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Chapter One

american military medicine faces west

On June 13, 1900, Captain S. Chase de Krafft, m.d., a volunteer as-sistant surgeon with the American forces in the Philippines, reported
from his post at Balayan the death from ‘‘hemoglobinuric fever’’ of Private

Glenn V. Parke of the 28th Regiment. In January, Parke had fallen out of

a march ‘‘from physical exhaustion’’ and was sent to the hospital in Ma-

nila. When he rejoined his company a few months later he appeared to be

well but soon succumbed to ‘‘malarial fever intermittent.’’ On the long, hot

march to Balayan, Parke had fallen out again and was admitted to the post

hospital with an acute attack of diarrhea. After daily doses of quinine and

thrice-daily strychnine, the soldier soon returned to duty. But his malarial

fever recurred: back in hospital he was ‘‘seized with a severe attack of bili-

ous vomiting,’’ and later his urine was red and scanty. The bilious vomit-

ing, diarrhea, and fever persisted, along with pain over the liver; his entire

body was soon ‘‘saffron-colored.’’ His urine became darker and more con-

centrated. Within a few hours, the patient sank into delirium and then coma,

dying early in the morning. Parke had told the surgeon he was twenty-three

years old, though most suspected he was no more than twenty-one; in any

case, his body was quickly buried in the north side of the cemetery at Balayan.

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14 american military medicine faces west

De Krafft then turned his attention to ensuring the well-being of the re-

maining troops.∞

Tropical disease would take the lives of many U.S. soldiers during the

Philippine-American War. From General Wesley Merritt’s assault on Manila

on July 31, 1898, until the war gradually eased in 1900, more than six hun-

dred soldiers were killed or died from wounds received in battle, and another

seven hundred died of disease.≤ The record of Parke’s clinical course presents

in unusual detail an example of diagnosis and treatment in the medical corps

of the U.S. Army during the first year of the campaign. The army surgeon in

the field was still likely to attribute illness to exhaustion or reckless behavior

and to favor explanations that implied a mismatch between bodily constitu-

tion and circumstance. In his extensive case notes, de Krafft nowhere men-

tions germs, even though the microbial causes of diarrhea and malaria had

been established for many years. Parke’s feces were not cultured for bacteria;

his blood was not examined for the malaria parasite. Instead, the surgeon

carefully described the vitality and appearance of the patient, the strength of

his pulse, the qualities of his dejecta, and the hourly variations in body tem-

perature. The diagnosis was expressed not in terms of any causative organism

but as a type of fever, a bodily response not identified with any inciting agent.

In a tropical environment, in conditions that supposedly depleted white con-

stitutions, the surgeon turned naturally to stimulants—strychnine, quinine,

mustard plasters, and eggnog—to rally Parke’s resisting powers.≥ There was

no suggestion that a medication might attack directly a microbe or other

specific cause. The surgeon hoped to restore his patient’s balance and vitality

and thus combat the nonspecific challenges of overwork or feckless behavior

in trying foreign circumstances.

The surgeon’s meticulous attention to this individual case reveals more

than just the expediency and deftness required in clinical engagement under

such grueling conditions. It also indicates medical priorities in the U.S. mili-

tary at the outset of the war. In an elaborate epidemiological reconstruction of

the effects of the Philippine-American War on the local population, Ken de

Bevoise has estimated that the annual death rate in the archipelago, previ-

ously a high thirty per thousand, soared to more than sixty per thousand

between 1898 and 1902, and that more than seven hundred thousand Fili-

pinos died in the fighting or in concomitant epidemics of cholera, typhoid,

smallpox, tuberculosis, beriberi, and plague.∂ Displaced and destitute, some-

times crowded into reconcentration camps, ordinary Filipinos were especially

vulnerable to disease. Endemic infection, previously contained, flared into

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american military medicine faces west 15

epidemics; new diseases, some perhaps carried by invading troops, soon be-

came rife. But the spread of disease among local communities was not, in the

early stages of war at least, the main concern of the medical corps of an

attacking army.

The job of a military surgeon, recently codified in the U.S. Army, was

clearly delimited.∑ During battle, the care and evacuation of sick and wounded

soldiers would inevitably preoccupy the military surgeon; at other times, in

the respite from the demands of surgical treatment of acute cases, the surgeon

worked to ensure the sanitation of camps and the hygiene of troops. ‘‘A

military surgeon who believes he is appointed for the sole purpose of extract-

ing bullets and prescribing pills,’’ according to Captain Charles E. Woodruff,

m.d., was ‘‘a hundred years behind the times.’’∏ The medical officer was also a

sanitary inspector, responsible for the scrutiny of food, provision of adequate

clothing, ventilation of tents, disposal of wastes, and the general layout and

‘‘salubrity’’ of camps. In the past, according to Woodruff, the military sur-

geon might have restricted himself to preventing and eradicating ‘‘hospital

contagion’’—gangrene among the wounded and fever (usually typhus) among

long-term inmates—but now, in the ‘‘modern era,’’ he had a duty to provide

for the well-being of troops. Thus de Krafft, after hastening the disposal of

Parke’s body, had gone about trying to prevent other cases. ‘‘The army medical

officer,’’ noted a contemporary observer, ‘‘ceased to be primarily a general

practitioner in becoming the administrative officer of a sanitary bureau, with

certain clinical duties when accident or the failure of prevention placed the

individual soldier for special care in a hospital ward.’’π

In seeking to protect white soldiers, the military surgeon in the Philippine-

American War repeatedly assayed the nature of the territory and climate and

the character and behavior of troops and local inhabitants. Like medicine

more generally, army sanitary science was heedful of environment, social life,

and morality; always conservative, it tried to guard against any radical depar-

ture from the body’s accustomed locale and mode of existence. Alterations in

living conditions, in patterns of human contact, and in exposure to different

climates might exert a direct impact on the soldier’s body and temperament,

or they might imply some perilous modification of his microbial circum-

stances. For troops like Parke, going to the tropics to fight a war meant

encountering a peculiar new physical environment and exotic disease ecology.

The conditions would be incongruent with those that whites experienced

in most of the United States, and therefore potentially harmful in ways as

yet undetermined. To predict and stave off disease, the medical officer had

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16 american military medicine faces west

figure 1. U.S. troops on the road to Malalos, 1899 (rg 165-pw-81608, nara).

to understand the effect of an alteration in circumstances or habits on his

charges and learn how to mitigate or combat the pathological concomitants

of change and mobility. To stay healthy the soldier must either reassert his

previous pattern of life or establish a different means of coping with the novel

environment and deployment. Military medicine in the Philippines thus was

predicated on appraisal of territory, climate, and behavior; it sought con-

stantly to protect the vulnerable alien race from strange circumstances and

dangerous habits and to teach presumably transgressive soldiers how they

might inhabit a new place with propriety and in safety.

Most of the troops in the Philippines would describe themselves as white—

the term crops up repeatedly in letters and reports—so it is tempting to regard

military medicine, at least in part, as an effort to gauge white vulnerability

and to strengthen white masculinity in trying foreign circumstances.∫ Indeed,

it often proves difficult to extricate concerns about the character of whiteness

from fears of disease in the tropics. Would the white race degenerate and die

off in a climate unnatural to it? Would the discord of race and place produce a

deterioration of white physique and mentality that shaded into disease? Were

the tropics inimical to the white man? Such questions still puzzled medical

officers and soldiers alike. Most of the time, of course, military surgeons like

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american military medicine faces west 17

de Krafft were preoccupied with alleviating disease and treating injuries. But

sanitary duties ensured that medical officers would also strive to restructure

and secure the boundaries of white masculinity in the colonial tropics, to

determine how to preserve Anglo-Saxon virility and morality in a hostile

region, a place bristling with physical, microbial, and native foes. As so often

in the past century, the U.S. Army provided a model, an ideal space, for

working out political and social problems that also beset the unruly public

sphere—whether in the metropole or the colony. Thus the care and disciplin-

ing of white troops would come to serve as a test case for how to manage

white American colonial emissaries and later as a guide to how natives might

be reformed into self-disciplined ‘‘nationals.’’Ω In order to understand these

subsequent transfers and substitutions it is necessary to take a closer look at

the fighting white man and his tropical burden.

to the philippines

Admiral George Dewey’s victory over the Spanish fleet in Manila Bay on

May 1, 1898—one of the early engagements of the Spanish-American War—

signaled the entry of a new colonial power into Southeast Asia. President

William McKinley hurriedly arranged to send a military expedition, assembled

mostly in the western states, to take possession of the Philippines. But by the

time the U.S. Army arrived later in 1898, Spanish authority had collapsed, and

Emilio Aguinaldo’s rebel forces had taken control of most of the provinces.

The commander of the Spanish garrison in Manila surrendered to the expedi-

tionary forces, and so Filipino troops, spurned as allies, decided to entrench

themselves around the city. In the Treaty of Paris, signed on December 10,

1898, Spain disregarded Filipino nationalist aspirations and formally awarded

the United States sovereignty of the archipelago. During the next four years,

American forces engaged in a bitter and brutal campaign against the Philippine

insurrectos in order to secure the new possessions.∞≠ The logic of westward

expansion was to leave the United States with a Southeast Asian empire, one

that would last another forty or so years. In supplanting Spain, America thus

unexpectedly took its place in the region alongside the Dutch in the East Indies,

the British in Malaya and Hong Kong, and the French in Indochina. But for

U.S. colonialists, these older European imperial entanglements would more

commonly constitute object lessons than models worth emulating.

The troops had arrived in an archipelago of over seven thousand islands,

supporting a population of close to seven million people, most on the island

of Luzon. With a mean annual temperature of eighty degrees Fahrenheit, an

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18 american military medicine faces west

average humidity of 79 percent, and distinct wet and dry seasons, the climate

of Manila assuredly is tropical, however one might imagine that indefinite

quality. The rainy season lasts from June through November, after which the

weather can be quite pleasant, tempered by sea breezes. Although Manila’s

average temperature may be a little higher and its humidity a little less, it

seemed to many Americans that the weather there might be similar to condi-

tions prevailing in Rangoon, Bombay, and Calcutta.∞∞ It was in any case a

climate few Americans had experienced.

As Benedict Anderson has remarked, ‘‘Few countries give the observer a

deeper feeling of historical vertigo than the Philippines.’’∞≤ In the late six-

teenth century, the Spanish had occupied Luzon and made Manila their capi-

tal. After three hundred years of Spanish clerical colonialism, fewer than 10

percent of the local inhabitants were literate in Spanish, yet some of the

Catholic religious orders—the Jesuits and Dominicans especially—had sup-

ported pioneering natural history and astronomical research, and from the

seventeenth century had even sponsored universities in the archipelago. Thus

José Rizal, novelist, physician, and nationalist, in the 1880s reflected that ‘‘the

Jesuits, who are backward in Europe, viewed from here, represent Progress;

the Philippines owes to them their nascent education, and to them the Natural

Sciences, the soul of the nineteenth century.’’ Various religious orders had

established hospitals for the poor, and colleges for the small mestizo and

criollo elite. The San Francisco Corporation founded the San Lazaro Hospital

in 1578, initially for the poor in general but after 1631 reserved for the

increasing number of lepers. In Manila, the Hospital de San Juan de Dios, for

the care of poor Spaniards, opened in 1596; and the Hospital de San José was

established in Cavite in 1641. The University of Santo Tomás, which the

Dominicans founded in 1611, belatedly allowed the organization of faculties

of medicine and pharmacy in 1871. Scientific and medical journals soon

proliferated: the Boletín de medicina de Manila (1886), the Revista farma-

céutica de Filipinas (1893), the Crónicas de ciencias médicas (1895), and

others. Provincial medical officers, the médicos titulares, were first appointed

in 1876; and the Board of Health and Charity, equivalent to a public health

department, was established in 1883 and expanded in 1886. Sanitary condi-

tions in the capital were changing during this period. The government put

sewers underground in Manila during the 1850s; in 1884, the Carriedo wa-

terworks opened, giving the city the purest water in Southeast Asia.∞≥ The

central board of vaccination had been producing and distributing lymph since

1806; by 1898 there were 122 regular vaccinators—notoriously inept and

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american military medicine faces west 19

figure 2. Manila street scene, Binondo 1899 (rg 165-pw-35-9, nara).

lazy—passing the time in Manila and the major towns.∞∂ In 1887, the Spanish

colonial authorities set up the Laboratorio Municipal de Manila to examine

food, water, and clinical samples—but evidently it was rarely used.∞∑ None-

theless, it is clear that recognizably modern structures of public health and

medical care were taking shape in Manila and its immediate hinterland.

The 1870s had witnessed vast improvements in communication with Eu-

rope and an expansion of traffic between metropole and colony. From 1868,

vessels could use the Suez Canal, reducing the journey between Europe and

the Philippines from four months to one month by steamer. In 1880, cable

linked Manila more closely to Europe than ever before. Better connections

with Spain reduced the influence of foreign traders in Manila and encouraged

Spaniards to move to the islands. In 1810, there had been fewer than four

thousand peninsulares and Spanish mestizos in the archipelago, mostly clus-

tered in Manila (compared to several million indios throughout the archipel-

ago); in 1876, four thousand peninsulares and more than ten thousand mes-

tizos and criollos lived in the Philippines; by 1898 the numbers had swelled to

more than thirty-four thousand Spaniards, including six thousand govern-

ment officials, four thousand army and navy personnel, and seventeen hun-

dred clerics.∞∏

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20 american military medicine faces west

As they increasingly became committed to nationalism, science, anticleri-

calism, and political reform, a growing number of mestizos and criollos in the

archipelago began to call themselves Filipinos and to represent themselves as

ilustrados, or enlightened reformers.∞π In part, the progressive sentiment, ex-

pressed first in the Propaganda movement, derived from Spanish liberal and

secular agitation, which had culminated in the revolution of 1868—just as

the conservative reaction in Spain was echoed in the Philippines after the

1872 Cavite rebellion. But local factors also contributed. The school reforms

of 1863 had established a framework, still grossly inadequate, for a state

system of primary education. Improved commercial opportunities allowed

the expansion of the middle class; ambitious and progressive Filipinos began

sending their sons to France and Spain for higher education; talented local

candidates resented the peninsulares, who took most of the top government

posts; and more efficient communication helped to break down regional sepa-

ratism and conflict in the islands. Furthermore, racial distinctions became

especially marked toward the end of the century, and there emerged ‘‘a ten-

dency to thrust the native aristocracy into a secondary place, to compel them

to recognize ‘white superiority,’ to a degree not so noticeable in the earlier

years of Spanish rule.’’∞∫ Initially, local ambitions and resentments found

expression in moderate groups such as Rizal’s Liga Filipina. But in 1892,

Andrés Bonifacio organized the Katipunan, an anticlerical and anti-Spanish

brotherhood that in 1896 led an insurrection against Spanish control. The

friars attributed disaffection to ‘‘Franc-Masonería,’’ for them the epitome of

everything pernicious in modern life; and the Spanish army attempted to

suppress the rebellion, employing such brutality that even moderates turned

against Spanish rule.∞Ω But by the time Aguinaldo was able to declare the

Philippine Republic in 1899, the United States had claimed the archipelago.

José Rizal, the so-called First Filipino, was one of the leaders of the rising

generation of nationalists. From the Jesuits at the Ateneo de Manila Rizal had

received a solid grounding in the sciences, even if he subsequently argued that

Jesuit education had seemed progressive only because the rest of the Philip-

pines was mired in medievalism. But at Santo Tomás, studying science, he

found that the walls ‘‘were entirely bare; not a sketch, nor an engraving, nor

even a diagram of an instrument of physics.’’ A mysterious cabinet contained

some modern equipment, but the Dominicans made sure that Filipinos ad-

mired it from afar. The friars would point to this cabinet, according to Rizal,

to exonerate themselves and to claim that it was really ‘‘on account of the

apathy, laziness, limited capacity of the natives, or some other ethnological or

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american military medicine faces west 21

figure 3. Interior of the Spanish Bilibid Hospital. Courtesy of the Rockefeller Archive
Center.

supernatural cause [that] until now no Lavoisier, Secchi, nor Tyndall has

appeared, even in miniature, in this Malay-Filipino race!’’≤≠ (Still, it should be

recalled that nowhere else in Southeast Asia was education available at such

an advanced level.)≤∞ In 1882, Rizal traveled to Spain to study medicine, and

he later visited France and Germany. He was astonished and embarrassed by

the political and scientific backwardness of the imperial power. In Europe,

medicine, political activism, and the writing of his brilliantly sardonic novels

occupied most of his time, but after Rizal returned to the Philippines and was

confined at Dapitan, he also began collecting plants and animals and discov-

ered new species of shells.≤≤ During this period, Rizal engaged in a copious,

self-consciously enlightened correspondence with Ferdinand Blumentritt, the

Austrian ethnologist, and translated into Spanish many of his works on the

Philippines.≤≥ For Rizal, a commitment to science and reason informed patri-

otism, and patriotism implied a scientific orientation to the world. Unim-

pressed, the clerical-colonial authorities executed the First Filipino in 1896.

Rizal did not live to see the United States completing the work of Spain and

crushing the nationalist forces. The Philippine-American War would directly

and indirectly cause widespread sickness, injury, and suffering as well as

destroy much of the recently constructed apparatus of education and public

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22 american military medicine faces west

health in the archipelago. The nascent, weak public health system broke

down completely, the Filipino sick and wounded overwhelmed local hospi-

tals, vaccination ceased altogether, and colleges and universities either closed

or struggled to graduate students. Thus as Americans assumed control they

found little evidence of previous scientific and medical endeavor and felt

justified in representing the Spanish period as a time of unrelieved apathy,

ignorance, and superstition, in contrast to their own self-proclaimed moder-

nity, progressivism, and scientific zeal.

the army medical department

When John Shaw Billings addressed the graduating class of the Army Medical

School in 1903, he celebrated the great progress in military medicine he had

observed over the past fifty years. Billings recollected that the president of the

Army Medical Board who examined him in 1861 had been inclined to remi-

nisce along the same lines, praising the recent introduction of anesthesia and

the new operations for excision of joints. The examining surgeon in those

days had heard of the clinical thermometer and the hypodermic syringe but

doubted that either would prove useful. The young physician, soon to join the

Army of the Potomac, was asked to describe ‘‘laudable pus’’ and the best

means of securing healing by second intention. He was questioned on the

means of preventing malaria and typhoid fever among troops. ‘‘If I had re-

ferred to bacilli, hematozoa, flies and mosquitoes, as you would probably do,

I don’t think I should have passed.’’ Just as the symbol of the old military

surgeon was the scalpel, his new emblem ought to be the microscope. ‘‘Forty

years ago the microscope was mainly used by physicians as a plaything, a

source of occasional amusement,’’ Billings recalled. ‘‘Today the microscope is

one of our most important tools.’’≤∂ Although the bookish sanitarian was

perhaps overestimating the bacteriological grasp of most military surgeons

and ignoring the difficulties of using the new techniques in the field, it was

true that during the previous forty years the role of the army medical officer

had changed beyond recognition.

The intellectual and professional transformation of military medicine en-

compassed both its therapeutic and its prophylactic aspects. The new medical

officer combined clinical duties with administrative tasks designed to prevent

disease outbreaks, or at least to provide early warning of them. Of course, in

times of war it was still the care of the sick and wounded that took most of the

time and energy of the military surgeon. Since the Civil War, changes in the

combat zone and in medical technology had transformed the scope and char-

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american military medicine faces west 23

acter of these clinical duties. By the 1890s, antiseptic methods prevailed in

the operating room, primary union could be secured in gunshot wounds,

depressed skull fractures were operable, and wounds of the intestine, once

considered beyond surgical relief, on occasion were sutured in risky laparoto-

mies. The military surgeon was more confident and optimistic than ever be-

fore in his ability to intervene clinically. General George M. Sternberg, m.d.,

the surgeon general of the army and the president of the Association of Mili-

tary Surgeons, in 1895 observed that his colleagues, as a consequence of these

advances, would have ‘‘to devote much more time to individual cases than

was thought necessary during our last war.’’≤∑ The army needed more medical

staff, with better training, and it needed more ambulance officers and sanitary

assistants to take on the first-aid work. The trained surgeon could then move

from the firing line, where staunching hemorrhage was the most that could be

done, to the new field hospital, where he now might operate.≤∏

If all had gone well, by the time the wounded soldier arrived at a distant

field hospital, an elastic bandage (or, more likely, the old-fashioned tourni-

quet) would have been applied on the firing line to stop any hemorrhage, and

at the dressing stations bleeding vessels tied with ligatures of catgut or silk and

wounds plugged with gauze.≤π In the field hospital, the patient might receive

opium to relieve pain and to prevent the ‘‘depression of shock,’’ though some

medical officers preferred to administer alcohol by mouth, enema, or hypo-

dermic injection, on occasion combining it with nitroglycerine. At the hos-

pital, surgeons took special care to remove any foreign bodies, any contami-

nants, and they would enlarge the wound if necessary. ‘‘One speck of filth, one

shred of clothing, one strip of filthy integument left in ever so small a wound

will do more harm, more seriously endanger life, and much longer invalid the

patient, than a wound half a yard long in the soft parts, when it is kept

aseptic,’’ warned one military sugeon.≤∫ If the campaign had been long and

severe, with the soldiers hard-pressed and huddled together without bathing

facilities or changes of clothing, ‘‘they are quite apt to get into a horrible

condition of filth and the presumption will be in favor of every wound being

infected and apt to do badly.’’≤Ω In such conditions, conservative treatment

was often fatal, and any attempt at asepsis would be better than none.

Of course strict asepsis was usually impossible in the field. And even when

antiseptics were available, it was sometimes hard to find the large quantities

of pure water required to dilute them. ‘‘You can imagine our horror,’’ a

surgeon recalled, ‘‘to find ourselves in the midst of a dozen or two operations

with dirty, bloody hands and instruments, blood, vomited matter and other

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24 american military medicine faces west

filth strewn on the ground, and no water to clean up.’’≥≠ Nor was it easy to

keep boiling water clean on an open campfire: the smoke would rise and

spread dirt and soot on it. Operations in the open and even in tents would

quickly be covered in dust if the wind rose, often making even ‘‘the antiseptic

lotions look like mud.’’≥∞ The exigencies of battle left no time for microscopic

examinations or bacteriological cultures: the surgeon depended still on his

senses and acted in response to his disgust with obvious filth and foreign

matter. For surgeons, even those trained in microbiology, dirt simply implied

the presence of germs of infection. And on the firing line and in the field

hospital, dirt was everywhere.

Increasingly, between battles and skirmishes, the military surgeon per-

formed sanitary duties too. ‘‘The progress and popularization of sanitary

science were such that commanding officers did not dare to pass unnoticed

the suggestions of their medical officers,’’ noted a contemporary observer

(and an inveterate optimist).≥≤ The sanitary science of the military officer was

still, in practice, largely predicated on knowledge of the geographical land-

marks of disease, although empirical suspicions of unhealthiness could in

theory be tested bacteriologically. Most physicians at the end of the nine-

teenth century expected to find a specific microbial pathogen for each disease,

but these etiological agents, even the more cosmopolitan bacteria, might still

have a distinctive geographical distribution. Captain Edward L. Munson,

m.d., in his massive Theory and Practice of Military Hygiene, conceded that

mosquitoes might transmit malaria, but still he wondered if drinking water

from marshes or swamps would also give rise to the disease.≥≥ Professor

J. Lane Notter, an international expert on military hygiene, advised an au-

dience of medical officers that, while each disease is ‘‘due to a specific micro-

organism,’’ all diseases ‘‘like plants and animals, can only flourish within

certain geographical limits.’’≥∂ Qualities of soil, water, and climate gave some

pathogens sustenance and not others: the sanitary officer therefore continued

to monitor the situation and ventilation of the camp. For the moment, bac-

teriology might adjust or extend the preexisting framework of geographical

pathology; it would take another decade or more to dismantle the old concep-

tual edifice altogether.

Medical geographers during the nineteenth century had suggested a great

many landmarks to identify pathological agency. For most of the century

scholars had assumed that the environment might exert a direct noxious effect

on the human constitution, with the exact outcome depending ultimately on

hereditary and behavioral factors.≥∑ But since the 1870s, it seemed that in-

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american military medicine faces west 25

direct mechanisms—microbiological mediators of physical and social cir-

cumstances—would incite most diseases.≥∏ This presented a practical prob-

lem for the military surgeon in the field since conditions were not stable

enough for a detailed, painstaking search for microbial nuisances. Medical

officers rarely had easy access to a laboratory, and microscopes and culture

media were scarce; nor was there time to wait for bacteriological confirma-

tion of pathogenic organisms. In order to act expeditiously, the military physi-

cian often fell back on the old, timeworn geographical settings and correlates

of pathology.≥π

In practice, then, bacteriology had touched little more than the margins of

the military surgeon’s spatial imagination. Munson advised that the location

of the camp was ‘‘a matter of the greatest importance in maintaining the

health and efficiency of troops,’’ but this precept was rarely put to bacterio-

logical test. Thus Munson drew on commonplace empirical knowledge when

remarking that ‘‘newly ploughed ground should never be employed for camp-

ing purposes, although a site which has long been under cultivation is usually

healthful.’’ He generally recommended a pure, dry, sandy soil: ‘‘Exhalations

from damp ground are powerfully depressing to the vitality of the human

organism, and favor the occurrence of rheumatism and neuralgia as well as

the invasion of the system by infectious germs, certain of which best retain

their vitality and perpetuate their kind amid such environment.’’≥∫ More fas-

tidiously still, Colonel C. M. Woodward advised his fellow surgeons that the

ground for camp should be elevated, bordering on a rapidly running stream,

and away from any swamps. Every tent must be raised during the day to

permit free circulation of air. ‘‘Company quarters,’’ he advised, ‘‘should al-

ways be kept thoroughly policed and freed from all appearance of evil—that

is, all scraps of paper and refuse of any kind should not be allowed to collect

on or about quarters or in camp, for although they may not be positively

unsanitary in their presence, they look so.’’≥Ω Professor Notter urged medical

officers to avoid valleys so narrow that the air stagnates, ground immediately

above marshes, and fresh clearings. ‘‘Dampness of soil adds immeasurably to

camp diseases’’; but he argued that sandy soils also ‘‘act prejudiciously both

by not disinfecting these organic matters and by their drying power, so that

when clouds of sand are raised by the wind, these clouds carry particles of

organic matter.’’ Men should never be allowed to sleep below the level of the

ground, in excavated tents, ‘‘exposed to ground-air emanations.’’∂≠ The de-

caying of organic material in the soil suggested the presence of pathogenic

germs—but on few occasions were these suppositions tested.

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Colonel Dallas Bache, m.d., expected that ‘‘certain sanitary interrogato-

ries will be put to any important situation, and the replies carefully consid-

ered,’’ before a place was chosen for camp: ‘‘manifestly a very great range of

questions upon climate, soil, water, and waste disposal must be met.’’∂∞ Evi-

dence pointed, for instance, to a ‘‘malady of the wind’’—as of the sea—

requiring the hygienist to consider carefully the lay of the land and its ventila-

tion. The attributes of the soil, including its texture, temperature, and water

and mineral content, also had ‘‘well-established or highly probable relations

to health,’’ contributing to the origin or spread of many diseases.∂≤ ‘‘We can-

not afford to neglect the evidence,’’ Bache warned his colleagues in 1895,

‘‘that makes a close ally of the soil with malaria, and proclaims it the nursery

of neuralgia, catarrhs, rheumatism, and consumption; more constant and

insidious foes to the military community than the Indian.’’ He suggested that

the new science of bacteriology had simply indicated that the soil ‘‘offers itself

as a culture medium or refuge in general terms’’ for the agents of cholera,

typhoid fever, diarrhea, and dysentery.∂≥ These diseases might lurk in the

environment, ready to subvert the soldier’s health.

Conditions of military life also drew attention to the health threats of

overcrowding and the need for meticulous group discipline and personal

hygiene. Thus concern with the management of populations would often

accompany territorial appraisal on the march. Just as the new bacteriology

might be superimposed on old landmarks of geographical pathology, so too

might it give further pathological depth to old fears of bad behavior and

unregulated social contact. The danger of contracting venereal disease, espe-

cially from prostitutes of another race, was well recognized, but increasingly

it was suspected that even nonvenereal social contact with one’s peers might

prove risky.∂∂ Therefore the bodies and habits of soldiers, as much as the

territories they passed over, needed constant surveillance and care. It was

important, from the beginning, to ensure that recruits derived from sturdy

and reliable stock. Since the 1880s, all recruits went through a physical exam-

ination and a cursory assessment of mentality and character before enlist-

ment. The advantage of this procedure, according to Bache, was that it re-

jected ‘‘material that would swell the death and discharge rates.’’∂∑ ‘‘A man

who is incapable of sustaining the fatigue of a four-mile march,’’ noted Colo-

nel Herbert Burrill, m.d., ‘‘would be an incubus on the rapid movement of

troops.’’∂∏ Worse, he was also more susceptible to disease, whatever its cause,

and perhaps more likely to pass it on. Munson observed that ‘‘recruits must

be of trustworthy physique and sound constitution before the military char-

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american military medicine faces west 27

acter can be developed, and the physically, mentally and morally defective are

hence to be uniformly rejected as unfit for service.’’ The army would take

sober men from the ‘‘lower walks of life and the laboring classes’’ and train

their character and body.∂π Those resistant to military discipline must be

excluded. In his revision of Tripler’s Manual, Colonel Charles R. Green-

leaf, m.d., an assistant surgeon general of the army, insisted that no recruits

be drawn from the ‘‘vagrant and criminal classes.’’∂∫ Munson, too, advised

against admitting ‘‘men whose physical faults render them unfit for duty and

susceptible to disease, whose undetected affections may be transmitted to

others or whose moral obliquities induce malingering and desertion.’’∂Ω

Military surgeons knew from experience that physical training and disci-

pline could transform eligible raw material into good soldiers. As Munson

wrote, ‘‘Strength, activity, endurance and discipline, combined with sound

bodily health, are the first requisites of the soldier.’’ These qualities, he ar-

gued, were ‘‘the foundation upon which the whole structure of military effi-

ciency rests.’’ But mental and moral training must always accompany physical

development; otherwise the recruit would become just ‘‘sluggish muscle piled

on the back of a listless and indifferent mind and an irresolute and halting

will.’’ Instead, the ideal citizen-soldier should be ‘‘of manly character, willing,

brave, steadfast, zealous, enthusiastic, of good humor, and possessed of initia-

tive.’’ Munson wanted thus to make ‘‘the man in the ranks a part of an

intelligent machine to act at the voice of a commander.’’∑≠ This efficient per-

formance demanded an education in temperance and self-restraint. In accor-

dance with the emphasis on a simple mode of life, the soldier was advised

against dietary indiscretion and alcohol abuse. It was important more gener-

ally to regulate intake and excretion to achieve a balance of the bodily system.

The soldier’s clothing, for example, ought to ensure that he maintained a

stable temperature and evaded heatstroke, fatigue, and any diseases brought

on by chill. The army ration would deliver a balanced diet of protein, starch,

fat, and salts.∑∞

The well-trained soldier was expected to recognize and avoid sanitary

hazards, especially those related to disposal of excreta. Munson, throughout

his career in the army, and later as advisor to the Bureau of Health in the

Philippines, would warn of the dangers of promiscuous defecation, a failing

that at least seemed readily disciplined in white soldiers. Experience had

convinced him that ‘‘the care of latrines is a most important factor in the

preservation of the health of the command.’’ Indeed, ‘‘raw troops living like

savages in their disregard of sanitary principles, without moving camp as

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28 american military medicine faces west

often as do these savages, cannot fail to be scourged by epidemic disease as a

result of their ignorance and neglect.’’ Education and camp inspection were

unremitting; ‘‘camp police’’ would discipline those who refused to find the

distant latrines.∑≤ In the military service, the removal of excreta and the main-

tenance of personal cleanliness would normally receive more emphasis than

in white civilian life, in recognition of the special health risks of shared and

often crowded living conditions. The personal hygiene of soldiers in the line

was regulated as never before. Since the 1880s, far in advance of the British

army, all military posts in the United States had provided bathing facilities for

troops. Each American soldier was now required ‘‘to wash the face, head,

neck and feet once daily, cleanse the hands prior to each meal and bathe his

entire body at least as often as once in five days.’’ His personal cleanliness and

propriety had become ‘‘a constant object of solicitude on the part of his

superiors.’’∑≥

When epidemics broke out among troops, as they often did despite even

the best policing, the military hygienist set about to inquire into their history

and predisposing causes and then recommend measures of control. In the

1890s, the sanitary officer could draw on a large repertoire of interventions.

These included isolation of the diseased, prevention of crowding, purifying of

food and water, avoidance of unripe or decomposing vegetables, eradication

of ‘‘soil pollution,’’ whitewashing or burning of infected localities. destruc-

tion of infected articles. disinfection of privies, urinals, sinks, and drains,

checking of ventilating appliances, protection from dampness, the daily airing

of bedding, healthy amusements and exercise, prevention of intemperance

and promiscuity, and, in the case of smallpox, vaccination.∑∂ It was gradually

becoming more likely that the surgeon would seek to identify a microbial

cause of the epidemic and, if successful, attune his response accordingly. In the

summer of 1898, when typhoid, or camp fever, spread among the troops

assembling in the United States to fight the war with Spain, General Sternberg

appointed a board of investigation that included Major Walter Reed, m.d., to

show what could be done with new scientific techniques.∑∑ The board visited

all the large camps in the United States, studying the water supply, the quality

and quantity of food, the nature of the soil, the arrangement and size of tents,

the location of sinks, and the disposal of human waste. ‘‘Scientific investiga-

tions of the blood,’’ including application of the Widal test for the typhoid

organism, indicated that most of what had passed for ‘‘malarial fever of a

protracted variety’’ should have been diagnosed as typhoid. Frequently, the

presence of typhoid was deliberately hidden: ‘‘in one command the death-rate

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american military medicine faces west 29

from indigestion was put down as fifteen percent.’’∑∏ The board carefully

assessed the various proposed explanations for the epidemic. They concluded

it derived not from sending northern men into a southern climate or from the

locality or simply the massing of so many men in one place. Rather, the cause

was ‘‘camp pollution,’’ that is, the improper disposal of excreta. On hearing

of this conclusion, Sternberg recommended to the adjutant general that sub-

ordinates clean up the camps, discourage flies, and sterilize the excreta of

typhoid cases.∑π But by then the disease had mostly run its course.

At the end of the nineteenth century, an education in the principles of

modern hygiene was supposed to inform the military surgeon’s sanitary work.

When a candidate passed the medical department’s competitive examina-

tions, he had to attend a four-month (later eight-month) course at the Army

Medical School in Washington, D.C. Sternberg had established the school in

1893 to teach army regulations, customs of service, examination of recruits,

care and transportation of the wounded, and field hospital management.

Special emphasis was placed on military hygiene and sanitation and on ‘‘clini-

cal and biological microscopy, particularly as bearing on disinfection and

prevention of disease.’’∑∫ Billings taught military hygiene, Reed instructed

students in bacteriology, Major Charles Smart, m.d., was in charge of sani-

tary chemistry, and Professor C. W. Stiles lectured on parasites in man. Ac-

cording to Dr. Charles H. Alden, the school’s director, the courses provided

for ‘‘a study of Hygiene in all its various branches, of air and water and their

impurities, clothing, food, exercise, barrack and hospital construction, sewer-

age and drainage, sanitary chemistry and practical bacteriology.’’ Laboratory

work was a prominent feature of the course, supposedly ‘‘consuming most of

the students’ time.’’∑Ω

In 1898, at the beginning of a long tropical war in the Philippines, the army

medical service appeared to exercise more influence over the care of troops

than ever before. Even if the medical department’s grasp on bacteriology was

still weak at times, its organizational structure was stronger than ever. At the

outbreak of the Spanish-American War the department consisted of 177 com-

missioned officers and 750 enlisted men. A permanent sanitary organization

was attached to each regiment. For every 1,000 of strength, there were now

3 medical officers, 1 hospital steward, 2 acting hospital stewards, 1 nurse,

1 cook, and 3 orderlies; 2 company bearers were detailed for every 100 men

on the line. Each division, 10,000 men strong, was provided with a field

hospital, including 9 medical officers and 27 privates, members of the hospi-

tal corps, male nurses or ‘‘sanitary soldiers,’’ who cared for the sick and

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30 american military medicine faces west

wounded.∏≠ In the recent past, line and staff were inclined to scorn medical

officers for their attempts to ‘‘coddle’’ soldiers. But this attitude was changing.

The military surgeon possessed the authority accorded to his rank, the grow-

ing dignity of his profession, and now the freshly minted currency of lab-

oratory science. Woodruff found that he rarely needed to compel ordinary

soldiers ‘‘to get well,’’ for they would ‘‘readily submit to all reasonable restric-

tions and methods of treatment, and many unreasonable ones too.’’∏∞ The

military surgeon toward the end of the nineteenth century was gaining confi-

dence in his new expertise, grappling with bacteriology, and attempting to

incorporate novel pathogens into familiar patterns of environmental and so-

cial etiology. But his skills would be severely tested abroad, among the foreign

disease ecology of the tropics.

american military medicine in the tropics

The warfare around Manila at first was mostly of a continental type, with the

deployment of columns and the entrenchment of positions. The medical de-

partment was hard-pressed with the care of wounded and the establishment

of divisional or general hospitals, though some public health work did begin

soon after the occupation of Manila. During the first year of the war, the

medical service concentrated on surgery and devising an easily movable front

line, a more or less constant means of supply and evacuation, and well-

determined depots for the sick in the general hospitals. The volunteer sur-

geons and those from the National Guard generally proved unprepared for

war conditions. According to Lieutenant Colonel John van Rensselaer Hoff,

m.d., the leading administrative reformer in the sanitary bureau, there was,

among regimental medical officers and hospital stewards, ‘‘scarcely an officer

or man who possessed the slightest knowledge of medico-military matters.’’

Indeed, the medical department was ‘‘quite as much in need of training in the

theory of the special military work of the sanitary corps, as were the troops of

the line in their routine of ‘fours right and fours left.’ ’’∏≤ Lieutenant Colonel

Jefferson D. Griffiths, m.d., the medical director of the Missouri National

Guard, found his new circumstances particularly challenging. ‘‘As surgeons,’’

he recalled, ‘‘we thought we could amputate a limb. We were familiar with

laparotomies, and had an idea that we were fully competent to deal with the

necessities of the occasion. Many of us even thought we knew something

about the proper sanitation of camps, and disinfection.’’ But after a few weeks

in the military, ‘‘we found our ignorance was sublime.’’∏≥

Most of the surgeons streaming into military service found themselves in

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american military medicine faces west 31

figure 4. Square at Malalos, March 1899 (rg 165-pw-3h, nara).

Griffith’s predicament. In particular, the contract surgeons had no special

training in military hygiene and knew nothing of army administrative proce-

dures. So pressing was the need for surgeons that the rigorous physical and

professional examinations for entry into the medical department had been

suspended. Few volunteers possessed Henry F. Hoyt’s experience of frontier

medical practice and knowledge of modern hygiene. The ‘‘red-haired Indian-

fighter,’’ as he called himself, had set up a practice in New Mexico and tended

railway workers there, before becoming commissioner of health for St. Paul,

Minnesota, where he vaccinated widely and opened a bacteriology labora-

tory. Assigned as chief surgeon in the Second Division, Eighth Army Corps,

Hoyt arrived in Manila in December 1898. The general advance of the army

on Aguinaldo’s trenches around the city was his first experience under fire.

Wearing a white cork East India helmet, ‘‘being fearful of sunstroke in the

tropics under a campaign hat,’’ the medical officer gave first aid to the

wounded and then sent some back for ‘‘aseptic surgery.’’∏∂ Regulations called

for two men of the hospital corps to carry each litter, but Hoyt soon saw that

‘‘even six white men’’ could not manage it ‘‘in that hot, humid tropical cli-

mate,’’ and he recommended that ‘‘Chinese coolies’’ be substituted.∏∑ The

army continued to advance through ‘‘rough country and impenetrable

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32 american military medicine faces west

jungle,’’ all the while dodging brisk sniper fire, leaving transportation for the

wounded far in the rear. The retreating army had destroyed the bridges, and

ambulances could not cross the streams. Although the railway track was

quickly repaired, Aguinaldo had kept most of the rolling stock. But using ‘‘a

bunch of Igarote [sic] prisoners as motive power,’’ Hoyt was able to improvise

boxcars as ambulances for the wounded. When a fierce battle outside Malalos

left four Americans dead, thirty wounded, and eleven with ‘‘heat exhaus-

tion,’’ he even tried ferrying the casualties by canoe.∏∏

In May 1899, Hoyt established the first field hospital in the islands. He se-

lected five ‘‘commodious houses’’ and connected them with a bamboo porch,

an expedient that won praise from Senator Albert Beveridge when he visited.

Soon afterwards, an ambulance brought Simon Flexner and Lewellys Barker,

a pathologist and a physician from the Johns Hopkins University, keen to

study tropical disease. According to Hoyt, they were like most young Ameri-

can men, ‘‘wild to get a taste of real war at the front.’’∏π But they did not linger.

Hoyt himself had by then tasted rather too much of the Philippines. During

the advance from Malalos he was ‘‘seized with a severe attack of amebic

dysentery’’ and ‘‘fainted away.’’ Sent to the new convalescent hospital on

Corregidor Island, he grew worse and was ordered home. ‘‘The change and

sea air did wonders,’’ and, as he neared his homeland, he began to gain

strength.∏∫

Lieutenant Franklin M. Kemp, m.d., also remembered clearly his first time

under fire, as the army attacked Aguinaldo’s trenches. Kemp, like Hoyt an

experienced hygienist, had arrived in Manila in August 1898 and spent the

next few months in ‘‘the teaching of men to save their lives, or those of their

comrades when wounded.’’ During his daily drill and lecture, Kemp gave the

men practical instruction in minor surgery, first aid, and transportation of the

wounded. ‘‘They were taught to regard the first aid packet as their most

precious possession, after their rifle.’’∏Ω On the night of February 4, 1899, as

the American forces moved out of Manila, Kemp stationed the hospital corps

with litters along the Singalong Road and was soon busy dressing the

wounded who staggered out from the brushwood. As they retreated, Filipinos

kept up a ‘‘constant and severe cross-fire,’’ yet ‘‘the hospital corps men seemed

to be ubiquitous, going from one pit to another, across open spaces, appar-

ently bearing charmed lives.’’π≠

By April, when the army was advancing on Santa Cruz, Laguna, Kemp had

learned to put the hospital corps five or ten paces in the rear of each company,

with Chinese bearers a further hundred yards behind. The Chinese were

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american military medicine faces west 33

proving themselves better able to withstand the intense heat than American

litter-bearers, and with ‘‘the usual Oriental stoicism’’ they often worked ‘‘ap-

parently beyond the limits of human endurance.’’ They were under the charge

of a private in the hospital corps ‘‘who could swear volubly in Chinese and

was further assisted by a huge navy revolver and a big stick.’’π∞ For two weeks

the troops moved through country that had never carried wheeled transporta-

tion before: they were compelled to make roads, build bridges, and ford

rivers, with little to guide them. But Kemp and his corps were by then pre-

pared for such conditions: ‘‘My coolies would have the locality all cleaned up

before the train arrived, the carts containing the medical, the surgical and the

sterilizing chests coming next. In a few minutes the division field hospital

would be established and in thorough running order, rounds made, operating

table improvised and all dressings and operations performed. Ambulances

would be parked and cleaned and made ready for instant use.’’π≤

And before long, they would pack up and move on again. After crossing the

Pasig River, the troops endured the hardest day’s march that Kemp could re-

member. All day, under fire from the enemy, they trudged across rolling land,

‘‘destitute of water,’’ covered with ‘‘rank weeds and grass to one’s waist,’’

intersected with deep ravines, with absolutely no shade and a temperature of

110 degrees Fahrenheit. ‘‘Water gave out early in the morning,’’ Kemp wrote;

‘‘tongues were so swollen that one could not speak; men dropped down in

simple heat exhaustion or in convulsions, not one at a time, but in squads of

five or six.’’ Even in the seasoned 14th Infantry, almost 40 percent of the

complement succumbed that day.π≥ Kemp was kept busy in his improvised

hospital till late at night.

Lieutenant Colonel Henry Lippincott, m.d., the chief surgeon for the Divi-

sion of the Pacific and Eighth Army Corps, recalled that the wounded and sick

generally did well during the early stages of the Philippines campaign, and the

medical department performed its duties ‘‘cheerfully and efficiently.’’π∂ ‘‘Of

course we had excellent surgeons on the firing line’’—men like Hoyt and

Kemp—who ‘‘saw the wounded were well cared for before transportation,

whether by ambulance, rail, or water, to the First Reserve [Hospital], and the

men arrived in as good condition as could be expected.’’π∑ Lippincott had

converted the Spanish military hospital into the First Reserve Hospital in

August 1898, a few days after the fall of Manila. Erected just twelve years

earlier, the hospital accommodated between eight hundred and a thousand

patients. The wards seemed well constructed ‘‘and very large and roomy, but

the location [was] bad owing to the swampy surroundings.’’ Not surprisingly,

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34 american military medicine faces west

figure 5. Wounded arriving in Manila, c. 1899 (rg 200-pi-46a, nara).

the ‘‘sewer and closet arrangements, like everything of the kind in Manila,

were unsanitary,’’ but they were soon altered to resemble ‘‘the good features

of the hospitals in America.’’ Initially, all the sick and seriously wounded

came to this large hospital, but less than a month later Lippincott established

the Second Reserve in an abandoned convent, for the overflow from the First

Reserve. In November 1898, the Corregidor Hospital opened on a site that

Lippincott described as ‘‘a model spot for a large hospital.’’π∏ The environ-

mental conditions of the island seemed to revitalize most American soldiers:

the temperature was ten degrees below Manila’s, there was no malaria, shade

trees abounded, and the saltwater bathing was excellent.

Yet medical conditions were not as satisfactory as Lippincott implied.

Lieutenant Colonel Alfred A. Woodhull, m.d., Lippincott’s successor as chief

surgeon in Manila, reported that the two reserve hospitals were ‘‘swollen out

of all proportions,’’ and barracks had to be used for the overflow.ππ He was

disturbed above all by the condition of the First Reserve Hospital: ‘‘The

hospital grounds have been in a wretched state of police; the Hospital Corps

seems to have neither system nor order for its control; there is no dining room,

no proper facilities for the preparation of food or its distribution . . . the wards

that I have incidentally passed through have been dirty and in poor order,

they are horribly overcrowded and insufficiently manned.’’π∫ He had found a

‘‘large and foul bathroom and privy’’ next to the main kitchen; many of the

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american military medicine faces west 35

wards were ‘‘polluted with the remains of food.’’πΩ During the wet season, the

tent wards were awash with water, ‘‘literally an ankle deep.’’∫≠ Lieutenant

Conrad Lanza, confined to the hospital in June 1899, complained that the

army ration he received was ‘‘uneatable’’ and members of the hospital corps

were ‘‘habitually disrespectful and inattentive.’’∫∞ Nurse Mary E. Sloper al-

leged that the sputum of tuberculosis patients overflowed receptacles onto the

floor; and the two large jugs in the center of the ward, filled daily with fresh

drinking water, contained bugs and worms in the slime at the bottom. Ac-

cording to Nurse Sloper, patients slept in dirty linen, discarded by previous

inmates, and their bodies were never washed.∫≤ Conditions in hospitals out-

side Manila were scarcely better. The hospital at Corregidor remained under

canvas six months after its establishment. The field hospitals proved woefully

inadequate too. ‘‘There are innumerable regimental hospitals that in my judg-

ment are pernicious,’’ Woodhull lamented, ‘‘but which are authorized and

supported. These are rendezvous of idlers and malingerers made possible

merely because efficient medical officers, or in fact any at all, cannot be as-

signed to them.’’∫≥

Others echoed Woodhull’s complaints of inadequate medical staffing.

Hoyt repeatedly pointed out the deficiencies in personnel, ambulances, and

transportation at the front. He could count on only two surgeons on duty

with each regiment when, for ‘‘service in the tropics,’’ there should be at least

three. Kenneth Fleming, in the hospital corps, wrote to his ‘‘dear ones at

home’’ to tell them that ‘‘the Stuerd is sick and the Dr. is in Bunate and that

leaves me in a pretty tight place but their is nothing much to do hear but hold

sick call and I can atend to one company . . . I havent killed any body yet and I

don’t intend to do that.’’∫∂ Major General H. W. Lawton criticized the scarcity

of medical attendants in his division: ‘‘At present one surgeon is forced to

travel a line of mud and water . . . a distance of some four miles by road in

performance of his duties, and he is far from being well himself.’’ To send

someone to his assistance would leave another command entirely without

medical services.∫∑ In response to these and other complaints, Sternberg dis-

patched more contract surgeons and hospital corps. But soon after arriving,

many of them would fall ill. Of the medical officers ‘‘actually on duty in

Luzon, seven are disqualified on account of sickness,’’ Woodhull reported,

and many others had been ‘‘placed upon selected duty on account of their

health.’’ The chief surgeon found himself constantly shifting the remaining

healthy medical officers from one battalion to another. It was difficult to keep

up. Woodhull’s first knowledge of an expedition was often ‘‘an announce-

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36 american military medicine faces west

figure 6. U.S. Ambulance Corps, c. 1899 (rg 200-pi-11c, nara).

ment from [the regiment] that it was moving off with an inadequate medical

force.’’∫∏ Sternberg sent out even more contract surgeons, but within months

Woodhull was listing another twenty-five vacancies, each case a result of

‘‘sickness,’’ ‘‘gastro-enteritis,’’ ‘‘dysentery,’’ ‘‘repeatedly breaking down,’’ or

just ‘‘weakened health.’’∫π

The duties of those medical officers who remained fit were long and ar-

duous. During the wet season the roads they traveled became quagmires, and

on crossing the rice fields ‘‘not infrequently the officers are wet up to their

waists even when it is not raining.’’ The daily sick call often took several

hours when companies were scattered across many miles of defenses. ‘‘The

weather is always warm,’’ Woodhull reported, ‘‘and the atmosphere is gener-

ally humid, so that when the sun is unobstructed its direct rays are distress-

ing and it is always oppressive in the field.’’∫∫ Woodhull found many of his

contract surgeons lacking in aptitude and industry under these conditions.

Among them was a man who had worked well in the field but had ‘‘no more

judgment than to turn over sick call to his wife’’ and therefore marked him-

self as ‘‘certainly not the sort of person from whom the best service can be

obtained.’’ Indeed, Woodhull constantly expected ‘‘to hear of his breaking

down.’’ Another was ‘‘notoriously frail physically’’ and ‘‘exceedingly slow

and over-cautious.’’ Others appeared to be malingering or else just ‘‘dead

wood.’’ ‘‘It is very trying,’’ Woodhull wrote, ‘‘to be credited with such as these

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american military medicine faces west 37

figure 7. Operating station, c. 1899 (rg 165-pw-g, nara).

and expected to get good work out of them.’’∫Ω Most of the contract surgeons

were merely ‘‘young men of small personal experience,’’ and very few had

made ‘‘a special study of the diseases of this climate.’’Ω≠

the racial economy of the tropics

In January 1900, Lieutenant P. C. Fauntleroy, m.d., proudly described his

Second Division field hospital at Angeles, which then consisted of nine adjoin-

ing dwellings, all connected by bamboo and nipa covered ways. The water

from the well seemed pure enough, but even so Fauntleroy made sure it was

always filtered and boiled. The hospital bedding was regularly disinfected and

boiled to prevent the spread of tinea, measles, and other skin irritations.

Fauntleroy suspected that the origin of the many cases of malaria and intesti-

nal disease he encountered was ‘‘to be found in the constant exposure while

on the march and especially on outpost duty at night, to the prevailing condi-

tions natural to this section, and to the flooding of the land for agricultural

purposes,’’ which had made the ground damp. ‘‘Irregular and often hasty

eating of food’’ may have added to the level of morbidity.Ω∞ These environ-

mental and behavioral explanations did not mean that the medical officer

discounted germs as the causes of disease; it was just that germs seemed to

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38 american military medicine faces west

possess older geographical and moral correlates. In perplexing cases of fever,

Fauntleroy would look for malaria parasites in the blood, but generally he

could discern clear clinical signs—often a distinctive rash or fever pattern—

indicating a specific disease and excusing him from deploying the microscope.

Lippincott reported that most of the ‘‘diseases incidental to the tropics’’

could be encountered in the Philippines. Dysentery was always present; lep-

rosy was common, and enteric fever, or typhoid, ‘‘long ago became fastened

to the coast line.’’ The ‘‘inordinate activity of the skin’’ made severe ‘‘dermatic

affections’’ nearly universal among white soldiers. ‘‘Slight injuries often result

in long unhealed ulceration,’’ the chief surgeon noted, ‘‘and this is due to

excessive perspiration with its attending debility.’’Ω≤ Vaccination and revac-

cination of the troops against smallpox ‘‘of a type especially severe to the

white’’Ω≥ and endemic among Filipinos went on ‘‘as systematically as the drills

at a well-regulated post.’’Ω∂ ‘‘Malarial poisoning’’ was widespread, though

not nearly as malignant as first feared; all the same, many regiments, beset

with sporadic outbreaks, had required quinine prophylaxis. Not surprisingly,

the wet season was the harbinger of death and disease, since ‘‘the camps were

not only quagmires, but the soldiers were often drenched for days together.’’

The results of this miserable predicament were dysentery, persistent diarrhea,

rheumatism, enteric fever, and more malaria. During 1899, the worst year of

the campaign, 36 officers and 439 soldiers were killed or died from wounds

received in action, 8 officers and 131 soldiers died from ‘‘other forms of

violence,’’ and 16 officers and 693 men fell to disease, principally diarrhea

and dysentery, smallpox and typhoid. Additionally, more than 1,900 soldiers

were transferred back to the United States on account of sickness. The Ameri-

can army in the Philippines therefore lost through death, discharge, or trans-

fer almost 14 percent of the average mean strength present (which was a little

under 28,000 men). The sick rate—a more accurate measure of the incapacity

of an army—was of course much higher.Ω∑

Although it was now generally accepted that ‘‘climate cannot generate

fever no more than it can generate plants and animals,’’ most physicians and

their patients continued to believe that tropical conditions would reduce an

alien race’s general resistance to disease and present it with novel microbial

pathogens for which it was unprepared.Ω∏ Malaria had become prevalent

among white troops because ‘‘the depressing influence of the tropical climate

lessens the individual’s normal resisting powers and thereby prepares a favor-

able soil for the invasion of parasites.’’Ωπ Even familiar, cosmopolitan diseases

exerted a more deleterious effect in the devitalizing tropics. Smallpox ‘‘in this

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american military medicine faces west 39

latitude and longitude,’’ according to Hoyt, was ‘‘very fatal, especially to the

white man.’’Ω∫ The experience of Major Charles F. Mason, m.d., in treating

typhoid among American soldiers in the Philippines convinced him that ‘‘the

disease is more severe than in the temperate zone, and more fatal in its re-

sults.’’ΩΩ Sternberg warned, ‘‘The spread of diarrhea and dysentery is indi-

rectly promoted and their danger aggravated by the alternate heat and rains

of a tropical climate and by the lowering of vital powers consequent on heat

exhaustion.’’∞≠≠ Notter, too, had observed that ‘‘the mortality from enteric

fever in hot climates is always more than in temperate zones,’’ owing no

doubt to ‘‘the diminished resistant power of the individual.’’ The more potent

‘‘undermining factors’’ appeared to be youth and recent arrival in the foreign

environment. Yet he had also noticed how ‘‘prolonged residence in a hot cli-

mate doubtless deteriorates the system’’ and led to the diminution of Anglo-

Saxon ‘‘energy’’—though he hastened to assure his readers that ‘‘the influence

of ‘climate’ as a direct etiological factor of cholera or enteric fever . . . is

baseless in fact.’’∞≠∞

The encounters of military surgeons in the Philippines seemed to confirm

that the white race was likely to degenerate and sicken in the tropics. Accord-

ing to Greenleaf, ‘‘the principal medical feature’’ of the San Isidro campaign in

April 1899 was the ‘‘severe physical hardship’’ white troops endured: ‘‘The

very bullock trains had to be helped by hand, under intense heat and at-

mospheric humidity.’’ As a result, many soldiers succumbed to exhaustion,

and 530 of them, almost 15 percent of the command, were admitted to the

field hospital. Such incidents reinforced the conviction, held by physicians

and ordinary soldiers alike, that ‘‘the Anglo-Saxon cannot work hard physi-

cally in the tropics without suffering physical harm from the sun and cli-

mate.’’∞≠≤ This meant in practice that only Filipinos and Chinese should per-

form heavy manual labor, such as lugging ambulance litters. But what was

fighting a war if not a form of hard labor? Few medical officers doubted that

the typical white soldier, marching and fighting ‘‘under very exhausting con-

ditions of country and climate,’’ could not ‘‘endure the same amount of nerve

tension and physical strain that he can in a temperate zone.’’ ‘‘Recuperation

and convalescence in this climate are slow,’’ reflected Greenleaf, and ‘‘were an

epidemic of any character to occur among men in that condition, its effects

would probably be very disastrous.’’∞≠≥ In Mason’s opinion, ‘‘the great major-

ity of white men in the tropics suffer a gradual deterioration of health and

year by year become less and less fit for active service.’’∞≠∂ American so-

journers might watch as ‘‘the sun cast long fingers of light’’ through the

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40 american military medicine faces west

banana palms; they might gaze on ‘‘a blue sky, a gray beach, besprinkled with

beautifully tinted shells’’—but they were never allowed to forget the ‘‘gener-

ally accepted fact that [whites] cannot permanently adapt to the climatic

conditions of this zone.’’∞≠∑

The mental and moral qualities of the white race, finely attuned to a more

stimulating environment, seemed especially likely to jangle and twang in trop-

ical circumstances. The common enervation might on occasion slide into

serious mental disorder. In the opinion of Surgeon Joseph A. Guthrie, ‘‘The

Philippine sun seems to have a powerful influence upon the body, an over-

stimulating effect, like unto the surcharged x-ray, penetrating the skin along

the nerve fibers and exerting its influence upon the entire nervous system.’’∞≠∏

Munson, in contrast, was convinced that tropical service inevitably caused ‘‘a

depression of vital and nervous energy’’ and bred ‘‘nostalgia, ennui and dis-

content’’ among nonnative troops. Soon they became ‘‘wearied, fagged, and

unable to concentrate their ordinary amount of brain power on any one sub-

ject.’’∞≠π Episodes of the ‘‘depressing condition known as nostalgia,’’ brought

on by fighting far from home in a foreign climate, occurred regularly, espe-

cially among the less worldly rural recruits. ‘‘In individual cases of illness,’’

Greenleaf reported, ‘‘nostalgia became a complication that aggravated origi-

nal disease and could not be removed while the patient remained in the

islands.’’∞≠∫ ‘‘The sudden transfer to a foreign land,’’ recalled Major Louis

Mervin Maus, m.d., ‘‘separation from sweethearts, wives and family, the

constant influence of conversation regarding the horrors of tropical diseases

and climate, mental forebodings as to evil happenings, produced in a large

number of the men, unaccustomed to absence from home, nostalgia which

gradually merged into mental depression, apathy, loss of vitality, neuras-

thenia, melancholia and insanity.’’∞≠Ω Reeling between overstimulation and

depression, the common soldier was struggling to maintain his usual equable

temperament. At home, many came to believe the heat had driven men mad.

In February 1900, the Evening Star in Washington, D.C., warned that ‘‘dur-

ing the last three months nearly 250 demented soldiers have been sent across

the continent [to Washington] and it is said that 250 more will arrive soon

from Manila. In nearly all cases the men are violently insane.’’∞∞≠

In 1902, reviewing the lessons of recent tropical service, Munson con-

cluded that there was ‘‘ample proof that tropical heat and humidity produce

marked changes in body-function which exert an effect adverse to the health

and existence of all but the native-born.’’ Heat and humidity increased Euro-

pean body temperature and perspiration while reducing pulse rate, blood

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american military medicine faces west 41

pressure, and urine production. The number and function of ‘‘red blood

corpuscles’’ diminished in whites transplanted to the tropics. Therefore, even

if they avoided specific disease, ‘‘residence in hot climates, under circum-

stances of ordinary life, has an adverse effect on the white race.’’ Speaking

from experience, Munson could not doubt that ‘‘the Anglo-Saxon branch of

the Teutonic stock is severely handicapped by nature in the struggle to colo-

nize the tropics.’’∞∞∞ It mattered little whether Providence or evolutionary

mechanism had matched race to climate: whatever the explanation, whites in

the tropics were out of place, and degeneration and disease would be the

natural rewards of environmental transgression.

The apprehensions and anxieties of American medical officers were hardly

novel. Most medical authorities and social theorists in the nineteenth century

held that the boundaries within which an individual could stay healthy and

comfortable coincided with the region in which his race had long been situ-

ated. To venture beyond this natural realm in any circumstances seemed

hazardous; to go abroad and fight a war on treacherous ground was to court

disaster. For the past century, medical geographers had discussed whether

Europeans might adapt themselves, or acclimatize, to a tropical environment

—and the answer was still, even in the 1890s, unsettled. A general sense of

climatic anxiety and pessimism pervaded the medical and colonial literature.

Thus E. A. Birch, in Andrew Davidson’s Hygiene and Diseases of Warm

Climates, explained to his readers that a tropical climate would always be ‘‘in-

imical to the European constitution.’’ A continued high temperature seemed

to produce in the white body ‘‘an excessive cutaneous action, alternating

with internal congestions.’’ Although ‘‘the effort of nature is to accommodate

the constitution to the newly established physiological requirements,’’ there

would be an inherent racial limit to this functional adjustment.∞∞≤ It comes as

no surprise that the conventional concern about racial displacement was

applied to the Philippines. Benjamin Kidd, an English social Darwinist, be-

lieved that ‘‘the attempt to acclimatize the white man in the tropics must be

recognized as a blunder of the first magnitude. All experiments based on the

idea are foredoomed to failure.’’ On the eve of the U.S. Army’s invasion of the

Philippines, Kidd pointed out that ‘‘in climatic conditions that are a burden to

him, in the midst of races in a different and lower stage of development;

divorced from the influences that have produced him, from the moral and

political environment from which he sprang, the white man . . . tends to sink

slowly to the level around him.’’ For in the tropics, ‘‘the white man lives and

works only as a diver lives and works under water.’’∞∞≥

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42 american military medicine faces west

But not all was lost on diving into the tropics. Medical officers in the

Philippines gradually became more confident that proper attention to per-

sonal hygiene at least slowed the decay of the white racial constitution in a

foreign environment. Thus the care of the body and the tempering of behavior

might preserve and supplement the white soldier’s powers of resistance and so

mitigate the presumed transgression against nature. In other words, personal

hygiene would perhaps allow alien Americans to function as if in sealed

hermetic microenvironments, to equip themselves with a sanitary armature

against the climate. Evidently, if a white American soldier was to withstand

his depleting circumstances, his ‘‘habits, his work, his food, his clothing, must

be rationally adjusted to his habitat’’—not to make him like the locals but to

protect him from going native. The basic precepts of tropical hygiene were

simple enough: avoid the sun, stay cool, eat lightly, drink alcohol in modera-

tion or not at all. In Mason’s experience, ‘‘errors of diet, abuse of alcoholics,

chilling after over-heating, especially at night, excessive fatigue, and the use of

the heavy cartridge belt’’ had all been ‘‘powerful disposing factors’’ to invalid-

ing and death in the tropics.∞∞∂

The proper attire, diet, and conduct of American troops in the Philippines

excited much expert commentary. Captain Matthew F. Stelle, m.d., in dis-

cussing the appropriate dress for a soldier in the tropics, admitted he had

scarcely heard of khaki before 1898, but since then it had rapidly replaced

blue as the distinctive coloration of the U.S. soldier. The lighter color, which

deflected the sun, certainly seemed better adapted to the tropics. But he re-

mained convinced that the old campaign hat used in the Philippines absorbed

and concentrated the sun’s rays and was ‘‘the most certain, rapid and perma-

nent hair-eradicator that was ever invented.’’∞∞∑ Mason confirmed the hat’s

evil effects. He reported that a thermometer placed under a felt campaign hat

registered 100.2 degrees, but under a khaki hat, left out in the sun, it never

exceeded 92 degrees. His conclusion was that the campaign hat was ‘‘not fit

for tropical service.’’∞∞∏

When Stelle first ventured into the tropics, it seemed he was asked at least

forty times a day, ‘‘Have you got an abdominal bandage?’’ ‘‘People were daft

on the subject,’’ he said. Although he later came to believe that ‘‘no greater

fake was ever perpetrated’’ and that it was ‘‘a bad habit, a vice, a disease,’’ he

had become addicted to it, as had so many others, and ‘‘nothing but death can

rescue us.’’∞∞π Guthrie was equally convinced that the popular flannel abdom-

inal bandage was unnecessary, yet he continued to advise Americans in the

tropics to protect their abdomen with a blanket when sleeping, to prevent

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american military medicine faces west 43

them ‘‘chilling’’ through evaporation of sweat.∞∞∫ Members of the Philippine

Commission, the new executive government, also concluded that the ‘‘ab-

dominal band is necessary for perhaps fifty percent of Anglo-Saxons. One can

try to do without it, but if one develops diarrhea, the best thing to do is wear

it.’’∞∞Ω Captain Woodruff, however, expressed his objections to abdominal

bands and other warm clothing with characteristic bluntness: ‘‘We are less in

danger of chills,’’ he declared, ‘‘than of being devoured by polar bears.’’ The

white man in the tropics could not cool off day or night, no matter how hard

he tried. In these circumstances, ‘‘as little clothing as possible is the rule, and

that clothing should be such as to interfere in no way whatever with getting

rid of surplus heat.’’∞≤≠

The effort to formulate the ideal ration for the white man in the tropics

was similarly predicated on the perceived need to prevent the accumulation of

excessive heat and thus restore the preexisting balance of the white constitu-

tion. Munson wanted more vegetables and less protein and fat in order to

avoid ‘‘hyper-stimulation of the liver.’’∞≤∞ Surgeon Hamilton Stone argued

that in the tropics, ‘‘where the excretory organs are always overtaxed,’’ there

was a marked tendency ‘‘for us to eat too much,’’ especially the bulletproof

army hardtack, some of it rumored to be left over from the Civil War.∞≤≤

Greenleaf, however, did not see any need to change the quantity of the tropi-

cal ration but suggested a decrease in the meat component and an increase in

cereals. If the ‘‘nitrogenous and fatty elements’’ were reduced, then the diet

would approximate that which sustained the local inhabitants.∞≤≥ But Wood-

ruff, not surprisingly, challenged this objective too. ‘‘If we eat like natives,’’ he

predicted, ‘‘we will become as stupid, frail and worthless as they are.’’ The

real reason disease seemed so severe in the tropics was, he thought, that ‘‘the

white man is exhausted by idleness and insufficient food and has no resis-

tance.’’ Experience had shown him that ‘‘the tropical heat causes a great

expenditure of nervous and muscular force,’’ so to balance this, to ‘‘supply the

wastes and help to prevent exhaustion,’’ more animal food was required, not

less.∞≤∂ Such debates over white nutrition, dress, and behavior in the tropics

would continue for the next twenty years.

manly white tropical soldiers

American whiteness and masculinity were both more readily discerned and

more highly valued in the tropics than at home; they appeared at once more

vulnerable and more necessary.∞≤∑ The figure of ‘‘whiteness,’’ whether defi-

cient or overassertive, became a means through which Americans declared

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44 american military medicine faces west

their presence in the Philippines. The white troops endured fatigue, fever, and

nostalgia, all of which seemed to sap or undermine the race’s reserves of

energy and character. They often felt out of place, not in sympathy with

tropical circumstances. Their medical officers attributed racial deterioration

and disease to a mismatch between bodily constitution and environment—

sometimes the environment was directly noxious, at other times it was micro-

biologically mediated. Soldiers felt awry and uncomfortable; their doctors

confirmed and further specified the pathological consequences of displace-

ment into a foreign climate and exotic disease ecology.

If whites were proving so vulnerable to tropical conditions, what was to be

done? Medical officers sought to limit the troops’ contact with microbes, espe-

cially the unfamiliar ones that appeared to prevail in the new territory. More-

over, they attempted to manage the selection, conduct, clothing, diet, and per-

sonal hygiene of soldiers in order to build up resisting powers and strengthen

the constitution. In multiple ways, then, the military sanitarian was delimiting

the boundaries of whiteness in the Philippines, counterposing it to an un-

wholesome and morbific climate and ecology and thus refiguring what it

would mean to be a real white man—a vigorous American citizen-soldier—in

the tropics. Evidently, remaining or becoming successfully white in the tropics

was going to entail continual medical surveillance and discipline.

Facing west from California’s shores, some Americans observed their

whiteness become more visible again, this time in relation to the multiply

threatening tropical milieu. Frederick Jackson Turner claimed that the strug-

gle with savages and wilderness on the continental frontier transformed Euro-

peans into Americans.∞≤∏ As that frontier closed, a new one opened on the

other side of the Pacific, one markedly more militarized and medical. In the

crucible of the Philippines ‘‘borderlands,’’ American whiteness and masculin-

ity would again be refashioned: now it was the medical officer who took

charge of the process and determined the results.

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