Medical support for the campaign against the Spanish in both the Caribbean and the Pacific in the summer of 1898 was heavily influenced by events that took place while V and VIII Corps troops were still gathering in Florida and California. The haste and confusion of Tampa haunted V Corps medical officers confronting the challenges of operations in Cuba, and those with the units that invaded Puerto Rico after the Spanish surrender in Cuba also experienced frustrations engendered by inadequate planning. In the Philippines, however, VIII Corps medical officers, relatively unburdened by handicaps imposed in the United States, encountered few difficulties caring for the soldiers involved in what proved to be an easy campaign against a thoroughly demoralized foe. An armistice signed on 12 August brought all hostilities between Spain and the United States to a halt the next day, but in both the Caribbean and the Philippines disease proved to be a more persistent and relentless enemy than the Spanish.¹

The active stage of the Cuban campaign (see Map 2) was very brief. General Shafter's V Corps troops landed at Daiquiri on 22 June and took Siboney, a better port eight miles to the west, a few hours later. They then moved inland and to the north to Las Guasimas, where two days later they suffered 52 or more wounded in defeating Spanish troops retreating toward Santiago. Much of the Medical Department's supplies and equipment needed to care for these men was on the transports. A week later, when U.S. troops met the enemy at El Caney and San Juan Hill, medical personnel, working without much of the equipment they needed, had to care for as many as 1,200 wounded, 932 from San Juan Hill. On 3 July the U.S. fleet destroyed the Spanish squadron when it attempted to leave the harbor at Santiago, removing both the need to take Santiago and the need to defend it. Except for exchanges of artillery, machine-gun, and rifle fire between troops entrenched around Santiago on the tenth and eleventh, which produced 2 more wounded for the V Corps, El Caney and San Juan Hill were the last engagements of the war in Cuba. On the fourteenth the Spanish opened discussions that led to the official surrender of Santiago three days later, thus bringing all pretext of Spanish resistance in the island to an end. By this point, the victims of disease rather than the wounded had already become the focus of the department's attention and concern.²

The abandonment of initial plans for the invasion of Cuba, which called for a land-

MAP 2

ing near Havana, where flat terrain and good roads would have made moving supplies with the troops a simple matter, led to the landing at Daiquiri, seventeen miles east of Santiago, where steep cliffs lined the beaches and roads were almost nonexistent. Although U.S. soldiers-6,000 on the first day and 11,000 in the following two days-landed unopposed, the surf was so heavy that the V Corps chief surgeon, Colonel Pope, considered it remarkable that only 2 died from drowning. Bringing Medical Department supplies ashore proved almost impossible-not only because the surf was high but also because the need for a multitude of small boats to unload the transports had been overlooked in the haste and confusion that characterized the invasion. Moreover, since the weapons of war had priority over medical supplies, Pope had no claim to the single lighter that was the only transportation consistently available. Unable to move his division hospitals ashore, he pleaded in vain for small boats and crews to move the sick and wounded to the hospital ship Olivette, where he had set up the 2d Division hospital.³

Although it was of the utmost importance that division hospitals be landed and established ashore as soon as possible, frustration after frustration continued to greet attempts to do so. After the troops had disembarked, the masters of the transports positioned their vessels five to fifteen miles offshore for fear of coming to grief on the rocky coast. The port of Siboney provided a landing beach nearer Santiago. Yet here, as at Daiquiri, small boats were rarely available to unload the transports. In addition, as many as 200 badly needed hospital tents were at the bottom of one ship's hold and inaccessible for many days until the rest of the cargo had been slowly unloaded. Much still remained on board when U.S. troops began their march toward Santiago. Since Medical Department baggage wagons and mules had been left behind in the turmoil at Tampa, medical officers had to improvise shore transportation over a road that was scarcely more than a rocky trail. Some used their own horses as pack animals, but asking hospital corpsmen to carry supplies in litters proved of little use because an average of only two per regiment had been brought ashore. The few surgeons who had taken chests of medical supplies along found them impossible burdens and abandoned them early in the march, to be retrieved later by passing wagons.⁴

The situation had not significantly improved when U. S. troops encountered the retreating Spanish on 24 June, although Colonel Pope attempted desperately to obtain additional supplies. His request for a

steam launch to enable one of his officers to pick them up from the various transports produced only a rowboat. Permission to use this craft was soon withdrawn because it was needed elsewhere, and, since the sea was calm only in the mornings, attempts to reach the transports that day soon ended. Pope did manage to board the Olivette and order it to Siboney, but wagons to move the more seriously injured casualties the four miles from the battlefield to the beach were difficult to obtain. Until the U.S. Navy could be persuaded to lend craft to move them out to the Olivette, they lay without blankets or pillows on the floor of the only available shelter, "a very foul old shed." Some of the wounded were taken on board the hospital ship the evening of the twenty-fourth, and the remainder were removed there before dawn the next day. By 3:00 A.M., after operating at four tables under electric lights, twelve surgeons-including Major Appel of the 2d Division and his three assistants-had completed all surgery. Some of the sick on the Olivette had by this time recovered, but with 128 patients on board, among them 40-50 wounded, she was nearing her capacity. As a result, with no tents or supplies on shore, Pope looked anxiously for the appearance of the hospital ship Relief, which finally arrived on 8 July.⁵

Fortunately, each soldier at Las Guasimas carried with him a first aid packet containing antiseptic dressings and sterile bandages, which had been distributed among the troops on the transports. Enabling the men to dress wounds even before the arrival of a physician lessened the chance of infection, which, because small-caliber bullets did not produce massive tissue damage, was the principal concern. Although Army surgeons credited these packets, used for the first time on 24 June, with a considerable saving of lives, many soldiers discarded them as they were marching through the tropical jungle after Las Guasimas.⁶

Despite the "fierce, scorching rays of the tropical sun," the health of the men was still good-fewer than 150 were sick. During the lull of several days in the fighting that followed Las Guasimas, Medical Department personnel were free to prepare to care for future patients. The transports were slowly unloaded. The Red Cross, apparently notified the moment the V Corps embarked, sent a steamer ready to help with the wounded. It reached Siboney on 26 June, and on the twenty-seventh a supply of medicines arrived from Tampa and was distributed among regimental medical officers. Major Wood brought the first field hospital, his 1st Division facility, ashore and, after collecting available transportation, including fourteen litters and sur-

geons' horses, moved it to a deserted mansion. Because of the low priority given medical equipment and the poor condition of the roads, his unit briefly functioned without beds or bedding. As Shafter's force advanced toward Santiago, Major Wood moved his facility again, this time to a site where, because no building was available for shelter and tentage was inadequate, his newly obtained bedding became wet.⁷

Removing the wounded from El Caney and San Juan Hill to Major Wood's facility proved exceedingly difficult. The entire line of evacuation was subject to fire, either from the guns on the battlefield or from guerrillas who hid in trees along the route and killed a contract surgeon during the battle of San Juan Hill. The litters needed to remove the wounded from the battlefield often had to be improvised from whatever materials were available, just as they had been during the Indian wars. The ambulance station-also referred to as the aid, dressing, or collecting station-to which the wounded were first taken had to be set up near the line of battle because the further back it was, the more vulnerable it became to spent bullets fired from as much as a mile away. Each regiment usually had its own station, but some units shared facilities. An intermediate station was occasionally established where walking wounded could rest, and, if necessary, be placed in wagons, and where those on litters could stop to have dressings checked or tourniquets loosened.⁸

A shortage of ambulance wagons complicated the rest of the journey back to the field hospital. Exactly how many were on hand by the time of the engagements on 1 July is not clear. Colonel Pope maintained that only three ambulances were ever placed on board the transports and that these were used on 1 July. In his autobiography, however, General Shafter wrote that seventeen were in Cuba by this time, a number that, he believed, would have been adequate had not the total number of wounded been higher than he had anticipated. The drivers of these vehicles and the mules that pulled them soon began to fall ill, often too ill to work, thus further complicating evacuation. Because of the shortage of ambulances, those available to the V Corps were posted near corps headquarters so that Pope, who considered them invaluable, could control their use personally.⁹

General Shafter differed with Colonel Pope on the value of the ambulance, rationalizing that "on muddy roads [supply] wagons could be made as comfortable as ambulances for the wounded." But a surgeon who saw the wounded and sick from El Caney and San Juan Hill packed into wagons "in an apparently pitiless manner" to avoid the "indefinite waiting by the road-

side" that would have been necessary to move them by ambulance was not so sanguine. He maintained that between the wagons and the "abominable condition of the roads, the unruly state of drivers and mules, and the great difficulty of obtaining means of preventing jars and jolts, . . . the 4 or 5 miles of wheeled transportation from the battlefields to the field hospital cost the lives of not a few patients."¹⁰

The only complete field hospital awaiting the wounded from El Caney and San Juan Hill was Major Wood's facility. Although the supply of tents, cots, and bedding was inadequate, the operating room equipment, instruments, and supplies of the three land-based division hospitals were by this point on shore and quickly readied for use. The rest of the division hospital supplies and equipment was reaching shore very slowly, most regimental equipment and medicines were still on board the transports, and much of Major McCreery's Cavalry Division hospital was apparently never unloaded before the ships moved away from the shore. Major Havard, the Cavalry Division chief surgeon, appealed for help to the Red Cross, which responded generously under the direction of its founder, Clara Barton. Surgeon General Sternberg thundered at "the military authority which ordered and superintended the embarkation at Tampa and which directed the forward movement, although the disembarkation of the medical stores and supplies was unaccomplished."¹¹

U.S. soldiers were not the only wounded for whom U.S. medical officers cared. From the outset, they had been assisting their Spanish counterparts until the injured prisoners-of-war could be moved to hospitals in Siboney accessible to Red Cross personnel. After the battles on 1 July, Barton, two Red Cross physicians, and

other Red Cross representatives joined U.S. medical officers in caring for 150 wounded enemy soldiers until they could be sent to a large Spanish hospital at El Caney. On the fourth, however, wanting to encourage surrender by disproving rumors among Spanish troops that suggested U.S. savagery toward prisoners, Shafter ostentatiously sent a group of patient-prisoners from El Caney to Santiago by ambulance, making "an excellent impression among the Spaniards."¹²

The ultimate destination of U.S. wounded after the battles at El Caney and San Juan Hill was a base hospital that Major LaGarde had finally been able to set up at Siboney, principally in the tents of his reserve division hospital. He used the furniture and furnishings of nearby buildings to supplement the hospital's supplies and equipment, which had been brought ashore only after Pope had obtained a personal order from Shafter for a steam lighter to unload it. Fortunately, the facility was ready when the vehicles that had carried the medical supplies stored at LaGarde's hospital to the front on 1 July began returning to Siboney laden with wounded. The most severely injured were the first to arrive, 2 among the initial 7 requiring major amputations. Another 1,000 flooded LaGarde's hospital when Major Wood attempted to clear his facility of patients so that he could follow the V Corps forward after the battle. The growing number of casualties at Siboney in the wake of El Caney and San Juan Hill led Pope to begin considering the feasibility of using transports to return some sick and wounded to the United States.¹³

For five days after the engagements at El Caney and San Juan Hill, the staff at the Siboney base hospital worked with little opportunity for rest, although most patients required only the redressing of their wounds. Doctors were prepared to care for a maximum of 200 men, and although 200 wounded apparently remained with he troops in their camp outside the city of Santiago, tents could not be put up fast enough to shelter the 1,142 injured at Siboney, many of whom were "entirely naked." Little in the way of "articles of light diet" was on hand, and the Olivette could not offer much help. The supplies brought in by the Relief were not enough, and Major LaGarde had to struggle to have even that much unloaded. Once again, the Red Cross came forward with the needed "delicacies," as well as with beds, bedding, and similar items. The Red Cross steamer stood by to provide further aid, and Red Cross nurses assisted in the operating rooms at Siboney, where four U.S. Navy surgeons, a surgeon from the Swedish Navy, and the assistant surgeon general of the Cuban rebel army joined U.S. Army physicians. Surgical teams worked at five to six tables, their members rotating to replace those who became too exhausted to continue.¹⁴

Hostilities did not officially end for another sixteen days, but when the guns fell silent at El Caney and San Juan Hill, almost 80 percent of the total of less than 1,500 U.S. soldiers wounded in the Spanish-American War in Cuba had already been injured. Some of these casualties required major surgery, which was most often accomplished in field hospital operating rooms; but, according to LaGarde, the damage done by "the portable hand weapons of to-day" was such that for the most part "the subject of military surgery [was reduced] to first-aid work." The Mauser used by the Spanish so impressed one medical officer that he called its ammunition "a humane bullet in every sense of the word." Since most of the wounds

had been inflicted at a sufficient distance to avoid "the explosive effects" that resulted from the use of this type of weapon at close range, wounds healed rapidly and fractures were few. The sterilization of instruments and the washing of surgeons' hands in antiseptics prevented hospital gangrene and many other forms of infection that had haunted the military hospitals of the Civil War. With a conservative approach to surgery now feasible, amputations were rare. Although some patients with abdominal wounds died following laparotomy (surgery that involves opening the abdomen), others whose wounds suggested that their intestines must have been repeatedly pierced nevertheless recovered uneventfully without surgery.¹⁵

In its annual report for 1898 the War Department proudly noted that of 1,431 regulars and volunteers who were wounded in the Santiago campaign, only 13, less than 1 percent, died of their injuries. The statistics cited, however, are contradictory. The preceding figure is apparently far too low. One of the reports estimated that among approximately 1,000 wounded sheltered in one hospital in Cuba, the mortality was 7 percent, or roughly 70. Elsewhere, the War Department listed for the entire Spanish-American War a total of only 65 men, regulars and volunteers, dying of wounds from 1 May through 30 September 1898. Of these, 8 wound fatalities occurred as a result of action in the Philippines, where approximately 106 regulars and volunteers were injured in combat, a deaths-from-wounds figure of more than 7 percent. Another 40 were wounded, most of them only slightly, in Puerto Rico, and thus, presumably, the number dying from their injuries was low. The surgeon general's totals suggest that for the calendar year 1898, 1,320 regulars were injured by guns in battle, whether in the Caribbean or in the Philippines, and that of 1,457 regulars wounded by gunshot under all circumstances in that period, 88, or 6 percent, later died as a result of injuries received in battle. Given the distribution of the total number of casualties, it is highly likely that most of the 89 regulars who died of wounds during the year died during the Cuban campaign, thus again bringing the figure above 13 even without counting volunteer casualties.¹⁶

Among the lessons medical officers learned while caring for those injured in June and July was that too early or too frequent changing of dressings could lead to unnecessary infection. Furthermore, as long as the wound could be kept reasonably clean, surgery could wait until the patient had been moved to a permanent hospital. The need for a better method of identifying casualties was also revealed in this conflict, since many of those who died were unidentified, with diagnosis tags either not used or, on the rare occasions when they were used, obliterated partially or entirely by rain. One surgeon suggested that a small metal tag be adopted, to be hung around each soldier's neck. Some medical officers discovered that X-ray pictures eliminated the need for extensive probing to locate bullets that had become lodged in the body and thereby lessened the chances of infection. But X-rays, discovered in 1895 by Wilhelm C. Roentgen, were still so new during the Spanish-American War that many surgeons did not understand their potential, and X-ray equipment was available only on two Army hospital ships and in general hospitals back in the United States.¹⁷

By the time peace officially arrived in Cuba, the men of the V Corps had already begun to discover that their most danger-

ous enemy was not the Spanish, and medical officers soon realized that their greatest struggle would not be against wounds and infection. Most of the necessary surgery had been performed, and wounds were beginning to heal when Army physicians found themselves struggling against disease that was running out of control, "a thousand times harder to stand up against than the missiles of the enemy," according to Shafter. It spared neither officers nor men, neither civilians nor soldiers. Even the general himself was briefly sick because of what he believed to be sunstroke, causing considerable anxiety for his superiors. His officers were soon falling by the wayside; he later recalled that eventually "all the general officers were ailing, more or less." Civilian employees of the Army also began to fall ill in increasing numbers, and if sick teamsters could not be replaced, the Army was in danger of losing the use of five to ten wagons a day. The sick rate was also high among the enemy-as many as a fourth or more of the Spanish force might be hospitalized at any one time, a figure that reached 2,600 by 2 August. Colonel Senn, of the U.S. Volunteers, now at the Siboney base hospital as chief surgeon of the operating staff, learned from a Spanish surgeon that in his army "many were sick and no one well."¹⁸

In the V Corps the escalating rate of disease alarmed Lt. Col. Theodore Roosevelt as early as 12 July, a day after the last U.S. soldier fell victim to Spanish guns. He informed Shafter that only 350 of the 600 officers and men among his Rough Riders were fit for duty.¹⁹ Almost half his men who had survived battle had already been laid low by wounds, fever, dysentery, and heat, and their living conditions in Cuba were causing an almost continuous deterioration in their health. The V Corps lacked both adequate shelter and clothing, and rain fell every night and almost every day. Temperatures might fluctuate from 120 degrees in the shade by day to the 60s once the sun had set. While maintaining that he was personally "as strong as a bull moose," Roosevelt noted that his men were suffering from the sun, the rain, the poor drinking water, and the "lack of plain food." Men became so thirsty that even a surgeon confessed that, having consumed all the boiled water in his canteen, he, too, drank from a puddle that he knew might be infected.²⁰

The start of negotiations with the Spanish on 13 July brought no respite from the onslaught of disease. By the twenty-second 75 percent of the civilian teamsters and packers working for the Army were ailing-doctors and a hospital were needed for sick civilians, whether Army employees or Cuban victims of the hostilities and the siege, who had no hospital to which they could go. General Shafter stated the following day that 1,500 soldiers were sick with fever, an estimated 10 percent of them with yellow fever. Although deaths were few, by 1 August Shafter was ready to admit that his "command [was] in no condition for active service at present." Four days later, Roosevelt reported that no more than 100 of his men were "fit for any hard work" and that 150 were probably too weak to walk any distance even without their packs. Since they had only one-third of the transportation they should have, they could not move from the site, despite its unhealthiness. Some tents and camp equipment were now coming in, and the delivery of canned tomatoes had reduced the threat of scurvy, but anxiety over the fate of the V Corps should it remain in Cuba continued to grow.²¹

Physicians were falling victim to the diseases they fought, as many as 15 percent being disabled at one time. U.S. Volunteer surgeon Maj. Victor C. Vaughan, who had

already earned an enviable reputation in the field of public health, fell ill with yellow fever on 12 July. Major McCreery died of dysentery on the transport that was taking him home to convalesce from yellow fever, and by the twenty-second Colonel Pope himself was very ill-"I have almost constant vertigo," he wrote, and "am unable to think, to plan, or to recollect." Although he remained with the V Corps until it left Cuba, he was relieved the next day at his own request and replaced by Major Havard. Both Major LaGarde and Maj. William C. Gorgas, who briefly succeeded the popular LaGarde in charge of the base hospital at Siboney, also fell ill. LaGarde, who apparently had malaria, had to return to the United States before the end of August, and Gorgas, a victim of typhoid, followed him in September. Little success met desperate attempts to locate physicians serving in the V Corps in a nonmedical capacity who might be willing to sign on as contract surgeons to fill the vacancies that were occurring. But since the number of physicians in Cuba who were at least temporarily unable to perform their duties grew, the number of patients also rose, and the struggle to provide adequate care for the sick was constant. Although Sternberg sent more physicians to Cuba, keeping an adequate number of doctors on duty remained difficult, and as late as 10 August General Shafter was still requesting that twenty more physicians, preferably medical officers, be sent to Cuba.²²

The number of men in the hospital at any one time did not accurately reflect the enormity of the problem, for those who were in the camps were generally weak and exhausted. While the number of those with fever who returned to duty often equaled or exceeded the number of those newly afflicted and while the total hospitalized was falling after 2 August, the death rate continued to increase at a frightening pace, from a monthly rate of 0.21 per 1,000 among the regulars in May 1898 to 1.81 per 1,000 in July, peaking at 6.14 per 1,000 in August. The debilitation of the entire V Corps had a disastrous effect upon morale and military effectiveness, which deteriorated still further because of the fear that a devastating yellow fever epidemic might be yet to come.²³

Several diseases contributed to the enfeeblement of the men of the V Corps at this time, but the most dangerous was malaria, which, because of the habits of the Anopheles mosquito, was a particularly great threat to the men camped outside Santiago during and after the siege of that town. To Roosevelt's surprise, malaria affected black units as much as it did white. An estimated 75 percent or more of the soldiers suffered from some form of the disease, but the most common was apparently falciparum. Although the fever usually lasted only four to six days, it left its victims too weak to return to duty. Fortunately, quinine was in sufficient supply by this point, for it was widely used, even for cases of diarrhea, which were often blamed on malaria and were, therefore, often treated with large amounts of quinine, usually administered by rectum. The way in which malaria was communicated from one man to another had just been established, and many Army surgeons still believed that the infection was acquired through water that carried the plasmodium. Thus when the malaria rate continued to rise even after the men were ordered to boil their drinking water, doctors assumed that the order had not been obeyed.²⁴

Typhoid, too, was soon exacting a higher death toll in the debilitated V Corps than among the units that remained in the United States, and diarrhea and dysentery

were becoming more common as time passed. Despite all efforts to keep drinking water pure, sources might be polluted by men, by animals, and by laundry washed in streams. Boiling large amounts of water was rendered difficult by the delayed arrival in Cuba of the necessary cauldrons and a shortage of fuel for fires. "Ephemeral fever," which did not respond to quinine and might have been either typhoid or dengue, and other fevers added to the miseries the men were enduring, since they were widespread and debilitating, involving a lengthy convalescence. None of the V Corps' many health problems involved the much publicized so-called embalmed beef. The meat was often unappetizing and sometimes had been so long unrefrigerated as to be inedible, but investigation failed to support charges that any that had been preserved with harmful chemicals had been fed to the troops.²⁵

Malaria and typhoid posed the greatest threats to the V Corps, but the most dreaded disease during the Caribbean campaign was yellow fever. Because of the sociable nature of the Aedes aegypti mosquito, this disease was more common in towns and cities than in the countryside and therefore a greater threat to an occupying army than to a force encamped outside its walls. The mere thought of yellow fever inspired a growing panic that was fed by uncertainty both about diagnosis and about the means of transmission. Distinguishing between malaria, typhoid, and yellow fever was difficult when neither adequate laboratory equipment nor physicians trained to make the distinction were present in Cuba. The role of the mosquito, only recently recognized as a possible carrier of disease, in spreading yellow fever was unknown. To physicians unaware of the importance of the Aedes aegypti mosquito, yellow fever infection seemed to lurk everywhere, in buildings taken from the Cubans and "in the shady nooks about rocky recesses, caves, arbors, etc." The customary approach to preventing disease, keeping camps clean and water sources unpolluted, proved to be as ineffective against yellow fever as that against malaria. Under such circumstances, constant preoccupation with yellow fever and the conviction that an epidemic was inevitable made both misdiagnosis and panic easy.²⁶

As some suspected at the time, the panic about yellow fever was not justified. Sternberg later concluded that many men supposedly ill with yellow fever were actually suffering from what was then called aestivo-autumnal malaria, the form caused by the falciparum parasite. U.S. Volunteer surgeon Maj. Francis J. Ives, chief surgeon of an independent brigade (also called a provisional division) that had been formed

of two infantry regiments and one unit of cavalry, concluded that the fear of Army surgeons in the field only made matters worse. He believed that they frequently misdiagnosed cases, hospitalizing men who did not have yellow fever with those who did, thereby contributing, as he thought, to spreading the disease. "The majority of these experts were completely stampeded, and were calling everything yellow fever," he reported to Sternberg.²⁷

As disease rates mounted and reports of yellow fever cases inspired dread in those who heard them, greater attention was devoted to means by which all disease might be prevented. The long-held belief that yellow fever was somehow related to contamination of the campsite had led to an approach to preventing its spread that was often successful-flight. Some authorities recommended that those diagnosed as having yellow fever be hospitalized and that the rest of their unit advance two miles and reestablish camp. Once Santiago had surrendered, General Shafter held a conference of his general officers and division chief surgeons to discuss an idea favored by Surgeon General Sternberg, that of relocating the entire V Corps from the area where yellow fever was endemic. At a higher altitude, if well cared for, the ailing troops might be restored to health. But in the mountains of Cuba no roads existed over which supplies could be moved, water sources were inadequate, and heavy rains turned mountain plateaus into quagmires where malaria reigned supreme. Shafter decided that "Dr. Sternberg's idea of going 700'-800' above sea level" was "all fol-der-rol, as you will see if his advice is followed." Changes of camp were difficult for all concerned, including medical officers who had to uproot hospitals and their many patients, and the sick rate apparently rose markedly with each move that was tried. The notion was finally abandoned as not feasible because the stress of repeated moves further lowered the resistance of the men to disease.²⁸

By the second week in July the common assumption was that a yellow fever epidemic was taking possession of Siboney, where hundreds of wounded, sick, and healthy nonimmune U.S. soldiers were gathered, a tempting smorgasbord to the city-loving Aedes aegypti. The first case was not diagnosed until the sixth, but panic was quick to set in. No more victims of Spanish weapons were being brought in to hospitals, but yellow fever had reportedly struck down 38 men in the town by the twelfth, when the commanding general of the Army and his chief surgeon arrived in Cuba. General Miles estimated at this time that 100 men had been stricken throughout the island. The spread was blamed on troops who, against orders, entered buildings believed to be infected. An attempt was made to keep word of the incipient epidemic secret, but when Colonel Greenleaf, who was responsible for the health of the invasion forces, was informed of the outbreak, he immediately launched an investigation into its origins. He also initiated an aggressive effort to improve sanitation and to exclude all Cuban and Spanish refugees from the city. Even after a Regular Army surgeon was made town administrator, these steps apparently had small effect upon V Corps disease rates at Siboney. In his frustration Colonel Senn, who for a time assisted "in the work of purification," blamed the failure of sanitary improvements to reduce disease levels on a lack of cooperation on Shafter's part.²⁹

Drastic steps were clearly called for. At the recommendation of Guiteras, who appears many times playing an advisory role

to U.S. troops in the Caribbean, and with the encouragement of Miles, the ultimate solution to the problem became obvious-the town must be burned down. Authorities believed that the source of the infection thus would be destroyed and the ground sterilized. Major LaGarde favored this radical step, even though he considered typhoid a greater danger than yellow fever, which was proving to be generally mild with a short recovery period. Following the prevailing line of reasoning, Siboney was emptied of its inhabitants and, beginning 11 July, each building was burned to the ground when it became vacant.³⁰

Attempts at preventing disease, no matter how drastic, proved clearly ineffective. On 21 July General Shafter reported that the number of fever cases in Santiago was increasing rapidly, but he added that observers disagreed about how many were yellow fever. A day later he recorded 214 more cases of various kinds of fever. On the twenty-third he noted a total of about 1,500 victims throughout the V Corps, about 10 percent of whom supposedly had yellow fever. New cases of fever continued to develop as the month wore on. One estimate suggested that as many as 1,300 to 1,400 in the Siboney area alone eventually caught yellow fever in spite of the burning of the city, and that about 15 percent died as a result. A physician commented that the incidence of yellow fever was no higher because it was a disease of the cities and the men were generally stationed about the countryside.³¹

Obviously the escalating disease rates were placing an increasingly heavy burden on V Corps hospitals and their personnel. With ambulances to move the sick back to

the base hospital at Siboney hard to find, regimental surgeons and their facilities were overwhelmed soon after El Caney and San Juan Hill by the ever-growing number of patients, some of whom at one point had to be left on the ground without adequate shelter. Recognizing that he might be inundated with casualties if the V Corps and the reinforcements then arriving from the United States with Miles should conduct a direct assault on Santiago, Major LaGarde cleared his hospital of most of its wounded by 11 July, sending a few back to duty and shipping the remainder north. He then turned an additional twenty-bed facility that he established for the wounded in a small cottage over to the Red Cross. Wishing to isolate those with contagious diseases, he set aside a railroad shed and tents for their exclusive use. He assigned a larger cottage to those with fever (most of whom probably had malaria) and placed Guiteras, who was continuing to serve as the command's expert on tropical diseases, in charge. Still more sick were cared for with the wounded in a hospital that Major Havard had improvised in an old store. The care of these 80 patients and the hospital itself were turned over to LaGarde when Havard and the Cavalry Division moved forward.³²

For Major LaGarde and the medical team at Siboney, the real trial began on 6 July, when the first case of yellow fever was diagnosed. The entire staff of the Red Cross cottage soon came down with the disease, even though those whom Guiteras questioned on the matter said the building had not been contaminated by yellow fever. It was burned nevertheless, and the ailing staff members joined other yellow fever cases, who were isolated in tents, where by the tenth LaGarde had fourteen patients-nine soldiers, five civilians. The number of yellow fever patients mounted in spite of the destruction of "this dirty little town." He found that having "room to extend our canvas hospital" did not cure the problem of finding enough hospital space, even though in anticipation of the possibility of an all-out assault on Santiago, all tents at Siboney and 200 from Daiquiri had been sent for his use by the thirteenth.³³

Although most cases of yellow fever proved to be mild, on 19 July, with further confrontation with the Spanish no longer a possibility, Colonel Pope reported to General Shafter that half the V Corps sick lacked shelter and he needed 1,000 more beds. In Siboney Major LaGarde was by this point both discouraged and exhausted. Colonel Greenleaf had put Major Gorgas in charge of the yellow fever hospital that LaGarde had set up, which seemingly freed Guiteras to resume his original role as consultant on tropical diseases, but LaGarde's responsibilities were still growing. His facilities were overflowing, three of his surgeons were ill, and the V Corps had left him no vehicles for transporting supplies. A move to set up a "yellow-fever floating hospital" at Siboney was apparently abandoned. On the twentieth, concluding that everyone had been exposed to yellow fever by that point, LaGarde in desperation threw open the entire tent hospital at Siboney to yellow fever victims, making no attempt to isolate them beyond giving them their own wards.³⁴

At some time, presumably shortly after Colonel Greenleaf's arrival in Cuba on 12 July but before the surrender, a detention camp where suspicious cases could be isolated was set up near V Corps headquarters just outside Santiago on the road to Siboney.³⁵ Soon thereafter a yellow fever hospital was established not far from the detention facility and a contract surgeon

assigned the responsibility for identifying cases to be sent to it. Both the camp and the hospital were placed under Major Ives on 21 July. Between them the two facilities held an average of about 115 patients. Both were "broken up and transferred to Siboney" sometime near the end of July.³⁶

Fortunately, on 17 July, the surrender of Santiago made it possible to open hospitals in that city. Regimental tents had at last been unloaded from all the transports, and with shelter available in quantity, accommodations could easily be made for as many patients as needed them. Each regiment was given four tents for patients who were only slightly sick. Each division set up its own hospital for those more seriously ill in the Santiago area. These facilities were soon well equipped with such items as steam sterilizers, water heaters, bath tubs, and steel operating room tables. A 300-bed general field hospital was established on a hill in a central location to house the overflow from division hospitals, and a separate building was set aside for sick officers.³⁷

A third yellow fever hospital was established with 150 beds at the beginning of August "across the bay from Santiago" to house all new yellow fever patients throughout the V Corps, making it possible to gradually close the Siboney facility. It was relatively isolated, and by continuing the policy of disinfecting the ambulances and wagons used to transport yellow fever victims, authorities hoped to prevent further spread of the disease. Even though yellow fever had apparently been raging in the city before the surrender, only 61 cases were taken to this facility in July and August. Of the U.S. soldiers stricken in the city before the epidemic ended, 29 died, among them the hospital's pathologist.³⁸

On 9 August Secretary of War Alger decided that the immediate establishment of a large general hospital in Santiago was "of the utmost importance" and promised to send as many nurses to staff it as General Shafter considered necessary. Since little lumber and no carpenters were available in Cuba, he had to request that both be sent from the United States to create the facility Alger had in mind. But the corps commander informed the secretary on the tenth that a new plant was not necessary because a large hospital capable of holding 2,000 beds had already been set up in tents and equipped with modern kitchen equipment, a sterilizer, and isolation wards. This facility, presumably an expanded version of the general field hospital, was, Major Wood maintained, "one of the best in the world."³⁹

Finding hospital beds at Siboney and Santiago proved in the end to be easier than finding competent personnel. Hospital corpsmen, always inadequate in number, were needed in the field. Volunteers who were left behind to serve as hospital guards attempted to assist in nursing chores, but few had had any training, and because they had other duties, they were not always present when most wanted. The fear of yellow fever exacerbated other difficulties. On at least one occasion at Siboney, where the problem was apparently most acute, the staff assigned to work during the day had to remain on duty around the clock. After his July arrival in Cuba, Colonel Greenleaf pointed out to the V Corps adjutant general that 500 hospital attendants, 100 nurses immune to yellow fever, and a large number of immune doctors were urgently needed. On the fifteenth General Shafter initially refused to grant Greenleaf's pleas for the assignment of more men on a permanent basis to the hospital because he did not want to expose

those at the front to yellow fever and because their services were vital where they were. Greenleaf immediately appealed to General Miles, and that very same day, presumably after Miles required him to do so, Shafter ordered the 24th Infantry, a regiment of black regulars, to help Major LaGarde at Siboney by performing guard duty, police, and nursing chores. Because of "the discipline of these seasoned troops," many of whom volunteered to care for yellow fever patients despite the danger this service appeared to pose to their own health, LaGarde noted that "for the first time in the history of Siboney, order loomed out of chaos."⁴⁰

Obtaining personnel for duties that would involve possible exposure to yellow fever remained difficult throughout the summer. Cuban nurses soon "proved to be worthless" and were discharged. Immune or supposedly immune nurses, many black and female, "a hardy lot of female nurses-I do not mean lady nurses," as Colonel Pope put it, came in from the United States and were considered invaluable. Although none of these nurses contracted yellow fever, 2 of the supposedly immune physicians who came in with them in late July did. The first of about 2,000 men from two immune black regiments, the 2d and 3d Infantry, U.S. Volunteers, ordered to Santiago by Secretary of War Alger in mid-July to care for the sick in that city, arrived in Cuba a month later. Unlike the men of the 24th Infantry, these soldiers, as General Shafter reported after a few weeks, were "undisciplined, insubordinate and vicious. Are not controlled by their officers, terrorize the community by violent acts and cannot be relied upon for any duty." Female nurses proved to be "in every respect superior to males in all division and general hospitals," according to Major Ives, who admitted that he had initially opposed their employment in Cuba.⁴¹

A continuing shortage of supplies added still further to the difficulties being experienced by medical officers in Cuba. Ives blamed the problem on "vital defects in the supply department of the Army," although he also thought that some reports exaggerated the severity of the problem. Ships were still not carefully loaded; when cargo was removed from two vessels arriving at Puerto Rico in late July, some items destined for Cuba were discovered. Delays in unloading in Cuban harbors also continued to contribute to supply problems. Fortunately, quinine, the most vitally needed medicine, was apparently never in short supply.⁴²

With adequate hospital space initially hard to find in Cuba, competent attendants to care for the sick rarely available, and supply problems unrelenting, the difficulties experienced at the V Corps' disease-crowded facilities would have been even greater had it not been for hospital and transport ships. These vessels were credited by Colonel Senn with the saving of "hundreds of lives which, without such means of transport, would have perished in Cuba and Porto Rico." Some of these ships evacuated wounded and convalescents to the United States, while a few others served as floating hospitals offshore and made periodic trips to move their patients back home.⁴³

The Army's first such vessel in the Caribbean, the Olivette, had started her career without much planning. At the time of the invasion she took on the sick from the transports, who were later transferred to the steamer Iroquois to make room for the wounded. The retention of the 2d Division's hospital on board the Olivette caused her to assume the character of a permanent hospital ship. She was soon full to capac-

ity, and Shafter requested and received the help of a Navy hospital ship, the Solace, while a third ship was apparently later stationed in Santiago Bay to accommodate sick officers and noncommissioned officers. On 9 July, with hospitals in Cuba overflowing with the wounded of El Caney and San Juan Hill and the disease rates climbing, the Olivette left Santiago with 279 wounded, arriving in New York City a week later. She returned to Cuba with medical supplies and immune nurses and physicians shortly thereafter.⁴⁴

By this point, the Relief had arrived in the Caribbean. Weeks had been consumed in converting her into a hospital ship for the Army, and she was superbly equipped. Her ice-manufacturing plant could produce two tons a day, her distillery 1,500 gallons of water. She carried 360 beds, 750 field cots, 650 extra mattresses, an X-ray machine, medical supplies, and two immune physicians for the Siboney yellow fever hospital. She was ordered to stay close to the scene of military operations and to send the less seriously sick and injured to the Solace, whence they would be shipped home if they were not in condition to be quickly restored to duty. After twelve days in port, the Relief sailed for New York with 254 wounded. After her return to the Caribbean, she was sent to support the troops who had invaded Puerto Rico, and only transports were left to move the sick and wounded from Cuba to the United States. One more hospital ship, the Missouri, put at the disposal of the Army on 1 July, was not ready for service until the end of August.⁴⁵

Because of the shortage of hospital ships, sending sick and wounded patients north was a complex matter involving confusion and ultimately scandal. The use of transports was considered as early as 25 June, after Las Guasimas, and on 4 July, in the wake of El Caney and San Juan Hill, Brig. Gen. Henry C. Corbin, the adjutant general, authorized Shafter to employ for this purpose any ships he found suitable. Shafter had already sent one transport north with 300 wounded on 3 July, and a second set sail with 325 wounded on the fifth. Hospital ships were reserved for the seriously ill and wounded, and transports were neither designed nor staffed to handle patients who came on board in marginal condition or who fell ill on the way. Patients eager to return home sometimes sneaked on board, only to collapse once under way.⁴⁶

Since the importation of yellow fever into the United States was very much feared, a medical board checked over all evacuees to exclude from ships returning to the United States all those even suspected of having yellow fever. Corbin ordered that at Santiago and, if possible, at every other important port, a ship be set aside where those about to return to the United States could be quarantined while they were observed for signs of yellow fever and their possessions disinfected. A doctor from either the Army or the Marine Hospital Service was assigned to certify that all passengers were free of infection; to supervise sanitation, including the quality of drinking water taken. on; and to guarantee that no transport crews went on shore, where they might become infected. As early as 22 May 1898 Marine Hospital Service doctors were also authorized to stop and inspect all vessels arriving at U.S. ports, to fumigate them if necessary, and to detain any passengers who might be carrying disease. In addition, Marine Hospital Service physicians sometimes helped with patient care on board the transports, a responsibility usually borne by Army doctors.⁴⁷

Preparing transports to carry convalescents from Cuba presented an even greater

challenge than preparing them to carry healthy troops to the island. Despite all precautions, vessels taking men from Cuba often lacked supplies for the sick and carried drinking water that, because of a long period of storage, was repulsive to both smell and taste. As a result of the shortage of medical officers, adequate medical care was hard to obtain. Attempts to modify these vessels by removing partitions to improve ventilation, to set up mess and laundry facilities, and to load needed supplies apparently aroused hostility on the part of captains and crews. Despite the difficulties, sanitation on these transports was regarded by the Medical Department as "fairly good."⁴⁸

No scandals developed concerning conditions on these vessels until mid-July brought what Colonel Pope called "the Seneca and Concho incidents." Pope, ill because of sunstroke when the Seneca left Cuba on the fourteenth, was "therefore unequal to the duties and responsibilities which devolved upon him." Major LaGarde, in his eagerness to have his facility at Siboney ready to take on more wounded should further hostilities place a premium on hospital beds, had loaded eighty-five patients on the Seneca three days earlier. On board both the Seneca and the Concho, the bad water and lack of supplies became a cause celebre. Seeretary of War Alger, obviously angry, asked General Shafter why these transports had arrived in the United States "without attendance and medicine."⁴⁹

Excuses and explanations for the situation on the Seneca and the Concho were many and contradictory. The Seneca's captain later maintained that he had told authorities that his ship was not prepared to carry the sick and that he had been ignored. After a water shortage was also reported on these ships, LaGarde insisted that their captains did not indicate a need for water when picking up patients at Siboney. He further emphasized that in spite of the fact that most of the passengers on these transports were assumed to be either convalescent or healthy, he had placed as much in the way of medical supplies as he could spare on the Seneca. He had even assigned the vessel two assistant surgeons, but one of them was later reported to have been sick most of the way. He could not assign a medical officer for the Concho, which carried a Red Cross surgeon and four nursing sisters. A nurse later alleged that the Seneca carried too many passengers, but the surgeon responsible for determining the load for each vessel denied the charge. Although the Medical Department blamed what was regarded as a high death rate aboard transports upon the "greatly debilitated condition of the men," outraged comments, once started, did not quickly end, and Sternberg's refusal to ac-

cept responsibility for any aspect of the situation only fueled public indignation.⁵⁰

Some confusion obviously also existed about the ports to which these passengers should be taken. Initially, Secretary of War Alger apparently wanted the wounded placed on vessels returning to Florida after unloading troops. By early July transports with convalescents were being required to bring their passengers to Fort Monroe, near Newport News, rather than to Tampa. When the message ordering ships to Virginia was received in Cuba, two more transports had just left, both bound for Florida. One off-loaded 100 of the most seriously wounded at Key West, where a convent had been converted into a joint Army-Navy hospital, before proceeding to Tampa. At Tampa the hospital train met the remainder of her passengers and took them to Fort McPherson in Georgia. Alger was particularly upset, however, that even in early August a transport arrived at Tampa when she was to have gone to New York.⁵¹

The rest of the V Corps, fleeing disease in a state approaching panic, soon joined the sick and convalescent that these transports were taking from Cuba. No efforts of the Medical Department could prevent the repeated attacks of malaria that were rendering these once-strong men ever more fragile. Typhoid and dysentery continued to undermine morale, and the fear that worse was yet to come grew as the number of diagnosed yellow fever cases mounted. By 8 August three-fourths of the men were, according to General Shafter, "in no condition to withstand an epidemic of yellow fever, which all regard as imminent."⁵²

Enthusiasm for the idea of withdrawing the V Corps from Cuba grew rapidly, but the fear that returning soldiers would carry the enemy back with them to the United States had not abated. Mail from Cuba was already being disinfected before entering the United States lest a letter bring in yellow fever, and General Miles had forbidden the circulation of paper money from infected units because it could not be disinfected. The Marine Hospital Service continued to check all vessels coming in from Cuba, whether troop transports or merchant ships. Nevertheless, believing that they had no alternative and convinced that wholesale deaths in their already seriously debilitated commands would follow a yellow fever epidemic, officers began bringing pressure to have their units brought home immediately. General Shafter noted that they agreed with him that "the only salvation for the survivors of the army was to leave Cuba as soon as possible." Roosevelt thundered that the men should be sent north, "not next month or next week, but now, today if possible."⁵³

Secretary of War Alger responded immediately and favorably to General Shafter's urgent request that the V Corps be moved back to the United States without delay. The decision made, preparations progressed swiftly, but with so many men sick, the evacuation took more time than the invasion had. Marine Hospital Service doctors in Cuba were ordered to inspect transports and their crews to ensure neither brought yellow fever back to the United States. Adjutant General Corbin cabled Shafter to emphasize his concern that sufficient effort might not be taken to make sure that men with yellow fever were not among those returning home. Those who were too ill to move or who were suspected of having the dread disease, about 1,300 in all, were to be left "in very comfortable condition" to recuperate in Cuba.⁵⁴

Except for the men who could not be moved, the entire V Corps was to be returned to the United States. In spite of the

probability that some would come down with yellow fever on the transports, General Shafter believed that to keep a sick man in Cuba until his fever had gone would be to inflict a death sentence upon him. Secretary of War Alger, undoubtedly motivated at least to some degree by the furor stirred up when the pleas of V Corps officers reached the press, sent south all the transports he could find. The Olivette initially assisted in removing the sick from Cuba; but, after carrying 203 sick to Boston on 15 August and heading south again, she foundered while coaling in heavy seas off Fernandina, Florida, fortunately without loss of life. Although Camp Wikoff on Long Island was not yet ready for them and hurricanes threatened, north they came, the first ship departing Cuba on 7 August, the last eighteen days later. The press attacked conditions on board the transports, and the debilitated condition of the men gave a poor impression, but no epidemics broke out during the voyage home, and the men themselves rarely complained. Major Ives concluded that the evacuation was well and humanely managed, given its hasty nature.⁵⁵

Spanish troops were also returning home-General Shafter's promise that all Spanish prisoners, sick or healthy, would be evacuated from Cuba had been part of the surrender agreement-but the role of the U.S. Army Medical Department in their care ended when they left Cuba. The disease rate among the hungry, demoralized enemy soldiers on the island had also risen with the passage of time, a situation blamed chiefly on poor sanitation in their camps. Since no hospital was available to house the growing number of sick, the Spanish commander, General Jose Toral, had been forced to seek help in establishing a hospital as well as in improving sanitation. The repatriation was to be managed by contract, with the contractor providing medical attendance as necessary on board the transports. Because the ships that were to return former enemy soldiers to Spain were slow to arrive, more than 1,000 Spanish sick were yet to be moved from the island when the last of Shafter's men began leaving Cuba, but almost all had left by mid-September.⁵⁶

The campaign in Puerto Rico (Map 3) was even briefer than that in Cuba. The initial landing took place on 25 July, and the armistice brought hostilities to an end on 12 August. For the troops and for their medical officers, the effort in Puerto Rico was less demanding from the outset. The transports that moved the men were far better equipped for the task than those carrying the V Corps. Although what was apparently falciparum malaria afflicted Puerto Rico as it did Cuba, U.S. forces under General Miles, who led this expedition personally, did not encounter the dreaded yellow fever. Because the port of Guanica, near Ponce, taken on the first day, was a good harbor and a highway went through the mountains between Ponce and San Juan, the capital, transportation did not pose the problems that characterized the Cuban campaign. With Miles on 25 July were 3,400 men, originally destined to reinforce General Shafter but who had been held on board their transports at Guantanamo; no troops from yellow fever-infected areas of Cuba were sent to Puerto Rico. Unfortunately, 3,500 reinforcements sent from the United States brought typhoid with them when they joined the troops already there in taking Ponce. Even-

MAP 3

tually 17,000 men from the I, II, and IV Corps were serving on that island under Miles, reinforcements having landed at such varied sites as Guayama, Ponce, and Arroyo. When the fighting ended, only four of Miles' force had been killed and forty wounded, few of them seriously.⁵⁷

Miles consulted often with his chief surgeon, Colonel Greenleaf, who, having arrived in the Caribbean just as disease was beginning to overcome the V Corps, accompanied the commanding general and personally directed the medical support of the effort in Puerto Rico. Nevertheless, some of the difficulties the Medical Department experienced during the invasion of Cuba recurred during the brief Puerto Rican campaign. Among the most persistent problems in this category was the shortage of hospital ships available to serve the troops in Puerto Rico. Last-minute arrangements for a vessel where those who fell ill on transports could be hospitalized became necessary. The Red Cross leased a steamer, the Lampasas, and staffed it with Red Cross doctors and nurses who had been prevented from landing at Guantanamo to avoid exposing them to yellow fever. None of the wounded from the first engagement near Ponce required care on the Lampasas, but her staff, with the aid of medical supplies from a transport and under the supervision of a contract surgeon appointed by Greenleaf, cared for eighty sick from the invasion force, many of whom were suffering from typhoid. Since no hospital ship accompanied the troops from the United States who landed a few days after the units from Guantanamo, as soon as supplies on the Lampasas and another steamer had been off-loaded, Greenleaf had the sick from all units on the island, among them many typhoid victims, loaded on the two vessels and sent north to Fort Monroe.⁵⁸

Secretary of War Alger was sufficiently concerned with the care of the wounded that he asked General Miles whether he should not plan to set up a general hospital in Ponce at once and promised to send as many physicians and nurses as might be needed. Although medical personnel presented few problems, for a time nurses were in short supply. Greenleaf asked Surgeon General Sternberg to send male nurses, although he considered females acceptable for service on a hospital ship or in a general hospital. Eventually, however, women were nursing not only in the Ponce general hospital but in smaller facilities, including four post hospitals.⁵⁹

An adequate number of medical officers and hospital corpsmen was present at each of the minor engagements that characterized the campaign. In one instance, however, the grounding of a transport near Ponce hampered the work of the medical staff of I Corps units that landed at Arroyo on 2 August. As a result, neither the many hospital corpsmen nor the animals used to pull Medical Department wagons rejoined the rest of their unit for more than a week, significantly delaying the unloading of the reserve division hospital and its equipment. Some hospital supplies were unloaded by regimental teams that, despite efforts by medical officers, sometimes succeeded in acquiring and retaining division property. Because a certain amount of materiel had already disappeared during the move from U.S. camps to Puerto Rico, the help of the Red Cross and other charitable organizations was again most welcome.⁶⁰

Other supply problems that followed the invasion of Puerto Rico resembled those experienced in Cuba, although they were not as severe. The first thirty-six ships

to arrive in Puerto Rico were not accompanied by invoices, and thus the entire cargo had to be searched to find what each vessel carried. Lighters to unload the transports were numerous, but minor delays resulted from the way in which the transports had been loaded. In one instance hospital tents were at the bottom of the ship's hold and were reached only a week after the landing. As a result, for a few days hospitals were overcrowded because of the lack of shelter. Similar minor delays involved both ambulances, which were, to Greenleaf's annoyance, sometimes used to move supplies, and medicines, causing temporary shortages on shore despite the amplitude of supplies brought with the invading force. Soon, too, "robbery was rife" as each shipment moved forward, but with, "more perfect organization and better personnel," the arrival of medical supplies intact became more frequent.⁶¹

The struggle between those favoring regimental hospitals and those believing that larger institutions were more efficient flared up once again in Puerto Rico, fueled in part by the fact that the invading force was scattered about the island in small units, each requiring medical personnel and supplies. Hospitals were officially organized by brigade, and the need to provide for both individual units and the larger facilities once more produced an apparent manpower shortage, despite the Medical Department's insistence that patients be consolidated in the larger facilities as promptly as possible. Some volunteer units brought no attendants with them other than hospital stewards, exacerbating the difficulty.⁶²

When the Army occupied towns in Puerto Rico, medical officers searched for buildings in which to house part or all of their hospitals. As soon as Ponce had been taken, they set up a general hospital there for U.S. patients in a former Spanish military facility, moving out its forty-four Spanish occupants, most of whom were the victims of venereal diseases. The building, according to Colonel Greenleaf, "was in an exceedingly filthy condition, with privies overflowing with liquid excrement and various rooms being indescribably dirty." On 9 August, when General Miles initiated the move on San Juan from Ponce, Secretary of War Alger suggested erecting a new building for the general hospital. Although Miles informed Alger that construction material was abundant, within ten days the surgeon in charge of the cleanup operation had the old structure in completely satisfactory condition, and a new facility never became necessary. The former Spanish hospital could accommodate 200 patients, but since it was initially overcrowded, Greenleaf obtained additional space in a well-run Ponce charity hospital. The Sisters of Charity also allowed him to use a girls' school as a hospital. A minimum number of men were detailed from the various commands to serve as nurses to allow as many corpsmen and medical officers as possible to accompany units into action.⁶³

When the troops left Ponce to continue the drive against the Spanish, Colonel Greenleaf was informed that 50 patients would be left in the Ponce hospital. Then "the building was invaded by a promiscuous crowd of stragglers, numbering 150, not over two-thirds of whom required hospital accommodation." Since no security had been set up at the hospital, confusion reigned. Greenleaf quickly set up a convalescent facility that could eventually house 500 in floored and framed huts, to which he sent 125 men. When the hospital ship Relief arrived shortly thereafter, some of the

men who were actively ill were placed on board with a few wounded for evacuation to the United States. As the vessel sailed north after leaving Ponce on 15 August, she picked up a few wounded from the brigade hospital at Mayaguez as well. Not long thereafter, however, Surgeon General Sternberg decided that, since the move might jeopardize the health of the increasing number of men actively suffering from typhoid, the Ponce facility should continue in use as a general hospital to shelter all who were still acutely ill with the disease.⁶⁴

Similar facilities were set up in other Puerto Rican communities as they were occupied. Even when of recent origin, the buildings used as hospitals required repair or remodeling of some kind before U.S. medical officers could consider them satisfactory, and Sternberg believed that tents were preferable. Moreover, the laboratory equipment necessary to examine blood samples from soldiers suffering from fevers was never present. Colonel Greenleaf warned against keeping the sick on the island any longer than absolutely necessary, both because of the climate and because of the effect the presence of debilitated soldiers had on morale. Since both he and Surgeon General Sternberg were reluctant, no doubt because of the experiences in Cuba, to use transports to move the sick and wounded, Greenleaf decided to use only hospital ships for this purpose, although he did allow convalescents to be moved by transport. He decided that when the patients in the Ponce hospital had been sent home, ambulance trains would move the sick from camp hospitals to Ponce, whence they, too, could be evacuated to the United States.⁶⁵

Familiar diseases afflicted troops in Puerto Rico as they had in Cuba, but the Army made sure by means of a quarantine that neither yellow fever nor smallpox came in from the outside. Investigation confirmed the fact that typhoid had been imported from the United States, although it was also endemic in Puerto Rico, and the debilitating effect of the island's malaria followed the pattern that had already become familiar in Cuba. Heavy rains increased the incidence of disease. The remedy of moving camp was again discussed, and Greenleaf suggested that the men of one particularly debilitated unit be sent to the mountains to regain their health and strength. At first the disease rate continued to climb-300 remained when the Lampasas sailed and new cases were occurring at the rate of ten a day in the Ponce area alone. As the campaign ended, the number of new typhoid cases was at last decreasing, but various digestive problems were increasing, and malaria continued to be a major problem for the army of occupation.⁶⁶

Unlike the campaigns in the Caribbean, the effort of General Merritt's VIII Corps to take Manila from the Spanish in the Philippines, so well begun in the United States, encountered few difficulties that could be attributed to poor planning. When General Anderson's vanguard of officers and men, the first troops to arrive, landed during the first week of July at Cavite, this peninsula on Manila Bay southwest of the city itself was already under the U.S. Navy's control. The guns of Commodore Dewey's fleet, capable of forcing the surrender of Manila but not of occupying it, and Filipino rebels surrounding the city already had the enemy at bay when U.S. troops began their advance. The Spanish put up little resistance, although for a week they exchanged fire with

the invaders approaching Manila, leaving more than sixty Americans wounded, until Dewey threatened to use his fleet's heavy guns. The outcome of the final battle for the city on 13 August, one day after the armistice had been signed but before the fact was known in the Philippines, was essentially prearranged during secret negotiations earlier in the month. The Spanish commander, who wished to both save face and surrender, agreed to limit his resistance in exchange for an agreement not to shell the city or to involve the Filipino rebel forces that were allied with the Americans. As a result, the final conquest of the city produced less than fifty U.S. wounded.⁶⁷

High seas and rough surf typical of the monsoon season complicated ship-to-shore movement and retarded all unloading at Cavite, but Medical Department personnel were spared the struggle to locate medical and hospital supplies that had hampered the work of their counterparts in Cuba. Thus, Capt. Harlan E. McVay was able to set up a small post hospital promptly. When the sick who were removed from incoming transports began to crowd the first facility, he appropriated a second building nearby so that he had room for 150 beds. Upon the arrival of the corps chief surgeon, Colonel Lippincott, in mid-July, McVay's facility was upgraded and classified as the VIII Corps' reserve hospital. A hospital steward and Hospital Corps privates from volunteer units were assigned to the hospital, and more joined them after the arrival of additional transports flooded it with new patients. When the third group of transports arrived at Cavite at the end of July, old Spanish cots of bamboo were used to accommodate all the sick. Although Colonel Lippincott considered the buildings at Cavite "unsuitable in every way," they continued in use and became the site of surgical operations then considered demanding, including appendectomies. Despite changing designations, the Cavite facility was apparently always regarded as "a kind of post hospital."⁶⁸

In actual fact, Cavite was a poor location for either a camp or a hospital. A stench blamed on rotting bodies trapped in the hulks of Spanish ships sunk in the bay by Dewey in May permeated the peninsula, and the seawall defenses trapped garbage and sewage near the shore. The buildings that sheltered troops were also "reeking with filth." Not even the rudiments of a sewage system could be found; in some barracks and in all private homes "the faeces of generations had been carefully preserved in cemented vaults." In one building where water closets discharging into sealed vaults had been installed, the gas vents had also been sealed, and from time to time "explosions of gas" drove the "trap water out over the room." The water supply was described as "worse than bad," inadequate in quantity, polluted, brackish, and "filled with organic matter." Bathing facilities as such were nonexistent. Lippincott believed that "the general insalubriousness of the locality" together with overwork was responsible for Captain McVay's death from typhoid in January 1899.⁶⁹

On 15 July General Anderson moved some of his men by water from Cavite north to a generally well-drained area only three miles south of Manila. Here, where peanuts had once been grown, Camp Dewey became a landing site for the rest of General Merritt's command. The water, once boiled, proved entirely satisfactory. Brigade surgeon Maj. William D. Crosby of the U.S. Volunteers, who arrived mid-July with the second group of transports, quickly set up "an excellent tent hospital," and Colonel Lippincott sent him fifty tents

and other supplies as they came in. Until the final day of the campaign, all wounded were sent to this facility. Although with the arrival of the expedition's headquarters the men in the Philippines were organized as the 2d Division, the chief surgeon decided, as had Colonel Greenleaf in Puerto Rico, to rely at least initially on a brigade organization rather than one by division.⁷⁰ Thus the Camp Dewey facility became the first of two brigade hospitals rather than a new division facility. A hospital would be ready to accompany a brigade on detached duty, and when still more troops reached the islands, each brigade hospital could be expanded, if need be, into a division facility. Shortly after the establishment of the first brigade hospital, Maj. George H. Penrose, a brigade surgeon of the U.S. Volunteers, set up the second. Some of the total of a hundred hospital tents on hand for the use of these two facilities were never needed. The men had been living under arduous conditions, "alternately roasted and basted by the sun and the rain," and, out of desperation in the last stages of the campaign, forced to drink whatever water they could find, but the sick rate was only 4 percent. Of the 124 still hospitalized on 13 August, more than half were wounded.⁷¹

The arrival of increasing numbers of soldiers dictated a more formal organization of the 2d Division's Hospital Corps personnel. Initially, only 144 Hospital Corps privates and the 48 men chosen from two volunteer units served under Colonel Lippincott. Of this group, 60 served with their regiments, 27 went to each of the brigade hospitals, and 25 were sent to the Cavite hospital. The division chief surgeon, Maj. Herbert W. Cardwell of the U.S. Volunteers, observed that regimental surgeons tended to keep the best of their men for themselves and to send the dregs to serve elsewhere. The first ambulance company, to which 50 privates were assigned, had been formed and its men instructed in their duties even before Lippincott's arrival in the Philippines. The fact that only two ambulances were available caused no great hardship because these vehicles were too heavy to be used over the muddy roads of the area, and the Quartermaster's Department located about forty local vehicles that proved adequate to the need. Since no tents or utensils were available to allow the members of the ambulance company to camp or eat together, they continued to live with their former regiments. Most of the hospital stewards with the volunteers also remained with their units, but a regular steward served in each hospital.⁷²

Although the shortage of qualified hospital corpsmen was chronic, the number of medical officers was essentially adequate during the first weeks in the Philippines. Colonel Lippincott found most volunteer physicians happy to be assigned to service in the brigade hospitals and only one colonel particularly reluctant to give up his medical officers. Initially, few regimental surgeons were needed for service outside their regiments, since less than 65 officers and men were wounded before the final day of the campaign. The corps chief surgeon required the services of only one regimental medical officer, an excellent surgeon, capable of performing, among others, "a great many operations for the radical cure of hernia, with wonderful success."⁷³

By the time Lippincott was preparing for the final move to Manila, the constant storms that were causing a delay in unloading the transports had rendered supply a major source of frustration. After considerable effort, the chief surgeon obtained a small launch for the exclusive use of the Medical Department so that medical offi-

cers could remove some of their own supplies directly. At Camp Dewey, rain added to the difficulties experienced by medical officers. Although a sufficient number of ponchos had been unloaded to cover the bamboo frames for hospital tents, on 31 July the physicians found themselves caring for patients while standing in water four inches deep. Problems with transportation even led to a shortage of food; for several weeks "but little more than half rations were available."⁷⁴

On 13 August, the final day of Spanish resistance, between 40 and 47 men were wounded. Majors Penrose and Cardwell were at the front all day, supervising care and evacuation. The rocks and holes characteristic of the roads in the area made it likely that litter-bearers would fall, tossing the wounded onto the ground, and thus only a few of the most seriously injured were moved in this way. Since the construction of travois for their patients would have been too time-consuming, surgeons resorted to "native carromatas, two-wheeled carts drawn by diminutive ponies . . . most abominable vehicles," to move the casualties three to five miles to Camp Dewey over "execrable roads" so rough that the jostling tore dressings loose. The natives who drove the "abominable vehicles" worked under guard to prevent desertion. Ambulance stations were set up along the road so that the damage to patients and their dressings could be repaired. Despite the difficulties, by 1900 hours of the day the guns fell silent, all wounded had received medical care and been placed in their beds in one of the hospitals.⁷⁵

The short-lived hostilities of the Spanish-American War taught a hard lesson about the dangers of going to war without adequate preparation. Had the enemy been a more able foe, the result for the Medical Department, as for the Army as a whole, would obviously have been far more tragic. Not surprisingly, therefore, those concerned with the ability of the United States to defend its new role as a world power after 1898 pushed to reorganize both the Army and its Medical Department so that involvement in modern warfare would not spell disaster.

For the Medical Department the greatest tragedy for troops actively involved in hostilities during the Spanish-American War had been produced by disease. The story of the care of wounds in this war was a triumphant one-whether in the Philippines or the Caribbean, the casualties of the Spanish-American War were far more fortunate than those of the Civil War. By 1898 physicians knew how wounds became infected, and the precautions necessary to prevent wound infection were easily taken. The wounded invariably did well in spite of large numbers of inexperienced physicians, difficult terrain, filth, and a shortage of suitable shelter for hospitals. An understanding of how typhoid fever, malaria, and yellow fever were spread was the necessary first step to eliminating the high toll these diseases traditionally took, and the medical profession was only on the brink of that understanding. In the care of wounds the war with Spain represented a new era in medicine, but in the prevention of disease it marked the last gasp of a long dark age.

1. Unless otherwise indicated, all material on the Spanish-American War is based on Graham A. Cosmas, Army for Empire.

2. War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1898, pp. 206, 215 (hereafter cited as WD, ARofSG, date). Exact figures on the number of wounded from the Spanish-American War in Cuba vary. See, for example, in the William R. Shafter Papers, Stanford University, Palo Alto, Calif. (hereafter cited as Shafter Papers, SU), the following: Ltr, Joseph Wheeler to AG, 25 Jun 1898, and Rpt, Shafter to AG, 8 Jul 1898, Microfilm (Mf) Reel 3; and V Army Corps GO 36, 19 Jul 1898, Mf Reel 4.

3. WD, ARofSG, 1898, pp. 116-17, 195, 206; idem, [Annual] Report of the Secretary of War, 1898, 1(pt.1):4 (hereafter cited as WD, ARofSW, date); Edward Marshall, The Story of the Rough Riders, p. 148; in Shafter Papers, SU: Ltrs, Edward J. McClernand to Ch Surg, 23 Jun 1898, and Benjamin F. Pope to Asst AG, V Army Corps, 23 Jun 1898, Mf Reel 3, and Report of Commission To Investigate the Conduct of the War, p. 71, Mf Reel 6 (hereafter cited as Com Rpt).

4. George Kennan, Campaigning in Cuba, p. 87; WD, ARofSG, 1898, pp. 116-17, 147, 192, and 1899, pp. 57-58; Erna Risch, Quartermaster Support of the Army, pp. 537, 541, 552-53; Ltr, Shafter to AG, 3 Jun 1898, Mf Reel 2, Shafter Papers, SU; United States, Congress, Senate, Report of the (Dodge) Commission To Investigate the Conduct of the War Department in the War With Spain, 1:645 and 8:137, 139 (hereafter cited as Dodge Commission Report).

5. WD, ARofSG, 1898, pp. 193-94, 198 (quotation), 215, 221-23, 225; Kennan, Campaigning, pp. 76, 83; in Shafter Papers, SU: Ltrs, B. Pope to Asst AG, V Army Corps, 23 Jun 1898, and Joseph Wheeler to Shafter, 24 Jun 1898, Mf Reel 3, and Ltr, B. Pope to SG, 25 Jun 1898, in Rpt, Benjamin F. Pope, Mf Reel 6; Dodge Commission Report, 6:2894.

6. Nicholas Senn, Medico-surgical Aspects of the Spanish-American War, pp. 363-64; WD, ARofSG, 1898, pp. 192, 209, 224, 233; Victor C. Vaughan, "The Care of the Wounded at Santiago," p. 32; Robert Reyburn, Fifty Years in the Practice of Medicine and Surgery, 1856 to 1906, p. 9; War Department, Surgeon General's Office, The Surgeon General's Office, p. 52 (hereafter cited as WD, SGO, SGO).

7. Kennan, Campaigning, pp. 5, 97 (quotation); WD, ARofSG, 1898, pp. 117, 194, 218-19.

8. WD, ARofSG, 1898, pp. 208-09 (quotation), 219, 224, 227-29, 231; Dodge Commission Report, 1:355.

9. Autobiography, William R. Shafter, ch. VII, p. 5, Mf Reel 6, Shafter Papers, SU; WD, ARofSG, pp. 116, 187, 195, 198, 206, 227; Dodge Commission Report, 1:589; John J. Bigelow, Reminiscences of the Santiago Campaign, p. 148; Theodore Roosevelt, "The Rough Riders," p. 678; WD, SGO, SGO, p. 52.

10. Shafter Autobiography, ch. VII, p. 4 (first quotation), Mf Reel 6, Shafter Papers, SU; WD, ARofSG, 1898, pp. 117, 206 (remaining quotations), 214, 224, 227; Dodge Commission Report, 6:2917, 8:527.

11. WD, ARofSG, 1898, pp. 117, 194-95, 206, 221-23, and 1899, p. 58 (quotation); Kennan, Campaigning, pp. 130-36; Ltrs, Shafter to SW, 27 Jun 1898, and to AG, 8 Jul 1898, and French E. Chadwick to E. McClernand, 27 Jun 1898, Mf Reel 3, Shafter Papers, SU; Dodge Commission Report, 6:3031, 8:141; "New York Academy of Medicine," p. 566; WD, SGO, SGO, p. 52.

12. John D. Miley, In Cuba With Shafter, pp. 137-38 (quotation); WD, ARofSG, 1898, p. 198; Ltrs, Shafter to CG, Spanish Forces, Santiago de Cuba, 4 Jul 1898, to Jose Toral, 5 Jul 1898, and to AG, 5 Jul 1898, Mf Reel 3, Shafter Papers, SU; Senn, Aspects, p. 322; Kennan, Campaigning, p. 148.

13. WD, ARofSG, 1898, pp. 117, 197-98, 212-13; Dodge Commission Report, 1:645, 5:1824.

14. Senn, Aspects, p. 320; Kennan, Campaigning, pp. 86, 114, 148; in Shafter Papers, SU: Ltr, Shafter to AG, 6 Jul 1898, Mf Reel 3, and Ltr, B. Pope to SG, 5 Jul 1898 (first quotation), in Pope Rpt, plus Com Rpt, p. 72, both Mf Reel 6; WD, ARofSG, 1898, pp. 198, 212 (remaining quotations), 213, 226.

15. WD, ARofSG, 1898, pp. 215 (fourth quotation), 216 (first two quotations), 222 (third quotation), 223, and 1899, pp. 305, 311-14; Senn, Aspects, p. 341; Ltr, Shafter to AG, 6 Jul 1898, Mf Reel 3, Shafter Papers, SU.

16. WD, ARofSG, 1898, p. 198, and 1899, pp. 235-36, 305, 308-14; idem, ARofSW, 1898, l(pt.1):5, 150, 273, 786, and l(pt.2):59, 124.

17. William C. Borden, "Conservatism in Military Surgery," pp. 250, 256; idem, The Use of the Rontgen Ray by the Medical Department of the United States Army in the War With Spain, pp. 29, 32-33; Valery Havard, "The Krag-Jorgensen Bullet-Wound," p. 1413; Nicholas Senn, "Recent Experiences in Military Surgery After the Battle of Santiago," p. 1164; idem, "Surgical Diseases of the Spanish-American War," p. 1419; WD, ARofSG, 1898, pp. 209, 221, 233; Com Rpt, p. 76, Mf Reel 6, Shafter Papers, SU; Dodge Commission Report, 1:616, 8:146-47; Bigelow, Reminiscences, p. 146; Narrative, Esther V. Hasson, Entry 230, Record Group (RG) 112, National Archives and Records Administration (NARA).

18. First quotation from Ltr, Shafter to Wilson, 9 Feb 1899, Mf Reel 6, Shafter Papers, SU. In loc. cit., on Mf Reel 3, see Ltrs, Edward J. McClernand to Joseph Wheeler, 1 Jul 1898, to SW, 3 and 5 Jul 1898, and to Henry W. Lawton, 12 Jul 1898; Henry M. Duffield to Shafter, 10 Jul 1898; Leon S. Roudiez to McClernand, 10 Jul 1898; Charles G. Starr to McClernand, 10 Jul 1898; J. C. Gilmore to J. Wheeler, 12 Jul 1898; and Lawton to AG, 12 Jul 1898. Second quotation from Senn, Aspects, p. 173. See also William R. Shafter, "The Capture of Santiago de Cuba," p. 625; Hermann Hagedorn, Leonard Wood, 1:212; War Department, Correspondence Relating to the War With Spain . . . , 1:196. Senn was initially assigned as chief surgeon of the VI Corps, but on 22 June, when he realized that this corps would not be organized, he asked for active duty. See idem, ARofSG, 1899, p. 65.

19. The famous Rough Riders were the lst Cavalry, U.S. Volunteers.

20. Quotations from Henry Cabot Lodge, ed., Selections From the Correspondence of Theodore Roosevelt and Henry Cabot Lodge, 1884-1918, 1:322, 327. See also ibid., p. 323; Victor C. Vaughan, A Doctor's Memories, pp. 336-37, 340; in Shafter Papers, SU: Ltr, Roosevelt to Shafter, 12 Jul 1898, Mf Reel 3, and Ltrs, W. W. Calhoun to AG, V Army Corps, 16 Jul 1898, and B. Pope to SG, 19 Jul 1898, in Pope Rpt, Mf Reel 6.

21. First quotation from Ltr, Shafter to J. C. Gilmore, 1 Aug 1898, and second quotation from Ltr, Roosevelt to Joseph Wheeler, 5 Aug 1898, both Mf Reel 4, Shafter Papers, SU. In loc. cit., see Ltrs, Charles F. Humphrey to Edward J. McClernand, 20 Jul 1898, Joseph T. Ch[?]pe to Adj, 22d Inf, 31 Jul 1898, and Shafter to QMG, 22 Jul 1898, and to AG, 23 Jul 1898, and, on Mf Reel 6, Ltr, Shafter to AG, 30 Sep 1898. See also WD, ARofSG, 1898, p. 197; Vaughan, Memories, pp. 334, 336-37, 340; Kennan, Campaigning, p. 216.

22. Quotation from Ltr, B. Pope to Asst AG, 22 Jul 1898, Mf Reel 4, Shafter Papers, SU. In loc. cit., see on Mf Reel 3: Ltrs, AG to Shafter, 3 and 5 Jul 1898, SW to Shafter, 4 Jul 1898, Shafter to AG, 5 Jul 1898, and J. C. Gilmore to COs [various], 14 Jul 1898, and V Army Corps SO 35, 11 Jul 1898; on Mf Reel 4: Ltrs, C. Humphrey to E. McClernand, 20 Jul 1898, Shafter to AG, 25 Jul and 6 Aug 1898, John D. Miley to E. McClernand, 27 Jul 1898, and E. McClernand to Henry W. Lawton, 28 Jul 1898, plus V Army Corps GO 27, 23 Jul 1898, and Ch Surg, 5th Army Corps, Cir (to Volunteers), n.d.; on Mf Reel 5: Telg, Shafter to AG, 13 Aug 1898; and on Mf Reel 6: Encl to Ltr, Charles D. Rhodes to William H. McKittrick, Nov 1931. See also Dodge Commission Report, 6:3044; WD, Correspondence, 1:217; idem, ARofSG, 1898, pp. 137-38, 200, 228, 230; Nelson A. Miles, Serving the Republic, p. 285; Charles H. Alden, "Roster of Volunteer Medical Officers Who Served During the Spanish-American War of 1898 in the Military and Naval Services," p. 58; "The Heroes at the Rear," p. 235; John Duffy, The Sanitarians, pp. 152, 194, 222.

23. Dodge Commission Report, 8:151; WD, ARofSG, 1899, pp. 236-39; in Shafter Papers, SU: Rpts, Shafter to AG, 27 Jul-23 Aug 1898, Mf Reels 4-5, and Shafter Autobiography, ch. VII, p. 6, Pope Rpt, 19 Jul 1898, Ltr, Shafter to J. Wilson, 7 Feb 1899, and Shafter Speech, all Mf Reel 6.

24. WD, ARofSG, 1898, pp. 199, 203, 235, and 1900, p. 74; in Shafter Papers, SU: Ltr, J. Ch[?]pe to Adj, 22d Inf, 31 Jul 1898, Mf Reel 4, and Telgs, Shafter to AG, 8 and 9 Aug 1898, Mf Reel 5; Joseph Wheeler, The Santiago Campaign, 1898, pp. 357, 359-60; Lodge, Selections, 1:332; Roosevelt, "Rough Riders," pp. 677, 680; Dodge Commission Report, 8:135; Fielding H. Garrison, An Introduction to the History of Medicine, p. 526; "Mosquitoes and Malaria," p. 324.

25. WD, ARofSG, 1898, pp. 199, 218-19, 229, 233 (quotation); Risch, Quartermaster Support, p. 534; Russell A. Alger, "The Food of the Army During the Spanish War," p. 58. See also in Shafter Papers, SU: Ltr, Henry W. Lawton to AG, V Army Corps, 24 Jun 1898, and V Army Corps GO 23, 10 Jul 1898, and Ltr, Roosevelt to Shafter, 12 Jul 1898, all Mf Reel 3; Ltrs, G. Creighton Webb to AG, lst Div, V Army Corps, 16 Jul 1898, and J. Ch[?]pe to Adj, 22d Inf, 31 Jul 1898, Mf Reel 4; and Ltr, Shafter

to Charles P. Eagan, 24 Dec 1898, and Com Rpt, pp. 51-55, 72, both Mf Reel 6.

26. WD, ARofSG, 1898, pp. 114, 196, 205, 216 (quotation), 228-29, 234, and 1899, p. 690; Ltr, Edward J. McClernand to Charles R. Greenleaf, 15 Jul 1898, Mf Reel 4, Shafter Papers, SU; Walter Millis, The Martial Spirit, pp. 346-47; Dodge Commission Report, 1:645; Hagedorn, Wood, 1:201; Miles, Serving, p. 282; Risch, Quartermaster Support, p. 532; William N. Bispham, Malaria, pp. 68, 74; Vaughan, Memories, p. 347; Roosevelt, "Rough Riders," p. 679.

27. WD, ARofSG, 1898, pp. 117, 230, 234 (quotation), and 1899, p. 251; Miles, Serving, p. 287; Kennan, Campaigning, p. 162; Ltrs, Shafter to AG, 6 Jul 1898, Henry M. Duffield to E. McClernand, 6 Jul 1898, and Charles S. Humphrey to QMG, 12 Jul 1898, Mf Reel 3, Shafter Papers, SU; Dodge Commission Report, 5:2104, 6:3049, and 8:151.

28. Dodge Commission Report, 1:588 (quotations), 614; WD, ARofSW, 1898, 1(pt. 1):33-34, 37; idem, Correspondence, 1:303; idem, ARofSG, 1898, pp. 145, 234-35, and 1899, p. 92; Hagedorn, Wood, 1:262; Miley, In Cuba, pp. 216-17; Roosevelt, "Rough Riders," p. 680. See also in Shafter Papers, SU, on Mf Reel 3: Ltrs, J. Wheeler to Asst AG, Cuba, 28 Jun 1898, B. Pope to Asst AG, 10 Jul 1898, and AG to Shafter, 13 Jul 1898; on Mf Reel 4: Ltrs, Miles to Shafter, 15 Jul 1898, and to AG, 1st Div, V Army Corps, 16 Jul 1898, G. Creighton Webb to AG, 1st Div, V Army Corps, 16 Jul 1898, and SW to Shafter, 2 Aug 1898; and on Mf Reel 6: Shafter Autobiography, ch. VII, pp. 5-6.

29. WD, ARofSG, 1898, pp. 144, 196 (quotation); idem, ARofSW, 1898, l(pt.1):30-31; Dodge Commission Report, 1:645; Miley, In Cuba, p. 155; in Shafter Papers, SU: Ltrs, H. Duffield to E. McClernand, 6 Jul 1898, and C. Humphreys to QMG, 12 Jul 1898, Mf Reel 3, and Ltrs, E. McClernand to C. Greenleaf, 15 Jul 1898, and Ch Surg, 1st Div, V Army Corps, to AG, 1st Div, V Army Corps, 16 Jul 1898, Mf Reel 4; Nicholas Senn, War Correspondence (Hispano-American War), pp. 81-82.

30. Miles, Serving, p. 293; WD, ARofSG, 1898, pp. 196, 213, 217; WD, ARofSW, 1898, 1(pt. 1):35; in Shafter Papers, SU: Ltr, Edward J. McClernand to Henry V. Boynton, 11 Jul 1898, Mf Reel 3, and Ltr, Boynton to Henry M. Duffield, 28 Nov 1898, Mf Reel 6.

31. Ltrs, Shafter to AG, 21-23, 25-26 Jul 1898, Mf Reel 4, Shafter Papers, SU; Dodge Commission Report, 1:645; Vaughan, Memories, p. 346; WD, ARofSG, 1899, p. 60.

32. WD, ARofSG, 1898, pp. 194-95, 212-13, 216; Dodge Commission Report, 5:1829 and 8:145, 150-51.

33. Quotations from WD, ARofSG, 1898, pp. 216-17; ibid., pp. 144-45, 196, 203, and 1899, pp. 145, 250; Miles, Serving, pp. 287, 292-93; Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas, pp. 67-68; in Shafter Papers, SU: Ltrs, Ch Surg to Asst AG, V Army Corps, 26 Jun 1898, and McClernand to Shafter, 11 and 13 Jul 1898, Mf Reel 3, and Ltr, H. Boynton to H. Duffield, 28 Nov 1898, Mf Reel 6; WD, ARofSW, 1898, 1(pt.1):30-31, 35; Vaughan, Memories, p. 346; Miley, In Cuba, p. 155; Senn, War Correspondence, pp. 81-82; Dodge Commission Report, 1:645, 5:1840; "The First Battle Against Yellow Fever," p. 126; Orlando Ducker, "The Troops in Santiago," p. 669.

34. Quotation from Dodge Commission Report, 1:573; ibid., 1:574, 616; Vaughan, Memories, pp. 345, 347; Esmond R. Long, A History of American Pathology, pp. 156-57; WD, ARofSG, 1898, pp. 115, 117, 145, 150, 170, 195-96, 216-17, 220, 234, and 1899, p. 170; Ltrs, J. C. Gilmore to Shafter, 18-19 Jul 1898, Maj Commanding to Asst AG, V Army Corps, 23 Jul 1898, and Edward J. McClernand to Louis A. LaGarde, 31 Jul 1898, Mf Reel 4, Shafter Papers, SU.

35. The detention camp was also referred to as a detention hospital.

36. WD, ARofSG, 1898, pp. 115, 195-96, 209, 220, 234 (quotation), 240, and 1899, p. 60; Dodge Commission Report, 6:3049.

37. Dodge Commission Report, 1:400-403; WD, ARofSG, 1898, pp. 185, 197, 209, 236-37, and 1899, pp. 57, 170; Telg, Shafter to AG, 10 Aug 1898, Mf Reel 5, Shafter Papers, SU.

38. Quotation from Ltr, McClernand to Tait, 3 Oct 1898, Mf Reel 6, Shafter Papers, SU (see also idem to LaGarde, 31 Jul 1898, Mf Reel 4); WD, ARofSG, 1899, pp. 60, 155, 170; idem, Correspondence, 1:140, 196.

39. First quotation from Telg, SW to Shafter, 9 Aug 1898, Mf Reel 5, Shafter Papers, SU. In loc. cit., see Telgs, Shafter to AG, 8 and 10 Aug 1898, and, on Mf Reel 4, Ltr, E. McClernand to H. Lawton, 20 Jul 1898. Second quotation from WD, Correspondence, 1:241. See also ibid., 1:217; idem, ARofSG, 1898, p. 209, and 1899, p. 170.

40. Quotations from WD, ARofSG, 1898, pp. 214-15; ibid., pp. 145, 207, 213, 216, 238; idem, Correspondence, 1:140, 197; idem, ARofSW, l(pt.1):35; Dodge Commission Report, 1:400-403, 8:145. See also in Shafter Papers, SU, on Mf Reel 3:

Ltrs, Shafter to AG, 6 Jul 1898, and to Henry L. Turner, 10 Jul 1898; on Mf Reel 4: Ltrs, McClernand to Greenleaf, Greenleaf to AG, V Army Corps, and Miles to Shafter, all 15 Jul 1898, plus Shafter to AG, 18 Jul 1898, and Alfred C. Markley to AG, 5th Army Corps, 1898; and on Mf Reel 6: Ltrs, Pope to SG, 10 and 19 Jul 1898, in Pope Rpt.

41. WD, ARofSG, 1898, pp. 117, 196 (first quotation), 217, 238 (fourth quotation); Dodge Commission Report, 5:1833, 6:3052 (second quotation); in Shafter Papers, SU: Ltr, AG to Shafter, 13 Jul 1898, Mf Reel 3, and Ltr, Miles to Shafter, 15 Jul 1898, Mf Reel 4, and Telg, Shafter to AG, 16 Aug 1898 (third quotation), Mf Reel 5; WD, Correspondence, 1:225, 231; idem, ARofSW, 1898, l(pt.1):34; Statement, [Anita Newcomb McGee], p. 9, Entry 230, RG 112, NARA; "The Yellow Fever," p. 128.

42. Quotation from Ives End to Ltr, Morrison, 3 Aug 1898, Mf Reel 4, Shafter Papers, SU. In loc. cit., see Ltrs, Leon S. Roudiez to Edward J. McClernand, 20 Jul 1898, and Shafter to AG, 1 Aug 1898, and to SW, 4 Aug 1898. See also WD, Correspondence, 1:197; idem, ARofSG, 1898, pp. 237-38; Dodge Commission Report, 8:135.

43. Senn, Aspects, p. 318 (quotation); Dodge Commission Report, 1:645.

44. WD, ARofSG, 1898, pp. 108-09, 217, 225, and 1899, p. 170; Dodge Commission Report, 1:645, 6:2897; in Shafter Papers, SU: Ltrs, Shafter to AG, 25 Jun 1898, and to William T. Sampson, 26 Jun 1898, Ch Surg to Asst AG, V Army Corps, 26 Jun 1898, and Sampson to Shafter, Mf Reel 3, and Ltr, Edward J. McClernand to Ch QM, 30 Jul 1898, Mf Reel 4.

45. WD, ARofSG, 1898, pp. 107-09, 145, 215, and 1899, pp. 202-03; Dodge Commission Report, 1:330, 339; WD, Correspondence, 1:196, 199; Ltr, Louis A. LaGarde to Shafter, 2 Aug 1898, Mf Reel 4, Shafter Papers, SU; Vaughan, Memories, p. 347; "War Articles," p. 39; Statement, Esther V. Hasson, Entry 230, RG 112, NARA.

46. WD, Correspondence, 1:197, 237; idem, ARofSW, 1898, 1(pt. 1):128; Ltr, AG to Shafter, 4 Jul 1898, Mf Reel 3, Shafter Papers, SU; Dodge Commission Report, 1:573.

47. Ralph C. Williams, The United States Public Health Service, 1798-1950, pp. 85-86, 559 (hereafter cited as USPHS); Dodge Commission Report, 1:571, 573, 646; in Shafter Papers, SU: Memo, J. C. Gilmore, 22 May 1898, Mf Reel 2, and V Army Corps GO 32, 7 Aug 1898, Mf Reel 4, and Telgs, AG to Shafter, 9 and 12 Aug 1898, Mf Reel 5; WD, Correspondence, 1:237; idem, ARofSG, 1899, pp. 59-60; Vaughan, Memories, pp. 358-59, 366.

48. Millis, Martial Spirit, p. 347; WD, ARofSG, 1898, pp. 118 (quotation), 197-98, 226; Dodge Commission Report, 1:646; Senn, Aspects, p. 173.

49. First quotation from WD, ARofSG, 1898, p. 197; second quotation from "The Medical Department of the Army Again," p. 178; third quotation from Ltr, SW to Shafter, 2 Aug 1898, Mf Reel 4, Shafter Papers, SU. In loc. cit., on Mf Reel 6, see Com Rpt, p. 39. See also WD, Correspondence, 1:141; Dodge Commission Report, 8:153.

50. WD, ARofSG, 1898, pp. 235-36 (quotation); "The Soldier and the Medical Department of the Army," p. 233; "The Responsibility of the Army Medical Department," p. 451; Dodge Commission Report, 1:143, 186-87, and 5:2108; WD, Correspondence, 1:141, 197, 241; "A Case for Investigation," p. 127. See also in Shafter Papers, SU, on Mf Reel 3: Ltrs, Edward J. McClernand to Charles F. Humphrey, 11 Jul 1898, and Humphrey to McClernand, 13 Jul 1898; on Mf Reel 4: Ltrs, AG to Shafter, 2 Aug 1898, and Louis A. LaGarde to J. C. Gilmore, 2 Aug 1898; on Mf Reel 5: Telg, Shafter to AG, 20 Aug 1898; and on Mf Reel 6: Com Rpt, p. 39.

51. WD, ARofSW, 1898, 1(pt.1):129; Scheffel H. Wright, "Historical Issue; Medicine in the Florida Camps During the Spanish-American War," pp. 24-25; in Shafter Papers, SU: Ltrs, AG to Shafter, 26 Jun and 5 Jul 1898, and Shafter to AG, 5 Jul 1898, Mf Reel 3, and Ltrs, SW to Shafter, 1 and 6 Aug 1898, and Shafter to AG, 7 Aug 1898, Mf Reel 4.

52. WD, Correspondence, 1:213 (quotation), 360; idem, ARofSG, 1898, pp. 118, 145, 235; in Shafter Papers, SU: Ltrs, Shafter to AG, 31 Jul 1898, SW to Shafter, [1 Aug 1898], and Joseph Wheeler et al. to Shafter, 3 Aug 1898, Mf Reel 4, and Shafter Autobiography, ch. VII, p. 6, Mf Reel 6; Miley, In Cuba, p. 223; Lodge, Selections, 1:332; Wheeler, Santiago Campaign, pp. 359-60.

53. First quotation from Shafter, "Capture," p. 629; second quotation from Ltr, Roosevelt to J. Wheeler, 31 Jul 1898, Mf Reel 4, Shafter Papers, SU. In loc. cit., see V Army Corps SO 40, 17 Jul 1898, and Ltrs, Shafter to AG, 31 Jul and 3 Aug 1898, AG to Shafter, 1 Aug 1898, J. Wheeler et al. to Shafter, 3 Aug 1898, and Valery Havard to AG, V Army Corps, 3 Aug 1898; and on Mf Reel 3: Ltrs, AG to Shafter, 13 and 14 Jul 1898. See also Williams, USPHS, pp. 85-86; WD, Correspondence, 1:360, 396.

54. WD, Correspondence, 1:204, 218, 224 (quotation); Ltr, AG to Shafter, 5 Aug 1898, Mf Reel 4, Shafter Papers, SU; Dodge Commission Report, 8:157.

55. Martha L. Sternberg, George Miller Sternberg, p. 178; WD, ARofSG, 1898, pp. 235-36; Roosevelt,

"Rough Riders," p. 688; Nicholas Senn, "The Medical Department of the Army," p. 215. See also in Shafter Papers, SU, on Mf Reel 4: Ltrs, Shafter to William H. Bisbee and to SW, both 4 Aug 1898, SW to Shafter, 4 and 5 Aug 1898, and J. C. Gilmore to CO, 8th Ohio Vols, 5 Aug 1898; and on Mf Reel 5: Ltr, AG to Shafter, 9 Aug 1898, and Telgs, Shafter to AG, 13 and 15 Aug 1898.

56. Dodge Commission Report, 1:135-36; "Echoes and News," p. 402; Leonard Wood, "Santiago Since the Surrender," p. 515; WD, ARofSG, 1898, p. 198; idem, Correspondence, 1:196, 204; George G. Lewis and John Mewha, History of Prisoner of War Utilization by the United States Army, 1776-1945, p. 45. See also in Shafter Papers, SU, on Mf Reel 4: Ltrs, Jose Toral to Shafter, 17 and 21 Jul 1898, and to C-in-C, 24 Jul 1898, AG to Shafter, 25 Jul 1898, and Edward J. McClernand to Alfred C. Markley, 27 Jul 1898; and on Mf Reel 6: Shafter Autobiography, ch. VII, p. 7.

57. James A. Huston, The Sinews of War, p. 284; WD, ARofSW, 1898, 1(pt.l):6-7; Senn, War Correspondence, p. 86; Lodge, Selections, 1:330.

58. WD, ARofSG, 1898, pp. 145-46; Dodge Commission Report, 1:574-78, 623; Nicholas Senn, "The Invasion of Porto Rico From a Medical Standpoint," p. 595; idem, War Correspondence, p. 86.

59. Dodge Commission Report, 1:592, 624; WD, ARofSG, 1898, pp. 171-72, and 1899, p. 184; idem, Correspondence, 1:373, 381.

60. WD, ARofSG, 1898, pp. 135-36, 171, and 1899, pp. 184-85; Dodge Commission Report, 1:600; Senn, War Correspondence, pp. 129-30.

61. WD, ARofSG, 1898, p. 146, and 1899, p. 185 (quotation); Dodge Commission Report, 1:137, 599, 601.

62. Dodge Commission Report, 5:1741; WD, ARofSG, 1898, pp. 171, 176.

63. WD, ARofSG, 1898, p. 146 (quotation), and 1899, p. 174; Dodge Commission Report, 1:578, 620, 625; WD, Correspondence, 1:373.

64. Dodge Commission Report, 1:578 (quotation), 591, 593, 623; WD, ARofSG, 1899, pp. 174, 180; Borden, Rontgen Ray, pp. 11-12, 29; Bigelow, Reminiscences, p. 146; Senn, War Correspondence, pp. 97, 99; Thomas C. Biddle, "Typhoid Fever in the Tropics," pp. 104-05.

65. Dodge Commission Report, 1:577, 581, 622, 624; Biddle, "Typhoid Fever," pp. 104-05; WD, ARofSG, 1898, pp. 124-25, 147, and 1899, pp. 174, 179-80, 185.

66. "The Hospital Ship 'Relief'," p. 310; WD, ARofSG, 1898, pp. 124-25, 146-47, 152; Dodge Commission Report, 1:575, 577-78, 594, 619, 621-23, 625, 629; Nicholas Senn, "Typhoid Fever in the Porto Rican Campaign," pp. 599, 604; idem, "Invasion of Porto Rico," pp. 597-98; idem, War Correspondence, p. 87.

67. Frederica M. Bunge, ed., Philippines, pp. 22-23; WD, ARofSW, 1898, 1(pt.2):58-59, 124.

68. WD, ARofSG, 1898, pp. 125, 263-64 (first quotation), and 1899, pp. 99, 122, 126, 133, 136-37; Huston, Sinews, p. 302; "Medical and Sanitary History of Troops in the Philippines," pp. 828 (second quotation), 830; Henry Lippincott, "Reminiscences of the Expedition to the Philippine Islands," p. 171.

69. WD, ARofSG, 1898, p. 264, and 1899, pp. 118, 133-34 (quotations), 135; Telg, Elwell S. Otis to AG, 5 Jan 1899, Harlan E. McVay Papers, Entry 561, RG 94, NARA.

70. The 2d Division was composed of two brigades at this time. See WD, ARofSW, 1898, l(pt.2):42.

71. WD, ARofSW, 1898, 1(pt. 2):123 (first quotation); idem, ARofSG, 1899, pp. 99, 118, 126-27, 135, 138 (second quotation); "Medical and Sanitary History," p. 826.

72. WD, ARofSG, 1899, pp. 102, 122, 124, 137.

73. WD, ARofSG, 1899, pp. 121 (quotation), 123; idem, ARofSW, 1898, l(pt.2):58-59, 71, 503; "Medical and Sanitary History," p. 826. Exact figures on the number of wounded in August vary slightly, probably because, as Lippincott explained, "a few slight wounds" were not initially reported (idem, ARofSG, 1899, p. 124).

74. WD, ARofSG, 1898, pp. 263-64, and 1899, pp. 127, 135 (quotation), 138; "Medical and Sanitary History," p. 830.

75. "Medical and Sanitary History," p. 829 (quotations); WD, ARofSG, 1898, p. 263, and 1899, pp. 99, 124, 137-38; idem, ARofSW, 1898, 1(pt.1): 273, 851, and l(pt.2):58-59, 60-61, 81-82, 124, 503.