History

The United States Army Medical Service Corps

EARLY MILITARY MEDICINE

The U.S. Army Medical Service Corps (MSC) traces its roots to the American Revolution. Today, MSC officers in twenty-six specialties (see Appendix M) are valued members of the Army`s medical team. They provide administrative skills ranging from health care administration to aeromedical evacuation, scientific expertise in fields as diverse as optometry and microbiology, and administrative services at all levels of the United States military medical establishment. Their corps, along with the Medical Corps (physicians), Army Nurse Corps (nurses), Dental Corps (dentists), Veterinary Corps (veterinarians), and Army Medical Specialist Corps (dietitians, physical therapists, occupational therapists, and physician assistants), constitute the officer corps of the Army Medical Department. Those officers are joined by enlisted soldiers, noncommissioned officers, and civilians to form the complete team.

The evolution of the Medical Service Corps as part of that team occurred as the United States Army learned that military medical support was impossible without officers specifically dedicated to a wide

variety of duties that someone other than physicians, nurses, dentists, or veterinarians should perform. Oftentimes those responsibilities involved health care specialties that emerged only gradually from developments in medical technology. In other cases they were functions that became necessary for the operation of an increasingly complex military medical support system that demanded professionalism and specialization.

The origins of the MSC predate the founding of the United States. On 30 April 1775, the Provincial Congress of Massachusetts Bay appointed Andrew Craigie, a graduate of the Boston Latin School, as apothecary of the Massachusetts Army. Congress referred to Craigie as the `commissary of medicinal stores` and charged him with providing beds, linen, and other supplies necessary for patient care to the troops gathering around Boston.¹ On 27 July 1775, the Continental Congress created `an hospital` (the forerunner of the Army Medical Department) for its army of 20,000 soldiers.² An apothecary was among the personnel specified in the resolution, and in time Craigie assumed that duty. His duties were similar to those performed by present-day MSC pharmacists and medical logistics officers. His legacy is commemorated by the Association of Military Surgeons of the United States, which recognizes a federal government pharmacist each year with the Andrew Craigie Award.³

The evolution from apothecary to pharmacist, and the development of the other medical administrative and scientific specialties of the present-day Medical

Robert A. Thom`s painting, America`s First Apothecary General, depicts Andrew Craigie

Service Corps, accompanied progress in medical technology. Revolutionary Army apothecaries, physicians, and surgeons did the best they could, but they practiced medicine before the invention of the stethoscope and general acceptance of the concept that living organisms, such as bacteria, cause disease. Sulfa drugs, antibiotics, x-ray, and the understanding that insects and animals can serve as vectors for disease were more than a century away. Bleeding was often the therapy of choice, and anesthetics had not yet muted the agony of patients in surgery.⁴

Progress in medical technology-along with public awareness that practitioners could actually do something for those in their care-produced new specialties and organizational requirements necessitating greater variety and sophistication of staff. The need for military officers in emerging health care specialties became evident in varying degrees during the period from the Revolution to World War I. Medical logistics, for example, increasingly became a vital element in the support of combat operations, and repeated failures illustrated all too clearly the need for individuals trained in management and business practices. The preparation and dispensing of medications became the province of pharmacists and, eventually, a specialty in military medicine. The need for a coherent medical evacuation and treatment doctrine became painfully apparent during the Civil War, and an effective response required the creation of a new commissioned officer specialty, the ambulance corps officer. Increased sophistication of organizations also required officers specializing in administration. And, as preventive medicine became a reality, the medical advances that made this possible spawned scientific specialties beyond the imagination of anyone in George Washington`s army.

From Revolution to Reform

Deficiencies in the Army`s medical support capability during the Revolution, 1775-1783, demonstrated a need for specialists in medical logistics and for a rational system of supply. The Army had no coordinated medical supply system; each colony raised its own regiments, and regimental surgeons relied on their home colonies for medical supplies. The chaotic system was made worse by inflation and problems in communication and transportation. Some commanders complained of severe shortages. There was great pressure on Andrew Craigie, who found in one hospital that there was not only a shortage of drugs but also of the most basic items such as bandages, needles, and blankets. The Massachusetts Bay Congress appointed a committee to study the medical supply problems, but the actions of one provincial body could not resolve the larger issues. The Continental Congress attempted a solution in August 1775 when it designated a druggist, Dr. William Smith, as purveyor for medical supply. Later, Congress reorganized the Army into three districts and provided each district with an apothecary general whose duty it was `to receive, prepare, and deliver medicines, and other articles of his department to the hospitals and army.` Craigie`s efforts contributed to an improved situation by the summer of 1778, the same year in which the first Army formulary appeared.⁵

The Regular Army nearly ceased to exist after the Revolution and was retained principally for Indian fighting. In 1784 Congress reduced it to eighty

enlisted soldiers, a few officers, and no medical personnel. Congress authorized an Army of 718 in 1789, one of about four thousand in 1794, and a medical department in 1799, but did little to organize the central medical establishment. Medical support for soldiers continued to remain primarily the responsibility of state militia regiments that remained under the control of the state legislatures. Control of medical logistics was held by those outside the Medical Department, and weaknesses that had surfaced during the Revolution were not corrected.

In 1809 Dr. William Upshaw, surgeon of the 5th Infantry near New Orleans, denounced the failings of the system, which were compounded by the corruption of his commander, Brig. Gen. James Wilkinson. An unfortunate force of about two thousand soldiers was decimated by disease as it deployed to defend the newly acquired lower Mississippi territories. Over one thousand soldiers fell ill, and most died. Upshaw bitterly complained of caring for sick soldiers, only to see them die for lack of food or medicine, declaring, `Humanity mourns such a sight."⁶

In addition to the need for a functional medical supply system, the necessity for basic management practices and for the relief of physicians from nonclinical duties contributed to the evolution of medical administrative specialties. In 1808 Dr. Edward Cutbush, medical director of the Pennsylvania militia during the Whiskey Rebellion, published the first manual on hospital administration. In it he defined the hospital steward, the forerunner of Army medical noncommissioned officers, in terms recognizable today as similar to those describing a hospital administrator.⁷

Cutbush`s hospital steward was necessarily an individual `of strict integrity and sobriety,` whose duties included discipline of staff and patients, personnel management, patient administration, food service operations, medical supply, cost accounting, procurement of supplies and equipment, subsistence, property accountability, and supervision of the ward master. The steward enforced hospital rules, seeing to it that `no one should spit on the floors or walls.`⁸ Cutbush`s hospital staff also included a purveyor, `not a medical man, but one conversant with business,` whose duty it was to purchase the items necessary for patient care.⁹ Pharmacy operations were provided by apothecaries who compounded medications for the patients from prescriptions written by the physicians and surgeons.

The War of 1812 resulted from increasingly tense relations between the United States and England over a variety of matters unresolved by the War of Independence. At the time a somewhat strengthened U.S. Army numbered just over sixty-five hundred soldiers.¹⁰ While inconclusive, the conflict increased national pride and produced a national anthem.¹¹ But military medicine differed little from that practiced during the Revolution, except that it was less organized-there was still no medical department. Its burdens were increased by poor military leadership, unpreparedness, and an amateurishness and confusion in organization and command that cost the nation many defeats in the field. The need for expansion of health care specialties was voiced in the reports of Dr. James Mann, medical director for the Northern Department. Mann complained that the press of his various administrative duties as hospital surgeon, including sanitation inspections, kept him from fulfilling all of his clinical tasks.¹²

Deficiencies in medical logistics again surfaced, and campaigns along the Canadian border were routinely marked by breakdowns in the medical supply system. Medical personnel were criticized for their part in the `great mortality` in 1813 at French Mills, a militia post just west of Plattsburg, New York. Dr. Mann argued that the absence of dedicated medical transportation assets was at fault. Medical supplies had been loaded wherever there was room on the boats and `were either consumed by the troops, damaged, or lost.` In other instances, medical supplies destined for Mann`s area had been diverted by higher authority outside the surgeon`s control.¹³ A 12th Infantry inspector noted that `the Surgeon complains he is without drugs, hospital stores, or surgical instruments.`¹⁴

Establishment of a Permanent Medical Department

The many failures in delivery of medical services during the war helped to provoke a strong movement for reform and organization after it was over. American military medicine took a great step forward on 14 May 1818, when Congress created a permanent chief of the Medical Department, an act which gave permanency to the department itself. Joseph Lovell, appointed as the surgeon general, set up his new office and, in accordance with the wishes of Congress, accounted for his actions in annual reports. He quickly moved to consolidate the authority of the Medical Department and to establish administrative procedures.¹⁵

The new department included an apothecary general and two assistants. They were responsible for purchasing medical supplies and equipment, compounding and preparing medicines, accounting for the distribution of supplies and equipment, and reporting expenditures annually. Surgeon General Lovell was confident that those medical administrative and scientific functions would be well executed by his apothecary general, Francis LeBaron, who was qualified `both from his knowledge of medicines and habits of business.`¹⁶

Medical logistics support for the Army was high among Lovell`s priorities. He feared the department would be handicapped by the low pay allotted to the assistant apothecaries general and by the difficulty this posed in recruiting from urban areas such as New York and Philadelphia. He was also concerned about control over medical logistics, believing that his greatest problem would be preventing interference in medical procurement by commanders outside the Medical Department who were subject to influence by private contractors and were often overcharged. Lovell`s fears were realized when the position of apothecary general was abolished even though the surgeon general was not released from responsibility for medical logistics.¹⁷

The small size and slender resources of the Medical Department were all the more noticeable by contrast with developments then going on in Europe. The time of the Napoleonic Wars and after was marked by great advances in military medical organization. Napoleon`s chief surgeon, Baron Dominique Jean Larrey, had in 1793 created a `flying ambulance,` a mobile field hospital with surgeons, stretchers, and supplies carried in horse-drawn conveyances that could be rapidly moved to the points of greatest need on the battlefield. Larrey had so refined his flying

Surgeon General Lovell

ambulance that in 1799, at Aboukir, Egypt, he reported that no casualties were left more than fifteen minutes without being properly treated.¹⁸

By 1831 French military medical doctrine encompassed Larrey`s mobile field hospitals and an ambulance corps. Manning tables for the medical evacuation and treatment system of French divisions included five administrative officers and three pharmacy officers.¹⁹ However, removal of the wounded was still performed by a soldier`s comrades, who would then return only reluctantly to the battlefield. The ambulance corps was thus a rudimentary organization that depended for litter bearers and other manual labor upon soldiers detailed from combat units.²⁰

A generation later Americans were also witness to the British experience in the Crimean War.²¹ Between April 1854 and June 1856 England sent some eighty-three thousand soldiers to fight in Russia; nearly twenty thousand died, over four-fifths of them from disease. The fate of the wounded within the evacuation and treatment system was precarious. Lifted from the mud of the field hospitals for transport by sea back to Turkey, many died from the rigors of the trip. Wounded soldiers were laid on the decks of ships, some of which foundered in the winter sea. Once in the British hospital at Scutari, the patients were placed in two rows, feet to feet, in wards where the dead could not be removed as fast as the sick came in. It was a `vista of woe.`²² Descriptions of suffering and the shortcomings of the British medical system caused a public outcry that catalyzed formation of a politically influential sanitary commission. This led to pressures in England and in other countries to improve the administrative and scientific capabilities of military medicine so as to prevent repetition of the catastrophes in the Crimea.

The more fortunate wounded and sick were taken to the improved British hospitals of Florence Nightingale. Nightingale had arrived in Constantinople in 1854 as the nursing superintendent of the English military hospitals in Turkey. Justly regarded as a pioneer in hospital administration as well as nursing education, Nightingale forcefully improved the sanitation of British hospitals at a time when filth was the standard. She proved politically astute and in time became a fixture in British national life. She personified a growing demand for public oversight of military medicine.²³

Nightingale`s observations on military hospitals demonstrated her understanding of them as complex enterprises requiring specialized management skills. She believed the head of a general hospital should be selected `for his fitness

alone, i.e., his capacity for administration, and not upon grounds of professional eminence.`²⁴ She also advocated an organization that would free physicians to practice medicine. The staff should include a registrar for maintenance of records and reports and a hospital treasurer, who would make payments, keep accounts of receipts and expenditures, and audit the steward`s account.²⁵ Finally, she vigorously supported creation of a statistical capability, calling it `the most important science in the world,` because it provided a mathematical distillation of clinical experience.²⁶ Nightingale`s grasp of the need for specialists in hospital administration, medical records and reports, medical financial management, and statistics shows that the need for a corps of officers for those specialties was recognized long before such organizations were ever created.

Such progressive thinking, unfortunately, was absent from the United States Army. Brig. Gen. Thomas Lawson, surgeon general for the twenty-five years from 1836 to 1861, served the longest of any surgeon general, but he led the department without imagination. His failure to undertake planning for large-scale hostilities resulted in a department incapable of handling the casualties from the early battles of the Civil War.²⁷

Yet he achieved some small victories, one of which was his success in obtaining permanent authority for appointing hospital stewards. He wrote Secretary of War Jefferson Davis that the important duties of the stewards required the selection of `steady, sober and intelligent men,` something that did not happen when line commanders had to detail personnel for those jobs. He recommended their appointment with the rank and pay of first sergeant.²⁸ The War Department provided for a competitive selection process and restricted their number to one at each post.²⁹ Lawson also recognized, though he did not succeed in establishing, the need for Medical Department control over medical logistics. He observed that medical items were liable to be stolen, damaged, or destroyed by storekeepers, teamsters, or muleteers who `handle a box containing the choicest medicines as roughly as if they were boxes of camp-kettles and mess pans.`³⁰

In the War with Mexico, 1846-1848, Maj. Gen. Winfield Scott commanded an expeditionary force that fought outside the United States, away from its support base. Disease continued to dominate the medical battlefront. Over one hundred thousand soldiers served in the conflict; 12,896 died, but of them only 1,629 were killed in action or died from wounds, a distressing ratio.³¹ There was no ambulance corps or hospital corps to provide a systematic evacuation and treatment system. Wounded soldiers were gathered up by soldiers detailed for that purpose and taken to hospitals, which were set up in the nearest convenient buildings. Wagons were used to evacuate casualties, but there were no vehicles designed expressly for that purpose. At least the agony of surgery was now diminished for some patients by the first use of anesthesia in wartime.³²

The remaining years before the Civil War were dominated by the Indian campaigns, which required small, mobile units stationed at widely separated posts. A progressive measure was the inclusion of ambulances in the force structure and the restriction of their use to movement of the sick and wounded. Medical Department regulations specified a leaner medical support for the Indian cam?

paigns than that provided for fighting `a civilized enemy.`³³ Commands smaller than five companies were allotted just one two-wheeled ambulance.

The last years of General Lawson`s administration witnessed some efforts at planning for medical support. The surgeon general convened a board of medical officers in 1858 that examined `ambulance wagons` and recommended Medical Department control over all its vehicles. Another board of medical officers was convened the following year to examine revised supply tables and to select a field ambulance, although it failed to adopt a standard design. That board also recommended a casualty evacuation doctrine, but no plan was adopted.³⁴ On the whole, the Medical Department between the time of Lowell and the Civil War failed to keep up with progressive developments abroad. Instead, progress would come through the shock of war.

At War With Ourselves

The Civil War brought misery to the Republic and extraordinary challenges to the Army Medical Department. It produced a casualty evacuation and treatment doctrine that continues today, and it drew the tapestry of evolving medical specialties into sharper relief. The fields of medical logistics, pharmacy, hospital administration, records administration, and statistical reporting grew as they contributed to the effectiveness of the department. Technology in such matters as instruments and ambulances advanced. And the work of sanitary commissions reflected a climate for change highlighted by politically charged public oversight of military medical activities.

The revolution in organization was all the more striking because the state of medical art had not changed that much from earlier days. Clinicians made increasing forays into a scientific understanding of health and disease, but the causes of disease were maddeningly perplexing. Fingers were not yet pointed at such things as germs and mosquitoes.³⁵ Both sides, Blue and Gray, shared a common military medical heritage. Sick call for Confederate soldiers in the Army of the Tennessee was held immediately after reveille, and their treatment depended upon whatever the medical officer happened to have. Dr. William H. Taylor, a Southern surgeon, said his medical practice became very simplified in the field. `In one pocket of my trousers I had a ball of blue mass, in another a ball of opium. All complainants were asked the same question: `How are your bowels?` If they were open I administered a plug of opium, if they were shut I gave a plug of blue mass [a commonly used medication whose principal ingredient was mercury].`³⁶ The use of anesthesia, typically chloroform, was common, but surgeons were in a quandary between the desire to use techniques made possible by anesthesia and the threat of infection that would follow if they did. Certainly their surgical techniques were not elegant: `We groped for bullets with roughened porcelain-tipped probes, the mark of lead on the probe recording the locality of the ball.`³⁷Field hospitals were marked by piles of amputated limbs.³⁸

The opening of the war gave little hint that progress of any sort lay ahead. The Army numbered only some twenty thousand soldiers when fighting began at Fort Sumter in April 1861, and the Medical Department was also very small-only

U.S. Sanitary Commission Lodge for Invalid Soldiers, Alexandria, Virginia

113 uniformed physicians, of whom 24 resigned to join the Confederacy. But the number of medical officers mushroomed to 3,000 as the department expanded to 204 general hospitals operating 136,894 beds.³⁹

Care of the wounded became an early preoccupation of the public. The pioneering efforts of Florence Nightingale and French and English sanitary commissions did not go unnoticed. Women formed soldiers` aid societies throughout the United States to provide organized help to the Union effort. One of those groups, the Woman`s Central Association of Relief for the Sick and Wounded of the Army, combined with other groups to form the United States Sanitary Commission, which soon won a presidential mandate to conduct its inquiries. Like its Crimean War predecessors, the Sanitary Commission served as an external catalyst for change, becoming known as Lincoln`s `fifth wheel` and acting as a gadfly to the War Department. It furnished supplies and volunteer assistance to the Medical Department and brought public opinion to bear on its operations. Its special investigators included experts in emerging disciplines related to medicine such as chemistry, physiology, and statistics, scientific specialties that would eventually be incorporated into the Medical Service Corps.⁴⁰

Members of the commission presented charges of Medical Department mismanagement on their first visit to the surgeon general, and from then on the commission and the department routinely clashed. The commission pushed for well-stocked medical depots, a large ambulance corps under direct medical control, and the construction of hospitals using the latest European innovations. In pursuing those aims it influenced the dismissal of one surgeon general, Brig. Gen. Clement A. Finley, and the selection of his replacement, Brig. Gen. William A.

Hammond. The commission also earned the unrelenting animosity of perhaps the most powerful man in Washington next to President Abraham Lincoln, Secretary of War Edwin M. Stanton.⁴¹ In the West, the Western Sanitary Commission also kept pressure on the Medical Department, forcing changes to the Army`s medical supply table over the objections of the Western Department`s medical director.⁴²

Medical support deficiencies, while perhaps not discernible in peacetime, became deadly in war. In 1862 the department`s inadequacies came under scathing attack in the Congress where there were charges of the `grossest mismanagement` of Army hospitals, demands for the employment of medical inspectors, and calls for General Finley`s removal. Army physicians were called self-satisfied old men (Surgeon General Lawson had been seventy-two and in bad health when Fort Sumter fell) who had removed themselves from the practice of medicine and were out of touch with contemporary practice.⁴³ What was reported in Congress was experienced firsthand by the writer Louisa May Alcott (she later would publish Little Women). Alcott volunteered for duty as a nurse at an Army hospital in Washington, D.C., in 1862. There she worked in `famine and filth` among `violent odors that assaulted the human nose.`⁴⁴ It was, said one soldier who also worked in a Union hospital, `our terrible Hospital Service.`⁴⁵

Yet, while Stanton accused the Medical Department of `general imbecility,` it would not be fair to ascribe all medical support failures solely to the department`s ineptitude.⁴⁶ After all, Army doctrine at the time was designed for fielding small detachments in the Indian campaigns, and the military buildup for the Civil War was dependent upon the formation of volunteer regiments (roughly equivalent to today`s battalions). Regiments provided for their own medical support, so medical officers quite naturally were concerned primarily with their own units, not others. The medical system in support of the regiments was sketchy, and there was no overall plan for evacuation and hospitalization of casualties in successive steps back to the general hospitals. There was no doctrine to unite people, equipment, and facilities into an integrated system of support.

The impact of this structural disarray was compounded by the lethality of Civil War battlefields. Though most individual weapons were muzzle-loading muskets, barrels had been rifled to increase the accuracy of fire and amplify its range. Rifled muskets fired the so-called mini? ball-not a ball at all, but a heavy, conical bullet that did great damage when it smashed into flesh and bone. Late in the war breech-loading rifles completed the revolution in weapons by giving a greater rate of fire. Yet tactics failed to keep pace with technological progress, and soldiers attacking in tight formations across open fields were simply mowed down. The resulting carnage ruthlessly exposed the inadequacy of the evacuation and hospital systems.

Toward an Ambulance Corps

Soldiers wounded in July 1861 at First Bull Run had to fend for themselves because there was a `pitiful absence of provision for the wounded.`⁴⁷ Ambulance drivers were generally either impressed soldiers or wagon and hack drivers pulled from the streets of Washington, and rumors of forthcoming roundups sent drivers

fleeing from the city. Surgeons reported drivers who were insubordinate or drunk or who appropriated space inside the ambulances intended for blankets and food. As to the vehicles themselves, the Army had been forced to round up commercial wagons and hacks to serve as ambulances.⁴⁸

Second Bull Run, the following summer, demonstrated that little had improved after a year of combat operations. Army surgeons at Centreville, Virginia, operated on casualties who lay without blankets on the bare earth. Surgeon Thomas A. McParlin, medical director of the Federal Army of Virginia, wrote that Americans should follow the lead of the Europeans. `A well-organized regularly established ambulance corps would have been a blessing.`⁴⁹ The need was felt in other theaters as well. In Missouri, Surgeon John H. Brinton reported that the lack of adequate evacuation capability had caused abandonment of the wounded. Those who were able crawled to whatever cover they could reach; many were captured.⁵⁰

The absence of personnel dedicated to the evacuation mission required commanders to use combat soldiers to remove the wounded from the battlefield, further reducing the Army`s fighting strength. Not surprisingly, the speedy return of soldiers who left the battlefield to assist the wounded was problematic. A Confederate report echoed the universal complaint of line commanders: `If any from the ranks are drawn from the fight to carry off the wounded, they never return until the fight is over, and thus three are lost to the company instead of one wounded.`⁵¹

Confederate Army medical organization mirrored the Union`s, as leadership of the Southern medical department was in the hands of former Union medical officers, including Confederate Surgeon General Samuel Preston Moore. While the Confederate medical manual was based on U.S. Army regulations, its field medical doctrine included the European concept of a sanitary corps with officers and soldiers designated for evacuating the wounded. Those soldiers would serve in the front lines, where `not infrequently they lose their lives in accomplishing their benevolent tasks.`⁵²

A variety of ideas for an ambulance system surfaced in the Union Army. One was for an ambulance company of two lieutenants and sixty-seven soldiers for each corps, with the entire ambulance organization under command of a medical officer. A variation of that idea was an ambulance company for each division. The Sanitary Commission proposed an ambulance regiment for the Army of the Potomac.⁵³ Some medical officers adopted partial remedies. The Army of the Potomac published an order written by Surgeon Charles S. Tripler, the medical director, detailing twenty-five soldiers per regiment as an ambulance corps under the supervision of the brigade surgeon. Tripler required the medical officers to train the medical soldiers on a daily basis and sent his medical inspectors out to check on the instruction. The inspectors also checked the number and kind of ambulances, their condition, and whether the soldiers and vehicles were employed solely in medical evacuation.⁵⁴ In the West, Surgeon Brinton organized the regimental ambulances into ambulance trains, each under a noncommissioned officer `whose business it was to see that a continuous line of wagons should ply between the scene of conflict and the general hospitals.`⁵⁵

Brig. Gen. William A. Hammond, a 34-year-old officer, replaced General Finley as surgeon general in April 1862. Hammond, at six feet, two inches in height, 250 pounds, possessing a booming voice and an aggressive and abrasive personality, was by no means a shrinking violet. Backed by the Sanitary Commission, he had been appointed by President Lincoln over Secretary of War Stanton`s objections and immediately incurred the wrath of that powerful man.⁵⁶ But at first inertia rather than hostility was Hammond`s chief problem. Hammond quickly focused on the need for a coordinated evacuation and treatment capability and recommended establishment of an ambulance corps. However, Maj. Gen. Henry W. Halleck, the Army`s general-in-chief, rejected the proposal, declaring that ambulances would add to the problem of large combat trains, the ever-present `tooth-to-tail` argument. Halleck also feared that the presence of medical personnel on the battlefield would spread panic among soldiers who might view them as harbingers of suffering and death. Hammond tried again in September, pleading: `I only ask that some system may be adopted.` He lamented that 600 wounded soldiers still lay unattended on the battlefield of Second Bull Run, dying of starvation and neglect. His pleas were again rejected.⁵⁷

The surgeon general persisted, making the establishment of a permanent hospital and ambulance corps the highest priority in his annual report for 1862.⁵⁸ He argued that it would enable the Medical Department to enlist soldiers specifically for hospital nursing duties and for the operation of field ambulances, rather than having to depend on the unreliable practice of detailing soldiers from other branches. However, he was unable to get War Department support for his proposal that year.

The Letterman Plan

That same year, however, Hammond selected Maj. Jonathan Letterman as medical director for the Army of the Potomac. What the surgeon general was blocked from doing for the Army, the 38-year-old Major Letterman was able to do for the Army`s largest combat formation by putting together an ambulance corps as part of a unitary medical support system. Letterman, a veteran officer with thirteen years in the Army and field medical experience in the campaigns against the Seminole, Navajo, Apache, and Ute Nations, reported on 1 July 1862 to Maj. Gen. George McClellan in Virginia at Harrison`s Landing on the James River. Here the Seven Days Battle was in progress and casualties were mounting. Letterman inherited what McClellan described as a collapsed situation: `Supplies had been almost exhausted or necessarily abandoned or destroyed, and the medical officers [were] deficient in numbers or broken down by fatigue.`⁵⁹

Letterman, a man of `remarkable energy and ability,`⁶⁰ moved quickly to establish an integrated medical capability based on three principal elements: a coordinated system of casualty evacuation from the point of wounding back through the division rear; organization of medical logistics, including supply tables and transportation; and establishment of division field hospitals as part of the evacuation chain. Supported by his commander, he set forth his plan in Army of the Potomac General Orders 147, 2 August 1862, which placed all ambulances

Major Letterman (second from left) with his staff

under the control of the medical director. Captains commanded the corps-level ambulance organization, first lieutenants commanded at the division level, second lieutenants led at the brigade level, and sergeants at the regimental level. Those ambulance officers were progenitors of present-day Medical Service Corps ground and air ambulance officers.⁶¹

Letterman`s use of nonphysician officers to command ambulance units represented a significant shift in Army Medical Department policy. He intended to relieve the physicians from duties that distracted them from their primary mission of patient care, especially in combat. Letterman knew that at such times the needs of the wounded `prevented any supervision [of ambulances], when supervision was, more than at any other time, required.`⁶²

Another important feature of Letterman`s plan was the assignment of vehicles to the direct control of the medical director. Two-patient ambulances, each with two privates and a driver, were allocated on the basis of three for each infantry regiment, two for each cavalry regiment, and one for each artillery battery. Two supply wagons were assigned to each division`s ambulance corps. The use of those vehicles was strictly restricted to the Medical Department. Only medical personnel were permitted to accompany the sick and wounded to the rear, and only bona fide patients were allowed to ride in the ambulances.⁶³ A Union chaplain described Letterman as `virtually a medical dictator.`⁶⁴

Letterman implemented his plan later in the year as the Army of the Potomac fought in Virginia and then moved north into Maryland. It was only partially in place for the Battle of Antietam in September 1862, where, during twelve hours of combat, casualties from both sides rose to over 22,700. McClellan`s casualties

Wagons of the 57th New York`s ambulance corps remove wounded from the field after the Battle of Fredericksburg

mounted to 25 percent of the soldiers who went into action. On the Union right wing, where Letterman`s plan was in place, casualties were rapidly evacuated and all wounded within the Union lines were removed during the night. Casualties on the left, where the new evacuation plan was not in place, were not removed until the following night.⁶⁵

Full implementation of Letterman`s plan occurred three months later, at Fredericksburg. There, Letterman reported that the ambulance corps had begun to evacuate the wounded after dark on 13 December and by daylight had removed all the casualties except some twenty soldiers who were within the Confederate lines. Surgeon General Hammond, visiting the Army of the Potomac, was pleased with the results;⁶⁶ even more important, commanders began to recognize the advantages of a system that reduced straggling as it saved the wounded.

General McClellan wrote that Letterman`s ambulance corps decreased the number of combat soldiers pulled from the battlefield, `one of the great desiderata for our armies.`⁶⁷ The Army of the Potomac continued to benefit from its unified medical support capability in battles after Antietam.⁶⁸ There were 14,193 wounded Union soldiers at Gettysburg, 1-3 July 1863, yet there were no wounded left on the battlefield within Union lines by early morning the day after the battle. Letterman reported: `I know of no battlefield from which wounded men have been so speedily and so carefully removed.`⁶⁹ By the summer of 1864 the Army of the Potomac`s ambulance corps numbered 800 ambulances with 66 officers and 2,600 enlisted soldiers. The medical director`s central control provided the flexibility necessary to tailor the medical system to meet changing requirements. Capt. J. G. Pelton, chief of II Corps ambulances, said he could easily shift

vehicles and medical soldiers throughout his corps area of operations so as to place the evacuation capability where it was most needed.⁷⁰

Union Army units that failed to adopt Letterman`s innovations continued to experience difficulty in battlefield evacuation. Surgeon Glover Perin, upon becoming medical director of the Army of the Cumberland in February 1863, found an inefficient ambulance service. He attributed this to the absence of commissioned ambulance corps officers, the lack of attendants, and the control of ambulances by the Quartermaster Department. He adopted a modified Letterman plan, but even with that in place the Army of the Cumberland left behind an estimated twenty-five hundred of its wounded at Chickamauga in September 1863.⁷¹ Surgeon Thomas A. McParlin, then medical director of the Army of Virginia, received a copy of Letterman`s plan and submitted it to his commander, Brig. Gen. John Pope, but there was not enough time to implement it before Second Manassas. McParlin believed that Pope`s army would greatly benefit from an ambulance corps. `The lessons of experience should not be disregarded, especially in matters of such transcendant importance. At such a time, a well organized, regularly established ambulance corps would have been a blessing.`⁷²

Other armies agreed. The South was never able to field an evacuation and treatment system as sophisticated as the North`s, but in Europe, French Army surgeons applauded the American innovation of placing the treatment and evacuation systems under complete medical control. As knowledge of Letterman`s innovation spread, European armies proceeded to adopt his system.⁷³

A by-product of these innovations was the emergence of a small cadre of junior officers who understood the problems of medical evacuation. Those ambulance corps officers were often recognized for their achievements and valor. Letterman cited Capt. J. M. Garland for outstanding service in equipping the II Corps ambulance organization and for the care and diligence with which his soldiers removed the wounded at Antietam. Surgeon Henry S. Hewitt recognized Capt. S. Windecker, 103d Ohio Volunteers, for managing the Army of the Ohio evacuation system `in the most systematic and praiseworthy manner.` Windecker`s leadership had enabled Hewitt to keep just one physician with each regiment, while moving the others to the field hospitals where their medical talents could be pooled.⁷⁴

Lt. Henry Knight was cited for his courage under fire during the Union Army`s disastrous assault at Fredericksburg in 1862. Capts. W. F. Drum, B. W. Baldwin, and J. G. Pelton of the Army of the Potomac won commendations for ambulance operations that were `well and gallantly performed.`⁷⁵ Lt. Joseph C. Ayer, chief of the 1st Division ambulances, estimated that his unit evacuated nearly six hundred soldiers during Fredericksburg, and in 1863 he reported that his ambulances evacuated 1,157 casualties in the Battle of Gettysburg.⁷⁶ Letterman commended the ambulance corps for performing in a `commendable and efficient manner` at Gettysburg, on a day in which one ambulance corps officer and four privates were killed.⁷⁷

On 11 March 1864, Hammond`s efforts and the success of Letterman`s plan, backed by petitions and lobbying efforts, resulted in congressional action that

established a permanent ambulance corps. The law authorized corps commanders to detail officers and enlisted soldiers to form their ambulance organizations and provided for the examination of candidates by boards of medical officers. As one citizens` committee put it, the Army should carefully screen the officer candidates because of the special trust it placed in them, and they should `at least equal the best of the fighting-men in gallantry.`⁷⁸ The War Department implemented the law in General Orders No. 106, 16 March 1864, a directive that also gave commanders the authority to create a distinctive uniform for members of the Ambulance Corps.⁷⁹

Despite his success, Letterman had grown tired. In December 1863 he asked for relief from `18 months of arduous and eventful duty.` He was reassigned as Medical Inspector of Hospitals, Department of the Susquehanna.⁸⁰ General Hammond, while successful in obtaining the Ambulance Corps legislation, had become further alienated from Secretary of War Stanton. In May 1864 he was dismissed from the service by a court-martial on charges trumped up by Stanton.⁸¹ Letterman resigned from the service at the end of the same year. The achievements of both lived on after them.

Other Emerging Specialties

Outside the Union`s Ambulance Corps, other specialists appeared during the Civil War. A remarkable example of hospital administration could be found on the Confederate side of the line. In Richmond, Sally Louisa Tompkins headed Robertson Hospital, which, staffed with Confederate Army physicians, had a mortality rate lower than any other in the city. Abuses by some private hospitals caused the Confederacy to pass a law restricting the treatment of Confederate soldiers to hospitals commanded by commissioned officers. Jefferson Davis desired to retain Tompkins` hospital, and thus Captain Tompkins became the only woman commissioned in the Confederate Army.⁸²

Such specialists were needed. Administrative requirements bedeviled medical officers of both sides, a situation aggravated by the rapid expansion from a small regular army to a very large, mostly volunteer, military. `Army doctors in administrative positions apparently were quite at a loss in performing the duties incident to them.`⁸³ They were assisted by enlisted hospital stewards, who were responsible for general administration and were superior to all other hospital noncommissioned officers, enlisted soldiers, and nurses.⁸⁴ But seldom was there the guiding hand of an officer who understood administration and was devoted to that function alone.

Pharmacy was emerging as the accepted specialty for the compounding and dispensing of drugs. Schools of pharmacy had been established in the 1820s and the American Pharmaceutical Association formed in 1852. Civilian pharmacists were employed in the larger Army hospitals in the Civil War because, unlike the French, the Americans provided no commissions for pharmacists. The American Journal of Pharmacy criticized the lack, but there was no movement in that direction, and the argument over commissioning pharmacists would continue well into the next century.⁸⁵

Captain Tompkins

Chiropody, performed by civilians under contract to the Army, would be incorporated into the Medical Service Corps in the next century. Isachar Zacharie, a skilled chiropodist and political opportunist, received publicity as the favored bunion cutter for Lincoln, Secretary of War Stanton, and General McClellan. Lincoln credited Zacharie as the specialist who `put me on my feet,` and his fame led to calls for the creation of a chiropody corps.⁸⁶

The need for a medical supply system operated by members of the Medical Department was a lesson learned over and over again. Supply problems generated frequent complaints, but line officers continued to relegate medical logistics to the status of `least important in the Army.`⁸⁷ Letterman, as he had done with the ambulances, worked out an arrangement with the Army of the Potomac`s quartermaster that gave him exclusive control of medical wagons. He said that it was very important to place this capability within the medical organization so as to make the medical system self-sustaining and largely independent.⁸⁸

Congress improved the situation on 20 May 1862, when it authorized the Medical Department to commission U.S. Army Medical Storekeepers (USAMS), a precursor of Medical Service Corps medical logistics officers. General Hammond, while pleased with the congressional action, said the number allotted was too small. The War Department appointed a selection board, limited appointments to apothecaries or druggists, and required applicants to post a $40,000 bond before entering active duty-an extraordinary sum for the day.⁸⁹

Hammond called the medical storekeepers `a most useful class of officers,`⁹⁰ and he expanded their duties to include medical purveying, thereby releasing physicians in those assignments to medical duties. Four of the six successful candidates were later given additional appointments as acting medical purveyors. Medical storekeepers were paid $1,750 a year, including the quarters and allowances of a first lieutenant, but no rank was assigned and by custom they were addressed variously as `captain` or `mister.` Their abridged military status meant that neither they nor their families were eligible for pensions or death benefits. Congress rectified the oversight in 1867 by giving them the rank and pay of cavalry captains.⁹¹

Henry N. Rittenhouse, USAMS, described his position as `one of considerable magnitude.` Hennell Stevens, USAMS, said accountability was `right and thorough.`⁹² George Taylor Beall, USAMS, was commissioned as a medical storekeeper in 1866 and assigned to the medical purveyor`s office in Santa Fe, New Mexico. In 1875 he transferred to the St. Louis Medical Depot where he was responsible for purchasing over $1 million in medical supplies and equipment before his retirement in 1894.⁹³ The duties of Rittenhouse, Stevens, and Beall required a knowledge of pharmaceuticals, but Rittenhouse insisted that the major prerequisite was general management skills. `Scientific knowledge is not much called into play; what is required is a thorough business knowledge, a familiarity with the various customs of ordinary business transactions, sound judgment, and intimate acquaintance with the regulations, laws, orders, and circulars of the Medical Department.`⁹⁴

Overall, Civil War advances in the care of the sick and wounded had resulted less from improvements in medical science than from improved organization for medical support and the addition of new specialists to the Medical Department, such as the officers of the Ambulance Corps and the U.S. Army Medical Storekeepers. The war had seen the emergence of a genuine chain of evacuation, the appearance of large numbers of female nurses in the military hospitals, and the creation of the largest, most complex, best integrated military medical system the United States was to know until the twentieth century.

From Appomattox to Havana

The period that followed was a contradictory time for military medicine. The Medical Department, like the rest of the Army, declined in numbers. The special laws that had been passed for the prosecution of the Civil War expired when the war ended, and along with them the wartime structure of the Ambulance Corps, the general hospitals, and the hospital transports and trains disappeared. The Medical Department forfeited the progress it had made toward establishing commissioned officers in medical administrative specialties. The law that created the Ambulance Corps expired in 1866. There were two commissioned U.S. Army Medical Storekeepers in 1888, but there were none ten years later when the United States went to war with Spain.⁹⁵

There were efforts to counter those unfortunate events. In 1885 the surgeon general, Brig. Gen. Robert Murray, said the department had plans for the reestablishment of an ambulance system in the event of war. General Murray also argued that the department needed soldiers trained to provide medical care and treatment in the hospitals, and his efforts led to the creation of an enlisted hospital corps in 1887. Those medical soldiers were charged with performing `all necessary hospital services in garrison, camp, or field.`⁹⁶ Some militia organizations began to experiment with dedicated medical units that would continue to exist during peacetime as well as during wars. Massachusetts established an ambulance corps for its militia in 1885, but without the provision of ambulance corps officers.⁹⁷

Above all, the period that followed the Civil War was the time when the revolution began that transformed medicine into a science. The germ theory of dis-

ease was gradually worked out by European researchers and slowly (and in some cases reluctantly) adopted by American doctors. Army medical officers provided some leadership in the new science, notably Brig. Gen. George Miller Sternberg, who served as surgeon general from 1893 to 1902.⁹⁸ Maj. Walter Reed studied the new science and began training others at the Army Medical School, established in 1893.⁹⁹ Treatment modalities had also improved. The clinical thermometer, hypodermic syringe, and ophthalmoscope were in common use, as was the `Roentgen Ray,` the x-ray, which permitted noninvasive viewing within the body. This new technology was used by the Medical Department in Cuba. Both anesthesia and aseptic surgery were accepted practices, and orthopedic surgery beyond amputation was possible.

The war against Spain in 1898 demonstrated the difficulties facing a fledgling world power as it quickly raised and moved ground forces in its first overseas deployment. Public support for Cuban independence and growing sentiment against Spanish influence in the Western Hemisphere turned to passion when the U.S. battleship Maine sank at anchor in Havana harbor on 15 February 1898. The United States declared war on the twenty-fifth, and the `splendid little war` was on. A hastily assembled expeditionary force arrived off Santiago, Cuba, on 21 June with seventy-one medical officers and eighty-nine reporters, `the former to experience many troubles, the latter to cause many.`¹⁰⁰ Santiago surrendered on 17 July, and Spain signed the Treaty of Paris in December, withdrawing from Cuba and ceding Guam, Puerto Rico, and the Philippines to the United States.

The mobilization was anything but efficient, but national policy dictated speed, and that policy was effective even though the war was over before the logistic support was fully organized. The weaknesses included medical support, and, as Major Reed put it, the Medical Department got a `black eye."¹⁰¹

After declaring war with Spain, Congress acted to increase the Regular Army and to create a volunteer force, and the Army grew from 28,000 to nearly 275,000 personnel. Despite this dramatic growth, Congress did not increase the hospital corps, which numbered 791.¹⁰² General Sternberg, unable to expand the corps, did obtain authority to transfer soldiers from the line. But, as one chief surgeon complained, `they palmed off on the Medical Department the most undesirable element in the companies, men whom the captains wanted to get rid of.`¹⁰³ On the brighter side, hospital corps volunteers included medical students, pharmacists, and recent medical school graduates, an infusion of talent embraced as a welcome asset.¹⁰⁴

Lessons From the War With Spain

The war with Spain brought into sharper focus some of America`s inadequacies in providing medical support to its military forces, part of the larger difficulty in projecting military power. The irony of organizational problems in the U.S. military at a time when the nation prided itself on its talent for business was not lost on those who sought to learn from the conflict. It moved Theodore Roosevelt to reflect that `it was curious that when war came we should have broken down precisely on the business and administrative side, while the fighting edge of the

Frederic Remington`s drawing, Field Hospital at the `Bloody Ford` of San Juan Creek

troops left little to be desired.`¹⁰⁵ In most cases, the cure for the Medical Department`s deficiencies required the addition of commissioned officers in administrative and scientific specialties necessary for a modernized military force.

The Medical Department`s problems were thrashed out by a presidential panel. Called the Dodge Commission for its head, Grenville M. Dodge, it began hearings in September 1898. President William McKinley asked the panel to investigate charges of `criminal neglect of the soldiers in camp and field and hospital and in transports.`¹⁰⁶

Medical logistics was a major source of complaint. Theodore Roosevelt, who would parlay his wartime exploits into the governorship of New York, testified that medical supplies were insufficient at the front. There had been no cots for the wounded and no ambulances at San Juan Hill. He later wrote that `the condition of the wounded in the big field hospitals in the rear was so horrible, from the lack of attendants as well as of medicine, that we kept all the men we possibly could at the front.¹⁰⁷ One field hospital in Cuba consisted of little more than a few tents without cots, mattresses, or clothing for the patients. When Clara Barton of the American Red Cross visited the hospital at Siboney, she found wounded lying on the ground. Brig. Gen. William R. Shafter, who complained that the surgeon general `does not seem to appreciate the situation,` had halted because his force could no longer handle the casualties.¹⁰⁸ Stateside camps also had problems. Col.

William A. Pew, Jr., commander of the 8th Massachusetts Infantry at Chickamauga Park, Georgia, pointed out that his surgeon had requisitioned drugs but never received any.¹⁰⁹

General Sternberg testified that shipping of medical supplies and equipment to Cuba had been outside the Medical Department`s control. Much was late and much was lost, including an entire 200-bed hospital. Seventeen ambulances had been loaded at Tampa for Shafter`s corps; three landed in Cuba. Other medical vehicles, supplies, equipment, and even animals loaded at Tampa were never seen again. The ambulance service, such as it existed, had been decimated by an ineffectual supply system.¹¹⁰

In some cases medical logistics difficulties had been ameliorated by detailing line officers to serve as quartermasters and commissary officers for medical units. But problems remained. At the heart of the situation was the structural weakness of the Medical Department in its lack of a dedicated medical logistics organization and specially trained officers, and this deficiency had inevitably led to shortages in needed supplies and equipment where they were needed most. The surgeon general`s lack of executive power underlay the failures, a point made by one of General Sternberg`s defenders. `Our experience has taught us in a most forcible way that the Medical Department should have charge of everything pertaining to the sick and wounded.`¹¹¹

Closely related to the lack of medical logistics officers was the absence of officers dedicated to medical administration, a subject that received attention by the Dodge Commission. Certainly the unfamiliarity of military physicians with Army procedures had complicated matters, but the administrative duties expected of physicians were counterproductive. Physicians assigned to field hospitals were saddled with numerous tasks ranging from the maintenance of patient records to the supervision of food service operations. Physicians commanded ambulance units because the Medical Department had lost its ambulance corps officers.¹¹²

Sternberg recommended simplification of administrative procedures so that physicians could concentrate on their professional duties, but the problem went further than that. Witnesses repeatedly observed that many medical officers were good physicians but incompetent administrators. The situation had become so muddled in the II Corps that the chief surgeon, frustrated with the volunteer medical officers, had taken direct action in selecting commanders of the hospital enlisted detachments.

The inability of medical officers to grasp the company organization and its papers and lack of mental force or training to control the men led finally to my requesting authority to place one of the officers of the line, who are allowed as quartermasters in the division hospitals, in command of the Hospital Corps companies, and gradually matters became systematized.¹¹³

That solution went to the heart of the matter by attempting to include in the structure of medical units officers dedicated to specific administrative functions.

The need for management expertise was also evident in the administration of Army hospitals. The commander of the hospital at Camp Wikoff, a rest camp hurriedly constructed at Montauk Point, Long Island, for soldiers returning from

Red Cross nurse helps a sick soldier at the railroad station at Camp Wikoff, Montauk Point, New York

Cuba, was battered by his experience. He said one of the lessons he learned was the need for `experienced executive men` on the hospital staff.¹¹⁴ Maj. Jefferson R. Kean, commander of the 2d Division hospital at Camp Cuba Libre, Florida, believed that the lack of hospital administrative staff was the principal deficiency during the war. He suggested two administrative officers for hospitals under 300 beds, three for those over that size: `Without such staff assistance it is impossible for the commanding officer of a large hospital to keep his property and money secure, and, what is even more important, to carefully supervise the medical administration and see to it that the patients are properly cared for.`¹¹⁵

Another witness proposed two surgeons for every headquarters, one for administrative duties, the other for clinical responsibilities. More than one military surgeon suggested that since good physicians were not necessarily good administrators, the administrative part of the work could and should be handled by a line officer detailed for that purpose. Brig. Gen. Joseph P. Sanger, a former inspector general of the Army and a division commander in Cuba, included the duty of hospital commander in that category.¹¹⁶

General Sternberg also came under fire for shortcomings in preventive medicine and sanitation. Line commanders were responsible for the state of sanitation in their units, while the surgeon general was responsible for the setting of standards and policy. Sternberg had acted upon his responsibilities by issuing a circular directing medical officers to undertake a series of sanitation measures, as well

as `buck-up` circulars when the first directive failed to make a dent in the ubiquitous sanitation problems. Unfortunately, a small regular army might be expected to respond to directives, but not so with a hastily formed army of volunteer officers and recently enlisted conscripts, and Army camps remained smelly pestholes. Sternberg was a distinguished scientist with an international reputation as a bacteriologist.¹¹⁷ Nevertheless, preventive medicine measures were ignored while he `rested on the power of his circular.`¹¹⁸

The results were unfortunate: 932 soldiers were killed in action or died from wounds, yet 5,438 died of disease. In some cases, as with typhoid, the mechanics of transmission were known; in others, such as yellow fever and malaria, they were not. In any event, disease took its toll of lives and affected national strategy. Fear of disease, particularly yellow fever, was intense. A round-robin letter, signed by all but one of Shafter`s commanders after the fall of Cuba, was sent to President McKinley demanding the withdrawal of American forces before yellow fever killed them.¹¹⁹ Part of the remedy lay with better application of existing preventive medicine doctrine. However, part of the remedy resided in medical advances that would increasingly provide medical officers with effective tools.

Emerging Themes

Some basic factors leading toward the creation of the Medical Service Corps had emerged by the late nineteenth century. One was the impact of outside influences upon the Medical Department. Examples included the influence of the U.S. Sanitary Commission during the Civil War, the Dodge Commission after the war with Spain, and the national press during both emergencies. Problems that the Medical Department could avoid addressing in peacetime it inevitably had to confront in war, when shortcomings in military medical support were discovered by families of casualties and the politicians who represented them. The formation of a casualty evacuation doctrine and a corps of ambulance officers was catalyzed by such outside intervention.

At the same time the evolution of the Army itself repeatedly demonstrated the need for new officer administrative specialties, particularly in medical logistics, casualty evacuation, and-for lack of a better word-paperwork. The creation of the Ambulance Corps, the institution of U.S. Army Medical Storekeepers, the detailing of line officers to medical units, and the desire for `executive men` in hospitals were all evidence of this movement. All of these needs resurfaced in 1916 during the Punitive Expedition in Mexico, led by General John J. Pershing. The surgeon of the Southern Department reported that administrative duties were a burden for his physicians, especially those called up from the National Guard `to whom the paperwork of the Medical Department is utterly unfamiliar.`¹²⁰ But Medical Department administrative functions would continue to be performed by physicians as long as other officers were unavailable.

Technology and doctrine advanced with the introduction of ground ambulance units into the force structure. The Medical Department bought its first motor ambulance, a White Steamer, in 1906. In 1911 the department established an organization for an ambulance company of 5 medical officers, 9 noncommis?

Dean Cornwell`s painting, Conquerors of Yellow Fever

sioned officers, and 69 privates. Each ambulance company had the capability of establishing a dressing station, providing ambulance support with twelve ambulances, and attaching litter squads and runners to battalion aid stations. Motorized ambulances were used for the first time in 1916 during the Mexican Punitive Expedition, and Pershing`s surgeon recommended replacing animal-drawn ambulances with motorized vehicles.¹²¹

As the Army changed, grew, and professionalized, so did medicine, creating a need for experts in new scientific specialties. During the early 1900s American medicine continued to expand its horizons. Synthetic drugs became a possibility, and in 1910 Paul Ehrlich developed an arsenic compound, salvarsan, to combat syphilis. Major orthopedic surgery and increasingly sophisticated laboratory tests were more widely available. X-ray diagnosis, sanitation, preventive medicine, and the general use of vaccines enhanced military medical capabilities while creating the need for new expertise.¹²² And a future surgeon general, Col. William M. Gorgas, learned to work with an expanded medical team during this period.

During the war with Spain the country had witnessed the devastating impact of disease upon its Army, especially the effects of yellow fever, typhoid, and

Colonel Gorgas in Panama during construction of the canal

malaria. The result was to add impetus to scientific investigations into diseases of military significance. General Sternberg supported research after the war, sponsoring Maj. Walter Reed`s work in Cuba, which identified the method of yellow fever transmission. Convincing proof of the mosquito`s role in the spread of yellow fever and malaria meant that those diseases could be prevented by controlling the insects.

Building on those findings, William Gorgas, then a major, waged a strenuous preventive medicine campaign beginning in 1898 in Havana and continued in pioneering work during construction of the Panama Canal. France`s futile attempt to build a transisthmian canal had made Panama synonymous with pestilence and disease. Indeed, fear of yellow fever was so intense that arriving Americans sometimes brought their own coffins. Gorgas and his wife, Marie, rendered immune because of earlier bouts with the disease, arrived in Panama in the summer of 1904.¹²³ By 1906 his medical team had eliminated yellow fever there by waging war on the Stegomyia mosquito and had greatly reduced malaria by attacking the Anopheles. Gorgas estimated that his team saved over seventy-one thousand lives in the course of the canal project, a figure he based on the mortality rates from the French experience.¹²⁴

An important member of Gorgas` team in Cuba and Panama was Joseph L. LePrince, a sanitary engineer who had trained at Columbia University. LePrince,

Gorgas` assistant in Havana beginning in 1900 and chief sanitary inspector of the Isthmian Canal Commission from 1904 to 1914, was regarded by Marie Gorgas as one of her husband`s most effective aides. Another member of Gorgas` team in Panama was his son-in-law, William D. Wrightson, a sanitary engineer who had served on a team in 1916 headed by Gorgas that traveled throughout Central and South America on behalf of the International Health Board.¹²⁵ Gorgas` experience in capitalizing on the talents of LePrince and Wrightson exemplified a new reliance on nonphysician medical scientists.¹²⁶

The Medical Department`s experience through the end of the nineteenth century thus pointed to the need for new doctrine, organization, equipment, and personnel. Fortunately, many of the lessons learned were acted upon during the period leading up to World War I. The department improved its doctrine and training, prepared new supply tables, distributed improved field equipment, and in 1908 established a Medical Reserve Corps for physicians, a forerunner of the Army Reserve.¹²⁷ It also set the stage for important steps in the evolution of the Medical Service Corps.

Notes

¹Craigie: William O. Owen, The Medical Department of the United States Army: Legislative and Administrative History During the Period of the Revolution (1776-1786) (New York: Paul Hoeber, 1920), pp. 19, 24, hereafter cited as Owen, Medical Department, Lyman F. Kebler, `Andrew Craigie, the First Apothecary General of the United States,` Journal of the American Pharmaceutical Association 17 (January 1928): 63, 65. Apothecary: Lines were not firmly drawn in colonial times. The English pattern was that physicians were a learned elite who did no work with their hands. Surgeons were a lower order and practiced a craft. Apothecaries, one of whom was the English poet John Keats, compounded and dispensed drugs and also saw and treated patients. John Morgan, A Discourse upon the Institution of Medical Schools in America (Philadelphia: William Bradford, 1765), pp. iii, v; Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), pp. 37-40; Joseph M. Toner, Contributions to the Annals of Medical Progress and Medical Education in the United States Before and During the War of Independence (Washington, D.C.: Government Printing Office, 1874), pp. 58, 105-06; Herbert Clarke, The Apothecary in Eighteenth Century Williamsburg (Williamsburg, Va.: Colonial Williamsburg Foundation, 1965), pp. 4, 5, 7, hereafter cited as Clarke, Williamsburg Apothecary; Edward Kremers and George Urdang, History of Pharmacy, 3d ed. (Philadelphia: J.B. Lippincott, 1963), pp. 145-49; Owen, Medical Department, p. 140; Philip Cash, Medical Men at the Siege of Boston (Philadelphia: American Philosophical Society, 1973), p. 3.

²Department: Owen, Medical Department, pp. 28-30, 32; Harvey E. Brown, The Medical Department of the United States Army from 1775-1873 (Washington, D.C.: Surgeon General`s Office, 1873), pp. 6-7, 10.

³AMSUS award: `Annual Awards,` Military Medicine 150 (December 1985): 708. The award was established in 1959. AMSUS, the Society of the Federal Health Agencies, was founded in 1891 and incorporated by Congress in 1903.

⁴Medical capability: M.A. Reasoner, `The Development of the Medical Supply Service,` Military Surgeon 63 (July 1928): 4-8, a good summary of medical progress, hereafter cited as Reasoner, `Development of Medical Supply`; Mary C. Gillett, The Army Medical Department, 1775-1818 (Washington, D.C.: U.S. Army Center of Military History, 1981), pp. 129-49; Richard H. Shryock, Medicine and Society in America, 1660-1860 (New York: New York University Press, 1960), p. 52.

⁵Medical supply: Cash, Medical Men at the Siege of Boston, p. 134; George B. Griffenhagen, `Drug Supplies in the American Revolution,` U.S. National Museum Bulletin 225 (1961, Contributions from the Museum of Science and Technology, Paper 16), pp. 110-15, 129-30. Reorganization: Owen, Medical Department, pp. 12, 59-60. Smith: Brown, Medical Department, p. 24. Quoted words: Law of 7-8 April 1777, cited in Gillett, Army Medical Department, p. 201. First formulary: William Brown, M.D., is credited as the author of the Lititz Pharmacopoeia, the first edition of which was printed on 12 March 1778. Edward Kremers, `The Lititz Pharmacopoeia,` Badger Pharmacist (June-December 1938): 5-6.

⁶Quoted words: Reasoner, `Development of Medical Supply,` p. 12.Wilkinson: Gillett, Army Medical Department, pp. 140-42; Russell F. Weigley, History of the United States Army (New York: Macmillan, 1967), p. 107, 113-14; David A. Clary and Joseph W.A. Whitehorne, The Inspectors General of the United States Army, 1777-1903 (Washington, D.C.: Office of the Inspector General and Center of Military History, U.S. Army, 1987), pp. 86-88. Wilkinson rented swampland as a campsite for his army.

⁷Stewards: Edward Cutbush, Observations on the Means of Preserving the Health of Soldiers and Sailors and on the Duties of the Medical Department of the Army and the Navy, including `Some Remarks on Hospitals and Their Internal Arrangement,` pp. 160-210 (Philadelphia: Thomas Dobson, 1808), pp. 198-201. Some observers cite Florence Nightingale`s Notes on Hospitals (London: John W. Parker & Sons, 1859) as the first manual; others point to Joseph J. Woodward`s The Hospital Steward`s Manual (Philadelphia: J. B. Lippincott, 1862).

⁸Quoted words: Cutbush, Observations, p. 208.

⁹Quoted words: Ibid., p. 166.

¹⁰Rebuilding: Ibid., pp. 80-81; Gillett, Army Medical Department, pp. 129-49.

¹¹War of 1812: See Weigley, History of the United States Army, pp. 117-33. It ended with the Treaty of Ghent, signed in Belgium on Christmas Eve, 1814.

¹²Need for administrative support: James Mann, Medical Sketches of the Campaigns of 1812, 1813, and 1814 (Dedham, Mass.: H. Mann and Co., 1816), p. vi.

¹³Failures: Ibid., pp. 120, 257, 259.

¹⁴Quoted words: Cited in Reasoner, `Development of Medical Supply,` p. 12.

¹⁵Lovell: Brown, Medical Department, pp. 107-08; U.S. War Department, Surgeon General`s Office, Annual Report of the Surgeon General, 1 May 1819, hereafter cited as SG Report, followed by date and page, when given.

¹⁶Apothecary general: Brown, Medical Department, p. 112;SG Report, 1 May 1819, p. 22. Quoted words: SG Report, 1 November 1819, p. 16.

¹⁷Apothecary general: Congress abolished the Medical Department apothecary general and assistant apothecary general positions in 1820. Brown, Medical Department, p. 145.

¹⁸Larrey: In time the vehicle used for moving patients became known as the ambulance, but in the beginning `ambulance` meant the entire evacuation and treatment unit. See: Dominique Jean Larrey, Memoirs of Military Surgery and Campaigns of the French Army, trans. Richard W. Hall (Baltimore: Joseph Cushing, 1814), pp. v-ix, 28-29, 78, 223-24; Leon Legouest, Chirurgie D`Armee (Paris: J.B. Bailliere, 1863), p. 984; M. Boudin, Systeme des Ambulances des Armees Francais et Anglais (Paris: J.B. Bailliere, 1855), p. 5; Julie M. DiGioia et al., `Baron Larrey: Modern Military Surgeon,` American Surgeon 49 (May 1983): 226-30; Lyman A. Brewer, `Baron Dominique Jean Larrey (1766-1842),` Journal of Thoracic and Cardiovascular Surgery 92 (December 1986): 1096-97; Thomas Longmore, A Manual of Ambulance Transport,ed. William A. Morris (London: Harrison and Sons, 1893), pp. 2, 7-10, 21-26, 39; Unpublished paper, James Warren Wengert, M.D., `The Military Ambulance,` September 1981, in Office of the Chief, Medical Service Corps, Office of the Surgeon General (DASG-MS); Mann, Medical Sketches, p. 247; Cutbush, Observations, p. 164; Gillett, Army Medical Department, pp. 85-87.

¹⁹French doctrine: Larrey, Memoirs of Military Surgery, p. 223.

²⁰Doctrinal weakness: Legouest, Chirurgie D`Armee, p. 984; Bennett A. Clements, `Memoir of Jonathan Letterman, M.D.,` Journal of the Military Service Institution 4 (September 1883): 5-6. Solferino: The weaknesses inherent to the incomplete system caused a debacle at Solferino, Italy, in June 1859. The suffering so distressed a Swiss banker, Henry Dunant, that he organized the Geneva Conventions for the sick and wounded and later formed the Red Cross. J. Henry Dunant, A Memory of Solferino, trans. District of Columbia Chapter of the American Red Cross (published 1862 as Un Souvenir de Solferino; reprinted Washington, D.C.: American Red Cross, 1939), pp. 39-46; Carol Z. Rothkopp, Jean Henri Dunant (New York: Franklin Watts, 1969), pp. 6, 40-48.

²¹Crimean War: Louis C. Duncan, `The Comparative Mortality of Disease and Battle Casualties in the Historic Wars of the World` (hereafter cited as Duncan, `Comparative Mortality`), in Duncan, The Medical Department of the United States Army in the Civil War, one volume printed in sections (Washington, D.C.: Office of the Surgeon General, 1910), pp. 25-26, volume hereafter cited as Duncan, Medical Department in the Civil War. England and France fought with Turkey and Sardinia against Russia, mostly on the Russian Crimea peninsula, to successfully block Russian designs on Turkish territories.

²²Evacuation: Louis Baudens, On Military and Camp Hospitals and the Health of Troops in the Field, trans. Franklin B. Hough (New York: Baillaire Brothers, 1862), p. 182; Edward Bruce Hamley, The War in the Crimea (reprint, Westport, Conn.: Greenwood Press, 1971), pp. 167-73, 179. Quoted words: Hamley, p. 173.

²³Nightingale: Zachary Cope, Florence Nightingale and the Doctors (Philadelphia: J.B. Lippincott, 1958), pp. 14-16, 61-62, 99.

²⁴Quoted words: Florence Nightingale, Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army (London: Harrison and Sons, 1858), p. 220.

²⁵Staff: Ibid., pp. 220-28, 288.

²⁶Quoted words: Ibid., p. 107.

²⁷Lawson: Mary C. Gillett, `Thomas Lawson, Second Surgeon General of the U.S. Army: A Character Sketch,` Prologue 14 (Spring 1982): 23-24.

²⁸Quoted words: SG Report, 1855, p. 13.

²⁹Stewards: War Department, Regulations for the Medical Department of the Army (1861; reprint Knoxville, Tenn.: Bohemian Brigade Bookshop, 1989), pp. 10, 16, hereafter cited as Regulations for the Medical Department.

³⁰Quoted words: Ibid., p. 5.

³¹War with Mexico: Weigley, History of the United States Army, pp. 173-96; Richard H. Coolidge, Statistical Report on the Sickness and Mortality in the Army of the United States, January, 1839, to January, 1855 (Washington, D.C.: A.O.P. Nicholson, 1856), pp. 606, 610; Leonard Wood, Our Military History, Its Facts and Fallacies (Chicago: Reilly and Britton Co., 1916), p. 147.

³²Military medicine: Louis C. Duncan, `A Medical History of General Zachary Taylor`s Army of Occupation in Texas and Mexico, 1845-47,` Military Surgeon 48 (1921): 79; Duncan, Medical Department in the Civil War, pt. 6, p. 37; Duncan, `Medical History of General Scott`s Campaign to the City of Mexico in 1847,` Military Surgeon 47 (1920): 604-07; Fielding H. Garrison, Notes on the History of Military Medicine (Washington, D.C.: Association of Military Surgeons of the United States, 1922), p. 170; J. Antonio Aldrete, `The First Administration of Anesthesia in Military Surgery: On Occasion of the Mexican-American War,` Anesthesiology 61 (November 1984): 585.

³³Indian Wars: Regulations for the Medical Department, pp. 17, 18.

³⁴Planning efforts: U.S. War Department, Surgeon General`s Office, The Medical and Surgical History of the War of the Rebellion, 2 vols., vol. 2, 2d ed., Surgical History (Washington, D.C.: Government Printing Office, 1883), p. 933, series hereafter cited as War Department, Medical and Surgical History; Brown, Medical Department, p. 212. Ambulances: Arnold G. Fisch, Jr., and Robert K. Wright, Jr., The Story of the Noncommissioned Officer Corps: The Backbone of the Army (Washington, D.C.: U.S. Army Center of Military History, 1989), p. 76, hereafter cited as Fisch and Wright, Noncommissioned Officer Corps.

³⁵Medical progress: Shryock, Medicine and Society, p. 150.

³⁶Quoted words: Horace H. Cunningham, Doctors in Gray: The Confederate Medical Service (Baton Rouge: Louisiana State University, 1958), p. 111. Also see George W. Adams, Doctors in Blue: The Medical History of the Union Army in the Civil War (New York: H. Schuman, 1952), p. 112; William M. Straight, `Medical Logistics of the Confederate Army,` Bulletin of the University of Miami School of Medicine 15 (Spring 1961): 60. Blue mass: Also called mercury mass and blue pills, a combination of several ingredients, of which approximately 35 percent was mercury. If the illness didn`t kill you the cure would.

³⁷Quoted words: Silas Weir Mitchell, The Medical Department in the Civil War (Chicago: American Medical Association, 1914), p. 11, hereafter cited as Mitchell, The Medical Department.

³⁸Hospitals: For an eyewitness account see Rice Bull, Soldiering: The Civil War Diary of Rice C. Bull, 123rd New York Volunteer Infantry, ed. K. Jack Bauer (Novato, Calif.: Presidio Press, 1977), pp. 73-74.

³⁹Medical Department: Speech, Henry W. Bellows, President, U.S. Sanitary Commission, at the Academy of Music, Philadelphia, 24 Feb 1863 (Philadelphia: C. Sherman, Son, 1863), pp. 8-9, in archives of the American Hospital Association, Chicago, Ill., hereafter cited as Bellows, 1863 Speech; Mitchell, The Medical Department, p. 5;SG Report, 1865, p. 3.

⁴⁰Sanitary Commission: William Q. Maxwell, Lincoln`s Fifth Wheel (New York: Longmans, Green, 1956), pp. 1-2; Charles J. Stille, History of the United States Sanitary Commission (Philadelphia: J.B. Lippincott, 1866), pp. 166, 551; Bellows, 1863 speech. The Sanitary Commission`s investigators included John W. Draper, professor of chemistry; Edward Jarvis, statistician; and H. A. Johnson, professor of physiology and histology. For an insider`s description of the commission`s activities, including the role of women, see Katharine Prescott Wormeley, The United States Sanitary Commission: A Sketch of Its Purposes and Work (Boston: Little, Brown, 1863). `Never before in the history of the world have women had such an opportunity to use themselves for great purpose` (ibid., p. 41).

⁴¹Commission influence: Stille, Sanitary Commission,p. 48; Maxwell, Lincoln`s Fifth Wheel, p. 94. Finley`s dismissal: Maxwell, Lincoln`s Fifth Wheel, p. 118; James M. Phalen, Chiefs of the Medical Department (Carlisle Barracks, Pa.: Medical Field Service School, 1940), p. 40; A. Howard Meneely, The War Department, 1861 (New York: Columbia University Press, 1928), pp. 227, 355. Frederick Law Olmsted, the Sanitary Commission`s outspoken secretary general, called Finley `a self-satisfied, supercilious, bigoted block-head` (Meneely, The War Department, p.227).

⁴²West: Jacob G. Forman, The Western Sanitary Commission (St. Louis: R. P. Studley, 1864), pp. 16-17.

⁴³Congress: `Management of Government Hospitals,` Francis P. Blair and John C. Rives, eds., Congressional Globe (Washington, D.C.: Blair and Rives, 1862), 37th Cong., 2d sess., 30 Jan 1862, pp. 557-59; quoted words, p. 557. The Globe was the predecessor to the Congressional Record. Lawson: Phalen, Chiefs of the Medical Department, p. 36.

⁴⁴Quoted words: Louisa May Alcott, Hospital Sketches (New York: Saganore Press, 1863), pp. 16, 57.

⁴⁵`Terrible`: Bull, Soldiering, p. 25. See his account of nursing a fellow soldier, pp. 23-25.

⁴⁶Quoted words: Allan Nevins and Milton H. Thomas, eds., The Diary of George Templeton Strong, 4 vols. (New York: Macmillan, 1952), 3: 218.

⁴⁷Quoted words: Duncan, Medical Department in the Civil War, pt. 1, p. 6.

⁴⁸First Bull Run: Maxwell, Lincoln`s Fifth Wheel, p. 167; Duncan, Medical Department in the Civil War, pt. 3, pp. 43, 54. See also Stewart Brooks, Civil War Medicine (Springfield, Ill.: Charles C. Thomas, 1966), p. 13.

⁴⁹Quoted words: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 117.

⁵⁰Brinton`s report: Ibid., p. 19.

⁵¹Evacuation: See Clements, `Memoir of Jonathan Letterman,` pp. 5-6; War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 23. Quoted words: J. Julian Chisholm, A Manual of Military Surgery for the Use of Surgeons in the Confederate Army (Richmond: West and Johnston, 1861), p. 92, hereafter cited as Chisholm, Confederate Manual.

⁵²Confederate doctrine: Cunningham, Doctors in Gray, pp. 27-28; Chisholm, Confederate Manual, pp. 92-93, 438-40, 443-47; Alvin R. Sunseri, `The Organization and Administration of the Medical Department of the Confederate Army of Tennessee,` Journal of the Tennessee State Medical Association 53 (April 1960): 168, hereafter cited as Sunseri, `Confederate Army of Tennessee.` Also see Frank R. Freeman, `Administration of the Medical Department of the Confederate States Army, 1861-5,` Southern Medical Journal 80 (May 1987): 637. Quoted words: Chisholm, Confederate Manual, pp. 92-93. System: For a wounded Union prisoner`s account of the Confederate medical support system see Bull, Soldiering, pp. 57-82.

⁵³Proposals: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 50, and pt. 3, vol. 2, p. 932; Stille, Sanitary Commission, p. 103.

⁵⁴Tripler`s plan: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 59.

⁵⁵Doctrine: Duncan, Medical Department in the Civil War, pt. 2, p. 21; John H. Brinton, Personal Memoirs of John H. Brinton (New York: Neale Publishing Co., 1914), pp. 124-25. Quoted words: Ibid., p. 27.

⁵⁶Hammond: Phalen, Chiefs of the Medical Department, pp. 42-46; Maxwell, Lincoln`s Fifth Wheel, pp. 169, 194; Louis C. Duncan, `The Strange Case of Surgeon General Hammond,` Military Surgeon 64 (January 1929): 102, 104, hereafter cited as Duncan, `Surgeon General Hammond.` Stanton was bitter: `I`m not used to being beaten, and don`t like it` (quoted in Nevins and Thomas, eds., Diary of George Strong, 3: 314).

⁵⁷Hammond`s pleas: Reprints of correspondence, Stanton to Hammond, 21 Aug and 7 Sep 1862, and Stanton to McClellan, 25 Oct 1862, in `Notes on the Recent Civil War,` Historical Magazine (April 1867): 231-32; Maxwell, Lincoln`s Fifth Wheel, p. 194; Duncan, `Surgeon General Hammond,` p. 110; War Department, Medical and Surgical History, app., pt. 3, vol. 2, pp. 933-34. After the war was over, the official Medical Department history concluded that `notwithstanding the opinion of General H.W. Halleck, no panics or stampedes were reported as having been caused by the presence of non-combatants of the Ambulance Corps` (ibid., p. 943).

⁵⁸Hammond persists: SG Report, 10 Nov 1862. Also see Henry I. Bowditch, A Brief Plea for an Ambulance System, pamphlet (Boston: Ticknor and Fields, 1863), p. 25.

⁵⁹Letterman: James M. Phalen, `The Life of Jonathan Letterman,` Military Surgeon 84 (January 1939): 62; Clements, `Memoir of Jonathan Letterman,` pp. 2-4. Quoted words: U.S. Congress, House, Report of George B. McClellan, Army of the Potomac, H. Exec. Doc. 15, 38th Cong., 1st sess., 22 Dec 1863, p. 26.

⁶⁰Quoted words: George B. McClellan, McClellan`s Own Story (New York: Charles L. Webster, 1887), p. 127, hereafter cited as McClellan, Own Story.

⁶¹Letterman`s plan: Later amended and reissued as War Department General Orders (WDGO) 85, 24 Aug 1863. War Department, Medical and Surgical History, app., pt. 3, vol. 2, pp. 933, 938-41; Jonathan Letterman, Medical Recollections of the Army of the Potomac (New York: D. Appleton, 1866), p. 20; McClellan, Own Story, p. 127; Duncan, Medical Department in the Civil War, pt. 4, p. 22; Edward Lymon Munson, The Principles of Sanitary Tactics; A Handbook on the Use of Medical Department Detachments and Organizations in Campaign (Menasha, Wisc.: Press of Bonta Publishing Co., 1911), pp. 18-19, hereafter cited as Munson, Sanitary Tactics; Clements, `Memoir of Jonathan Letterman,` p. 10; George H. Lyman, Some Aspects of the Medical Service in the Armies of the United States During the War of the Rebellion (Boston: S. J. Parkhill, 1891), p. 22, hereafter cited as Lyman, Medical Service During the War of the Rebellion.

⁶²Quoted words: Letterman, Medical Recollections, p. 23.

⁶³Ambulances: For a harrowing description of an ambulance ride see Bull, Soldiering, pp 83-85.

⁶⁴Control: War Department, Medical and Surgical History, pt. 3, vol. 2, pp. 938-41. Quoted words: Duncan, Medical Department, Civil War, pt. 6, p. 39.

⁶⁵Antietam: Letterman, Medical Recollections, pp. 42-43, 80; Stephen W. Sears, Landscape Turned Red (New York: Ticknor and Fields, 1983), pp. 295-96; Livermore, Numbers and Losses in the Civil War in America, 1861-1865 (New York: Houghton Mifflin, 1900), pp. 92-93; War Department, Medical and Surgical History, pt. 3, vol. 2, p. 937; John W. Schildt, Antietem Hospitals, (Chewsville, Md.: Antietem Publications, 1987), pp. 10-11.

⁶⁶Fredericksburg: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 131; Brinton, Personal Memoirs, p. 222.

⁶⁷`Desiderata`: Bowditch, A Brief Plea, pp. 27-28.

⁶⁸Successes: War Department, Medical and Surgical History, app., pt. 1, vol. 1, pp. 141-42, 148, 205.

⁶⁹Gettysburg: Ibid., pp. 141-42. Quoted words: Ibid., p. 142.

⁷⁰Pelton`s report: Ibid., p. 219.

⁷¹Chickamauga: Ibid., pp. 265-66.

⁷²Quoted words: Brinton, Personal Memoirs, pp. 111-12.

⁷³South: Sunseri, `Confederate Army of Tennessee,` p. 168. European status: Jean Larrey, Memoirs of Military Surgery, pp. v-ix, 28-29, 78, 223-24. Legouest`s views: Leon Legouest, Le Service de Sante des Armees Americaines, (Paris: J.B. Bailliere, 1863), p. 4.

⁷⁴Garland and Windecker: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 98; Letterman, Medical Recollections, pp. 42-43, 313.

⁷⁵Quoted words: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 167.

⁷⁶Ayer: Duncan, Medical Department in the Civil War, pt. 6, p. 15, and pt. 7, p. 16.

⁷⁷Killed in action and quoted words: War Department, Medical and Surgical History, app., pt. 1, vol. 1, p. 142.

⁷⁸Quoted words: The Ambulance System: Reprinted from the North American Review, January 1864, and Published, for Gratuitous Distribution, by the Committee of Citizens Who Have in Charge the Sending of Petitions to Congress for the Establishment of a Thorough and Uniform Ambulance System in the Armies of the Republic (Boston: Crosby and Nichols, 1864), p. 15.

⁷⁹Ambulance Corps legislation: 13 Stat. 20-22, 11 Mar 1864; William O. Owen, A Chronological Arrangement of Congressional Legislation Relating to the Medical Corps of the US. Army from 1785-1917 (Chicago: American Medical Association, 1920), p. 24, hereafter cited as Owen, Legislation, 1785-1917; WDGO 106, 16 Mar 1864, Pentagon Library, The Pentagon, Washington, D.C. (PL).

⁸⁰Letterman: Maxwell, Lincoln`s Fifth Wheel, p. 179, 185; Clements, `Memoir of Jonathan Letterman,` p. 20; Phalen, `The Life of Jonathan Letterman,` pp. 63-64. Letterman`s daughter believed he was frustrated by the Army`s slowness in adopting his plan. Catherine Letterman to Wilber M. Brucker, Secretary of the Army (Sec Army), 4 Oct 1957, Medical Service Corps history files, U.S. Army Center of Military History, Washington, D.C. (MSC-USACMH). Quoted words: Letterman, Medical Recollections, p. 185.

⁸¹Court-martial: War Department Special Orders (WDSO) 3, 3 Sep 1863, PL; Phalen, Chiefs of the Medical Department, pp. 44-45; Maxwell, Lincoln`s Fifth Wheel, pp. 233-47; Brown, Medical Department, p. 235; Brinton, Personal Memoirs, p. 256. President Hayes exonerated Hammond in

1878, belatedly restoring the reputation of a man who had pushed the Medical Department into action. Congressional action on 15 March restored Hammond to the Army and placed him on the retired list in the grade of brigadier general. In his brief tenure Hammond had organized a medical museum, a Medical Department school, and a military medical history program that would make major contributions to medical literature. He had pressed for the creation of permanent hospital and ambulance corps and for departmental autonomy in its facilities, construction, supply, and transportation.

⁸²Tompkins: Robert S. Holzman, `Sally Tompkins: Captain, Confederate Army,` American Mercury 88 (March 1959): 127-30; Dictionary of American Biography, `Sally Louisa Tompkins`; David B. Sabine, `Captain Sally Tompkins,` Civil War Times Illustrated 4, no. 7 (1965): 36-39. Tompkins was buried with full military honors in 1916. Her hospital had 73 deaths for 1,333 admissions from August 1861 to April 1865. Brooks, Civil War Medicine, p. 57.

⁸³Physicians and administration: Cunningham, Doctors in Gray, pp. 126, 249; Sunseri, `Confederate Army of Tennessee,` p. 18. Quoted words: Charles Lynch, Frank W. Weed, and Loy McAfee, The Surgeon General`s Office, vol. 1 of the series The Medical Department of the United States Army in the World War (Washington, D.C.: Government Printing Office, 1925), p. 47, hereafter cited as Lynch, Surgeon General`s Office.

⁸⁴Stewards: War Department, Regulations for the Medical Department, p. 8; Joseph J. Woodward, The Hospital Steward`s Manual (Philadelphia: J.B. Lippincott, 1862), pp. 43-45, 313. See also George R. Wren, `The First Trained U.S. Hospital Administrator and His Textbook,` Hospital & Health Services Administration 26 (Winter 1981): 56; Joseph P. Peters, `How the Civil War Changed Hospital Care,` Modern Hospital 98 (May 1962): 114, 172; Brooks, Civil War Medicine, pp. 34, 50; Joseph Israeloff, `The Emerging Role of the Medical Service Corps Officer in the Evolution of the Army Medical Service,` Military Medicine 125 (April 1960): 269.

⁸⁵Pharmacists: Shryock, The Development of Modern Medicine (New York: Alfred A. Knopf, 1947), p. 152; Edward R. Fell, `The Pharmaceutical Department of a U.S.A. Hospital,` American Journal of Pharmacy 37 (1865): 107-10; Editorial, `Military Pharmaceutists,` American Journal of Pharmacy 34 (1862): 94. For example, the 3,600-bed Army General Hospital at Chestnut Hill, Pennsylvania, had twelve contract pharmacists.

⁸⁶Zacharie: `The Head and Foot of the Nation,` New York Herald, 3 October 1862; Charles M. Segal, `Isachar Zacharie: Lincoln`s Chiropodist,` American Jewish Historical Quarterly 43 (December 1953): 78-79, 81. Quoted words: Segal, p. 71.

⁸⁷Quoted words: Letterman, Medical Recollections, p. 32.

⁸⁸Medical logistics: SG Report, 1855, p. 5; Duncan, Medical Department in the Civil War, pt. 5., p. 21; Maxwell, Lincoln`s Fifth Wheel, p. 171. For complaints see: Surgeon Charles B. Tripler to Surgeon General William A. Hammond, 9 May 1862; Brigade Surgeon J.H. Thompson to Brig. Gen. J.G. Foster, USA, 1 Mar 1862, and subsequent correspondence ending in Maj. J. Belga, Quartermaster Corps (QM), to Thompson, 21 Mar 1862, Record Group (RG) 112, Series 12, Box 99, National Archives, National Archives and Records Administration, Washington, D.C. (NARA?NA). Letterman`s view: Letterman, Medical Recollections, pp. 178-79; War Department, Medical and Surgical History, app., pt. 1, vol. 1, pp. 133-34.

⁸⁹USAMS: 12 Stat. 403, 20 May 1862; Owen, Legislation, 1785-1917, pp. 21, 28, and 29; WDGO 55, 24 May 1862, PL; Brown, Medical Department, pp. 224-25, 253; Henry N. Rittenhouse, `U.S. Army Medical Storekeepers,` American Journal of Pharmacy 37 (1865): 88-89; Caswell A. Mayo, `Why the Pharmaceutical Corps Should Be Established,` American Druggist 66 (April 1918): 25.

⁹⁰Quoted words: SG Report, 10 Nov 1862, p. 7.

⁹¹Rank: 14 Stat. 423, 2 Mar 1867. Congress abolished the USAMS in 1876, but grandfathered those on active duty. 19 Stat. 61, 26 Jun 1876.

⁹²Quoted words: Rittenhouse, `U.S. Army Medical Storekeepers,` p. 89; Hennell Stevens, `The Medical Purveying Department of the United States Army,` American Journal of Pharmacy 37 (1865): 98.

⁹³Beall: Biographical note, Charles Ellsworth, U.S. Army Center of Military History (USACMH), 2 Sep 1967, drawn from RG 94, Records of the Adjutant General`s Office (AGO), Appointments, Commissions and Personnel Branch, DASG-MS.

⁹⁴Rittenhouse: Rittenhouse, `U.S. Army Medical Storekeepers,` p. 90.

⁹⁵Dismantling: Surgeon General Joseph K. Barnes summarized the process in SG Report, 1866, p. 2. For numbers, see SG Report, 1888, p. 145, and 1898, pp. 1154-56. Also see Lyman, Medical Service During the War of the Rebellion, p. 40; James A. Tobey, The Medical Department of the Army (Baltimore: Johns Hopkins, 1927), pp. 20-24. General Hammond`s successor, Brig. Gen. Joseph K. Barnes, bemoaned the loss of Medical Department capability. `Congress followed the usual plan of reducing the Army and throwing into the discard everything learned in the meanwhile` (Reasoner, `Medical Supply Service,` p. 19).

⁹⁶Murray: SG Report, 1885, p. 39. Quoted words: Statutes at Large of the United States of America, December 1885-March 1887 (Washington, D.C.: Government Printing Office, 1887), 24: 435-36.

⁹⁷Massachusetts: Fisch and Wright, Noncommissioned Officer Corps, pp. 76-78.

⁹⁸Sternberg: See James S. Simmons, `Military Preventive Medicine: The Keystone of Military Strength,` in Military Medicine Notes, 3 vols. (Washington, D.C.: Army Medical Service Graduate School, 1951), 1: 4-5, copy in the Joint Medical Library of the Army and Air Force Surgeons General, Washington, D.C. (JML).

⁹⁹Reed: SG Report, 1896, p.23. Reed, professor of clinical and sanitary microscopy, trained medical officers in pathogenic bacteria and the microscopic study of sputum, urine, blood, and tumors.

¹⁰⁰Quoted words: Percy M. Ashburn, A History of the Medical Department of the United States Army (Boston: Houghton Mifflin, 1929), p. 185.

¹⁰¹Mobilization: David F. Trask, The War with Spain in 1898 (New York: Macmillan, 1981), pp. 192-93; Weigley, History of the United States Army, pp. 308-09. Quoted words: Maj Walter Reed, MC, to Maj William C. Gorgas, MC, 29 Jul 1901, cited in William C. Gorgas, Sanitation in Panama (New York: D. Appleton, 1915), p. 89. For discussion see: Lynch, Surgeon General`s Office, p. 32; James Johnston, `Army Medical Service in the Spanish War,` New York Medical Journal 82 (5 August 1905): 301-05.

¹⁰²Expansion: Weigley, History of the United States Army, p. 297; SG Report, 1898, pp. 102, 148. The Regular Army strength was 2,143 officers and 26,040 enlisted. U.S. Congress, Senate, Report of the Commission Appointed by the President To Investigate the Conduct of the War Department in the War with Spain, 56th Cong., 1st sess., S. Doc. 221, 1: 113, hereafter cited as Dodge Commission Report. Hospital Corps: SG Report, 1899, p. 24.

¹⁰³Quoted words: Rpt of Lt Col AC. Girard, Chief Surgeon, II Corps, SG Report, 1898, p. 157.

¹⁰⁴Volunteers: SG Report, 1891, p. 10.

¹⁰⁵Quoted words: Theodore Roosevelt, The Rough Riders(New York: Charles Scribner`s Sons, 1920), p. 185.

¹⁰⁶Quoted words: Dodge Commission Report, 1: 6-7.

¹⁰⁷Quoted words: Roosevelt, The Rough Riders, p. 119. Roosevelt`s testimony: Dodge Commission Report, 5: 2267-69.

¹⁰⁸Quoted words: Shafter to Adjutant General, War Department (WD), 29 Jul 1898, in War Department, Correspondence Relating to the War with Spain (Washington, D.C.: Government Printing Office, 1902), p. 186. `I will not quietly submit to having the onus laid on me for the lack of these hospital facilities` (ibid., 3 Aug, p. 187).

¹⁰⁹Colonel Pew: Dodge Commission Report, 4: 1011.

¹¹⁰Medical deployment: SG Report, 1898, pp. 103, 116; Weigley, History of the United States Army, p. 302; Margaret Leech, In the Days of McKinley (New York: Harper and Brothers, 1959), pp. 261-62.

¹¹¹Quoted words: Nicholas Senn, Medico-Surgical Aspects of the Spanish American War (Chicago: American Medical Association, 1900), p. 182, hereafter cited as Senn, Medico-Surgical Aspects.

¹¹²Shortcomings: SG Report, 1898, pp. 115-42, 158; SG Report, 1899, pp. 60-65; Dodge Commission Report, 1: 188-89, 571, 574, 686-87, and 5: 2107.

¹¹³Quoted words: Lt. Col. A.C. Girard in SG Report, 1898, p. 158.

¹¹⁴Quoted words: Maj. Frank J. Ives in Dodge Commission Report, 4: 2107. Camp Wikoff: `The strongest survivors of Shafter`s campaign were not fit for a tramp of several miles . . . the regulars shambled into line like a retinue of ghosts with skeleton faces and blank unseeing eyes.` Leech, In the Days of McKinley, p. 308.

¹¹⁵Quoted words: Ltr, Maj J. R. Kean, 18 Oct 1898, cited in Col E. M. Wones, MSC, Ret., draft section, sub: Introduction and Early Requirements, 1961, in 1958 MSC History Project, folder 239, box 15/18, MSC-USACMH. Also see report by Lt. Col. Louis M. Maus, Chief Surgeon, VII Corps, Fort Hamilton, New York, on the difficulty of converting civilian physicians into military medical officers. SG Report, 1899, p. 72.

¹¹⁶Proposals: Dodge Commission Report, 7: 325, and 4: 1121, 1146-47, 1413.

¹¹⁷Sternberg: He was called the father of American bacteriology. See Simmons, `Military Preventive Medicine,` 1: 4-5.

¹¹⁸Sternberg`s circular: Surgeon General`s Office (SGO) Circular (Cir) 1, 25 Apr 1898; Cir 5, 8 Aug 1898; Cir 7, 5 Sep 1898, in Sternberg, Sanitary Lessons of the War (Washington, D.C.: privately published by Byron J. Adams, 1912), pp. 9-12. Criticism of Sternberg: Leech, In the Days of McKinley, pp. 300-308; Weigley, History of the United States Army, pp. 304-05. Sternberg defended himself (including criticism by Theodore Roosevelt) in his Sanitary Lessons of the War, pp. 8, 26. Other defenders include John M. Gibson, Soldier in White (Durham, N.C.: Duke University, 1958), pp. 199-209; Senn, Medico-Surgical Aspects, pp. 73-78, 182; Martha L. Sternberg, George Miller Sternberg (Chicago: American Medical Association, 1920). Sternberg did admit disappointment over the mortality rates (ibid., p. 188). Quoted words: Leech, In the Days of McKinley, p. 301.

¹¹⁹Disease: Duncan, `Comparative Mortality,` p. 32. Round-robin letter: Leech, In the Days of McKinley, pp. 274-77; Roosevelt, The Rough Riders, pp. 209-12, 280-83.

¹²⁰Quoted words: SG Report, 1917, p. 172. That sentiment was echoed by the 11th Division (Provisional). See ibid., p. 144.

¹²¹First ambulance: Rpt, George A. Scheier, Managing Editor, Bulletin of the U.S. Army Medical Department, Office of The Surgeon General (OTSG), sub: Army Medical Department Chronology, 1775-1947, 1 Oct 1947, pp. 35, 37, 46, copy in DASG-MS. Doctrine: James L. Bevans, `The Ambulance Company,` in Sanitary Field Service School for Medical Officers (SFSS), Sanitary Field Service (Fort Leavenworth, Kans., 1912), pp. 4-9, 34, hereafter cited as FS Schools, Sanitary Field Service. First use: SG Report, 1917, p. 158.

¹²²Advances: Louis H. Roddis, `Ten Greatest Advances in Medicine,` Military Surgeon 115 (December 1954): 449; M.A. Reasoner, `The Development of the Medical Supply Service,` Military Surgeon 63 (July 1928): 4; David McCullough, The Path Between the Seas (New York: Simon and Schuster, 1977), p. 416.

¹²³Gorgas: SG Report, 1883, p. 12.

¹²⁴Yellow fever: Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas: His Lift and Work (New York: Doubleday, Page and Company, 1924), pp. 8-11, 174, 187-88. Gorgas` estimate: William C. Gorgas, Sanitation in Panama (New York: D. Appleton and Company, 1915), pp. 182-204, 230-31, 283. Black workers found Panama four times as deadly as did whites. See McCullough, The Path Between the Seas, pp. 581-85.

¹²⁵Wrightson: Biographical Sketch, The Historical Unit (THU), OTSG, in MSC?USACMH; 1st Lt R.W. Bamberg, MSC, citing memo, The Surgeon General (TSG) for Wrightson, in draft rpt, sub: History of the Medical Service Corps, 20 Sep 1954, THU, OTSG, folder 260, box 16\u00018, MSC-USACMH; Gorgas and Hendrick, William Crawford Gorgas, pp. 297-301.

¹²⁶LePrince: Gorgas and Hendrick, William Crawford Gorgas, pp. 104, 150, 172, 254; McCullough, The Path Between the Seas, pp. 419, 449; Gorgas, Sanitation in Panama, pp. 182-204, 230-31; Gordon Harrison, Mosquitos, Malaria and Man (New York: E.P. Dutton, 1978), p. 164; Joseph A. LePrince and A.J. Orenstein, Mosquito Control in Panama (New York: G.P. Putnam`s Sons, 1916), p. 303. LePrince became a commissioned officer of the U.S. Public Health Service in 1915 and served as its senior sanitary engineer from 1917 to 1935. He headed the antimalarial activities at Army and Navy training camps in the United States during the war, a program that reduced the malaria sick rate to less than one-half of one percent of that which occurred on Army bases in the South during the Spanish-American War.

¹²⁷Reserves: Richard B. Crossland and James T. Currie, Twice the Citizen: A History of the United States Army Reserve, 1908-1983 (Washington, D.C.: Office of the Chief, Army Reserve, 1984), pp. 17-20.