Chapter 2
SUPPORTING THE ARMY
The administrative difficulties encountered in the Surgeon General`s Office in the first decades after the end of the Civil War did not significantly affect the work of military physicians serving posts scattered about the United States. Neither Reconstruction in the South, where "federal military activity . . . was negligible," according to historian John Hope Franklin, nor labor unrest in the more northern states in 1877 brought major new challenges. Wherever they were, Army surgeons continued to care for soldiers who had to endure long hours of physical labor under miserable conditions and disability from the ravages of disease. Because of corruption and wrangling between government and private contractors, the prompt and reliable delivery of the items of diet needed to preserve health still could not be guaranteed, even after the nation`s railroad network had spread far through the West and refrigerated cars had joined the other cars that ran the rails. Finally, until the germ theory was widely accepted, Army physicians had no reason to change the way in which they attempted to maintain the health of the garrisons they served.1
Preventive Medicine
In the United States in the decades immediately following the end of the Civil War, preventive medicine remained the only effective weapon against disease. The public health movement was just beginning to gain real momentum. Although military physicians did not understand the relationship between poor sanitation and disease, they traditionally recognized the importance of preventive medicine. The surgeon general emphasized his belief in the vital role played by sanitation in maintaining the health of the Army by requiring surgeons to report regularly to him about the condition of their posts. Line officers were not motivated to take the recommendations of post surgeons seriously until 1874, when the Army required the latter to submit official reports on post sanitation to the commanding officer, who in turn had to record any objections and then forward the reports to the commander of the territorial command.2
Immunization against smallpox was, like sanitation, a weapon in the fight against disease that was employed by the Army far more than it was by the civilian population. An antivaccination movement that discouraged immunization contributed to a rising incidence of smallpox in the communities near military posts and increased the exposure of soldiers to the disease. Although vaccination was mandatory in the Army, those who had not been immunized for several years or who had
40
been vaccinated with questionable material might be susceptible to this highly contagious and dreaded disease. Authorities blamed a postwar letdown in precautions for an epidemic among black soldiers that resulted in more than 800 deaths in the year ending 30 June 1866.3
In spite of the Medical Department`s efforts to prevent illness, Army physicians still encountered a high rate of both disease and discharge for chronic disease and disability, and even occasional terrifying epidemics. Many more soldiers were discharged because of the effects of rheumatism, venereal disease, heart disease, alcoholism, hernia, epilepsy, dysentery, and chronic respiratory disease than because of crippling wounds. From 1 July 1868 through 30 June 1873 the rate of discharge for blacks and whites combined averaged 32 per 1,000 men, a figure that Surgeon General Barnes attempted to put into perspective for the secretary of war by pointing out that during the period 1861-1870 the annual discharge rate for British troops stationed in the United Kingdom was 33.76 per 1,000.4
Major fluctuations in the overall disease rate in the Army from year to year resulted chiefly from epidemics of cholera and yellow fever. Because both illnesses were associated with "dirt and unclean habits" (wrongly in the case of yellow fever, which is transmitted only by several species of the Aedes mosquito, most often Aedes aegypti), they were grouped with those that medical scientists classify as "filth diseases," spread through the feces and urine of their victims. U.S. soldiers were vulnerable to both cholera and yellow fever. Any immunity acquired from cholera is short-lived, and although one attack of yellow fever confers permanent immunity, winter temperatures in the United States were too cold for the Aedes aegypti to survive. Epidemics of yellow fever occurred only when ships from Caribbean ports where the disease was endemic brought these insects with them to the United States. A large majority of soldiers came from northern cities; because of the vulnerability of Aedes aegypti to low temperatures and the duration of the voyage from the Caribbean, the likelihood of their gaining immunity to yellow fever was small. Together the two diseases were responsible for almost half the total numbers of Army deaths from all causes. Only 9.7 percent of the fatalities among the blacks and 13 percent among the whites resulted from wounds or injuries in 1867. With blacks now serving in the Army, medical officers studying possible racial differences in disease susceptibility noted that while 10.7 percent of total deaths among blacks resulted from yellow fever, the comparable rate among whites was 31.6 percent. The number of cholera fatalities steadily declined after 1867, whereas in 1868 yellow fever deaths were high. Beginning in 1869, disease rates from all causes fell, largely because of an overall decrease in yellow fever and cholera cases.5
Yellow fever struck units in Florida with particular severity in the decade after the end of the Civil War. In 1867 it killed one soldier at Key West and twenty-seven more at Fort Jefferson. The surgeon general asked the Army surgeons involved to send him any information they had on how the epidemic might have started, and by 1868 Billings was actively attempting to add more books on yellow fever to the Surgeon General`s Library. In 1869 yellow fever hit Pensacola. Despite efforts to isolate the garrison from the civilian population, among whom the disease first appeared, twelve soldiers at Fort Barrancas fell ill and died. While assigned to the post, Assistant Surgeon Sternberg, then
41
a captain, contracted yellow fever, acquiring both a lifelong immunity and a lifelong interest in the disease.6
Yellow fever reappeared at Fort Jefferson in 1873. The attempt to spare the garrison by moving some men to Loggerhead Key was only partially successful; a few cases occurred within five days of arrival at the new site. Almost all those who remained at the fort fell ill, and thirteen of the twenty-five who contracted the disease died. Moving the garrison stationed in the Mobile, Alabama, area proved more successful; although many civilians in Mobile died, soldiers were spared. The disease continued to follow essentially the same pattern in subsequent years, threatening posts from Charleston to New Orleans. The Army continued to respond in the same way, moving as many men as possible away from stricken areas until the epidemic had run its course, an approach that was generally effective. Among those who contracted the disease, mortality remained high, with a third or more dying.7
In 1879 Sternberg was detailed to join the civilians on the newly created Havana Yellow Fever Commission of the National Board of Health,8 which had been formed following a deadly yellow fever epidemic the preceding year. With three other members, Sternberg traveled to Cuba to study the disease. Two of the men with whom Sternberg worked, commission member Juan Guiteras and Carlos Finlay, an adviser to the commission in Cuba, would later play significant roles in the Army`s struggle against yellow fever, but at this time a year`s study led only to the conclusion that the science of bacteriology had not yet progressed to the point where the secrets of this deadly disease could be revealed. Despite strong efforts, the Medical Department lacked an effective weapon against yellow fever except flight. Without an understanding of how it was spread, doctors could not otherwise prevent it, and the purges and emetics still used to treat almost all diseases were of no avail as a cure.9
Although yellow fever was widely feared, cholera could be more dangerous, especially in epidemic years. Because cholera was spread mainly through water contaminated with the cholera vibrio, it was not confined to the South. At the time, the understanding of how this disease was spread was limited. Although an English physician, John Snow, had proved in the 1850s that water contaminated with the feces of cholera victims transmitted cholera, medical historian Wesley W. Spink maintains in his Infectious Diseases: Prevention and Treatment in the Nineteenth and Twentieth Centuries that "it was not until 1892 that the etiology and mode of transmission of cholera was recognized." Many
42
in the United States who accepted the idea that cholera was "portable" continued to believe that something in the atmosphere was also involved or that "predisposing causes" were necessary for its spread. The number of titles that Billings listed in his 1875 bibliography on cholera illustrate the widespread concern caused by this disease, which could survive in almost any climate and kill in a matter of hours. In 1864 another worldwide pandemic struck the United States, causing 278 fatalities along the coast of North Carolina, and by 1866 the disease was spreading to the West at a rapid rate, helped in part by the failure of the Army to realize that those without symptoms could be carrying the disease. Some mild cases of cholera might have been diagnosed as simple diarrhea, which also afflicted the Army at this time.10
From collecting points on Governor`s Island in New York harbor, where "carcasses, offal, and floating debris of every description" covered the beaches, soldiers and the cholera vibrio boarded trains and boats together to journey to Fort Monroe, Virginia; to forts on the Mississippi River; and to posts in Missouri, Arkansas, and Texas. From July through December 1866, 192.6 of every 1,000 white soldiers and 258.4 of every 1,000 black soldiers contracted Asiatic cholera. More than 40 percent of white cases were fatal; almost half the total of 1,527 white soldiers dead from disease in 1866 and 1867 fell victim to cholera, while wounds or other injuries killed only 155. The Medical Department, its interest in the question of the extent to which health varied according to race unabated since the Civil War, noted that blacks, too, suffered severely from cholera, more than half the black victims dying. Their mortality rate from all causes was 12 percent, three times that of whites, and cholera caused two-thirds of the total of 536 black fatalities. Cholera also killed several medical officers and contract surgeons, including one who had left his sickbed to care for his patients. Among the civilians succumbing to cholera at Fort Harker, Kansas, in the summer of 1867 was Sternberg`s first wife, and for some time after this tragedy he "was unfitted [sic] for duty from physical and mental prostration."11
Because of repeated epidemics since the first in 1832, Asiatic cholera was more familiar by the late 1860s, but Army surgeons treating patients stricken with the disease were still unable to mitigate its terrifying symptoms. Despite their efforts, the cholera victim suffered from diarrhoea, vomiting and purging of rice water, cramps, collapse, cold surface, cold extremities, cold tongue, cold breath,. . . leaden hue . . . , shrunken features, anxious expression, sunken eyes . . . , incessant thirst, . . . entire suppression of urine, jactitation [tossing back and forth], nervous agitation, sometimes slight delirium, [and] finally coma from uraemia, loss of pulse, and death.
The mere sight of such a victim was horrible even after his death because of the corpse`s "very striking . . . muscular movements."12
With Army physicians unable to prevent deaths from cholera, the Medical Department redoubled its efforts to avert epidemics. Especially after 1868, the most favored approach involved quarantine; men were moved neither into nor out of infected areas. Often when the need for such an approach became obvious, troops had already spread the disease far and wide. Efforts to prevent local contagion among the soldiers at each individual post sometimes required "extraordinary precautions." A guard might be stationed over
43
the latrines to require any man who had "two actions of his bowels within twenty-four hours" to use an "earth closed commode" the next time so "that its character might be inspected." Considerable attention was focused on the quality of the drinking water and upon improved sanitation. Water might be sent to the department in Washington for testing, but this step was taken in the belief that any "organic matter" in it was harmful to the patient who was already suffering from cholera. Potassium permanganate was used to purify water found to contain such "organic impurity."13
Army surgeons also implicated crowding, bad ventilation, "crowd poisoning," and human waste as factors contributing to cholera outbreaks. They intensified efforts aimed at keeping quarters "scrupulously clean" and latrines disinfected in times of epidemic; interest in disinfectants and methods of disinfecting was considerable, even before the role of germs was generally recognized. The presence of vermin and swarms of flies was noted at one New York port where cholera had taken a high toll, but apparently no one suggested that these creatures were more than a mere reflection of poor sanitation. Those responsible for the care of cholera patients might require that their soiled bedding be burned and their unsoiled bed linen disinfected and boiled before laundering.14
The efforts of 1866-1867 produced little in the way of concrete and demonstrable results, despite at least one attempt to study the blood and urine of victims and the appointment of a board to study sanitation and ways to prevent the spread of cholera on Governor`s Island. A circular issued in June 1868 required Army surgeons to use special forms to record the details of cases of epidemic disease, especially yellow fever and cholera. With the coming of the public health movement and the use of the laboratory to make prompt diagnosis of the first cases possible, cholera ceased to be a major threat in the United States after its final appearance as a significant problem in 1873. Only after this epidemic did Congress order the Medical Department to conduct the investigation of the disease, which was carried out by Assistant Surgeon McClellan.15
In spite of epidemics, the Medical Department`s advice was not necessarily followed, and the conditions under which the average enlisted man lived remained primitive. Housing was put up casually and became increasingly defective with the passage of time. Latrines were poorly located and maintained. Beds were crowded and vermin-infested. Although weekly baths were required, adequate facilities were often lacking, especially at smaller and older barracks and in the years immediately following 1865.16
Although the water supply at most forts was apparently satisfactory, it was recognized as a possible source of disease. Surgeons could send samples to the Army Medical Museum laboratory for "biological examination" and "chemical analysis," but the analysis resulted in a report that detailed only the presence and amount of chlorine, nitrites, nitrates, free ammonia, albuminoid ammonia, and total solids in the water, not the presence of bacteria. Although by 1890 many posts were tapping into municipal water supplies, this move guaranteed neither quantity nor quality. Experiments with effective means of producing safe city water were under way in the late 1880s and 1890s, but as late as 1911 only 20 percent of city populations drank filtered water. Cisterns used to collect rain water could also accumulate for-
44
eign matter if not carefully maintained, springs and wells might be contaminated by runoff, and summer droughts could concentrate pollutants to the danger point.17
In working up criteria for improved sanitation, the Medical Department was particularly concerned with ventilating barracks and particularly with venting sewer gases, commonly believed to be capable of spreading typhoid and other diseases. With the passage of time, therefore, medical officers were increasingly involved in designing and installing effective sewage systems. Post surgeons became very knowledgeable on the subject of the design of sewers, flush toilets, and vent stacks, and devoted much time and energy to the improvement of post sanitation. They rarely seemed concerned, however, that even the most effective system discharged raw sewage into the nearest river, from which the water supply of the post or of some other community might be drawn. As garrisons grew in size, the question of sanitation became more acute, yet the expense involved in installing new systems was discouraging. As a result, some surgeons continued to struggle to improve sanitation at bases where years of accumulated human wastes oozed to the surface with every rainstorm and the urine-saturated wood of ancient outhouses reeked in the sun. Others wrestled with problems originating in sewers that, while possibly of recent origin, were poorly designed, constructed, and maintained. The services of an experienced and careful plumber were necessary to ensure the proper installation of new sewer systems. The proper pipe, the caulking of the joints, the venting of the traps, and the ventilation by soil stacks were all important, but qualified plumbers were hard to find.18
45
Between the inept installation of new facilities and the poor design and condition of older structures, unusual problems could arise. At Jefferson Barracks, Missouri, the cold air shaft of the furnace in the hospital basement ran within a yard of an open sewer vent. Because the wood of the shaft had rotted and was full of holes, sewer fumes were drawn into the furnace, heated, and sent throughout the building. Furthermore, since none of the soil pipes rose above the roofline, few fumes ever left the building. When attempts to improve the plumbing were undertaken in the 1880s, the post surgeon faced multiple problems. He insisted that he "had closely watched the work as it was being done, but under [his] very eyes the soldier plumber had his own way." The miscreant connected the water closets in the new hospital annex not to the new pipe that ran to the river but to the old one, which led to an abandoned sinkhole. He also set ventilation pipes for the water closets so low that when a toilet was flushed, the water flowed into the ventilation pipe. Rather than resetting the pipes after this disaster, he filled them "so completely with putty that neither air nor water could escape." The surgeon reported that "this evil was corrected," but the "discovery and removing [of] defective plumbing" continued. The decision to take water from the St. Louis mains, following on the heels of the installation of the new plumbing system, was regarded as "a great sanitary improvement."19
Another post with a high disease rate was Fort Douglas, Utah Territory, where the enlisted men did not have the benefit of a sewer and had to use earth closets (latrines in which excreta were covered with earth) that were "unsuitable, offensive to both sight and smell, dangerous to health, as well as indelicate from the mode of operating them." For a while the sewer serving officers was not flushed frequently enough, and the odors that resulted mingled with those from the earth closets and from the "fecal matter" spilled onto the ground when the closets were emptied. "The stench from this cause and from the buildings themselves is very great," the surgeon noted. He had also to contend with "waste pipes of the bath-room and kitchens of two barracks" that emptied onto the ground so that in winter, with the ground frozen, their effluent flowed "under the barracks, saturating the ground with filth." The ground was "strewn with filth dripped from the boxes when emptied, filling the air with foul odors," and effluent from the post polluted the river from which water was drawn.20
Old forts in the East experienced similar problems with sanitation. At Fort Hamilton, New York, where as late as 1890 most of the garrison was still lodged in damp, leaky, badly ventilated casemates that provided "just the kind of quarters in which rheumatism, pulmonary trouble, and low fevers are developed," the enlisted men`s toilet facilities consisted "of an immense trough with a beam . . . laid along the front edge on which a man must sit. Everything behind is open. . . . The disgusting sights and odors and the lack of privacy condemn the plan utterly."21
Recruiters traditionally counted on the large northern and midwestern cities to provide a major proportion of new soldiers, but a common assumption was that rural areas provided the best soldiers. Crowded quarters and poor sanitation were undoubtedly especially hard on the morale of
a young raw recruit, pure as the air upon his native hills, and as verdant as the grass and leaves of his rural home, fresh from clean feather-beds, butter, eggs and pumpkin pies, when . . . he is
46
ordered to report to the Sergeant . . . , and is assigned to little else than standing room in a dormitory and a place in line to wait his turn for a seat in the mess-room, to a pine-table, tin-cups, and everlastingly boiled meat.22
Convinced by his experience and research that "nothing certainly is more productive of contentment than a generous and varied diet," Billings examined the Army ration. Far from butter, eggs, and pumpkin pies, it was conducive not only of poor morale but of disease as well; the field ration consisted principally of greasy salt meat, dry bread, and thoroughly sweetened coffee, occasionally supplemented with beans. The Army officially insisted that it was more than adequate. Billings, however, maintained that "nothing can be more certain . . . than that the ration per se, that is, without addition by exchanges and purchases, is insufficient." Until the late 1880s the formal ration did not contain "any vegetable element," and without it, Billings pointed out, the men would "soon be affected with the scurvy." This deficiency emanated, apparently, from a widespread failure to understand the importance of vegetables in the diet. Tomatoes were better for preventing scurvy than the traditional potato and could be easily provided in cans, yet ignorance about their importance sometimes led to a refusal to issue them on the grounds that they could be used only to replace an item in the regular ration. As a result, although at least one surgeon regarded even a single case of scurvy as disgraceful, in the years 1865 through 1874 few forts west of the Mississippi escaped without at least one or two cases. A post`s record for a single year sometimes showed more than a dozen victims, but only once did a severe problem run unchecked into a second year.23
Despite the growth of the nation`s network of railroads, the increasing availability of canned goods, and the advent of ice machines and refrigerator cars to preserve fresh foods, the Army ration remained grossly deficient for many years. The Medical Department encouraged soldiers to hunt and garden to supplement their diets and also suggested that a portion of the allotment of such items as bacon, sugar, coffee, soap, and vinegar be sold and that the money received in return be used to buy more valuable items of diet. To raise their own antiscorbutics, however, soldiers had to pay for the seeds from their own pockets, and to save items from the ration in order to sell them or trade them to make up for deficiencies, they had to deprive themselves. Some contributed their own money toward the purchase of vegetables and fruits. Even these options, however, were unavailable to members of the exploratory team that Lt. Adolphus W. Greely led into the Arctic in 1884. The largest number of Army deaths related to diet in this period resulted from the failure of a relief ship to arrive before Greely`s food reserves gave out. With the expedition`s contract surgeon among the dead, the medical details of the disaster will never be known, but the deaths of twelve of Greely`s men were attributed to starvation and one to scurvy. Even after 1890, when vegetables became a required part of the official ration, occasional cases of scurvy still appeared.24
Other facets of the Army`s ration also came under fire. In the course of his examination of Army posts in 1875, Billings concluded that it lacked not only vegetables but "albuminates" (or proteins). An experiment in preserving beef by freezing all the meat for the season in ice and snow in early winter was conducted at Fort Bu-
47
ford in the Dakota Territory. The savings in forage that resulted from not having to feed the cattle during the winter months was counterbalanced by the poor quality of the meat so preserved. Billings also questioned the soldier`s allotment of bread. In his opinion, 18 ounces a day was inadequate unless "supplemented by a good supply of the starchy vegetables."25
In the final analysis, cooks could spoil not only the appeal to the palate but the healthfulness of any food, and some items were beyond redemption. Billings quoted a Civil War authority as saying that "beans, badly boiled, kill more than bullets" and particularly deplored the custom of detailing unqualified enlisted men to cook for hospitalized patients. He noted that the Army surgeon who was required to inspect the post`s food once a week was also required to inspect the way the ration was prepared whenever he suspected that a food-related disease might be afflicting the garrison. Neither cooking nor refrigeration could make salt pork palatable in hotter climates. Even in the late 1880s it was "condemned as repugnant to the taste and sight" in Texas, but the commissary general of subsistence insisted that it was "one of the most important and valuable components of the ration."26
Post surgeons were also concerned with personal hygiene. Billings believed that "next to fresh air and proper food, personal cleanliness is the most important agent in preserving the mind and body in proper working order. . . . A dirty man will, in most cases, be a discontented, disagreeable, and dissolute man; for the condition of his skin has more to do with a man`s morale than is generally supposed." His studies of Army posts in 1870 and 1875 revealed his awareness of the difficulties involved in providing bathing facilities. Both officers and men seemed to understand the importance of personal cleanliness, but a poor water supply and a lack of adequate heat all too often discouraged attempts to bathe. Available facilities were sometimes antiquated, especially in the South. At Fort Monroe, where saltwater baths were possible in warm weather, "the greater part of the command do not wash their whole persons from November till June." Billings recommended the use of showers rather than tubs and urged that warm water be made available. "It is," he noted, "economy and good policy to make the facilities for this purpose such that men shall consider their bath a pleasure and a necessity." Commanding officers generally cooperated with efforts to encourage cleanliness, but the secretary of war apparently wanted garrisons to set up their own bathhouses without charging the government for the expense.27
The Medical Department was also concerned about the clothing soldiers wore. In the summer of 1867 medical directors in the various parts of the country were polled for their opinions on the "hygienic fitness (for the localities where they are now on duty)" of the uniform. One such report, printed by the Surgeon General`s Office in the spring of 1868, was the work of Capt. Alfred Alexander Woodhull. Woodhull emphasized the importance of different designs and weights of uniform for different seasons and climates. He believed that a lighter and better ventilated hat was needed for warm weather, and a different, more protective version for cold weather. The undershirt, its thickness varying with the seasons, should reach "the middle third of the thigh," thus guaranteeing adequate protection for "the organs most sensitive to changes of temperature." Woodhull suggested that this
48
garment would be easier to wash if a fabric containing 35-percent cotton were substituted for all wool. Beyond this, "company officers should be held responsible that their men always wear drawers," both for comfort and health, and, in addition, "large and warm leggings" for those at "exposed, north-western posts."28
Woodhull was particularly critical of the design of the Army uniform. It was "tight-fitting, wadded," restricting breathing and preventing the evaporation of perspiration. In the South it was "insufferable in the warmer months." The soldier`s "martial bearing," Woodhull believed, should result from his training, not from clothing so thick and so tight as to "hold the soldier in position." In 1878 commanding officers in the Deep South were permitted to use lighter-weight clothing, some of which had to be purchased out of the individual soldier`s salary.29
The combination of complaints from the South about clothing that was too warm with complaints from the North about the inadequacies of cotton underclothing during harsh winters only served to emphasize the need for a new approach to the design and fabric of uniforms. In 1893 a medical officer maintained that recent changes in clothing had only made matters worse.
It seems essential to tie the soldier down with straps and strings and then load him up like a freight car. He is half-choked with high-standing collars; he has straps ingeniously arranged across his chest so that he cannot breathe by his chest muscles; he has belts and clothing so tightly bound around his waist that he can not breathe by his abdominal muscles, and on his head is placed a contrivance that is protection neither to eyes nor head.30
The design of the uniform of the cadets at West Point was no better. The clothing in question was so tight that it interfered "materially with the natural development of the muscular, circulatory, and respiratory systems." It caused nausea, headaches, and faintness, but the cadets liked the appearance of close-fitting uniforms so much that they had their tailors alter them to be tighter still. The only way to eliminate the problem, therefore, was to completely restyle the uniform. An investigating committee agreed and recommended that trousers be designed to be looser at the waist than the ones in use.31
In the decades after the Civil War a broader and more positive approach to the Army`s health was also evident. The Army began promoting health of mind and body rather than merely preventing disease. Much effort was devoted to reducing problems caused directly and indirectly by alcoholism and to advocating athletic
49
training and specific programs of recreation. Echoing the philosophy then being espoused by such civilian authors as William James, Surgeon General Sutherland believed that "the athlete cares more for his training than for vicious indulgence" and that the encouragement of athletics could be expected to "reduce the prevalence of drunkenness to a minimum." This approach may have been in part responsible for the decrease in overall venereal disease and alcoholism rates after 1879. By 1889 most Army surgeons rated "the personal habits, cleanliness, etc., of the men as excellent," but the number of alcohol-related admissions, more than 40 per 1,000 mean strength in the 1880s, continued to arouse concern. Prohibition of alcohol on base resulted only in the growth of "dens of dissipation and disease just beyond the jurisdiction of the commanding officer," and with venereal diseases an important cause of ineffectiveness, doctors began to favor establishing post canteens serving beer.32
Although respiratory diseases traditionally took a considerable toll among the nation`s soldiers, they were taken for granted, perhaps because they did not have the chronic character of such problems as alcoholism and venereal disease. The common cold affected many. In fiscal year 1887, 80.9 men out of every 1,000 were admitted to sick report because of "catarrhs and common colds" and another 62.24 per 1,000 because of more serious problems, primarily bronchitis, pneumonia, pulmonary tuberculosis, and pleurisy. In 1890, however, a major influenza epidemic caused the Medical Department some concern, and it was followed in 1891 and 1892 by occasional serious but localized influenza outbreaks.33
Surgery
Although disease remained a significant cause of ineffectiveness despite determined efforts of medical officers to prevent its spread with improved sanitation, deaths from wounds increased as campaigns against the Indians became more intense and inspired greater interest in target practice. In fiscal year 1870 wounds killed half as many as disease among whites and more than a quarter as many among blacks. Thus the work of the surgeon who repaired the damage resulting from Indian attacks and mishaps with weapons continued to be vital to maintaining the Army`s effectiveness.34
The use of anesthesia no longer caused dissension within the medical profession. Since the days of the Mexican War in the late 1840s, with rare exceptions, surgeons had not had to deal with struggling and terrified patients. By late 1883 both Army surgeons and civilian practitioners were using cocaine and its derivatives as local painkillers. Chloroform was falling deeper into disfavor because of its effects upon the heart. Medical Department physicians preferred ether, which in fiscal year 1886 they used almost twenty-four times as often as a combination of ether with chloroform. No anesthesia deaths were reported that year, although surgeons noted problems related to the use of anesthesia in three cases receiving ether, one receiving chloroform, and one a mixture of the two.35
In surgery as in preventive medicine the period 1865-1893 was one of transition. For many years after the Civil War, physicians who did not appreciate the implications of the germ theory hesitated to perform complex operations for fear of infection. When an assassin`s bullet cut President Garfield down in July 1881, doc-
50
tors did not undertake exploratory surgery to determine the extent of his injuries. Instead, they repeatedly poked and probed the wound with unsterilized instruments and unscrubbed hands. Even the use of a primitive metal detector, devised by Alexander Graham Bell, failed to locate the bullet. In the postmortem examination performed following Garfield`s death two months later, Army Museum pathologist and contract surgeon Daniel Smith Lamb traced the bullet`s ten-inch course through the body to its final lodging near his pancreas. Lamb blamed the death on secondary hemorrhage, but modern scientists familiar with the records of Garfield`s care have concluded that the cause of the fatal bleeding was infection.36
For those fated to attend a dying president at a turning point in the history of medicine, the strain of the unusual responsibility they bore was almost unbearable, especially when coupled with the flood of criticism that appeared in both professional and more popular publications from those who would second-guess their approach to the president`s care. Garfield`s physicians, among them Maj. Joseph J. Woodward, considered by those who knew him to be "highly strung," were emotionally drained. In July 1882, a year after the president`s death, Woodward was still so overwrought that he was unable to attend the autopsy of Garfield`s executed killer, Charles J. Guiteau.37
An increased appreciation of the benefits of antisepsis would eventually produce a major change in the approach of medical officers to surgery. Initially, they remained very cautious about undertaking abdominal surgery. A psychological barrier still lay between the surgeon, military or civilian, and his undertaking a type of operation previously associated
51
only with the direst of consequences. He first had to be sure in his own mind that removing an infected appendix, for example, would save a life that would otherwise probably be lost, and thus he would perform an appendectomy only when the patient was so close to death that nothing was likely to save him. Nevertheless, as early as 1885, an optimistic Surgeon General Murray foresaw a day when that barrier would fall, when
the hope of modern abdominal surgery will . . . be realized, by the application, at the hands of military surgeons, of abdominal section [surgery involving an incision into the abdominal cavity], under antiseptic precautions, to gunshot wounds of the abdominal viscera, with ligature of all bleeding vessels, and the closure by suture of all intestinal wounds.38
Elaborate routines before beginning to operate became increasingly common as physicians began to realize that more than mere cleanliness was necessary to prevent the development and spread of infection during operations. Representative of this approach was the procedure recommended in 1892 to surgeons of the National Guard. They were to scrub their hands with a sterilized brush in hot water for several minutes before operating, then immerse them for three minutes in a hot saturated solution of potassium permanganate. A three-minute soak in a hot solution of oxalic acid followed, with three minutes in a hot solution of bichloride of mercury completing the routine. Understandably, the adoption of rubber gloves in 1889 was dictated by concern for the hands rather than by any belief that germs on them might survive to infect the victim.39
Hospitals
When so many units were isolated and disease rates were high, even the smallest Army post had to have a building where the sick could be sequestered for care. The temporary field hospitals and dressing stations that served troops in the field were in use too short a time to become contaminated with disease, but Medical Department experts believed that permanent hospitals were inevitably reservoirs of disease after ten years of use. Anticipating a regular need for new construction, they developed standardized designs for 12-, 24-, and 48-bed facilities. They recognized that while few posts were large enough to justify building the largest size, the 12-bed design that met most requirements was inefficient because the space necessary for office and storage was almost as great as that taken up by its single ward. The money necessary to build and maintain these facilities was initially part of the Army`s annual budget for construction, but after 1874 it was voted as specific sums appropriated for hospital construction and maintenance. Although willing to fund a joint Army-Navy general facility, Congress gave the department less than half that required to give each Army post a hospital, to keep it in good repair, and to replace it every ten years. Medical officers were all too frequently forced to watch their facilities deteriorate, powerless to remedy the situation.40
In actual practice, many post hospitals occupied makeshift quarters, poorly constructed and of inappropriate design, where ventilation and heating systems worked at cross-purposes. An 1875 inspection revealed that the facility at Fort Hamilton, New York, was a "temporary hospital" in which "the original materials and workmanship were so inferior that a
52
constantly increasing expenditure was necessary to keep the buildings in repair." At Fort Wood in New York Harbor, the hospital`s drinking water supply was compromised by the location of the cistern in which it was collected less than three yards from another that received the discharge from the water closets. Furthermore, many of the numerous posts hastily established in the Reconstruction South had to adopt whatever shelter was available until suitable buildings could be built. In 1877, with Reconstruction at an end, the secretary of war ordered that no building be either constructed or occupied as a hospital without first obtaining the written opinion of the medical officer concerned.41
The surgeon general never stopped urging that medical officers be directly involved in the design of hospitals and the improvements made in them. Surgeon General Sutherland expressed himself as particularly pleased with the plans that had been used to build hospitals in 1887 and 1889. These facilities were heated "by steam" and ventilated "by aspiration," their walls were covered with an "asbestos finish," and the woodwork was unpainted. Sutherland termed the design "a complete aseptic building." By 1892 he was able to report that there were few complaints about hospital accommodations. A sign of the changing times was the debate that arose in the late 1880s about whether construction funds should be used to cover the cost of installing telephones.42
Although the Army no longer had any use for the huge general hospital that served the men of many regiments during the Civil War, the Army-Navy Hospital at Hot Springs, Arkansas, was a new type of general hospital, staffed by both Army and Navy medical officers. Opened in January 1887 to supplement the care offered by the network of post hospitals, it took in patients from all military services, both those on active duty and retirees, officers and enlisted, from all parts of the country. Among the maximum of eighteen officers and sixty-four enlisted men treated there at any one time were patients suffering from diseases that were expected to respond to hot mineral waters, including rheumatism, gout, and neuralgia, as well as chronic diarrhea, skin diseases, alcoholism, and other chronic conditions resulting from malaria or syphilis. Surgeon General Moore hoped that the hospital would significantly reduce the number of disability discharges. After four years, Surgeon General Sutherland was pleased with what the new hospital`s hot mineral waters could do for its patients, especially for sufferers from rheumatism. Half of those sent to this facility because of "diseases of the nervous system" and "nervous depression, brought on by the great strain of our modern life with its increased mental activities," were also returned to duty. Among the total number restored to duty, however, "necessarily, in a certain proportion, there is a return of the disease."43
Above and Beyond Health Care
In the course of guarding the Army`s health during the years following the end of the Civil War, medical officers were swept up by forces well beyond the field of medicine that were shaping the nation`s history and the Army`s role in it. As Weigley wrote in his history of the U.S. Army, "These were the Army`s last years as the constabulary for pacifying Indians. . . . A restlessness of coming change was already present." Almost imperceptibly at first, the foundations were being laid for a new
53
Army, one in which the medical officer would be increasingly required to develop administrative skills.44 The nation itself was becoming more industrialized, and the labor upheavals that accompanied this change at times reached such a pitch that military intervention was needed, and physicians had to accompany Army units sent to the sites of violence or anticipated violence.
Neither disease nor injuries ever seriously threatened the troops called out to maintain the peace in the summer of 1877, when waves of labor disorder hit the East and Midwest. Nevertheless, surgeons from far distant posts had to be called in to support soldiers who, with little if any planning, were moved in small units from one place to another in response to violence and reports of violence. Although this type of threat was not limited to the East, eventually most of the soldiers in the Division of the Atlantic became involved in preserving order.45
For the Medical Department, this situation again exacerbated the shortage of surgeons. Any time a small garrison remained at a post when most of the men were sent to the areas of greatest unrest, two physicians instead of one were needed, one for the post and one for the men in the field. The surgeon general ordered that civilian doctors be hired to care for the men of posts whose surgeons were on detached duty, but only on a by-the-visit basis. Additional difficulties arose when, because of the rapidity and the lack of preparation that characterized these troop movements, surgeons found themselves short of supplies. One serving in West Virginia was forced to plead vigorously by telegraph for replacements for medicines and instruments that were apparently lost in transit, either from his post or from the New York supply depot. Fortunately, the acute stage of the situation lasted only a few weeks, and troops were soon on their way back to their regular posts.46
With labor violence contained and with the dwindling of the Indian threat,47 time was available to consider and prepare for the role the Army would play in the future should the United States become involved in a major war. The increasingly intricate administrative duties that would be assumed by medical officers trying to meet the needs of an army functioning in ever larger units dictated a greater emphasis on education and training at all levels. The involvement of medical officers in this effort was initially somewhat sporadic, but it grew in magnitude and scope as both medicine and the organization of the Medical Department became more complex.
One early teaching responsibility lasted only three years. In 1886 surgeons at posts whose garrisons demonstrated an interest in first aid were ordered to conduct informal classes for officers and enlisted men. They were to lecture on "practical treatment of the unhidden diseases, early aid to the injured, the most expeditious and proper manner of treating temporarily gunshot wounds, poisoned wounds, frostbite, bruises, dislocations, hemorrhage, and fractures of bones; applications of the tourniquet, the most approved method for resuscitation from drowning and other kindred subjects."48
Although this order setting up these classes was rescinded in June 1889, the involvement of post surgeons in training continued. Many found themselves responsible for training unenthusiastic litter-bearers and, after 1887, Hospital Corps members in first aid as well as in the other aspects of their duties; they were particularly encouraged to use marches to famil-
54
iarize hospital corpsmen with their responsibilities. Field operations were established at camps of instruction to train large numbers of men, which was not possible at individual posts, and details from the Medical Department joined them. The trainees learned how to set up dressing stations and field hospitals,49 as well as how to move "dummy wounded" back through the chain of evacuation much as had been done during the days of Jonathan Letterman and his ambulance corps in the Civil War. Emphasizing the experimental nature of these training operations to its surgeons, the department urged participants to make suggestions for improvement.50
Experience brought several weaknesses to light. Ambulances proved to be fragile and their equipment inadequate. Additional problems resulted from the fact that, as in the past, commanding officers did not assign their ablest men to help the wounded. Moreover, those detailed as litter-bearers often ignored the required training drills. One surgeon reported that "the personnel is not select, the service is unattractive, and the training inadequate." The work of the hospital corpsmen, on the other hand, proved more encouraging. "All duties were performed by the Hospital Corps cheerfully and in a satisfactory manner," reported an assistant surgeon with troops from Fort Niobrara, Nebraska. Because these camps were often unable to provide the hospital corpsmen with the horses they needed for maximum mobility, the "opportunity for instruction and practice" was limited, but it was nevertheless of "benefit to the service."51
Training varied from group to group under this system, and little uniformity was achieved. To help standardize procedures, Surgeon General Moore encouraged his officers to work on training manuals. In time several of good quality were developed. For example, with the aid of a board of medical officers and the advice of other experienced Army physicians, a provisional manual for training hospital corpsmen was revised and published in 1891 as the Drill Manual for the Hospital Corps. Also, the volume Notes on Military Hygiene, based on lectures that Woodhull, by then a major, gave to line officers studying at Fort Leavenworth beginning in 1886, was recommended for use in new courses being taught line officers at Fort Leavenworth, West Point, and Fort Monroe. Surgeon General Sutherland urged that companies of instruction be created for hospital corpsmen at a few posts so that medical officers could train large numbers together. This approach, he believed, would also simplify the problem of enlisting civilians directly into the Hospital Corps who might already have received education as druggists or cooks but who still needed military training.52
In 1891, to try out his idea, Sutherland began organizing three companies of instruction. He had those training west of the Mississippi spend six months at either Fort Riley in Kansas, Fort D. A. Russell in Wyoming, or Fort Keogh in Montana. Three or more medical officers, three hospital stewards, four acting hospital stewards, a bugler, an artificer, a tailor, and forty or more privates were to form each company. At the time of the surgeon general`s retirement in May 1893 these schools were still being run on an experimental basis, but the general testimony was to the superiority "of the schools-instructed men . . . , and no one who has seen the work of the companies as units can question the certain superiority of bodies of men so trained over any organization locally gathered and individually instructed."53
55
Medical Department officers were also requested to help in training the physicians serving with the National Guard, whose supporters were growing because of the labor unrest of 1877. The relationship of the state-controlled Guard to the Regular Army was characterized by misgivings on both sides, but because Guard units would have to work closely with regulars in the event of war, wisdom dictated that the Guard`s "organization and methods [be] based upon or assimilated with those of the regular troops." During their tenure as surgeon general, both Moore and Sutherland expressed significant reservations about the custom of having National Guard surgeons appointed by their colonels without the benefit of an examination for professional competence. Yet when the surgeon general of the Michigan National Guard urged the creation of a state examining board, Sutherland refused to allow Regular Army surgeons to serve on it, lest they be drawn into acrimonious disputes.54
Nevertheless, the Medical Department did, upon request, detail medical officers for duty at National Guard encampments to advise Guard doctors how best to maintain the health of their troops, to handle their administrative responsibilities, and to assist in training nonprofessional medical personnel. One Regular Army physician, not particularly impressed by what he saw, noted that the National Guard surgeons seemed to regard "the annual encampment in the light of a picnic, an `outing,` which offers them relaxation from work, and which should be spent in frolic and festivity." Some camps were almost luxurious, equipped with electricity and city water and supplied with fresh fish and fresh vegetables and fruits, as well as eggs, butter, and milk, even though their latrines might be "neglected and offensive." Familiar with neither the importance of discipline and sanitation nor the everyday routines of the Medical Department, the average National Guard physician was unable to advise his commanding officer on sanitary matters, to train stretcher-bearers and attendants, or to deal with reports, supplies, and other administrative requirements. Thus Surgeon General Sutherland welcomed enthusiastically the formation of the Association of Military Surgeons of the National Guard of the United States.55 From the outset it was an important vehicle for the education of the National Guard`s medical staff, and, through its journal, for the education of all military surgeons. The surgeon general assigned some of his most experienced medical officers to attend the association`s meetings.56
Sutherland also criticized Guard units because of their lack of a permanently organized hospital corps to evacuate and care for the sick and wounded. Even though National Guard corpsmen were merely detailed to their duties from the line, some took to their responsibilities with enthusiasm. In 1889 Regular Army Capt. Louis Brechemin complimented Illinois Guard corpsmen upon their unfailing "zeal and intelligence in learning the drill" and the "promptness and faithfulness" with which they "attended to their other duties," praise that another medical officer echoed in 1892 in describing the men of Michigan units. Despite earnest efforts, Medical Department officers were only beginning to impress both medical and line officers in the National Guard with the necessity for close attention to sanitation and hygiene and to familiarize them with the routines of the Regular Army.57
Off-duty Pursuits
Since military posts were usually small, the surgeon was responsible for the care of
56
only a few men, and the necessity for examining occasional local pension applicants added little to the demands made upon him. What he did in his off-duty hours was largely his personal choice. He might turn to private practice, to the study of the fauna and the flora of the area around his post, or to other scientific pursuits.
Surgeon General Barnes believed that caring for local citizens enabled his medical officers to provide better care to their soldier patients, "by reason of the experience gained by becoming familiar with the diseases prevalent in the locality." The tradition of private practice was thus encouraged for many years, as long as care of private patients did not cause the medical officer to neglect his Army duties. The War Department, too, apparently supported this approach, but civilian physicians, resenting competition from military physicians, occasionally protested that Army medical officers often treated even well-to-do patients without charge and sometimes supplied them with the Army`s medicines. In 1877 members of the Medical Association of the District of Columbia complained about Colonel Baxter, then serving in Washington as chief medical purveyor. They alleged that he deliberately, and with some success, tried to lure female patients away from the city`s physicians and that he used the opportunity to care for prominent politicians as a means of furthering his own career. They charged that President Grant had benefited both from the free services of medical officers and from medicine provided by the Army. The extent to which the medical officer in the field was obliged to care for the civilians at his post, most often quartermaster employees and officers` families and servants, had never been entirely clear, but in 1884 the Army stated specifically that both regular and contract surgeons must care for the families of officers and enlisted men without pay as part of their normal duties whenever "practicable." This move deprived medical officers of a previously available source of added income, but since they had traditionally cared for families as part of their private practices, it could not have added to the demands made upon their time. As Army posts diminished in number and grew in size, significant amounts of spare time were not as easily found, and in 1892 Surgeon General Sutherland concluded that a private practice interfered "materially with the performance of public duties" and ordered the time-honored custom abandoned.58
Having devoted his off-duty hours as a young medical officer to research, Billings was convinced that a post surgeon should always have some type of research project available to work on as time permitted, "for
57
his own mental health and pleasure." Army surgeons continued to use their spare time to increase their knowledge of natural history, just as they had before the Civil War. The surgeon general officially ordered Capt. Elliott Coues, who would become a widely respected naturalist, to work at the Smithsonian Institution classifying specimens he had collected while serving beyond the Mississippi. In 1881, concluding that he could not serve in the Medical Department and devote the time he wished to his work as a naturalist, Coues left the Army. Medical officers unwilling to give up their careers might be forced to sacrifice their work in natural science. Although the official responsibilities of the medical officer became increasingly demanding and complex and his time for other pursuits was diminishing, within the limitations that their careers in the Army permitted, a few always found time to pursue their interests in sciences other than medicine.59
The decades between the end of the Civil War and 1893 were, because of the impending revolution in medicine, the last in which the Medical Department officer would be forced to wage war against disease with few weapons other than smallpox vaccine, the traditional devotion to cleanliness, and common sense. They were the last when he would be routinely required to work in relative isolation, unable to obtain the prompt advice of his peers whenever he needed it and to obtain supplies rapidly whenever he needed them. They were also the last when the Army would have to fight the Indian.60
NOTES
1. Quotation from John H. Franklin, Reconstruction, p. 120; War Department, Surgeon General`s Office, Manual for the Medical Department, 1906, pp. 209-12; Jack D. Foner, The United States Soldier Between Two Wars, p. 15; John Shaw Billings, "Progress of Medicine in the Nineteenth Century," in Smithsonian Institution Report for 1900, p. 637; Edward M. Coffman, The Old Army, pp. 246, 251-52; War Department, [Annual] Report of the Secretary of War, 1878, 1:102; James A. Huston, The Sinews of War, p. 256.
2. The number, boundaries, and names of the geographic, or territorial, divisions and the departments and districts into which they were divided and subdivided changed from time to time. See AGO GO 125, 17 Nov 1874. In Chapter 9 of his volume The Sanitarians, John Duffy provides a detailed discussion of changes in public health in the United States after the Civil War.
3. Austin Flint, Clinical Medicine, p. 751; Martin Kaufman, "The American Anti-vaccinationists and Their Arguments," pp. 464, 467-68; War Department, Surgeon General`s Office, Medical and Surgical History of the War of the Rebellion, 1-3:624, 627; War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1886, p. 9 (hereafter cited as WD, ARofSG, date); John McL. Keating, A History of Yellow Fever, pp. 103-04; Wilson G. Smillie, Preventive Medicine and Public Health, p. 8; Ltr, Crane to Post Surg, Fort Craig, N. Mex., 9 Feb 1869, Entry 2, and Rpt, Samuel Jessop, 15 Jan 1869, Entry 51, Charleston, Record Group (RG) 112, National Archives and Records Administration (NARA), Washington, D.C.
4. WD, ARofSG, 1874, pp. 5-7.
5. Quotation from Dorland`s Illustrated Medical Dictionary, 24th ed., s.v., "disease, filth d."; WD, ARofSG, 1868, pp. 3-4, 1869, pp. 6-7, and 1870, pp. 4-5; Coffman, Old Army, p. 328.
6. WD, ARofSG, 1869, p. 4, and 1874, p. 12; Ltrs, Crane to E. Thomas, and to W. F. Cornick, both 14 Nov 1867, and J. S. Billings to S. W. Butler, 14 Jan 1868, Entry 2, RG 112, NARA; George M. Sternberg, "An Inquiry Into the Modus Operandi of the Yellow Fever Poison," pp. 22-23; idem, "A Study of the Natural History of Yellow Fever and Some Remarks Upon the Treatment . . . ," p. 639; Keating, Yellow Fever, pp. 15, 17.
7. WD, ARofSG, 1874, pp. 10-12, 1875, pp. 6-7, 1876, pp. 7-9, and 1878, pp. 6-7.
8. The founders of the National Board of Health were, for the most part, those who had created the American Public Health Association seven years earlier. The board lasted only three years, being "doomed to failure almost from the start," according to one medical historian, in part because "the country as a whole was not yet ready for a nationwide health promotion service." Quotation from Smillie, Public Health, p. 18.
9. Ibid., pp. 18, 21, 576; Ralph C. Williams, The United States Public Health Service, 1798-1950, pp. 76-79, 165; Martha L. Sternberg, George Miller Sternberg, p. 274; James M. Phalen, Chiefs of the Medical Department, United States Army, 1775-1940, pp. 71-72; William B. Bean, Walter Reed, p. 73.
10. First quotation from Wesley W. Spink, Infectious Diseases, p. 165; remaining quotations from Charles E. Rosenberg, The Cholera Years (1987), pp. 196-97; Lloyd G. Stevenson, "Science Down the Drain," p. 10; Wyndham D. Miles, A History of the National Library of Medicine, p. 33; War Department, Surgeon General`s Office, Report on Epidemic Cholera in the Army of the United States During the Year 1866, p. 22 (hereafter cited as WD, SGO, Epidemic Cholera, 1866). The first epidemic, in 1832, precipitated more terror in the United States than subsequent pandemics, presumably because cholera had never been encountered before in this country. See Mary C. Gillett, The Army Medical Department, 1818-1865, pp. 11-13.
11. First quotation from John Shaw Billings, A Report on the Hygiene of the United States Army. . . , p. 18; second quotation from WD, SGO, Epidemic Cholera, 1866, p. 35; ibid., pp. vi, xiv-xv, xviii; WD, ARofSG, 1866, p. 5, and 1867, pp. 3-4.
12. WD, SGO, Epidemic Cholera, 1866, p. 26.
13. First four quotations from War Department, Surgeon General`s Office, The Cholera Epidemic of 1873 in the United States, p. 492 (see also pp. 471-72); remaining quotations from idem, Epidemic Cholera, 1866, pp. xvii and 61 (see also pp. xiv-xvi); idem, Report on Epidemic Cholera and Yellow Fever
59
in the Army of the United States, p. 35; WD, ARofSG, 1866, p. 4.
14. Quotations from WD, SGO, Epidemic Cholera, 1866, pp. 25, 27 (see also pp. 23, 29, 37, 64); idem, Cholera Epidemic of 1873, p. 479; SGO Cir 5, 20 Apr 1867.
15. John S. Chambers, The Conquest of Cholera, pp. 335-36, 351; WD, SGO, Cholera Epidemic of 1873, p. 476; idem, Epidemic Cholera, 1866, pp. 26, 62-63; WD, ARofSG, 1874, p. 19; William G. Rothstein, American Physicians in the Nineteenth Century, pp. 265-66; Duffy, Sanitarians, pp. 193-94.
16. Foner, United States Soldier, pp. 8-9, 17-19; Edward J. Forster, A Manual for Medical Officers of the Militia of the United States, pp. 12, 68; Coffman, Old Army, pp. 385-86; WD, ARofSG, 1887, pp. 73-74, 83, 1890, p. 77, and 1892, pp. 87-88.
17. WD, ARofSG, 1885, pp. 37-38, 1888, pp. 120-26, 1889, pp. 81-82, 1890, pp. 81-86, 1891, pp. 61-63, and 1892, pp. 70-84; Duffy, Sanitarians, pp. 201-02; in RG 112, NARA: Ltrs, SGO to Charles E. Goddard, 23 May 1884, D. L. Huntington to Goddard, 9 Oct 1884, and to Ely McClellan, 22 Dec 1884 (quotations), and Charles R. Greenleaf to George E. Pond, 8 Feb 1888, and to John van R. Hoff, 19 Mar 1888, all Entry 2, and Ltrs, Greenleaf to W. M. Mew, 24 Jan 1890, and to SG, 17 Feb 1890, and [Mew?] to SG, 1 Apr 1891, plus Memo, SG, 3 Jul 1890, all Entry 22.
18. WD, ARofSG, 1886, p. 78, 1889, pp. 55-57, 59, 87, and 1890, pp. 57-69.
19. Ibid., 1889, pp. 56, 59; quotations from pp. 61-62, except last, from p. 82.
20. Ibid., 1886, p. 80; quotations from pp. 77, 81, 82-83.
21. Ibid., 1889, p. 55 (first quotation), 57-58, 1890, p. 58, and 1891, p. 56 (second quotation).
22. Quotation from Billings, Report on Hygiene, p. xvii; Coffman, Old Army, pp. 329-31.
23. Quotations from Billings, Report on Hygiene, pp. xxxii, xxvii, xxx; ibid., pp. xxxviii-xxxix; Ltr, E. P. Morang to SG, 5 Sep 1865, vol. 10, Entry 10, RG 112, NARA; Don Rickey, Jr., Forty Miles a Day on Beans and Hay; Darlis A. Miller, Soldiers and Settlers, pp. 42-44.
24. Billings, Report on Hygiene, p. xxx; WD, ARofSG, 1885, p. 52, 1889, pp. 71, 74, 1891, p. 4, and 1892, p. 84; Ltrs, D. L. Huntington to Zilla M. Pavy, 7 Dec 1885, and J. H. Baxter to R. H. Firth, 24 Sep 1886, Entry 2, RG 112, NARA; Erna Risch, Quartermaster Support of the Army, p. 507; Huston, Sinews, p. 268.
25. Billings, Report on Hygiene, pp. xxix (first quotation), xxx, xxxiii (second quotation), xxxiv-xxxvi.
26. First quotation from ibid., p. xl; remaining quotations from WD, ARofSG, 1889, p. 79 (see also pp. 76-77, 81, 81n3).
27. First and second quotations from Billings, Report on Hygiene, pp. x, 52 (see also p. 107); third quotation from idem, A Report on Barracks and Hospitals . . . , p. xvii; Risch, Quartermaster Support, pp. 488-89.
28. Quotations from Alfred Alexander Woodhull, A Medical Report Upon the Uniform and Clothing of the Soldiers of the U.S. Army, pp. 1, 16, 19, 18 (see also pp. 5-9, 24-25); Foner, United States Soldier, p. 86.
29. Quotations from Woodhull, Medical Report, pp. 10, 11; WD, ARofSG, 1889, p. 68n.
30. Quotation from Charles E. Woodruff, "Military Medical Problems," p. 235; ibid., p. 236; WD, ARofSG, 1887, pp. 74, 78-80, 1888, p. 102, 1889, p. 68, 1890, p. 76, and 1891, pp. 68-69; AGO GO 80, 17 Oct 1888; Alfred Alexander Woodhull, Notes on Military Hygiene for Officers of the Line, 1899, p. 24; in RG 112, NARA: Ltr, C. R. Greenleaf to Post Surg, Fort Huachuca, Ariz., 22 Jun 1888, Entry 2, and Ltr W. C. Gorgas to Post Adj, 31 Mar 1889, Entry 22.
31. WD, ARofSG, 1889, pp. 63 (quotation), 67-68.
32. Ibid., 1887, pp. 64-65, 1889, p. 90 (third quotation), 1890, pp. 78 (fourth quotation), 79; 1891, pp. 69-70; 1892, p. 91 (first two quotations); Rickey, Beans and Hay, p. 159.
33. Chambers, Cholera, pp. 351-52; WD, ARofSG, 1866, p. 5, 1867, pp. 3-4, 1868, pp. 3-4, 1869, pp.6-7,1870, pp.4-5, 1885, p.7, 1886, pp. 8-9, 1887, p. 104 (quotation), and 1891, p. 17; Ltrs, Joseph C. Brown to Med Dir, Dept of Texas, 20 Feb 1890 (and those for March-May on influenza), Moore to E. Leyden, 17 Jun 1890, J. O. Kennedy to "Our Dear Protector," 16 Mar 1891, and Arnold to Asst AG, 25 Jan 1892, Entry 22, RG 112, NARA; Coffman, Old Army, p. 390; Billings, Report on Hygiene, pp. vii-viii; Edgar Erskine Hume, Victories of Army Medicine, p. 187.
34. WD, ARofSG, 1870, pp. 4-5, 1876, pp. 6-7, 1884, pp. 20-21, 1885, pp. 47-48, 58-59, 1886, p. 26, and 1887, p. 65.
35. Erwin H. Ackerknecht, A Short History of Medicine, p. 177; Rothstein, American Physicians, p. 193; WD, ARofSG, 1886, p. 28; "Miscellany-The Danger of Chloroform and the Safety of Ether as an Anaesthetic," p. 223.
60
36. Robert S. Henry, The Armed Forces Institute of Pathology, pp. 68-69 (hereafter cited as AFIP); Charles G. Heyd, "The Evolution of Modern Surgery," p. 63; Daniel S. Lamb, "Record of the Post-mortem Examination of the Body of President J. A. Garfield . . . ," p. 585; Ms C66, Official Medical Bulletins Relating to the Health of the President, National Library of Medicine.
37. Quotation from R. Murray, "Necrology, Joseph Janvier Woodward," p. 280; Henry, AFIP, p. 81; "Obituary," p. 250; Charles E. Rosenberg, Trial of the Assassin Guiteau, pp. 239-40; Daniel S. Lamb, "Report of the Post-mortem Examination of the Body of Charles J. Guiteau," p. 43.
38. WD, ARofSG, 1884, p. 23, 1885, pp. 26 and 27-28 (quotation), and 1886, pp. 96-97; Ackerknecht, Short History, pp. 177-78; Rothstein, American Physicians, p. 258.
39. The Goodyear Rubber Company made the first pair of rubber gloves to be used in surgery on the order of Johns Hopkins surgeon William S. Halsted, who wished to protect the hands of the operating room scrub nurse who would soon become his wife. See Owen H. Wangensteen and Sarah D. Wangensteen, The Rise of Surgery From Empiric Craft to Scientific Discipline, p. 476; idem, "Lister, His Books and Evolvement of His Antiseptic Wound Practices," p. 124; SGO Cir, 1 May 1888, Entry 2, RG 112, NARA; Charles B. Ewing, "The Treatment of Wounds From the Aspect of Germ Infection," pp. 147-49; Rudolph Matas, "Surgical Operations Fifty Years Ago," pp. 52-53.
40. Billings, Report on Hygiene, p. 2; Ltr, SG to P. H. Sheridan, 31 Oct 1872, and Announcement, Charles H. Crane, 20 Mar 1876, Entry 2, RG 112, NARA; Foner, United States Soldier, p. 23; Fielding H. Garrison, John Shaw Billings, pp. 156-57; Risch, Quartermaster Support, p. 486.
41. Billings, Report on Hygiene, pp. lvii, 32 (quotations), 101; Rpt, S. Jessop, 15 Jan 1869, Entry 51, Charleston, RG 112, NARA; AGO GO 98, 20 Oct 1877.
42. WD, ARofSG, 1889, pp. 56-57, 1890, p. 12 (quotations), and 1892, p. 59; Ltrs, SG to William B. Allison, 18 Jun 1884, and C. R. Greenleaf to Post Surg, Willett`s Point, NY Harbor, 16 Aug 1887, to SG, 20 Sep 1887, and to C & P Tel Co., 1 Oct 1887, Entry 2, RG 112, NARA.
43. WD, ARofSG, 1887, p. 92, and 1891, p. 9 (quotations); AGO Cir, 20 Dec 1886; in RG 112, NARA: Ltrs, SG to A. A. Sulcer, 4 Sep 1883, and to Med Dirs, 3 Oct 1888, and C. R. Greenleaf to Charles Lilime, 26 Apr 1889, Entry 2, and Ltr, SG to AG, 5 Mar 1894, Entry 22.
44. Russell F.Weigley, History of the United States Army, pp. 265 (quotation), 292.
45. Telg, SG to J. M. Dickinson, 11 Aug 1877, Entry 34, RG 112, NARA. Unless otherwise indicated, material on the 1877 strikes is based on Jerry M. Cooper, The Army and Civil Disorder, pp. 43-66.
46. Ltrs, L. D. Maurice to SG, 23 Jul 1877, WD to Crane, 23 Jul 1877, and C. G. Sawatte [?] to SG, 3 Aug 1877, Entry 12; Ltr, SGO to Med Dir, Div of Atlantic, 7 Aug 1877, Entry 2; Telgs, SG to John M. Cuyler, 21 Jul 1877, and to S. M. Horton, 23 Jul 1877, J. H. Baxter to C. Sutherland, 23 Jul 1877, Cuyler to SG, 23 Jul 1877, E. McClellan to SG, 24 Jul 1877, and C. S. DeGraw to SG, 7 and 31 Aug 1877, Entry 34. All in RG 112, NARA.
47. See Chapter 4 for a discussion of the Medical Department`s role when the Army again became involved in social unrest in the 1890s.
48. AGO GO 86, 20 Nov 1886.
49. A general hospital was a facility that served more than one regiment, a field hospital a facility of whatever size set up in the field. The dressing station was the ambulance station or the clearing station.
50. WD, ARofSG, 1890, p. 44 (quotation), 1891, p. 40, and 1892, p. 17; AGO GO 56, 24 Jun 1889, and GO 3, 13 Jan 1891; in RG 112, NARA: Ltrs, D. L. Huntington to M. W. Wood, 3 Jul 1886, C. R. Greenleaf to J. E. Pilcher, 15 Mar 1887, and to Charles Page, 20 Mar 1888, and J. H. Baxter to Med Dirs, 23 Apr 1888, Entry 2, and Cir Ltr, Charles Page, 28 Aug 1888, and Ltr, Louis Brechemin to Med Dir, Dept of Platte, 15 Oct 1888, Entry 17.
51. First quotation from WD, ARofSG, 1890, p. 49 (see also pp. 50-55, and 1891, pp. 40-41); second quotation from Ltr, Timothy E. Willing [?] to Med Dir, Dept of Platte, 2 Dec 1888, and remaining quotations from Ltr, C. H. Alden to SG, 14 Aug 1889, both in Entry 17, RG 112, NARA. In loc. cit., see Ltrs, J. Meacham to Med Dir, Dept of Platte, 22 Sep 1888, and L. Brechemin to Med Dir, Dept of Platte, 15 Oct 1888; Rpt, William D. Dietz, 9 Oct 1889; and Note, [signature ?], 1889.
52. WD, ARofSG, 1891, p. 37; Alfred Alexander Woodhull, Notes on Military Hygiene for Officers of the Line, 1909, Note to 4th Edition; ibid., 1890; in RG 112, NARA: Ltrs, C. R. Greenleaf to Lewis Balch, 21 Jul 1888, and to C. S. Weizmann, 10 Jun 1887, Entry 2, and Ltr, Greenleaf to J. S. Billings, 12 Mar 1890, and 2d End, CRG, 6 Aug 1898, Entry 22, and Ltr, L. Brechemin to Med Dir, Dept of Platte, 15 Oct 1888, Entry 17.
61
53. Ltr, J. M. Schofield to SW, 31 Dec 1892, John McA. Schofield Papers, Manuscript Division, Library of Congress, Washington, D.C.; WD, ARofSG, 1891, p. 12, 1892, pp. 15-17, and 1893, p. 16 (quotation); John van R. Hoff, "Some Notes on Military Sanitary Organization," p. 79; Charles H. Alden, "Instruction of the Hospital or Ambulance Corps in the United States," p. 450.
54. Ltrs, C. M. Woodward to SG, 10 Nov 1891, and SG to AG, 8 Mar 1889 (quotation), and to Woodward, 14 Nov 1891, and Rpt, Louis Brechemin, 2 Dec 1889, Entry 17, RG 112, NARA; WD, ARofSG, 1890, p. 56, and 1892, p. 19; Charles R. Greenleaf, "The Necessity of a Properly Organized Hospital Corps in the National Guard," p. 496; Peter Karsten, "Armed Progressives," in The Military in America From the Colonial Era to the Present, pp. 252-53.
55. Although the membership was initially limited to National Guard physicians, it was soon opened to medical officers from all the military services.
56. WD, ARofSG, 1890, p. 55, 1891, p. 35 (quotations on pp. 34, 36), and 1892, pp. 19-22; Greenleaf, "Necessity," p. 493; idem, "The Medical Officer of the Summer Encampment," pp. 145-46; Alfred C. Girard, "The Sanitary Duties and Rights of Medical Officers as Affecting Their Relations With the Commanders of the Line," pp. 68-69; Hoff, "Some Notes," p. 79; Ltr, AGO to SG, 21 Mar 1889, and Rpts, Louis Brechemin, 2 Dec 1889, and William Owen, 18 Aug 1891, Entry 17, RG 112, NARA; Edgar Erskine Hume, The Golden Jubilee of the Association of Military Surgeons of the United States, p. 7.
57. Rpt, Louis Brechemin, 2 Dec 1889 (quotations), and Ltr, William Corbusier to SG, 21 Aug 1892, Entry 17, RG 112, NARA; WD, ARofSG, 1892, p. 19.
58. First quotation from Ltr, SG to W. J. Purnam, 5 May 1874, Entry 2, RG 112, NARA. In loc. cit., see also SG to H. J. McGaffigan, 8 Feb 1872, and to James B. Belford, 9 May 1884, and Crane to Med Dir, Dept of California, 28 Apr 1873, and to Med Dirs, 22 Oct 1879. Second quotation from Raphael P. Thian, Legislative History of the General Staff of the Army of the United States . . . , p. 433. Third quotation from SGO Cir, 11 May 1892, Entry 66, RG 112. See also WD, ARofSG, 1886, p. 7, and 1890, p. 57; AGO GO 55, 27 Jul 1883, GO 75, 23 Oct 1883, and GO 65, 9 Jul 1884 (p. 8); Samuel C. Busey Personal Reminiscences and Recollections, pp. 303-09; Phalen, Chiefs, p. 63; Sylvia D. Hoffert, "Childbearing on the Trans-Mississippi Frontier, 1830-1900," p. 279.
59. Quotation from John Shaw Billings, Selected Papers, p. 266; Paul R. Cutright and Michael J. Brodhead, Elliott Coues, pp. 91, 123, 139-40, 150, 200-201; Edgar Erskine Hume, Ornithologists of the United States Army Medical Corps, pp. xxiv-xxv, 1-6, 77, 546-47.
60. Miller, Soldiers and Settlers, p. 330.
