Letterman was pleased with the first test of his ambulance philosophy, writing: “It is well to remember than no system devised by man can be perfect, and that no such system, even if it existed, could be carried out perfectly by human agency. Calling to mind the fact that the ambulance system, imperfect as it may be found, could not be fully put into service—remembering the magnitude of the engagement, the length of time the battle lasted, and the obstinacy with which it was contested—it affords me much gratification to state that so few instances of apparently unnecessary suffering were found to exist after that action and that the wounded were removed from that sanguinary field in so careful and expeditious a manner.”
Some criticized the thousands of post-battle surgeries that left men disfigured or minus a limb. Some characterized it as butchery by incompetent doctors who had rushed to the battlefield as volunteers. Letterman saw it differently. While he acknowledged the care by a few contract civilian and state regiment volunteer doctors was poor, he felt that probably more amputations should have been conducted in what he viewed as “conservative surgery.” He believed that given the likelihood of deadly infection following a severe leg or arm wound littered with dirt and debris, the conservative approach was prompt amputation to give the patient the best possible chance at survival.
Lieutenant Spurr’s upper thigh wound made amputation impossible. A few days after the battle, an infection took hold and spread. Ten days after he had been wounded, at 9:00 a.m. on September 27, Spurr faded quickly as his eyes grew glassy. “Mother!” he cried, moments before he died. He became one of 20,950 Union and Confederate soldiers who were killed or wounded at Antietam, a battle that produced nearly five wounded men for every soldier killed outright on the battlefield.
Coping with families searching his hospitals, hoping to find that their loved one had survived the fighting, was one of Letterman’s post-battle priorities. He also turned his attention to maximizing a rebuilt supply line that fed Frederick and dozens of hospitals in the region. He established procedures to transfer thousands of wounded men from rural barns to metropolitan hospitals, sometimes one hundred miles away. He also focused on post-battle analysis.
In the aftermath of General Lee’s retreat to the South, Letterman knew that the Army of the Potomac’s pursuit would produce massive battles, perhaps as large as the one that had been fought at Antietam. His battlefield evacuation system had been proven, despite inadequate time for training. However, the skyrocketing numbers of wounded from a single battle revealed the army’s vulnerability to a poorly organized and fragmented supply system. The destruction of a single railroad bridge could put thousands of lives in jeopardy. Too many doctors at Antietam had been inadequately equipped for the initial wave of patients delivered to their operating table.
It also became clear that Letterman’s encouragement of hospital organization by division was insufficient. The chain of care at the edge of the battlefield from aid station to field hospital to evacuation hospital to convalescent hospital had to be as comprehensively overhauled as he had reorganized the battlefield ambulance system. Battlefield care could not be a twoway street. He had to reverse the tide of battlefield care from bringing surgeons to the wounded to efficiently transporting the wounded to an organized and tiered hospital structure that could move with the army and become established on as little as a few days’ notice. To accomplish that, reliance on civilian transports instead of assigned military personnel could not continue.
Long before the last of the major Antietam hospitals at Keedysville and Smoketown were closed, Jonathan Letterman knew he had to turn his attention to supply and hospital structure. Reorganization of both might have to take place while the army marched. Having resisted a prompt pursuit of Lee after allowing him to escape into the South, McClellan faced mounting pressure from President Lincoln to take the initiative.
His reluctance to pursue began to cost him the confidence of some of his medical officers under Letterman. “I am loosing (sic) all confidence and respect for McClellan—a man who a year ago I verily believed to be an agent of God to put down the rebellion in the shortest, cheapest, and most approved manner. . . . Three times we have moved expecting to follow up their retreat; and three times we have not done it,” surgeon Holt wrote in a letter to his wife.33
In approximately three months, the survival of thousands of men charging another sunken road would depend on how well McClellan, Letterman, and other officers could plan and coordinate the missions of combat, care, and if necessary, pursuit of the enemy.
6
FREDERICKSBURG
“A huge serpent of blue and steel”
J. H. Woodbury of Massachusetts, George Simons of New Hampshire, and Henry Dyke of New York were typical of those who volunteered to serve in their state’s regiments as part of the Army of the Potomac. They joined an army still struggling to adapt to a new type of warfare that required far more mobility than any American army had faced in 1776, 1812, or 1846.
The army’s medical department had been crippled by an outdated command structure that left it vulnerable to the quartermaster corps, which controlled a supply chain that sometimes overwhelmed and sometimes starved those who depended upon it. On more than one occasion, soldiers had to carry more rations than they could manage on the march. While they tossed food, coats, and knapsacks aside, medical officers went begging for missing wagons filled with medicines, tents, and other supplies that frequently were marooned at supply depots, abandoned in the rush to find the enemy, or commandeered by other officers for their personal use. Tens of thousands of wounded and dying young men had suffered as a result of unpreparedness and inefficiency.
Jonathan Letterman had now experienced firsthand the unique medical needs of an army equivalent to the combined populations of Pittsburgh, Memphis, Peoria, and Sacramento when it was on the march.1 Standing atop a barren hilltop, he had watched massive armies collide on the battlefield at Antietam and had seen how Civil War battles could produce more casualties in a few hours than America had experienced throughout the Revolutionary War.
For the first time, Letterman had to look backward as well as forward in managing the Army of the Potomac’s medical department. Thousands of the most-seriously wounded men facing extended and uncertain recovery as they lay in Antietam-area hospitals remained his responsibility. At the same time, Letterman had to prepare for the next clash between McClellan and Lee without knowing where it would take place.
Although Antietam generally had been judged as a victory both for Letterman and McClellan, both had faced public criticism in its aftermath. While that represented a new experience for Letterman, McClellan had long been the target of military critics. McClellan’s commander in chief, President Lincoln, now was foremost among those who questioned McClellan’s appetite for battle. After meeting with McClellan, Letterman, and others in early October, President Lincoln remained far from mollified, later calling the Army of Potomac “McClellan’s bodyguard.”2 Letterman reported to a general who no longer enjoyed the confidence of his boss. McClellan defenders, however, argued that political meddling had kept the general from carrying the fight to Lee.
On the other hand, Letterman’s organization of the ambulance corps three months earlier and his ability to plan for the unprecedented casualties at Antietam, had justified McClellan’s original judgment of him. As an exhausted Army of the Potomac spent October in the Sharpsburg area following Antietam, the opportunity to complete his medical department’s reorganization was at hand. Letterman turned his attention to overhauling the medical supply system and then the hospital structure as dozens of regiments arrived to create a 135,000-man army by October 20.3
As he had done with his ambulance reorganization, Letterman made a frank assessment of the waste of war and then, based on that assessment, took a logical approach to ensuring the optimal disbursement of medical supplies. After Antietam, he knew he had to calibrate the availability of medical supplies with the reality of war. “Hitherto medic
al supplies for three months had been furnished directly to regiments, and no wagons allowed expressly for their transportation. From these causes large quantities were lost, and in various ways wasted; and not unfrequently [sic] all the supplies of a regiment were thrown away by commanding officers, almost in sight of the enemy, that the wagons might be used for other purposes. I desired to reduce the waste which took place when a three months’ supply was issued to regiments, to have a small quantity given them at one time, and to have it at all times replenished without difficulty; to avoid a multiplicity of accounts, and yet preserve a proper degree of responsibility; to have a fixed amount of transportation set apart for carrying these supplies, and used for no other purpose,” wrote Letterman.4
Letterman conceived a tiered supply chain beginning at the brigade level and ending on the battlefield, perhaps on the backside of a hill that offered a fragile refuge for the wounded. With McClellan’s consent, on October 4, 1862, he issued a set of standing orders that reflected the new medical supply protocols. Each brigade was assigned one hospital wagon filled with medical supplies in bulk; one filled medicine chest and one wagon of hospital supplies for each regiment in the brigade; and one medical knapsack for each medical officer in the regiment. Each brigade was issued one month of medical supplies, which could be replenished from a nearby supply depot, ideally near rail or water transport.
Regimental medical officers could requisition supplies for their knapsacks from the brigade without a receipt, but Letterman held brigade officers accountable for the consumption of their supplies and prompt resupply from the regional depot. Ambulances accompanying regiments also carried supplies. In this way, Letterman decentralized medical supplies from brigade headquarters in the rear to the regiments on the battlefield.
He also mandated what must be available in the brigade’s supplies and aboard ambulances and hospital wagons. Required supplies for individual ambulances included beef stock; leather bucket; camp kettle; lantern and candle; tin spoons and tumblers; and ten pounds of hard bread. When regimental ambulances could not approach the battlefield with the troops, his order required an orderly to carry a knapsack filled with medical supplies instead. A hospital wagon had to be equipped with twelve pints of alcohol, eight dozen opium pills, one pound of opium tincture, twenty-four bottles of whiskey, ten pounds of arrowroot, one pound of zinc chloride, four quarts of castor oil, and twenty-four ounces of quinine as well as a variety of other chemicals, instruments, foodstuffs, bedding, and equipment.
With this single order, Letterman restructured the concept of military medical supply so that supplies could more reliably be delivered where needed on the battlefield. His fluid system reflected the increased mobility of armies. As the tide of battle flowed from invasions to flanking counterattacks to massive frontal collisions, the supply chain needed to expand and contract to match the exigencies of war and the movement of regiments, brigades, and divisions, and now it could. The wagons transporting the supplies were now the property of the medical department and no longer subject to misappropriation or abandonment by others. This meant less potential waste of precious materiel and a greater ability to reliably plan on their availability.
This restructuring of medical supply built on recent efforts to ensure the good health of the troops through proper nutrition. The average soldier’s diet continued to be a concern of the army, particularly given the incidence of disease that had ravaged the weakened troops early in the war, and, two months before Letterman’s medical-supply mandate, Congress had formally established the basic army ration:
A ration is the established daily allowance of food for one person. For the United States Army it is composed as follows: twelve ounces of pork or bacon, or one pound and four ounces of salt or fresh beef; one pound and six ounces of soft bread or flour, or one pound of hard bread, or one pound and four ounces of corn-meal; and to every one hundred rations, fifteen pounds of beans or peas, and ten pounds of rice or hominy; ten pounds of green coffee or eight pounds of roasted (or roasted and ground) coffee, or one pound eight ounces of tea; fifteen pounds of sugar; four quarts of vinegar; one pound and four ounces of adamantine or star candies; four pounds of soap; three pounds and twelve ounces of salt; four ounces of pepper; thirty pounds of potatoes, when practicable, and one quart of molasses.5
Now, for the first time in the war, soldiers could with some reliability count on a structured and more nutritious diet as well as the availability of necessary medical supplies if they were wounded on the battlefield. These two improvements, guaranteeing adequate food and giving them confidence of good care for their wounds, addressed two of the fundamental needs crucial to ensuring the troops’ morale.
The Army of the Potomac had less than three weeks to assimilate Letterman’s medical supply system before it crossed the Potomac River at Harpers Ferry and Berlin, Maryland, in a cold rain, finally on the trail of General Lee. Its late-October pursuit into Virginia became a muddy one. It took six days to move the entire army across the river before it marched through a valley between the Blue Ridge and Bull Run Mountains toward Warrenton on a line almost due south toward Richmond.
As the Army of the Potomac marched through the Virginia countryside, Letterman’s mission of reorganization was not yet complete. Although he had imposed a structure both for battlefield evacuation and medical supply, the flawed organization of military hospitals desperately needed a similar overhaul. When individual battles produced so many casualties that more than one hundred temporary hospitals could be required, fundamental changes had to be made in how triage and treatment were managed.
Letterman’s experience at Antietam demonstrated that he needed to forge a more comprehensive and efficient organization: it would need to integrate battlefield first-aid stations that might lie behind rocks and in creek beds with field hospitals that were sometimes within range of enemy artillery and with general hospitals in major cities perhaps one hundred miles distant from the fighting. Having the benefit of experience, he now understood what was needed to treat thousands of men wounded in a single day’s fighting. With respect to staffing, surgeons who refused to treat men who were not members of their regiment could not be tolerated. In addition, those selected to make critical treatment decisions and perform surgery had to be the best surgeons available, not simply those assigned to their posts on the basis of seniority or politics. Finally, there had to be a coordinated command-and-control structure that reflected the battlefield realities of more than 100,000 warring soldiers producing thousands of casualties in a single battle.
Letterman recognized that having hospitals dedicated to specific regiments was military medicine’s weak link. At Antietam, regimental surgeons had sometimes turned away the wounded from other regiments, denying them timely treatment. Field hospitals that made no distinction about a soldier’s regimental affiliation were critical to quick access to care. “As far as I knew, no system of field hospital existed in any of our armies, and, convinced on the necessity of devising some measures by which the wounded would receive the best surgical aid which the Army afforded with the least delay, my thoughts naturally turned to this most important subject,” wrote Letterman.6 Battlefield chaos, he understood, had to be channeled into coordinated care. “On the field of battle, where confusion in the Medical Department is most disastrous, it is most apt to occur, and unless some arrangement be adopted by which every Medical officer has his station pointed out and his duties defined beforehand, and his accountability strictly enforced, the wounded must suffer.”7
Again with McClellan’s endorsement, on October 30, 1862, Letterman issued a directive that recast the military hospital system as completely as his ambulance and medical supply orders had done in the preceding months. Letterman began by requiring a hospital for each division and setting standards for the number of surgeons and assistant surgeons in each. Some assistant surgeons were assigned record keeping duties, while others became specifically responsible for pitching hospital tents or organizing kitchens
or burial details and ensuring adequate supplies for each. Surgeons chosen to perform operations were to be selected “solely on account of their known prudence, judgment, and skill.”8
Letterman’s order also converted what had been regimental hospitals close to the fighting into aid stations, designed to provide immediate lifesaving care before the wounded were transported to the newly designated field hospitals at the division level. Surgeons at the aid stations decided who among the seriously wounded had a chance at survival. The lucky ones might get a tourniquet to stop their bleeding, see some morphine sprinkled into their gaping wound, and be given some water or a swallow of whiskey before being carried to a collection point. Horsedrawn ambulances positioned at a nearby collection point could transport them to a division field hospital, often located in a church, courthouse, or barn. In the span of a few pages, Letterman’s order created a “critical link—missing for most of military medical history—between the frontline aid stations and the rear-area general hospitals,” according to one historian.9 Just as his innovative approach organized regimental hospitals into aid stations, it established the division field hospital as the critical provider of intermediate care before the wounded were transferred to general hospitals.
This new system enabled medical officers at regimental aid stations to keep the slightly wounded closer to the battle and more readily available to return, while sending more seriously wounded soldiers to the mobile division field hospital. In addition, Letterman’s order required hospital guards at both the regimental and division field hospitals to “be particularly careful that no stragglers be allowed about the hospitals, using the food and comforts prepared for the wounded.”10 Hospitals were no longer havens for thousands of soldiers looking to avoid battle.
Surgeon In Blue Page 14