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Chapter 4

Table of Contents

Chapter 4

A NEW DIRECTION

In 1893 the United States was entering a period of great change. The Indian wars were over. The nation's productivity, like its population, was increasing rapidly. The expansion of foreign trade focused attention on trade routes and international competition. President Grover Cleveland had scarcely been inaugurated, however, before a growing number of bank closings and business failures brought the nation to the brink of economic chaos. By the summer of 1894 four million unemployed were seeking work. Among those still employed, wage reductions triggered strikes and related violence greater than those of 1877. By 1895 the threat to the economy was waning, and the nation was ready to channel its energies in new directions. Enthusiasm for the destiny of the United States as a world power was burgeoning, and the outbreak of revolution in Cuba appeared as a promising opportunity to demonstrate U.S. strength and righteousness.1

The world of medicine was also rapidly changing. In Europe in the two decades immediately following the end of the Civil War, the pace of the medical revolution was accelerating, and American physicians who had studied in Europe were leaders in an increasingly successful effort to bring European standards in medical education to the United States. European scientists discovered the causative agents of an impressive list of diseases, among them amebic dysentery, gonorrhea, typhoid fever, malaria, tuberculosis, erysipelas, cholera, diphtheria, and tetanus, all threats to an army's effectiveness. Each discovery produced a host of new challenges for those who sought to prevent or cure disease. The isolation of the diphtheria bacillus was followed by the finding that it produced a deadly toxin. The subsequent development of an antitoxin that was clearly lifesaving convinced many doubters that the new scientific medicine was not mere "bacteriomania" and encouraged scientists to seek out other diseases whose ravages could be defeated in the same way. The discovery that serum from a patient who had recovered from typhoid, when mixed with the typhoid bacillus, would clump, or agglutinate, made possible the Widal test for diagnosing typhoid in 1896. A similar principle would eventually be used to develop the valuable Wassermann test for syphilis.2

The proof that the so-called filth diseases-principally typhoid fever, cholera, and the various forms of dysentery-were spread by infected excreta and by anything that came in contact with them enabled doctors to develop more effective and efficient approaches to sanitation. The public health laboratories that began to appear in major U.S. cities in response to developments in Europe tested water supplies and assisted


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SURGEON GENERAL STERNBERG

in the diagnosis of communicable diseases. Towns and cities set up water and sewage systems, and more local governments accepted garbage collection as one of their responsibilities. In the United States, public health was beginning to become "both institutionalized and professionalized."3

In providing "definite proof of the value of the laboratory approach," according to noted medical historian Erwin H. Ackerknecht, these and similar developments encouraged the entry of the Army Medical Department into what would be a new and glorious era, one in which the new science of bacteriology would make the laboratory an indispensable institution. The surgeon general who would now triumphantly take the department to the forefront of the medical revolution was the 55-year-old Brig. Gen. George M. Sternberg. Restive under the regimes of his predecessors, Sternberg was apparently eager to create for his subordinates the climate he had long sought for himself.4

During the last decades of the nineteenth century, however, Congress made it impossible either for the Medical Department to take full advantage of the medical revolution in Europe or for the Army to prepare for the possibility of a foreign war. Sternberg himself believed that "the principal reason for supporting an army in time of peace" was the maintenance of "an efficient organization . . . which will be ready for service in any emergency and serve as a nucleus for the larger army which will be required in case of war." Because the legislature failed to vote an increase in the size of the nation's armed forces, preparations to meet future challenges had to be based on quality rather than quantity. Even this approach proved difficult to follow, for the nature of war was becoming ever more complex, and as Civil War veterans aged, fewer trained men were available for call-up. The need for planned, systematic training of the men, both officers and enlisted, who would be asked to meet the challenge of large-scale modern warfare became increasingly obvious.5

The New Surgeon General

After years of bitter political infighting, during which he had learned how to manipulate legislators and politicians to his own advantage, Sternberg succeeded Sutherland upon his retirement as surgeon general in May 1893. Sternberg was not the most senior member of the Medical Department. He had ranked at the very bottom of the list of those who passed the department's entrance examination when he took it during the Civil War. He could not claim to have had the administrative experience of his predecessors or of some of the other candidates


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for the position, nor had he spent any appreciable length of time in Washington, where he might have become familiar with the work of the Surgeon General's Office. Nevertheless, at a critical time in both the nation's history and the history of medicine, Sternberg was the man for whom the moment called. Unlike his predecessors and his rivals, he was a scientist in the modern sense of the word. Years of determined, painstaking research, conducted under often difficult circumstances, had made him a widely respected bacteriologist, one of the few Americans whose accomplishments rivaled those of the Europeans.6

Sternberg developed his skills in the use of both camera and microscope while still a post surgeon and also familiarized himself with the latest laboratory techniques while working with Koch in 1886. His discoveries paralleled some of those of his famous contemporaries. Although the European bacteriologist Elie Metchnikoff received credit for having discovered the phagocytic action of white blood cells in 1892, Sternberg had independently theorized about the scavenging activities of these corpuscles in the early 1880s. Almost simultaneously with the French scientist Louis Pasteur he discovered the organism later identified as the principal cause of lobar pneumonia. He conducted experiments with disinfectants and established the fallacy of several highly regarded theories concerning the causes of yellow fever and malaria, publishing many articles and books based on his research.7

When Baxter died in 1890, physicians and military officers-among them Maj. Gen. John McA. Schofield, the Army's commanding general; United States senators; and such eminent citizens as Andrew Carnegie and Enoch Pratt-had joined an effort to have Sternberg appointed to the vacancy. But the importance of bacteriology and the significance of Sternberg's achievements were not as widely appreciated as they would become by 1893, by which time the picture had changed. On learning that medical officers junior to him were applying to succeed Sutherland, Sternberg decided to present his own name formally to the president as a candidate. This time his candidacy, again supported both by men of influence and by an outstanding record as a scientist, was successful.8

After his selection as surgeon general, Sternberg continued to publish and to assume positions of leadership in various civilian associations, clubs, and other organizations. These included Washington's Cosmos Club, the District of Columbia Subcommittee on Permanent Relief and Sanitary Dwellings for the Poor, the Sanitary League of Washington, D.C., the American Medical Association, of which he was president in 1897, and various scientific bodies. He also became a frequent visitor to the White House, as physician and then as friend, under both Cleveland and McKinley.9

The Medical Department had been moving forward into the new world of science before Sternberg's appointment, and the use of antiseptics was by this time taken for granted. The new surgeon general stood as a symbol both of what the department had been and of what it should be in the years to come. While others in the department would have undoubtedly made better administrators, Sternberg, with a record both of physical courage in war and of scientific accomplishment in peace, was essentially the man of the hour. Captain Reed greeted Sternberg's appointment to head the department in May 1893 with the comment, "The fossil age has passed."10

But Sternberg had a darker side. The driving ambition that had enabled him to con-


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tinue his research even during assignments to isolated posts was not an unalloyed blessing. Perhaps because he was frustrated that much of his work consisted of disproving the purported discoveries of others and that his positive achievements so often seemed to be anticipated by others, his continual need for recognition eventually became strong enough to cause resentment. While many physicians who joined the Medical Department during Sternberg's tenure became leaders in a golden age of military medicine, some became wary of their chief's private ambitions. Initially enthusiastic about Sternberg, even Reed was eventually convinced that the surgeon general would try to claim credit for his accomplishments.11

Personnel and Training

Although the number of posts and post surgeons had diminished since the late 1860s, the responsibilities of the individual medical officer, for the most part, had grown. The garrison he served was larger, he was usually required to care for military families, and he was involved in training litter-bearers and hospital corpsmen. The management of post hospitals grew in complexity with the recognition of the importance of antiseptic surroundings and the accompanying increase in the number of operations. An understanding of exactly how filth was related to disease gave rise to an appreciation of the need to advise post commanders on the upgrading of sanitation and to remain abreast of the latest changes in the state of the art. Sternberg believed, moreover, that the medical officer had a responsibility to the public as well as to the Army and should therefore be willing to discuss hygiene and sanitation with all who were interested. Thus he raised no objection when medical officers taught in civilian medical schools.12

A small staff of six medical officers worked in the Surgeon General's Office to coordinate the efforts of Army surgeons in the field. The way in which the various administrative functions were organized varied with the passage of time. During most of the period of Sternberg's service as surgeon general, the office consisted of four divisions: the Library and Museum Division; the Hospital Corps and Supply Division, which bought and distributed medical and hospital supplies to the National Guard as well as to the Regular Army; the Record, Correspondence and Examining Division, whose functions included managing the department's accounts; and the Sanitary and Disbursing Division, which handled the prostheses issued to veterans, the personal identity section, and similar matters. A medical officer stationed in Washington was also responsible for health at the Soldiers' Home, although he was apparently not regarded as part of the administrative staff of the Surgeon General's Office.13

Unappreciative of the increased responsibilities of Army surgeons and not content with having entirely eliminated funds for contract surgeons from the Medical Department budget, Congress proposed in 1893 reducing the number of assistant surgeons from 125 to 95. The legislators reasoned that if the department could handle 210 posts in 1869 with only 193 medical officers, the loss of 30 assistant surgeons would not cause a problem when only 120 posts remained in existence. In 1869, however, the department had been able to hire 184 contract surgeons. Repeated reductions in the number of contract surgeons over the years and the elimination of this position had already resulted in leave being


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a rare privilege for the department's regular surgeons, as Sternberg emphasized in his annual reports. Congress finally agreed to a reduction to 110 assistant surgeons, this figure to be attained by attrition.14

The decreasing number of surgeons in the Medical Department and the growing range of the duties that rested upon their shoulders made it more desirable than ever that Army doctors be completely prepared from the outset to meet the challenges that would face them. But even the best of neophyte medical officers was inadequately trained to deal with several aspects of his new responsibilities. Civilian medical schools devoted scant time to the preventive medicine that was so vital to maintaining the health of any Army unit. Since only in the last quarter of the nineteenth century did American schools begin to offer courses in bacteriology, U.S. physicians had to go abroad to study in this field. Moreover, the administrative aspects of military medicine were expanding and becoming more complex, but civilian medical schools did not familiarize young physicians with either the intricacies of the resultant paperwork or such matters as the design of hospitals and ventilating, heating, and sewer systems. Had study in an Army medical school been available earlier, a Civil War veteran pointed out, the new medical officer would have been "spared some of those hard lessons of laborious and dearly bought experience" and enabled "to adjust [his] previously acquired information to the exigencies and changing phases of military life." Although several European countries had established military medical schools and former Surgeon General William Hammond had tried to start one during the Civil War, in 1893 the United States Army still had no such institution.15

Since by this time advanced schools were being established for different branches of the Army, Sternberg easily persuaded Secretary of War Daniel S. Lamont, a personal friend, to order that a graduate school be established for the Medical Department. Perhaps as persuasive an argument as any in favor of the new institution at this point was that of Sternberg, who spoke in terms of "improvising a school" that would add "nothing to the expenses of the Army Medical Department" while offering "all the advantages that could be derived from one costing heavily for its establishment and maintenance." It would use facilities, equipment, and materials, including biological specimens, that were already in the department's possession. Its regular staff would be composed of men working in Washington, although some lectures were to be given by experts who were not in the Medical Department-whether they contributed their services without charge is not stated in Sternberg's annual reports. Since Sternberg believed that the principal "duty of an Army Medical officer is to preserve the efficiency of his command by guarding it against unsanitary influence and preventing disability from diseases that are known to be preventable, "the new school became the first institution in the country to specialize in public health and disease prevention. It also familiarized the neophyte medical officer with military regulations and provided him with the understanding of military discipline, authority, and training that would enable him to command respect as a military officer.16

The Army Medical School's first session, held in the Army Medical Museum, ran from November 1893 to March 1894 and was attended by five newly commissioned medical officers and four experienced assistant surgeons. The regular staff was composed of Col. Charles H. Alden, who as-


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ARMY MEDICAL MUSEUM CLASSROOM

JOHN SHAW BILLINGS

sisted Sternberg in his office and served as president of the faculty; Lt. Col. William H. Forwood, attending surgeon at the Soldiers' Home; and Majors Billings and Reed. An understanding of bacteriology was required, and the first graduates had to pass examinations in duties of medical officers, military surgery, military medicine, military hygiene, chemistry, pathology, and Hospital Corps drill. They were also given instruction in riding and "auxiliary courses," among them military law.17

Reed, who was the Army Medical Museum curator and director of the museum's pathology laboratory, taught clinical and sanitary microscopy, subjects whose importance grew with every passing year. The number of "pathogenic organisms" that his class studied was considerable. They included both staphylococci and the bacilli responsible for such diseases as anthrax, typhoid, tuberculosis, and diphtheria. Apparently not all of his students were impressed by the American Medical Association's stand that "the investigation of . . . microscopic organisms and their effects lies at the very foundation of modern medicine and surgery"; a few showed little sign of effort beyond the absolute minimum necessary to pass.18

Another important subject in the new school's curriculum was surgery, a rapidly expanding specialty. By 1897 young Army physicians were being trained in the new field of abdominal surgery, learning how to manage intestinal anastomosis (the surgical joining of two separate sections of intestine to restore their continuity) and the removal of the gallbladder or kidney. William W. Keen, a Civil War surgeon so highly regarded that he had been asked to help care for the ailing President Cleveland in 1893, lectured on surgery of the head. In spite of the breadth of the curriculum,


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"field service," or the management of the wounded and their evacuation away from the front, was not, as a medical historian of World War I commented, "dignified by a special course of lectures. . . ."19

The 1894 decision to reduce the size of the Medical Department by attrition forced the cancellation of the session scheduled for the winter of 1894-1895 because of the lack of students, although the laboratories continued to be used as classrooms for several medical officers requesting instruction. When the school was reopened in November 1895, the number of students was again small, but the classes were considered so valuable that on 6 July 1897 the school's session was lengthened to five months, beginning the following November.20

Part of the value of the Army Medical School was the opportunity to study specimens on display in the Medical Museum, among them some that had been involved in a series of experiments conducted by Capt. Louis A. LaGarde in cooperation with the Ordnance Department. Using an experimental .30-caliber Springfield rifle and the standard .45-caliber Springfield, LaGarde sought to determine the effects on both men and armies of newly developed small-caliber rifles and the steel-jacketed bullets they fired, a topic of concern to all military surgeons. The tests used a variety of subjects, including rabbits, horses, powder cans filled with wet sawdust, and, apparently, human corpses. Of particular interest in this connection was LaGarde's report that the bullet fired by the .30-caliber weapon had greater penetration than the .45 and caused less shock. He also determined that the heat generated by the firing was never high enough either to cause damage to the flesh about the wound or to kill germs.21

The collections managed by the Library and Museum Division of the Surgeon General's Office under Billings' direct supervision continued to increase in value. Both military and civilian scientists used them to further their own professional growth. Many sources, including both dentists and physicians, contributed items for the museum, some of which were used to educate the public as part of the Medical Department's exhibits at such widely publicized events as the World's Columbian Exposition in Chicago in 1893. This fair also featured a regulation post hospital "and a field hospital under canvas, adjoining."22

Many studies were conducted at the Army Medical Museum, including those Reed designed to improve methods of handling and preserving specimens. Among the most interesting were those involving the newly discovered "weird and wonderful" X-ray, first publicly demonstrated in Germany in December 1895. Reed's initial request for permission to buy X-ray equipment was rejected, but by 10 June 1896 he had an X-ray machine with which he located a bullet in the thigh of a patient in a local hospital. Sternberg soon thereafter obtained machines for several post hospitals. Much was yet to be learned about the use of this revolutionary device, particularly the unpleasant nature of the burns that resulted from the long exposures then required. A medical officer reported that one of his patients with a gunshot wound had been irradiated in a civilian hospital for twelve hours to make eight pictures. The bullet sought in this instance was never located, but the patient suffered an 8- by 15-inch burn that was still not entirely healed six months later. The "most distressing feature of the case," the surgeon noted, was "the intense pain, which nothing but morphine will control."23

Wishing to offer medical officers opportunities to improve their skills beyond


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those available in Washington, Sternberg assigned promising young officers to posts near civilian medical schools to encourage them to undertake further study and research, an approach used by Baxter when he was surgeon general. Following Sternberg's lead, the medical directors of some military departments also attempted to increase the professional expertise of their subordinates, presenting them with hypothetical practical problems to which they were expected to devise solutions. The goal of this type of exercise was not so much testing the medical officers' knowledge as stimulating their minds. They were encouraged to include line officers in discussions of assigned problems so that their active cooperation in preventing disease might be more easily obtained.24

The training of the recently formed Hospital Corps also concerned Sternberg, who sought to perfect its organization and utilization. He decided that because many of its members would be serving in the East, a school of instruction should be established at Washington Barracks (now Fort McNair), a site ideally located for units along the Atlantic Coast. Hospital Corps training could be run in conjunction with the medical school, providing inexperienced surgeons an opportunity to observe and participate. The program at Fort D. A. Russell in Wyoming was cut back and eventually eliminated in favor of that in Washington, where a new hospital was built in connection with the Barracks.25

Before hospital corpsmen could be adequately trained, decisions had to be made about the role they would play in the future. Medical officers studied the way in which other armies handled the challenge of managing casualties on the battlefield and discussed the location and manning of field hospitals, dressing stations, ambulance and medical supply depots, and the desirable amount and type of equipment. Since specific doctrine to guide the use of medical personnel in the field had yet to be determined, developing guidelines for training corpsmen to meet wartime responsibilities was difficult. At least one surgeon believed that the availability of medical officers at the front would make the utility of first aid training for corpsmen questionable. The likelihood that the longer range of newly developed weapons would require the dressing station as well as the field hospital to be located farther from the front made it difficult to predict whether medical officers or hospital corpsmen would in the future be responsible for the initial care of the wounded.26

The training offered hospital corpsmen, however, was still principally designed to prepare them to meet the demands of a peacetime Army whose greatest challenge might continue to be Indian warfare. As a result, the course in the East differed slightly from that in the West, because the hospital corpsmen in the West were more likely to have to bear arms to defend their patients. The school in Washington did not require drill with firearms, although all schools of instruction gave classes in cooking, riding, the care of horses, first aid, anatomy, physiology, nursing, and pharmacy. Doubts about the worth of ambulance and litter drills remained.27

In 1896 the Medical Department found it necessary to change its approach to the training of hospital corpsmen. From 1891 to 1896 schools of instruction had trained more than 400, but attrition was so great that only a minority of those serving in 1896 had been through the formal program. The department thus decided that schools in the West should return to the concept of training in small groups. The surgeon general


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had the training company at Fort Riley, Kansas, broken up and the men distributed among other posts. The benefit anticipated from this approach was apparently entirely financial-once trained, these men would not have to be sent as far to reach their new assignments. Sternberg did not, however, break up the company of instruction that had been organized for corpsmen in Washington; it served as a pool from which men could be drawn to assist in emergencies wherever they occurred.28

Although much of the Medical Department's effort concerned corpsmen working in the field, further changes involved those serving in hospitals. Experience showed that it was both impractical and unsanitary for such corpsmen to wear their regular uniforms while on duty. Sternberg suggested that they be given white linen or duck uniforms to be worn over the regular clothing in cold weather and as a substitute for it in hot. These fabrics would not absorb infectious material as easily as the customary uniform, and the conspicuousness of stains would make it easier to spot areas that should be soaked in disinfectant before washing. Despite the logic of the suggestion, several years passed before the white uniform was adopted.29

The increased salary available to corpsmen after July 1892 resulted in an improvement in the quality of men submitting applications to take the Hospital Corps entrance examination. Nevertheless, complaints arose concerning their performance, since successful candidates were often the most intelligent rather than those best suited physically and morally for the work. They also proved less able to direct the efforts of others than those who had functioned as attendants in previous years. Sternberg pointed out to those who complained that if the officers making the recommendations had exercised better judgment in their choice of candidates, the problem would never have arisen.30

As forts were abandoned and Congress continued its drive to reduce expenses, the number of hospital corpsmen and stewards, like the number of assistant surgeons, began to drop. Of the 589 privates in the Hospital Corps on 30 June 1893 (positions for 598 were authorized), only 530 remained in 1895. In the same year 6 of 122 hospital stewards left the service, and in March 1896 Congress reduced that figure to 100. Most medical officers publishing articles on the Hospital Corps seemed to agree that the ratio of Hospital Corps privates to the total strength of a command should approximate 2 percent, with 1 hospital steward and 3 acting hospital stewards assigned for every 30 privates.31

The notion that every company had four good men who were willing to add the work of the litter-bearer to their other duties proved unrealistic, as had been predicted when the concept was originally proposed not long after the creation of the Hospital Corps. In March 1896, therefore, the War Department issued a general order requiring all enlisted men to be taught how to carry litters and to administer first aid. Surgeons were to familiarize company officers with the litter drill and with emergency care of the wounded so that these officers could then train their men. In October 1897 a second general order required that enlisted men practice these skills at least four hours every month and that each post surgeon train his hospital corpsmen in first aid and litter-bearing for at least eight hours in that period.32

The expertise of Regular Army hospital corpsmen was of little help to their National Guard counterparts. Guard components met rarely and briefly, and if, as was


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often the case, a National Guard unit was not in the same brigade with a regular regiment, then regular corpsmen were not available to familiarize their counterparts with their work. Training standards and equipment differed from unit to unit. The relationship of Regular Army and National Guard medical officers continued, however, to be generally pleasant. Guard physicians often displayed an active interest in the Medical Department's most recently acquired equipment and requested copies of the new supply table, which listed the furniture, appliances, and drugs used by the department, including "appliances for operating in accordance with the requirements of aseptic surgery." The two groups exchanged information through the Association of Military Surgeons, which in the summer of 1893 opened its membership to Regular Army medical officers. A few Guard doctors even attended some Army Medical School classes.33

Preventive Medicine

In an era when disease was not often treated successfully, prevention was critically important. After a year as surgeon general, Sternberg presumably believed that his medical officers were handling their responsibilities in this area satisfactorily, despite the obstacles they encountered in their work, since he maintained that the health of the Army was generally good. The great majority of the enlisted men continued to come from cities where, through exposure since childhood to a host of diseases, they had acquired a certain resistance to many of the most common ailments. The health of black troops had improved markedly, and only Indian scouts suffered to any great extent from sickness. The accommodations given to Indian soldiers were inferior, often old, dilapidated, badly ventilated, and dirty. Crowding aggravated what was regarded as an inborn tendency to tuberculosis, while a high rate of alcoholism only exacerbated all other problems. Black soldiers, on the other hand, were sick even less than white; their rate for 1895 was 811.6 per 1,000 versus 1,116.44 for whites. High rates of sickness at a few posts served as reminders of the need for careful and constant attention to sanitation and hygiene.34

In his attempts to maintain the Army's health, Sternberg found himself fighting many of the problems that had challenged his predecessors. Casemates used as sleeping quarters, defective ventilation, vermin, dilapidation, overcrowding, and poor sanitation were still common wherever troops were stationed, although by 1896 he could report that "facilities for personal cleanliness have been greatly improved at our military posts." Determined to be fully and accurately informed about living conditions wherever Army units were stationed, he emphasized to his medical directors that he expected them to conduct personal inspections of all posts within their territories, avoiding reliance on the opinions of nonmedical officers about sanitation and the work of surgeons.35

Water supplies remained a major concern-soldiers used many sources, including rivers, cisterns, wells, artesian wells, streams, and ponds-but two new approaches to the problem of obtaining a safe supply gained strength in the mid-1890s. One involved drinking only the water obtained from ice machine condensers. This move was so successful at Fort Ringgold in Texas, where it was inexplicably followed by a drop in malaria as well as typhoid rates, that a larger condenser was installed to


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produce 2,000 gallons a day. More popular were filters, often employed in conjunction with boiling. Such a system had apparently been in use for some time at Jefferson Barracks, where water was obtained from the St. Louis mains.36

For a period in 1895 while its settling basin was being cleaned, the local company that supplied water to Fort Leavenworth pumped directly from the Missouri River. Since the water came from a point less than a mile below the spot where the post sewage spewed into the river and less than two miles below the outlet of a sewer system serving a village of more than 1,500 people, it was not surprising that those who drank it found it was "not only very muddy, but positively foul." Typhoid appeared at the fort, and efforts to have the drinking water boiled were only partially successful. By 1896 some families who relied upon river water for drinking were using filters.37

Properly used, some models of filters could remove an average of 98.54 percent of the bacteria in the water, but they required frequent cleaning and were very fragile. In 1897 the Medical Department began urging the use of portable filters in the field, where troops often drank from streams despite surgeons' efforts to discourage the practice. Although effective portable filters proved expensive, the cost seemed justified because of the long-range savings that would result from improved health.38

In an era when enthusiasm for physical education and the vigorous life was growing, the discipline gained through athletics was increasingly valued as a means both of preventing disease and of creating a state of glowing health. Believing that "the true athlete is he who has taught his muscular system absolute, unquestioning obedience, and such a one is most amenable to control," the Medical Department continued its efforts to encourage athletics and physical fitness. Capt. James E. Pilcher pointed out that "preparatory training, by which deficiencies are corrected and a proper equilibrium of the system secured," required medical supervision. But the money for building the necessary gymnasiums was not always forthcoming, even when without them the men might head for the "evil resorts" of a nearby city. Recreation and stimulation for the mind were also desirable as a means of filling the soldiers' spare time and lessening the temptation to indulge in the excessive use of alcohol.39

Several other approaches to the problem of alcohol abuse were tried during this period. The canteen system was not universally favored. Some believed that selling beer on base encouraged young men to start drinking. Once they started, they might be more easily tempted to seek hard liquor off post. In any event, a reduction in the number of inebriates might come at the cost of increasing the total number of men who drank. The fact that the revenue of the canteen accrued to the fund used for the food that was bought to supplement the regular ration only tended to make a disinterested judgment more difficult.40

Few Army doctors attempted to cure alcoholics. The Medical Department recommended that they be dismissed from the Army or, at the very least, be refused reenlistment. Captain Arthur devised a method of treating drunken episodes that was designed to restrain the alcoholic from further pursuing his inebriated ways. Arthur believed that it was important not to excuse the drunk from his duties any longer than absolutely necessary because this only encouraged his overindulgence. To speed the miscreant's return to sobriety, his stomach should be pumped, with the aid of a


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CHARLES SMART

hospital corpsman and a wooden gag if he protested the procedure too vigorously. "Hot beef extract, with cayenne pepper," should then be administered and after an hour, the soldier should be returned to duty. Only if the drunkard fell into a coma or showed signs of delirium tremens would Arthur hospitalize him. In attempts to retain the services of an otherwise worthwhile alcoholic sergeant, Lt. Edward L. Munson devised a slightly different approach. His cure used "suggestion and . . . the association of ideas, combined with the effect of whatever tonic and anti-alcoholic properties that was possessed by strychnine." The sergeant was given a hypodermic of sulphate of strychnine, atropine, and morphine each day and allowed to drink all he wanted. After he had consumed alcohol, he was given a hypodermic of apomorphine, which worked as an emetic. The resultant "intensifying nausea," together with assurances that the intolerance for alcohol caused by these drugs would be long-lasting, made the very thought of alcohol sickening. Both the Arthur and Munson approaches apparently won adherents among post surgeons.41

In its drive to prevent disease, the Medical Department also took part in efforts to design an adequate emergency ration, one that would be light in weight and high in calories. Studies of various concentrated forms of food began in 1895, and when a decision was reached a year later, forty-five officers, nine of them medical officers, had participated. In the summer and fall of 1895 units in the field tested some of the proposed items. On one occasion soldiers were supplied with a coffee tablet, a bean soup tablet, crackers, and bacon. Each man then prepared his own lunch. By 1400 hours some participants were feeling nauseated, and others were actively vomiting. Diarrhea added further to the misery of many. Within two more hours the landscape was littered with wretched and retching bodies, although all soon recovered. Interviews and further personal testing of the individual components of the ration by the intrepid surgeon involved in this test suggested that both the bean soup and the crackers were in some way to blame for the fiasco. During another test, the men of the 1st Cavalry subsisted on a different ration without apparent harm for five days of a ten-day march.42

In December 1896 a 4,110-calorie emergency ration was adopted, following its recommendation by a four-man board headed by Major Smart. It called for sixteen ounces of hard white bread of the kind normally provided to the Army, since it kept well and was familiar to the men; roast ground coffee beans or tea, to be sweetened with saccharin rather than sugar to


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keep the weight of the ration down and to lessen "the prevalence of diarrhea due to intestinal fermentations"; and ten ounces of bacon, also of a type with which the men were familiar. The board believed that the high proportion of fat was necessary to add calories to a ration that had to be compact and light in weight. A soup tablet was on the list, but the board could not find a manufacturer who would guarantee the use of the desired formula. This ration was not to be used for more than ten days at a time.43

The drive to prevent disease, coupled with the realization that insects might in some manner spread "the germs of cholera and other diseases," led to suggestions that window screens were more than a mere luxury. Army surgeons were aware of the malaria parasite and searched for it in the blood of their fever patients. Some believed that these organisms were transmitted directly through drinking water, but Sternberg was skeptical of this theory Although the role played by the mosquito in malaria was not yet firmly established, the connection of malaria with the sort of wetlands that breed mosquitoes had long been noticed. Having observed that at Fort Myer, Virginia, where the malaria rate was high, the number of patients with this disease went up rather than down after the drinking water was filtered, Surgeon Reed theorized that "emanations from the Potomac Flats" might have something to do with the malaria rate.44

In diphtheria and, subsequently, tetanus, prevention was made easier by the availability of both positive diagnosis and treatment. Since supplies of the diphtheria antitoxin were inadequate, the Army established its own "diphtheria antitoxin 'plant'" at Jefferson Barracks. Here horses were injected with the toxin in gradually increasing doses until a high level of antitoxin had been produced in their blood. Some patients in whom the antitoxin from horses was used experienced typical immune reactions in the form of rashes, joint pains, and, in one instance, a fatal paralysis, all of which were blamed on the antitoxin. Nevertheless, reports on its use as both a cure and as a preventive for this terrifying disease were generally favorable.45

Despite the precautions taken to purify drinking water, typhoid and fevers with typhoid-like symptoms continued to plague the Army. The new Widal test would in time prove especially valuable, but its true value would not be appreciated until physicians learned how to administer it and until they realized that different fevers were spread in different ways and that, therefore, prevention depended on distinguishing between them.46

Treatment of typhoid, like that of other fevers, had changed to some degree through the years. Patients were no longer bled, and although the noted physician Sir William Osler maintained that purging had also been abandoned, Army surgeons were still dosing typhoid patients with calomel (mercurous chloride), followed by castor oil. Antipyretics, among them quinine and phenacetin, were frequently used, and other preparations, such as chloral or mixtures containing a narcotic, were employed to induce sleep.47

Efforts both to prevent and to treat disease still often followed lines developed decades, even centuries, earlier. But new discoveries were beginning to provide explanations about why improved sanitation and hygiene resulted in lowered disease rates and to suggest different approaches to both diagnosis and treatment. In his "Valedictory Address to the Graduating Class of the Army Medical School, Washington, D.C.," in 1896, Civil


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War surgeon John H. Brinton rejoiced that "the bright days of advancement illuminate the whole horizon." In 1897 a physician wrote in the Boston Medical and Surgical Journal that it was "but yesterday that medicine [became] a hand-maiden of science and . . . escaped from the domain of inexact empiric art."48

Surgery

Progress in surgery was more dramatic than that in the prevention and treatment of disease. Encouraged by the optimistic reports of colleagues who traveled abroad to observe the best surgeons of Europe, Medical Department officers were undertaking a wider range of operations than ever before. They not only performed abdominal surgery, but they performed it earlier in the course of the patient's disease, before a fatal outcome became inevitable. The resultant improvement in the survival rate led to further and still earlier attempts. One civilian physician used an article in the Journal of the American Medical Association to urge in the strongest terms that surgeons operate "in every case of appendicitis, promising or unpromising, at the earliest possible moment." Nevertheless, the belief that the patient might recover from appendicitis without an operation and thus that surgery might subject him to unnecessary risk still caused many doctors to hesitate.49

Surgery to repair hernias had not been common before the era of antiseptic surgery. Even when it was performed, it was done only in desperate attempts to relieve strangulation. Fewer attempts to force the protruding intestine back into place without an incision were made as surgeons experienced increasing success with what was then called the "radical cure," or surgical repair involving an incision. Sternberg made herniotomy part of a campaign to keep good men with curable disabilities in the Army-one estimate suggested that twenty to thirty men received discharges each year because of hernias. He hoped thereby also to limit the number of disability pensions the government had to pay. In 1895 the Army gave the soldier with an operable hernia the option of having this problem repaired by an Army surgeon chosen by the surgeon general, thus avoiding a disability discharge. Sternberg noted that even when surgery did not enable the hernia victim to remain in the military, it at least made earning a living as a civilian easier. Medical officers performing herniotomies appear to have been successful; in sixty-seven cases dating from 14 August 1895, there were only three relapses and no deaths.50

Success in simpler forms of surgery encouraged attempts to conduct more demanding operations. In addition to herniotomies and appendectomies, Army surgeons were by 1898 undertaking hysterectomies and other forms of gynecological surgery, nephrectomies (removal of the kidney), and surgical repair of abdominal wounds. They removed gallstones and attempted the surgical relief of peritonitis, peritoneal abscesses, and intestinal perforations. Their few failures no longer discouraged them, and the number of patients undergoing abdominal surgery grew. Of eighty-one patients upon whom such operations were performed in fiscal year 1898, seventy-seven survived.51

Caution also marked postoperative care. Medical officers waited several days before allowing their patients to take nourishment by mouth. Lieutenant Munson permitted nothing by mouth for two days after surgery, while Maj. George W. Adair


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recorded nourishing one of his patients by enema exclusively for five days postoperatively The postoperative recovery period for herniotomy patients in the mid-1890s was also prolonged. Deputy Surgeon General Forwood kept his hernia patients in bed for thirty days after surgery and insisted that they refrain from "violent exertion" for at least three months thereafter. Other Army surgeons kept their patients in bed as long as six weeks.52

The frequency of abdominal surgery led Sternberg to order post surgeons not only to set aside a room to be used exclusively for surgery but also to develop routines designed to reduce the chance of infection and enhance the likelihood of an uneventful recovery. After administering thirty cc. of sherry as preoperative medication (whiskey was also used for this purpose), one Army surgeon had a large area around the operative site shaved and scrubbed with soap, water, and a solution of bichloride of mercury. The patient's stomach was washed out by means of a lavage tube "as a special precaution against vomiting" before the ether was administered. Immediately before the operation began, all gauze, absorbent cotton, and other materials that would be needed were routinely sterilized. Once a patient entered the operating room, the area around the operative site was covered with "hot, sterilized towels." Kangaroo tendon was recommended for deeper sutures, although catgut was used for more superficial stitching. At least one surgeon preferred "silkworm gut" for stitches taken in the skin; since they were non-absorbable, they were removed a week after the operation. To avoid infection and the failure of hernia repair because of sloughing of internal stitches, the kangaroo tendons were sometimes soaked for forty-eight hours in ether and for another twenty-four hours in bichloride of mercury in ether, then stored in a solution of carbolic acid and alcohol. Surgeons and attendants in the Army's operating rooms were beginning to wear "linen suits, linen operating aprons, and canvas shoes, the arms being bare to the elbow." Hands and forearms were always subjected to the usual scrubbings and soakings to render them as germ free as possible.53

The progress that had been made in the field of surgery since the death of President Garfield in 1881 was most eloquently demonstrated when, a few weeks before Sternberg's appointment as surgeon general, President Cleveland first noticed a growth in the roof of his mouth. Maj. Robert M. O'Reilly, one of his personal physicians, was asked to examine the growth when he arrived at the White House to pay a social call. Alarmed by what he saw, he returned the next day to remove a bit of the abnormal tissue. This he sent, without identifying his patient, to the Army Medical Museum's laboratory for examination. Having established the malignant nature of the tumor, O'Reilly called in Cleveland's civilian physician, Joseph Decatur Bryant of New York, who had the grim diagnosis confirmed by Dr. Welch at Johns Hopkins. From this point onward O'Reilly helped Bryant coordinate the president's care, but played only a minor role in it himself.54

Much involved in the nation's problems, Cleveland postponed the necessary surgery until July. His physicians then faced a double challenge-to do whatever could be done to preserve the president's life and ability to function effectively at the head of a troubled nation, and to keep word of the seriousness of his condition from reaching a public already on the verge of panic because of the depressed state of the economy When rumors about Cleveland's health began to


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circulate, his doctors informed the press that he was suffering only from rheumatism and dental problems. Even the families of the surgeons involved were kept in the dark about the identity of the patient.55

Although Cleveland was only 56 years old in 1893, he was close to exhaustion because of his efforts to guide the nation through a critical period. He also had a history of kidney problems and was "very corpulent, with a short, thick neck, just the build and age for a possible apoplexy." Nevertheless, Cleveland's physicians moved with a confidence that contrasted sharply with the uncertainty that afflicted Garfield's medical attendants. Particularly concerned about the anesthesia to be used, they decided that as much of the surgery as possible would be done under nitrous oxide and arranged to have it administered by a dentist known for his skill and experience with its use. On 1 July, after two teeth had been removed and the initial incisions made in Cleveland's upper jaw, O'Reilly took over from the dentist and administered ether for thirty-one minutes while two civilian surgeons removed all the upper jaw on the affected side except "the floor of the orbit and the intermaxillary portion." A second operation, much smaller in scope, was performed on the seventeenth to remove remaining traces of the cancer. The prosthesis that replaced the missing bone enabled Cleveland to speak normally almost from the outset so that neither the press nor the public appreciated the extensive nature of the surgery he had undergone. Unlike his unfortunate predecessor, Cleveland did not have to contend with infection. He recovered with impressive rapidity from his ordeal, and Bryant was soon able to return to his practice, leaving Sternberg to watch over his patients recovery until 1 September, when Cleveland was found to be "all healed."56

Ever since the operation, much controversy has centered about the question of the true nature of Cleveland's tumor. In 1975 the late Gonzalo E. Aponte, former chairman of pathology at the Jefferson Medical School in Philadelphia, initiated a thorough study of the tissue removed from Cleveland's mouth and held since 1917 by the Mutter Museum in Philadelphia. After both considering the historical background of the controversy and examining the tissue itself, the scientists conducting the study concluded that the tumor was "verrucous carcinoma, a low-grade malignant tumor known to behave more mildly than the ordinary oral cancer."57

The growing complexity of surgery and the frequency with which it was now undertaken, the emphasis on antisepsis, and the greater reliance on diagnostic tests, antitoxins, and immunization in the battle against disease, all had increasingly widespread effects on hospital design. The old style of post hospital was not large enough to shelter both a room reserved exclusively for surgery and the laboratory without which the physician could not offer his patients the benefit of modern medicine. In addition, proper accommodations were also needed for various types of equipment, including that for applying plaster casts, whose use eliminated the long confinement to bed that was otherwise necessary.

Congress voted money for hospital construction on a year-by-year basis, and special bills were required for expenditures that went beyond the yearly sum. But Sternberg was able to obtain money both for new post hospitals and for the modification of existing facilities. The plans for the new hospitals called for hot water heat, concrete basements, and pressed steel ceilings for the ground floor. Additions to existing facilities at some posts included op-


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erating rooms and laboratories. At other posts, operating rooms were enlarged or new ones installed in existing rooms. More space for beds also occasionally proved necessary. The joint Army and Navy general hospital in Arkansas was not being fully utilized, however, and an appeal went out to the medical directors of the various military departments to refer more patients. In 1897 eligibility was extended to include, whenever there were vacancies, honorably discharged soldiers and sailors, both regulars and volunteers.58

Domestic Conflict

With the period of major Indian depredations in the past, few of the Medical Department's patients were the victims of intentionally inflicted wounds. The only action Army units saw from 1893 to the spring of 1898 involved social unrest. Labor violence was not a new problem to the post-Civil War government, but Army units were used more intensively than ever before to deal with strikes, riots, and threats of riot that occurred during Cleveland's second administration. In the West the unemployed stole trains or forced their way upon them in attempts to make their way East. Workers in mines and factories protested reduced wages. Strikers at the Chicago Pullman plant were supported by mobs who harassed railroads west of the Mississippi and interfered with their operations. Although governors mobilized the National Guard in their states to help restore order, appeals to Washington for assistance were numerous. Regular Army units were ordered to guard bridges and tunnels, reclaim stolen trains, and restore and maintain order from Chicago to Sacramento. An estimated two-thirds of the Army was eventually involved in dealing with labor violence spawned by the railroad strikes alone. Injuries to Army regulars were few and usually minor, but since disease spread easily in areas where many men were camped together in temporary accommodations, surgeons were needed to advise on sanitation and to care for the sick.59

In July 1894, in response to one of the most threatening episodes of labor violence of his administration, President Cleveland sent approximately 2,000 men, most of them from Fort Sheridan, near Chicago, and Fort Leavenworth, to Chicago to guard government property and restore the mail service during a strike by Pullman workers. The soldiers were stationed at various sites about the city, but the largest number camped in Lake Front Park. Because of the lack of trees there, the sun blazed directly upon the men, an "impalpable black dust, which was exceedingly unpleasant" covered everything, and the ground "emitted a disagreeable odor, when disturbed by digging or sprinkling with the hose."60

Unsure both about the possible inroads of disease and about the number of casualties for which they might be responsible, the Medical Department contingent at Chicago was ready for all eventualities. Since some units arrived unaccompanied by doctors, Maj. Alfred C. Girard, the post surgeon at Fort Sheridan who served briefly as the chief medical officer, was required to assign Army physicians recalled from leave in such a way as to have at least one at each major camp. To ensure adequate coverage, a minimum of two civilian physicians also had to be brought in for the emergency. With the arrival of Maj. Daniel G. Caldwell with troops from his post at Madison Barracks, New York, and with his assumption of responsibilities as


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DANIEL G. CALDWELL

chief medical officer, the medical staff at Chicago was almost complete. The greatest number of Regular Army surgeons serving at any one time in the Chicago area during the strike was ten, six of whom were sent to the Lake Front camp. Four hospital stewards, four acting hospital stewards, and twenty-five Hospital Corps privates assisted them.

Girard set up a field hospital in tents erected at the Lake Front site, ordering the equipment he needed from Fort Leavenworth by telegraph. Supplementary equipment and supplies were contributed by the medical officers of the various units sent to the area. Only a few days after the first troops arrived, a thirty-bed facility awaited the sick and injured. Each bed had mosquito netting because of the many flies that inhabited the Lake Front Park. The hospital remained open until 18 July, when the camp was broken up and patients sent to the hospital at Fort Sheridan.

Each day a surgeon and a hospital steward, equipped with a medicine chest, made the rounds in a light wagon from the Lake Front headquarters to each of the small units that were scattered about the area. The medical officer held sick call and had the Lake Front camp send an ambulance to pick up anyone in need of hospitalization. Caldwell stated that this approach to the problem of providing care to the men of small units proved to be a "very satisfactory plan."61

Most patients seen by medical officers suffered from acute diarrhea, blamed by Caldwell upon the heat and the fact that soldiers often drank water from fire hydrants. Girard, on the other hand, maintained that the cause was "prolonged use of the canned meat of the travel ration," which caused "intense thirst. . . ." He noted that the meat was of such quality that a man had to be very hungry indeed to eat it more than once. The injured who needed the help of Army doctors were few. A caisson explosion on 16 July killed three and wounded ten, but Army surgeons arrived too late to help. The physicians of the nearby Illinois Militia cared for the victims and sent them on to civilian hospitals in Chicago. When the explosion victims were in a condition to be moved further, they were taken to the Fort Sheridan hospital.62

The troops sent to maintain order when the railroad strike spread to the Sacramento area, early in July, included approximately eight Army companies and three from the Marine Corps. These men originally bivouacked in the railroad station, sleeping upon the hard surface "in the midst of the heat and roar and glare." After seventeen days they were permitted to pitch tents in the shop yards, where they


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could construct floors and paths of wood in the shade of eucalyptus trees and piles of lumber. Only the cavalry troops lacked tents, and some of them were able to seek shelter in railroad cars. The men's food consisted of the field ration supplemented "with a fair proportion of fresh vegetables," but the water taken from city mains contained "considerable river mud." Those who regularly drank this "beverage" pronounced it safe, despite the misgivings of medical officers.63

The Medical Department contingent at Sacramento grew gradually. The initial two doctors, acting hospital steward, and two Hospital Corps privates were reinforced by four more privates on 13 July and the next day by a hospital steward, an ambulance, four mules, and the private who was detailed to drive them. Because of the presence of Marines, a Navy medical officer, a Navy apothecary, and two male Navy nurses were also available to care for the sick and injured, although the senior medical officer at Sacramento was Major Pope, post surgeon at the Army's Angel Island in San Francisco Bay. A civilian physician normally employed by the railroad also offered his services. As units were sent from Sacramento to guard the rail line at other points, medical personnel were detached to go with them, an Army assistant surgeon and two Hospital Corps privates to Truckee, California, on the thirteenth and Navy medical personnel to Rocklin, California, on the fourteenth.

Pope selected the railroad depot dining room at Sacramento as the site of the field hospital, since it was large, well lighted, and well ventilated. Inside, shutters blocked the heat and glare, and a Pullman car standing in the depot supplied bedding. Under orders from the city's mayor, the restaurant provided special diets. The Navy surgeon contributed a filter for the water so that patients did not have to imbibe mud. To remove the casualties of labor violence and to guard them from the mob, the hospital sent out four armed litter-bearers with an ambulance accompanied by a deputy U.S. marshal to guide the medical unit through the local streets.

Like their colleagues in Chicago, medical officers in Sacramento encountered few injured men in need of treatment. On 11 July, however, strikers derailed a train carrying U.S. mail when it was three miles from the station, killing four men and injuring six, one fatally. The train sent to assist the victims carried armed guards, an Army assistant surgeon, a Navy assistant surgeon, and two Hospital Corps privates. Except for a man whose hideous injuries proved fatal while he was still in the operating room, the casualties quickly recovered. Two days later Pope and four members of the Hospital Corps were again called to the scene of violence, but the only casualty was a striker shot in the abdomen. Pope cared for him until a patrol wagon arrived to take him to a civilian hospital, where he later died.

The health of the men at Sacramento was initially regarded as excellent, since an average of only 1 percent needed treatment. The diarrhea that afflicted the few who were ill was blamed on the heat and the drinking of too much ice water. Doctors had those suffering from heat prostration sponged with cool water and dosed with "a little digitalis or Aromatic Spirits of Ammonia." They treated diarrhea with a saline laxative, followed by "diarrhea tablets" containing calomel (still in use despite its removal from the supply table by Surgeon General Hammond during the Civil War), morphine sulphate, capsicum, ipecac, and camphor.64


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Although marshes bordered the camp at the railroad station on two sides, malaria did not appear until 2 August. The fact that so many developed the disease apparently took medical officers by surprise, for they had noted that civilians working in the area had not been severely afflicted in years past. By the time the troops left Sacramento on 3 September, doctors were treating forty-three cases, many suffering from gastric pain as well as fever. Pope used atropine and morphine in combination to treat these sufferers until their stomachs would tolerate quinine. Even after the men had left Sacramento, cases of malaria continued to develop among them-more than eighty were treated for the disease at the Presidio in San Francisco. Thus, despite the occasional violence that marked the disorders, disease proved to be the greatest enemy faced by the units called upon to restore order in the Sacramento area during the strikes of 1894.65

In spite of labor problems, the period from 1893 to the outbreak of the Spanish-American War in 1898 was quiet for the Army. For the Medical Department, however, it was a period of great change. During these five years under Sternberg's leadership, the department entered the era of modern medicine. An increasing number of Army hospitals became small medical centers in the modern sense, complete with laboratories and well-equipped operating rooms. With Sternberg's encouragement, surgeons successfully performed operations that they would not have dared to attempt ten years earlier. At his insistence, young physicians began to receive formal training in military medicine, instead of being sent out to sink or swim on their own or being thrown upon the mercies of a senior surgeon for indoctrination. Medical officers also continued to educate National Guard officers about the basic requirements of Army medicine and the absolute necessity for strict attention to sanitation. Despite the advances made under Sternberg, supplies on hand were of the type needed by post surgeons-not by physicians caring for the wounded of a modern fighting force-and the department itself remained small. As a result, the number of medical officers who benefited from Sternberg's efforts was also small, too small to overcome the ignorance of military medicine of the hordes of civilian physicians who would swell the department's ranks in 1898.66

The effects of these deficiencies were multiplied by the fact that Medical Department leaders were not preparing plans for meeting the demands of a major war that would result in large numbers of sick and wounded. The Franco-Prussian War of 1870-1871 had had much to teach about the organization and operation of the medical service of troops in such a conflict, but no one in the United States studied its lessons in any depth until after the Spanish-American War. Successive manuals designed to guide members of the department continued to concentrate almost entirely on the management of medical care at the various posts, and the need for field service regulations for the Army had not become apparent. Furthermore, the demands of the new military medicine were greater by far than those of the old, and the department had not yet had sufficient time to create all the laboratories, to acquire all the equipment, and to train all the men needed to meet the new expectations. These deficiencies would prove devastating as an abruptly swollen Army gathered to launch the invasion of Cuba and the Philippines.67


NOTES

1. Allan Nevins, Grover Cleveland, pp. 523-24, 528; Edward M. Coffman, The Old Army, p. 246.

2. Quotation from D. W. Cathell and William T. Cathell, Book on the Physician Himself, 11th ed. (Philadelphia: Davis, 1902), p. 109, as cited in William G. Rothstein, American Physicians in the Nineteenth Century, p. 266; James H. Cassedy Medicine in America, p. 89; Harry F. Dowling, Fighting Infection, pp. 14, 29-30, 99-100. Forms of dysentery other than the amebic include shigellosis, or bacillary dysentery, and giardiasis. A recently discovered cause of dysentery is Campylobacter. The Widal agglutination test was developed by French physician Fernand Widal. The Wassermann test was developed by August von Wassermann, a German bacteriologist.

3. John Duffy, The Sanitarians, pp. 126-56, 175-97, 254 (quotation); Cassedy, Medicine in America, pp. 108-09.

4. Erwin H. Ackerknecht, A Short History of Medicine, p. 161. See also pp. 167-70, 199.

5. Quotations from War Department, Surgeon General's Office, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1894, p. 16 (hereafter cited as WD, SGO, ARofSG, date); James L. Abrahamson, America Arms for a New Century, pp. xiv, 14, 34-35, 37-38; Peter Karsten, "Armed Progressives," in The Military in America From the Colonial Era to the Present, p. 247; Graham A. Cosmas, "From Order to Chaos," pp. 105-06.

6. Ltrs, Sternberg to John M. Schofield, and Schofield to Sternberg, both 10 Apr 1893, John McA. Schofield Papers, Manuscript Division, Library of Congress, Washington, D.C.; Rpt, 1 May 1861, p. 6, Entry 77, Record Group (RG) 112, National Archives and Records Administration (NARA), Washington, D.C.; Fielding H. Garrison, An Introduction to the History of Medicine, p. 718; Ltrs, R. C. Davis to Sternberg, 7 Mar 1887, Jos. C. Bailey to SG, and J. C. Breckinridge to SG, both 31 May 1893, J. P. Wright to SG, 8 Jun 1893, and other correspondence in Ms C100, George Miller Sternberg Papers, National Library of Medicine, Bethesda, Md.

7. Esmond Long, A History of American Pathology, pp. 206-07; in Entry 63, RG 112, NARA: Instrs for Med Offs to Whom a Microscope Is Furnished, 1 Jul 1868, vol. 3, SGO Cir 1, 1 Jul 1871, vol. 4, and Supply Tables, 1883, vol. 7; Mary C. Gillett, "A Tale of Two Surgeons," pp. 406-07, 411-13; Frederic P. Gorham, "The History of Bacteriology and Its Contribution to Public Health Work," in A Half Century of Public Health, p. 73; William Bulloch, The History of Bacteriology, pp. 182-85, 187, 214. See also articles by and about Sternberg in the Bibliography.

8. John M. Schofield, Forty-six Years in the Army, p. 183; John M. Gibson, Soldier in White, pp. 159-60, 166-67; Martha L. Sternberg, George Miller Sternberg, p. 130.

9. Sternberg, Sternberg, pp. 139-40, 148-49; "Public Health," p. 98; George M. Sternberg, "The Address of the President," p. 1373; Gibson, Soldier in White, pp. 178-79, 243.

10. Cited in William B. Bean, Walter Reed, p. 55.

11. Ltr, G. M. Sternberg to SG, 10 May 1869, vol. 12, Entry 10, RG 112, NARA; Bean, Reed, p. 153 (quotation from Reed to Mrs. Reed, 9 Dec 1900). Among the medical officers who joined the department in the late 1890s whose names would be well known by the time of World War I were Bailey K. Ashford, Frederick F. Russell, and the Philippine Tropical Disease Board members (see Table, Chapter 11).

12. According to Edward M. Coffman, in 1890-1891 alone, the Army abandoned roughly a fourth of its posts (see "The Long Shadow of the Soldier and the State," p. 80). See also "Examination of Army Medical Officers for Promotion," p. 694; Sternberg, "Address," p. 1374; Alfred Alexander Woodhull, "The Better Type of Medical Officer," pp. 341, 345; Bean, Reed, p. 64; WD, ARofSG, 1895, p. 50.

13. For a time before June 1894 supply and the Hospital Corps were managed in two separate divisions. See WD, ARofSG, 1898, pp. 100, 138, and 1899, p. 22; Preliminary Inventory of RG 112, pp. 28-32, NARA; Ltr, Charles Smart to SG, 30 Jun 1894, Entry 245, RG 112, NARA.

14. "The Fifty-third Congress, the Army and Navy Medical Services and the Marine-Hospital Service," p. 413; AGO GO 43, 6 Sep 1894; WD, ARofSG, 1893, pp. 13-14, and 1894, pp. 14-15, 17.

15. Quotations from John H. Brinton, "Valedictory Address to the Graduating Class of the Army Medical School, Washington, D.C.," p. 604; "Army Medical School," p. 352; Samuel C. Busey "Address


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Delivered at the Closing Exercises of the Army Medical School, March 12, 1897," pp. 671-72; Charles H. Alden, "The Special Training of the Medical Officer. . . ," pp. 676-77; WD, ARofSG, 1893, p. 15; George Rosen, Preventive Medicine in the United States, 1900-1975, pp. 23-24; John Z. Bowers and Elizabeth P. Purcell, eds., Advances in American Medicine, 1:258-59.

16. WD, ARofSG, 1893, pp. 14-15, and 1894, pp. 21 (final quotation), 22 (other quotations), 24-25; Stanhope Bayne-Jones, The Evolution of Preventive Medicine in the United States Army, 1607-1939, p. 121; "Army Medical School," p. 353; Charles E. Woodruff, "Military Medical Problems," pp. 227, 236-37; Sternberg, Sternberg, pp. 132-34; Gibson, Soldier in White, p. 175; Graham A. Cosmas, An Army for Empire, p. 8; AGO GO 51, 24 Jun 1893.

17. WD, ARofSG, 1894, pp. 21-34 (quotation).

18. Ibid., pp. 23, 25, 30 (first quotation), 1896, p. 22, and 1898, p. 23; "Army Medical School," p. 353 (second quotation); Coffman, Old Army, p. 384.

19. Quotations from War Department, Surgeon General's Office, The Surgeon General's Office, p. 46 (hereafter cited as WD, SGO, SGO); Rpt, Louis A. LaGarde, 31 Oct 1893, Entry 53, RG 112, NARA; Robert S. Henry, The Armed Forces Institute of Pathology, p. 95 (hereafter cited as AFIP); WD, ARofSG, 1894, pp. 23, 27, 32, 1896, pp. 118-21, and 1897, pp. 26-27; Nicholas Senn, "Abdominal Surgery on the Battlefield," p. 2.

20. Sternberg, Sternberg, p. 132; AGO GO 51, 24 Jun 1893, and GO 43, 6 Jul 1897; "Army Medical School," p. 353; WD, ARofSG, 1894, p. 23, and 1895, p. 15.

21. WD, ARofSG, 1893, pp. 73-95.

22. Quotation from LaGarde Rpt, 31 Oct 1893, Entry 53, RG 112, NARA; Williams Donnally "An Opportunity for a Great National Museum," p. 137; WD, ARofSG, 1894, p. 28, and 1896, p. 15; Henry, AFIP, pp. 93, 101, 103.

23. First quotation from Henry W. Cattell, "Roentgen's Discovery," p. 169; remaining quotations from WD, ARofSG, pp. 106-07; ibid., pp. 104, 108; M. Goltman, "The History of X-rays and Their Application in Medicine and Surgery" p. 293; Henry, AFIP, p. 100; Gibson, Soldier in White, p. 177; Ltr, Henry Lippincott to SG, 10 Jan 1898, Enry 26, RG 112, NARA.

24. Sternberg, Sternberg, p. 138; Kimball, Soldier Doctor, p. 153; Alfred Alexander Woodhull, "Military Medical Problems," p. 540.

25. H. S. Turrill, "Instruction of the Hospital Corps of the U.S. Army," p. 395; WD, ARofSG, 1893, pp. 15-18, 1894, p. 36, and 1895, p. 14.

26. WD, SGO, SGO, p. 48; Charles Smart, "Transportation of Wounded in War," pp. 35-36; William C. Borden, "Hospital Corps Instruction at Military Posts," pp. 402-04; Louis A. LaGarde, "The Medical Department in Time of War," p. 585; John van R. Hoff, "Scheme of Military Sanitary Organization," pp. 437-47; idem, "Outlines of the Sanitary Organization of Some of the Great Armies of the World," pp. 426-514. The need to develop specific doctrine for the U.S. Army stimulated increased interest in foreign armies, which in turn inspired many articles on the subject in the Proceedings of the Association of Military Surgeons of the United States during this period.

27. AGO Cir 2, 6 Feb 1896; Turrill, "Instruction," p. 400; Charles H. Alden, "Instruction of the Hospital or Ambulance Corps in the United States," pp. 451-52; Borden, "Hospital Corps Instruction," p. 401; Senn, "Abdominal Surgery," pp. 7-8.

28. Alden, "Instruction," p. 99; Turrill, "Instruction," p. 395.

29. WD, ARofSG, 1893, p. 19, 1896, p. 15, and 1897, pp.7-8.

30. Ibid., 1893, pp. 15, 18, and 1895, p. 13.

31. Smart, "Transportation," pp. 35-36; Hoff, "Scheme," pp. 446-47; LaGarde, "Medical Department," p. 585; WD, ARofSG, 1894, p. 35, 1895, p. 13, 1896, p. 14, and 1897, p. 6; Coffman, Old Army, p. 282.

32. AGO GO 9,13 Mar 1896, and GO 60, 28 Oct 1897; LaGarde, "Medical Department," pp. 585-86; WD, ARofSG, 1896, pp. 14-15.

33. WD, ARofSG, 1893, p. 8, 1894, pp. 38-39, 1896, pp. 13 (quotation), 16, 33, and 1897, pp. 40-41; Alden, "Instruction," pp. 94-95; Brinton, "Valedictory Address," p. 599; Edgar Erskine Hume, The Golden Jubilee of the Association of Military Surgeons of the United States, pp. 13-14; Karsten, "Armed Progressives," in Military in America, p. 249.

34. WD, ARofSG, 1893, pp. 22, 63, 102-03, 1894, p. 16, 1895, p. 17, 1897, p. 49, and 1898, p. 28; Coffman, Old Army, p. 328.

35. WD, ARofSG, 1893, pp. 141-42, 1894, pp. 34, 65-66, and 1896, p. 143 (quotation).

36. Ibid., 1893, pp. 119-20, 125, and 1896, p. 57.

37. Ibid., 1895, p. 26 (quotation), and 1896, pp. 56, 140.

38. Louis C. Parkes, The Elements of Health, pp. 29-30; William Osler, "A Study of the Fevers of the


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South," p. 1006; WD, ARofSG, 1895, pp. 94-95, and 1897, pp. 67-68, 160-61.

39. John S. Kulp, "What To Avoid in Army Athletics," p. 312 (first quotation); James E. Pilcher, "The Place of Physical Training in the Military Service," pp. 170, 173 (second quotation), 178; WD, ARofSG, 1893, pp. 138-39, 140-41 (third quotation), 1894, p. 75, and 1895, pp. 98-99; Cassedy, Medicine in America, p. 104; Howard E. Ames, "The Hygienic Condition of Enlisted Men as Affected by Moral and Intellectual Influences," pp. 422-24; Coffman, Old Army, p. 282.

40. WD, ARofSG, 1893, pp. 138-39.

41. Ibid., 1895, p. 43 (first quotation), and 1896, pp. 84-87, 88-89 (remaining quotations).

42. Charles E. Woodruff, "Emergency Rations," pp. 309-44; Louis A. LaGarde, "Notes on an Emergency Ration," pp. 345-51; "The Emergency Ration of the Army," p. 37; "Miscellany-Emergency Rations for the Army," p. 43.

43. Quotation from "Miscellany-Emergency Rations," p. 43; ibid., pp. 42, 44; "Emergency Ration," pp. 37-38.

44. WD, ARofSG, 1893, p. 102 (first quotation), 1894, p. 52, 1895, p. 27, 1896, pp. 67, 74 (second quotation), 77, 79, and 1898, p. 39; Bayne-Jones, Preventive Medicine, p. 129; Osler, "Fevers of the South," pp. 1002-03; "Are Malarial Diseases Airborne?," p. 943.

45. Quotation from "Public Health-Diphtheria Antitoxin," p. 67; George W. Cox, "Present Status of Serum Therapy," pp. 830-31; H. W. Berg, "The Treatment of Diphtheria, Including Serum Therapy," p. 41; WD, ARofSG, 1896, pp. 36-40, and 1897, pp. 58-59; Rothstein, American Physicians, p. 278; Hans Zinsser and Stanhope Bayne-Jones, A Textbook of Bacteriology, pp. 180-81; William D. Foster, A History of Medical Bacteriology and Immunology, p. 102; George M. Sternberg, "Science and Pseudo-science in Medicine," p. 200; idem, Immunity, pp. 160, 266-68; Leonard Pearson, "Tetanus," pp. 381, 384.

46. The Widal test took advantage of the fact that the antibodies to typhoid fever found in the blood serum of victims will cause typhoid bacteria to clump. See William H. Welch, "Principles Underlying the Serum Diagnosis of Typhoid Fever and the Methods of Its Application," p. 301; Walter Reed, "Typhoid Fever in the District of Columbia," pp. 145-46; WD, ARofSG, 1893, p. 59, 1894, pp. 48-49, 1895, 28-30, and 1898, p. 38.

47. Osler, "Fevers of the South," p. 1001; WD, ARofSG, 1895, pp. 27, 31-34, and 1897, pp. 9-12, 79.

48. First quotation from Brinton, "Valedictory Address," p. 604; second quotation from A. T. Cabot, "Science in Medicine," p. 481; Lester S. King, "Germ Theory and Its Influence," p. 797.

49. Quotation from John B. Murphy, "Appendicitis," p. 436; Alfred C. Girard, "Letter From Europe," pp. 319-20, 361-62, 397-98, 435-37, 636-37; WD, ARofSG, 1889, p. 44, 1895, pp. 57, 64-65, 1896, pp. 95, 108-16, 1897, pp. 96-97, 109, 114-15, 128-29, and 1898, p. 45; Senn, "Abdominal Surgery," p. 1.

50. Quotation from John M. Banister, "The Radical Cure of Inguinal Hernia From the Standpoint of the Military Surgeon," p. 478; ibid., p. 485; "The Radical Cure of Hernia," p. 506; Sternberg, Sternberg, p. 139; Owen H. Wangensteen and Sarah D. Wangensteen, The Rise of Surgery From Empiric Craft to Scientific Discipline, pp. 111-25; Arpad G. Gerster, "How Should the General Practitioner Deal With Strangulated Hernia?," p. 61.

51. WD, ARofSG, 1897, pp. 96-97, 99, 109, 128-29, and 1898, p. 45.

52. Ibid., 1895, p. 74, and 1896, pp. 98 (quotation), 102-03.

53. Ibid., 1895, pp. 58, 71 (first two quotations), and 1896, pp. 10, 99 (fourth quotation), 101 (third quotation), 103; SGO Cir 6, 18 May 1895, Entry 66, RG 112, NARA.

54. O'Reilly would become surgeon general in 1902. Welch was not positive that the lesion was malignant, but believed that it probably was. See John J. Brooks, Horatio T. Enterline, and Gonzalo E. Aponte, "The Final Diagnosis of President Cleveland's Lesion," p. 5; Nevins, Cleveland, pp. 528-29; Charles L. Morreels, Jr., "New Information on the Cleveland Operations," pp. 542-44; William W. Keen, The Surgical Operations on President Cleveland in 1893, p. 30.

55. Keen, Cleveland, pp. 1-17, 32.

56. Ibid., pp. 34 (first quotation), 37; Morreels, "Cleveland Operations," p. 547 (second quotation); Nevins, Cleveland, pp. 530, 532 (third quotation); Brooks, Enterline, and Aponte, "Final Diagnosis," p. 5; Sternberg, Sternberg, p. 136.

57. Brooks, Enterline, and Aponte, "Final Diagnosis," p. 23.

58. WD, ARofSG, 1893, p. 13, 1894, p. 13, 1896, pp. 9, 11-12, 1897, pp. 14-16; AGO GO 26, 5 May 1897.

59. Jerry M. Cooper, The Army and Civil Disorder, pp. 99, 101-02, 106-08, 115-18, 120. There is also an excellent discussion of the Army's role in civil affairs in Coffman, Old Army, pp. 246-54. Un-


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less otherwise stated, material on the Chicago aspects of the 1894 strikes is based on Rpts, Daniel G. Caldwell and Alfred C. Girard, and that on the Sacramento aspects on Rpt, Benjamin F. Pope, all in Entry 26, RG 112, NARA.

60. Caldwell Rpt, Entry 26, RG 112, NARA.

61. Ibid.; Telg, S. M. Appel to SG, 5 Jul 1894, Entry 26, RG 112, NARA; Schofield, Forty-six Years, p. 495.

62. Girard Rpt, Entry 26, RG 112, NARA.

63. Pope Rpt, Entry 26, RG 112, NARA.

64. Ibid.

65. Cooper, Civil Disorder, p. 121.

66. Sternberg, Sternberg, p. 158; Mil Svc Card, Benjamin F. Pope, Entry 89, RG 112, NARA.

67. Gibson, Soldier in White, pp. 184-85; Sternberg, Sternberg, p. 169; WD, ARofSG, 1898, p. 103; WD, SGO, SGO, pp. 43, 47, 62-63.