FALLS CHURCH, Va.- During the second week of December in 1862, the Battle of Fredericksburg raged halfway between Washington and Richmond. Although the Union suffered 12,000 casualties, the battle was significant for Army Medicine, not because of the battle's outcome on the Civil War, but because it was the first test of Maj. Jonathan Letterman's insightful organization of battlefield medicine to rapidly evacuate and care for the wounded. Letterman also was an early promoter of readiness by improving health and wellness of the Union troops.

In 1862, the Army of the Potomac was ragged in terms of health and fitness. Regular Army soldiers and tens of thousands of new recruits were cobbled together into fighting units that were proving to be ineffective. One key reason for lack of effectiveness was illness and wounds. Maj. Gen. George McClellan replaced his Medical Director in July with Maj. Jonathan Letterman on the recommendation of the William Hammond, the Surgeon General.

Letterman found the Army of the Potomac had more than 100,000 men and nearly 30 percent were not able to fight. McClellan orders Letterman to solve this problem of inability to fight because of sickness and wounds. Letterman's rapidly developed an understanding of the problems and later wrote that it was critical to support commanding generals by keeping the Army healthy, resilient, and in the fight.

First, Letterman attacked the problem of poor sanitation that was compounding the severity of illness.

Letterman ordered changes to personal and unit hygiene. He required troops to bathe weekly in a river for at least 15 minutes. Pits were to be dug for latrines and six inches of fresh earth thrown into them each day. When filled within two feet of the surface, they were to be completely covered, and a new pit dug. A similar approach is used for kitchen and animal waste.

Letterman second problem was battlefield organization and logistics of moving wounded soldiers. To relieve physicians of their burden of assessing wounded soldiers on the battlefield and also moving them to regimental hospitals, Letterman makes the physician's sole responsibility to provide clinical care in treatment areas.

At the time, no wagons dedicated to transport the wounded existed; most wagons had multiple functions and were used by both the Quartermaster Corps and the Medical Department. Until the summer of 1862, quartermasters had the primary responsibility to transport the injured.

Ambulances with dedicated personnel, including stretcher bearers, were needed, so Letterman established the Ambulance Corps. He procured wagons to support the frontline units. To build esprit de corps and make the Ambulance Corps easily recognized, Letterman ordered distinctive changes to the uniform caps and chevrons.

Letterman moved on to his third issue: medical supply logistics. To ensure supplies got to where they were needed and not lost when brought too far forward, Letterman ordered changes in the medical supply system in Oct. 1862. His plan makes the brigade surgeon responsible for distribution and accountability. Letterman even created a standardized stocking system for the hospital wagons and ambulances for dressings, medical instruments, and medications. Regimental Surgeons are furnished with stocked medicine chests to be carried on horseback; enlisted orderlies are issued the equivalent of a modern day aid bag.

Finally, Letterman focuses the organization of field hospitals at the division level. In this plan, one physician from each regiment established an aid station near the front; the remainder gathered at the division field hospital.

Letterman ordered that surgical procedures be performed by three dedicated physicians per division; those physicians needed the greatest surgical experience and proven competence. Any physician who wanted to perform surgery was expected to have technical expertise required for the title of Operating Surgeon. For the first time, specialized surgical skills are required for recognition of proficiency. Letterman builds the first medical Quality Assurance service into his plan to improve care for the wounded. One medical officer in every field hospital is ordered to keep detailed records on every patient brought to the hospital.

Letterman's reorganization goes into full effect at the Battle of Fredericksburg during the second week of Dec. 1862. The Army of Potomac had more than 12,000 casualties, but Letterman's system quickly evacuated and treated them. Likely, the casualty count would have been higher.

The battle on Dec. 13 with its high number of casualties was the first test of Letterman's strategy for battlefield evacuation and medical care. It worked well, and the basic organization plan for medical logistics and evacuating the wounded designed by Letterman is still in effect to this day.

Many key tenants of Army Medicine today can be traced to Jonathan Letterman, one of the great leaders and visionaries of Army Medicine.

We place the most skilled surgeons at the Forward Surgical Team. The idea of treating wounded soldiers near the fight so they can return to their units as soon as possible keeps platoons and companies closer to full strength. We evacuate the more seriously wounded to the nearest military medical center with all speed and have multiple echelons of medical care. We are masters of medical logistics and supply. Promoting resilience of Soldiers by encouraging a proper diet, good sleep habits, and fitness support Army readiness.

The origins of these concepts and practices date to 1862 when Jonathan Letterman was appointed Medical Director of the Army of the Potomac by George McClelland. Letterman is one of the great minds of Army Medicine history, and his practices and policies are still widely used today.
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Source: Place, R.J. The Strategic Genius of Jonathan Letterman: The Relevancy of the American Civil War to Current Health Care Policy Makers. Military Medicine, 180(3), 259-262, 2015.