Pox
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As the first major U.S. military action since the germ theory of disease gained broad acceptance in the medical profession, the war with Spain should have been a milestone in military medicine. And, in important respects, it was. The decades since the Civil War had witnessed the creation of modern health departments in the major U.S. cities, a greater recognition of the importance of aseptic practices in the treatment of wounds, and, in 1895, the discovery of X-rays. During the Civil War, Army surgeons had still probed bullet wounds with unsterilized instruments and unwashed fingers. By 1898, most Army doctors and volunteer nurses knew better. On the battlefield, they wrapped soldiers’ wounds in antiseptic dressings. In the field hospital, they used X-rays to locate bullets and assess damage to bones. At the operating table, they followed aseptic techniques. The results (aided by the introduction of small-caliber bullets) were extraordinary. The death rate of wounded U.S. troops during the Spanish War was the lowest in military history: fully 95 percent recovered. And blessedly rare in this war were the heroic amputations that had moved Walt Whitman to poetry during his stint as a hospital volunteer with the Union Army (“the smell of ether, the odor of blood”). As Army Surgeon General George M. Sternberg reported with pride after the Spanish War’s end, his surgeons had performed only thirty-four amputations in a wounded list of some sixteen hundred men.20
Notwithstanding these achievements, the record of the Army Medical Department during the Spanish War was a public disgrace. “Now that actual fighting is over,” wrote Dr. Carroll Dunham in the American Monthly Review of Reviews, “it is undeniable that failure adequately to safeguard the health of the American troops is the one blot on an otherwise fair account.” In an era of rising expectations about the power of preventive medicine, the department failed to conserve the health of the troops. Only 345 U.S. soldiers died from wounds of combat during the war; 2,565 men died from disease. The ratio of disease fatalities to combat deaths (more than 7 to 1) exceeded those of the Mexican-American War (6.5 to 1) and the Civil War (2 to 1). Tens of thousands of U.S. soldiers spent the Spanish War in the department’s ill-equipped hospitals, suffering from preventable infectious diseases. The vast majority of the men who died in this overseas war never left the mainland.21
Established in 1818, the U.S. Army Medical Department consisted during peacetime of a small corps of professional officers, reinforced during time of war or emergency by state-appointed surgeons from the volunteer militias and civilian physicians hired on contract. For centuries, medical men had marched with armies, but their status had always been less than heroic. In eighteenth-century Prussia, army doctors still shaved the officers of the line. The very title of “surgeon”—invoking both civilian status and the rough craft of stitching wounds and removing bullets and limbs from wounded soldiers—was viewed as a put-down by some nineteenth-century Army medical officers. The official duties of the U.S. Army surgeon did consist, first and foremost, of evacuating and treating troops wounded on the battlefield. But in the age of modern sanitary science, the duties did not stop there. America’s best-known citizen-soldier, Theodore Roosevelt, saluted the profession as a bastion of manly heroism in a feminized age, noting that the surgeons’ job required them to be not merely doctors and soldiers but “able administrators.” Responsible for the health of thousands of troops in camps and crowded transport trains and ships, the modern Army surgeon was necessarily a public health officer, charged with examining the recruits (rejecting those unfit for duty), vaccinating the line, securing pure food and water, and preaching modern hygiene to line officers and troops.22
Under Surgeon General George Miller Sternberg (1893–1902), an internationally recognized epidemiologist who published the first American textbook on bacteriology in 1896, the surgeons of the Army Medical Department aspired to a high degree of professionalism. Like many of the department’s senior officers, Sternberg, a Civil War veteran, had honed his medical skills in the late nineteenth-century campaigns against the Indians in the American West. By the 1890s, new candidates for the corps learned their trade in the classroom. They had to take a rigorous entrance exam; in 1897, only 6 out of the 140 applicants passed. The surgeons underwent a five-month program of postgraduate education at the Army Medical School in Washington, where they studied bacteriology, sanitary chemistry, pathology, and military hygiene under a faculty that included such leaders in the discipline as John Shaw Billings and Walter Reed. Reed’s academic title—professor of clinical and sanitary microscopy—captured the dramatic changes in military medicine since the Civil War. The microscope and bacteriological culture had taken their places alongside the scalpel and saw as tools of the trade.23
On the eve of the war with Spain, the professionalization of the Army Medical Department was still a work in progress. As was the case with practitioners in many other disciplines at the turn of the century, including law and civilian medicine, the military surgeons’ claims to the rigor and status of a science outpaced the workaday reality. Under U.S. military law, neither their medical credentials nor their commissioned ranks entitled medical officers to command in the line. The surgeons could only make recommendations regarding camp sanitation to the line officers, who decided whether to implement them. In the past, many line officers had shown little patience with regimental surgeons, insisting that their intrusions interfered with military discipline. During the Civil War, one Union Army colonel had shrugged off his medical officer’s complaint that the camp smelled of excrement, insisting the stench was “inseparable from the army. . . . [I]t might properly be called the patriotic odor.” (No wonder Whitman recalled that war as “nine hundred and ninety-nine parts diarrhea to one part glory.”) By 1898, many line officers and soldiers had grown more respectful of the surgeons’ expertise, and the medical corps consequently wielded greater authority over camp conditions. But the national military school still did not offer a course in hygiene. And the advance of scientific medical knowledge since the Civil War had eliminated neither the patriotic odor nor the old tension between line officers and their medical men.24
Even within the medical corps, the new knowledge of the microbe did not overthrow older ideas about disease causation that centered on the relationship between bodily constitutions and their geographical environments. Major Reed and two other senior department surgeons, who toured many of the training camps in 1898, found that even “intelligent medical officers” instinctively looked for the sources of camp epidemics in “intangible local conditions inherent in the place.” It was as if the old miasmatic theory of disease remained unchallenged. “There is apparent in man a tendency,” noted Reed and his colleagues, “to believe in the evil genius of locality.” Military surgeons still relied more on their senses than their microscopes, reflexively associating filth and foreign surroundings with pathogens.25
When Congress declared war against the Kingdom of Spain, on April 21, 1898, the U.S. Army consisted of just 28,183 men, stationed at eighty posts across the nation. Apart from the late-century campaigns against the Indians, in which many men of the current officer corps had participated, the Army had not fought a war in thirty-three years. By the end of May, the Army mustered in 125,000 Volunteers, men from all walks of life whose military experience was limited to service with their state volunteer militias, units of the National Guard. The regiments bound for Cuba and Puerto Rico assembled throughout the spring and summer in camps in the southeastern states. After Commodore George Dewey’s victory in Manila Bay, the Army mobilized an expedition in the western states to steam across the Pacific and take possession of the Philippines. By mid-August, when the fighting with Spain ceased, the Regular Army and the Volunteers had a combined strength of over a quarter million men—the great majority of them inexperienced volunteers.26
The War Department and its medical branch were unprepared for this sudden buildup. Like the Army itself, Sternberg’s Medical Department was a stripped-down affair during peacetime. The department had no stockpile of supplies and no ready reserve of fiel
d-tested surgeons. Many of the older surgeons had been serving at desk jobs and were in no shape to take the field. To the small corps of properly trained field surgeons were hastily added more than one hundred commissioned officers and nearly four hundred medical officers from the state militias. During the summer, the Army would add more than five hundred contract surgeons. The Medical Department suspended its rigorous examination requirement. Lieutenant Colonel John Van Rensselaer Hoff, a seasoned surgeon with the Medical Department, found among the volunteer surgeons “scarcely an officer who possessed the slightest knowledge of medico-military matters.”27
Some of the civilians, however, were seasoned public health officers who brought that experience to the Medical Department. If military discipline was new to these men, the police power was not. Several of them would play leading roles in staging the overseas campaigns against smallpox. Dr. Azel Ames, who served as a brigade surgeon with the U.S. Volunteers in Puerto Rico, had founded the board of health in Wakefield, Massachusetts. Dr. George G. Groff, who would serve with Ames as a director of vaccination in Puerto Rico, had a peacetime career as professor of organic science at Bucknell University and president of the Pennsylvania State Board of Health. Like many of the older surgeons of the Regular Army, Dr. Henry F. Hoyt was a veteran of the Indian campaigns—he called himself a “redhaired Indian fighter.” But he had also served as commissioner of health for St. Paul, Minnesota, where he enforced smallpox vaccination and established a bacteriological laboratory before receiving his wartime commission as chief surgeon of the Second Division, Eighth Army Corps, bound for Manila.28
Smallpox loomed on everyone’s mind as the troops and doctors streamed into the national assembly and training camps in Pennsylvania, Virginia, Florida, and Georgia. By the spring of 1898, the new mild type smallpox had spread across much of the South, shaping the War Department’s decisions about where to locate the encampments. C. P. Wertenbaker, dispatched to South Carolina just two days after the declaration of war, advised strongly against using smallpox-ridden Columbia as an assembly area.29
Since 1834, Army regulations had mandated that all U.S. soldiers submit to vaccination. The Volunteers had their arms scraped as they mustered into service. Army reports and soldiers’ letters home recounted the vaccine-induced fevers and inflamed arms that afflicted men in camps and aboard ships headed for the war zones. Lieutenant Colonel Hoff insisted the Army’s vaccine was sound, attributing the soldiers’ woes to the “hurry and turmoil” of the mobilization and the inexperience of the Volunteers’ medical staff. The virtue of compulsion seemed ably demonstrated by the remarkable absence of smallpox in the assembly areas, as tens of thousands of soldiers mobilized for war in the midst of an emerging regional epidemic. Among more than fifty thousand Regular Army troops, only one smallpox fatality occurred on the mainland.30
The real horror of the national encampments turned out to be typhoid. The infectious disease had haunted armies since time immemorial, earning the nickname “camp fever.”
By 1898, typhoid fever held few mysteries for Army surgeons. They knew its causative agent (Bacillus typhosus), its mode of transmission (“the transference of the excretions of an infected individual to the alimentary canals of others”), and the sanitary measures that would keep it at bay (keeping troops from fouling their own water, food, and personal effects). But the surgeons, particularly those serving with the Volunteers, proved incapable of preventing its spread. The hastily constructed camps provided ideal conditions for an epidemic: poor drainage, a dearth of pure water, and thousands of undisciplined recruits, who, disregarding the entreaties of their medical officers, preferred the nearby woods and streams to the newly dug latrines. Typhoid took hold almost everywhere.31
The camp epidemics made a deep impression on the surgeons who would soon accompany the American regiments overseas. Lieutenant Colonel Hoff witnessed the suffering up close; he may even have felt some responsibility for it. Assigned as chief surgeon with the all-Volunteer Third Corps at Camp Thomas, in Chickamauga Park, Georgia, he arrived at the camp in May 1898, after the Regular Army troops had pulled out. By the end of June, Camp Thomas teemed with nearly sixty thousand green recruits and fifteen thousand horses and mules. One line officer remarked how the Volunteers had turned the campground into “a mass of putrefaction.” No amount of quicklime could overcome it. For the American public, the typhoid horror stories told by the troops at Camp Thomas recalled the Confederate prisoner of war camp at Andersonville. “Bad Water, Unfit Food, Brutally Stupid Treatment,” read one New York Times headline. More than ten thousand soldiers contracted typhoid fever at Camp Thomas that summer; 761 of them died. Even more unseemly was Camp Alger, an assembly center just an hour’s ride from the Washington offices of the camp’s namesake, Secretary of War Russell A. Alger. With its drinking wells driven too close to the regimental sinks, Camp Alger had become a “nursery of typhoid.” Soldiers at the Florida encampments—Camp Tampa and Camp Cuba Libre—suffered, too. In all, nearly 21,000 American soldiers caught the disease in the national encampments during the summer of 1898, and 1,590 died. Most of the dead were Volunteers.32
Close on the heels of the camp typhoid epidemics came the highly publicized withdrawal from Cuba of the Fifth Corps, overwhelmed by typhoid, yellow fever, and malaria. With the fighting finished on the island by July 17, Colonel Roosevelt warned that 90 percent of the soldiers were incapacitated by disease and would, as The New York Times put it, “die like sheep if left in Cuba.” The plight of the Fifth Corps—compounded, some said, by Major General William Shafter’s refusal to cooperate with his medical officers—confirmed the public’s worst fears: America was sending its young men to do battle with tropical diseases more deadly than Spanish cannon.33
The health crises in the assembly camps and the Fifth Corps tarnished the reputation of the War Department and emboldened critics of the war. In September 1898, shortly after the cessation of hostilities, President McKinley appointed a presidential commission, headed up by General Grenville M. Dodge, to investigate the “charges of criminal neglect of the soldiers in camp and field and hospital.” The Dodge Commission’s report, released to the White House in February 1899 and made public the following year, concluded that the Army Medical Department, for all of the “good work” it had done during the war, had committed “manifest errors,” beginning with its failure to properly investigate the sanitary conditions of the assembly camps. Modern scientific knowledge and professionalism had not yet usurped the age-old dominance of disease over combat in the actuarial tables of warfare.34
The tragedy of the assembly camps would continue to haunt and motivate the surgeons of the Army Medical Department as they settled into new positions with occupying regiments and the U.S. military governments in Cuba, Puerto Rico, and the Philippines. The shame of the assembly camps heightened the Medical Department’s obsession with the health of the troops on the ground. It contributed to the intensity with which the Army prosecuted its sanitation and vaccination campaigns in all three places. And it gave additional motivation to the scientific work of the Army medical men as they pursued exciting new lines of research.
In 1901, Walter Reed and a team of colleagues in Cuba, in a bold and risky series of experiments, confirmed the Cuban physician Carlos Finlay’s theory that yellow fever was spread by the Stegomyia fasciata mosquito (now called the Aedes aegypti). Under the command of Major William C. Gorgas, the Army launched a campaign to destroy the mosquito’s breeding grounds in Havana. By the summer of 1901, the Stegomyia had virtually disappeared from Havana, and so had yellow fever. Reed expressed his relief in a private letter to Gorgas. “Thank God that the Medical Department of the U.S. Army, which got such a ‘black eye’ during the Spanish-American War, has during the past year accomplished work that will always remain to its eternal credit.”35
A strong desire to clear the good name of their institution only begins to describe the range of aspirations and interests U.S. military surgeons carried with them or di
scovered within themselves in the cities, garrisons, and villages of Cuba, Puerto Rico, and the Philippines. Military surgeons went to extraordinary lengths to protect the troops in those tropical places. Over time the surgeons would turn their medical gaze outward, from a narrow professional concern for the health of the troops—the maintenance of a continually shifting cordon sanitaire—to a broader interest in governing the health of the civilian populations of the newly subordinated territories. These agents of the American nation seized upon the vast and (to their eyes) exotic field of medicine, administration, and humanitarian intervention opened up by the Navy’s gunboats and the Army’s rifles. The worlds they entered would never be the same.
The lingering shame of the national encampments did not diminish the air of sanitary superiority with which American military men and civilians took in the sights, sounds, and smells of their new tropical surroundings. Disembarking from Army transports and commercial steamships, the Americans first encountered the old Spanish port cities. Judging the coastal population centers of Cuba, Puerto Rico, and the Philippines by standards of cleanliness only recently (and all too incompletely) achieved in American cities, the occupiers attributed the unsanitary state of affairs in equal parts to the incompetence of their Spanish predecessors and the indifference of “the natives.” “Nauseating odors” assaulted the nostrils of one American visitor to Havana: “dead animals abounded, garbage was encountered everywhere, and open mouths of sewers running in to the ocean and harbor were reeking.” Captain L. P. Davison of the Fifth Infantry, newly installed as president of the San Juan Board of Health, described the Puerto Ricans as “a poverty-stricken and extremely dirty and mixed population, living in absolute violation of all civilized rules.” In Manila, where residents reportedly thought nothing of relieving themselves at the side of the road or dumping chamber pots from windows, one American official advised his countrymen to walk in the center of the street and always carry an umbrella. To these Americans abroad, filth signified disease. And filth was everywhere.36