The Development of Triage

Robert Slawson, MD, FACR

Originally published in June 2014 in the Surgeon’s Call, Volume 20, No. 1

In today’s world there is an interest in the origins of systems for handling casualties in battles and in civilian life. Little is known about the fate of the wounded in early times. Whether any system existed is questionable. Certainly there was always a body of people, men and women, who followed the armies and who would provide some of the ancillary services to the soldiers. These included, of course, food preparation and laundry but also care for the sick and wounded. These camp followers were legend and were still in existence at the time of the Civil War. However, this group was unable to provide all of the necessary care. Gradually this was recognized and armies started to provide for medical care. It is uncertain exactly when this began, but at some point physicians/surgeons began to accompany the armies.

Baron Dominique-Jean Larrey.
Courtesy of Musée du Louvre, portrait by Anne-Louis Girodet de Roussy-Trioson, 1804

The first known system for caring for the wounded in a timely fashion appears to have been organized by Dominique-Jean Larrey. Larrey was a surgeon in revolutionary France and became the surgeon in charge of the medical care for Napoleon’s Imperial Guard in the early 1800s. Larrey noticed that many men were being injured; and because there was no organized system for removing these men from the battlefield until the fighting was done, many men were dying from wounds that should have been treatable. Larrey reasoned that, if the men could get medical care early enough, many could be saved.  He organized a system of medical teams and wagons into mobile hospitals. The units would go onto the battlefield to treat the men, including performing any necessary surgical procedures. He called the units ambulance volante, or “flying ambulances.”

In France at that time, the word “ambulance” applied not only to the wagons that carried the wounded, but also to the mobile hospital itself–the teams of surgeons, assistants, and nurses who accompanied these wagons. Larrey sorted the casualties according to the severity of wounds, and gave first priority to the most seriously wounded as these would die first if not treated immediately.  Operations and amputations were done on the battlefield, even under fire.  He also stated that only the severity of the wound mattered, and he disregarded rank or prominence.  His ambulances subsequently removed the wounded to the hospitals. Larrey became well-known for his plan and was created a Baron by Napoleon because of his work.  On one occasion he was captured but was recognized and freed.  His work was also well known in Britain. Note that the term “triage” was not used at this time. Larrey’s system of handling casualties did not agree with what later became known as triage because his priorities were different.

A note about British military medicine at this time is also relevant. Michael Crumpler, in his book Men of Steel, describes the care of the wounded in the Napoleonic wars, and states that a sorting of casualties was done although not yet called triage. Details of the sorting are not clearly given.  He describes the medical care system consisting of aid stations, field hospitals and general hospitals. This system was soon forgotten in the peacetime years, as happens in many countries without large standing armies.

In 1846 British Naval Surgeon John Wilson approached casualty sorting differently, and with a different goal. Wilson argued that surgeons should focus on the patients who needed immediate treatment and for whom treatment was likely to be successful, deferring treatment of those whose wounds were less severe and those whose wounds were probably fatal with or without immediate intervention.

The next major war took place in Turkey and the Crimean part of Russia between the British, the French, and the Turks against the Russians in the mid-1850s. The French and the British had medical units and ambulances but no reported system of prioritization for handling casualties. While the French had an organized ambulance corps prior to the war, the British did not. The British used heavy wagons pulled by six-horse teams and used retirees as ambulance drives and stretcher-bearers. These men could not tolerate the hard physical labor involved. The lack of adequate roads and railroads, as well as poor harbor facilities, added to their problems.

The British system never worked well.  For the British, the main emphasis was on the regimental hospitals located near the battlefields. Handling of the wounded prior to arrival at the regimental hospitals is not discussed.  General hospitals did exist but initially they were several days’ journey from the battlefields and transport was slow and disordered. Later in the war, general hospitals were established in the Crimea but medical evacuation was still very poor. In either case evacuation home to England was a long slow journey.  Florence Nightingale’s involvement was with the sanitary conditions in the general hospitals, primarily in Turkey; but her ideas did later influence hospitals in the Crimea as well.  There is no evidence that she was involved with the regimental hospitals.

Surprisingly the next chapter involves the Russians. The great Russian surgeon, Nikolai Pirogov, came to the Crimea and, with the help of Grand Duchess Helena Pavlovna, he established hospitals and developed a system of sorting battle casualties. He divided the casualties into four groups in order of care priority. The mortally wounded were assigned to the care of the Sisters of Mercy. The seriously wounded who required urgent surgery received it at the emergency dressing station. The less seriously wounded were transferred for surgery the next day. Those who had minor wounds were treated and returned to their units. Pirogov would not have used the word “triage” for this sorting of casualties because of the language he spoke, but it was triage.  Hospitals were established and nursing care was under the care of the Sisters of Mercy, a nursing order started by Grand Duchess Helena Pavlovna.

Although we use the term “triage” to apply to battle wounded and usually date it from the Civil War, there is no evidence that the term was ever used during that war.  The term is in none of the many surgical manuals of the time or in the Medical and Surgical History of the War of the Rebellion. None of the many published letters and diaries of surgeons and nurses from the Civil War ever used the word. But although the term “triage” is not used, there was clearly some sorting being done. At the First Battle of Bull Run, Union Surgeon C.C. Gray stated “We were obliged to select some for immediate removal as it seemed possible to save them by treatment and shelter.” Union Assistant Surgeon John H. Brinton, serving in the west at Fort Henry and Fort Donelson in early 1862, described some sorting of the wounded while under fire, with the less gravely wounded being removed to the rear. Cornelia Hancock states at Gettysburg that the surgeons left behind “began the paralyzing task of sorting the dead and dying from those whose lives might be saved.”

Confederate Surgeon J. J. Chisolm discussed the role of the surgeon, stating that all of the wounded must undergo a thorough exam. Chisolm also described the duties of the assistant surgeon on the battlefield stating that he must look at all wounds, do hasty dressings, and place men on the litter, but not do surgery. He further stated that at the field hospital the wounded were not treated in the order in which they arrive but that the more severely wounded would always receive the earliest attention.

The term “triage” is derived from the French word “trier” meaning “to sort” and was initially used for sorting food products such as coffee. Its first known medical use was in World War I, when the French used it to apply to the sorting of casualties. It was rapidly adopted by the British who assumed only three levels of classification: minimally wounded; seriously wounded but treatable; and mortally wounded.  Triage stayed in the international medical lexicon and is still widely used.

Because it is popularly believed that triage had its origin in the Civil War, it is necessary to look at the developments in handling casualties in that war. At the outset of the war, no system of medical evacuation existed and no ambulance corps or effective use of ambulances was present. With the disarray in casualty handling at the First Battle of Bull Run, it became obvious to many that a system had to be devised. As recently as 1859, the Union Army had had no ambulances. The war began with a mix of two-wheeled and four-wheeled ambulances, predominated by the two-wheeled variety. These would prove inadequate for the terrain and the number of casualties. Even worse, the ambulance drivers were not only untrained, they were not in the army but were civilian workers responsible to the Quartermaster Corps.

The hospital system that existed was still that of the pre-war army, with the major focus on the regimental hospitals. The first line of care was at the regimental level, and the sick and wounded that could not readily be returned to battle were sent to the regimental hospital. They remained there as long as possible, hoping for recovery and a return to duty. Those that could not be adequately treated at this level were ultimately sent to the general hospitals.

Union Surgeon Charles Tripler
Courtesy of the National Library of Medicine

Efforts were made beginning in the summer of 1861 to create an ambulance corps with personnel, wagons, and horses under the direct control of the Medical Department. Union Surgeon Charles Tripler made such a recommendation soon after becoming Medical Director for the newly formed Army of the Potomac. Surgeon General Clement Finley rejected this proposal, as did the higher military staff and the Secretary of War. Such a proposal was also made early by the newly-formed United States Sanitary Commission.  This later proposal also went nowhere.  Tripler did try to institute an ambulance corps by directing the brigade surgeons to muster the regimental musicians and the delegated surgeons’ helpers for weekly instruction in proper handling of ambulances and stretchers.

Another early source agitating for the creation of an ambulance corps was the Boston surgeon, Henry Bowditch, whose son had suffered from lack of care at the First Battle of Bull Run. Tripler also began record keeping within the regiments regarding the sick, the wounded, and their treatment and disposition. Only prearranged transfers were allowed. He directed that the newly created brigade surgeons give regular help and instruction to the regimental surgeons.   Unfortunately Tripler received little support from Surgeon General Finley in any of his efforts.  Tripler had great difficulty obtaining supplies, tents, blankets, and, of course, ambulances. This was, in part, because adequate numbers of these items did not exist and the Quartermaster Corps gave precedence to “war materials.” The Quartermaster Corps did not consider medical supplies and ambulances high-priority items. When the spring offensive began in 1862, only a small percentage of the requested, required, ambulances and supplies were available.

The appointment of William Hammond as Surgeon General in April 1862 helped Tripler to some extent. The problems with the Quartermaster Corps persisted; and, in spite of repeated requisitions for more ambulances, the ambulance shortage was still acute at the time of Tripler’s resignation in June of 1862. It did not begin to improve until after the arrival of his replacement, Jonathan Letterman. In August 1862, Letterman attempted to solve the ambulance problem by creating, within the Army of the Potomac, an ambulance corps with officers, men, ambulances and horses all under the control of the Medical Department. This proposal was sent to the Surgeon General, who endorsed the system; but the proposal was again rejected by the senior army staff and therefore by the Secretary of War. Nevertheless, Letterman persisted and obtained approval from the Commander of the Army of the Potomac, Major General George McClellan, who happened to be a friend of his. McClellan may well have been receptive to this idea because he had been one of the official observes the Army had sent to the Crimean War, and would have seen the problems caused by the lack of coordinated care.

Letterman’s system was instituted within the Army of the Potomac but this army was soon fragmented when many of the units were sent to General Pope and McClellan’s command was lessened. It would be re-instituted in September when the entire Army of the Potomac was returned to the command of McClellan, on the way to the battles of South Mountain and Antietam. Many of the units in the new army had never been trained in the system, so it was only partially effective in these battles.

Evacuating the Wounded at Antietam, Courtesy of the LOC

In October 1862, Letterman, with approval from the Surgeon General and the army commander, re-organized medical care, thus creating a medical evacuation system. Medical care would start with an assistant surgeon and attendant at the edge of the battle who provided the first level of care. Those lightly wounded were sent back to battle and those who could benefit from medical care were sent to the field hospitals located beyond cannon range where urgent care would be given. Most amputations took place in these field hospitals. Patients would then be sent to brigade hospitals, then on to general hospitals for recuperation and further care.  Gradually such systems evolved or were adapted in other armies and gradually what would become known as “the Letterman Plan” developed.  Even though most armies had developed similar evacuation systems, these did not become official until February 1864.

In World War I, the approach to handling casualties changed again, with the emphasis on helping the largest number of people. It was stated that a single case, even if it urgently required attention, should wait if it would absorb a good deal of time. In the same time frame a dozen others might be treated. The greatest good for the greatest number of people was the rule. Many supported giving treatment to the less severely injured so that more soldiers could return to duty. It was during this time that the French first applied the term “triage” to the sorting of casualties.

Today the term “triage” is routinely applied to both military and civilian disasters. The term should only be used when true mass casualties occur, where the number of casualties is expected to exceed the care facilities available in the area. This is much more likely to occur in a military situation, although several recent weather-related catastrophes have shown the need for such a system as care facilities are damaged and reduced. Medical triage is not needed when there is no shortage of medical care facilities or when no medical care facilities existed at the start. A health care worker evaluates each patient’s medical needs and specific recommendations are made in each instance. The sorting of casualties according to a predetermined scheme, applied throughout all echelons of the system, is essential to its successful operation. The triage officer uses an established plan with specific criteria. Triage planning has already decided the conditions to use based on resources available and such planning, of necessity, involves a certain degree of health care rationing.

Sources

Adams G.W. Doctors in Blue: The Medical History of the Union Army in the Civil War. Baton Rouge, LA: Louisiana State University Press; 1952.

Barnes J., editor. The Medical and Surgical Reports of the War of the Rebellion. Appendix to Part I, Containing Reports of Medical Directors, and Other Documents. Washington DC: Government Printing Office; 1870.

Bernard C., Huette C. Illustrative Manual of Operative Surgery and Surgical Anatomy. New York, NY: Bailliere; 1861.

Blagg C. Triage: Napoleon to the Present Day. J. Nephrology 2004;17:629-32.

Bollet A.J. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press, Ltd.; 2002.

Brinton J.H. Personal Memoirs of John H. Brinton, Civil War Surgeon, 1861-1865. Carbondale, IL: Southern Illinois University Press; 1996.

Chisolm J.J. A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army. Columbia, SC: Evans & Cogswell; 1864.

Crumpler M. Men of Steel: Surgery in the Napoleonic Wars. Shrewsbury, UK: Quillen Press; 2007.

Cunningham H.H. Doctors in Gray: The Confederate Medical Service. Baton Rouge, LA: Louisiana State University Press; 1960.

Cunningham H.H. Field Medical Services at the Battles of Manassas. Athens, GA: University of Georgia Press; 1968.

Duncan L.C. The Medical Department of the United States Army in the Civil War. Gaithersburg, MD: Olde Soldiers Books, Inc.; 1903.

Fromento Jr., F. Notes and Observations on Army Surgery. New Orleans, LA: L. E. Marchand; 1863.

Gillett M. The Army Medical Department 1818-1865. Washington, DC: Center of Military History, United States Army; 1987.

Grace W. The Army Surgeon’s Manual. New York, NY: Bailliere Brothers; 1864.

Greenleaf C.R. A Manual for the Medical Officers of the United States Army. Philadelphia, PA: Lippincott; 1864.

Gross S.D. A Manual of Military Surgery. Philadelphia, PA: Lippincott; 1861.

Hamilton F.H. A Practical Treatise on Fractures and Dislocations. Philadelphia, PA; 1860.

Hamilton F.H. A Practical Treatise on Military Surgery. New York, NY: Bailliere; 1861.

Hammond W.A. A Treatise on Hygiene. Philadelphia, PA: Lippincott; 1863.

Iserson K.V, Moskop J.C. Triage in Medicine. Part I: Concept, History, and Types. Ann Emerg Med 2007;49(3):275-81.

Jacquette H.S., editor. Letters of a Civil War Nurse: Cornelia Hancock, 1863-1865. Lincoln, NE: University of Nebraska Press; 1998.

Letterman J. Medical Recollections of the Army of the Potomac. New York, NY: D. Appleton & Co; 1866.

Llewellyn C. Triage: In Austere Environments and Echeloned Medical Systems. World J. Surg 1992;16:904-09.

Mayer H.A. Belonging to the Army: Camp Followers and Community during the American Revolution. Columbia, SC: University of South Carolina Press; 1996.

McCaw J.B., editor. Confederate States Medical and Surgical Journal. Richmond, VA: Confederate States of America; 1864-1865.

Mitchell S.W., Morehouse G.R., Keen W.W. Gunshot Wounds and Other Injuries of Nerves. Philadelphia, PA: Lippincott; 1864.

Moore S.P. A Manual of Military Surgery Prepared for the Use of the Confederate States Army. Richmond, VA: Ayres & Wade; 1863.

Moskop J.C, Iserson K.V. Triage in Medicine. Part II: Underlying Values and Principals. Ann Emerg Med 2007;49(3):282-87.

Pearce R. Historical Developments in Casualty Evacuation. Aust Mil Med 2005;14(2):54-57.

Robinson J., editor. Mary Seacole: The Charismatic Black Nurse Who Became a Heroine of the Crimea. London, UK: Constable.; 2004.

Rutkow I.M. Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine. New York, NY: Random House; 2005.

Shepherd J. The Crimean Doctors: A History of the British Medical Services in the Crimean War. Liverpool, UK: Liverpool University Press; 1991.

Smith S. Hand-Book of Surgical Operations. New York, NY: Bailliere; 1862.

About the Author

Dr. Robert G. Slawson is a 1962 graduate of the University of Iowa School of Medicine. He spent eight years as a medical officer in the United States Army and had training in Radiology and Radiation Oncology, ultimately serving as Director of Radiation Oncology at Walter Reed General Hospital. In 1971 he joined the faculty of the University of Maryland School of Medicine in Baltimore, MD, where he remained until his retirement in 1998; although he still has a part-time faculty position. He is currently a Master Docent at the NMCWM in Frederick, MD. Dr. Slawson also is actively involved in researching new topics on Civil War medicine and life in the nineteenth century. He has presented and published on several topics both for the Museum and for articles in other publications. He has written a book called Prologue to Change: African American Physicians in the Civil War Era. Dr. Slawson is a member of the NMCWM and the Society of Civil War Surgeons.