Clinical Presentation

The Napoleonic and the European Wars during the Second French Empire (1792 to 1815 and 1852 to 1870, respectively) revolutionized armed warfare due in great part to the introduction of mass conscription and the use of artillery.1 ^, 2 The injured soldiers of the day made their way after trauma by walking from the lines of confrontation to distant health stations for wound care; rarely was retrieval by horse or horse and wagon available. The less able were left to await assistance or suffer an agonizing death.3 ^– 6

Significant refinements in evacuation and triage awaited World War I, when Antoine De Page established an Ordre de Triage.6 The injured were “whisked” by motorized ambulances to dressing stations and centers of progressively more definitive care ( Fig. 3.1 ).

Patients in acute distress from hemorrhage or with critical cavity wounds were taken to mobile surgical centers nearby, but others, with cranial and/or facial injuries, were evacuated to Versailles or Compegne, France (some 10 or 12 miles from the front) or to La Panne, Belgium, near the coast, collectively considered a final level of triage ( Fig. 3.2A,B ).

Some soldiers subsequently underwent reconstructive procedures at centers in metro-Paris, such as Neuilly Hopital (Lycee Pasteur), and in metro-London, at Saint Hughes College. There, patients entered the care of Morestin, Gillies, and Cushing, to name a few.6 ^– 10 These early efforts at triage of the injured and management of their wounds were utilized decades later, during care of the injured in World War II.

Algorithm of Repair

Open wounds during World War I were dressed with linen at so-called dressing stations immediately behind the lines of confrontation. Priority was given to those suffering acute bleeding, as they were shuttled to close-by mobile centers. Wounds of the thorax or abdomen were given “higher status” for intervention as soon as conditions permitted. Débridement of open wounds and neurosurgical care were given priority at more distant hospital centers, relatively far from the battlefield. The repair of cranial or maxillofacial fractures was deferred, pending long periods of observation while awaiting improved neurologic status6 ^, 11 ( Fig. 3.3 ).