"The Development of Triage" Topic

"In today's world there is an interest in the origins of systems for handling casualties in battles and in civilian life. Little is known about the fate of the wounded in early times. Whether any system existed is questionable. Certainly there was always a body of people, men and women, who followed the armies and who would provide some of the ancillary services to the soldiers. These included, of course, food preparation and laundry but also care for the sick and wounded. These camp followers were legend and were still in existence at the time of the Civil War. However, this group was unable to provide all of the necessary care. Gradually this was recognized and armies started to provide for medical care. It is uncertain exactly when this began, but at some point physicians/surgeons began to accompany the armies.

The first known system for caring for the wounded in a timely fashion appears to have been organized by Dominique-Jean Larrey. Larrey was a surgeon in revolutionary France and became the surgeon in charge of the medical care for Napoleon's Imperial Guard in the early 1800s. Larrey noticed that many men were being injured; and because there was no organized system for removing these men from the battlefield until the fighting was done, many men were dying from wounds that should have been treatable. Larrey reasoned that, if the men could get medical care early enough, many could be saved. He organized a system of medical teams and wagons into mobile hospitals. The units would go onto the battlefield to treat the men, including performing any necessary surgical procedures. He called the units ambulance volante, or "flying ambulances."…"
Main page
link

Amicalement
Armand

Don't forget about Pierre Francois Percy-inspector general of military hospitals and surgeon-in-chief to the Grande Armee…

It was Percy who in 1808 in Spain organized a battalion of soldier-infirmiers the success of which prompted Napoleon to organize ten companies of infirmiers d'hopitaux, sometimes called soldats de'ambulance. Their service was uneven and sometimes disappointing.

"The first known system for caring for the wounded in a timely fashion appears to have been organized by Dominique-Jean Larrey."

Not my area of expertise, but a bit over-simplistic perhaps?

very true, what is about Percy? and the rest of all military surgeons who did this for ages.

Why don't you look it up and find out? There is a lot of material on Larrey and his innovative medical care.

How is it 'over-simplistic'? Making simple things difficult is somewhat pedantic, is it not?

Thanks!.

Amicalement
Armand

It has just this minute been suggested to me, by someone of many years' experience in medicine, that the good Doctor Larrey should feature in any possible Spielberg film/movie about Napoleon. She said he should be played by a certain Hugh Jackson.

Seemingly I did express myself not clear enough

Not my area of expertise, but a bit over-simplistic perhaps?

Very true – moreover wrong in the historical context. Ambulances to bring back casualties in a more comfortable way than in usual waggons existed already in the Prussian and British Army at the end of the 18th century (or even earlier).

Larry's system did not work, due to the fact that the casualty figures were enormous, who could he evacuate them with so view – in real numbers existing ambulances? Another physician Percy – played an at least equal important role for the French field medical system, and most other armies did the same, that is to bring forward to the actual fighting area – bandages and surgeons to establish first line "field hospitals" in as good as sheltered areas as possible.

In case Larry did invent the triage system, who was his triage physician or triage nurse?

It is the usual propaganda to diminish the equal heroic efforts of field surgeons and medical personal of other armies.

A newer article about the history of triage with referral to the military (particularly the Napoleonic era) had been published 2016 in a Japanese medical journal – cf. link … there Percy and Larrey are mentioned and examples given.

Greetings from Berlin
Markus Stein

And another overview articles about the history of war injuries treatment at link and at link

"Why don't you look it up and find out?"

Er, because this is a forum. Forums discuss things, and I know there are people on here with more interest/knowledge than I have?

It's called humility, but I don't think it's that popular.

@NapStein

Thank you Markus, those links were very informative.

As the first article mentioned the citation of "triage" in Percy's journal I studied it and, indeed, I found the "triage" on page 409 (edition of 1904):

"Sa Majesté m'a appelé et demandé depuis quand j'étais arrivé : « Depuis deux jours, lui ai-je répondu. Je serais arrivé plus tôt si je n'eusse été obligé d'aller d'hô- pital en hôpital pour faire le triage des soldats réellement malades et de ceux qui simulent des maladies, pour faire rejoindre ceux-ci et assurer des secours aux autres."

Greetings from Berlin
Markus Stein

I checked the "Histoire de la Médecine aux Armées", volume 2, published by the French Comité d'Histoire du Service de Santé, Paris 1984 … and there is mentioned that Larrey first described the process of treating the most severe wounded first – he didn't use the word triage but according to the authors he's the first to talk about "triage in war surgery".

Now, I checked the Memoirs of Larrey, to which the authors referred, and here's the quote out of volume 3 of "Mémoires de chirurgie miitaire, et campagne" of Larrey, published in 1812, where he described the method during the battle of Jena in 1806:

"Il faut toujours commencer par le plus dangereusement blessé, sans avoir égard au rang et aux distinctions. Les moins maltraités peuvent attendre que leurs frères d'armes, horriblement mutilés, aient été pansés et opérés; autrement ceux-ci ou n'existent déjà plus quelques heures après, ou ne vivent que jusqu'au lendemain, ce qui est encore assez rare. Il est facile d'ailleurs, avec de légères blessures, de se rendre aux hôpitaux de première ou de deuxième ligne, surtout pour les officiers, qui ne manquent pas ordinairement de moyens de transport; enfin, la vie des ces blessés n'est point en danger."

So, Larrey may have described the system of separating the most severe wounded from the less severe wounded and Percy his "triage" by separating the real ill persons from those simulating to be ill. Both are right in their way.

Greetings
Markus Stein

@brechtel198

"How is it 'over-simplistic'? Making simple things difficult is somewhat pedantic, is it not?"

Because the reality of history is often more complex than the sweeping statements that historians are fond of. Scientific innovation is usually part of a collective movement, with innovation being but one step, rather then a leap. I don't douby Larrey's greatness, but my experience of sciience and engineering is that greatness does not exist in a vacuum.

Anyway, there is a title for those who think the world is simple but I will refrain from using it.

The absolute failure in this discussion is to ignore all the other medical systems in the other armies, by reading about those very worthwhile colleagues of mine, Larrey and Percy exclusively, we ignore the others in other armies, due to the fact that no research is as handily available.

In case I do understand Percy correctly his triage was to sort out those pretending to be ill to those of being realy ill.

What Larrey describes is common sense and is already mirrored in the organisation of medical surgeons in all armies of those times – so he is doing his own triage – which he shouldn't do – instead delegating it to a triage responsible and by that he would have more time to devote his skill to those who need to be treated first and who also have a good potential to survive those wounds, at those times very difficult to asses.

Hi von Winterfeldt,

for me there's no failure, as I checked articles of historians in medicine – and I think they're not too bad to consult. As you know medical research well too, I think you agree that there's a large community, even in medical / surgical history – more than in military history.

But let's get back to some facts:

1) the academic and therefore scientific appreciation of surgeons is founded in France during the revolutionary period – so even if there are some hints of "other armies", they weren't followed the same scientific approach as in France – in case of surgery (not medicine in general)

2) the "delegation" of triage is a common method in case of having too many victims in comparison to the own resources (I don't want to give examples of the present regarding COVID-19) … so I don't think Larrey went wrong in just setting a general frame for helping the wounded soldiers

3) "common sense" should be published too in other states, and btw: if we think of a common sense in military thinking, it would be better to treat the less injured soldiers (to get them back into "work") as the more severe injured soldiers (as Larrey described)

And finally I would like to get samples of other armies during the Revolutionary or Napoleonic period acting the same – I'll check the Prussians as I've some good sources about their medical/surgical methods.

Greetings from Berlin
Markus Stein

…there is a title for those who think the world is simple but I will refrain from using it.

'The art of war is like everything else that is simple and beautiful. The simplest moves are the best.'-Napoleon

Anything you'd like to add?

'After the battle of Talavera…our wounded were put up as well as we thought they could be, in some large buildings in the town, and laid on the ground in their blankets. There were necessarily left to the mercy of the enemy…When the French entered, a general officer visited the hospital and said the accomodation was not at all sufficient for de braves soldats; and, before evening, the town was ransacked for mattresses, and the condition of the poor patients was greatly ameliorated in every respect.'-Sir John Fox Burgoyne.

common sense as in saving lives – not as in the sense of the military, a lightly wounded can wait – same if you go to A & E – when you have a minor laceration and are already on the brink of getting stiched up – you might find all of a sudden being alone when a multi trauma case comes in.

The main motivation by surgeons were / are driven by humanity and not by military thinking.

Read Roos – and what he has to say.

Come on vW – that's not the appropriate discussion format – it is not sufficient to refer like "read this or that" … I checked some documents and quoted out of them. So, if Roos has some remarks it would be nice if you may provide them.

Thank you and greetings to Franconia
Markus Stein

The highly recommended book "Wellington's Doctors" by Dr. Martin Howard (he also wrote a book about Napoleon's Doctors) contains a chapter regarding the acting of the British Medical Services in battle.

And as an experienced surgeon he examines the point of "triage" – I may quote from the pages 59-60:

"In the face of all these inadequacies and shortages, there was every need to have an arrangement for prioritizing treatment. On a modern battlefield this is referred to as 'triage' …"

Then he quotes from Hennen's "Principles of Military Survey" and concludes:

"Hennen similarly expresses the needs to prioritize the removal of wounded to the rear. He warns that 'the most clamorous and troublesome among the wounded in the field, or before the walls of a besieged town, are generally the worst characters of the army, and the most slightly injured'. …
Did Surgeons practice triage and treat the wounded soldiers on the basis of their clinical need alone? …"

Then Howard talks about Larrey and his triage system, given an example of Eylau.

After that Howard comes back to the British system:

"In the British Army, all the available evidence suggests that rank was the dominant consideration in determining the likelihood of receiving treatment and its rapidity. At Waterloo, Ensign Howard of the 33rd Regiment makes the telling comment, 'we were charged so furiously that we could scarcely send our wounded officers to the rear and much less the men'.
It is important to remember that it is the officers who have left most of the anecdotes of wounding on the battlefield. Their experiences were not typical of those of the men – indeed, many would probably not have survived to write their memoirs if they had not received the favorable treatment accorded to those of senior rank."

So beside the bias of more existing memoirs from officers than soldiers Howard concludes the "triage by rank" which he founded later by another statement on page 60:

"In their accounts of battle, regimental medical officers do not generally volunteer the fact that they treated the officers first, but this was the reality."

BUT: I won't be surprised if the French medical officers acted the same, although Larry, Percy and perhaps other doctors give controversial statements.

Greetings from Berlin
Markus Stein

Brechtel198

Only that over-confidence is a symptom of a narcissitic personality.

Seems like defeating a sepoy general and an old hussar was not as simple as he first thought, apparently.

From a military perspective, treating officers first, particularly if they are lightly wounded enough to return to the battle, would make more sense.

It may be that the French, with the concept of Egalite ringing in their ears, would be less likely to regard rank as important. I seem to remember reading that in the Royal Navy casualties had to wait in turn.

But even in modern times, military triage in a mass casualty setting is very different to civillian triage I think.

The following books are helpful when discussing or researching the subject:

-Larrey: Surgeon to Napoleon's Imperial Guard by Robert Richardson.

-Napoleon's Doctors by Dr Martin Howard.

-Men of Steel: Surgery in the Napoleonic Wars by Michael Crumplin.

-Memoir of Baron Larrey

link

-Journal Des Campagnes Du Baron Percy: Chirurgien En Chef de la Grande Armée (1754-1825)

link

Come on vW – that's not the appropriate discussion format – it is not sufficient to refer like "read this or that" … I checked some documents and quoted out of them. So, if Roos has some remarks it would be nice if you may provide them.

You are right of course, but I don't have the time – nor the motivation to look this all up. There due to profession I have to read medical periodicals and text books all the time, even historic ones are low on my agenda in my spare time – which I like to use to escape the medical dead lock.

So take my jibs light minded, Roos did come to may mind – because he was a non French medical officer.

Also in case – google Dr. Görcke and will find a lot interesting sources, amongst else that one

link

I know I have it somewhere, but I cannot find it :-((((((.

Well triage is selling well, despite Larrey had much more important discoveries from the medical point of view – like open wound treatment (discovered in the Russian campaign, there thanks to the immense logistical failures of Boney, there wasn't enough bandage around) – or that Percy experimented with iv shots prae operation to relieve pain.

Larrey was certainly top notch due to his extensive experience, curiosity and analytical mind.

Still, we don't know, at least I don't know a lot about field medicine of other armies and there they delt with identical problems, they found their own solutions.

Otherwise I am stuck with the Prussian Army of 1806 again, due to your contributions on your web site.

so take my contribution more or less as small talk.

Greeting to the capital of Prussia

There no longer is a Prussia…it was abolished.

I did forget one volume that is useful:

-Wellington's Doctors: The British Army Medical Services in the Napoleonic Wars by Dr Martin Howard.

…because this is a forum. Forums discuss things, and I know there are people on here with more interest/knowledge than I have?

So you don't wish to contribute and help others out?

Only that over-confidence is a symptom of a narcissitic personality.

Apparently not.

Perhaps this will help you:

link

From the link regarding 'overconfidence':

"Superiority is the No. 1 sign of a narcissist. This is different from self-confidence alone."

Undoubtedly you will now bust a gut in an attempt to 'demonstrate' the traits that Napoleon 'undoubtedly' possessed.

@Brechtel198

Please do me the service of not predicting my response. That argument has been made by others far more qualified than you and I, all I do is accept it and you do not. That's fine by me.

I love to contribute and help, when I think my area of knowledge or expertise can assist. Particularly for what is decribed as a "newbie". I think we have a duty to be welcoming and inclusive, or our hobby will eventually die with us.

However, I am well aware that this forum is populated by medical experts that are also historians. I have all the titles you quoted, but I still wouldn't describe myself as an expert. Any more than I would expect an artilleryman with only general staff officer training to fully understand the development of telecommunications and information systems in the late 20th and early 21st centuries, for example.

I therefore defer to others when a topic is outside my comfort zone, and only comment to move the conversation along or widen the conversation into an area which I would be intrigued to see their contribution. I am delighted when it does, and it adds to everyone's knowledge as a result.

I don't try and close down debate, make definitive statements, correct others, score points or provoke arguments for the sake of them. Following the logic of the last two paragraphs, others seem much better at that than me, so I generally decline.

There are some titles I would add to your list that I have found useful:

The Bloody Fields of Waterloo by MKH Crumplin MB BS FRCS (Eng and Ed) FINS Ken Trotman 2013

Waterloo The Aftermath by Paul O'Keefe Vintage Books 2014

Waterloo: After the Glory by Michael Crumplin and Gareth Glover Helion & Company 2019

Guthries War by Michael Crumplin Pen and Sword 2010

I cannot rate Michael Cruplin's knowledge and expertise highly enough. It has been my great privilege to hear Mick present a number of times, and he has contributed to a number of TV documentaries. His work on the hospital at Mont St Jean has bee phenomenal. I've even managed to chat to him a couple of times at Waterloo Association meetings. I therefore recommend his works unreservedly to anyone interested in the topic.

I'm not a medical doctor (like vW is), but before entering the field of hospital management and health information management I worked as a nurse for some years … and therefore may really recommend the quoted work of Michael Crumplin "Men of steel" as he wrote from the perspective of a General Surgeon, so experienced as a medical officer and experienced staff officer.

Of course it is easier to follow the medical issues of the book if you got some education and/or experience in the medical field.

@Handlebarpleep: I'd like to be in a position like you to discuss with Dr. Crumplin :-)

Greetings from Berlin
Markus Stein

@NapStein

Are you a member of the Waterloo Association Markus?

Mick often attends the meetings, and despite being the consumate expert is really engaging and unfailingly welcoming. My job has taken me away from more of the meetings more than I would have liked, but having so many knowledgeable and enthusiatic people in one room is a delight.

Hopefully, when we get back to something approaching normal, let me know if you can make it over, if I'm in reach of London or my work brings me close to Berlin, you must let me stand you a beer.

David

As a FRCS it would be Mr. Crumplin, to distinguish between a surgeon and the rest of the medical world – in the UK.

only comment to move the conversation along or widen the conversation into an area which I would be intrigued to see their contribution. I am delighted when it does, and it adds to everyone's knowledge as a result.

Beautifully put.

@Handlebarbleep (David): indeed, it would be a nice afternoon/evening to have one (or more) beers discussion about the Triage or other things :-)

Send a note, if you're in the Berlin area at stein AT napoleon DOT de – and if I'm in London (had been there two years ago and made some photos of the Life Guards museum – some of them could be found at link

Greetings from Berlin
Markus

@NapStein

Thank you Markus,

I'll bear it in mind. I've been promising myself a return to Berlin since the wall fell! Probably well overdue.

Whilst the National Army Museum in Chelsea has great treasures, there are also many gems to be found in regimental museums throughout the UK. My home town of Nottingham has the 45th for example in the castle (once it's completed it's restoration).

We have so many of these Corps and Regimental museums, many with their own archives. Most have a 'slice' of Napoleonic material, particularly the ones with "Egypt" "Peninsula" or "Waterloo" as battle honours. Post Covid it would make a fascinating touring holiday (Beware – uninterested partners would get a great itinery of very beautiful cities, market towns and extrememly expensive shopping opportunities)

The museum of military medicine is in Keogh barracks in Surrey link for example.

I'm starting to sound like the tourist office!

David