Pirogov’s Surgery Innovations in Crimea, 1855

From The Crimean War: A History, by Orlando Figes (Metropolitan, 2011), Kindle Loc. 5191-5224:

Born in Moscow in 1810, Pirogov began his medical studies at Moscow University at the age of just 14, and became a professor at the German University of Dorpat at the age of 25, before taking up the appointment of Professor of Surgery at the Academy of Military Medicine in St Petersburg. In 1847 he was with the Russian army in the Caucasus, where he pioneered the use of ether, becoming the first surgeon to employ anaesthesia in a field operation. Pirogov reported on the benefits of ether in several Russian-language publications between 1847 and 1852, though few doctors outside Russia were aware of his articles. Apart from the relief of pain and shock through anaesthesia, Pirogov emphasized that giving ether to the wounded on arrival at the hospital kept them calm and stopped them from collapsing so that the surgeon could make a better choice in selecting between those cases requiring urgent operation and those that could wait. It was this system of triage pioneered by Pirogov during the Crimean War that marked his greatest achievement.

Pirogov arrived in the Crimea in December 1854. He was outraged by the chaos and inhuman treatment of the sick and wounded. Thousands of injured soldiers had been evacuated to Perekop on open carts in freezing temperatures, many of them arriving frozen to death or with limbs so frostbitten that they had to be cut off. Others were abandoned in dirty barns or left by the roadside for lack of transport. There were chronic shortages of medical supplies, not least because of corruption. Doctors sold off medicines and gave their patients cheaper surrogates, exacting bribes for proper treatment. The hospitals struggled to cope with the enormous numbers of wounded. At the time of the allied landings, the Russians had hospital places for 2,000 soldiers in the Crimea, but after Alma they were overwhelmed by 6,000 wounded men, and twice that number after Inkerman.

Conditions in the Sevastopol hospitals were truly appalling. Two weeks after the battle of the Alma, the surgeon from Chodasiewicz’s regiment visited the naval hospital:

He found the place full of wounded men who had never had their wounds dressed from the day of the Alma, except such dressings as they could make themselves by tearing up their own shirts. The moment he entered the room he was surrounded by a crowd of these miserable creatures, who had recognized him as a doctor, some of whom held out mutilated stumps of arms wrapped up in dirty rags, and crying out to him for assistance. The stench of the place was dreadful.

Most of the surgeons in these hospitals were poorly trained, more like ‘village craftsmen’ than doctors, in the estimation of one Russian officer. Practising a rough-and-ready surgery with dirty butcher’s knives, they had little understanding of the need for hygiene or the perils of infection. Pirogov discovered amputees who had been lying in their blood for weeks.

As soon as he arrived in Sevastopol, Pirogov began to impose order on the hospitals, gradually implementing his system of triage. In his memoirs he recounts how he came to it. When he took charge of the main hospital in the Assembly of Nobles, the situation was chaotic. After a heavy bombardment, the wounded were brought in without any order, those who were dying mixed with those who needed urgent treatment and those with light wounds. At first, Pirogov dealt with the most seriously wounded as they came in, telling the nurses to transport them to the operating table directly; but even as he concentrated on one case, more and more seriously wounded men would arrive; he could not keep up. Too many people were dying needlessly before they could be treated, while he was operating on those patients too seriously wounded to be saved. ‘I came to see that this was senseless and decided to be more decisive and rational,’ he recalled. ‘Simple organization at the dressing station was far more important than medical activity in saving lives.’ His solution was a simple form of triage which he first put into practice during the bombardment of Sevastopol on 20 January. Brought into the Great Hall of the Assembly, the wounded were first sorted into groups to determine the order and priority of emergency treatment. There were three main groups: the seriously wounded who needed help and could be saved were operated on in a separate room as soon as possible; the lightly wounded were given a number and told to wait in the nearby barracks until the surgeons could treat them; and those who could not be saved were taken to a resting home, where they were cared for by medical attendants, nurses and priests until they died.