Combat casualty care and surgical progress.

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. 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. 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. 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). 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. In 162, he moved to Rome, where his success in treating the wounds of gladiators attracted the attention of the emperor, Marcus Aurelius, who made Galen his personal physician. Galen was the author of some 400 works in which he describes removal of nasal polyps, removal of varicose veins, plastic surgery for cleft lip, uvulectomy for coughing, trepanning of the skull, and intestinal or abdominal wall suture of penetrating abdominal wounds of the gladiators. He is considered to have had an overall negative effect on surgical progress because of his advocacy of suppuration as an essential and beneficial component of wound healing. That is cited as being contrary to Hippocratic teachings, but the supposed difference may be the consequence of mistranslation of Hippocratic Greek into Galenic Latin. With regard to wound care, there was essentially no difference between the 2 because, as noted above, Hippocrates also insisted on treatment that promoted pus formation as soon as possible in wounds caused by weapons. In the following years of the Middle Ages, surgical progress was modest at best because of the unquestioning acceptance of Galen’s writings and the edicts of 2 ecclesiastical Councils. The Council of Clermont (1130), to preserve traditional monastic lifestyle, decreed that priests and monks should no longer practice medicine. Consequently, the monastic hospitals established in the fifth and sixth centuries were deactivated or taken over by lay physicians. Surgical progress was further impeded in 1163 when the Council of Tours issued the “Ecclesia Abhorret a Sanguine” (“the church From the Department of Surgery, University of Texas Health Science Center, San Antonio, TX. Reprints: Basil A. Pruitt, Jr., MD, Department of Surgery, Mail Code 7740, University of Texas Health Science Center, 7330 San Pedro Ave., San Antonio, TX 78216. E-mail: [email protected]. Copyright © 2006 by Lippincott Williams & Wilkins ISSN: 0003-4932/06/24306-0715 DOI: 10.1097/01.sla.0000220038.66466.b5