MISSILE INJURIES – Historical developments in casualty evacuation and triage 1

In   Issue .

R. Pearce


With the vastly different technology, and almost primitive surgical skills, available to military commanders at the beginning  of the nineteenth century, their attitude  towards the wounded would appear to be callous. Apart from the commanders themselves, and perhaps some officers of nobility who might depend upon aides or personal servants to recover them from the battlefield,1 there was rarely any plan for critical care or evacuation of the injured soldier, of which there were commonly vast numbers. Henri II of France developed  the concept for a mobile hospital in 1550, but one can readily understand  that the contingencies of war during the campaigns of Napoleon Buonaparte would not allow for delays and interruptions necessitated  by the care of the wounded. Yet it is precisely during  this period in Europe, when Buonaparte was intent upon  expanding his empire through military conquest  that the most notable efforts were made to institute a system of casualty evacuation.

Napoleon’s early campaigns left thousands of dead and dying on the fields of battle, some crying out after the army had moved on for a merciful death. Knowing the practice of local villagers, who plundered anything of value from the casualties left behind,  they preferred to seek a swift and humane outcome. Those fortunate enough  to find their way to a local shelter or bam might receive medical attention. When it was known that a surgeon like Dominique Jean Larrey was on hand, the casualties could be brought  to him with some hope or expectation  of treatment within sight and sound  of the war.2 Dominique Jean Larrey, who served with  Napoleon in every one of his campaigns, became not only a skilled surgeon through his military experience but was essentially humane. He was prepared to take surgery to the battlefield, where he ignored the obvious risks to himself. Larrey then devised his flying ambulances, horse drawn carts to carry the wounded from danger to a collective area for treatment. His efforts to evacuate the wounded and his tireless endeavours  to relieve their suffering earned him the respect of officers and men on both sides. But, more important, was the value he placed on the lives of individuals by his concern for their welfare, regardless of rank. It would be reasonable to state that Larrey set a standard of care that was difficult for most other military surgeons to emulate, yet he simply demonstrated  the need for early evacuation and treatment if lives were to be saved.

In casualty evacuation, Larrey demonstrated his

ingenuity and resourcefulness. After the battle of Bautzen, he wrote ” …. it is important for the head surgeon to study well the countries  that the armies cross, in order that he might know to benefit the injured using resources that localities might offer.”3

Larrey evacuated 150 wounded from Bautzen to Dresden using wheelbarrows in a single file, utilising local resources. He described medical evacuation as “the salvation of the injured and the conservation of the morale of the soldier.”

Once the spectre of Napoleon had disappeared from Europe, there was a period of relative peace and adjustment during which the medical profession addressed their short-comings while the military became progressively more dormant.  In the years between Waterloo and the Crimea, a large number of books appeared dealing with gunshot wounds and war surgery (Larrey, 1812-1817; Guthrie, 1815; Dupuytren, 1834; Stromeyer, 1855), particularly in Edinburgh, where the first Chair in Military Surgery was established in 1806 and young surgeons were trained in the management of trauma.4

In 1815, two experienced Scottish surgeons were amongst those who visited Waterloo: John Thomson, the first Regius Professor of Military Surgery at Edinburgh University, and Charles Bell, whose illustrations of some of the wounded depict better than words the injuries sustained in this battle.5 As usual, inexperienced military surgeons quickly learned how to deal with major trauma. Although their system of triage was possibly as primitive as selectively treating only those who might have a chance of survival, such decisions were not always simple. Limb

injuries from cannon or musket ball were readily assessed and subsequently were commonly treated by amputation. Their success  or survival rate varied from five to sixty-five percent  and depended largely on the experience of the surgeon. Head injuries and body cavity injuries from saber, lance or shot  were generally considered to be potentially fatal, although there are reports of some  miraculous recoveries which no doubt benefitted from being untreated by the surgeons. While we have no statistics on the wounds sustained by those killed in battle,  the fate of the injured  who could  receive treatment was determined significantly by the delay in receiving attention, a delay which could  extend  to several hours or even days.

It soon  became  obvious,  even to Wellington, that his army had no-one to match the daring  or courage of Napoleon’s surgeon,  Dominique Larrey.6 Larrey taught and practiced  a form  of triage or casualty selection. He was a prolific writer, and in his extensive “Memoires de chirurgie militaire, et compagnes”, published between  1812  and 1817, he records “…it is necessary  to always begin with  the most dangerously injured, without regard  to rank  or distinction.” In practice,  of course  he could  not afford to waste time on the critically  wounded where  there was no chance of survival.  It must  also have been obvious and frustrating to Larrey, and  to all military surgeons of his time, to realise that selection of casualties for treatment was dictated  by their own very limited surgical knowledge and expertise.


The first military surgeon credited  with using a formally graded system of triage under battle conditions was the famous  Russian surgeon, Nikolay Ivanovich  Pirogov (1810-1881).7 Pirogov, who referred  to battle casualties as an ‘epidemic of trauma’, arrived at the Crimea in November  1854, af ter the battles of Alma and Inkerman, where the sick and wounded numbered in the  thousands and established medical facilities were inundated. He came with the blessing  of the Grand  Duchess, Helena Pavlovna, whose  personal concern  for the care and welfare of Russian wounded had prompted her to found many charitable institutions including the Sisters of Mercy of the Community of the Cross. This latter organisation is recognised as one of the first professional  nursing organisations in the world.

For  the first time in the history  of military and field surgery, all nursing sisters  and doctors  were allocated to functional groups. On Pirogov’s orders, the first group  was in charge of sorting out the wounded, according to the type and severity  of disease or injury, and of keeping  a register  of their belongings. Thus,  the Pirogov plan of triage was put into  practice at the first aid stations in Sebastopol, where wounded were assessed in four categories.

The hopelessly sick and mortally wounded were entrusted to the care of the Sisters of Mercy and priests. The seriously wounded, who required  urgent surgery, received it at the emergency  dressing station in the hospital referred to as the ‘Building of the Assembly of Nobles’. With  three teams operating, it was possible  to perform  ten major amputations in an hour and  up to one hundred major  surgical procedures each day.

The  third  group was those less seriously wounded who  could  be transferred for surgery  the following day. Finally, those  troops who sustained minor  injuries were given immediate treatment and returned to their regiments. This enlightened plan was necessary  to deal with  the large number of casualties and with limited resources.  But it is obvious  that  the Sisters of Mercy played an impressive role in making  the system work.  Eventual  evacuation of amputees and other casualties from the battle zone was by horse and cart over rather rough  terrain  and significantly long distances.

One positive  outcome from this period followed a publication of]ean Henri  Dunant  (1828-1910), who was present at the battle of Solferino  (Un souvenir  de Solferino, 1862).8 His account of the sufferings of the wounded in that battle led to the Geneva  Convention of 1864 and  the foundation of Red Cross, both  of which  would subsequently endeavour to ensure the humane care and safety of prisoners and wounded.

It is unlikely that Pirogov would  have used  the term ‘triage’ to describe  his method of sorting casualties. In the eighteenth century,  the word ‘triage’ (derived from the Fr verb trier, meaning ‘to sort,  to select’) was applied by traders to the sorting of wool clips, and  in the 1820’s the term was applied  to the sorting of coffee beans. Today, “triage”  is used to indicate the application of priorities to injuries/ casualties for the sake of management where medical resources may be limited.

Historically, by far the greatest  experience in the treatment of mass casualties belonged  to the military Missile Injuries where experience and organisation were intended to anticipate the trauma and  sickness that  befell an army at war. Civilian management of mass casualties from natural disasters has evolved in relatively recent  times and draws extensively  on  that military preparation. But there is evidence that earlier  consideration was given  to some form of selection in hospital practice.

During  the eighteenth century and  the first half of the nineteenth century in Britain, where  charitable care was made available to large sections of the community who were unable to pay for medical treatment, facilities in most  centres were  inadequate for the numbers seeking  help. At the London Foundling Hospital at Great  Ormond Street, for example, a ballot system  was introduced which randomly selected those children who  could  be seen or examined in a session.9 In fact, Thomas  Coram, the hospital’s founder,  disapproved of the ballot system  as in his opinion it did  not contain “…any test by which  the merits  of each  case could  be ascertained.” Coram obviously would  have  preferred a system of priority based upon  some initial assessment and classification according to degree  of urgency, but his pleas were in vain.

The British Army at the Crimea  (1854-1856), for all its mismanagement, recorded some important firsts during this campaign.  Florence  Nightingale, with a small band of women  under her  tutelage, provided essential  nursing  care to the sick  and wounded at Scutari. Journalists and photographers were  allowed to observe and record  details of the war  first hand, and casualties were further  evacuated from  the scene  by train and ship. However, the railroad was a method of casualty  evacuation  used more extensively in South Africa (1899-1902), where  distances were great,10 and during World War One in France.


Meanwhile,  the Civil War in America  (1861-1865), which  was essentially a war of secession between  the North and the South, provided  few innovations in casualty collection or management. The  numbers of casualties were horrendous, in the region  of two hundred thousand  dead and over four  hundred thousand sick and wounded. As with  previous conflicts,  the non-battle casualties far outnumbered the wounded, but they all required medical attention and  the outcome  in terms of mortality was often worse where some diseases were present in epidemic proportions. 11 It is fair to say, however,  that the Crimean disease rate  was halved in Union  camps and hospitals where Sanitary Commissioners constantly demanded better hygiene, better  food, more comfort and  medical care for the men.12

Records show  that surgical field stations dealt  with limb injuries by amputation, commonly without anaesthetic due to the shortage of supply, while injuries to the head and  body cavities were rapidly assessed and considered inoperable. Acute medical cases were managed in field hospitals or transferred with serious or convalescent battle casualties  to the nearest town facility. One advantage the Union  Army had  over the Confederate forces was ready access to established roads and railroads  for resupply and for evacuation of casualties. But here again, the shortage

of facilities and trained surgeons was compounded by the delayed collection and evacuation of casualties from  the battlefield. An Ambulance Corps consisting of horse-drawn wagons was established, but surgeons often  elected  to operate  at field stations close to the field of battle, unwittingly placing themselves and their wounded at further risk. A comprehensive “Medical and Surgical History of the War of the Rebellion”, written  by George Alexander Otis,l3 appeared in three volumes between  1870 and 1881.


Throughout all of these conflicts, stretcher bearers played  a major  role in transporting wounded (Hannibal had provided litters to carry the wounded while crossing the Alps in 219 BC). In the British Army, stretcher bearers became part of the establishment of Regimental Aid Posts (RAP) and Casualty Clearing Stations. Bandsmen attached  to a deployed Regiment  also filled the dual  role as stretcher bearers when required.

Lessons  were learned from the British and Colonial forces involved  in the  South African War (1899-1902), more in  terms of preparedness and  the management of large numbers of non-battle casualties, but here the main lethal weapon  was the rifle with small calibre bullets. The introduction of antiseptics and anaesthetics, together with  the earlier  treatment of casualties by field hospitals, considerably lessened the suffering of the wounded. Public awareness  of progress in the war, or lack thereof, was influenced by the stories submitted by journalists such  as Winston Churchill who reported the victories and the blunders of the British Generals. But not until after the disclosure of incriminating evidence, at two Royal Commissions after  the war had ended, was there any significant effort made to reorganise  the army medical service.14 By the commencement of the First World War, this reform  was in place.


During the Great  War of 1914-1918, for the first time deaths from wounds now exceeded those from disease. Machine  guns  were more lethal  while shell­ fire produced more dreadful wounds and new methods of treattnent were devised  which included debridement and  irrigation with hypochlorite antiseptics.

The new military organisation catered  for improved medical and surgical facilities and casualty evacuation, particularly using  the new motorised ambulances. But there  was room for ingenuity too. The steep  hills and  gullies of Gallipoli proved ideal terrain  for donkey transport of the wounded, as demonstrated to good  effect by Simpson and others  at ANZAC Cove in 1915. The desert  sands covered by Chauvel’s Desert Mounted Corps  on its way to Damascus provided opportunities for evacuation by camel, and  the flimsy aircraft of the day were not confined to aerial combat but were gradually utilised in suitable  conditions for reconnaissance, aerial photography and evacuation of wounded.

Although World War One is considered by some to be the true birthplace of triage, the concept obviously developed over many generations from the experience of military  surgeons  faced with the prospect of dealing with  mass casualties under less than ideal conditions. However,  there is no doubt that military  doctors in

this war were better organised to take advantage  of those  developments in medicine and surgery  that would benefit the troops significandy. The emergence of new specialties in radiology, pathology and various departtnents of surgery may have resulted from or been promoted by the necessity of war but  they also assisted  in the process of triage as medical staff could provide  earlier  and more accurate diagnosis and treannent of injuries. Since then, the processes  of casualty  evacuation and triage have continued to develop in association  with advances in technology and  the requirements of modem  warlare.15,l6 It is evident, however, that to an increasing extent, the organisation of emergency services in peacetime  and the management of civilian casualties from natural disasters becomes  more closely parallel  to that of military  experience.




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