Yet, as the army and its medical department returned to outpost assignments and isolated Indian battles, much of the masscasualty medical knowledge acquired in the Civil War became more academic than practical. “While all other nations made haste to apply the lessons of our war and to remodel their medical organizations in accordance with them, our own Medical Department reverted to antebellum conditions and went backward. The hospital stewards were the only permanent enlisted personnel and all nursing and other work about the hospitals was done by an uninstructed and constantly changing personnel of men detailed from the companies,” wrote a reporter for the Journal of the American Medical Association in 1904.
In fact, the army’s medical department in the decades following the Civil War became saddled with many of the same issues that Letterman had confronted. The lack of trained medical personnel persisted until 1887, when a hospital corps was established. Medical officers with military rank implemented training programs, but, like Letterman’s medical staff, faced resentment by some line officers for having an officer’s rank that the line officers deemed unworthy. At the start of the Spanish-American War, the army medical department again was unprepared for a military force that stood to increase tenfold to approximately three hundred thousand men. Volunteer regiments with civilian doctors unfamiliar with the demands of military medicine produced many of the same challenges Letterman had faced.
Disease remained the deadliest enemy. Five times more soldiers died from disease than from enemy fire during the Spanish-American War. Malaria, yellow fever, and typhoid fever decimated some units. Secretary of War Russell Alger noted, “More than ninety per cent of the volunteer regiments developed (typhoid fever) within eight weeks after their enrolment; and the deaths from this camp scourge alone amounted to more than eight per cent of the total deaths from disease.”11 Appalled at the deaths caused by disease, President William McKinley appointed a postwar commission to investigate. The Dodge Commission issued a set of recommendations that called for additional commissioned officers, trained support staff, and greater surgeon authority to secure medical supplies. All were challenges faced by Letterman, and Congress addressed none of the Commission’s recommendations when it reorganized the army in 1901.
Alger concluded that “camp pollution” was the culprit of rampaging disease and was due to either the inexperience or negligence of officers and enlisted men. On April 25, 1898, Surgeon General George Sternberg issued Circular No. 1, which was practically a rewrite of the report Letterman submitted to General McClellan two weeks after Letterman had taken medical command of the Army of the Potomac in 1862. Army camp conditions had required Letterman’s immediate attention to improve soldiers’ diet, sleeping conditions, work schedule, food preparation, personal hygiene, and officer accountability. Like Letterman, Sternberg urged that camps be established on welldrained high ground and required that human waste sinks be carefully located, covered regularly, and discontinued before fecal waste reached the surface. Both Letterman and Sternberg recommended rest during the hottest portion of the summer day. Like Letterman, Sternberg also believed in hot coffee and recommended it prior to going on duty at night or early in the morning.12
The first full-scale test of “The Letterman System” came in World War I, along front lines that extended from the English Channel to the Swiss Alps. Stagnant war with weapons of vastly increased lethality presented new challenges to the Letterman philosophy of rapid battlefield evacuation and treatment as close to the fighting as possible. During the world’s first industrialized war, the army medical department refined the Civil War–era division hospital by establishing more specific levels of care, including collection stations, field hospitals, and evacuation hospitals that often were permanently built near rail lines. Yet despite that development in World War I, the U.S. Army found it necessary in 1923 to issue Regulation 1427, which again prohibited the non-medical use of vehicles intended to be ambulances— another reissue of a standard that Letterman had fought to establish.13
With each ensuing war, many of the medical lessons of the previous war were forgotten. Now, as world affairs have evolved from massive wars around the world to more isolated and marathon regional wars, military medical philosophies, protocols, and advances have similarly evolved. Today, the National Museum of Civil War Medicine is preserving and teaching the fundamental lessons of past wars to modern-day military medical professionals. Under the leadership of executive director George Wunderlich and museum founder Gordon Dammann, the museum’s Letterman Institute has taught more than 4,500 medical professionals from the Army, Navy, Air Force, and Veterans Administration, and other public safety personnel the value of linking battlefield medicine with military field command. To these new medical professionals, the institute imparts the golden lesson that integrated decision-making processes save lives and contribute to accomplishing command missions. Jonathan Letterman’s legacy is the basis of the successful training program.
Nearly 150 years ago, Jonathan Letterman’s fellow medical officers proved clairvoyant when they petitioned Congressional recognition for Letterman. They instinctively knew that in less than two years of war he had created a legacy that would benefit countless future generations of wounded. “We may search history in vain for campaigns of equal severity, for battles of equal magnitude, with those of this Army for the past eighteen months, and we challenge history to produce a battle wherein the hundreds of wounded have been so well and so rapidly provided for, as the thousands in the great battles of this Army (of the Potomac).”14
It is a legacy that has continued to instruct and inspire subsequent generations of military medical officers. As warfare evolves, the wounded soldier lies on the battlefield still, desperately hopeful that someone will race toward enemy fire, slide to a stop, and say, “It’s okay, I’ve got you.” Every word of encouragement and care is an echo of Jonathan Letterman’s legacy.
So, too, is the ongoing appreciation by the community of military medicine for what Letterman accomplished within the enveloping chaos and cacophony of war. “When (Letterman) assumed charge, he did not proceed by precedent, but had the vision to see what was wrong, and the energy and courage to carry out those reforms that he deemed necessary. Undoubtedly he was prepared when the opportunity came to do those things which are demanded of all military men when the supreme moment comes—to efficiently and thoroughly do the job. May his life actions be an example to us all.”15
13
EPILOGUE
“Today I am used up.”
An estimated 3.5 million Americans fought in the Civil War. There are no reliable statistics reflecting the number who served as career, volunteer, or contract surgeons. A minority of those who did were career military officers, summoned from remote outposts. Many more volunteered or sold their medical services to the U.S. Army. Some of the career medical officers, like Letterman, resigned during the war, while others endured to war’s end and either left the service or received orders for another outpost. Some of the others served only with the aim to survive and return home. Others willingly risked their lives in a spirit of unity and emancipation.
It would be hard to believe that the horrors of the Civil War did not leave scars on every man. Those whose lives crossed Letterman’s path met fates as varied as the roles they played throughout his life and on the battlefield.
LETTERMAN FAMILY
Although Jonathan Letterman had little use for them, the Union army’s contract surgeons included Letterman’s younger brother, William Henry. Like Jonathan, William excelled at Jefferson Medical College, graduating in 1856 as president of his class. Four years earlier, in 1852, when he lived with his mother a few blocks from Jefferson College during his undergraduate education, he cofounded Phi Kappa Psi.
After practicing medicine in Pennsylvania, he moved to Baltimore where he suffered from a heart condition. After eight years in failing health, and despondent over his mother’s death, William moved to Cotton Hill, West Virginia, in 1871. Diary entries reflect a man
at a loss with life. “The lovely waters of the Ohio are peaceful, but I am plunging amidst the tumultuous stream of life which flows within. How little we know those around us. The smile or the laugh may come from a heart that is bowed down. May God grant true wisdom unto me and good health, and may I be prospered far beyond my hopes and anticipation. May those dear ones at home be preserved and may we meet again.”1
William developed an interest in geology. He became an expert in coal deposits and purchased coal land for mining interests. In 1875, at forty-three years of age, he met and married Laura Slaughter. But his health continued to plague him. A move to Missouri near her family led to another move to Texas in 1878 with Laura and two young daughters. His family joined the third Letterman brother, Ritchie, who also had graduated from college and become a Texas farmer.
William started a medical practice and helped establish a local medical society and a Masonic Lodge. In 1881, another move became necessary, this time to the Gulf, in search of better health. Prior to leaving, an exhausted William wrote his father-in-law. “Today I am used up right sharp—does not express my case too strong. . . .Your next, if answered, will direct you to Austin. Good-by. Love to all, W. H. Letterman.”2 William Henry Letterman died nine days later on May 23, 1881, at the age of forty-eight. He was buried near Ritchie’s farm, in Duffau, Texas.
MEDICAL SCHOOL
Jonathan Letterman received one of the best medical educations possible before enlisting in the army. Several members of the medical faculty at Jefferson Medical College achieved national recognition in their respective fields following the war. Dr. Thomas Mutter taught surgery to Letterman and then retired seven years later, in 1856, due to poor health. He donated a collection of more than 1,300 medical specimens and a $30,000 endowment to the College of Physicians in Philadelphia, which remains one of the foremost medical-specimen museums in the country. Like William, he died at forty-eight years of age, two years later.
Dr. Charles Meigs became a widely recognized expert in pediatrics. He also spent much of his professional life translating medical journals and texts from French. Cultured, and full of humor, Meigs favored poetic phrases and mixed philosophy with his instruction. A colleague, Dr. John Mitchell, likewise was a man of literature. A published specialist in several diseases, he also published such diverse works as poetry, treatises on nature, and “The Means of Elevating the Character of the Working Classes.” Both writers were topped by Dr. Robley Dunglison, another professor of Letterman. His works ultimately sold more than 150,000 copies. Although he became known as “the father of American physiology,” Dunglison delved into many aspects of society in America and abroad. The one-time dean of the medical school published works on English fashion, word construction, superstitions, and languages, as well as a dictionary for the blind.
EARLY MEDICAL CAREER
Fellow officers who developed close friendships while spending long months at isolated outposts sometimes later found themselves on opposite sides of the battlefield during the Civil War. Early in his career, Letterman refused to get involved in a dispute between a young officer, Thomas Jackson, and the commanding officer of Fort Meade in Florida where Letterman served as medical officer. Jackson resigned from the army shortly thereafter and became a professor at Virginia Military Institute. Early in the Civil War, Jackson demonstrated his verve, audacity, and leadership for the Confederates, becoming known as Stonewall Jackson after his inspirational bravery at the first Battle of Bull Run. He died from friendly Confederate fire when Letterman and the Army of the Potomac fought at Chancellorsville, a loss General Robert E. Lee considered irreplaceable.
Letterman treated his first wounds inflicted by enemy fire— several arrow wounds after an Indian engagement as Loring sought marauding Apaches—in 1857, on an expedition led by Colonel William Loring. Loring had served in the Mexican-American War and later fought for the Confederacy throughout the Civil War. After the war, Loring was hired by the Egyptian army, where he rose to prominence before being dismissed in 1878. The North Carolina native moved to Florida and practiced law. He died in 1886, after unsuccessfully running for the U.S. Senate.
Prior to the Civil War, Letterman participated in one other expedition against an Indian tribe, the Paiutes. Under the command of James Carleton at Fort Tejon (north of Los Angeles), Letterman served as the medical officer on an extended march in search of Paiute leaders. Again he treated arrow wounds, suffered in a battle near Camp Cady in the Mojave Desert. Carleton spent most of the Civil War commanding the California Volunteers, guarding the Southwest against Confederate incursion. Following the war, Carleton commanded the Department of New Mexico. He ordered the forced relocation of 8,000 Navajos to a reservation. The march became a failure when many Navajos returned to their homeland. In 1867, he was transferred to San Antonio, where he died from pneumonia in 1873.
THE FRINGE OF WAR
When Letterman was transferred to the Department of West Virginia as medical director in January 1862, another medical officer arrived the same month. Introductions were not necessary, as William Hammond had attended Jefferson Medical College at the same time as Letterman. Their career paths had taken different routes in the ensuing thirteen years. Letterman worked in relative anonymity at various military outposts, while Hammond had developed a national reputation as a military medical officer, scientist, and researcher. They worked together for four months before Hammond became surgeon general.
They remained close friends after Hammond was removed from office in 1864, following his conviction of conduct unbecoming an officer and not following medical-supply purchase procedures. Many thought Hammond’s conviction was based more on politics than evidence, because he had made a number of powerful enemies in Washington. He moved to New York in the Civil War’s final year, borrowed money to start a medical practice, and again rose to national prominence in the emerging field of neurology. During the next ten years he held a series of medical-school professorships before launching a successful campaign in 1878 to overturn his military conviction.
An act of Congress restored his rank as brigadier general and placed him on the army’s retired list as surgeon general. Hammond spent the next decade studying mental diseases, established a sanatorium in Washington, and resumed his prolific writing. A cardiac problem led to his death in 1900 at seventy-one years of age.
In West Virginia, Hammond and Letterman were under the command of General William Rosecrans. An intellectual of varying interests, Rosecrans had served in the army for twelve years until 1854, before resigning to become an architect, engineer, and inventor. He volunteered at the start of the Civil War and served with modest distinction until the close of the war. His largest contributions came in West Virginia, where he and Letterman worked on an improved ambulance design and where Hammond and Letterman built one of the first pavilion-design hospitals, a design that influenced hospital construction for the remainder of the nineteenth century. At one time a possible running mate of Abraham Lincoln, Rosecrans moved to Los Angeles following the war and became minister to Mexico. He developed mining operations, was elected to Congress, and bought speculative real estate in downtown San Diego. He also served as register of the Treasury before dying in Los Angeles in 1893.
Almost as soon as William Hammond became surgeon general, his clash with Secretary of War Edwin Stanton affected Letterman. Stanton refused Hammond’s recommended appointment of Letterman as a hospital inspector in Washington, a precursor of Stanton’s insistent role in surgeon general and Army of the Potomac affairs. Stanton remained secretary of war until the end of the Civil War.
Lincoln tolerated the sometimes disrespectful Stanton, admiring his tenacity, organization, and work ethic. Generals, colleagues, and employees found him opinionated, supremely self-confident, insensitive, and short-tempered. As Letterman made preparations to leave the army in late 1864, Stanton lobbied for an appointment to the Supreme Court. Lincoln demurred, believing his irascible confidant was more valuable as secretary of war.
Following Lincoln’s assassination, Stanton’s relationship with President Johnson deteriorated quickly. When Stanton refused to leave his office after President Johnson fired him, the Senate attempted to impeach Johnson in the belief that Stanton’s dismissal required Congressional approval. When impeachment fell one vote short, Stanton promptly resigned. He planned to resume a lucrative law practice, but when another Supreme Court vacancy occurred, Stanton was named to the bench by Johnson’s successor, President Ulysses S. Grant. However, Stanton died before he took his seat on the bench, five days short of his fifty-fifth birthday.
BATTLE SCARS
Jonathan Letterman fought the war on several fronts. He had to build a medical department on the march, comprised of volunteer regiments, civilian doctors, intrusive humanitarian organizations, and a relative handful of military surgeons, most of whom were strangers. Four different commanding officers held authority to either facilitate or foil his ability to treat thousands of wounded men. He had to earn their respect and trust quickly after each change of command. The surgeon general likewise wielded significant power in dictating Letterman’s ultimate effectiveness. The cast of characters on and near the battlefield sometimes played key roles for only a few months, but some held sway for extended periods of time. Their final fates were as varied as the roles they played in Letterman’s battlefield career.
Charles Tripler, Letterman’s predecessor as the Army of the Potomac’s medical director, never completely recovered from the disastrous Peninsula Campaign, in 1862, that cost him his job. After losing the confidence of both his commanding officer and the surgeon general, Tripler was granted his requested transfer to Detroit in the Department of the Lakes. Five years later, he developed a brain tumor and died in 1866. His Manual of the Medical Officer of the Army of the United States became his professional legacy and the universal guide for recruit examiners for the next half century.
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