Widely publicized filthy military camp conditions and chronic army malnutrition in the first year of the war were ample evidence in support of Letterman’s initiatives. Union troops were chronically underequipped and often hungry or thirsty. A soldier counted himself lucky if he owned a tin dipper, plate, knife, fork, and spoon. Few men washed utensils and plates after a meal, other than with a swipe of a piece of bread or clump of straw. When on the march, a soldier’s daily ration consisted of sixteen ounces of hard bread, twenty ounces of fresh meat (or twelve ounces of salt pork), plus sugar, coffee, and salt. When in camp, the meat ration remained the same, plus a prorated share per 100 men of beans, rice, coffee, tea, sugar, salt, pepper, and, when available, potatoes.10
Hardtack and meat of varying quality were a soldier’s staples. Neither was particularly nutritious. Soldiers considered hardtack biscuits too hard to chew and nearly inedible. Porous hardtack boxes stored outside at supply depots leaked rainwater, turning soldiers’ food moldy. Maggots and weevils commonly riddled the biscuits. Insects’ webs covered some biscuits and disappeared when soldiers crumbled biscuits into their coffee to serve as a breakfast or supper. Some added hardtack to thicken soups, fried the crumbs in fat (called “skillygalee”), or toasted hardtack over a fire. It was often eaten with salt pork, the most common meat available. Boiled or fried, salt pork sandwiched between two pieces of hardtack made a quick meal that could be eaten on the march.11
Most soldiers derided army-issued dried vegetables. A concoction of dried carrots, turnips, beans, onions, and sometimes roots, twigs and pebbles were molded into square cakes about one inch thick. Thorough boiling rendered them borderline edible but void of most vitamins. Letterman, however, considered them useful if used as a soup base.
“The desiccated vegetables should be steeped in water for two hours and boiled with the soup for three hours . . . and a half ration of desiccated vegetables previously soaked in cold water for an hour, with a few small pieces of pork, adding salt and pepper, with water sufficient to cover well the ingredients, and stewed slowly for three hours, will make an excellent dish. . . . The secret in using the desiccated vegetables is in having them thoroughly cooked. The want of this has given rise to a prejudice against them which is unfounded; it is the fault of the cooking, and not of the vegetables,” he wrote.12
Hospital patients were at the mercy of sporadically available medical supplies and unappetizing food. They couldn’t forage in the countryside for fresh meat and produce as healthy soldiers did. Nor could they buy food from the sutlers, private merchants who followed the paymasters when they visited armies on payday. At a pay rate of about $13 monthly, soldiers were hard-pressed to pay the going rates of fifty cents for a pound of cheese, seventy-five cents for a can of condensed milk or a dollar for a pound of butter.13
Consequently, patients cherished donations from private relief societies, which typically spiked following newspaper reports of horrific battle casualties. Soldiers prized lemon and blackberry syrup as flavor additives to a bland diet. Valuable sources of seasonal nutrition included pickles, onions, sauerkraut, potatoes, horseradish, and cabbage.
Soldiers slept where they could on the march and built primitive huts when establishing semi-permanent winter quarters. Six or eight men often shared a single hut, hollowed out of the ground with short side walls made of logs or hardtack boxes. Beds were little more than pine saplings or grain sacks on the ground. A few boxes at the head of the hut contained soldiers’ personal belongings. Sometimes soldiers built a makeshift fireplace, but that often resulted in huts burning to the ground. Men endured the long winters at night in the dim light of a candle stuck on the end of an upright bayonet or in a hollowed-out potato. Warm clothes and blankets were always in demand. In 1861, Sanitary Commission inspectors surveyed 200 regiments and found that one in four lacked one good blanket per man and 5 percent had no blankets at all.14
Impossibly cramped, damp, and poorly ventilated quarters spawned all manner of disease, infection, and infestation. Just as Letterman had experienced insect infestations in the poorly built military outposts of the West, the Army of the Potomac’s soldiers were plagued by similar misery. Lice proliferated by the millions in thousands of rarely washed uniforms. Adult lice thrived in the seams of uniforms and reproduced prolifically, and their larva began sucking soldiers’ blood almost immediately upon emerging. A soldier could pick dozens of lice off a single shirt. If a man couldn’t boil his clothing to kill the infestation, he suffered until he received a new uniform and then he burned his old clothes as soon as possible.15
Although Letterman had never been in medical command of an assemblage of men the size of the Army of the Potomac, he understood the measures necessary to protect the health of tens of thousands of soldiers living shoulder to shoulder for months at a time, exposed to the elements. General McClellan codified his camp sanitation recommendations in General Orders No. 50. The effect was immediate and profound. By August, the Army of the Potomac disease rate declined by one-third in Letterman’s first month of medical command.16
While military camp hygiene remained a priority, the early Civil War horrors on the battlefield also had made it clear that the army’s medical department had to reinvent itself to cope with thousands of wounded and possibly dying men after a few hours’ fighting. Advances in weaponry had outpaced both an army’s tactical battle plan and its medical department’s organization, neither of which had changed in more than half a century. The first year of the war had hardly done anything to change that.
Both generals and their medical directors were unprepared for the weaponry available at the start of the Civil War. For more than one hundred years military tactics had been built around the short-range, highly inaccurate musket. It was lethal to about fifty yards. It took a soldier nearly half a minute to reload as he bit open a paper cartridge, poured gunpowder down the barrel, tamped the paper cartridge down onto the powder, rammed a bullet onto the paper, inserted a firing cap above the trigger, cocked the weapon, aimed, and then fired.
As a result, commanders had crammed their troops together, shoulder to shoulder, often three rows deep. When the front row fired in unison, it dropped back to reload as the next row moved up to fire. Rigid ranks of attackers mounted frontal assaults against defensive lines similarly assembled in order to consolidate their limited firepower. It was effective when bullets flew only 100 yards. It became suicidal in the Civil War, when soldiers on both sides had rifles that were deadly at nearly 1,700 yards and reliably accurate to 250 yards.
The Civil War’s .58 caliber Springfield musket and .69 caliber Harpers Ferry rifle made condensed, frontal assaults obsolete. Both weapons had rifled barrels that greatly increased their accuracy by spinning the bullet as it left the barrel. Improved range and accuracy were matched by greater lethality inflicted by new ammunition, called the Minie ball. It had been invented near the end of the Mexican War, in 1848, by a French army captain. It was smaller than previous bullets, so the soldier could ram it into the bore faster. When fired, the half-inch hollow bullet expanded up against the rifling that spun it as it traveled through the barrel, producing greater range and accuracy. It also tended to yaw and then tumble as its speed decreased.
When the Minie ball slammed into a human body, often at an angle, it flattened and obliterated the surrounding tissue. It splintered bone and sent shock waves through the victim. It produced massive and complicated wounds never before seen by most doctors at the outset of the war. “One poor fellow . . . was wounded in four places, namely: in the neck, breast, shoulder, and right arm—all the wounds having been made by a single ball.”17 A volunteer doctor typically had limited general healthcare experience, and most military doctors like Letterman were more familiar with arrow wounds than gunshot injuries.
Artillery also produced far greater injuries than previously experienced. The U.S. military adopted a small, relatively portable piece of artillery, the “Napoleon,” four years prior to the outbreak of the Civ
il War. The smoothbore, muzzle-loading cannon fired a twelve-pound projectile that terrorized troops tightly positioned for either assault or defense. It functioned as a massive sawed-off shotgun. It fired canisters that exploded, freeing hundreds of small iron balls to tear through groups of men. An accurate artillery fusillade could vaporize a group of soldiers clustered together along the enemy line. Although its maximum range extended to nearly a mile, it was particularly lethal inside 250 yards, the typical spread of many Civil War fire exchanges.
Early in the war, outdated military tactics in the face of far more lethal weaponry produced horrific numbers of dead and wounded. Despite the unexpected casualty rates, taking care of the wounded remained a secondary priority for many generals. Winning the battle at hand took precedence. Some generals considered their army’s medical department little more than a nuisance, and assigned slackers and sick soldiers to care for the wounded. Several generals abandoned medical supplies in their rush to engage the enemy. Battlefield evacuation remained as haphazardly organized as it was left to circumstance.
The world’s armies had no organization for battlefield evacuation. Some had tried, such as the French, who in 1859 relied on military musicians as stretcher bearers. In America, the concept of corpsmen and medics didn’t exist. A soldier relied on his comrades to possibly drop their rifles and staunch his bleeding or push his intestines back into his lacerated abdomen. Frequently, a handful of soldiers who had no stomach for the fighting carried him off the battlefield, and then the rescuers somehow “got lost” on their return to the field of fire. On occasion, the regiment’s band members carried him away from the most intense fighting. More likely, he lay on the battlefield until the fighting had ended and then yelled for help as survivors searched the cratered and shredded landscape for the wounded. He couldn’t be sure if his rescuers would be from his army or the enemy. His survival typically depended on a pain-wracked return to friendly territory and a makeshift hospital in a barn, under a tree, in a cluster of tents, or perhaps a brutal ride in a suffocating boxcar, destined for an enemy prisoner-of-war camp.
Letterman knew the existing fragmented approach to battlefield care could no longer be tolerated in the face of thousands of casualties in a single day. An effective ambulance system could not remain the province of both the medical staff and the supply corps. “Medical officers and quartermasters had charge of (ambulances), and as a natural consequence little care was exercised over them and they could not be depended upon during an action or on the march. . . . It seemed to me necessary that whilst medical officers should not have the care of the horses, harness, etc., belonging to the ambulances, the system should be such as to enable them at all times to procure them with facility when wanted for the purposes for which they were designed, and to be kept under the general control of the medical department. Neither the kind nor the number of ambulances required were in the army at that time, but it nevertheless remained necessary to devise a system that would render as available as possible the material on the spot, particularly as the army might move at any time, and not wait for the arrival of such as had been asked for, only a portion of which ever came,” wrote Letterman.18
Within a few weeks after taking medical command, Letterman devised a coordinated and centralized approach that would redefine the realities of battlefield care under fire. In clear, direct language, Letterman forged a philosophy and organization for battlefield evacuation whose premise underlay many Letterman achievements: organization and accountability. On August 2, General McClellan issued General Orders No. 147, the latest in a series of orders stemming from the medical department and grounded in those principles.
The sixteen provisions of General Orders No. 147 became the foundation of battlefield evacuation as a subspecialty of the medical department, eliminating it as an afterthought among many line officers. For the first time an ambulance corps was created that carried the command and authority of the Army of the Potomac’s headquarters. Letterman now commanded a new ambulance structure that extended from army’s medical director down through divisions and to the regiment level. He consolidated authority of all ambulances by establishing a defined chain of command. A captain was designated as commander of all ambulances in each army corps. His new duties were clear. “He will pay special attention to the ambulances, horses, harness, etc., requiring daily inspections to be made by the commanders of the division ambulances, and reports thereof to be made to him by these officers. He will make a personal inspection once a week of all the ambulances, transport carts, horses, harness, etc., whether they have been used for any other purpose than the transportation of the sick and wounded and medical supplies, reports of which will be transmitted, through the Medical Director of the Army Corps, to the Medical Director of the Army every Sunday morning.”19
In addition, each division had a first lieutenant responsible for its ambulance service. A second lieutenant had similar duties at the brigade level, and each regiment had a sergeant in charge of ambulances. Each officer had a prescribed number of twohorse and four-horse ambulances and transport carts for which he was responsible. All were required to regularly inspect and report on the status of both equipment and the men assigned to the ambulance corps.
Chronic shortages and often the absence of ambulances on the day of battle would no longer be tolerated. Letterman attached ambulances to specific units and prohibited their use by non-medical officers. No longer could they be used at the whim and convenience of line officers. Ambulances were parked together when in camp and kept under supervision. Officers responsible for them had to remain with the ambulances in the army train when on the march to ward off unapproved use.
For the first time, each ambulance was staffed by two men and a driver. Fully trained soldiers would be assigned to ambulance duty, subject to approval by each ambulance corps commanding officer. Line officers could not transfer derelict soldiers to ambulance duty. Each ambulance crew also had to be trained in the proper way to load and unload patients from an ambulance. Letterman also forbade non-ambulance corps soldiers from evacuating wounded men. Letterman believed that disciplined men from the same unit, trained as ambulance crews, were more motivated to evacuate wounded men from their own unit and return to battle than the undisciplined, volunteers, contract civilians, and army musicians who had evacuated the wounded in the Civil War’s early battles. No longer would half a dozen spirit-broken men “help” a soldier off the battlefield and then fail to return to battle.20
In the space of a single order, Letterman redefined battlefield evacuation from a post-battle scavenger hunt to one marked by military discipline. Too, he integrated the battlefield medical service into military operations. A line officer could be arrested for non-authorized use of an ambulance. Weekly reports up the medical command hierarchy instilled accountability. Each ambulance corps officer now was as responsible for the ambulances, crews, and supplies in his charge just as the line officers held responsibility for the conduct and efficiency of the soldiers under their command.
Letterman’s philosophy became the first step toward battlefield medical specialization. His medical officers could now focus on the care of thousands of wounded men, while others were responsible for the efficient operation of the ambulance service. He had created a central authority and chain of command similar to that which had been the hallmark of combat troops for centuries. Similarly, he created a sense of unity by prescribing a green band and chevrons to be worn only by the ambulance service. He applied a basic military principle: uniforms foster identity and cohesiveness.
Yet the day the Army of the Potomac adopted his plan, the army’s new general in chief, Major General Henry Halleck, ordered McClellan back to Washington and to send his army’s Third, Fifth, and parts of the Ninth Corps to reinforce General John Pope’s Army of Virginia. Disheartened by his military defeat and his army’s recall, McClellan delayed his return, giving Letterman valuable time to begin implementing the army’s medical department reorganization.
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br /> But there wasn’t enough time before the fighting resumed. Letterman received copies of his orders from the printer for distribution to units a few days before the Army of the Potomac was broken apart, some departing for General Pope’s forces and the remainder bound for Washington. As a practical matter, the Army of the Potomac ceased to exist when Letterman prepared to fully implement his plan. On August 23, General McClellan boarded a steamer at the city of Hudson. His departure marked the end of the Peninsula Campaign, fourteen weeks of fighting that cost thousands of lives and ended in a defeat that made it clear battlefield care no longer could be entrusted to amateurs.
The chaos that confronted Letterman when he arrived in Virginia extended beyond the Army of the Potomac. A feud had developed between Surgeon General Hammond and the quartermaster general, Montgomery C. Meigs. Meigs’s father and brother were physicians in Philadelphia. But that didn’t help Meigs and Hammond reach an agreement over control of medical department ambulances and supplies. Although the Sanitary Commission agreed with Hammond that he should control the ambulances, Meigs refused to cede his authority, resulting in a persistent split of command and control at the army’s top level when it came to its ambulances.
Hammond also stumbled when he sought Union army–wide adoption of Letterman’s ambulance system. The surgeon general pressed for an independent organization premised on providing six ambulances with trained crews for each regiment. McClellan agreed, but on August 21 Stanton rejected the proposal, believing it would “increase the expenses and immobility of our army . . . without any corresponding advantages.”21 General in Chief Halleck also opposed army-wide adoption. A dedicated ambulance corps would remain the exclusive province of the Army of the Potomac, a fighting force that now had been split into two groups, one of which was bound for the Second Battle of Bull Run eight days later.
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