Ancient surgery
Alexander the Great
Horrible wounds forced the surgeons of Alexander the Great (356–323 BC) to find new ways of keeping him and his men alive and on the march.
As civilisations developed, wars became much more extensive than before, and thousands were killed or wounded on ancient battlefields. It was the campaigns of Alexander the Great in the 4th century BC that gave military surgeons (whom Alexander had introduced to the battlefield) new insights into anatomy.
An expensive investment
The Macedonian king’s empire eventually stretched from Italy to India. It was the result of 50,000 intensively trained soldiers marching across Europe, Africa and Asia, forcibly uniting the known world and reaping the wisdom of the civilisations they encountered.
Alexander saw each soldier as an expensive investment, and he protected them by providing dedicated medical teams. He invented the field hospital, and it was the doctors in these who helped lay the foundations of modern Western surgery.
Untried techniques
‘War surgery always moves knowledge on in the field of medicine, not just in surgery, the whole of medicine. And that’s been true since the beginning of time and was just as true in Alexander’s day,’ says Jim Ryan, former professor of military surgery at the Royal Army Medical College, who served as a surgeon during the Falklands War.
‘Faced with large numbers of wounded, the war surgeon’s got nothing to lose – there are no lawyers around. I don’t mean to be glib, but if a guy’s dying in front of you and there are some untried techniques that they’ve picked up by word of mouth, they’re going to try them – a better means of haemorrhage control, application of tourniquets, packing new wounds, whatever. Most of these would not have been thought of in civilian practice. They’ll have come off the battlefield.’
Invincible?
Alexander was a product of the Greek tradition of reason and scientific study. A century earlier, Hippocrates had separated medicine from magic and cults of healing and turned it into an empirical practice. From then on, doctors looked at the physical reality of illness and injury rather than invoking the gods as cause and cure.
So, just as rational thinking made Alexander’s battlefield strategy a success, this new scientific approach helped his battlefield surgeons keep his soldiers fighting fit.
Alexander himself was wounded many times, but he always survived and never lost a battle. As his victories accumulated, his men began to believe he was invincible, as did his enemies. But invincibility had nothing to do with it. His secret weapon was his surgeon Kritodemos of Kos, whose greatest challenge would come in India, near the end of Alexander’s campaign.
Operating with a spoon
While Alexander had his surgeon Kritodemos, his father Philip of Macedon had his surgeon Kritoboulos. In 354 BC, during the siege of Methone, Philip was hit in the eye by an arrow. According to the Roman writer Pliny the Elder, ‘Kritoboulos achieved great renown for having removed the arrow from Philip’s eye, and having treated the loss of the eyeball without disfiguring his face.’
To achieve such impressive results, the surgeon probably used a specialised surgical instrument designed to remove arrows. It was known as the ‘spoon of Diokles’ after its inventor Diokles of Karystos, a contemporary of Aristotle.
Inefficient ventilation
During the siege of the capital of the Mallians (modern Multan in Pakistan), Alexander was seriously wounded by an arrow in the chest. His faithful general Ptolemy, later king of Egypt, said: ‘His breath as well as his blood spouted from the wound.’ According to Professor Ryan, that is a very clear description of a penetrating injury into the lung: ‘This is what is now called an open chest wound or sucking chest wound. When you have this wound and you try to breathe in, only some of the air goes down there. So you have extremely inefficient ventilation and that’s one of the ways you die.’
The Macedonian leader was carefully placed on a shield and carried out of the citadel to his tent. The arrow in his chest was heavy, with a large barbed head. It was the most lethal kind and the hardest to remove. His men thought that, this time, Alexander really was going to die.
Unnerved
Kritodemos ordered Alexander stripped naked and the shaft of the arrow cut off. The doctor decided that the only way to extract it without the barbs doing greater damage was to enlarge the wound.
He was extraordinarily skilful, but the prospect of Alexander dying at his hands evidently unnerved him. Even the young commander, who had regained consciousness, was aware of his fear. ‘Why are you waiting?’ he asked. ‘If I have to die, why do you not at least free me from this agony as soon as possible? Or are you afraid of being held responsible?’
First principles
Told that he would have to be held down during the operation, Alexander said there was no need and, it is said, went through the ordeal unflinching. However, when the barbed head was finally removed and blood spurted from the wound, he finally fainted.
At first, the haemorrhage could not be stopped, and onlookers began to wail as if Alexander had died. ‘Without really knowing why, just applying his basic good first principles,’ says Professor Ryan, ‘Kritodemos would have covered the wound, probably to control the haemorrhage. But in so doing, he stopped the open chest wound sucking further – and saved Alexander’s life.’
Act of will
For the wound to heal, Kritodemos would have had to stitch muscle, tissue and skin separately. These are the basic skills of the modern surgeon, and they were brought back home from the battlefields.
Barely a week after being injured, and with his wound incompletely closed, Alexander arranged to be carried by ship down the river Hydraotes to the main camp. As the ship docked, his guard brought out a litter, but Alexander refused it. Instead, he walked down the gangplank and, in an act of extraordinary will, mounted his horse to ride to his tent.
