“Three Points Forward” System

This drawing illustrates the “Three Point Forward” system of battlefield medical care devised by New Zealand surgeon Douglas Jolly. This was one of a number of major advances in wartime medicine made during the Spanish Civil War.

These advances came in three areas: blood supply and transfusions, the treatment of wounds and fractures, and the organization of military medical services. They were the work of both Spanish and foreign medical professionals, all of whom served with the Republic. Most Spanish military medics joined the rebels, and their replacements were predominantly young, relatively inexperienced civilian doctors who faced demanding conditions, including the unprecedented aerial bombardment of cities and towns, that stimulated innovation.

Today, the most widely- remembered of those medical innovators is the Canadian surgeon Norman Bethune (1890-1939). He created the independent, Madrid-based Hispano-Canadian Blood Transfusion Service, that transported blood along an extensive front. Less well-known but more consequential was Frederic Duran i Jordà (1905-1957) who developed a service for collecting and distributing blood on large-scale. Operating from August 1936 until January 1939, his Blood Transfusion Service in Barcelona had 28,900 donors and collected 9,000 litres of blood, mostly from group O “universal” donors, treated with sodium citrate to prevent coagulation. After leaving Spain, Duran i Jordà went to the UK, where he advised on the creation transfusion services there. 

The great innovator in the treatment of wounds and fractures was Josep Trueta (1897-1977). Having to deal with both battlefield casualties and the civilian victims of Francoist air raids on Barcelona, he perfected the technique of excising the wound and immobilizing the limb in a plaster cast with the wound open.  By drastically reducing infection, the Trueta method, which was used throughout the Republican military, reduced the need for amputations and saved thousands of lives. Trueta too went into exile in the UK. In 1939, he published his Treatment of War Wounds and Fractures, with special reference to the Closed Method as used in the war in Spain, a book that had massive impact on the treatment of wounds during World War II and after. 

Douglas Jolly (1904-1983) served with the medical service of the International Brigades from December 1936 until November 1938 and made significant innovations in two areas: trauma surgery, especially for abdominal injuries, and the provision of frontline medical close to the front. His “three-points forward” system of triage aimed to reduce the time between a soldier was wounded and received treatment by establishing a site for classifying casualties close to the lines and two hospitals at differing distances from the front with the closer one handing the most urgent cases. After leaving Spain Jolly went to the UK. His book Field Surgery in Total War, from which the drawing comes, was published there and in the United States in 1940. It had a huge impact on military surgeons in both countries and remained influential for decades. Jolly’s system was the model for the MASH units in the Korean War.