Chapter 13
THE MEDICAL SERVICE IN ACTION
Although nothing could adequately prepare the Medical Department for the struggle to come, the challenges medical officers faced in peacetime gave them experience that would prove valuable after the United States entered the war in the spring of 1917. Large-scale training maneuvers offered medical officers a greater understanding of their ability to handle military problems similar on a small scale to those they would face in France. A city temporarily paralyzed by a natural disaster provided insights that would help deal with the helpless, homeless, and terrified populations of Europe once the war was over. Finally, troops stationed within the United States and at posts scattered about the new empire continued to benefit from the ever-growing insights and revelations that characterized the new era in medicine.
Fighting Disease and Disability
Before the medical revolution, the Army's physicians had worked in the dark in their unending struggle to limit the inroads of disease and infection. Although they relied heavily on sanitation in their attempts to prevent epidemics, they had lacked a clear understanding of why it was effective. Since the discovery that vaccination prevented smallpox had been accidental, scientists had been unable to develop a similar approach to other diseases. Complex surgery had rarely been undertaken because fatal infection so often resulted. By the turn of the century the efforts of medical officers to maintain high standards of sanitation were increasingly effective because they now understood what they were fighting. Their ability to develop vaccines with which to immunize troops against the most prevalent diseases was growing. Because they knew how wound infection developed, they could attempt forms of surgery they had never dared before, invading even the abdomen, which until the medical revolution had been largely a forbidden territory.
The most obvious approach to preventing a recurrence of the epidemics of 1898 was improved sanitation. In December 1898 Sternberg named Colonel Greenleaf medical inspector for the Army, making sanitation in the field, at posts, and in hospitals one of the major responsibilities of the new office. In the camps established for volunteers in the summer of 1899, tents were placed a tent's width apart, and all tents were floored, with the flooring raised well above the ground. The contents of camp latrines were either flushed into a sewerage system or regularly removed. Water supplies were carefully monitored, and kitchens closely supervised. Bathhouses
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with hot and cold running water were available to encourage personal cleanliness.1
The triumph over typhoid fever, traditionally a great danger to any military force, represented one of the Medical Department's most significant victories. A major factor in this achievement was the recognition of the fact that the key to maintaining sanitation at a consistently high level was discipline. Discipline was not always easily maintained among new recruits, especially when line officers tended to treat medical officers' warnings about poor sanitation with contempt. Recognition of this situation led the members of Major Reed's Typhoid Board to conclude that immunization might be a more effective approach to preventing typhoid in the Army than sanitation alone. Because the department's attempts to develop an oral vaccine had failed, in 1908 Surgeon General O'Reilly appointed a new board to study the problems involved in immunizing an army against typhoid. The board was composed of both military and Medical Reserve Corps members, among them reservist Dr. Victor Vaughan, the lone survivor of the first Typhoid Board, and medical officer Capt. Frederick F. Russell, who was promoted to major shortly after he assumed his new responsibilities.2
Under Major Russell's guidance, U.S. soldiers were injected with a vaccine of a type developed by the British that had been prepared by the Army Medical Museum as part of an effort to develop standardized dosages. Experience gained through a voluntary immunization program started in 1909 proved that though the protection given was relative rather than absolute, the results justified wider use, especially since only 1.2 percent of those given the vaccine had severe reactions, while 92.1 percent had mild reactions or none at all. In 1911 immunization was made compulsory first for a division serving in Texas near the Mexican border, then for the entire Army, and in 1912 for all recruits. The process of immunizing the entire Army was completed early in 1913, when the last men in the Philippines received their third and final shots. As a result, the 1907 typhoid admission rate of 379 per 100,000 men dropped to 243 in 1910 and to 4.41 in 1913. But only time would answer the question of how long immunity lasted.3
The Medical Department set aside a room in the Army Medical Museum specifically for the manufacture of vaccine in large amounts. "Entirely new apparatus" was used in a way that would assure the purity of the vaccine, and no exchange of equipment with other laboratories was allowed. Another laboratory to make typhoid vaccine was established in Manila so that soldiers serving in the Far East could
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be promptly immunized. The Army was soon supplying thousands of units of vaccine to the U.S. Navy, where immunization had been made mandatory, as well as to National Guard units and various departments of the federal government and state and city boards of health. Surgeon General Torney proudly noted that "among the sanitary achievements of the Medical Department in preventive medicine since the time of the Spanish-American War this sanitary measure for the prevention of typhoid fever should . . . rank second in importance only to the discovery of the method of transmission of yellow fever."4
The phenomenon of the typhoid fever carrier, however, was yet to be completely understood. Major Russell, the medical officer most closely associated with the development of the typhoid vaccine, noted in 1909 that he had encountered few carriers up to that point in the United States, a fact that he believed might be related to the relative youth of the American soldier and to a possibly greater prevalence of the carrier state among women than men. In the course of their effort to identify carriers, Army doctors concluded that the Widal test was not as reliable as the examination of blood, urine, and fecal samples. As a result, three consecutive negative reports based on laboratory examinations of fecal and urine samples collected at six-day intervals were required before an Army hospital could release a typhoid patient. When a carrier was identified, he was immediately isolated, and every effort was made to eliminate the typhoid bacillus from his body. In two chronic carrier cases reported by Surgeon General Torney in his 1913 annual report, when all else failed, gallbladder removal proved successful in ending the carrier state.5
Even while significant progress was being made in the battle against typhoid, venereal diseases-specifically syphilis, gonorrhea, and chancroid, a localized nonsyphilitic infection that produced genital ulcers-were causing increasing concern. The identification of the gonococcus in 1879 and of Treponema pallidum, which causes syphilis in man, in 1905 and the development of the Wassermann test for syphilis in 1906 made the diagnosis of venereal disease easier. Recognition of the extent to which both diseases were responsible for deteriorating health and damage to organs outside the genitourinary system led Surgeon General O'Reilly to comment in his 1907 annual report that they caused a loss in service "equal to the loss for the entire year of the service of about 11 full companies of infantry." Civilian physicians could avoid dealing with venereal disease because of their personal distaste for conditions associated with moral degradation or could conceal its presence to protect their patients from disgrace. By 1913 only five states required doctors to report cases of venereal disease. Medical officers had no such options. The need to prevent the spread of the disease was more important than either the physician's qualms or the patient's privacy.6
The ability to identify the causative organisms led to an awareness both of the prevalence of these diseases in the Army and of the embarrassing fact that they were more common in the U.S. Army than in any other major military force in the Western world. The number of cases diagnosed was increasing rapidly, from an annual average of fewer than 75 per 1,000 from 1889 to 1898 to 128 per 1,000 in 1900. By 1905 the figure stood near 180. Venereal disease was the primary cause of rejection of recruits in both 1911 and 1912, although by 1913 it was only the third. In the Philippines the rate of cases reported among U.S.
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soldiers-275.64 per 1,000 in 1910-was much higher than the 62.05 per 1,000 characteristic of the Philippine Scouts, who generally lived with their families. The 1909 figure of 11.44 per 1,000 soldiers in the continental United States rendered actually noneffective by venereal disease was a record high and obviously posed a serious concern for an army being prepared for possible wartime service. As late as 1913 the gonorrhea rate remained higher than that of any other nation's army on record, while only the British Army, with its large numbers of men serving far from home, suffered more from syphilis.7
The realization of how prevalent these diseases were made discovering a successful treatment for them all the more urgent. At the turn of the century the only treatment for syphilis with hope of success-mercury-was a grim one that could result in loosened teeth, kidney damage, anemia, tremors, and various mental problems, side effects that physicians may have considered only fitting for the victims of a disease they associated with depravity. At least one Army surgeon treated syphilis with two injections a week of "gray oil made of metallic mercury, carefully rubbed up with lanolin," which added occasional local abscesses to the patient's miseries. Injections were given once a week for another twelve to fifteen weeks after all symptoms had disappeared. Injury could also follow the injection into the urethra of a solution of bichloride of mercury given in what was usually a vain attempt to cure gonorrhea.8
For a time high hopes were held for a newly discovered treatment for syphilis, Salvarsan, known in the United States as arsphenamine. The Medical Department was apparently aware of the new drug from its inception, since when Paul Ehrlich developed it in 1909, Army assistant surgeon Capt. Henry J. Nichols was working in the German bacteriologist's laboratory. Nichols began his own experiments in 1910 and for several years worked in the Army Medical School laboratory with Capt. Charles F. Craig, who was studying syphilis there. For their tests of the new approach, they used subjects in the Washington, D.C., area, including soldiers and patients in the Government Hospital for the Insane who were the victims of advanced syphilis. Time proved that Salvarsan produced significant side effects, some of which, as both civilian and military physicians soon realized, were related to the method of administration. Given by intramuscular injection, it caused swelling and pain that could last as long as four days and was severe enough to require the use of narcotics for relief. In some cases the tissue around the site of injection died. Even intravenous administration was accompanied by nausea, diarrhea, headache, a low fever, and a minor amount of vomiting.9
The greatest question about Salvarsan concerned its effectiveness. Although treatment with mercury was far from ideal and doctors were eager to find something better, they were not initially sure about the dosage and timing of the new drug and thus could not accurately estimate its worth. To evaluate their experiments, they decided that if a patient's Wassermann was still negative after a year without symptoms, they would consider him cured. Judged on this basis, cure with a single dose, as recommended by Ehrlich, rarely proved possible. Surgeon General Torney blamed failures on insufficiently vigorous treatment and in 1912 recommended using Salvarsan and mercury together. Captain Nichols preferred to treat primary syphilis with an intravenous injection of Salvarsan and a month of mercury "by in-
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unction [rubbing in a mercury ointment] or injection," followed by a second injection of Salvarsan and possibly another month of mercury. Patients with secondary or tertiary, or advanced, syphilis received even more energetic treatment. Those with secondary syphilis suffered from fever, a rash, hair loss, headache, and pain in the joints that appeared six weeks after exposure and lasted roughly three months. The symptoms of those with tertiary syphilis often occurred after a period without symptoms and affected skin, bone, and internal organs. Nichols found that his approach produced a negative Wassermann in 72 percent of his cases within two months. Hope for a new drug, Neo-Salvarsan, a supply of which Ehrlich sent the Medical Department in 1912, was high for a time, since it was reported to have fewer unfortunate side effects than Salvarsan. After establishing a register of patients so that the results of treatment could be evaluated even when the men involved had been transferred, the department determined that Neo-Salvarsan was less effective than Salvarsan. Experience had suggested that those being treated with either drug could remain on duty without unfortunate consequences and thus that the loss to the Army through ineffectiveness could be held to a minimum. Torney was sufficiently impressed with the findings of the various studies to urge that prompt treatment of syphilis be made mandatory.10
Since the Medical Department relied heavily on the Wassermann reaction both to detect unsuspected cases of syphilis and to show the progress of treatment with the various drugs, extensive studies were conducted to ascertain the accuracy of this test. By the end of 1911 it had been used more than 6,000 times, but often no conclusions could be drawn from test results.
In others they proved misleading; in one group of 1,661 men believed to have syphilis, for example, only 1,315 tested positive. Medical officers eventually concluded that negative test results could not be relied upon, since such factors as recent heavy alcohol intake could interfere with the Wasserman's accuracy. They learned that false positives were also possible in patients suffering from such diseases as malaria, scarlet fever, and leprosy, and on occasion even cancer or tuberculosis. Although experiments with different cultures and with varying methods of preparing antigens led to improvements in accuracy, misinterpretations by technicians who did not understand the test also caused difficulties. As a result, Captain Craig emphasized that the test should be done only in well-equipped laboratories and by a well-trained staff.11
With venereal disease rates alarmingly high and treatment likely to do more harm than good, the Medical Department urged that greater emphasis be placed upon prevention. Because rates in the newly occupied areas were particularly high, troops serving overseas should be warned that local "hovels are sources of infection," whose occupants might carry both venereal disease and tuberculosis. Punishment only led to concealment and very possibly the infection of others. After returning from Belgium, where he was a U.S. delegate to the Second International Conference for the Prevention of Venereal Disease, held in 1902, Lt. Col. Valery Havard suggested that consideration be given to strictly controlled prostitution. This approach was popular in Europe and, in modified form, had been tried in at least one area in the Philippines. Some posts where venereal disease rates were low credited their success in part to the cooperation of nearby
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communities in controlling prostitution, often by using medical examinations to identify infected women. Although the concept of dealing with venereal disease by such unofficial licensing of prostitutes was distasteful to all, its proponents believed that this trade, "vicious and shameful" though it might be, should be subject to legal control, just as less distasteful businesses were. Recognizing that those who had no source of recreation on post would be "tempted to drink distilled liquors" in locations where they would be "exposed to the solicitations of the worst class of prostitutes," some post commanders and also some surgeons urged that post canteens again be allowed to sell beer.12
Although he supported the "reglementation" of prostitutes, Colonel Havard noted that "it is in the conscience of the young man that prophylaxis should begin." Many favored a campaign of education designed to encourage the recruit to report at once for treatment if a disease were contracted and to convince him that "not only are chastity and continence not prejudicial to health, but, on the contrary, [they are] most commendable from the medical point of view." Since "popular opposition to taking preventive measures" continued to complicate the Army's attempts to combat syphilis and gonorrhea and since in theory abstinence was the simplest and surest way to avoid venereal disease, Surgeon General Torney, too, supported education, urging his surgeons to teach the men about the dangers of unmarried sex and "the advantages of sexual continence."13
In no position to entertain illusions about the effectiveness of this approach, Surgeon General Torney pointed out that while it was "a grievous fault that a young man should fail to control his passions, it is a far worse thing for him and for the country if... he acquire an infectious disease which unfits him for the performance of his duty as a soldier." The War Department should, therefore, adopt "a philosophical indifference to criticism on the part of self-constituted censors of the public morals whose susceptibilities are offended by a public discussion of these questions" and seek more realistic approaches to the problem.14
The use of prophylaxis should be encouraged "for those who have not the moral stamina and self-control to observe continence." Post surgeons should experiment with the exact methods to be used. One possibility was setting up a room at either the barracks or the post hospital to which a man newly returned from a night of uncontained passion could retreat to take advantage of a supply of prophylactic medications. These often included calomel ointment for external use and an Argyrol, silver nitrate, or potassium permanganate solution for irrigating the urethra, stored with the syringes needed to inject the fluid. The Medical Department also made available individual packages of disinfectants, known as K packets, for men apprehensive about being seen entering a room known to have been set aside for those lacking moral stamina. These packets contained, as Edgar Erskine Hume put it, "a tube of mercurous ointment with added colloidal silver." The medications appeared to be effective if the men using them were neither befuddled by alcohol nor repelled by stains left on clothing. Precautions proved to be most effective when handled in a hospital under the supervision of a corpsman.15
The condom was apparently never given serious consideration, although its effectiveness against venereal disease was generally recognized. The reasons for the
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failure to incorporate the condom in the campaign, a failure shared with the Canadian Army at the time, are not clear. Jay Cassel in The Secret Plague: Venereal Disease in Canada, 1838-1939, speculates that perhaps in the period of World War I the condom was regarded as less effective in preventing disease than ointment, or that, since it was a very effective means of birth control, encouraging its use might appear to be advocating illicit sexual activity as well. Apparently the condom did, however, play an important role in the anti-VD effort in the New Zealand Army.16
The ultimate success of any campaign against venereal disease depended upon line officers as well as physicians. The commanders of some geographical departments gave their subordinates specific orders to cooperate with post surgeons in their efforts, and Surgeon General Torney urged that both post surgeons and post commanders report on their work to reduce venereal disease rates and on the results they attained. The cooperation he received varied considerably from post to post. At least one officer refused to permit the distribution of K packets at his post, while others allowed them to be doled out to any soldier requesting them. In the Philippines post commanders sponsored lectures on the need for continence; encouraged inspections to detect signs of infection; and punished those who, despite the availability of preventive measures, contracted a venereal disease. Punishment added another difficulty to efforts to keep track of disease rates, however, since it might lead soldiers who had contracted syphilis or gonorrhea to conceal their condition.17
After an encouraging drop in 1910, venereal disease admission rates rose again in 1911. The rate for syphilis, at times higher in whites than in blacks, continued to climb, but the increase may have been only apparent because the Wassermann test now revealed cases, particularly secondary cases, that might otherwise not have been diagnosed. The average soldier, unmoved by the grim details of the effects of venereal diseases upon his health, all too often ignored the prophylactics made available to him. Thus the appeal of docking the enlisted man's pay for time lost from his duties because of venereal disease grew. The judge advocate general pointed out that only enlisted men could be dealt with in this manner, since the Army could not legally reduce the pay of officers because of sickness.18
The anti-venereal disease campaign also needed to be made more systematic and less dependent on the whim of the officers at the individual posts. In 1912, therefore, the War Department issued an order that made both venereal prophylaxis administered in the hospital and unannounced medical examinations for venereal disease mandatory; the soldier who contracted a sexually transmitted illness after failing to avail himself of the hospital-administered program would have his pay docked for time lost from duty, as would all others losing duty time because of a disease contracted through misconduct. No serious opposition to this campaign ever developed. Many inquiries came in about it from those concerned with public health, but to Surgeon General Torney's distress, a circular he issued detailing anti-VD measures was "furnished confidentially to medical officers" rather than being made freely available to all who were interested.19
Care must be used in evaluating the statistics of this period, since some include each time a soldier reported for treatment, regardless of when he contracted the disease, while others represent only new cases. Nevertheless, the use of a threat to
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the soldier's wallet appeared to have a positive effect. Beginning in 1912, the rates of venereal disease began to drop more rapidly, from 163.49 first-time admissions per 1,000 in 1911 to 136.70 in 1912 and 97.22 in 1913. The total Army-wide noneffective rate from this cause fell to 10.14 per 1,000 in 1911 and to 4.51 by 1913. Even in the Philippines the VD rate was "markedly reduced." These figures reflected a decline in the individual rates of each of the three prevalent venereal diseases, but the surgeon general was not entirely happy; at some posts, rates remained high, leading him to suspect that the regulations were not uniformly enforced. Moreover, the possibility that men were, under the threat of punishment, failing to report to sick call cannot be ruled out. When men were allowed to delay reporting for prophylaxis more than six hours after sexual intercourse, they ran higher risks of contracting an infection. Prophylactic packets, which could be used immediately after exposure and were sold at a nominal price, were not popular. Torney concluded that either the packets must be given out without any charge or passes must be limited so as to require soldiers to return to base for treatment within the allotted time after exposure.20
Associated with the venereal disease rate was the old problem of the alcoholism rate, which was also greater in the U.S. Army than in the other forces whose statistics were available to the surgeon general. Alcoholism was a problem chiefly among white troops. After years of rising rates, the incidence finally began falling in 1908. In 1912 the rate dropped from the 28.26 per 1,000 of the previous year to 16.67, lower than it had been since 1873. This achievement, too, was credited in part to the stoppage of pay for those whose ineffectiveness was deemed to be the result of their willful behavior. The improvement dampened enthusiasm for restoring the institution of the canteen.21
Unlike alcohol addiction, drug addiction had received little attention from Army authorities. Beginning in the twentieth century, attitudes toward this problem began to change, and habitual use came to be regarded as a sign of moral weakness. Occasional instances of heroin addiction were uncovered, this drug being easily obtained, but cocaine was not widely recognized as a threat to either health or moral strength; former surgeon general William Hammond was reported to take "a wineglass of cocaine with each meal." Cocaine was named "the official remedy of the Hay Fever Association" and was also used to treat addiction to opium, morphine, and alcohol.22
Nevertheless, at least one Army surgeon recognized the dangers of cocaine. At Texas City, Texas, young Lt. William B. Meister was alarmed by the addicted soldiers he discovered in the spring of 1913. He concluded that because few cases were normally encountered, the surgeon general had never attempted to discover the extent of the problem in the Army. After positively identifying eleven cases in which the men had been found to be in actual possession of cocaine, Lieutenant Meister became convinced that this drug was a "new Ogre" that was "gathering adherents unto itself." He noted that the men involved usually first tried it because of curiosity reinforced by the persuasion of a friend or a prostitute who raked in a considerable profit from its sale. Users eventually found that cocaine, often taken by inhaling from a quill or a knife blade, was "more necessary than food itself." "Whosoever worships at the Shrine of
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Coca," Meister noted, "remains faithful unto the End." He believed that the problem was "alarmingly on the increase in our army" and that the habit was impossible to break, but his warning to medical officers to be on the alert for it apparently made no impression.23
The U.S. Army tended to have a higher rate of mental illness as well as higher rates of venereal disease and alcoholism than other armies. In the continental United States in 1910, for example, 1.58 men in 1,000 were hospitalized because of mental illness, while in 1909 the comparable figure in the British Army was 0.8, in the Bavarian Army 1.4, in the Austro-Hungarian Army, 1.3, and in the Japanese Army 0.32 in 1,000. In the continental United States in 1912, 2.78 soldiers per 1,000 were diagnosed as suffering from mental problems, while in the Philippines, although the troops still had to contend with guerrillas, the rate was only 2.19 per 1,000. The surgeon general's annual report recorded 2.57 per 1,000 discharged from the Army in 1913 because of mental alienation, but statistics for mental illness are of little value, since much depends on how a given Army defines it and how ill a patient has to be before he is included in the records. The high rate of alcoholism among soldiers was believed to contribute to the situation. The surgeon general's annual report for 1910 shows that the rate of acute alcoholism in the U.S. Army in 1909 was 22.19 per 1,000, while the rate for the British Army was 0.9 per 1,000; in 1907 in the French Army the rate was 0.35, while in the Prussian Army it was 0.11. Other cases of mental illness were blamed on sunstroke and such diseases as malaria, typhoid fever, and dysentery. Since the diagnosis of mental alienation included homesickness, then called nostalgia, and hypochondriasis, as well as a "constitutional psychopathologic state" and retardation, comparisons to rates in other armies were not necessarily valid. The problem was of such magnitude that a building was set aside at the Presidio in San Francisco where those believed to be insane could be held for observation before being sent east to the Government Hospital for the Insane in Washington, D.C.24
With tuberculosis, as with venereal disease, the increased ability to diagnose that followed in the wake of the medical revolution exacerbated anxiety about the prevalence of the illness. Recognizing the organism that caused tuberculosis, the second greatest cause of noneffectiveness in the U.S. Army, led to the chilling discovery that the bacillus might live in dust for long periods of time if it was not exposed to sunlight. This fact further complicated control of the disease.25
The rate of tuberculosis, too, was higher among U.S. soldiers than among those of many European armies, in part, presumably, because so many Americans were stationed in the tropics. Even Filipino troops easily contracted the disease because of what Sternberg called "the enervating effects of the tropical climate." Tuberculosis was especially devastating to black troops in the Philippines and, because they were so often exposed, to hospital corpsmen. By 1903 more than 4 of every 1,000 soldiers in the United States had been discovered to have TB. With so many new cases originating in the tropics, rates did not fall appreciably in the first years of the new century in spite of the Medical Departments efforts.26
As late as 1912 tuberculosis was still a major health problem for the Army, causing 17.48 percent of all disability discharges among troops in the Philippines at a time when disease in general was responsible for more than 86 percent of dis-
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charges there. Since the Medical Department found it impossible to screen out all recruits with tuberculosis, which was common in the civilian population, a third of the Army's cases were found in men who had not yet completed a year of service. X-ray pictures were not routinely used in the diagnosis of TB until 1917, and the tuberculin test did not distinguish between those who had been exposed to the disease and those who actually had it. Thus, rejecting all those who tested positive was not feasible because it would drastically reduce the number of recruits. Finally the Army adopted a policy common in Europe, dismissing from the military service rather than hospitalizing those who were diagnosed as having TB during their first enlistment, thereby lowering the Army's admission and death rates.27
To further reduce the incidence of tuberculosis in the Army, the Medical Department suggested that no one under the minimum weight for his height be taken into the Army, since 74 percent of those treated for TB in 1911 were underweight. Surgeon General Torney also continued to urge that proper attention be paid to ventilation and other sanitary measures, including removing TB victims from their barracks. Some urged that this step should be taken as soon as the disease was suspected, but those who favored delaying it until the diagnosis was definite eventually prevailed. Torney concluded that greater care in the selection of recruits and improved sanitation had contributed to the fall in the tuberculosis rate, which, by the end of 1913 was at an all-time low of 3.07 per 1,000 for soldiers stationed in the United States. Because of a minor increase in the incidence abroad, the overall rate was slightly higher than it had been in 1911 and 1912.28
Soldiers sent to the tuberculosis hospital at Fort Bayard, New Mexico, received treatment that was, as Surgeon General O'Reilly put it, "simply hygienic and climatic, with the treatment of intercurrent complications as they arise." Sleeping out of doors was recommended, and tents and porches were provided for the purpose. In the attempt to keep abreast of their physical condition, the sputum of all patients was regularly examined, after which each sufferer was classified as "arrested," "improved," or "unimproved." Longer hospital stays had been shown to result in a higher survival rate, but most patients at Fort Bayard were discharged from the Army after a two-month stay. Although they could then immediately be taken onto the rolls of the Soldiers' Home and remain at the tuberculosis hospital as veterans, they could not be forced to stay at the sanitarium once they were no longer in the Army. Those whose condition permitted their release were regarded as "missionaries in the education of the general public in the all-important knowledge of the hygienic mode of life and protective measures so practically learned."29
Enforcing regulations designed to enhance the chances for recovery of patients who remained at Fort Bayard was difficult, in part because many victims of the disease were alcoholics with considerable skill in sneaking in supplies of their favorite beverage. Among other patients who apparently bent or broke some regulations was contract surgeon Joseph Curry, formerly a member of the Tropical Disease Board in the Philippines, who obviously did not take the thorough rest insisted upon for other patients at the sanitarium. Curry continued to examine possibly infective material gathered from the hospital's effluent until a short time before his
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death from tuberculosis in January 1903, presumably jeopardizing his chances for recovery; like so many other patients, he may have already been too ill when he arrived to be saved.30
Malaria was yet another disease whose rates were falling in the period immediately preceding World War I, in this case because of campaigns to kill mosquito larvae and to keep man and the adult insect separate. In the Philippines malaria rates were invariably higher among Filipino troops than among Americans, presumably because mosquitoes could not be entirely excluded from the houses where they slept with their families in malaria-infested villages. Surgeon General Torney insisted that all occupied buildings in those islands should be screened. Although the malaria rate for U.S. troops unexpectedly increased in 1912, a fact for which Torney could not find an entirely satisfactory explanation, by 1913 it was lower than it had been in any year previously recorded by the Surgeon General's Office.31
Strangely, in the United States the greatest difficulties in dealing with malaria were experienced not at a post in the Deep South but at Fort Washington, Maryland. Here dense undergrowth and a nearby marsh favored the breeding of mosquitoes, and the rate resembled that in the Philippines. When cases increased from 144.3 per 1,000 in 1908 to 333.33 per 1,000 by 1911, a board of doctors and representatives of the Quartermaster's Department called together to study the problem recommended draining wet areas, oiling standing water, and eliminating all growth more than an inch high. A Medical Reserve Corps officer was assigned to serve as sanitary inspector at the fort. When the herd of goats bought to deal with the brush proved unequal to the task, prison labor had to be used. The time-consuming work was not completed until the spring of 1913, by which time the malaria rate had fallen below 175 per 1,000. Continual vigilance remained necessary, for malaria was a common affliction among the civilians of the area, who served as a reservoir to infect new generations of mosquitoes.32
Encouraged by successive surgeon generals, medical officers also became bolder in their attack on health problems that could be relieved by surgery. Their success in exploring the new world that antisepsis had opened to them rendered previously dangerous surgery safe and effective. A study of operations to repair hernias, a common but disabling affliction, revealed only three recurrences of the condition out of 591 operations in the period 1898-1903. Because this operation was now regarded as safe, men with hernias could be required to undergo the procedure-only "in case of a capital operation involving the risk of life" could a soldier refuse surgery without risking court-martial. Experience also proved that appendectomies did not have to be followed by disaster. When the operation was performed promptly, most patients recovered without major difficulty. But Medical Department surgeons could not save one of their own; Major Reed died in 1902 when peritonitis followed long-delayed surgery to remove his appendix.33
Much surgery now involved the abdomen and would thirty years earlier have almost inevitably led to the patient's demise, but deaths were few. Although Army surgeons apparently had not yet begun to use rubber gloves in the operating room, in one series of 904 operations only twenty-four patients died, among them four after amputations following leg wounds, two as a result of gunshot wounds of the abdomen, and two following surgery
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to relieve empyema (the accumulation of pus, most often in the pleural cavity). Since anesthesia also made a vital contribution to successful surgery, physicians attempted to learn more about using it; studies of the use of spinal anesthesia aroused enthusiasm about its advantages for both the patient and the surgeon. Nothing medical officers encountered in peacetime could entirely prepare them for the wounded they would encounter in war, but, no longer restricted to dealing with injuries by fear of infection, Army surgeons could undertake surgery of a complexity rarely attempted before the Spanish-American War.34
Sanitation and hygiene remained strong weapons in the arsenal of those fighting disease and disability. The need to find a simple and effective device to purify water without adding a disagreeable flavor encouraged Maj. Carl R. Darnall of the Medical Corps to apply his ingenuity to yet another problem that concerned the Medical Department. Seeking an uncomplicated, movable device that would process large quantities of water in a short time without giving it an unpleasant taste, he first experimented with a siphon filter and the use of an agent to precipitate solid particles. To kill bacteria, he eventually turned to chlorine in gaseous form rather than the hypochlorous salts and ozone generally used. Major Darnall's approach had never before been tried, but it required only simple and inexpensive equipment, and he could easily obtain chlorine gas since it was a by-product of the manufacture of sodium hydroxide (caustic soda). Chlorine used in this form proved more effective than filtration alone, although coarse filters might still be needed in some instances to remove particles. The addition of the gas to the water was also easier to regulate than that of the salts tried earlier. In 1910 Darnall's device was put into use with great success. Only three years later, another Army physician, Maj. William J. L. Lyster, developed a simple apparatus to be used to purify water quickly in the field, using calcium hypochlorite added to water stored in what became known as a Lyster bag.35
Water purification was of particular interest to the Army because efforts to keep sewage out of the water supply were not always successful. Badly designed systems to handle sewage could still leak polluted material into water supplies, and sewage could still be dumped directly into a post's water source by a nearby civilian community. Should local conditions lead to a temporary contamination of wells, an easily moved apparatus like that devised by Major Darnall would be especially valuable. In October 1909 the War Department appointed a board to study water and sewage disposal problems at Army posts. Captain
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Russell and Colonel Kean joined a representative of the Quartermaster's Department to find that although "notable progress" had been made in the management of sewage, difficulties remained at a few posts, sometimes because a disposal system was defective or too small for the effluent it was required to handle. In at least one instance the system recommended by the board was highly elaborate, yet it, too, relied on guaranteeing the elimination of bacteria by using calcium hypochlorite.36
Eternal vigilance was also necessary to prevent overcrowding and poor ventilation in barracks and guardhouses. Surgeon General Torney recommended posting on the doors of dormitories and squad rooms the maximum number of people to be allowed in each and was shocked to learn that at some posts "overhead or double-deck bunks, a sanitary abomination which was believed to be obsolete in the United States Army, had reappeared." He also advocated using electric rather than gas lights in barracks with poor ventilation and resisting the temptation to use the more economical soft coal in preference to hard. "It certainly does not seem desirable to this office," he reported to Secretary of War Stimson, "that for the purpose of a little supposed economy that the beauty of a post should be destroyed, the buildings rendered unsightly, and the health of the inhabitants endangered by clouds of smoke."37
Disease was not the only problem that could undermine an army's effectiveness. The problem of ill-fitting shoes had concerned Major Munson for several years. After spending four years examining soldiers' feet by the thousands as one of the officers appointed to the Army Shoe Board to study the problem, he published a book in 1912 on the subject of Army shoes and their fit that Surgeon General Torney recommended to "all officers and noncommissioned officers who are concerned in the fitting of shoes." While the board was at work, medical officers checking the fit of the shoes of the enlisted men at their posts discovered the discouraging fact that more than half of the Army's soldiers might be wearing shoes too small for them. One study of almost 600 men revealed that only 43 pairs of shoes were perfectly fitted, while 451 were too short, 33 too long, 111 too wide, and 266 too narrow, with some obviously misfits in both dimensions. Corns, bunions, ingrown toenails, and other ills were the inevitable result. At least some examinations of the fit of shoes involved the use of X-ray pictures, although Munson, who examined various approaches to fitting shoes, did not recommend this step as a general procedure.38
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As a result of his study of shoes and soldiers' feet, Major Munson designed a special last, wider and thicker in proportion to its length than the model usually used. Unfortunately, although the new last was adopted, soldiers received the new shoes only after the supply of the old model had been completely exhausted. Surgeon General Torney urged that an officer supervise all fittings, since a shoe that did not fit would cause problems regardless of its design. The Army Shoe Board also made recommendations about the fitting of shoes and pointed out that adequate supplies of the various sizes must always be available. As a result of Torney's concern about the fact that enlisted men were issued only one pair upon joining the Army, leaving them nothing to change into when their shoes became wet, orders were issued that in the future each soldier be issued two pairs. The shoe that was developed as a result of the work of Munson and the board was regarded as the best ever used in the Army.39
Although medical officers were experiencing success along many fronts, the Army's improved effectiveness resulted largely from their victories over the principal diseases that had afflicted military forces for centuries. Their achievements in the battle against tropical diseases and typhoid led to a drop in overall disease rates from their 1899 peak, with death and noneffective rates at last falling below those of the pre-1898 period shortly after Torney became surgeon general. The number unable to perform their duties at any one time fell from 41.48 per 1,000 in 1909 to less than 25 per 1,000 in 1913, a year when roughly a fifth of hospital admissions resulted from injury, which caused only one-tenth of the total number of deaths. Only 20.02 per 1,000 were unable to perform their duties in 1913 specifically because of illness rather than injury, as opposed to 42.83 in 1904 and 35.62 per 1,000 in 1909. Tuberculosis continued to be the greatest killer, followed in an order that varied from year to year by heart disease, nephritis, alcoholism, and pneumonia. The disease rates for troops in the Philippines continued to be higher than for those in the continental United States; overall disease rates in the Philippines in 1910, for example, were 544.68 per 1,000, while in the United States the comparable figure was 347.79 per 1,000. Torney noted in his last annual report that overall admission rates in the U.S. Army were now lower than those in the French and British armies and, indeed, than those in all major armies in Western Europe and Asia except those of Prussia, Bavaria, and Russia. Moreover, the death rate among U.S. soldiers, which at one point had been twice that of civilians, was now much less, thanks in part to the Army's attention to sanitation as well as to careful selection of men allowed to enter the Army.40
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Hospitals and Laboratories
As small posts were slowly consolidated into large ones after the end of the Indian wars, the Medical Department, always hard-pressed for funds, began to discover that the new and large post hospitals it had to build were both more cost effective and more efficient than small ones. Since every post facility now had to have a room set aside specifically for surgery, a reduction in the number of hospitals minimized the expense imposed by this new requirement. Another new concept, one first put to use in 1906 at Fort Myer, Virginia, the isolation pavilion with its own steam sterilizing plant, diet kitchens, and bathrooms, promised to wreak further havoc upon the department's hospital construction budget. Its drive to replace many of the deteriorating small post hospitals with larger buildings was handicapped by a lack of funds. Although willing to vote the funds necessary to increase the personnel of the Medical Department, Congress had never repealed a law dating from the 1850s that limited the money to be spent on such construction to $20,000 unless special legislation were passed waiving the requirement. Costs had more than doubled in the fifty years since the law was passed, and post surgeons were still occasionally forced to rely upon antiquated and dilapidated hospitals and even to take over old barracks. In the Philippines, where post facilities were often particularly makeshift, were made of local materials, and were subject to rapid decay, patients with more than passing illnesses or minor wounds had to be transferred promptly from inferior accommodations to newer and better facilities, which became known as "base hospitals."41
Before the medical revolution arrived in the United States, the laboratory at the Army Medical Museum was adequate to handle the Medical Department's laboratory work. Since U.S. physicians tended to be concerned considerably more with the practical than the theoretical, when the value of the laboratory for diagnosis became apparent, the demand for its services grew rapidly. But if diseases were to be diagnosed promptly enough to allow effective measures to prevent epidemics to be taken, specimens could not be sent great distances, especially since any microbes involved might not survive a long journey. Surgeon General Sternberg was not slow in dealing with this problem; by 1902 he could boast that the department had established "a thoroughly equipped laboratory" at the Army Medical School, in each of the general hospitals in the United States and the Philippines, and "at every military post of any importance" in the United States. With the opening of the Southern Department laboratory at the post hospital at Fort Sam Houston in 1912, each military department had its own laboratory. The facility at the Medical School, where much Medical Department research took place, became the main laboratory for the Eastern Department. The general hospital in San Francisco, which served as the post facility for the Presidio and other posts in the San Francisco area, housed the major laboratory for the Western Department. The Central Department laboratory was at the Fort Leavenworth post hospital. The division hospital in Hawaii housed another major laboratory, while the main laboratory for the Philippines shared the facilities of the Tropical Disease Board. A medical officer was specifically assigned to direct each of these large laboratories.42
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Evacuation
Providing beds and care for men who became sick while en route by train or ship to a new assignment and removing to a hospital those who fell ill or were injured in the field were both continuing concerns for the Medical Department. Evacuation by sea or rail, significant while so many U.S. troops were still stationed overseas, required chiefly the further refinement of an approach initiated during the Civil War. To stay abreast of the most recent developments in evacuation by ambulance, the department had to enter a new era, that of the motor vehicle.
Since isolating troops for an adequate period before they embarked on long journeys to guarantee that none of them would come down with a contagious disease proved impossible, the Medical Department ordered that each troop train have a sleeping car where the sick could be sequestered. A hospital car was to be used when troops were en route for longer than two days. Physicians were to inspect all passengers twice each day to determine whether any were coming down with measles or a similar disease. A contract surgeon chosen by the department was responsible for each ship's sanitation, and if no medical officer accompanied the troops, he was responsible for the health of the men on board as well. Facilities where the sick could be isolated were required on every transport, and at least two hospital corpsmen were assigned to each vessel to care for them.43
Although evacuation by ship involved no radical innovations, evacuation on land was being affected by a revolution that would soon end the era of the horse- or mule-drawn ambulance. One of Surgeon General O'Reilly's more unusual quandaries involved the question of what a newfangled machine, the motor ambulance, had to offer. The Medical Department provided its own ambulances, although the Quartermaster's Department remained responsible for "the accessory motor vehicles which experience shows are necessary." When the Medical Department's first motor ambulance, a steam-powered model, proved its superiority to the horse-drawn version at the Washington Barracks, a second was acquired for West Point. A certain distrust for this unfamiliar machine led a board of officers from both departments to go on with plans to adopt a new design for horse-drawn ambulances. To find the best vehicles for moving the wounded, the department even resorted to considering several types of travois.44
Obtaining the vehicles needed to move patients and medical supplies was a longstanding problem, especially since the Medical Department was dependent on the Quartermaster's Department for animal-powered ambulances, mule teams, and harness. Although reactions to the new type of vehicle were mixed, with the cooperation of the Quartermaster's Department, the Medical Department continued experimenting with the motor ambulance after Torney became surgeon general. Initial purchases involved several different types of "motor trucks and machines adaptable to ambulance construction" to determine which model best suited the need. At least some purchases apparently involved the frame, engine, and wheels only, with the Army supplying the body. When heavy commercial truck chassis proved to be too heavy, twelve of medium weight were ordered from the Keeton Motor Company, which agreed to supply a six-cylinder vehicle with special wheels and tires for just under $3,000. The Medical Department
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sent ambulance bodies to Keeton for that firm to mount on the chassis, but confusion developed concerning the type of body to be sent. When Torney died, the problems between Keeton and the Medical Department were still increasing, but the advantages offered by the motor ambulance, including a diminished need to rely on railroads, had been recognized.45
Practice for War
The Medical Department's plans both for disease prevention and for the care and evacuation of the sick and injured were repeatedly tested at camps established for National Guard summer training and during joint maneuvers staged by the Guard and regular units. The combination of large numbers of inexperienced soldiers with inexperienced doctors, all camped at sites without sewers or safe water supplies, produced problems similar to those that had proved so devastating during the Spanish-American War. The situation was further exacerbated by the fact that some National Guard line officers had concluded that sanitation required no greater attention in camp than in the field, where the men would not remain long in one location. Although typhoid did appear at some maneuver camps, constant vigilance kept the disease under control. Septic systems, where bacteria destroyed sewage, were tried at more permanent campsites, and the department began experimenting with the use both of Major Darnall's water filter and of an especially designed incinerator to dispose of excreta where permanent arrangements were lacking.46
Summer training and maneuvers where militia and regular troops trained together afforded an opportunity to indoctrinate corpsmen in field duties, especially those involved in maintaining high levels of sanitation. The need to organize and train each ambulance company and to have it capable of rapid wartime expansion was obvious, especially since the militia corpsmen were often "poorly developed boys, without experience or training." In 1906, in response to Surgeon General O'Reillys urging, sanitary squads consisting of both hospital corpsmen and hired civilian employees were appointed at maneuver camps and were set to work purifying water, killing mosquitoes, and disposing of waste material. O'Reilly considered the use of "the medical department for more extended executive sanitary functions" a significant development.47
The reservations of many military officers about the Army's readiness for war were not dispelled by the experiences of the maneuver camps. Such doubts were to a large degree justified in 1911, when political turmoil in Mexico led to an attempt to gather U.S. troops at the border in what proved to be another giant training exercise. Three months were required to bring 13,000 officers and men together in a maneuver division near San Antonio, Texas, and in two separate brigades, one at Galveston, Texas, and the other at San Diego, California. Although these units proved woefully unprepared for combat, the performance of Medical Department personnel, including the men of the Guard, formed a bright spot in the gloomy picture. The department organized the first complete sanitary train, consisting of four field hospitals and four ambulance companies, since the days of the Civil War. When the maneuver division was broken up in July, the department was the undisputed victor over disease. The division's chief surgeon maintained that the health of the men had been "uniformly good," with a noneffective
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rate that remained below 2.5 percent, and as the Medical Department's representative in the Army's Division of Militia Affairs, Captain Thomason noted a "very marked advancement in sanitary service . . . in the recent maneuver division in Texas."48
The low disease rate at the camps near the border with Mexico was largely the result of immunization against typhoid, coupled with strict attention to sanitation. The close working relationship that developed between Medical Department and Quartermaster's Department (after 1912, the Quartermaster Corps) personnel also "proved to be of mutual advantage and to the best interests of the service." Presumably not only the lessons of the Spanish-American War but the guidelines laid down in the Field Service Regulations encouraged and facilitated cooperation. Because adequate quantities of equipment and supplies were promptly delivered to Medical Department representatives, both the division's chief surgeon and sanitary inspector had the means as well as the authority necessary to devise and execute a sound plan for sanitation. Sanitary experts studied each camp to determine the most suitable methods for managing human and kitchen wastes. All recruits were segregated and inoculated. If after two weeks no signs of disease had appeared, they were sent to join their units.49
At San Antonio, when efforts to form sanitary squads of medical officers and corpsmen at the regimental level encountered difficulty because only a little more than three-quarters of the required number of hospital corpsmen reported for duty, those available instructed enlisted men in such matters as the operation of incinerators. A medical officer, two noncommissioned Hospital Corps officers, five Hospital Corps privates, and four to ten civilian laborers were appointed to a "general sanitary squad" that kept drains clear, spread oil over standing water, and performed similar tasks, among them removing and burning horse manure so that disease-spreading flies could not live and breed in it. Because of the efforts of medical personnel and the use of vaccination, even though "all rules governing continued or repeated use of camp sites [were] violated," typhoid never appeared in the brigade at Galveston. At San Diego only two cases developed, with two more being diagnosed at San Antonio.50
Militia physicians spent two weeks with units along the Mexican border in 1911, with one week usually devoted to camp sanitation and management of a regimental infirmary and the second to the administration of an ambulance company and field hospital. These tours helped demonstrate that "to be a good sanitarian," the medical officer "must develop his executive ability." Experienced physicians closely supervised the inexperienced, most of whom were soon performing satisfactorily, but some militia medical officers who, familiar with the old ways, could not easily accept the new encountered considerable difficulty. Nevertheless, some former contract and volunteer surgeons were inspired to attempt to rejoin the Medical Department, leading Surgeon General Torney to decide that those under forty-five years of age with good records could be taken into the Medical Reserve Corps.51
Reviewing the maneuvers, Surgeon General Torney concluded that the Medical Department had done well in its first division-level test. In his annual report for 1913 he pointed out that "for the first time a division appeared with a complete modern sanitary organization and with its full quota of field hospitals and ambulance companies in addition to the regimental medical service." The contrast to the situ-
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ation in the camps of 1898 was obvious, not only because of the vastly improved health record but because of the relative lack of administrative confusion.52
When the turmoil in Mexico became threatening once more in 1913 and a division was again dispatched to the border, the Medical Department welcomed the opportunity to further refine its approach to managing the health of a division in the field. A sanitary inspector was assigned to each camp, and each regiment had its own sanitary squad under the direction of the regimental surgeon. Outside the area for which the individual regiments were responsible, a civilian sanitary squad worked directly under the authority of the division's sanitary inspector. In Texas City, when the diseases of the civilian population seemed to threaten the health of the soldiers camped nearby, a sergeant first class of the Hospital Corps was sent to inspect each restaurant. Any establishment that did not heed his recommendations was declared off limits. Since soldiers brought substantial income to local businesses, compliance was usually not difficult to obtain. All men were required to sleep under mosquito netting because of the danger of malaria. Even though some camps were poorly sited, no typhoid cases appeared and health again remained good, fewer than 2 percent being sick at any one time. An Army surgeon who served at Texas City and Galveston believed that this success in 1913 served to enhance the respect of line officers for medical officers and thus to increase their cooperation.53
Disaster Relief
As more effective organization and training programs were developed to deal with the Army's increasingly complex needs, the Medical Department could offer those outside the Army more effective aid when called upon to do so. Although the department helped the civilian population on many occasions, perhaps never in the early twentieth century was its aid more evident than in the aftermath of the earthquake of 18 April 1906 at San Francisco, when two shocks, ten seconds apart, collapsed buildings, sent chimneys crashing upon their occupants, and filled streets with rubble. Within minutes, fires began to break out all over the downtown sections of the city. For a brief time, while flames fed by gas from ruptured lines slowly but inexorably consumed block after block, broken water mains crippled firefighting efforts, and cracked sewer lines spewed their contents into the streets, the Army, "the only undisturbed and thoroughly equipped organization in California," ran the stricken city of San Francisco. More than 220,000 people were rendered homeless, but how many hundreds died because of earthquake, fire, disease, and shock may never be known.54
Brig. Gen. Frederick Funston, acting commander of the Pacific Division, estimated at the time that the death toll was 1,000. Maj. Gen. Adolphus W. Greely, commander of the Pacific Division, later reported that in the city of 500,000 only 498 lost their lives. Contemporary reports suggested that in the outlying communities fewer than 200 were dead and less than 500 of the 5,000 injured were seriously hurt. Authorities, who were determined not to discourage investment in the rebuilding of the city, dismissed out of hand claims that the loss of life resulting from the earthquake was actually much greater. Thus the low figures were accepted for more than fifty years, until brought into question by
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SAN FRANCISCO, APRIL 1906, following the earthquake
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the work of the San Francisco Earthquake Research Project, operating from the San Francisco Public Library's archives. This research suggested that more than 2,500 may have eventually died as a direct or indirect result of the disaster.55
Among the first to offer aid to the stricken populace was Capt. Henry H. Rutherford, an Army medical officer at the general hospital at the Presidio. He was watching the smoke that began to rise from the city when the second shock struck, "a great many seconds long, like the first one." His patients and their attendants did not panic, even though "the shadow of an unearthly stillness seemed to have fallen amongst us. We all spoke softly, in whispers some of us." When the tremors ceased, the hospital power plant and telephone and telegraph lines were no longer operative, the hospital water pipes were dry, and brick and plaster were everywhere. All buildings were to some extent damaged. In spite of the situation at the Presidio, Captain Rutherford and eleven other members of the hospital staff, without waiting for official orders and "all laden down with medical supplies," hiked three miles to San Francisco's Convention Hall in forty-five minutes. A civilian doctor turned down their offer of help as not needed, "an interesting and amusing commentary on the characteristic of self-sufficiency and independence of the native Californian of the time." He soon had a change of heart, however, and began personally helping to load patients for transport to the Presidio hospital. By day's end, with the fire threatening city hospitals, 127 injured civilians had taken refuge at the Army facility, where 145 patients from San Francisco's seven hospitals would join them the next day.56
Only 40 of the 2,000 men stationed at the Presidio itself were injured, but by evening, as the flames began to consume the city, Captain Rutherford could see "multitudes seeking refuge, as the livid menace in the skies grew ever more appalling." Hospital Corps and engineer barracks at the hospital and at Fort Mason nearby were emptied so that refugees could be taken in. Mattresses were laid out on the general hospital porch, and tents began to go up on the grounds. From 18 April to 23 May, 756 new patients were cared for at the general hospital, of whom no more than 56 died. Since the general hospital, which held 700 patients when the earthquake struck, was in danger of being overwhelmed, Rutherford was ordered to set up an emergency receiving facility through which all incoming patients could be cleared before being assigned either to a hospital or to outpatient care. From 150 to 200 outpatients a day were treated at this station, while three dispensaries established on the Presidio grounds handled 300-400 dressings a day. A total of more than 4,000 refugees, half sick, half injured, were eventually treated as outpatients. At nearby Fort Mason three of the 365 admitted to the temporary hospital died. The hospital at another nearby post also took in civilian patients. Doctors and nurses among the refugees fleeing the city joined Army personnel to provide first aid and to distribute patients in need of further care among available facilities.57
On the evening of the nineteenth, when the peak of the demand placed on the general hospital was reached, "the fire could be seen gathering his mighty forces," Captain Rutherford remembered, "consolidating them into one awful tremendous roar, driving the homeless in before him. . . . They were everywhere and still they came; old and young, sober ones and the hilarious, hysterical men, women, and children;
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horses and mules and dogs and cats." Under the strain, those of less than robust health broke down; "apoplectics had their strokes, worn old hearts gave out, neurotics went to pieces and drunkards had D.T.s. Most embarrassing of all were the numerous cases of childbirth. Women were having babies all over the woods. . . . The illumination from the skies, brighter by the moment, was a godsend. It helped mightily in our ministerings."58
The initial reactions of the medical officers in the San Francisco area to the disaster were instinctive and improvised. Torney, at the time a lieutenant colonel and the chief surgeon at the general hospital, together with the post surgeon at nearby Fort Mason and presumably others as well, unhesitatingly made financial commitments without the authority to do so, correctly assuming that the formalities would be taken care of later. Now at the request of city officials, General Funston, in the absence of General Greely, who was on leave, moved to restore system and order in the wake of the disaster. One of the first steps he took was to relieve Colonel Torney, who was also acting chief surgeon of the Department of California at the time of the earthquake, of his command of the general hospital so that he could take "charge of the sanitary arrangements for the city of San Francisco," coordinating all medical efforts, both civilian and military, in the area and advising the city's health commission about sanitation. In this capacity, Torney became head of a committee of civilians responsible for ensuring the cooperation of Army and civil authorities in sanitary matters.59
When General Greely returned from leave on 22 April, water had been restored to the general hospital and repairs to the electrical system were almost complete. Although he continued the effort to design a plan to maximize the effectiveness of the Army's contribution to the relief of the city, Greely was concerned that the Army's activities might undermine the city's ability to take care of itself. On 7 May, therefore, when he announced that he was making each of the six military districts into which General Funston had divided the city a sanitary district, he had civil authorities assign each a civilian rather than a military doctor to be responsible for "all sanitary matters other than hospitals in the military district in which he is stationed." While these civilians would still report to Colonel Torney, Greely retained direct Army responsibility for sanitation and health only at the camps under military control.60
In the confusion that followed the earthquake, a week passed before shelter was found for all in need. Sanitation in these hastily erected camps, except those under military control, was often poor. General
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Greely soon concluded that the homeless would be better off in the twenty-one camps that were eventually established by the Army. Although the first of these communities were set up on an emergency basis, the remainder were created only after Colonel Torney had worked with civilian authorities to choose healthy sites. The operation of all Army camps, which at one point held 20,000 refugees, was supervised by a chief camp surgeon, who inspected both military and nonmilitary camps. Reporting to him in each camp was a medical officer named to work with the camp's commanding officer to maintain the sanitation of the community and the health of the refugees. Hospital corpsmen were also assigned to each camp, as was a civilian physician. Sick call was held every day, and all those more than slightly ill were hospitalized. Patients with contagious diseases were isolated in hospitals established for the purpose.61
The initial Medical Department response to the disaster had involved only the department personnel who were in the area at the time, but the needs of hundreds of thousands of people sheltered in hundreds of camps required a much larger medical team than could be found in northern California. The first shock was scarcely over, therefore, before Medical Department resources, both human and materiel, together with much from civilian agencies, began coming in from far as well as near. A special train, bearing a medical officer, three noncommissioned officers, and a hundred men of a Hospital Corps company, was soon speeding west from Washington, D.C., picking up Red Cross nurses and doctors and extra carloads of supplies as it went. The attempts of the Red Cross team to provide aid aroused resentment; a member of the Oregon National Guard stated that too many Red Cross officials were "riding about in automobiles making much noise and fuss, promising all sorts of relief for everybody and so far as my observation went failing to execute these promises." Efforts of the Hospital Corps unit were apparently more successful. It spent almost two months in the San Francisco area, on 25 April setting up a field hospital in the Golden Gate Park, "a model institution" with one ward specifically for maternity cases, where future surgeon general Lt. Robert U. Patterson assisted the chief sanitary officer. A second ward and a 200-bed hospital that had been established four days earlier served patients with contagious diseases.62
Before the end of the month two Hospital Corps detachments came in from St. Louis, one of which brought another field hospital. Fifteen surgeons from western posts, six recently returned from the Philippines, and two on leave in the area were also assigned to work in San Fran-
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cisco. By 22 April forty-two doctors were serving the Presidio sanitary division alone, and on the twenty-fourth Colonel Torney notified Surgeon General O'Reilly that no more medical officers were needed. The Medical Department supplied the twenty-six dispensaries opened at Torney's suggestion by the city's health commission, although twenty-five of them were closed shortly thereafter when the city's health remained good and local pharmacists and physicians began to complain about the harm done their sources of livelihood by government competition. Units of the Oregon National Guard also joined those helping the refugees, opening an emergency hospital in a school.63
Supply was not a serious problem, though the fire that followed the earthquake had destroyed the San Francisco medical depot. A new depot was quickly set up, first in the basement of the general hospital and later, because of the danger of fire and the crowded conditions there, in tents near the hospital. All items except those needed by the general hospital were pooled at this site, to be drawn upon as needed. Medical officers filled the new depot with supplies brought in from neighboring cities or shipped in from St. Louis. On 28 April it was closed in favor of a larger depot. Even a fire that destroyed the general hospital's laundry was taken in stride.64
The authority of the Army to provide assistance at San Francisco had never been clear, and its resources in supplies and manpower were limited, but the Medical Department played a vital role in the prevention of epidemics among refugees as well as in the care of the sick and injured. Three times in April 1906 Congress voted money to aid earthquake victims, and on the twenty-fourth and the twenty-eighth Secretary of War Taft allotted the Medical Department a total of $400,000 to meet its share of the expenses. In June Congress appropriated another $100,000 to replace medical and hospital supplies destroyed at San Francisco. The sanitary inspectors assigned to refugee camps worked to ensure that water supplies were safe, latrines properly located and maintained, and food properly prepared and protected from flies. By the end of April the Army was also issuing smallpox vaccine at the rate of 3,500 doses a day. Although no compulsion was used, all who were willing were immunized. In the two months following the quake, military and civilian authorities and hospitals also cooperated to create a comprehensive daily report on typhoid cases so that their origin could be traced. When several cases appeared in the same area, the Pacific Division's sanitary inspector checked into conditions and, working through the mayor's office, had those camping in the area removed. In spite of the strain under which the dispossessed inhabitants of San Francisco lived, a brief increase in typhoid and smallpox cases in the six weeks immediately after the earthquake did not lead to epidemics. Moreover, of the 123 cases of smallpox with 11 deaths that were reported in the two months after the earthquake, only 1 was found in a camp under military control. Only 5 of the 95 cases of typhoid fever diagnosed among refugees after 18 April originated in a military camp. The average number of typhoid fever cases in San Francisco before the earthquake had been 12 a month, but 30 were diagnosed in April and 55 in May, with the rate falling back to 10 in June.65
In mid-May 50,000 people were still sheltered in a hundred or more camps when General Greely announced that he was turning over to city officials complete responsibility for sanitation in San Fran-
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cisco. The Army began returning the civilian patients remaining in military facilities to civilian hospitals. As part of the Army's gradual withdrawal from the relief effort, on 13 May Colonel Torney's almost unlimited authority ended. From this time until he was relieved on 23 May, his responsibility for civilians was confined to that of the chief surgeon to the newly appointed commander of permanent camps. Torney's successor, the new chief surgeon of the Department of California, also served as chief sanitary officer of the Army-controlled camps. As medical officers returned to their normal stations, the number serving in the city dwindled. By July only those camps located on the Presidio grounds remained under the Army's control, and by the end of that month the Army's role in the relief of San Francisco in the aftermath of the earthquake had been played out.66
Dealing successfully with the often terrified victims of fire, flood, storm, and earthquake at the turn of the century emphasized the importance of capabilities civilian agencies did not have. Among the advantages the Army had were a tightly controlled organization and a dedicated force of men and women too well disciplined and too well trained to panic, who were prepared to obey orders promptly and without argument, and who were familiar with maintaining standards of sanitation in primitive circumstances. Furthermore, to meet the sudden and overwhelming needs arising from unpredictable natural disasters, large amounts of medicines, vaccine, and hospital supplies unlikely to be immediately available from civilian sources and the transportation to move them and additional manpower swiftly to the disaster site were necessary. Equipped with reserves from the Army's warehouses, the Army Medical Department's professionally trained men and women could be moved promptly to the site of the disaster, where, regardless of the conditions surrounding them, they were capable of functioning effectively both to care for the sick and injured and to prevent further disaster in the form of an epidemic.
In the field, Medical Department personnel handled the challenges that they encountered in the period of peace between the Spanish-American War and the outbreak of World War I in Europe efficiently and effectively. One of the Army's most dangerous foes, typhoid fever, had been defeated. Disease rates were low. Surgeons were experiencing ever greater success in surgical operations that had been never before successfully undertaken. The population of a disaster-stricken city owed its health to the Army and, in particular, to Army medical personnel. But the scale of the challenges was small. Success in preventing a recurrence of the disaster of the Spanish-American War camps, even under circumstances resembling those that spawned 1898's epidemics, may well have encouraged medical officers to believe that they were far more ready for any future war than they were. As 1913 drew to a close, department leaders still had only their Spanish-American War experience to guide them.
NOTES
1. War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1900, pp. 83-86 (hereafter cited as WD, ARofSG, date); idem, [Annual] Report of the Secretary of War, 1899, l(pt.2):556, 560 (hereafter cited as WD, ARofSW, date).
2. "Antityphoid Vaccination in the Army," p. 728; Edgar Erskine Hume, Victories of Army Medicine, p. 102; Thomas J. Kirkpatrick, "Camp Sanitation," p. 426; Stanhope Bayne-Jones, The Evolution of Preventive Medicine in the United States Army, 1607-1939, pp. 139-43; Frederick F. Russell, "The Prevention of Typhoid Fever," pp. 482, 485; Percy M. Ashburn, A History of the Medical Department of the United States Army, pp. 272-73; WD, ARofSW, 1899, 1(pt.2):560; W. D. Tigertt, "The Initial Effort To Immunize American Soldier Volunteers With Typhoid Vaccine," pp. 342-49; Memo, Harry L. Gilchrist to SG, 30 Jan 1934, Ms C322, Harry L. Gilchrist Papers, National Library of Medicine (NLM), Bethesda, Md. Russell became a major on 1 January 1909.
3. Ashburn, History of MD, pp. 272-75; Hume, Victories, p. 103; Ltr, Frederick F. Russell to Valery Havard, 11 Nov 1908, Entry 231, Record Group (RG) 112, National Archives and Records Administration (NARA), Washington, D.C.; WD, ARofSG, 1909, pp. 46, 48, 1911, p. 50, and 1912, pp. 52-54; Frederick F. Russell, "Antityphoid Vaccination," pp. 816, 821-22; idem, "Anti-typhoid Vaccination in the American Army," p. 479; idem, "Progress in Antityphoid Vaccination During 1912," p. 667; idem, "Prevention," pp. 481-82, 518; William J. L. Lyster, "Vaccination Against Typhoid in the United States Army," pp. 511-12; F. J. Conzelmann, "Typhoid Inoculation," p. 316; Henry E. Meleny, "Tropical Medicine in United States Military History," p. 332; Frank W. Foxworthy, "Anti-typhoid Vaccination," pp. 333-34; Frank R. Keefer, "The Prevention of Typhoid Fever," pp. 290-91; United States, Army Medical School, Immunization to Typhoid Fever, pp. 7-8, 10-11, 13; Bayne-Jones, Preventive Medicine, pp. 141-43; Robert S. Henry, The Armed Forces Institute of Pathology, pp. 143-44, 146.
4. WD, ARofSG, 1909, p. 46 (first quotation), 1910, p. 148, 1911, p. 53, and 1912, pp. 56-57 (second quotation).
5. Ashburn, History of MD, p. 273; Charles F. Craig, "The Army Medical Service," p. 419; WD, ARofSG, 1913, pp. 54, 142, 212-13, and 1914, pp. 11-12; Kirkpatrick, "Camp Sanitation," pp. 423, 425; Russell, "Prevention," p. 500.
6. WD, ARofSG, 1902, pp. 94-95, 1903, p. 98, 1905, pp.14-15, 55, 1906, pp.19, 81, 1907, p. 13 (quotation), 81, and 1909, pp. 14, 93; George Rosen, Preventive Medicine in the United States, p. 37; Harry F. Dowling, Fighting Infection, pp. 91, 104; Valery Havard, "The Value of Statistics in Connection With Venereal Diseases in the Army and Navy," pp. 114-15; Anita Newcomb McGee, "Facts About the Army Canteen," pp. 262-63; Allan M. Brandt, No Magic Bullet, pp. 9-11, 14-15, 22, 40, 42; Prince A. Morrow, "Publicity as a Factor in Venereal Prophylaxis," p. 1245.
7. WD, ARofSG, 1902, p. 94, 1906, p. 49, 1910, pp. 16, 23, 28-29, 58-60, 86-87, 1911, pp. 126-27, 1912, pp. 104, 107, 1913, pp. 22, 38, 60, 124, 128-29, 1914, pp. 12, 57, 117, 120, 123, and 1915, p. 187; Dowling, Fighting Infection, p. 100; Brandt, No Magic Bullet, pp. 12-13.
8. WD, ARofSG, 1904, p. 90 (quotation); Dowling, Fighting Infection, pp. 83, 89, 92-93; Brandt, No Magic Bullet, pp. 11-12; William G. Miller, "The Treatment of Gonorrhea by Irrigation," p. 231.
9. Champe C. McCullough, "The Scientific and Administrative Achievement of the Medical Corps of the United States Army," p. 425; Henry J. Nichols, "The Present Status of Salvarsan Therapy in Syphilis," pp. 603-05; Brandt, No Magic Bullet, p. 40; WD, ARofSG, 1911, p. 160, and 1913, p. 155; Matthew A. Reasoner and Ray W. Matson, "The Treatment of Syphilis," pp. 741-42; "Salvarsan," p. 179; James S. Fox, "Prophylaxis of Syphilis and Practical Points on Its Treatment by Salvarsan," pp. 95-96.
10. Nichols, "The Present Status," pp. 604-05, 608 (quotation); Brandt, No Magic Bullet, p. 41; WD, ARofSG, 1909, p. 143, and 1912, pp. 70-71, 169-70; Dowling, Fighting Infection, p. 94; Reasoner and Matson, "Treatment," pp. 735, 739, 742; McCullough, "Achievement of Medical Corps," p. 425; Henry J. Nichols, "The Immediate Clinical Results of the Use of Salvarsan in the Army," pp. 212-13; Claude Quetel, History of Syphilis, p. 142.
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11. WD, ARofSG, 1911, pp. 161-62, 165, 1912, pp. 169-73, and 1913, pp. 155-58; Charles F. Craig, "The Interpretation of the Results of the Wassermann Test," p. 565.
12. J. Hamilton Stone, "Our Troops in the Tropics," p. 365 (first quotation); Jefferson R. Kean, "A Plea for Applying the Usual Methods of Preventive Medicine to Venereal Diseases," p. 199 (second quotation); WD, ARofSG, 1903, p. 99, 1905, p. 88, and 1911, pp. 60-61 (remaining quotations), 104-05; Ltr to Ed., W. A. Wiseman and W. W. Keen, Journal of the American Medical Association 58 (1912): 575; A. S. Condon, "The Army Canteen," p. 721; Brandt, No Magic Bullet, p. 35; Charles H. Alden, "Porto Rico," p. 21; Jerome H. Greenberg, "Venereal Disease in the Armed Forces," p. 172.
13. WD, ARofSG, 1902, p. 95, 1903, pp. 99-100 (first three quotations), 1909, p. 19 (fourth quotation), 1910, p. 62, and 1911, p. 57 (fifth quotation); "Syphilis of the Innocent," p. 526; Greenberg, "Venereal Disease," p. 172.
14. WD, ARofSG, 1910, p. 59 (second quotation), and 1911, p. 59 (first quotation).
15. Ibid., 1911, pp. 57 (first quotation), 59-60, 104, and 1912, pp. 64, 67; Hume, Victories, p. 123 (second quotation); Greenberg, "Venereal Disease," p. 177; Quetel, Syphilis, pp. 122-23, 141.
16. Jay Cassel, The Secret Plague, pp. 129-30; Brandt, No Magic Bullet, p. 99.
17. WD, ARofSG, 1910, pp. 60-61, 1911, pp. 57-61, 104-05, 1912, pp. 64-67, and 1914, p. 55; Greenberg, "Venereal Disease," p. 172.
18. WD, ARofSG, 1911, pp. 23, 54, 59-61, 63, 66, 69, 1912, p. 26, and 1914, p. 56.
19. Ibid., 1908, p. 28, 1909, p. 26, 1911, p. 55, 1912, pp. 40, 57-58, 60, 1913, pp. 19, 35, 58 (quotation), and 1914, p. 58; Jefferson R. Kean, "The Venereal Problem in the Army and Navy," p. 285.
20. WD, ARofSG, 1913, pp. 14, 59-60, and 1914, pp. 55-58, 62, 93 (quotation); Mahlon Ashford, "Statistical Report of Venereal Prophylaxis . . . ," pp. 9-10.
21. WD, ARofSG, 1908, p. 53, 1911, pp. 25, 71, 107, 1912, pp. 28, 78, 1913, pp. 14, 76, and 1914, pp. 12, 69.
22. Virginia Cowart, "Control, Treatment of Drug Abuse, Have Challenged Nation and Its Physicians for Much of History," pp. 2465 (quotations), 2469; R. M. Blanchard, "Heroin and Soldiers," pp. 141-42.
23. Quotations from William B. Meister, "Cocainism in the Army," pp. 344-45, 348. See also ibid., pp. 346, 350; Edgar King, "The Use of Habit-forming Drugs (Cocaine, Opium and Its Derivatives) by Enlisted Men," pp. 380-81.
24. R. L. Richards, "The Importance of Alcohol, Heat, and Acute Infectious Diseases Occurring in the United States Army in the Past Ten Years," pp. 616, 626; WD, ARofSG, 1910, p. 58, 1911, pp. 25, 107, 237-38, 1913, p. 98, and 1914, pp. 22, 69 (quotation). The latter source, 1911, reports on alcoholism in European armies; however, the figures cited are not based on the same years for all armies (see Tables 65 and 66, pp. 237-38).
25. WD, ARofSG, 1902, pp. 75-76, and 1905, p. 144; Rosen, Preventive Medicine, p. 28.
26. WD, ARofSG, 1902, pp. 70 (quotation), 71-72, 1903, pp. 65, 132, 1904, p. 57, 1905, pp. 115, 144, 1906, p. 122, and 1908, pp. 21, 51, 89; Fielding H. Garrison, An Introduction to the History of Medicine, p. 579; Rosen, Preventive Medicine, pp. 10-11, 28; Daniel M. Appel, "The General Hospital and Sanatorium for the Treatment of Pulmonary Tuberculosis at Fort Bayard, New Mexico," p. 215; Spink, Infectious Diseases, p. 225.
27. WD, ARofSG, 1909, pp.55-56, 1910, pp. 54, 137-38, 1911, p. 67, 1912, p. 40, and 1913, p. 99; George E. Bushnell, "The Diagnostic Use of Tuberculin in Pulmonary Tuberculosis," Entry 231, RG 112, NARA; Rosen, Preventive Medicine, p. 28.
28. WD, ARofSG, 1910, p. 80, 1912, pp. 75-76, 1913, p. 70, and 1914, pp. 65-66; Ltr, Jefferson R. Kean to Surg, Vancouver Barracks, 22 Sep 1912, Entry 231, RG 112, NARA.
29. Quotations from WD, ARofSG, 1904, pp. 122-23, 126. See also ibid., 1903, p. 124, 1905, pp. 54, 142-43, 1908, p. 21, and 1909, p. 138.
30. Appel, "The General Hospital," p. 211; Richard Johnson, "My Life in the U.S. Army, 1899 to 1922," p. 82, Spanish-American War, Philippine Insurrection, and Boxer Rebellion Veterans Research Project, Military History Research Collection, U.S. Army Military History Institute, Carlisle Barracks, Pa.
31. WD, ARofSG, 1909, p. 19, 1910, p. 51, 1911, pp. 64, 127, 1912, p. 71, 1913, pp. 62-63, 67, 101, 1913, p. 112, and 1914, pp. 12, 65, 93, 115.
32. Ibid., 1911, pp. 64, 66, 1912, pp. 73-74, 1913, pp. 64, 68, and 1914, pp. 64-65.
33. War Department, Surgeon General's Office, Manual for the Medical Department, 1906, p. 123 (quotation); WD, ARofSG, 1905, pp. 38-39, and 1908, pp. 28-29; William B. Bean, Walter Reed, pp. 181-82; William H. Crosby, "The Death of Walter Reed," p. 1342; William C. Borden, "History of Doctor Walter Reed's Illness From Appendicitis," pp. 425-26.
34. WD, ARofSG, 1904, pp. 115-16, 1905, p. 145, 1906, pp. 29-30, 1910, p. 28, 1911, p. 150, 1912, p. 30, and 1914, p. 36; Josiah C. Trent, "Sur-
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gical Anesthesia, 1846-1946," in Theory and Practice in American Medicine, pp. 209-11; Henry D. Thomason, "Personal Experience With Spinal Anesthesia, and Its Application to Military Surgery," p. 297; Owen H. Wangensteen and Sarah D. Wangensteen, The Rise of Surgery From Empiric Craft to Scientific Discipline, pp. 58-59; Bruce D. Ragsdale, "Gunshot Wounds," p. 310.
35. Bayne-Jones, Preventive Medicine, pp. 143-44; Carl R. Darnall, "The Purification of Drinking Water for Troops in the Field," pp. 268, 272-76; idem, "Water Purification by Anhydrous Chlorine," pp. 787, 783, 796-97; WD, ARofSG, 1911, pp. 82-83, and 1912, p. 99; William J. L. Lyster, "Sterilization of Drinking Water by Calcium Hypochlorite in the Field," pp. 223, 225-28.
36. WD, ARofSG, 1910, pp. 74 (quotation), 75-76, 78, 148, 1912, pp. 94-95, and 1914, p. 88.
37. Ibid., 1910, pp. 56, 79 (first quotation), 80, 1911, p. 82, and 1912, p. 96 (remaining quotations).
38. Ibid., 1911, p. 82, 1912, p. 91, and 1913, p. 88 (quotation); Hume, Victories, p. 178; Bayne-Jones, Preventive Medicine, pp. 145-46; Edward L. Munson, The Soldier's Foot and the Military Shoe, pp. 60-63.
39. WD, ARofSG, 1908, p. 63, 1912, pp. 96-97, and 1914, p. 85.
40. Ibid., 1897, pp. 48-49, 1902, pp. 136, 150, 1908, pp. 13, 17, 59, 1909, pp. 13, 17, 37-38, 1911, pp. 12, 16, 39, 99, 224-31, 1912, pp. 12, 41, 1913, pp. 24, 36, and 1914, pp. 11, 20-22, 24-27, 32, 36; John van R. Hoff, "Experience of the Army With Vaccination as a Prophylactic Against Smallpox," p. 497.
41. WD, ARofSG, 1902, p. 13, 1904, p. 111 (quotation), 1905, pp. 39, 147-48, 1906, pp. 123-24, 1907, pp. 70-71, and 1909, pp. 145, 148; WD, SGO, Manual, 1906, p. 62.
42. Martha L. Sternberg, George Miller Sternberg, p. 244 (quotations); WD, ARofSG, 1911, pp. 151, 165-67, 1912, pp. 152, 167-76, 1913, pp. 152, 187-92, and 1914, p. 131; James M. Phalen, Chiefs of the Medical Department, United States Army, 1775-1940, p. 86; Percy M. Ashburn, "The Board for the Study of Tropical Diseases as They Occur in the Philippine Islands," p. 300; Rosen, Preventive Medicine, p. 23.
43. WD, ARofSG, 1899, pp. 193-95, 1902, p. 51, 1906, p. 110, 1907, p. 117, and 1908, pp. 97-98; WD, SGO, Manual, 1906, p. 32.
44. WD, ARofSG, 1905, p. 140, 1909, p. 149, and 1917, p. 158 (quotation); Norman M. Cary Jr., "The Mechanization of the United States Army, 1900-1916," M.A. thesis, pp. 26, 28.
45. Quotation from Ltr, SG to SW, 26 Aug 1913, Entry 28, RG 112, NARA. In loc. cit., see the following: Ambulance Specs, Keeton Motor Co., 13 Nov 1913, and Ltrs, H. D. Snyder to Keeton Motor Co., 28 Aug, 9 Sep, 6 Dec 1913 and 16 Jan 1914; Keeton Motor Co. to SG, 4 Sep 1913; Charles M. Gandy to Ch, QM Corps, 17 Feb 1914; H. H. Newson to QM, Fort Wayne, 18 Feb 1914. See also Louis C. Duncan, "The Use of Motor Vehicles in Transporting Wounded," pp. 241-43; George M. Ekwurzel, "Observations of a Regimental Surgeon With the Maneuver Division," pp. 52-53; WD, ARofSG, 1912, p. 194; War Department, Surgeon General's Office, The Surgeon General's Office, p. 65 (hereafter cited as WD, SGO, SGO).
46. WD, ARofSG, 1899, p. 329, 1902, p. 59, 1903, pp. 42-43, 1904, pp. 31-32, 74-76, 112, 1905, pp. 39-40, 126-27, 1906, pp. 65, 130, 1907, pp. 69, 71, 113, 1908, pp. 63-64, and 1909, pp. 72-74, 77, 118; Darnall, "Purification," pp. 253-85.
47. WD, ARofSG, 1904, pp. 30, 36, 39 (first quotation), 40, 42, and 1908, pp. 126-27 (second quotation).
48. WD, ARofSG, 1911, pp. 92, 94 (first quotation), 95, and 1912, p. 51; Henry D. Thomason, "Sanitary Troops in the Organized Militia of the United States," p. 521 (second quotation); Joseph H. Ford, "Galveston Maneuver Camp," pp. 282-83; Paul F. Straub, "Sanitation of the Maneuver Camp at San Antonio, Texas," pp. 607-08; WD, SGO, SGO, p. 70; Hermann Hagedorn, Leonard Wood, 2:111.
49. Straub, "Sanitation," p. 622 (quotation); Field Service Regulations, 1910, pp. 126, 131-32, 181-82; WD, ARofSG, 1911, pp. 92, 94-95, 184.
50. WD, ARofSG, 1911, pp. 93 (first quotation), 94-96, and 1912, pp. 51-52; Herbert A. Arnold, "Report on Maneuver Camps at San Antonio and Leon Springs, and on Juarez, Mexico," p. 22 (second quotation); Straub, "Sanitation," pp. 620, 622, 626, 629-30; C. W. Decker, "San Diego Maneuver Camp," pp. 271-72; Ekwurzel, "Observations," pp. 57-58.
51. Charles S. Young, "The Advantages Accruing to the National Guard From Tours of Duty With the Regular Establishment . . . ," p. 62 (quotation); WD, ARofSG, 1911, pp. 95, 170, 172; Straub, "Sanitation," pp. 627-28; Arnold, "Report," p. 24.
52. WD, ARofSG, 1913, pp. 91-93, 214 (quotation).
53. Ibid., ARofSG, 1914, p. 82; Reuben B. Miller, "The Sanitation of the Second Division, U.S. Army, at Texas City and Galveston, Texas . . . ," pp. 515-16.
54. Adolphus W. Greely, Earthquake in California, April 18, 1906, p. 15 (quotation); WD, ARofSW, 1906, p. 101; Charles Keeler, San Francisco Through Earthquake and Fire, pp. 4, 9, 26, 48; Gordon Thomas
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and Max M. Witts, The San Francisco Earthquake, pp. 71, 78, 149. An excellent study of the Medical Department's role in aiding the victims of disaster, including those of the San Francisco earthquake, can be found in Gaines M. Foster, The Demands of Humanity, on which this account of the San Francisco disaster is based, except where otherwise indicated.
55. Gladys Hansen and Frank Quinn, "The San Francisco Numbers Game," Paper of the San Francisco Earthquake Research Project, San Francisco, Calif.; Terry Link, "The Great Earthquake Coverup"; Greely, Earthquake, pp. 7-8, 14-15, 30, 32, 44; WD, ARofSW, 1906, p. 200.
56. Quotations from Henry H. Rutherford, "Experiences of an Army Medical Officer During the San Francisco Earthquake," pp. 208-09. See also ibid., p. 210; WD, ARofSG, 1907, p. 126; Greely, Earthquake, pp. 31, 129; Keeler, San Francisco, pp. 9-10; John C. Kennedy, The Great Earthquake and Fire, p. 132; Rpts, George H. Torney to Adolphus W. Greely, 14 May 1906, vol. 3, and J. M. Kennedy, vol. 4, Ms B286, "Report on Sanitation in San Francisco After the Earthquake," NLM; Thomas and Witts, San Francisco Earthquake, p. 71.
57. Rutherford, "Experiences," p. 210 (quotation); Greely, Earthquake, pp. 31, 129-30; Rpts, Henry H. Rutherford, J. M. Kennedy, and William Stephenson, vol. 4, Ms B286, NLM; WD, ARofSG, 1907, p. 126.
58. Rutherford, "Experiences," pp. 210-11.
59. Quotation from Pacific Div GO 11, 20 Apr 1906, vol. 3, Ms B286, NLM. See also Greely, Earthquake, pp. 5, 11, 18, 24-25, 31-32, 60, 72, 130; Kennedy, Earthquake, p. 169; WD, ARofSG, 1906, pp. 131-32.
60. Greely, Earthquake, pp. 10, 58-59, 66 (quotation); Rpts, Albert Truby and J. M. Kennedy, vol. 4, Ms B286, NLM; WD, ARofSG, 1906, p. 132.
61. Greely, Earthquake, pp. 33, 35, 66, 73, 130-31; Kennedy, Earthquake, pp. 109-10; Rpts, Kenneth A. J. Mackenzie, vol. 1, A. Truby, vol. 4, and H. H. Rutherford, vols. 1 and 4, Ms B286, NLM.
62. William E. Carll, "The Oregon National Guard at the San Francisco Earthquake Disaster," p. 462 (first quotation); Greely, Earthquake, pp. 20-21, 31-32, 131 (second quotation); WD, ARofSG, 1906, pp. 116, 132-33; Rpts, H. H. Rutherford, vol. 1, and Robert U. Patterson, 5 Jun 1906, vol. 4, Ms B286, NLM; George H. Kress, "United States Army Field Hospital in San Francisco in 1906. . . ," p. 215.
63. Carll, "Oregon National Guard," p. 462; Kennedy, Earthquake, pp. 109-10; Greely, Earthquake, p. 44; Roster, Sanitary Div, Presidio, 22 Apr 1906, vol. 1, and Rpts, George H. Torney to SG, 24 Apr 1906, and to Greely, 14 May 1906, vol. 3, Ms B286, NLM.
64. WD, ARofSG, 1906, pp. 126, 132-33; Kennedy, Earthquake, p. 45; Greely, Earthquake, pp. 32, 131-32; Rpt, J.M. Kennedy, vol. 4, Ms B286, NLM.
65. Greely Earthquake, pp. 32-34, 58-59, 131, 133-34; Rpt, A. Truby, vol. 4, Ms B286, NLM; WD, ARofSG, 1906, p. 12, and 1907, p. 9.
66. Greely, Earthquake, pp. 32-33, 72, 131; Pacific Div SO 66, 23 May 1906, vol. 3, and Rpts, H. H. Rutherford, J. M. Kennedy, and W. Stephenson, vol. 4, Ms B286, NLM. According to WD, ARofSG, 1906, p. 12, the secretary of war allotted the Army Medical Department $400,000 of money voted for the "relief of sufferers from earthquake and conflagration on the Pacific coast (joint resolutions of April 19, 21, and 24, 1906)."
