The Greatest Good for the Greatest Number: Triage in the Civil War and Today

Amidst the current COVID-19 global pandemic, hospitals and public health officials in the United States are preparing for the day when hard choices must be made regarding who receives lifesaving treatment and who does not. Steps are being taken to establish triage guidelines for hospitals to follow should the number of critically ill patients outweigh the number of available ventilators. These guidelines vary by state, but they have one common thread: giving priority to those who are most likely to recover if given treatment.

The term “triage” is derived from the French word “trier”, meaning “to sort.” Triage has been practiced in the military at least since the Napoleonic era. Though triage was not used as a medical term until WWI, it was the advances made during the Civil War by Dr. Jonathan Letterman that impact us the most today. 

At the outset of the Civil War, no organized system of medical care and evacuation existed. This changed on July 4, 1862 with the appointment of Major Jonathan Letterman as Medical Director for the Army of the Potomac. Letterman re-organized the Medical Corps and created a system of medical evacuation, which became known as the Letterman Plan. In March 1864, Congress implemented Letterman’s changes across the entire U.S. Army. They remain today, a basis for modern EMS and military combat medicine.

The first stop of Letterman’s plan was the field dressing station, located as close to the battlefield as possible. This is where triage was first performed. Here, the wounded were administered first aid and sorted according the seriousness of their wounds. Patients were sorted using the following criteria: severe, mild, slight and mortal. Severe wounds included serious bleeding, compound fractures, missing limbs or major trauma to the arms and legs. These were taken by ambulance to the nearest field hospital for immediate care. Mild wounds included excessive bleeding with the patient in stable condition and were evacuated after all the severely wounded were removed from the battlefield.

Slight wounds were minor injuries that could be treated and patients sent back to their units. Mortal wounds were the lowest priority and included wounds that pierced the trunk of the body or head. These patients were made as comfortable as possible and set aside until there was time to return to them; this was not due to cruelty on part of doctors, they simply lacked the knowledge and technology to treat those wounds at the time. With the implementation of this system of triage, wounded soldiers were given a better chance of survival and went into battle knowing they would not be left on the battlefield for days waiting for help.

Modern triage closely mirrors its Civil War counterpart and is based on the principle of doing the greatest good for the greatest number with the available resources. While it is practiced throughout medicine by first responders and emergency room personnel, we usually think of triage in terms of mass casualty incidents, or incidents in which the number of casualties overwhelms medical personnel and resources.

In these instances, it is ideally performed rapidly, with 15 – 60 seconds spent on each patient who are then categorized according the universal colors of red, yellow, green and black. Red (immediate) patients are the first priority and include pneumothorax (collapsed lung), hemorrhagic shock (significant blood loss), closed head injury and diminished mental capacity (unable to follow simple commands).

Yellow (delayed) patients have major or multiple bone, joint, back and spine injuries with an unobstructed airway. Those placed in the green (minor) category are the “walking wounded”- those who can follow commands with minor cuts, bruises, painful and swollen deformities and minor soft tissue injuries. The lowest priority is given to those who fall in the black (deceased) category. These include obvious mortality or death including decapitation, blunt traumatic cardiac arrest (no pulse or spontaneous respiration), injuries incompatible with life and visible brain matter. Keep in mind that triage is an ongoing process that is performed continuously throughout the primary assessment, treatment, transportation and hospital phases of care.

While medical care and knowledge of physiology has far surpassed that of the 19th century, triage categories remain largely unchanged since the Civil War. Our modern red, yellow, green and black triage categories all closely mirror the Civil War era categories of severe, mild, slight and mortal wounds. In both instances severe or red are given first priority, mild or yellow treated next, green or slightly third and very last are the black and mortal wounds.

The measures taken by the medical community to respond to the current COVID-19 pandemic is demonstrative of the evolving nature of triage and the ability of medical personnel to adapt to these changing circumstances. Thanks to Dr. Letterman and the advancements made in medical evacuation during the Civil War, medical personnel have the framework they need to utilize available resources to save the greatest number of lives. As our world struggles to deal with a deadly pandemic, the changes wrought during the Civil War remain just as pertinent, if not more so, today.

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About the Author

Rachel Moses is the Site Manager for the Pry House Field Hospital Museum. She received her M.A. in History and Museum Studies from Youngstown State University in Ohio. She most recently worked as an Education Specialist for the West Virginia State Museum in Charleston, WV from 2011 to 2018.