Military medicine has received a lot of well-deserved attention in the wars launched since 9/11. More wounded troops than ever are surviving the battlefield, and there are many advances both there and back home that have made their lives easier.
But battlefield medicine is hardly a new story. One of its pioneers was Dr. Jonathan Letterman, a Union Civil War doctor who found himself the chief medical officer of the Army of the Potomac amid some of the conflict’s bloodiest battles. Military historian Scott McGaugh has just written Surgeon in Blue: Jonathan Letterman, The Civil War Doctor Who Pioneered Battlefield Care. He discussed this military-medicine miracle worker in a recent email exchange with Battleland:
Who was Jonathan Letterman?
Letterman was a small-town physician, the son of a prominent doctor in Canonsburg, Penn. Upon graduation in 1849, he enlisted in the Union Army.
He served as an Army outpost surgeon in the Everglades, Minnesota, eastern Arizona and New Mexico, responsible for the health of 100-200 soldiers.
In 1861 he was transferred to West Virginia and began working with William Hammond on ambulance and hospital designs. Hammond later became Surgeon General and then promoted Letterman to medical director of the Army of the Potomac.
How bad was military medicine at the start of the Civil War?
America’s military medical department has been unprepared for every major war in our country’s history.
At the Civil War’s outset, the Union Army had less than 100 doctors. The aged Surgeon General bragged about not spending his entire budget and considered medical texts for his surgeons unnecessary.
Physicians had almost no authority within the Army. There was no professional ambulance corps; and regimental surgeons were free to refuse treatment of wounded from other regiments. Deplorable camp hygiene and an army diet heavy on salted pork, weevil-filled biscuits, and a daily alcohol ration led to disease rates of 40%.
Disease was the army’s deadliest enemy.
At Bull Run in 1861, hundreds of wounded lay abandoned for days on the battlefield for lack of an ambulance corps, while the ambulatory wounded wandered the streets of Washington looking for a hospital bed.
Letterman was on hand for four major Civil War battles. Tell us a little about each.
— Antietam (Sept. 17, 1862): Letterman had been in medical command of the 100,000-man Army of the Potomac for less than two months. But within that time he created the first professional ambulance service and battlefield evacuation plan.
Derelict soldiers and Army musicians no longer were stretcher bearers. He created a corps of professional and trained ambulance crews; established a military-style chain of command and accountability.
As a result, his medical corps successfully evacuated nearly all of Antietam’s 10,000 casualties to field hospitals within 24 hours of a battle that had lasted less than a day and became the bloodiest day in American history.
— Fredericksburg (Dec. 11-15, 1862): By now Letterman had established military camp hygiene standards; a new hospital organization in which surgeons were appointed on merit instead of seniority; and had had instituted a “just in time” medical supply system that greatly reduced chronic shortages.
Fredericksburg became the first real test of what became known as “The Letterman System.” More than 9,000 casualties were promptly evacuated and treated in far more organized hospitals and many were efficiently placed on steamers bound for hospitals in the north.
Both disease incidence and battlefield fatality rates were now on the decline.
— Chancellorsville (April 30-May 6, 1863): The last component of the Letterman System now was in place: a new Army diet regimen that included detailed cooking instructions and holding commissary officers accountable for fresh food availability.
Disease rates declined by half, and far fewer soldiers were being shipped north (and lost permanently). The AOP’s medical corps now was directly contributing to the sustained fighting strength of the Army.
— Gettysburg July 1-3, 1863): Despite the AOP’s fourth commanding general in a year, the medical department now had grown in size and sophistication to meet what would become the unprecedented scale of Civil War destruction at Gettysburg.
Letterman commanded 650 physicians in 225 regiments, 1,000 ambulances, and established dozens of hospitals in a tiered treatment system he had created.
As a result, an average of more than 4,600 wounded soldiers on each of three days’ fighting were almost immediately care for by the close of each day’s battle.
At Gettysburg alone, Letterman was responsible for and successfully treated as many wounded soldiers and those who had been wounded in the Revolutionary War, War of 1812, and Mexican War combined.
By the end of Gettysburg, Letterman had become personally responsible for nearly 50,000 casualties and had revolutionized battlefield care. A year later, “The Letterman System” became federal law and mandatory in every Union Army.
What was his most important contribution?
Jonathan Letterman made battlefield survival possible by professionalizing combat medicine.
He made sure it was no longer an organizational afterthought, for which sickened and wounded soldiers paid with their lives.
He recognized an Army’s fighting strength and a more expeditious end to the war began with a healthy and well-fed Army; prompt battlefield evacuation; first-rate surgeons appointed on merit; recovery in the theater of operation; and unerring medical accountability.
He set combat medicine on a course that has seen wound fatality decline steadily to a point that less than 10% of wounded soldiers today die of their wounds (compared with 25% in World War II).
There are three things critical to every soldier and every army’s morale: good food, a reliable supply of ammunition, and the confidence he will be taken care of if he falls in battle. Jonathan Letterman pioneered new standards in two of those areas.
What made him a good doctor?
It may not be sexy, but it was his holistic organizational ability, grounded in the innate compassion of caring for the sick and bloodied.
Despite having only remote military outpost medical experience, he was able to identify and understand the medical needs of a 100,000-man Army, and prepare it for the bloodiest day in American history in less than two months.
He understood that an army’s diet, cooking standards, living quarters, medical personnel, and tiered trauma care were all inextricably linked. In the course of four major battles in less than one year, he blended the compassion of a small-town doctor with the acumen and the weltanschauung of an innovative leader.
Why should today’s soldiers care?
Jonathan Letterman set combat medicine on a path leading to contemporary combat, where disability has replaced death as the signature image of the battlefield.
He professionalized battlefield medicine by creating independent authority, instilling accountability, and requiring specialized training.
While he did not invent triage, he institutionalized tiered and specialized trauma care that is the basis of both battlefield care and our 911 system today. As a direct result, combat survival has never been greater, even as weaponry has become almost incalculably more lethal.
While there are several factors for this new reality, it was Jonathan Letterman who laid the foundation of combat survival and who deservingly became known as “the father of battlefield medicine.”