The birth of modern emergency medicine (Part 2)

During the Napoleonic wars at the turn of the 18th century, Surgeon Dominique-Jean Larrey developed new emergency procedures, many of them still in use today in modernized forms. Not only did he create “flying ambulances” that brought immediate and well-provisioned aid to the battlefield, but he also imposed order on the treatment that was taking place in the most disorderly of environments.

Larrey’s organization led to the creation of an early version of triage—a word that comes to us by way of the French trier, “to sort”—in a way that reflects both his commitment to saving lives and the democratic principles of the French revolution. Larrey decreed that more severely wounded soldiers would be treated first, regardless of their rank. This was a departure from the procedures of the time, both in his willingness to treat common soldiers before the officers and in his insistence that the lives of badly injured soldiers were worth saving. At the time, the military wanted the less wounded soldiers to be patched up so that they could be returned to battle. Badly wounded soldiers were unwanted mouths to feed: if they couldn’t fight, they weren’t of use.

Underlying Larrey’s work were the limitations of 18th century medicine. In the absence of antibiotics (or even germ theory, although the dangers of infection had long been observed) or anesthesia, saving lives required speed—and a lot of amputations. Although Larrey saved limbs when he could, the gunpowder-propelled projectiles newly in use created wounds so filthy that the gunpowder itself was believed to be a poison that caused infections. Frequently, amputation was the only treatment, within 24 hours, or immediately when possible.

Larrey learned to do amputations very quickly—he could amputate a leg in three minutes—but avoided the common practice of making a single straight cut and then sewing the loose skin over the wound, which generally produced gangrene and death. Instead, Larrey made three cuts, creating an inverted cone that could later be fitted with a wooden leg. The flaps of skin fell over the cuts, and the wound was bandaged in a way that allowed it to drain. Larrey soaked bandages in wine, vinegar, or saline, and applied a variety of early (and effective) antibiotics. He packed the injured limb in snow and ice when possible before and after surgery to dull the pain. Alcohol was applied externally and internally, further improving patient satisfaction. He also washed his surgical instruments in brandy at a time when doctors didn’t always find it necessary to wash anything at all, including their hands.

Other armies failed to follow Larrey’s lead in his provisioning and deployment of ambulances and in his speedy treatment. His system of battlefield ambulances and trained responders were not adopted by the British army until 1875.


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