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Timely Wound Care: The Birth of the Triage System

Christine Miller, DPM, PhD, CWSP, FACCWS

Introduction: Debridement

War has often been the driver of medical innovations; the battlefield has been the birthplace of many advancements that have shaped modern health care. One war in particular, The Napoleonic Wars (1803-1815), which took place during the early part of the 19th century, was a major global conflict and, like most wars, the horrific sight of wounded soldiers left to die unattended on the battlefield was indeed a tragedy.1 Dominique Jean Larrey, a French surgeon, saw firsthand the catastrophic effect of delayed care on the seriously injured. He recommended immediate surgical intervention for traumatic wounds, including debridement (removal of devitalized tissue) and amputation (for severe injuries), which resulted in better survival rates.1 He and fellow French surgeon Pierre Joseph Desault (1744-1795) are credited for coining the term debridement, referring to the unbridling of flesh.1Debridement continues to be widely performed in the field of wound management.

Flying Ambulances

To prevent soldiers from being left behind, Dr. Larrey established an organized system of evacuation for the wounded. This initiative would be named “les ambulances volantes” or “flying ambulances,” where skilled medics were dispatched with equipment to render emergent care and evacuate the injured in an efficient manner with horse-drawn carts.1 This well-organized model of care saved countless limbs and lives, even catching the attention of Emperor Napoleon Bonaparte. Napoleon embraced this novel, proficient method of caring for causalities, and it became standard operating procedure within the French army.

The Triage System

The “flying ambulance” concept would be revisited later during the American Civil War (1861-1865). The Union and Confederate armies faced similar obstacles regarding the evacuation of wounded soldiers during the 1st Battle of Bull Run in 1861, where approximately 5,000 soldiers lay stranded for up to 1 week after the fighting had ceased.2 Major General George McClellan appointed Dr. Jonathan Letterman as medical director of the Army of the Potomac in the summer of 1862. Dr. Letterman was chosen for his organizational skills and tasked with improving overall care coordination in the Union army.2 His plan had each regiment supported by 3 dedicated ambulances (horse-drawn carts), each with 2 privates and a driver.3 It required a surgeon and an assistant to initially assess the patients to decide the appropriate level of care required, which is known today as triage, a French term meaning “to sort.”3 Those with minor injuries were treated at “first aid” stations and returned to fighting, while the more critically wounded were transported to field hospitals beyond cannon range for the best chance of survival. This method of triage was the basis for Mobile Army Surgical Hospitals (MASH) units implemented in the 20th century, and its tenets are still observed in modern emergency departments and trauma centers.3


The treatment of wounds has been a compelling force throughout history to maximize healing, even in the most dangerous environments. It has been stated “necessity is the mother of invention," which is certainly evident here. What began initially with horses carrying the wounded to safety for treatment evolved into transportation via automobiles, trains, and helicopters. Modern wound clinicians owe a debt of gratitude to the 19th-century surgeon Jean Larrey and physician Jonathan Letterman who is widely considered the father of battlefield medicine.


  1. Brewer LA. Baron Dominique Jean Larrey (1766-1842). J Thorac Cardiovasc Surg. 1986;92(6): 1096–1098.
  2. Place RJ. The strategic genius of Jonathan Letterman: The relevancy of the American Civil War to current health care policy makers. Military Medicine. 2015;180(3): 259–262.
  3. Miller C, Musselman T. Surgeons in Blue and Gray: The Lasting Impact of Civil War Medicine.” Journal of America's Military Past. 2018;XLIII: 5–11.

About the Author

Christine Miller, DPM, PhD is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.