Surgical care has played a role in military conflicts since time immemorial. Towards the end of the Great Northern War the Swedish King Charles XII entered Ukraine to rendezvous with Ivan Mazeppa, Hetman of the Zaporozhian Host, who had switched sides. Charles was hit by a Russian musket ball which shattered his calcaneum. His leg became discolored, and the surgeons wanted to amputate it. But one of the surgeons, called Newman, better skilled and braver than the rest, was certain he could save the leg by means of a deep incision. “Begin at once, then,” said the King. “Cut boldly, fear nothing.” He held his leg with his own hands, looking at the incisions as if they were in the leg of another’ [3].
At the origins
However, one of the earliest texts describing the treatment of wounds sustained in armed conflict is the Edwin Smith Papyrus. Egyptologist James Henry Breasted believed that the document was written in 1700 BC, but the original versions may have been a millennium older [4]. The papyrus’s description of traumatic injuries is consistent with archaeological findings from local military burials dating back to around 2000 BC. Breasted also believed that the descriptions of penetrating skull wounds probably came from the direct experience of medical support for ancient Egyptian armies. The papyrus first describes “compound and comminuted fractures” and contains the earliest documented reference to the brain. The author recognized that head injuries in certain anatomical locations may be associated with characteristic limb weakness. There are descriptions of sutures, splints, and cloth bandages. Linen cloth impregnated with glue and plaster resembles modern plaster casts. The author even noted that the pulse comes from the mechanical activity of the heart. From Egypt, such knowledge spread to the Middle East. For example, inscriptions on a statue of a doctor who treated the Persian royal family according to the achievements of Egyptian medicine have been preserved. Herodotus describes how the Persians invaded Scythia, which is now Ukraine [5]. The Scythians were nomads and “remained invisible” until the Persians gave up and returned home. It is possible that surgeons trained in Egyptian medicine accompanied the Persian army at this time. It is also interesting to trace the connection of Kievan Rus’ with the traditions of ancient Greek medicine through Byzantium. In particular, the Church had access to several medical texts, including the Hexaemeron, written by John, Exarch of Bulgaria (second half of the 9th century — first third of the 10th century). The document contains a rich collection of ancient and medieval natural science knowledge and ideas, originating from Aristotle, Dioscurides, Hippocrates, and Galen. The later, for example, spent several years at the medical school in Alexandria, where he learned Egyptian surgical techniques, after which he worked caring for wounded gladiators, developing a new method of closing muscle injuries. Dioscurides was a Greek physician who “lived the life of a soldier” in the Roman Empire and wrote his extraordinary work “De Materia Media” on the use of medicinal plants and plant substances.
Armed conflicts and improvements in techniques
The invasion of Batu Khan in the 1230s and 1240s led to the destruction of Kyiv, the death or enslavement of its inhabitants. The invaders may have brought with them Mongol medical practices, as their tradition dates back at least 2,000 years [6]. This included the use of herbs and animal products such as bear bile and vulture dung. It is not surprising that the Mongols admired the monks in the surviving cities for their medical knowledge. In 1812, Napoleon’s Grand Army passed through Volhynia during its ill-fated attempt to capture Moscow. They were accompanied by the great military surgeon Dominique Jean Larrey, who introduced the concept of battlefield triage and “flying ambulances” (ambulances volants) to provide rapid care for the wounded [7]. This achievement was noted by the British Duke of Wellington at the Battle of Waterloo, who forbade his artillerymen from firing on carts, saying: “Give the brave gentleman time to pull out the wounded.” The Crimean War, which ranged from 1853 to 1856, was the first to leave behind photographic memories. This made the horror understandable to the British public and led to the professionalization of nursing, for which the British Florence Nightingale was largely responsible. Significant progress in trauma care was achieved during the First World War. In particular, the introduction of Thomas splints for immobilization and traction in case of femoral fractures dramatically reduced mortality [7]. Blood transfusions also became common. Tetanus antiserum began to be used on a massive scale. Also, during World War II, British troops were vaccinated against tetanus, which dramatically reduced the death rate from tetanus infections. The use of penicillin to treat wound infections gradually became common.
Current situation
During a recent webinar organized by EUSEM, many Ukrainian doctors shared their thoughts on the implementation of clinical guidelines, simulation training, and advances in psychological care [2]. It is significant that Olena Zelenska’s “How are you?” campaign is a great initiative that other countries can copy in the future [8]. Providing advanced surgical departments with sufficient supplies of refrigerated blood products is mentioned as a pressing and not yet fully resolved problem. Indeed, up to a quarter of those arriving at hospitals have hypovolemic shock. In this regard, it is worth noting that a team in Japan has developed artificial vesicles containing hemoglobin [9]. They are stable at room temperature and remain in the blood for eight hours, which may make them a useful option in Ukraine.
References
- 1. Epstein A., Lim R., Johannigman J. et al. (2023) Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries. J. Am. Coll. Surg., 237(2): 364–373. doi: 10.1097/XCS.0000000000000707.
- 2. European Society for Emergency Medicine (2025) EM Monthly Webinar: Living in a War Zone and Saving Lives,
eusem.org/webinars/1030-em-monthly-webinar-living-in-a-war-zone-and-saving-lives (Accessed 11 June 2025). - 3. Voltaire’s History of Charles XII, King of Sweden. Translated by Winifred Todhunter. (1908) dn790007.ca.archive.org/0/items/voltaireshistory00voltuoft/voltaireshistory00voltuoft.pdf (Accessed 3 June 2025).
- 4. Breasted J.H. (1930) The Edwin Smith Surgical Papyrus, archive.org/details/eberspapyrusbookbybreasted (Accessed 29 May 2025).
- 5. Godley D., Ed. (1920) Herodotus, The Histories, www.perseus.tufts.edu/hopper/text?doc=Perseus:text:1999.01.0126:book=4&force=y (Herodotus Book 4) (Accessed 29 May 2025).
- 6. Bai L., Fu M. (2022) Traditional Mongolian Medicine: Past, Present and Future. Chin. Herb. Med., 14(3): 343–344.
- 7. Gibson J. (1967) The Development of Surgery. Published by McMillan and Co Ltd.
- 8. How are you? As part of Olena Zelenska’s initiative, Ukrainians will be told about the importance of taking care of mental health
www.president.gov.ua/en/news/ti-yak-u-mezhah-iniciativi-oleni-zelenskoyi-ukrayincyamrozk-81777 (Accessed 11 June 2025). - 9. Azuma H. et. al. (2022). First-in-human trial of haemoglobin vesicles as artificial red blood cells developed for use as a transfusion alternative. Blood Advances, 6(21): 5711–5715.
