Civil War surgeon Army Maj. Jonathan Letterman built blueprint to save the wounded

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Prior to the Civil War, evacuating those wounded in battle was limited — there was an organized method, but most U.S. Army units did not have a standardized way to implement the system sufficiently.

Yet the lifesaving innovations of Army Maj. Jonathan Letterman revolutionized medical evacuation. Known as the “father of battlefield medicine,” Letterman devised an intricate system of casualty evacuation and aid stations to bring the wounded from the battlefield into care.

His visionary leadership in military medicine endured through multiple iterations of a hospital that took his name in 1911 as the Letterman General Hospital.

Laying the groundwork of medevac

A Pennsylvania native, Letterman graduated from Jefferson Medical College in 1849.

His military medical career began at the outset of the Civil War. Already an assistant surgeon in the Army Medical Department, he was promoted to major and named medical director of the Army of the Potomac, according to historical accounts.

Letterman’s wartime experiences drove him to overhaul military casualty care. He refined medical transport into the "Letterman System" — a tiered network of medical stations stretching from the front lines to safety miles away.

According to U.S. Army historical writing, under Letterman’s direction, various methods of existing casualty care were organized into a teachable system — with the introduction of field hospitals to move the wounded out of harm’s way and into treatment as fast as possible.

Letterman emphasized the practice of:

• Assigning each regiment two surgeons and two assistants
• Designating men to carry stretchers
• Establishing a system of battlefield ambulances, drawn by men or animals, to extract the wounded from the fighting
• Bringing the wounded to a triage center for evaluation and treatment based on the severity of their injuries
• Delivering them to a field hospital, where casualties could receive further treatment at a safe distance from artillery

Then the Army of the Potomac convened at the Battle of Antietam Sept. 17, 1862, supported by Letterman’s medical evacuation system and the newly established ambulance corps, both ordered by Army Maj. Gen. George McClellan the month prior, according to U.S. Army sources.

About the battle — which stands as the bloodiest single day in American wars, with more than 22,000 killed, wounded or missing in 12 hours of combat — Letterman wrote, “It gives me great pleasure to state that the wounded had every care bestowed upon them — that they were willingly, promptly, and efficiently attended — and I cannot refrain from mentioning here the untiring devotion shown to the wounded of that day.”

After news of the system’s efficacy and value at the Battle of Fredericksburg reached Gen. Ulysses S. Grant, he established an ambulance corps in the Army of Tennessee.

Dr. Dale Smith, a foremost expert in military medicine history and professor emeritus at the Uniformed Services University, recounted Letterman’s actions: “Letterman said, ‘We need control of the placement of hospitals above the regiment …I need control of the ambulance corps … I need control of supplies … I need reports,’” explained Smith on an MHS Military Medicine 250 video podcast. “Letterman realized he needed a second level of evacuation to move people from the forward hospitals that were backing up the regimental hospitals, corps and division hospitals, back to Washington and Philadelphia.”

With Letterman’s methods fully implemented at the Battle of Gettysburg, the whole of the Union Army ultimately adopted the plan in 1864.

At Gettysburg, Letterman created a central hospital facility, and 800 men moved through the tiers of care each day. Medical staff eventually loaded them into specially fitted railway hospital cars to be dispersed from field hospitals to larger, permanent general hospitals. This updated, more organized system of casualty evacuation marked a significant innovation in American military medicine.

“He has a system — it’s a system that picks people up from where they're wounded and takes them to the regimental hospital,” Smith said.

Letterman also understood the power of a second opinion, Smith added. “He looked at the records of the battles of Shiloh and Antietam — where we were criticized for doing too many amputations. He assigns particular surgeons to do surgery, and says patients have to be checked by a second doctor before an amputation.”

Letterman retired in San Francisco, writing about the history of medical care during the American Civil War in his memoirs, “Medical Recollections of the Army of the Potomac.” He died in 1872 and was buried in Arlington National Cemetery.

Honoring Letterman through high-quality wartime care

A hospital at the Presidio in San Francisco, California, was established by 1898 and was instrumental during the Spanish-American War, as service members departed for and returned from the Philippines. Fitted with cutting-edge technology of the time, staff had use of an intercom telephone system and early versions of X-ray equipment, according to the National Park Service.

In 1901, the hospital led workforce innovations by becoming the first U.S. Army general hospital to employ women of the Army Nurse Corps, according to the NPS. Contributions to tropical disease research and pivotal work in orthopedics placed the hospital on the world stage. The hospital shifted from operating solely as a military hospital and began treating civilians in the wake of the 1906 San Francisco earthquake and fire.

It was named the Letterman General Hospital in 1911 and was of unparalleled importance for wounded, ill, and injured service members in the Pacific theater. The NPS cited at the peak of World War II in 1945, the hospital treated more than 73,000 patients.

According to the NPS, the U.S. Army renovated the time-worn hospital in 1969, coinciding with military operations in Vietnam. The new 10-story facility had 550 beds and was renamed the Letterman Army Medical Center, and treated warfighters wounded in Vietnam for the duration of the conflict. The hospital also trained 25% of the U.S. Army’s medical specialists at that time.

For the final two decades until its deactivation in 1995, the hospital remained at the forefront of pioneering medical developments in artificial blood, laser physics, and trauma care.

The site of the hospital is in the care of the NPS and stands as a monument to Letterman’s decades of medical leadership and his invaluable impact on battlefield care. _______________________

For more on the legacy of remarkable medical heroes and significant medical advances that have kept America’s warriors fit to fight, listen to the Military Medicine 250 video podcast.

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