with abdominal wounds, prohibition of walking, standing, and even sitting, and making pus form in the wound as soon as possible for the counterintuitive reason of reducing inflammation in the wound. Insertion of a tube in the chest wall for empyema drainage and the use of traction for fracture alignment are described. The oath attributed to Hippocrates is considered to be the earliest codification of medical ethics. Subsequent Hellenistic doctors beginning with Polybos, the son-in-law of Hippocrates and including Aristotle, adapted the classic Greek doctrine advanced by Empedocles that all materials were composed of the 4 elements fire, water, earth, and air to a system of medicine based on 4 elements (yellow bile, phlegm or mucous, black bile, and blood).4 Since disease was considered to be caused by an imbalance of those elements, treatment consisted of attempts to restore balance by medical means with little if any role for surgery.
The shift of the center of medical progress to Rome over the next 4 centuries was accelerated by Galen, 130–200 A.D., who began his practice as physician to the gladiators in Pergamon, his birthplace.
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