Surgeon In Blue

by Scott McGaugh

  That respect extended well into the next century. In 1911, the War Department renamed a 300-bed San Francisco military hospital Letterman General Hospital. The pavilion-style hospital, remarkably similar to the design Letterman helped establish with Surgeon General William Hammond in the Civil War, had been built from 1899 to 1902 to treat Spanish-American War troops. Seven years later, the Board of Regents of the Smithsonian Institution wrote in its annual report, “The name of Jonathan Letterman should always be remembered by military surgeons as the greatest sanitary organizer of modern times.”

  In World War II, fluid battle lines, amphibious assaults, and troop movements across continents placed a premium on mobile and well-organized combat medical care. Despite the mechanization of the army that had first taken place in World War I, the fundamental principles forged by Letterman remained as valid as when they had been pioneered decades earlier. The nation took notice. In June 1943, nearly on the eightieth anniversary of Gettysburg, American troops prepared to invade Sicily. In the eighteen months America had been at war, Letterman’s accomplishments once again had become evident. “Jonathan Letterman, medical director of the Army of the Potomac . . . could not tell surgeons to beware of bacteria, because Pasteur and Koch had still to do their great work and Lister had not yet shown the importance of asepsis. But Letterman could reorganize the medical services of the army and reorganize them he did. Four days before Antietam he collected supplies and thirty ambulances, so that he was able to move 10,000 to shelters within twenty-four hours. He made military history. Every army in the world profited by his example,” wrote a New York Times reporter.28

  As chief surgeon for the European Theater of Operations and later medical chief of the Veterans Administration, Major General Paul R. Hawley, grew passionate about Letterman’s contributions. “Compared with what Letterman did for the wounded soldier, the contributions of Florence Nightingale seemed small,” he said following World War II. “There is not a day during World War II that I did not thank God for Jonathan Letterman. He was truly a surgeon for the soldiers.”29

  12

  AN ENDURING LEGACY

  “War is a terrible thing at best.”

  Over the course of eight generations, more than 40 million Americans have served in times of crises and conflict. Nearly 1.5 million have survived wounds received on the battlefield. “War is a terrible thing at best; and all the horrible things you read of it are inseparable from it,” wrote surgeon J. Franklin Dyer of the 19th Massachusetts Regiment on July 17, 1863, two weeks after Gettysburg.1 Yet it is also true that through the horrors of the battlefield, military medicine has validated and sometimes pioneered advances in medicine.

  War strategist Karl von Clausewitz wrote that organization is fundamental to the order of battle. Military organization takes time to develop, but in most of the wars America has entered, the military medical department has been undermanned, outdated, poorly equipped, and unprepared. In each new generation of war, it has fallen to a relatively small number of innovative thinkers to manage human carnage of an unimagined scale, and in the Civil War the task fell to William Hammond and Jonathan Letterman.

  Horrific suffering by the wounded and dying may have been inevitable, but the chaotic, poorly organized battlefield evacuation and inadequately coordinated post-battle care that exacerbated and cruelly prolonged it could not be allowed to continue. Letterman responded to what he saw as a doctor devoted to the compassionate care of the sick and wounded. He also was motivated to arm his commanding officer with a healthy and sound fighting force that could contribute to a more prompt end to the war. In eighteen months, the introspective and unassuming doctor from Pennsylvania forged a legacy through his exceptional organizational ability, which enabled him to recast the military’s medical corps into a professional, recognized, and accountable entity essential to battlefield victory.

  On July 4, 1862, it fell to Letterman to create order out of chaos in the face of a diseased and dispirited Army of the Potomac. Following the failed Peninsula Campaign, more than one in three soldiers in the staggered army were ill. The chaotic river of wounded, sick, and cowardly to hospitals far from the battlefield threatened the fighting force from the rear. Letterman discovered one-fifth of the soldiers who had retreated to hospitals at Fortress Monroe were fit for duty.2 He realized he had to focus first on the health of his army in camp, long before it met the enemy on the battlefield. Within three weeks of his arrival Letterman rewrote the standards of military camp hygiene; living conditions; diet; and the process of authorizing transfer to hospitals in the rear; and he delineated who would be held accountable for enforcement. The benefits of Letterman’s approach to preventive medicine appeared quickly. Within a month, the sickness rate in the Army of the Potomac decreased to 20 percent.

  He described the results as follows: “It is impossible to convey in writing to any one not mingling with the troops a true idea of the improvement which took place in the health of the troops while we were encamped at that place . . . there are many ways in which improved health manifests itself that cannot be adequately described. There was so much in the appearance, in the life and vivacity exhibited by the men in the slightest actions, even in the tone of the voice, which conveyed to one’s mind the impression of health and spirits, of recovered tenacity of mind and body, of the presence of vigorous and manly courage, an impression which to be understood must be felt—it cannot be told.”3

  Letterman stood in a unique position to improve the health, morale, and fighting strength of the army. Every soldier wants to be fed well and know that he will be taken care of if he falls wounded on the battlefield. Letterman turned his attention to the latter. Within a month of taking medical command, he rewrote battlefield evacuation. He codified a system establishing a dedicated ambulance corps that included a leadership structure, command responsibilities, organization on the march, and supply. The ambulance corps he created became a strategic element of the army, not a tactical afterthought.

  But the wounded could only be cared for by well-supplied medical officers. Both the availability of medical supplies and wagons to carry them must be organized, and officers had to be accountable for both. Letterman knew that stacks of supplies without adequate transportation “were lost, and in various ways wasted; and not unfrequently 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.”4 After his first battle at Antietam, Letterman rewrote medical supply requirements, mandating that medical officers have fewer supplies on hand but were authorized to order resupply more efficiently. This just-in-time inventory management reduced waste and made his army’s medical facilities more mobile.

  A few weeks later, in October 1862, Letterman completed his overhaul of battlefield medicine by recasting the military hospital system. He established field hospitals at the division level close to the battlefield. Now his stretcher bearers could evacuate the wounded to aid stations on the battlefield, knowing an organized ambulance corps could transport them from there to field hospitals not far away. This missing link, between aid stations and general hospitals far to the rear, proved critical to battlefield survivability. Ambulances could make regular runs between aid stations where the wounded had been collected and division hospitals, rather than scavenge the battlefield for survivors. The field hospitals’ effectiveness improved significantly when Letterman’s system also established organizational structure by assigning doctors to specific duties such as triage, surgery, administration, and supply.

  In less than four months, Jonathan Letterman had eliminated much of the anarchy of getting the wounded off the battlefield. He had organized a system of tiered hospital care, from the aid station to the general hospital in a large city many miles away. He had made sure medical supplies could be reliably procured at each stage of the process and had established a measure of independence and control of transport between each level of care. He had organized and professionalized a me
dical corps that some commanding officers deemed a necessary evil by creating a corps that directly improved those officers’ ability to defeat the enemy.

  As one measure of his system, 37 percent of the Army of the Potomac was unable to report for duty in July 1862, due to sickness, but a year later only 9 percent were sick. Similarly, the mortality rate of wounds dropped from 26 percent the first year to 15 percent and then 10 percent the next two years.5

  The role of General McClellan and Surgeon General Hammond in Letterman’s overhaul cannot be overstated. McClellan and Letterman became more than senior officers and colleagues. Letterman earned McClellan’s strong backing within weeks of joining the Army of the Potomac and developed a friendship that extended beyond their time together in Virginia, Maryland, and Pennsylvania. He also had a staunch ally in Hammond. They shared an analytic approach to medicine as well as a propensity to question and challenge established procedures and protocols. The support from McClellan and Hammond enabled Letterman to reorganize care on perhaps the most scrutinized battlefield of the Civil War, the region mostly spanning Maryland and Virginia between Washington and the Confederate capital, Richmond, less than one hundred miles away. In the aftermath of battle, newspaper reporters, humanitarian commission representatives, politicians, and President Lincoln himself visited where the two armies, often with a combined fighting strength of 175,000 men, had collided.

  Letterman’s work also came in the midst of ongoing political intrigue and Machiavellian plots at the highest levels of the Union army. In eighteen months, the Army of the Potomac was handed to four commanding officers who could not have been more different in their ability to command and in their leadership style. The diminutive George McClellan was armed with an outsize ego and disdain for his commander in chief. His hesitancy to aggressively attack General Lee led to Ambrose Burnside taking command, a general who didn’t want the responsibility. A friend of McClellan, he clumsily reorganized the army, feared he was unworthy of the job, and lost the confidence of some senior officers to the extent they attempted a coup in Washington. His feud with General in Chief Henry Halleck led to his dismissal and the appointment of the raucous Joseph Hooker. Hooker unwound Burnside’s “grand division” scheme, was popular among the troops for improving their living conditions, but also feuded with Halleck, so that Lincoln again concluded he had to make a change in command. Once again Letterman’s commanding officer was a near polar opposite of his predecessor. Only days before Gettysburg, George Meade, a pensive, thoughtful, short-tempered man some officers called “Old Brains” took command. Few medical officers had to deal with a more fluid and unpredictable cast of commanding officers was than did Jonathan Letterman. Similarly, William Hammond had battled against the secretary of war while humanitarian commissions sought to exert their influence on how soldiers should be treated and cared for.

  Armies around the world paid careful attention to America’s Civil War. Several sent observers to learn from the American experience and from the high-profile Army of the Potomac in particular. British inspector general Edward Muir visited Letterman shortly after Antietam and reportedly was impressed with what became widely known as “The Letterman System.” British surgeon general Thomas Longmore wrote a book in 1869 on the care of sick and wounded soldiers, and his argument was significantly influenced by Letterman and the book Letterman had published three years earlier. Two Prussian physicians, Rudolf Virchow and Theodore Billroth, similarly were impressed. They later were influential in the Prussian army’s adoption of Letterman’s philosophy of battlefield care.

  Observers also drew on the bulk of the Civil War medical legacy, and in some areas, where advances had not been achieved outright, anecdotal progress was gained. Medical officers knew diet and hygiene were critical in the war against disease but did not understand the micro-organism agents of illness, an enemy that killed far more soldiers than rifle and artillery fire. Reliance on mercury- and opium-based medicines remained prevalent. Without understanding the scientific basis for it, doctors serving in the war saw that improved hygiene standards, healthier food preparation techniques and a more nutritious diet reduced the incidence of disease, lessons they took home after the war. Sickness rates for diarrhea and dysentery generally declined throughout the war, although mortality rates in the ranks of the weakened armies increased.

  Many of those who survived, like Letterman, faced a lifetime of disability. Civil War veterans were more than fifty times more likely to suffer from diarrhea and dysentery than civilians and suffered significantly higher rates of heart ailments and rheumatism, among other maladies.6

  Civil War surgeons did not understand the agents of infection any more than they did the agents of disease. But anecdotal experience demonstrated that regularly cleaned wounds and a well-ventilated environment facilitated recovery from wounds. Wounded soldiers generally fared better in barns and tents than in farmhouses. Noting that well-ventilated hospitals also held fewer cases of infection, Hammond and others developed a pavilion-style design that influenced civilian hospital design over the next seven decades. That innovation became a major step in military medicine’s battle against hospital gangrene, a ghastly complication that was frequently fatal and nearly always disfiguring.

  Surgeons performed tens of thousands of amputations, giving rise to a national debate over their frequency. Given the almost certain infections that resulted from being wounded, Letterman and others believed amputation was often the advisable medical approach in order to reduce the chances of fatal infection from a dirty wound,. He noted: “From my observations I am convinced that if any fault was committed it was that the knife was not used often enough.”7 Surgeons learned that prompt surgery, within forty-eight hours of battle, improved the odds of surviving the subsequent infection. That became an early step in the progressive realization by twentieth-century surgeons that “the golden hour” after suffering a wound was critical. Today, twentyfirst century military surgeons recognize that “the platinum ten minutes” for trauma care is even more critical to survivability.

  The nature and location of the wound in the Civil War largely dictated a soldier’s odds of survival. Fatal infections from amputation ranged from 20 percent for arms to more than 80 percent for amputations at the hip. The abundance of amputations and infections was ample opportunity for surgeons to learn the value of ligature, tying off arteries as part of the amputation process. A wound to the torso was devastating, with 62 percent of chest wounds becoming fatal and nearly 90 percent of abdominal wounds producing death.8 The first widespread use of anesthesia for surgeries, principally chloroform, produced a death rate of five per thousand cases.9 Although the wounded now could be safely anesthetized, surgeons were still limited in what kinds of severe wounds they could effectively treat.

  Thousands of Civil War soldier case histories document the horrors that both the wounded and their surgeons endured. For example, John Peters of the 11th Pennsylvania Volunteers reached a Washington hospital on June 15, 1863, after being wounded thirty-three days earlier at Chancellorsville. He had been shot through the thigh, broken his femur, and suffered a skull fracture. “His general condition is not promising,” wrote the attending physician.

  His tongue is red and dry, his pulse frequent and feeble, his spirits somewhat depressed, and he has but little appetite.

  June 27:The wound in the head is again suppurating (oozing pus) and he has no fever. Removed from the thigh a detached fracture splinter about one inch in length.

  July 1: The discharge of pus from the wounds in the thigh is profuse. He looks pale and anemic.

  July 18: He has diarrhoea.

  July 25: He has loose stools occasionally, which are controlled by the use of opium.

  July 28: Removed another detached splinter from the thigh.

  August 10: His general condition has much improved. The fracture of the femur has united, but necrosed (dead) bone is discernable on exploration of the thigh wound.

  September 11: There is swell
ing, redness, and pain in his thigh. Ordered lead and opium wash to be applied to it.

  December 20: He complains of debility and want of appetite; is pale and anemic, and the thigh continues to discharge freely. Prescribed extract. Nucis vomicae gr 1/6 (strychnine).

  February 14: The diarrhoea continues. Ordered (opium) and comphorae to be taken after each stool.

  April 14: The patient was transferred to Philadelphia, Pa., being in good flesh and spirits, and abundantly able to stand the journey. The injured limb is recovering from atrophy occasioned by the long disuses, that is, it is increasing in size, and the patient is rapidly regaining use of it. The limb was shortened about three inches.10

  Peters spent nearly one year in the hospitals recovering from his wounds.

  Other medical advances included limb immobilization (notably the Hodgen splint) and the birth of medical specialties. Surgeon General Hammond dedicated one hospital exclusively to the treatment and study of neurological injuries. Another was devoted to venereal disease. Plastic surgery became an emerging specialty as some soldiers survived horrifically disfiguring injuries and their ensuing infections. Hammond also created the Army Medical Museum, sending doctors into the field to collect thousands of specimens. The multivolume Medical and Surgical History of the War of the Rebellion that took more than a decade to compile and publish remains an unprecedented chronicle of disease, trauma, and their treatment in mid-nineteenth century war.