September 6, 2017

The Crimean War and the Evolution of the United States Medical Department During the American Civil War

Historians have consistently emphasized the fact that the Union army was wholly unprepared for the Civil War in April of 1861. In almost every aspect of what it takes to wage war on the scale that this conflict required, the army had neither the resources nor the experience to execute a war of this magnitude. One area where this became blatantly obvious very early in the conflict was the Army Medical Department’s care and treatment of the sick and wounded. The Bureau had neither the administrative resources and experience nor the logistic support system for the conflict in the early months. Weighed down by legal limitations, regulations, and army dogma, the department struggled to adapt to rapidly changing requirements placed on medical personnel both clinically and administratively.

Despite the Herculean task, the Army did adapt to the war’s demands in a relatively short time. Historians have often attributed intrinsic factors in the maturation of the department. They have cited innovative leadership in the Medical Bureau, supportive leadership in the line community, and the exigencies of war as major reasons for the transition from an anachronistic regulation bound institution to the state-of-the-art organization emulated internationally.

Viewed through the lens of the American experience, this evolution was unique and innovative. However, when examined from a broader international perspective, the problems and changes that took place looked strangely familiar. Specifically, the problems faced by the United States Army Medical Department during the early stages of the war were very similar to those experienced by British Expeditionary Forces and its Medical Department in the Crimea between 1854-1856. The initial failure of the British government and the Army to rapidly adapt to the exigencies of the war and its cost in human lives became a highly publicized scandal both at home and abroad. In contrast, the subsequent successful evolution of the Medical Department during the latter stages of the war and afterwards, was a powerful influence on future military planners including the United States Army Medical Department. In effect, the Crimean War both directly and indirectly influenced the rapid evolution and expansion of the United States Army Medical Department during the Civil War.

The Crimean War

The Crimean War was a conflict between Russia and the Allied forces composed of Britain, France, Sardinia and Turkey between 1853-1856. It revolved around control of the deteriorating Ottoman Empire and impeding the expanded influence of Russia in the Mediterranean and the near east. The British forces of about 100,000, who had overwhelming support of the public, deployed to Turkey and the various operational areas that border the Black Sea thinking the conflict would be over in a matter of months.

Accompanying the soldiers in the field were reporters of the popular press like William Russell of the London Times. Unlike the French, the British did not limit media access nor censor their coverage. As a result, the British public had, thanks to the telegraph and rapid ship transit-times, a detailed and up-to-date view of the war on the front lines and the theater of operation. Americans, too, were interested in the war and monitored it through the British press. Though delayed by a ten-day Atlantic transit time, the American public seemed as interested in the war as their British counterparts.

Unfortunately, both the British government and the public very quickly realized that the war was going to be neither a rapid victory nor without huge costs in human life. They also learned their own expeditionary forces were mismanaged and poorly organized. The British read how the common soldier suffered in the field because of government deficiencies and mismanagement. More concerning and critical to the folks at home was the care and treatment of the ill and injured in the theater especially in the various General Hospitals at Scutari.  They were critical of the medical department’s inability to rapidly and safely care for their soldiers and felt that the deficiencies were due to poor planning, organization, and inadequate resources for the operation.

The public pressure levied against the government forced the political and military leadership to address the concerns directly. One of the first things the Aberdeen Government did at the suggestion of a London Times article was to deploy female nurses to the war.  Then Secretary at War, Sidney Herbert, selected Florence Nightingale, a family friend and experienced medical administrator and nurse, as superintendent of the cadre of nurses. He gave her authority to select the nurses for the deployment and clearly defined her role and responsibilities within the theater of operation. Almost immediately her success in decreasing the morbidity and mortality of the Scutari Hospitals became a point of interest to both the British and American reading public. Her expertise in the tenets of the sanitary sciences as well as her poised leadership skills became well known as well.  At about the same time Miss Nightingale left for Scutari in October of 1854, Parliament organized the Newcastle Commission to investigate the medical service of the army.

The Newcastle Commission’s mandate was to, “enquire into the condition and wants of the sick and wounded officers and soldiers, the state and condition of the hospital accommodation in Scutari and the Crimea, the state of medical and other hospital staffing, and the adequacy of medical stores, medicine, and comfort for the sick.”

Between November1854 and April 1855, the government sponsored three more commissions to evaluate and improve the care and treatment of the individual soldier in the field. They included the Sanitary Commission, the Supplies Commission, and the Pathological Commission. During this same period they also ordered a select committee to determine responsibility for poor performance of the medical department in the Crimea called the Roebuck Committee. Of the four commissions, the Sanitary Commission, composed of civilian public health and sanitary reform experts, was the most important. It had the mandate not only to investigate the cause of the problems but the authority to order appropriate changes in resources and procedures in the field. In contrast, the Roebuck committee was only interested in determining responsibility for the poor medical management of the troop.

Appropriately, both military and government leadership were held responsible while the Army Medical Department leadership was, for the most part, exonerated. The Roebuck Committee discovered the Medical Department was neither included in the operational planning for the expedition nor given adequate time for its preparation. It revealed the Medical Department in this expedition was responsible to five different chain of commands. In addition, it had little time to mobilize resources and little control over its logistics, especially transport resources. It therefore came as no surprise that the department had difficulty adapting to the exigencies of this war. As a result of the fallout of the Committee’s investigation, Lord Aberdeen’s government was replaced.  By the war’s end, about 18,000 of the estimated 97,000 deployed died and of these over 16,000 died of disease and not wounds.  These statistics forced the government to study the Army Medical Department to improve the health and welfare of the British soldier.

To accomplish this, the government organized a Royal Sanitary Commission after the war to investigate the “Regulations affecting the Sanitary Condition of the Army” and as quoted in Shepherd’s Crimean Doctor, to “…inquire into the organization, government and direction of the Medical Department of the Army.” They were also tasked with making recommendations to Parliament and the military for improving the health and welfare of the British soldier. The changes they recommended included: an increased role of the medical officer as a command staff advisor, the creation of a General Hospital system under the command of medical personnel, recommendation for Pavilion-style hospital construction, a reorganization of the medical department with an emphasis on preventive medicine, improved medical purveyor support, the creation of a trained hospital corps as medical attendants, an emphasis on appropriate casualty transport, improved medical statistical methods, improved screening of physician candidates, and the establishment of an army medical school

The end result was the evolution of the Army Medical Department and improvement in the care and treatment of the soldier in the field and in garrison. However, this was not without its cost. The controversy essentially resulted in the political downfall of the Aberdeen government and significant criticism of Army leadership. Careers were lost or at the very least damaged by the events of the war.  The catalyst for these changes was the public and ensuing political pressure placed on Parliament and the Military.  It should come as no surprise, therefore, that when the Civil War broke out, a repeat of the Crimean War debacle was a basis for significant public concern for the Union’s volunteer forces.

The United States Sanitary Commission

On May 15, 1861 four men representing a consortium of New York women’s relief organizations called the Woman’s Central Association of Relief and New York medical organizations left the city for Washington D.C. both for fact finding and lobbying reasons. They, like most Americans, were aware of the medical disaster in the Crimea five years before and wanted to prevent a repetition. When they arrived, the disorganization and chaos of the mobilized forces in and around Washington made it very clear that a national organization to assist the Army Medical Bureau in the sanitary sciences was needed for all the volunteer regiments and not just their own New York troops. Calling themselves a “Sanitary Commission,” a direct and overt reference to the British Sanitary Commission, the four men realized that it was just a matter of time before the same health-related disaster in the Crimea was duplicated in this conflict if action was not taken.

In his history of the United States Sanitary Commission, Alfred Stilles, a leader in the Commission, wrote how in 1861 the Crimea experience was still “…fresh in the memory of all.” In his account he reviewed the history of the Crimean War and its importance to the origin of the Commission. He also acknowledged the informal political role of the Commission in influencing public opinion.  He stated, “The importance, therefore, of rousing public opinion to the absolute necessity of forcing upon the government the adoption of precautionary measures to insure the lives and safety of our troops in camp, in barracks and in hospitals, was the practical lesson which was taught by the Crimean experience to those who had studied it with a view of rendering it applicable to our needs.” He and his colleagues undoubtedly recognized the potential political power of their informal organization

The Crimea was unquestionably in the minds of all whom the Commission petitioned in Washington. The Crimea debacle was the unmistakable elephant that accompanied them into every room they entered and they knew it. It had only been six years prior that the front page of Washington’s Evening Star as well as small town papers like the Gallipolis Journal reviewed the findings of the Roebuck Committee. More significant was William Russell’s tour of America begun in New York the month before the first shots on fort Sumter. The same reporter who was credited with exposing the mismanagement of the Crimea expedition was writing about his American experience in the London Times. Americans therefore were well aware of this 19th century media celebrity’s presence.  By the time the Commission arrived in Washington Mr. Russell was in the Confederacy having already been entertained by the Washington elite including Lincoln, his cabinet, members of Congress, and General Winfield Scott.

For the next four weeks the Sanitary Commission lobbied the representatives of both houses of Congress, the Secretary of War, the acting Surgeon General, and the President for a government authorized national sanitary organization.  Unfortunately, though they were treated with respect and encouragement, the authorities were still very skeptical.  Though Washington could not ignore the obvious political risk of repeating the Crimea, there was no significant proof at the time that the Medical Bureau was not up for the task at hand. As a result neither the government nor the military were sympathetic to a British model commission.

During this period not only was the American public concerned about the health and welfare of the troops, the international community was monitoring the war effort as well and warned Americans of a potential repeat of the Crimea. One such observer was British writer, Harriet Martineau, an internationally known social theorist and abolitionist. On June 3rd The National Republican, a Washington D.C. newspaper, published a letter written by her entitled, ‘Health of Soldiers.” In the front-page article she reviews the initial failure of her government to provide for the soldiers in the field and the cost in human life in the Crimea. She goes on to state,” We should be thankful that you should start from the point attained so calamitously by us.” She affirms a need for a sanitary agency with appropriate authority as well as necessary personnel trained in the sanitary sciences to prevent the loss of life noted in the Crimea.  Finally, she forewarned her reader, “I trust something of the sort has now been improvised on behalf of your new levies of troops. It would grieve the world’s heart if thousands of them, or hundreds, or tens, should be swept away by fever or cholera, or die of hunger, or damp, or cold, for want of the new knowledge which other nations have gained in so costly and dreary a way as the French did in Algeria, and we and they in the Crimea.”

By the beginning of June it became very clear that there was not going to be a duplicate of the British Sanitary Commission. Instead, the lobbyists had to compromise and propose a financially self supporting “Commission of Inquiry and Advice in respect of the Sanitary Interests of the United States Force,” which had no direct authority over military medical resources.  It included a cross section of military and civilian leaders. The mandate was later modified to include only volunteer regiments.  On June 13, President Lincoln signed the order creating the United States Sanitary Commission or the USSC. However, he too was skeptical of the commission referring to them in private as a possible “fifth wheel to the coach.” It didn’t matter, however, since their foot was in the door and they knew their services were going to be needed in a very short time.

Immediately the Commission set about organizing the leadership and grassroots support network in most communities within the north. What the newspapers called “Ladies Relief Organizations” and “Female Patriots” became the broad base support for the newly sanctioned agency. Henry Bellows, one of the original four lobbyists, was elected President and Frederick Olmsted was chosen supervisor general of the organization.  They, along with an Executive Committee, represented the administrative leadership of the national organization who set about creating an organization that did not limit itself to providing material assets to the troops. Instead, the Commission also provided a broad spectrum of resources to the volunteer regiments that included: dietetics and preventative medicine expertise, camp inspection, patient transport resources, medical statistic analysis, and clinical medicine guidelines. Unfortunately, despite the scope of support, the military medical leadership remained uncooperative and quite resistant.

The Army Medical Department

When the American Civil War broke out, many in the government and military thought it would be a short conflict, including the acting Surgeon General. At the time Lincoln called for the activation of the authorized 75,000 volunteers, the Army Medical Department was designed to adequately support a 15,000-man army that consisted of less than 100 career medical officers. The primary concern of the antebellum Medical Department revolved around the health needs of regimental size units and small outposts. No Army surgeon, including the Surgeon General and veterans of the Mexican war, had the experience of caring for the sick and injured that this war would create. Clearly most regular Army surgeons had little or no experience in planning the care and treatment of casualties of a brigade size command let alone Corps or Army. Most regular Army surgeons had never planned the evacuation for hundreds let alone thousands of battle casualties in a theater of operation. In fact, they had never even developed plans for the prevention of disease in camp or on the move for any unit larger than the regiment or small outpost.  Essentially, the command physician had never been an integral part of the command staff and had a minimal role in operational planning just as in the British Army in the Crimea. More importantly and more damning was the fact that the seniority system had nurtured a cadre of senior surgeons who were without insight into the scope of the impending conflict. Often referred to as “fogies” and “superannuated officials,” they were regulation bound men unlikely to change the medical administration paradigm.  At a time when innovation, flexibility and an increased command staff role were essential, they appeared impotent.

At the onset of the war the Medical Department as well as the Army as a whole was in effect unprepared for the scope of this conflict. The department not only had an insufficient and burdensome supply system with a Medical Purveyor system bound in red tape, it had no General hospital system and no established system of evacuation, nursing or Hospital Corps. The basic unit of care for the common soldier like the Crimea and wars past was the regimental field hospital. With an influx of inexperienced civilian doctors-turned-soldier who had no standard level of training the potential for inefficiency and poor care was obvious. The regimental leadership including the surgeon was unfamiliar with the military supply system and basic tenets of field sanitation. Additionally, there was wide variability in the quality of medical expertise. Unlike regular army physicians who had to pass a relatively rigorous examination to be accepted in the military, the volunteer doctors’ medical qualifications varied widely. Yet despite these challenges the Medical Department ‘s leadership felt they could handle the Army’s needs. It seems hard to believe they hadn’t learned from their British counterparts. But at this stage, they were myopic and slow to respond to deteriorating conditions that the Commission clearly recognized.

From the very beginning, the new Surgeon General, Colonel C. A. Finley, a 64-year-old army veteran, was more than resistant to USSC’s help; he obstructed their efforts at every opportunity. Though he had to abide by Lincoln’s order and accept the commission’s existence, he did not have to accept their advice or investigative findings.  Where the government initially had their doubts about the commission, the Medical Department leadership clearly discounted their role and expertise and refused to cooperate. These circumstances could have aborted the USSC ‘s efforts from the outset if the exigencies of war and the commission’s willingness to apply political pressure had not come in to play and forced the Surgeons General limited cooperation.

Around this same time letters home and reports in local newspapers were beginning to acknowledge what the four lobbyists had initially suspected; there were growing health and sanitation needs that the Medical department was unable to provide, including the care of the growing number of sick and injured by the various novice regimental surgeons. As a result, the General Hospital system was reintroduced into the Army but it too was inadequately organized and supplied for the needs at the time. The similarity between their circumstances and the Crimea was becoming obvious to both the commission and the public. However, it was the chaos of Bull Run that convinced the public, government, military and the USSC that the Medical Department was not prepared for this war or at least not yet.

Despite the obvious, Surgeon General Finley continued to obstruct the Commission’s efforts at every turn. Interestingly, this did not stop the Commission from expanding their efforts for the troops. Though officially it had no authority, it also had few governmental regulations and restrictions limiting the scope of care they could provide the soldier. To the men and officers of the Army they very rapidly began to demonstrate, in practical terms, their ability to provide both valuable material resources and professional expertise in Preventive Medicine. With a clear understanding of their role in this conflict, the executive committee did not hesitate to continue to use its public and political influence to force change in the Medical Department.

Throughout the fall of 1861, the rift between the Medical Bureau and the Commission continued to widen. Though early in his tenure the Surgeon General had significant political influence, as the war progressed his leadership ability became questioned. Over the next several months the Commission’s lobbying and networking intensified while Finley’s inability to adapt to the contingencies of this war became blatantly obvious to Congress, the public and the military leadership. More importantly the Surgeon General had made an enemy of Edwin Stanton, the new Secretary of War.  And though the Secretary had no love for the Sanitary Commission, he also had no confidence in Surgeon General Finley. He wanted his resignation.

While Stanton maneuvered to have Finley replaced, the Commission focused its attention on getting congressional support for a bill to reorganize and improve the Medical Department in April of 1862. The Commission and the Crimea’s influence were unmistakable. Ushered through both houses by the Commission’s advocates, including Senator Henry Wilson, the bill was designed, with the Commission’s input, to improve the efficiency and function of the Medical Bureau.  The bill contained such innovations as the Medical Inspector General position and associated Medical Inspectors fashioned after the European model and the British Sanitary Commission’s inspector role. Additionally, the Medical Purveyor function throughout the Army was modified to eliminate red tape and to be more flexible and responsive to the medical needs of the combat forces as recommended by the Royal Commission.  And just as Herbert had suggested that the rank of the British Medical Officers should be commensurate with their role and responsibilities so, too, should their American counterparts including the creation of the Flag rank of Brigadier General for the Surgeon General. They even tried to have the title of Surgeon General changed to Director General like his British counterpart, but this was rejected in Committee.

Additionally, the Commission pressured Congress to eliminate the seniority system for selection of the Surgeon General.  The Commission feared that even though it was clear that Surgeon General Finley was on his way out (thanks to Secretary Stanton), there was no guarantee that another ‘Fogie’ wouldn’t take his place. So by selecting the most qualified candidate for Surgeon General, the bill would prevent another Clement Finley.  This was congruent with the British Royal Warrant of 1858, a by-product of the Royal Sanitary Commission, which stated that senior medical officers should be promoted based on “ability and merit” and not solely on seniority. Not so coincidentally, the new policy allowed the Commission an opportunity to submit their recommendation for the position. Seeing the handwriting on the wall, Surgeon General Finley elected to retire just before it’s signing on April 18, 1862. One week later, Congress confirmed Assistant Surgeon William Hammond as the new Surgeon General.

William Hammond

Months before the signing of the new bill, the Commission lobbied Congress, the War Department, and the President for their choice of Surgeon General, who was a young well-educated and well -trained 33 year old physician with a predilection for science and scientific study. William Hammond was an 11-year veteran of the US army and already a well-known research physiologist. It was, however, his understanding of sanitary sciences and his reputation among the medical leadership of the commission and key line commanders that put him on the top of the USSC short list of candidates.

A year before the war, Hammond resigned his commission for a position on the faculty of the medical school at the University of Maryland in Baltimore and Surgeon to the Baltimore Infirmary. When the war broke out he immediately returned to the Army losing his seniority and spent the first few months organizing the military hospitals in Chambersburg, Pennsylvania, and Hagerstown and Frederick, Maryland. Interestingly, his deployment as hospital organizer may not have been a random selection by the Surgeon General. In 1858, around the time of the Royal Sanitary Commission investigation, Hammond took a medical leave of absence from the Army and went to England and Europe. While recuperating from his illness he toured English and European military and civilian hospitals; he had a clear interest in hospital design and organization. He also gained detailed insight into tenets of sanitary science and hospital construction. So it came as no surprise that when he was transferred in January of 1862 to Western Virginia as Medical Director Jonathan Letterman’s Medical Purveyor, he was a committed Sanitarian and an expert in hospital organization and design.

It was during this period in western Virginia that General William Rosecrans, his commanding officer, and Jonathan Letterman gave him the task of investigating the state of the command’s general hospitals. The report was a detailed description of the poor conditions in several hospitals and an analysis of the root cause for their state. It also made suggestions for improvement based on accepted medical and sanitary guidelines that evolved from the Crimean War. It demonstrated such a clear understanding of the sanitary sciences as promoted by the USSC that they reproduced it in their circular #41 for distributions to the regimental surgeons. The Sanitary Commission had their man.

Surgeon General Hammond

On April 25, 1862, Congress confirmed William Hammond as the most qualified man for Surgeon General.  Immediately, the relationship and the dynamics between the USSC and the Medical Bureau improved. With the reorganization of the Medical Bureau, as mandated by Congress and the new leadership, both institutions began to work together to enhance and expand the medical resources for the troops. As time progressed, the Medical Department began to provide many of the services the USSC delivered early in the war and assumed the leadership role as the public and government expected.

One of the most important features of Surgeon General Hammond’s tenure was his understanding of the lessons learned in the Crimea. This is very clearly demonstrated in his Treatise on Hygiene with Special Reference to the Military Service published in 1863 where he references the Crimea and the associated changes to the British military medical system after the war.

As a student of the “Crimea experience” he reproduced, adapted, or improved innovations that evolved from the Crimea. This included a comprehensive theater casualty evacuation system as well as an organized field Ambulance system under the direction of the medical department. With the revival of the Army General Hospital, he utilized the Pavilion style hospital design advocated by the Royal Commission, as well as administrative suggestions to improvement efficiency, effectiveness, and inter-department relations. He advocated the creation of a permanent General Hospital system. He wholeheartedly supported the Medical Purveyor’s new and expanded role and the elimination of logistical red tape. He recognized the importance of broadening the role of female nurses in military medical facilities as well as, modeling the medical statistics function of the Surgeon General’s office after the British in the Crimea. In addition, Hammond immediately started the process of collecting information and data for what would become The Medical and Surgical History of the War of the Rebellion, an account of the Medical Department fashioned after the Crimean Report. He also started the process of collecting pathological samples from the field both for the Medical and Surgical Report and a proposed Army Medical Museum. The inspiration for this may have been the British Pathological Commission and the British Army’s Museum of Natural History and Pathological Anatomy.  Other Crimea related innovation he proposed was the creation of the hospital corps for the training of field medical personnel and the creation of a military medical school. These changes could not have taken place without the support and acceptance of select members of the line community.

Essential to the evolution of the Medical Bureau was the acceptance and application of the Medical Departments recommendations in the field by line commanders.  No amount of common sense, good advice or science was going to change the system and get results if the field commanders didn’t support changes. Very early in both the western and eastern theater it became evident to the line community that the health and welfare of the troops in camp, on the march, or on the battlefield, was impacting the commanders’ ability to efficiently and effectively accomplish their strategic goals.  Even more, the parallels with the Crimean war were just as obvious to these Generals as it was to the public. It was, however, the support of the commanding general of the Army of the Potomac, Major General George McClellan, that provided the opportunity for Surgeon General Hammond to initiate and underscore the necessary innovations to improve field medical care and the Army Medical Department. Interestingly, General McClellan’s understanding and support of the Medical Director on his command staff was likely neither visionary nor solely the result of the exigencies of war; instead it likely evolved from his personal experience as the junior member of the Delafield Commission in 1855.

The Delafield Commission

The Delafield Commission was a US government sponsored fact-finding authority lead by Major Richard Delafield, Engineer Corp, that included Major Alfred Mordecai, Ordinance Corps, and Cavalry Captain George McClellan. Just as the average American was interested in the Crimea expedition so, too, were Washington and the military leadership. Practically speaking they were interested in the military innovations that the war was demonstrating including the care and treatment of the sick and wounded.  It was for this reason that Secretary of War Jefferson Davis in 1855 sent the Delafield Commission to Europe and the Crimea to obtain “ useful information with regard to the military service in general, and especially the practical working of the changes which have been introduce, of the late years, into the military systems of the principle nations of Europe.” Additionally he gave the Commission a list of about a dozen subjects such as innovation in ordinance, fortification, and supply to address in their report. Included among the items to investigate was, “ The medical and hospital arrangements, both in permanent hospitals and in the field-the kinds of ambulances or other means used for transporting the sick and wounded.”  Secretary Davis obviously recognized the importance of innovation and improvements in field medicine for both practical and political reasons.

For over a year they traveled through Europe, Russia and the Crimean theater gathering information to answer the Secretary’s questions, including the medical concerns. By the time they got to the Crimea, the war was essentially over. However, this did not stop them from collecting information about the care and treatment of the sick and wounded. They visited Scutari and the Barrack Hospital. They also interviewed Florence Nightingale. More importantly, they observed first hand the improvement in the Medical Departments as a result of the various commissions. Upon returning to America, each man was tasked with reviewing his area of expertise. Since there was no medical officer on the commission, it fell to Major Delafield to address the medical aspects of the war. In 1860 his report was officially published.

When the report came out, it was widely distributed among the line community. Almost immediately the Army began to adjust their practices based on the lessons learned in the Crimea such as standardization of ordinance and cavalry practices. However, the one department that seemed least impressed by the study was the Medical Bureau since the only innovation the department appeared interested in was ambulance design.  It still seems odd that this was the only aspect of the war that the Medical Department considered important even considering the fact that there was neither a medical representative on the commission to focus the medical assessment nor the pressure of war to compel innovation.

Interestingly, Delafield reviewed improvements in patient care beyond ambulance transport including hospital ship transport and General Hospital design and organization even though the US Army had no such assets at the time. These were clearly wartime innovations. He also introduced the importance of transferring the authority over field medical transport from the Quartermaster corps to the command medical director. He lamented the fact that prior to the Crimea, armies paid very little attention to the wounded in the battlefield and to the fact that the medical department was a ‘minority’ branch of the military with little influence beyond the immediate care of the sick and wounded.

Basically, the Medical staff officer’s role in the command structure was minimal. In his report Delafield made the point that public sentiment in general and Florence Nightingale, specifically, were instrumental in forcing commands to look at medical as an important staff function. What Delafield didn’t say outright but clearly inferred was that commands could no longer ignore the role and importance of the medical staff officer in planning an operation for moral and practical reasons.

Major General Mcclellan

It comes as no surprise, therefore, that Major General McClellan, the former member of the Delafield Commission and commanding general of the Army of the Potomac was both familiar with the risks of a failed medical department and very receptive to any Medical Bureau recommendations to improve the conditions of his army when he took command in July 1861.  Within weeks of taking command he recognized the inadequacy of the Bureau’s efforts to support the troops and the positive role of the USSC in the field.

In September 1861 General McClellan forwarded a Sanitary Commission status report to the then Secretary of War, Simon Cameron. In it he wrote an addendum in support of the Commission and diplomatically acknowledging the difficult task the Army Medical Department had transitioning from a small peacetime organization to the size required for the war. In this correspondence he also affirmed support of a list of suggestions by the Commission which included: the appointment of a medical director by the commanding general, the organization of an ambulance service under the command of the medical director, the employment of a corps of men and women nurses by the medical director to act under his supervision, and the congenial and confident cooperation of the Medical Bureau with the USSC. Regrettably, McClellan’s first Medical Director, Charles Tripler, whom he knew from the Mexican War, proved not to be up for the job.

Though clearly conscientious and experienced as a former Division Medical Director in the Mexican War, Tripler failed to adapt to the exigencies that this war and the Peninsular Campaign, in particular, created. McClellan’s Medical Director was still regulation bound, and unwilling to think outside the box. In his defense he did initiate changes to accommodate the troops in camp and on the march but they were inadequate and limited. When McClellan initiated the Peninsular Campaign and the ensuing battles took place, Tripler still clung to the regiment model of field medicine with no efficient field ambulance or evacuation system. In fact, just before deploying on the Peninsular Campaign, he rejected a proposed Ambulance Corps plan and affirmed,  “…all necessary and practicable arrangements for the transportation of our wounded will have been made.” He clung to the use of regimental designees and band members for the task. During the course of the campaign, Major General McClellan witnessed the poor performance of the Medical Department and recognized how this was affecting his ability to wage war. The Army’s sick rate alone went from six per cent before the deployment to twenty percent during the operation.

Also, during this time the General saw how the Sanitary Commission continued to play a significant role in augmenting the Medical department and in some cases, supplanting it. The Commission demonstrated its ability to provide medical supplies, medical personnel, sanitation inspection and water transport for evacuation out of operation areas.  The parallels with the Crimea were blatantly obvious. Essentially, McClellan was ready and willing to expand the role and authority of his Medical Director as suggested by the Crimea experience. Unfortunately Major Tripler could not provide the innovative leadership the operation required.

Within weeks, McClellan had lost confidence in his Medical Director and both Hammond and Tripler knew it. It is likely that if Tripler had shown the slightest ability to adapt to the exigencies of the ongoing campaign, the new Surgeon General would have likely supported him. But this was not the case. As a result, when Major Tripler requested a reassignment to another command during the Peninsula Campaign, Surgeon General Hammond immediately approved the request and replaced him with his friend and former Medical Director, Jonathan Letterman.

Major Jonathan Letterman

Major Letterman was a career Army Surgeon who clearly understood the importance of his position as a command staff officer and the need for innovation and flexibility. It comes as no surprise therefore that the Surgeon General would choose a colleague who he knew had clear administrative talent, field experience and understood the scope of the mission to initiate and execute his command staff vision. In his June 19, 1862 letter to Major Letterman, Surgeon General Hammond spelled out the Medical Director’s mission, his authority and his responsibilities. The letter made it clear that Major Letterman had the authority to make on-site decisions to provide the personnel and supplies to support the Army, and he was given the mandate and authority to, “ hold the [regimental] senior medical officer to a strict accountability for any deficiency,” regarding medical supplies. Additionally, he instructed Letterman to coordinate efforts with the medical purveyors, Medical Director of transport, and the Quartermaster to improve the medical condition of the Army of the Potomac. Most importantly, he was to communicate directly with the Army Commander and the Surgeon General about any needs and or help required to fulfill the mission thus eliminating regulation red tape.

Major Letterman, like the Surgeon General Hammond, demonstrated a clear understanding of the British Army sanitary reforms and immediately adapted several of them to his new command. For instance, on arrival, Letterman made a general inspection of the army and shared his concerns about the sanitary status of the army with his commander. In a short time, General McClellan enacted General Order 50 that detailed sanitary regulation throughout the command. This sent a message to his Corps commanders highlighting the importance of the Medical Director to the mission in the field. The effect of the new approach rapidly decreased the sick rate within the deployed forces. Additionally, though Letterman was not the first to propose an Ambulance Corps with dedicated trained personnel, he was the first to have a system under the command of the Medical Director that was officially sanctioned and supported by Army Commander and General Order. Where Surgeon General Hammond coordinated the lessons learned strategically, Medical Director Letterman, adapted them to the field and the associated operational constraints.

In essence, General McClellan made his Medical Director a more important part of his command staff.  This same level of authority and trust evolved in other Army commands including General Grant’s Army of the Tennessee and General Rosecrans’ Army of the Cumberland. At Fort Donelson, Grant’s army was the first to use the division field hospital as the center of care rather than the regiment even before Letterman had formalized it. He also was one of the first field commanders other than the Army of the Potomac to incorporate Letterman’s Ambulance Corps model in the field. To Rosecrans, tenets of sanitation were important and a point of emphasis in his command.  After he took command of the Army of the Cumberland in October 1862, the sick rate in his command immediately dropped as a result of his command sanitation policies. Though it is likely he had read the Delafield Commission, a more important source of influence on him was his association with John Letterman, his Medical Director, and William Hammond, his Medical Purveyor, when he commanded the forces in western Virginia. The Special Staff paradigm had changed thanks to the influence of the Crimean War.

The Crimean Influence

By the end of 1864, the Army Medical Department had finally evolved into an efficient and effective administrative organization. Though leadership changed in both the line and medical communities, the evolution of the department continued. It became a smooth running institution that no longer required any specific individual for guidance.

A major contributing force to the evolutionary process was the lessons learned in the Crimea and their adaption to the exigencies of the American Civil War. In effect, the Crimean War had four major areas of influence on the Medical Bureau. First, just as the Crimea had the Sanitary Commission to effect change, the Union had the United States Sanitary Commission. A modified version of the British commission, the USSC anticipated the problems seen in the Crimea and very early organized a system of support similar to their British counterpart. The American version catalyzed improvements and bought time while the bureau matured and adapted. In addition, the significance of the Commission as a political force cannot be overstated.  In its first year, the Commission’s role as petitioner was just as, if not more, important than its material and administrative support in the Medical Department’s maturation. Second, William Hammond, an innovative medical administrator and student of history, applied specific lessons learned from the Crimea to modify and improve the Medical Bureau during his tenure as Surgeon General.  Though he took more than a few ideas right out the Crimea playbook, the scope and detail of his modifications are quite his own. Also important to the rapid evolution of the Bureau was his willingness to work with the USSC and the line community to expand and adapt the bureau to the needs of the fighting forces and to allow his Medical Directors a significant level of autonomy. Third, line commanders used the lessons learned from the Crimea to modify the command staff role of the Medical Director. They supported broadened Medical authority within the command thus allowing for the necessary flexibility and innovation to adapt to the exigency of the war. And finally, the Crimean war had substantial effect on public opinion and consequently American politics. Time and time again the importance of public opinion and the fear of another Crimea placed pressure on Lincoln, the government, and the military to monitor and improve the medical bureau throughout the conflict. Essentially, the horrors of the Crimea were still fresh in the minds of American public. And though the USSC helped shape and focus this opinion, the public had a formidable influence on Washington independent of the Commission.

Historians have often recognized the Crimean conflict’s influence on the Civil War as an obscure footnote in the narrative. Even Florence Nightingale, clearly an important medical administration figure both during and after the war, has had her impact on the American struggle limited to the introduction and professionalization of female nurses in military medicine. An exception to this perspective is historian Fielding Garrison’s assessment of the war. In his Notes on the History of Military Medicine, he affirms that,“ Of all recorded wars the Crimean War…has perhaps the greatest teaching value for Military Medicine.” He concludes that a central civil government will not succeed in war if it neglects adequate logistics, personnel and medical aid to the frontline forces. Nor will it succeed if it does not provide field commanders and medical officers adequate authority to adapt to the contingencies in the  “Theater of war”.

This review has attempted to demonstrate a broader assessment of the Crimean War’s effect on military medicine. More than a footnote, the Crimean war had a major role in changing the paradigm of military medical administration and helped shaped the evolution of the Army Medical Department. Though strong visionary leadership and the necessities of war contributed to its development, it was the Crimean War and the lessons learned which provided the template and catalyst for the successful transition from an outdated and inflexible organization to an innovative and adaptive institution.


Notes

1. Guy Arnold,  Historical Dictionary of the Crimean War (London: The Scarcrow Press, Inc., 2002), 17-20; John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War 2 vols. (Liverpool: Liverpool University Press, 1991), 30-33.

2. Anthony Dawson, “ The French Army and British Army Crimean War Reforms,” Interdisciplinary Studies in the Long Nineteenth Century, May 13, 2015, 11, accessed March 1, 2016, http://www.19.bbk.ac.uk/articles/10.16995/ntn707; William Howard Russell, Despatches from the Crimea. ed. Nichcolas Bentley (Annapolis: Naval Institute Press, 2008), 14-18; Editorial, “ The War in the Crimea,” Weekly National Intelligencer (Washington D.C.), October 28, 1854, Chronicling America: Historical American Newspapers; Eufronsina Dvoichenko-Markov, "Americans in the Crimean War," Russian Review 13, no. 2 (Apr., 1954): 137-145, accessed September 28, 2015, http://www.jstor.org/stable/125706; Horace Perry Jones, “Louisiana Opinion on the Crimean War as Expressed in the Newspaper,” Louisiana  History, the Journal of the Louisiana Historical Society 18, no. 3  ( Summer 1977): 323-334, accessed September 28, 2015, http://www.jstor.org/stable/4231698; The Library of Congress resource, Chronicling America, archived 206 newspaper references for the term ‘ Crimean War" between 1854 &1857.

3. John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War, 2 vols. (Liverpool: Liverpool University Press, 1991), 154-201; Editorial,  "Condition of the English Army in the Crimea." The American Patriot- Clinton, Louisiana, February 14, 1855: 2, Chronicling America: Historical American Newspapers; Editorial, "Shocking Conditions of the British Army in Crimea." New York Daily Tribune, February 3, 1855: 6, Chronicling America: Historical American Newspapers; Editorial,  "Horrors of War." Washington Sentinel, February 6, 1855: 2, Chronicling America: Historical American Newspapers. Scutari was a town across the Bosphorus from Istanbul where the Turks had a military hospital and Barracks.

4.  John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War, 2 vols. (Liverpool: Liverpool University Press, 1991), 256-284. The term  “Aberdeen Government” refers to British Prime Minister who was the Earl of Aberdeen; Chronicling America archived 132 newspaper references to “ Florence Nightingale” from 1854 to 1857.

5. John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War 2 vols. (Liverpool: Liverpool University Press, 1991), 374

6. John Shepherd,  “Commissions and Committees (1854-1855),” in The Crimean Doctors: A History of the British Medical Service in the Crimean War, 2 vols. (Liverpool: Liverpool University Press, 1991), 373. The Supplies Commission investigated the “ whole arrangement and management of the Commissariat’ while the Pathological Commission investigated “the pathology of diseases in the East.”

7. John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean Wa,r 2 vols. (Liverpool: Liverpool University Press, 1991), 381-395, 591.

8. Florence Nightingale,  Notes on Hospitals (1859; repr., New York: Dover Publications, Inc., 2015), 32, Nook.

9. John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War 2 vols. (Liverpool: Liverpool University Press, 1991), 593.

10. Sidney Herbert, The Sanitary Condition of the Army (1859; repr.,Westminster Review, London:John Chapman, 1859), 1-48; Google-books; John Shepherd, The Crimean Doctors: A History of the British Medical Service in the Crimean War 2 vols. (Liverpool: Liverpool University Press, 1991), 592-597; Florence Nightingale, Army Sanitary Administration, and Its Reform Under the late Lord Herbert (London: McCorquodale & Co., 1862),1-11. The commission was basically the brainchild of Lord Sidney Herbert and Florence Nightingale; the Pavilion model was a one-story open ward construction style limited to 30-50 patients, which emphasizes ventilation, sanitation, and ease of supervision.

11. North American Review, "ART. VII-1. The United States Sanitary Commission." North American Review (January 1, 1864): 153-163; Charles J. Stille, “ The Nature and Object of Army Relief” and “Development of the Theory of a Preventive Service” in History of the United States Sanitary Commission (Philadelphia: Lippincott & Co., 1866), 17, 39; William Quentin Maxwell,  “Making and testing the Fifth Wheel” in Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 1.

12. Charles J. Stille, History of the United States Sanitary Commission (Philadelphia: Lippincott & Co., 1866), 27.

13. Charles J. Stille, History of the United States Sanitary Commission (Philadelphia: Lippincott & Co., 1866), 30.

14. Great Britain. The Weekly Evening Star, July 6, 1855, Chronicling America: Historical American Newspapers; The Report of the Roebuck Committee. The Gallipolis Journal, July 19, 1855, Chronicling America: Historical American Newspapers; William Howard Russell, My Diary North and South (Barnes & Noble, Inc. digital edition, 2012) 36-95, Nook.

15. Harriet Martineau, “ the Health of Soldiers,” The National Republican, June 25, 1861, Chronicling America: Historical American Newspapers.

16. William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 7.

17. William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 8.

18. William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 6-8 ; Charles Stille, History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 52-58; Mary C. Gillett, The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987),160-162; North American Review, "ART. VII-1. The United States Sanitary Commission." North American Review (January 1, 1864): 153-167; Abraham Lincoln, "Order creating the United States Sanitary Commission, signed and approved by President Lincoln on Jun 13, 1861. Counter signed by Simon Cameron, Secretary of War." The New York Public Library: Digital Collection. June 13, 1861. digitalcollections.nypl.org (accessed January 27, 2016).

19. Editorial, “The Ladies Home Sanitarian Association and Female Patriotism and Charity-Nurses for the War,” The New York Herald, April 30, 1861, Chronicling America: Historical American Newspapers; Editorial, “ The Sanitary Commission-from the London Times,” Washington, D.C. Evening Star, February 19, 1862, Chronicling America: Historical American Newspapers; North American Review, "ART. VII-1. The United States Sanitary Commission." North American Review (January 1, 1864): 168-171; William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 8-13; Charles Stille, “ Organization of the United States Sanitary Commission,” in History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 63.

20. George Templeton Strong, Diary of the Civil War 1861-1865. Edited by Allan Nevins. (New York: The Macmillan Company, 1962), 181.

21. Mary C. Gillett, “Administrative Problems of the Medical Department,” in The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987), 153; William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 1

22. Mary Gillett,  “Administrative Problems of the Medical Department” in The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987), 153.

23.North American Review, "ART VII-1. The United States Sanitary Commission." North American Review (January 1, 1864), 171-172; William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 12-13; Charles Stille, History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 66-68, 100-102.

24. Frederick Olmsted, Letter to the Editor, January 27, 1861,” The Army Hospitals,” The Independent, February 6, 1862, American Periodicals; Frederick Law Olmsted,  "Report of the Secretary with regard to the probable origin of the recent demoralization of the volunteer army at Washington: and the duty of the Sanitary Commission with reference to certain deficiencies in the existing army, arrangements, as suggested thereby." (United States Sanitary Commission , September 11, 1861).

25. North American Review, "ART. VII-1. The United States Sanitary Commission."  North American Review (January 1,1864),168-171; Charles Stille, History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 76-99.

26. North American Review, "ART. VII-1. The United States Sanitary Commission." North American Review (January 1, 1864), 171-174; Charles Stille, History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 55-81, 100-114; William Quentin Maxwell,  “Winds of Controversy” and “Mixed Blessings” in Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 93, 116.

27. Charles Stille, History of the United States Sanitary Commission, (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 114-128; Sir Neil Cantilie, A History of the Army Medical Department, Vol. 2 (Edinburgh and London: Churchill Livingston, 1974) 428-432; Harvey E. Brown, The Medical Department of the United States Army from 1775-1873 (Washington, D.C.: Surgeon General Office, 1873), 215-262; the term Director General was also once used to designate the head of the American Army Medical department during the Revolutionary War but later changed to Surgeon General. It is likely that that the proposed title changes was more an effort to reflect the British System than a return to an older sobriquet.

28. Sir Neil Cantilie, A History of the Army Medical Department, Vol. 2 (Edinburgh and London: Churchill Livingston, 1974), 429.

29. Charles Stille, History of the United States Sanitary Commission (Philadelphia, Pennsylvania: Lippincott & Co., 1866), 128-137.

30. Bonnie Ellen Blustine,  Preserve Your Love for science - Life of William A. Hammond-American Neurologist (Cambridge: Cambridge University Press, 2002) 49, 53-58; Mary C. Gillett, The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987), 178-179; Frank R. Freeman, "Lincoln finds a Surgeon General: William A. Hammond and the transformation of the Union Army Medical Bureau." Civil War History 33, no. 1 (March 1987): 5-21, accessed provided by University of Alabama on 5Feb2016, DOI:10.1353/CWH.1987.0023. In the pre-germ theory era, Sanitarians were those who believed poor sanitation and poor hygiene and ensuing miasma and pathological effluvia were the root causes of disease and not specific entities like bacteria.

31. United States Sanitary Commission. Documents of the U.S. Sanitary Commission vol. I number 1 to 60, (New York: United States Sanitary Commission, 1866,), 397-428, accessed via google book; Scott McGaugh, Surgeon in Blue- Jonathan Letterman, The Civil War Doctor Who Pioneered Battlefield Care (New York: Arcade Publishing, 2013), 65-67.

32. Bonnie Ellen Blustine,  Preserve Your Love for science - Life of William A. Hammond-American Neurologist (Cambridge: Cambridge University Press, 2002), 58-75; Frank R. Freeman, "Lincoln finds a Surgeon General: William A. Hammond and the transformation of the Union Army Medical Bureau." Civil War History 33, no. 1 (March 1987), 5-21 ; William Quentin Maxwell, Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 139; North American Review, "ART. VII-1. The United States Sanitary Commission." North American Review (January 1, 1864), 177.

33. William A. Hammond,  Treatise on Hygiene with special reference to the Military Service (Philadelphia: Lippincott & Co., 1863), accessed via Google book, 11-14, 197,233-234, 285.

34. William A. Hammond,  Treatise on Hygiene with special reference to the Military Service (Philadelphia: Lippincott & Co., 1863), accessed via Google book, 11-14, 197,233-234, 285; Bonnie Ellen Blustine, “Reorganization of the Medical Department,” in  Preserve Your Love for science - Life of William A. Hammond-American Neurologist (Cambridge: Cambridge University Press, 2002), 58; Frank R. Freeman, "Lincoln finds a Surgeon General: William A. Hammond and the transformation of the Union Army Medical Bureau." Civil War History 33, no. 1 (March 1987): 5-21; John T. Greenwood, "Hammond and Letterman: A Tale of Two Men Who Changed Army Medicine (Association of the United States Army Medical Symposium and Exhibition ( San Antonio,texas: Institute of Land Warfare-Association of the United States Army, 2003), 1-6; Mary C. Gillett, The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987), 177-184.

35.Jefferson Davis, "Letter of Instruction to the Delafield Commission."  Washington DC: United States War Department, April 2, 1855.

36. Mathew Moten, “Part Two: The Delafield Commission,” in The Delafield Commission and the American Military Profession (College Station, texas: Texas A&M University Press, 2000), 73. In June of 1861 General Grant while in the field asked his wife to send his copy of McClellan’s portion of the report to him. It is reasonable to assume he reviewed the entire report including Delafield’s portion as well.

37. Richard Delafield, Colonel U.S.A, Report on the Art of War in Europe in 1854, 1855, and 1856 (Washington: George W. Bowman, 1861), 61-86, 272-277.

38. The United States War Department, The War of the Rebellion: A Compilation of the Official records of the Union and Confederate Army: Series1-Volume 5, CHAP. XIV, (Washington, D.C.: US Government Printing office, 1881), 598.

39. The United States War Department, The War of the Rebellion: A Compilation of the Official records of the Union and Confederate Army: Series1-Volume 5, CHAP. XIV, (Washington, D.C.: US Government Printing office, 1881), 100.

40. Captain Louis Duncan, The Medical Department of the United States Army  (Gaithersburg, Maryland: Olde Soldier Books, Inc., 1985), 100-106;Scott McGaugh,  Surgeon in Blue- Jonathan Letterman, The Civil War Doctor Who Pioneered Battlefield Care (New York: Arcade Publishing, 2013), 56-64.

41. William Quentin Maxwell, “Mixed Blessings” in Lincoln's Fifth Wheel: the Political History of the United States Sanitary Commission (New York: Longmans, Green & Co., 1956), 118.

42. Bonnie Ellen Blustine,  Preserve Your Love for science - Life of William A. Hammond-American Neurologist (Cambridge: Cambridge University Press, 2002), 60-62; Mary C. Gillett, The Army Medical Department 1818-1865 (Washington, D.C.: US Government Printing office, 1987), 184-191.

43. Willliam Hammond, "Letter from the Surgeon-General to Surgeon Letterman, Medical Director of the Army of the Potomac." Medical and Surgical Reporter (July 12, 1862): 376.

44. Scott McGaugh, “Taking Medical Command” in Surgeon in Blue- Jonathan Letterman, The Civil War Doctor Who Pioneered Battlefield Care (New York: Arcade Publishing, 2013), 75; Mary C. Gillett, The Army Medical Department 1818-1865  (Washington, D.C.: US Government Printing office, 1987), 190-194; Captain Louis Duncan, The Medical Department of the United States Army (Gaithersburg, Maryland: Olde Soldier Books, Inc., 1985), 104-111; ; John T. Greenwood, "Hammond and Letterman: A Tale of Two Men Who Changed Army Medicine (Association of the United States Army Medical Symposium and Exhibition ( San Antonio,texas: Institute of Land Warfare-Association of the United States Army, 2003), 1-6; Jonathan Letterman M.D.,  Medical Recollections of the Army of the Potomac, (New York: Appleton and Co., 1866; revised, Polizzi and Polizzi:2013), 6-21.

45.Ironically, by this time William Hammond had been dismissed from the Army as the result of conflict with Secretary of War Stanton, McClellan had been relieved of command of the Army of the Potomac and had recently lost the presidential election, and Letterman had resigned his commission from the Army.

46. Ironically, by this time William Hammond had been dismissed from the Army as the result of conflict with Secretary of War Stanton, McClellan had been relieved of command of the Army of the Potomac and had recently lost the presidential election, and Letterman had resigned his commission from the Army.

47. Fielding Garrison, Notes on the History of Military Medicine (London: forgotten books, 2015) 171-172.

Larry Conley, MD, FACEP