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What happens when a soldier is injured during a battle? In the past, they would have been left on the battlefield until the end of the battle. Fortunately, military medicine has improved.

A soldier being carried off the battlefield seated on a bayonet carried by his comrades Wellcome Collection, CC-BY
A badly wounded soldier being carried off the battlefield on a makeshift stretcher made of bayonets

For most of military history, if a soldier fell in battle, there was little chance of survival.

The days when a solider might lay on a battlefield for days are not so long ago. Even during the First World War (1914–18), a soldier lay in the 'no man's land' between the two armies, until a truce for collecting the wounded could be agreed.

Military surgeons knew that rapid treatment was the only hope for wounded soldiers. But in the midst of battle, it was difficult to persuade combat officers to risk healthy men to rescue the wounded.

The field ambulance

Portrait of Dominiq Jean, Barron Larrey Wellcome Collection, CC-BY

Napoleon's chief surgeon Dominique Larrey devised the 'flying ambulance' to help evacuate the wounded from the battlefield.

The French army was among the first to realise that an organised system of military medicine would help to save the lives of soldiers so that they could fight another day.

The flying ambulance was more than a mode a of transport. It was a mobile treatment centre equipped with medical staff, equipment and padded mattresses for the wounded. The horse drawn vehicle itself was called the ambulance wagon.

 

Portrait of Dominiq Jean Larrey (1766–1842). Image credit: Wellcome Collection.

From chaos to triage

The triage system is a way to direct medical staff and resources to where they will be most effective. It was devised by Dominique Larrey, and it is still used today, in busy Accident and Emergency departments as well as in combat.

Painting of the Battle of Waterloo by Denis Dighton: British Hussars of Viviene's Brigade. Wikimedia Commons, public domain Image source
The Battle of Waterloo, 1815. Painting by Denis Dighton: British Hussars of Viviene's Brigade.

By the end of a battle, medical teams were often be overwhelmed by the sheer number of casualties arriving at the field station on foot, by stretcher bearers and in ambulance wagons.

Charles Bell, a surgeon who volunteered at the Battle of Waterloo, described the situation at one of the base hospitals in Belgium:

While I amputated one man's thigh, there lay at one time thirteen, all beseeching to be taken next... It was a strange thing to feel my clothes stiff with blood, and my arms powerless with the exertion of using the knife...

Charles Bell, Quarterly Review volumes 72–73, Surgeon (1843)

In triage, the wounded were divided into three categories that could be summed up as 'trivial, treatable and terrible'. Soldiers with minor injuries were treated quickly and returned to the front line. Those with more serious but still treatable injuries were either operated upon or prepared for transportation to the base hospital. Those with little chance of recovery were given pain relief, usually opium or morphine, and seen by the surgeons when the other categories had been cleared.

The system was only effective if patients were dealt with quickly and constantly reassessed while waiting for further treatment, because the 'treatable' might slip into the 'terrible' if the patient had to wait too long for attention.  

Triage brought organisation and efficiency to urgent medical treatment, and by the First World War, it was standard practice in military medicine.

Transporting the wounded

Time is of the essence when treating war wounds. But with limited medical resources on the battlefield, the wounded have to be moved from the front line to base hospitals as quickly as possible.

It took a catastrophic war in the Crimea for the British military to realise that a well organised transport network was essential to saving soldiers' lives. 

By the time of the South African War (1899-1902), the British Army was better resourced with hospital trains such as the Princess Christian, which could transport over 7,000 wounded. It included ambulance vehicles for operating, a pharmacy and a kitchen with refrigeration. The remaining coaches housed bunks and lockers, as well as toilets and seating for attendants.

Interior of a hospital train with wounded soldiers in bunks, Boer War Wellcome Collection, CC-BY
Interior of a hospital train used in the Boer War

The message was getting through that rapid treatment was essential if more wounded were to survive. Data gathered by the French in the First World War led to the concept of the golden hour—that vital first hour in which a patient with multiple trauma had to be treated if he were to survive.

The First World War saw the introduction of an infrastructure for medical transportation called a 'chain of evacuation', which took an injured soldier from the front line to the  dressing station, then on to a field hospital and if necessary, on a motorised ambulance or ambulance train to the base hospital. 

Interior of a World War One ambulance with a doctor and nurse inside Wellcome Collection, CC-BY
Interior of a World War One field ambulance

In the Second World War, aeroplanes were added to the chain of evacuation and used to send the seriously wounded to base hospitals. By the Korean War, helicopters could transport the wounded to local Mobile Army Surgical Hospitals within minutes.

And the chain of evacuation has kept up with improvements in global transport. During the Vietnam War, it took 45 days for a seriously injured soldier to return to the United States. In the second Iraq War, it took less than four days.

Improvements in medical transportation and mobile equipment meant that doctors could bring surgery and other medical services close to the front line, and treat more of the wounded within the 'golden hour'.

Suggestions for further research

  • Between Flesh and Steel by Richard A Gqabriel, Potomac Books, 2013
  • War Medicine and Modernity edited by R Cooter, M Harrison and S Sturdy, Sutton Publishing UK, 1998
  • Wars, Pestilence and the Surgeon's Blade by T Scotland and S Heys, Helion and Company Ltd, 2013
  • How did WW1 change the way we treat war injuries today?, BBC iWonder website (viewed February 2019)