C
o m m e n ta r y
MILITARY MEDICINE, 180, 3:259, 2015
T h e S tra te g ic G en iu s o f J o n a th a n L e tte rm a n : T h e R e le v a n c y o f th e A m e ric a n Civil W a r to C u rre n t H e a lth C a re P o licy M a k e rs COL Ronald J. Place, MC USA
ABSTRACT With expanding health insurance coverage, innovative technologies, improved diagnostic acumen, and pharmaceutical additions combining to increase life expectancy, quality of life, and concomitant costs, the American health care system is under significant stress. However, it pales in comparison to the challenges faced by health care leaders during the American Civil War. As we approach the 150th anniversary of the conclusion of that war, it is appropriate to review key strategic health care decisions faced by military leaders during the Civil War and how their resultant outcomes may provide an appropriate perspective for today’s leaders.
AMERICAN HEALTH CARE CIRCA 1860 To effectively evaluate the strategic health care decisions of the American Civil War, it is imperative to consider the context of the 1860s for the organization of the Union Army, along with the overall American and military health care systems. The Army operates in terms of the regiment: regi mental personnel, regimental supplies, regimental fighting, regimental ambulances, and regimental hospitals.1(pl44) In many cases, regimental surgeons, like the colonel command ing the regiment, are appointed based upon political favorit ism and not necessarily on qualifications.2^ 8' Likewise, the unit’s morale is often a reflection of the community they represent, and civilian support of the war is linked to the health and wellness of “their” regiment. Physician training in America is changing with the first true Medical School opening in the 1820s, but most are trained as apprentices. Medical School matriculation requires only an ability to pay the tuition and does not include any measure of intellect or morality. Students earn a bachelor’s degree in 1 year and Medical Doctor in 2 years. Medical course-work is nonstandardized and does not include clinical examinations or surgical observation; a fact that would not change until the start of the next century. There are no state licenses, standardized examinations, or board certifications. Germ and microbe theory is essentially unknown with surgical care being primitive and unsanitary. Anesthesia is in its infancy with the first surgical case utilizing ether as an anes thetic occurring in 1846.3 Hospital use is uncommon and the overwhelming majority of people receive care in their
Office of the Surgeon General, 800 Army Pentagon, Room 3E585, Washington, DC 20310-0800. doi: 10.7205/MILMED-D-14-00419
MILITARY MEDICINE, Vol. 180, March 2015
home. Phannaceuticals are limited, generally local remedies, and compounded on-site with varied strengths and often unproven effectiveness. Public Health is in its infancy with the 1861 establishment of the U.S. Sanitary Commission, but especially absent in the military. Communicable diseases are rampant; the worst of which is smallpox, but malaria, typhus, typhoid fever, and gonorrhea are common. Ambulances or other evacuation sys tems are missing from the belligerents of the Civil War and almost every other army. Medicine as a discipline offers little to the sick and injured, whereas caring for them diverts per sonnel and supplies away from those fit to fight.
LETTERMAN BECOMES MEDICAL DIRECTOR Shortly after the outset of hostilities, Major General George McClellan assumes command of the Union Army of the Potomac in direct combat with the Confederate Army of Northern Virginia. By early July of 1862, the Army of the Potomac is in abysmal condition recovering from the Seven Days Battle as part of the Peninsular Campaign. A patchwork of regular Army soldiers supplemented with tens of thousands of new recruits, they fought poorly and the Army is riddled with sickness and wounds. Upon the advice of the new Army Surgeon General William Hammond, MG McClellan changes his unit Medical Director by replacing the indecisive and seemingly overwhelmed 56-year-old Colonel Charles Tripler with a dynamic 37-year-old Major named Jonathan Letterman. Hammond recommended Letterman as a new type of Medical Director “not quite so thickly incrusted with the habits, forms and traditions of the service.”4 Letterman discovers an Army of 103,000 troops with 29% listed as ill and no longer able to fight.Upl27) In truth, MG McClellan and his staff know that the sick lists, even as
259
Commentary long as they are, denote only a portion of the ill. Riddled with sickness, the Army of the Potomac is an ineffective fighting force. MG M cClellan’s order to Letterman; cultivate a strat egy to solve this problem and return his army to fighting strength. Letterm an’s initial and most important task was developing an understanding of the overarching problems, and doing so quickly. Showing the objectivity of his decision making, he later wrote that there, “ .. .is a popular delusion that the highest duties of medical officers are performed in prescribing a drug or amputating a limb. The true function is to strengthen the hand of the Commanding General by keeping his army in the most vigorous health, thus rendering it in the highest degree efficient for enduring fatigue and privation, and for fighting.”5(p9SM00> In essence, preserving the fighting strength by reducing infectious diseases is the first priority. Long before the concept of the “Golden Hour” in trauma care, Letterman concludes that the second unsolved problem is the inability to specifically direct soldiers to the appropriate sur geon and hospital. The process of transporting casualties is fraught with chaos, and the disorganized logistics system that is not supporting the surgical teams is the third problem. The fourth and final major challenge identified by Letterman is the quality of care at the treatment area; whether it be an aid station, during operative procedures, or care within hospitals. After considering the means at his disposal, Letterman determines that to be successful, he must radically alter the performance of battlefield medicine. Constrained by limits in specialized personnel, training, medical supplies, and authority, he organizes a multiphased and seemingly prioritized strategic plan. The initial thrust focuses on simple and easily imple mented initiatives that will be widely accepted by commanders and encourage them to “buy in” to his plan. He follows with the more complex reorganization and policy implementations.
IMPROVING SANITATION, THE FIRST TASK Understanding that this war may be prolonged, Letterman quickly issues specific personal and unit hygiene directives based upon vague Sanitary Commission recommendations. He compels troops to bathe weekly in a river for at least 15 minutes. Pits are dug for latrine usage and six inches of fresh earth thrown into them daily. When filled within two feet of the sur face, they are completely covered and replaced with a new pit. Similar trenches are directed for kitchen refuse. Animal dung is collected and buried two feet below ground or bum ed.1
o m m e n ta r y
MILITARY MEDICINE, 180, 3:259, 2015
T h e S tra te g ic G en iu s o f J o n a th a n L e tte rm a n : T h e R e le v a n c y o f th e A m e ric a n Civil W a r to C u rre n t H e a lth C a re P o licy M a k e rs COL Ronald J. Place, MC USA
ABSTRACT With expanding health insurance coverage, innovative technologies, improved diagnostic acumen, and pharmaceutical additions combining to increase life expectancy, quality of life, and concomitant costs, the American health care system is under significant stress. However, it pales in comparison to the challenges faced by health care leaders during the American Civil War. As we approach the 150th anniversary of the conclusion of that war, it is appropriate to review key strategic health care decisions faced by military leaders during the Civil War and how their resultant outcomes may provide an appropriate perspective for today’s leaders.
AMERICAN HEALTH CARE CIRCA 1860 To effectively evaluate the strategic health care decisions of the American Civil War, it is imperative to consider the context of the 1860s for the organization of the Union Army, along with the overall American and military health care systems. The Army operates in terms of the regiment: regi mental personnel, regimental supplies, regimental fighting, regimental ambulances, and regimental hospitals.1(pl44) In many cases, regimental surgeons, like the colonel command ing the regiment, are appointed based upon political favorit ism and not necessarily on qualifications.2^ 8' Likewise, the unit’s morale is often a reflection of the community they represent, and civilian support of the war is linked to the health and wellness of “their” regiment. Physician training in America is changing with the first true Medical School opening in the 1820s, but most are trained as apprentices. Medical School matriculation requires only an ability to pay the tuition and does not include any measure of intellect or morality. Students earn a bachelor’s degree in 1 year and Medical Doctor in 2 years. Medical course-work is nonstandardized and does not include clinical examinations or surgical observation; a fact that would not change until the start of the next century. There are no state licenses, standardized examinations, or board certifications. Germ and microbe theory is essentially unknown with surgical care being primitive and unsanitary. Anesthesia is in its infancy with the first surgical case utilizing ether as an anes thetic occurring in 1846.3 Hospital use is uncommon and the overwhelming majority of people receive care in their
Office of the Surgeon General, 800 Army Pentagon, Room 3E585, Washington, DC 20310-0800. doi: 10.7205/MILMED-D-14-00419
MILITARY MEDICINE, Vol. 180, March 2015
home. Phannaceuticals are limited, generally local remedies, and compounded on-site with varied strengths and often unproven effectiveness. Public Health is in its infancy with the 1861 establishment of the U.S. Sanitary Commission, but especially absent in the military. Communicable diseases are rampant; the worst of which is smallpox, but malaria, typhus, typhoid fever, and gonorrhea are common. Ambulances or other evacuation sys tems are missing from the belligerents of the Civil War and almost every other army. Medicine as a discipline offers little to the sick and injured, whereas caring for them diverts per sonnel and supplies away from those fit to fight.
LETTERMAN BECOMES MEDICAL DIRECTOR Shortly after the outset of hostilities, Major General George McClellan assumes command of the Union Army of the Potomac in direct combat with the Confederate Army of Northern Virginia. By early July of 1862, the Army of the Potomac is in abysmal condition recovering from the Seven Days Battle as part of the Peninsular Campaign. A patchwork of regular Army soldiers supplemented with tens of thousands of new recruits, they fought poorly and the Army is riddled with sickness and wounds. Upon the advice of the new Army Surgeon General William Hammond, MG McClellan changes his unit Medical Director by replacing the indecisive and seemingly overwhelmed 56-year-old Colonel Charles Tripler with a dynamic 37-year-old Major named Jonathan Letterman. Hammond recommended Letterman as a new type of Medical Director “not quite so thickly incrusted with the habits, forms and traditions of the service.”4 Letterman discovers an Army of 103,000 troops with 29% listed as ill and no longer able to fight.Upl27) In truth, MG McClellan and his staff know that the sick lists, even as
259
Commentary long as they are, denote only a portion of the ill. Riddled with sickness, the Army of the Potomac is an ineffective fighting force. MG M cClellan’s order to Letterman; cultivate a strat egy to solve this problem and return his army to fighting strength. Letterm an’s initial and most important task was developing an understanding of the overarching problems, and doing so quickly. Showing the objectivity of his decision making, he later wrote that there, “ .. .is a popular delusion that the highest duties of medical officers are performed in prescribing a drug or amputating a limb. The true function is to strengthen the hand of the Commanding General by keeping his army in the most vigorous health, thus rendering it in the highest degree efficient for enduring fatigue and privation, and for fighting.”5(p9SM00> In essence, preserving the fighting strength by reducing infectious diseases is the first priority. Long before the concept of the “Golden Hour” in trauma care, Letterman concludes that the second unsolved problem is the inability to specifically direct soldiers to the appropriate sur geon and hospital. The process of transporting casualties is fraught with chaos, and the disorganized logistics system that is not supporting the surgical teams is the third problem. The fourth and final major challenge identified by Letterman is the quality of care at the treatment area; whether it be an aid station, during operative procedures, or care within hospitals. After considering the means at his disposal, Letterman determines that to be successful, he must radically alter the performance of battlefield medicine. Constrained by limits in specialized personnel, training, medical supplies, and authority, he organizes a multiphased and seemingly prioritized strategic plan. The initial thrust focuses on simple and easily imple mented initiatives that will be widely accepted by commanders and encourage them to “buy in” to his plan. He follows with the more complex reorganization and policy implementations.
IMPROVING SANITATION, THE FIRST TASK Understanding that this war may be prolonged, Letterman quickly issues specific personal and unit hygiene directives based upon vague Sanitary Commission recommendations. He compels troops to bathe weekly in a river for at least 15 minutes. Pits are dug for latrine usage and six inches of fresh earth thrown into them daily. When filled within two feet of the sur face, they are completely covered and replaced with a new pit. Similar trenches are directed for kitchen refuse. Animal dung is collected and buried two feet below ground or bum ed.1
