Playing Catch-Up: Jonathan Letterman and the Triage System

"Dr. Jonathan Letterman (1824-72)," Wikimedia Commons.
“Dr. Jonathan Letterman (1824-72),” Wikimedia Commons.

By Bryan Caswell ’15

Gettysburg has more than its fair share of heroes. While the overwhelming majority of these larger-than-life figures was intimately acquainted with the conduct of the Battle of Gettysburg, a few stand apart from tales of martial valor. The most famous, of course, is Abraham Lincoln, yet he is not the only man associated with the aftermath of Gettysburg. In the immediate aftermath of the battle, provisions for the care of the wounded and dying left behind by both armies were organized by Major Jonathan Letterman, Medical Director of the Army of the Potomac. Known today as the ‘Father of Battlefield Medicine,’ Letterman has been hailed by historians of the American Civil War as a great medical and surgical innovator, revolutionizing methods of efficient care for wounded soldiers in the field and inventing what has become known as the triage system for prioritizing wound treatment. I’ve been party to numerous tours and talks that have recognized and hailed Letterman for these landmark accomplishments. There is simply one problem with this widespread notion, however: it is, in fact, incorrect.

As the traditional accounts go, the medical and surgical practices of the Union Army were woefully inadequate during the first year of the American Civil War. Observing many problems with the organization of hospitals throughout the army, but particularly at the regimental level, Letterman introduced a system of swift-response hospital wagons that assisted in the rapid removal of casualties from the field of battle. Letterman further devised a system to maximize the lifesaving effects of wound treatment by stipulating that, rather than being treated on a first-come-first-serve basis, those soldiers who could survive with immediate attention were given priority over those with mortal and minor injuries. This system of treatment priority is what is now known as triage, though it would not gain that name until the First World War.

The attribution of these advancements to Letterman ignores the development of battlefield treatment in Europe during the seventeenth, eighteenth, and nineteenth centuries. A system of large, fixed hospitals coupled with small, rapid-response ‘flying’ hospitals was instituted in the English Army as early as 1690, becoming well-used in the wars of Revolutionary and Napoleonic France as well as during the Siege of Sevastopol in the Crimean War (1853-1856). Triage itself has been traced back to the armies of Napoleon and the efforts of the chief surgeon of the Imperial Guard, Baron Dominique-Jean Larrey. Larrey devised a system for treating and evacuating those wounded who required the most urgent attention, performing hundreds of amputations during battle. In 1846, British Naval surgeon John Wilson further refined ideas of treatment prioritization, arguing that surgeons should focus their efforts on men who required immediate care and for whom such efforts would be the most successful. This led to the British policy in the Crimea and elsewhere to proceed with amputations as quickly as possible rather than waiting until stricken soldiers arrived at a fixed hospital behind the lines.

Jonathan Letterman must, then, be placed into this context of European medical and surgical innovation. Union surgeons, doctors, and armies of 1861 were not only horribly ill-equipped to deal with the carnage that would come in the following four years of war, but were also significantly less advanced than the professional armies of Europe. In order to remedy these deficiencies, Letterman introduced pre-existing systems of battlefield surgery and triage rather than inventing them himself. This is not to diminish Letterman’s accomplishments. A consummate organizer, Letterman made great strides in streamlining the practical application of flying ambulances and battlefield surgery. A revised narrative is essential, however, to give due credit to the true innovators of such revolutionary reforms in the treatment of fallen soldiers.


Sources:

Iserson, Kenneth V. and John C. Moskop. “Triage in Medicine, Part I: Concept, History, and Types.” Annals of Emergency Medicine 49, No. 3 (2007): 275-281.

Letterman, Jonathan. Medical Recollections of the Army of the Potomac. New York: D. Appleton and Company, 1866.

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

 

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