Past And Present

The earliest days of first aid

BMJ 1994; 309 doi: http://dx.doi.org/10.1136/bmj.309.6970.1718 (Published 24 December 1994) Cite this as: BMJ 1994;309:1718
  1. John Pearn, national director of training St John Ambulance Australiaa
  1. a Department of Child Health, Royal Children's Hospital, Herston Qld 4029, Australia

    First aid, as a profession in its own right, has a history of only 120 years. It evolved from the teachings of the Royal Humane Society and military surgeons, who saw the wisdom of training in splinting and bandaging for battlefield wounds. In 1878 two Aberdeenshire military officers, Surgeon-Major Peter Shepherd of the Royal Herbert Military Hospital, Woolwich, London, and Colonel Francis Duncan established the concept of teaching first aid skills to civilians. This radical new enterprise, conducted under the auspices of the newly formed St John Ambulance Association, was a natural evolution from the body's philanthropic and ambuance transport work. Shepherd conducted the first class in the hall of the Presbyterian school in Woolwich using a comprehensive first aid curriculum that he had developed. Within months of that first class, local Woolwich civilians used their skills when the pleasure boat Princess Alice sank in the Thames at Woolwich, killing 600 people. Within a decade, the new discipline of first aid spread rapidly throughout the world, and by the end of the 19th century, hundreds of thousands of St John first aid certificates had been awarded in four continents. Shepherd's pioneering classes changed the world's concept of the need for the provision of skilled prehospital care.

    From the perspective of 20th century medicine the need for first aid training seems self evident. But first aid, as it exists today, has a history of only about 120 years. First aid comprises a series of drills and skills which have doctrinal underpinning and which require training; the procedures are constantly revised and are subject to ongoing medical audit. The discipline originated in 1878 from a pioneering and revolutionary experiment to teach members of the general public skills that had been developed for military stretcher bearers in the previous decade. This paper documents some details of that milestone event.

    Originators

    The application of woundworts to cuts and abrasions is older than recorded history.1 Bandaging skills, particularly for wounds sustained in battle, were documented on Grecian pottery from around 500 BC, by the enigmatic vase painter Sosias. The good Samaritan, with his ethic of succour and his efficiency of bandaging, dates from the bronze age in the Middle East, and is immortalised in the gospel of St Luke (x, 30). The Royal Humane Society, founded in 1774, did much to promote the attempted resuscitation of the apparently drowned. It was not until the 1870s, however, that the Prussian military surgeon, Johannes Friedrich August von Esmarch (1823-1908) first used the term “Erste Hilfe” and taught that soldiers could help their wounded comrades on the battlefield by using a standard set of prelearnt bandaging and splinting skills.

    In the same decade in England a groundswell of charitable fervour changed the English Priory of the Order of St John from a religious and fraternal body into a useful charitable organisation, initially with the concept of alleviating human suffering by philanthropic work. One of the advocates for this practical innovation was Colonel Francis Duncan (1836-88), a career artillery officer from Aberdeen. After six years of garrison duty in Canada he was posted to Woolwich Arsenal, London, in 1875. A devout Presbyterian, a keen historian, and a gunnery officer in the highest traditions of the Royal Regiment of Artillery, he established a number of good works in Woolwich, a south eastern suburb of London. In particular he enthusiastically espoused the humanitarian principles of battlefield ambulance transport. His young colleague, Surgeon-Major Peter Shepherd (1841-79), also from Aberdeenshire, had also been posted to the garrison and was based at the Royal Herbert Military Hospital at Woolwich. Shepherd had the complementary medical skills needed to provide the technical training in what was to be the new profession of first aid.

    Shepherd saw the value of von Esmarch's new teaching in bandaging and other elementary first aid skills as these were evolving in the Prussian army. He quickly developed and extended these skills for British stretcher bearers in the army medical department. It was Shepherd who first used the English term “first aid for the injured” and developed the doctrine in an unpublished series of lectures covering a comprehensive range of first aid skills for a wide range of medical emergencies, not just battlefield wounds.

    Chronology

    Shepherd's role was the primary practical influence in establishing first aid as a major theme in the work of the Venerable Order of the Hospital of St John of Jerusalem. In 1870 the Order of St John, with its tradition of “muscular” hospice care but unrealised infrastructure, had “grand possibilities … to establish and develop a system of practical philanthropy that would benefit the whole community.”2 By 1872 the order had contributed £100 towards establishing Britain's first ambulance transport service, and in 1875 it had developed its own wheeled transport litter, called the St John Ambulance. It was a short step, in 1877, to the establishment of the volunteer St John Ambulance Association. This was intended to be “a civilian reserve for the Army Medical Department … to train men and women for the benefit of the sick and wounded.”3 Within months the need for first aid skills that would be used in the normal daily life of the civilian population had become obvious. These evolving concepts were accompanied by increasing zeal and had their tangible results in the first public first aid class, in Woolwich in January 1878.4

    Woolwich was the centre of a vigorous and thriving military community. It had a large army training area, and the artillery, which obtained its equipment from the armouries and munitions factories nearby, had its regimental epicentre there. The entire military community was served medically by the Royal Army Medical Establishment at Woolwich Garrison and by the massive Royal Herbert Military Hospital, also in Woolwich, which was opened in 1866.5 Many military surgeons were based there, and patients were admitted from the many units which comprised the Woolwich military community. Shepherd was posted to Woolwich as Surgeon-Major in 1872 and served there for five years.

    Both Duncan and Shepherd were active members of the Scottish Church in Woolwich. There Duncan held the first public meeting to inaugurate civilian first aid classes,4 5 6 and it was in the hall of the Presbyterian school beside the church that Shepherd, together with a Dr Coleman, conducted the first aid class. The Presbyterian school provided an education for local children. It was a “penny a week” school, teaching local children in the tradition of Calvinist education. The Scottish system of education had a long tradition of excellence, and teaching the new skills of first aid, as a novel educational experience, fitted well with this tradition.7

    From the outset the community responded enthusiastically to the first aid classes. The Kentish Independent reported on the inaugural meeting, saying that: “Major Duncan L.L.D., Director of the Ambulance Department, Order of St John, was on rising greeted with loud cheers.”4

    Curriculum

    Shepherd had written a comprehensive series of lecture notes entitled “Aids for Cases of Injuries and Sudden Illness,” which, after Shepherd's premature and tragic death, were codified and published as First Aid to the Injured over Shepherd's name, by Dr (later Sir and Lieutenant-General) James Cantlie.8 The curriculum of that first Woolwich class was published in the Kentish Independent of March 2, 1878.

    The subjects taught were the use of bandages for injuries to the head and jaw, and for fractures and dislocations -afterwards the circulation of the blood in the human body was considered, and the seat of the principal arteries, where pressure is necessary in cases of bleeding, was pointed out -the illustrations being sometimes given on the human body, and sometimes by means of diagrams. Burns and scalds were also touched upon, and the general treatment to be pursued was pointed out. The recovery of men who were insensible from immersion in water or from exposure to mephitic gases, formed also the subject of comment, and directions were given as to what was to be done with persons suffering from drunkenness, epilepsy, fainting, and appoplexy (sic), and the means of detecting the latter from drunkenness. Finally, the use of the stretcher was explained, and the drill connected with the conveyance of injured persons carried out.7

    Classes were segregated by sex, with Duncan opening his house for a private class for ladies.

    From the outset, Shepherd's St John first aid classes provided for an examination of competence at the end fo the course. Within a short time the principle was established that the examiner who certified competence and recommended awarding a course certificate should be someone other than the person who had conducted the classes. This principle has stood the test of time and continues to the present day.

    Aftermath

    No one could have foreseen the immediate and local use to which the new first aid skills were put. Woolwich had a history of terrible industrial accidents at the munitions factories and at the dockyard.9 Within seven months of Shepherd's pioneering first aid classes two civil disasters occurred in Woolwich. On 13 March 1878, 160 men were building a new shed for storing forage at Woolwich dockyard when “it collapsed like a pack of cards, burying the workmen … its fall was strangely sudden and complete … at the time of the catastrophy the greater number of men being inside.”10

    The Daily Telegraph reported that the mass rescue was followed by the emergency admission to the Royal Herbert Military Hospital nearby of all injured workmen, who were “conveyed from the spot in the ambulances of the Society of St John, [and] the distressing scene immediately after the accident afforded admirable evidence of the advocacy of military [first aid] training in such help as is necessary in such emergencies … had it not been for the promptitude of the assistance thus rendered many of the wounded must have remained some time in a position which would have reduced their hope of recovery to a minimum.”10

    Six months later, on 3 September 1878, the Bywell Castle accidentally rammed the Princess Alice, on the Thames at Woolwich. The Princess Alice was the largest saloon pleasure steamer of the London Steamboat Company and was filled with families on a day's pleasure cruise on the Thames. Over 600 lives were lost in the water. The local military and civilian population quickly gathered on the Thames and first aid procedures were attempted as the bodies were brought ashore.

    It was recorded that the would be rescuers “provided warm clothing and nourishment for the survivors … Some of the living were, however, in such a prostrate condition that but for the help they received they too must have added to the long list of dead.”11

    Legacy

    It would be difficult to overestimate the significance of that pioneering first aid class in January 1878, conducted in the hall of a small church school in an unpretentious part of south east London. The concept of first aid teaching quickly extended7 12 13 14 15 16 17 18—in a week a similar public meeting was held at Chelsea Barracks, and another soon after at Blackheath.13 14

    By the end of June 1878, “at least 1,100 people had been taught [St John first aid skills] to treat the wounded, and in case of war [the St John Ambulance Association] had registered the names of 192 men and women, all skilled nurses, who were prepared to go abroad at any moment for the purpose of attending to injured soldiers.15 By July 1878, provincial centres at Worcester,18 Malvern, Chesterfield, Southport,16 and Clay Cross (Derbyshire)17 had established first aid classes. And the enthusiasm in provincial Scotland in 1885 knew no bounds: “The [St John] Ambulance movement has something of the contagiousness of the ‘Salvation Army’. It is extremely popular in Scotland, and is consequently spreading … where all the ambulance pupils are to find an outlet for their talent and instruction it is somewhat difficult to imagine.”19

    In the first decades of first aid instruction classes were segregated by sex. Women espoused the concepts of first aid teaching for members of the general public enthusiastically. In 1885 ladies' first aid classes were being held at the Mansion House in central London for the benefit of ladies employed in offices and places of business in the City and Port of London district under the auspices of the Lady Mayoress of London.20

    By the end of 1887 St John first aid classes were being taught to the general public in Malta (1882), Cannes, Melbourne (1883), Bermuda, the Bahamas, Bombay, Gibraltar, Hong Kong (1884), New Zealand (1885), Singapore, South Africa (Kimberley in 1885), and Borneo (1887). Within a century of Shepherd's first class in the Presbyterian School at Woolwich, millions of people of all ages and from all walks of life had been trained in the rudiments of first aid. In 1993, in Australia alone, one in 80 of the general population had completed a 16 hour senior first aid course under the auspices of St John Ambulance Australia.

    Within a year of Shepherd's pioneering class, the pioneer himself was dead. He was one of almost 2000 killed in the massacre at Isandhlwana.21 22 23 Shepherd's legacy lives on, however, in the “new” profession of first aid, of which he was a signal pioneer.

    I thank the Reverend Derek Baker of the United Reform Church (Presbyterian Amalgamated), Woolwich, London; Mrs Irene Riden, secretary and archivist of St Andrew's with St Mary's, the Ecumenical Church of Woolwich; Mr Murdoch Wales, archivist of St John Ambulance Australia (Queensland); Mr Jonathan Morgan, historian to the Priory of St John, St John's Gate, London; and Dr Christopher Gardner-Thorpe, Esquire in the Order of St John, London, for their help and encouragement.

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