The "splendid little war" was over almost as soon as it began, and in the United States even disease was defeated within a few months. But for U.S. forces in the Far East, the surrender of the Spanish was only the start of a long struggle. Beginning in the spring of 1900 and continuing for years thereafter, soldiers in the Philippines would be involved in guerrilla warfare, and the medical officers with them would face challenges rendered more demanding than those of the Indian wars both by the complexities of the campaigns and by the tropical climate and its diseases. American soldiers and marines would also be called upon to join troops from other major powers to end violence engendered in China by members of a secret organization, the Boxers, who, with the tacit approval of the Dowager Empress, sought to end foreign exploitation of their nation. The physicians with them would be required to deal with the consequences of generations of abysmally poor sanitation and of the diseases that inevitably resulted.

The defeat of the Spanish brought in mid-August 1898 only a short respite for General Merritt's VIII Corps. During this period, beginning shortly after the surrender, a flurry of changes took place at the highest level of command in the Philippines. On 25 August the 1st Division of the VIII Corps was organized under the command of General Anderson, who was recently promoted to major general in the volunteers. On the twenty-eighth Anderson was relieved as commander of the 2d Division by Arthur MacArthur, now too a new major general in the volunteers, and General Merritt as commanding general of the VIII Corps by Elwell S. Otis, also a major general in the volunteers. On the twenty-ninth Otis also relieved Merritt as military governor and commanding officer of the Department of the Pacific.¹

Thus General Otis was in command of U.S. forces in the Philippines when, in February 1899, the Filipinos, suspicious about the motives of their liberators, turned to violence, initially in the form of warfare as orthodox as it could be among the narrow jungle trails and waterways that surrounded Manila. U.S. units, and the medical officers accompanying them, gained their first taste of what was to come when they attempted to defeat their new enemy and found themselves struggling to penetrate the mountains northwest of Manila-essentially impassable for vehicles-and, once beyond the mountains, to progress along bad roads and across "insecure" bridges. These early efforts were success-

ful, but U.S. troops were not yet ready to seize and retain control of any extensive area, because all the volunteers and a third of the regulars in the VIII Corps were entitled to return home in the spring of 1899. When the volunteers of 1898 were mustered out, they were replaced by 35,000 men of new United States Volunteer regiments. By the autumn of 1899, with the arrival of new troops, U.S. forces in the Philippines numbered 66,000, more than 30,000 of them volunteers.²

The Americans now moved to take control of the islands, beginning with Luzon and a three-pronged push north of Manila (Map 4). In this campaign too, as Secretary of War Elihu Root noted in his report for 1899, "all . . . movements were accomplished under great difficulties owing to the almost impassable condition of the country." By the end of November the resistance was abandoning its attempts to conduct conventional warfare, and U.S. troops in northern Luzon were "actively pursuing the flying and scattered bands of insurgents, further dispersing them. . . . " American forces soon extended the drive to take complete control of the Philippines to the east and south of Manila as well, into another area of difficult terrain. So successful were these efforts that by the spring of 1900 General Otis concluded that the insurrection had been defeated and in May asked to be relieved. Nevertheless, troops under General MacArthur, who replaced Otis as commanding general in the Philippines, still faced guerrilla attacks and had to remain in the field and establish what would eventually be more than 500 posts to hold what they had taken.³

During the earliest and most conventional stage of the Philippine Insurrection, a single military department formed the basis for the government of the islands. The organization of VIII Corps medical personnel still reflected that of the corps itself. A chief surgeon headed the medical service of the entire corps, and a chief surgeon was assigned to each division and brigade of the corps. The regimental staff, which normally consisted of three physicians, increased significantly after the change from more conventional warfare to a guerrilla conflict in early 1900 and the increase in the number of posts that resulted. Eventually, although as many as seven medical officers sometimes served on a regimental staff, their numbers could still be too small to provide a physician for each garrison in its district. As a result, hospital corpsmen might be assigned to assume the physician's role for the smallest detachments and subposts.⁴

At the end of March 1900 the complexities involved in dealing with the guerrillas and governing the islands led to the transformation of what had been the Department of the Pacific into the Division of the Philippines with four geographical departments, each of which was, in turn, divided into military districts. This step brought an end to the VIII Corps.⁵ The corps chief surgeon become the chief surgeon of the Division of the Philippines. The position of the chief surgeon of a military division was transformed into that of the chief surgeon of a department and that of the chief surgeon of a brigade into that of the chief surgeon of a district. The district form of organization was dropped late in 1901 and replaced by an organization by brigade.⁶

The government of the Philippines changed again in the spring of 1901, after U.S. forces captured the chief guerrilla leader, Emilio Aguinaldo. Although minor guerrilla activity would continue for many years thereafter, a successful effort to reduce expenses by concentrating resources

MAP 4

was initiated, and the four departments were consolidated into two. President McKinley confidently appointed a civilian government for the islands in the form of a commission with legislative and limited executive power and a civilian governor. By November fewer than 45,000 U.S. soldiers remained of the 100,000 who at one point were serving in the Philippines.⁷

Although the organization and size of the medical service in the Philippines was adjusted to conform with the organization of the Army and the needs of forces spread out over an increasingly large area, the basic nature of the challenge facing medical personnel in the field changed only gradually. In this primitive land, the terrain controlled medical evacuation, while the number of sick and wounded and the difficulties experienced in moving them dictated the nature of the hospital system. The change of the conflict from conventional to guerrilla warfare in the space of a few months had less direct influence on the demands placed on the Medical Department than did the gradual isolation in well-nigh inaccessible locations of the small units that were sent to fight the guerrillas.

Initially, the Medical Department's chief responsibility was establishing a system of base hospitals in the Manila area to care for the sick, for those recovering from wounds sustained in the brief hostilities with the Spanish, and for convalescents. The department then expanded the size of this system and extended it geographically to care for those disabled during the insurrection that followed. In a former Spanish military hospital, Major Crosby set up the first division hospital to be established in Manila. Before the first patients arrived on 17 August 1898, the building of the newly created First Reserve Hospital was thoroughly cleaned and the necessary repairs were made. To avoid crowding, Crosby erected tents to handle the overflow. The unsatisfactory state of the hospital's plumbing and the poor drainage of the land nearby initially caused the Medical Department to be uneasy about using this structure, despite its electric lights and excellent ventilation. In time, the sewer system was replaced, water closets were installed, and each ward was given its own bathroom with showers. The city water works provided ample supplies, from which drinking water was distilled.⁸

The First Reserve soon became the keystone of the Army's hospital network in the Philippines.⁹ Its surgical facilities, which included three operating rooms, were the most important in Manila. A two-ward smallpox unit was established 1,200 yards from the main building; another ward, consisting of two tents erected over raised platforms, was added later for those suspected of having smallpox; and a third tent was set up to isolate patients suffering from bubonic plague, if that disease ever afflicted the Army. All patients arriving in Manila by boat came through a First Reserve unit established near the docks, where the victims of accidents on the city streets or on the railroad also received emergency treatment. The hospital laboratory, set up by Captain McVay, was well equipped to handle all pathological examinations for the Manila area. This entire division hospital, including the smallpox facility, eventually held 400 beds. Sixteen mules drew four ambulance wagons around the Manila area to pick up patients in response to telegraphed requests for their services.¹⁰

Two more hospitals were established not long after the fall of Manila. The Sec-

ond Reserve Hospital opened in September 1898 in a modern and attractive building that had been built to serve as a young women's school. With its eight porcelain bathtubs and its acres of walled gardens, complete with fountains and flowering trees, this facility was "a really fine establishment." Initially most of its 300 beds were assigned to convalescents who were transferred from the First Reserve Hospital or from regimental hospitals; but, as time went by and the disease rate rose, the seriously ill were also sent there. Convalescents did not have to share yet another facility, which was set up on Corregidor Island, a site only thirty miles from Manila that was chosen in November because of the city's poor health record. The climate was more pleasant than that of the city, the natural drainage of the soil was good, the sea air was mild, and many trees tempted those whose health was still fragile to rest in their shade. This hospital initially occupied tents and a few old buildings, where 250 beds were placed. In September 1899, with activity against the Filipinos intensifying, the first of a series of new structures was completed to replace the old ones, and by June 1900 the facility held 220 beds. As described by the surgeon in charge of the Corregidor facility, "The first dental office ever fitted out officially by the United States government" was also set up, to be managed by a hospital corpsman who in private life had been a professional dentist. Plans to expand this hospital had to be suspended because of high construction costs that resulted in part from a conspiracy among lumber dealers.¹¹

In May 1899 another hospital, known simply as Hospital No. 3 or the supplementary hospital, was opened just outside the city walls in barracks once belonging to the Spanish infantry. An enormous amount of work was necessary to make it fit for use. One medical officer noted that "only one who has seen the filth can appreciate what that labor was." Among its 285 patients were those scheduled for disability discharges. No civilian nurses served on its staff, since the surgeon in charge regarded them as neither necessary nor desirable.¹²

In November 1899, in response to the mounting disease rate and growing activity against guerrillas, the Medical Department increased the number of available beds by taking over a former barracks at Santa Mesa, a suburb of Manila, for a new 1,000-bed unit. The staff of this new facility, eventually the largest in the Philippines, included 10 physicians, 25 female nurses, 4 hospital stewards, 2 acting hospital stewards, and 122 Hospital Corps privates. As late as June 1900, however, the laboratory of Santa Mesa was regarded as completely inadequate, and earth closets had not been replaced by more modern equipment. By 15 August the hospitals in Manila, together with that on Corregidor, held a total of more than 2,200 beds. Space was also available at a 600-bed Navy hospital in Yokohama, Japan, and in Hong Kong.¹³

The Medical Department used the hospital ships Scandia, Missouri, and Relief both to supplement its hospitals on land and to move patients by water to and from locations within the Philippine Islands. The Scandia, a transport fitted out to serve as a hospital ship and carrying with her 5 medical officers and 139 hospital corpsmen, was dispatched from California on 27 August 1900. Although in the fall of 1899 the Missouri briefly joined the transports in taking invalids back to the United States, the Relief, which had arrived in the Philippines on 8 April, rarely took patients all the way to San Francisco because of her light construction and the limited amount

of coal she could carry. Except for service during the China Relief Expedition and trips to Hong Kong for repairs, she remained for the most part in Philippine waters. As she cruised up and down the coast of the Philippines, rendezvousing with units on the march, leaving off supplies, and picking up the seriously ill or wounded from regimental surgeons or post hospitals, the Relief provided her passengers with a "sea trip and good food." The restorative effect of such a journey upon the debilitated caused the Medical Department in March 1901 to put 140 patients on board the Relief merely to enjoy the trip from Manila up the coast. More than half her invalid passengers, including the 51 she picked up on the way, improved markedly because of their sea voyage, and she was assigned to make several more such journeys. Because the Relief's deep draft prevented her from entering shallow waters and because a transport that picked up patients from south of Manila was equally handicapped, the Medical Department also employed shallow-draft vessels to move patients, including a hospital launch that took patients from Manila on three- to four-hour sea jaunts.¹⁴

The need for hospital beds dropped significantly following the capture of Aguinaldo in March, although some resistance, especially in the form of terrorism, continued for several months, and disease remained an enemy even after much of the countryside had been pacified. A one-third reduction in the number of hospital beds was planned early in 1901, but the mass evacuation of patients to the United States upon which the reduction depended progressed more slowly than had been anticipated because of a shortage of transports. Only in July, when the effort to concentrate the Army's resources in the Philippines was

under way, could one of Manila's facilities, the Second Reserve Hospital, be closed. The remaining patients and staff were sent to the Santa Mesa hospital, which, in turn, was closed before the end of the year. A 125-bed hospital was established on Nozaleda Street in Manila on 18 December to shelter patients still hospitalized at Santa Mesa when it was closed. On its attractive grounds a 20-bed isolation facility was set up in six tents for the victims of tuberculosis.¹⁵

Although from the outset the Medical Department relied heavily on the major hospitals of Manila and Corregidor, supplemented by those on hospital ships, much smaller facilities on the transports returning patients to the United States were also available. The Army Transport Service, established in November 1898, was responsible for seeing that each ship had the proper facilities for its passengers, whether they were en route to the Philippines or on their way home. The larger vessels of the Transport Service carried hospitals complete with isolation wards and diet kitchens, and even smaller ships carried medical personnel to care for the sick. Two Regular Army surgeons served as medical superintendents for the Transport Service, one in New York and the other in San Francisco. Their duties included advising the service's general superintendent in each city, supervising the work of the contract surgeons on service ships, and inspecting each vessel. A contract surgeon who was chosen by examination from among applicants who were graduates of "regular reputable" medical schools accompanied each transport, as did a hospital steward or acting hospital steward and one to three Hospital Corps privates. Thus, by relying on transports equipped with hospital facilities, the Army could return the sick and wounded to the United States without using hospital ships.¹⁶

Establishing the system of base hospitals, hospital ships, and transports was not as great a challenge as caring for the sick and wounded when troops were pushing through the jungle, far from good roads and intact portions of the rail line. Initially, medical officers did not anticipate the difficulties they would soon be encountering in the struggle with the Filipinos. As chief surgeon of the VIII Corps, Colonel Lippincott had planned a system of field hospitals in which he had great confidence. In the winter of 1899 he rejoiced that the medical service in the Philippines had been "in fine condition at the moment of first fire" and had "continued to improve from day to day, so that there was never a delay in securing excellent attention for the wounded."¹⁷

In the early spring of 1899, when troops began pushing as much as thirty miles beyond Manila, they encountered terrain that made evacuation very difficult, regardless of the size of the units involved or the nature of the operation. When the Army began working in smaller units to deal with the guerrillas and the number of posts more than tripled during the first six months of 1900 to "embrac[e] the furthermost limits of the islands," the lightly equipped field hospitals that accompanied the men had to become both smaller and more numerous. The nature of the problems involved in moving the disabled first to such small facilities and then from them to the rail line or to a major hospital did not change.¹⁸

To carry litters for these units in the field, natives of the area, and sometimes even prisoners, were hired or impressed into service, but for a time the most successful bearer was the Chinese coolie. If assured of his pay and rations, the coolie proved to be, according to some authorities, "patient, tireless, and brave" and better able to bear great heat than American

hospital corpsmen. Others were considerably less enthusiastic about this practice. General Schwan, who commanded forces involved in the campaign in southern Luzon in late 1899 and early 1900, considered "the use of coolies, either for company or hospital use on a campaign, . . . injurious to discipline and of no value to the service." He regarded them as "great looters," noting that "about all they do after a few days' march is to carry their own food and what they have stolen out of houses and churches." Early in 1900, when the end of the conflict seemed near and an awareness of the threat that cheap Chinese labor posed to local workers was growing, the Army forbad the hiring of Chinese for this type of work in the Philippines.¹⁹

Evacuation demanded much from those responsible for moving the wounded, especially from the many areas that were inaccessible to wheeled vehicles. The poorest lines of communications were in the Camarines area of southeastern Luzon. An officer leading two of the four companies involved in an operation in late February and early March 1900 reported:

The trails on either side . . . are something that language can not describe. In all my experience in the mountains of Colorado, in the Bad Lands of Montana, in Cuba, and other parts of the world where I have traveled, I have never seen worse. They are single-file trails the greater part of the way, closely hedged in by a dense jungle of trees and undergrowth, with mud and mire on the sides. Then every few hundred yards a mountain stream must be forded, the banks of these streams being precipitous, with a drop of 40 to 70 feet. The cut down these banks resembles a tunnel, except that it is open at the top. . . . Nor is it possible to flank these positions, on account of the dense growth, nor can anything be seen except directly to the front, and then only for a short distance.

Because units fighting in the countryside could not take large amounts of equipment with them, corpsmen sometimes had to improvise litters from bark, bamboo, or items of clothing just as surgeons had done in the Indian wars. Some trails were too narrow and twisting to permit the use of travois, and each litter had to be carried by four men.²⁰

Even in areas from which wheeled vehicles could carry the disabled directly to a hospital or to a train or vessel that would take them the remaining distance to a hospital, difficulties arose. Native carts, including one described as "distantly related to the one-horse buggy," sometimes had to be substituted for the few available ambulances, which tended to be both old and fragile. The animals that pulled these wagons were usually either mules or native ponies so small that they had to be unhitched to swim across deep streams, leaving the larger mules to make several trips back and forth with the carts. Major Cardwell, now chief surgeon of the 1st Division, noted while with an expedition to the north of Manila in the spring of 1899 that ponies that were often "balky and vicious" forced "the hardest kind of physical labor" upon all the men with an ambulance train. In April of that year, another kind of problem arose when a bridge north of Manila proved too badly damaged for use. The chief surgeon of the 2d Division, Maj. Henry F. Hoyt of the U.S. Volunteers, reported that ambulances had to disgorge four dead and twenty-six wounded on one side of a river. A small canoe then picked them up, going back and forth until all had been deposited in a second set of vehicles on the far shore. Patients brought to the coast near Manila might be spared further land travel if they could reach a hospital launch to take them to one of the city's facilities. But reaching the launch from the shore was complicated

when the water was so shallow that only "a fair size flat boat" could move supine patients out to the larger vessel.²¹

Advancing along the rail line was also difficult when roads were lacking and the track was in poor condition. Initially, only portions of the rail line that ran north of Manila were open for use, and patients were sometimes evacuated in handcars operated by Filipino prisoners or, at best, in boxcars equipped with cots. The ability to use the railroad greatly eased the problems involved in evacuation. By mid-1900 cars specifically equipped to move patients were part of a train sent along the complete length of the line each day.²²

The hospitals that lay along the line of evacuation varied greatly in size and number, according to the distance from the major facilities of the Manila area, the difficulties involved in evacuation, and the nature of the campaign under way. For men who were only slightly injured, the application in the field of an initial dressing taken from the first aid packet often eliminated entirely the need for hospitalization. From the beginning of the insurrection, dressing stations, sometimes referred to as light field hospitals, accompanied troops in the field to care for the sick and wounded until a more permanent facility could be found or set up for them. When units were serving in the jungle far from roads and navigable waterways, dressing stations sheltered those who might have to accompany their units for several days before evacuation became possible.²³

Since small hospitals lightened the load of larger institutions and patients could be returned to duty more expeditiously if they remained nearer the front, regimental facilities were occasionally utilized in the field. As Colonel Greenleaf, who became chief surgeon for the troops in the Philippines in January 1900,²⁴ noted in his report of 15 August, they were "for emergency purposes only." Here, as many as 14 percent of the sick and wounded in the Philippines might be receiving care at any one time. Surgeons with troops on the move also set up camp hospitals, where those who were only slightly ill could rest for a brief period before returning to duty. These small hospitals were often housed in native dwellings, and native beds were used if the five to ten cots issued for this purpose proved insufficient. In areas where the troops could be cut off from large facilities by the weather and deteriorating roads, camp hospitals were organized before the rainy season. The Medical Department preferred to avoid relying on small hospitals, however, because they represented an inefficient use of personnel and caused administrative confusion. Thus, as the campaign progressed, larger ones were established in the field, sometimes in abandoned Spanish facilities of major towns, for the care of those with more than trivial injuries.²⁵

As U.S. forces advanced, the network of larger hospitals set up in the countryside was extended to spare patients the ordeal of evacuation. Although the journey south to Manila by rail from San Fernando, captured in the spring of 1900, was less than fifty miles, it might take twelve hours. Before hospital cars became available, the move could be particularly trying for the sick and wounded. Thus 2d Division surgeons at San Fernando, which was directly on the railroad line, set aside five buildings for a 200-bed field hospital. In October 1899, when the campaign to take northern Luzon was just getting under way, this facility was moved further north to a church in Angeles, also on the rail line, where by mid-August it still held more than 100 beds. By then

the largest base hospital on northern Luzon was the approximately 350-bed facility established in December 1899 at Dagupan, ideally located at the northern end of the rail line from Manila and on the coast as well. Patients from advanced units were brought to Dagupan for care or for evacuation back to Manila or to the United States. A wood and masonry building once belonging to a Dominican college housed this hospital. By the spring of 1900 fifteen trained nurses there had earned the praise of the surgeon in charge, who reported that he found it "a satisfaction to have in immediate charge of the sick persons trained to do the work" and that he was unhappy that the only lodging he could offer these women was native houses.²⁶

The establishment of many small post hospitals reminiscent of those once scattered about the American West, some merely dispensaries, or subpost hospitals, precipitated many of the same problems that Surgeon General Sternberg's predecessors had come to know so well during the Indian wars in the United States. The shortage of medical officers was chronic as long as these small posts were required, and keeping each facility adequately supplied with medicines and equipment was difficult. As the area under U.S. control expanded, however, smaller hospitals could be consolidated, and the need for a multitude of extremely mobile or very short-lived hospitals also diminished. The Medical Department continued to establish larger and more permanent institutions, variously classified as field, brigade, and base hospitals, usually of 50 or more beds, where men with typhoid, malaria, chronic dysentery, or wounds requiring skilled surgery could be cared for without being evacuated back to the Manila area. Such facilities were located where they could be easily supplied, along the rail line or the coast. When necessary, patients could be easily evacuated from them, either to Manila or to transports that would take them home.²⁷

Representative of Medical Department field organization as it had developed by the spring of 1900, six months after the initiation of the drive to control Luzon, was the hospital system in the most northern district of the island. It consisted of a fifty- to sixty-bed unit on the northern coast at Aparri and five post and camp hospitals, all housed in buildings considered comfortable. The ten medical officers who accompanied the one regular regiment and two battalions of a volunteer regiment stationed in the district had to be divided among the hospitals, and their supplies and equipment also had to be parceled out among six institutions. Forty-one hospital corpsmen, including a graduate dentist, were required to care for the patients at Aparri and to handle the clerical work. Because the facility was likely to be needed for some time to come, the surgeon in charge also requested contract nurses, obtained permission to acquire an ice plant, and sought to obtain a small steam laundry and iron bedsteads.²⁸

The hospital network serving 1st Division forces fighting in southern Luzon resembled that of the 2d Division north of Manila, but on a smaller scale. By mid-August 1900 the largest hospital was the base facility at Calamba, on Laguna de Bay, which was rivaled for size by the brigade hospital at Bacoor, on the coast south of Manila, each of which held more than 100 beds. A 60-bed hospital stood at Santa Cruz, on the eastern side of the Laguna, while two smaller base hospitals were also located along the seacoast south of Manila. Since almost every town in this area had a substantial church building that could be

taken over to serve as a hospital, here, too, even the smallest facilities were well housed. In the absence of a rail line, ambulance wagons had to be used to move patients from mobile and temporary facilities to base hospitals, from which water transportation could be used, if necessary, to reach Manila.²⁹

The Bacoor facility, established in July 1899, before the beginning of the guerrilla phase of the insurrection, was for some time the largest in southern Luzon. Since it was only twelve miles from Manila by sea and fourteen by land, it was a good point through which to deliver supplies and evacuate patients. Although in the spring of 1900 tents at Bacoor held 85 of a total of 125 patients, surgeons were pleased with the situation because the tents were cool. The Calamba hospital, set up in a former Spanish convent in February, was initially smaller than that at Bacoor. Located in an area swarming with mosquitoes carrying dengue or malaria, it eventually grew to shelter more than 150 patients, with hospital corpsmen assisting the eight female nurses who were responsible for patient care.³⁰

Hospitals were also established where needed on the various smaller islands of the Philippines, with a particularly large facility set up as a brigade hospital in February 1899 at Iloilo, on Panay in the Visayan Islands. Originally located in a private home, one of the few buildings that had not been burned by the insurgents, the hospital grew by taking over other private homes until by February 1900 it had 300 beds. The use of several separate buildings, however, made for an inefficient use of staff, since more hospital corpsmen were required to care for patients than would have been necessary in one structure. The shortage of medical personnel was also demonstrated in the spring, when twenty-five posts in these islands, which included those of Samar, Leyte, Cebu, and Bohol as well as Panay, lacked a medical officer. The surgeons circulating between inland substations often encountered almost impassable roads and guerrilla attacks, while those visiting coastal positions required the services of a hard-to-find steamer or sailboat.³¹

The shortage of physicians and hospital corpsmen was one of the greatest challenges to those responsible for the care and evacuation of the sick and wounded of occupation troops in the Philippines. The Washington Barracks program for training hospital corpsmen had been for a time suspended because of the demands of the war, but it was resumed shortly thereafter. A similar school for corpsmen was opened at Angel Island, California, so that men could be taught while they awaited embarkation for the Philippines. In the twelve-month period ending in June 1900, 692 trained at Angel Island and 726 at Washington Barracks, with most of both groups sent to the Pacific. The first class from a fourteen- to eighteen-week course for future acting hospital stewards taught at Manila's Hospital No. 3 graduated in June. In spite of the establishment of these schools, many corpsmen in the Philippines had little experience or formal training, although they seem to have been wisely selected. One surgeon reported that "he never knew of a hospital corps man who failed in his duty in any way under fire." Another later commented that the Hospital Corps had much improved since the Spanish-American War, many stewards and even some privates being "capable of rendering very valuable assistance

to the surgeons." Keeping the proportion of corpsmen to the number of wounded high so as to guarantee casualties adequate attention on the field caused the demand for attendants to remain greater than the supply. Nevertheless, by August the Army was preparing to cut back the number of hospital corpsmen in the Philippines from 2,356 to 2,000, as required by Congress. The Medical Department warned that many problems could be anticipated as a result unless a greater number of Filipinos could be found to replace them.³²

With some hesitation, Secretary of War Alger allowed female nurses to be sent in from the United States to supplement the work of hospital corpsmen. According to Colonel Greenleaf, they became known in the Pacific for their "good work," which was "much appreciated by all." By mid-August 1900, 140 of these women had served in hospitals in the Philippines and 120 were still on duty there, along with 7 male contract nurses. Improving conditions in the interior of the Philippines eventually made it feasible to send American women to some of the facilities located further out into the countryside.³³

The need to provide medical coverage for a multitude of posts increased the demand for physicians and caused a shortage of medical officers so severe that Surgeon General Sternberg had to send in doctors who were unfamiliar with military medicine and who created confusion as a result. He again used the latest edition of the Manual for the Medical Department in his attempt to indoctrinate the new physicians. Ironically, many of them were contract surgeons whose contracts would run out just at that point when they were becoming most effective and who might leave even earlier, as soon as the novelty of the situation began to pale. Because of the shortage, at various times a contract doctor from the Relief was brought ashore, Navy physicians were pressed into Army service, or hospital corpsmen were left to assume responsibilities usually managed by physicians. Corpsmen often had to be responsible for reports and administrative duties when camp surgeons had no time for such things, but in one instance two corpsmen had to perform an amputation. Unfortunately, because more hospital corpsmen were also needed-when General MacArthur requested the "immediate dispatch" of 100 more medical officers in July 1900, he also asked for 300 more corpsmen-having them fill in for physicians merely exacerbated one problem in the attempt to ease another.³⁴

The need for physicians increased so rapidly that Colonel Greenleaf could not keep up with the demand. On 31 December 1899, when 257 physicians were serving in the Philippines, the chief surgeon concluded that he should have 360. By 31 May 1900, when he reported that 364 were serving under him, medical officers were lacking for 20 new posts that had been recently established and 5 to 10 more were needed to accompany two transports returning to the United States from the Philippines. As a result, in June Greenleaf called for 75 more surgeons and for 20 more to be sent each month thereafter. Although as many physicians as could be spared were sent in, by the end of the fiscal year 1900, 120 posts out of the almost 400 then in the Philippines still had no surgeons, leaving 10,000 men without a source of adequate care. Concerned that the situation in the Philippines might be misunderstood, General MacArthur emphasized to the adjutant general that as long as the number of posts in the Philippines remained constant, the number of medical officers required would

also remain constant, regardless of the number of troops serving there. By 31 May 1901, although the situation had improved, 479 posts lacked medical attendance and only 423 surgeons were available for assignment. Greenleaf maintained that because of the need to have a reserve against the possibility of epidemic, the figure should be at least 500.³⁵

In the 2d Division, difficulties engendered by the shortage of physicians were exacerbated by confusion over the responsibility for the assignment of surgeons and the granting of their leave in 1899. Communications between the headquarters and the units strung out from Manila to the Gulf of Lingayen were poor. Orders given to medical officers at many levels were rarely reported back to Colonel Greenleaf at corps headquarters. Local commanding officers granted leave to surgeons and then requested the assignment of another surgeon when no replacements were available. Early in 1900 orders were issued requiring that the division chief surgeons be informed whenever leave was granted to a medical officer and that each brigade surgeon keep a current roster of the medical officers and hospital corpsmen in his unit. Changes of assignment were to be reported to the brigade surgeon as soon as they were made.³⁶

Medical officers assigned to the Philippines experienced their share of danger because of the guerrilla war, still further reducing the number available to care for the sick and wounded. A surgeon was one of the thirty-six men killed and horribly mutilated by bolo knife-wielding guerrillas in September 1901 in a surprise attack upon the garrison at Balangiga, on Samar. Yet another surgeon barely escaped death when he was ambushed during his attempt to bring ambulances to the aid of wounded insurgents. The shortage forced many physi-

cians to spend much time riding through the hostile countryside from post to post, each five to fifteen miles from the other.³⁷

In spite of the difficulty medical officers experienced in providing adequate care for American soldiers, some had the time to care for Filipinos. Unfortunately, in at least some instances they may have been involved in extracting information from captured Filipinos, who were considered to be waging "irregular warfare against the only constituted authority" and therefore were, in theory, "merely bandits, . . . and as such . . . not entitled to treatment as prisoners of war." Americans serving in the Philippines evidently did not always regard torture as reprehensible; but, to prevent serious or permanent injury to the victim, a medical officer was apparently often present when torture was being used. Army surgeons did not take their scorn for the guerrillas as far as to neglect Filipino casualties, though they were more difficult to care for than American soldiers because they tended to remove dressings and touch their wounds. Even with the best of intentions, medical officers were unable to achieve as good results with Filipino wounded as with their own men, although their attempts nevertheless contributed to pacification efforts.³⁸

For troops fighting in the Philippines, as it was for those in the Caribbean, disease was the cause of most disability and death. Combat injuries took only 10.6 percent of the command out of action in the first half of 1900, for example, and rarely caused difficulties for American surgeons treating their own men, even when wounds were caused by bolo knives, daggers, knives, bamboo spears, and clubs. The surgical operations performed on U.S. soldiers in the Philippines more often involved hernias, appendicitis, liver abscesses, malignancies, and other problems unrelated to war wounds.³⁹

The real challenge resulted from the cumulative and debilitating effect of physical exhaustion, inadequate diet, temperatures of well over 100 degrees, and malaria and the various forms of dysentery upon men already working under great stress. Medical officers became the victims of diarrhea, dysentery, typhoid, malaria, and sheer exhaustion; Lippincott himself was among those felled by disease. Soldiers at the front suffered the highest disease rates, as much as three times those experienced by the garrisons of even the most unsanitary towns, where rates were usually under 10 percent. Attention to personal hygiene and the use of screens and nettings to prevent mosquito bites were almost impossible for soldiers fighting guerrillas in the jungle. "The terrible nervous exhaustion which results from long continued exposure to great heat and moisture," as one Army surgeon put it, severely undermined effectiveness, although with time many men became better able to tolerate the heat. For the 1900-1901 fiscal year period the disease rate among the volunteers, who were for the most part new in the country, rose by almost 50 percent, while among acclimated regulars it fell by 10 percent. The gradual end of active campaigning contributed to a drop in the disease rate, but physicians concluded after months of experience that many patients would never entirely recover if they remained in the Philippines.⁴⁰

Although typhoid was endemic and the troops arriving in 1898 came from camps where typhoid had been a problem, careful attention to sanitation reduced its inroads

markedly. Despite its high death rate, this disease was never the serious threat to the Army's effectiveness in the Philippines that it had been both in the United States and in the Caribbean in the summer of 1898. New volunteer units coming in from the United States to replace state volunteer units returning home continued to bring typhoid with them, and from time to time medical officers feared an epidemic. Occasional cases were acquired at local restaurants or from streams so "clear and sparkling" that the troops drank directly from them until the appearance of typhoid made them realize the error of their ways. Heat exhaustion, an ever-present threat, added to the typhoid danger. In moments of desperation when extreme heat led to the rapid emptying of canteens, soldiers were willing to drink "from ditches and holes when the water looked green and tasted very badly," though they knew that it was hazardous to do so. Renewed attention to sanitation and to the accuracy of diagnoses, however, limited the spread of this disease.⁴¹

Return to the United States was believed particularly necessary to the complete recovery of the victim of dysentery, which, together with diarrhea, caused much havoc to the health of those serving in the Philippines. Dysentery and diarrhea rates climbed until they were four or more times higher than the rate characteristic of the peacetime Army in the United States, and, as time went by, dysentery seemed to become more virulent. The death rate rose from 2.52 per 1,000 troops in 1898 to 4.58 per 1,000 in 1899, perhaps because the stress of active campaigning lowered resistance. A few cases were identified as amebic, but at some hospitals the most commonly seen cases were those in which malaria was accompanied by dysentery. In these instances, good results in the treatment of dysentery were often achieved with quinine, and many physicians concluded that blood tests for malaria should be administered to all dysentery sufferers. An increase in diarrhea cases in the spring of 1899 was blamed in part on the indiscriminate consumption of the locally available fruits. Surgeons also noted that many of the men with diarrhea were also among the many serving in the tropics who had very bad teeth, and they blamed this apparent and unexplained coincidence on the climate.⁴²

Although dysentery tended to peak in the summer, the rainy season in the Philippines, malaria caused much ineffectiveness from October through December, the coolest months of the year, and was more common inland than along the coast or in the area around Manila. The form of malaria seen in the Far East tended to recur but constituted no appreciable direct threat to life, even though, because of its chronic nature, it tended to wear out its victims. The time the malaria victim spent in the hospital was often lengthened because of the accompanying diarrhea, for which one gram of quinine twice a day proved to be a very successful treatment. Discretion was necessary in prescribing quinine, however. Attempts to give quinine by injection to increase the speed with which it acted tended to produce local abscesses. Too prolonged a course of quinine, moreover, was believed to lead to mental and nervous complications and even anemia.⁴³

Among other threats to health, venereal diseases apparently posed the greatest challenge to physicians. Major Cardwell, then the 2d Division chief surgeon, reported in September 1898 that as the men became "habituated to the repulsiveness of the native women, sexual immorality [became] more common," as did syphilis and gonorrhea. In 1902 a medical officer noted

in an article in a professional journal that the rate of venereal disease in the Philippines was not unusual and that this fact was "a tribute to the Filipino women who, as a class, I do not hesitate to say, are fully as virtuous as their American sisters." An attempt to register and inspect prostitutes, hospitalizing those found to be diseased, was strongly opposed by a visiting missionary, who wrote the secretary of war that such a program was tantamount to licensing prostitution. The paucity of healthful amusements lowered morale, although the amount of drunkenness and alcoholism, so often associated with high venereal disease rates, seemed no greater than that usually found in the United States. Canteens where cool beer could be bought, together with hard work and hard play, were seen as minimizing the temptation to associate "with natives, of the lowest class" and as relieving any "craving for immoral pursuit." Authorities attempted to set up a resort for troops in the mountains of north Luzon, but the lack of roads held up the project. An order issued in 1901 requiring all men to be inspected weekly for signs of such diseases was, to some degree at least, successful in lowering the incidence.⁴⁴

Among lesser threats to health and effectiveness were smallpox and bubonic plague epidemics that developed in the Filipino population of Manila. Although plague never became a problem for U.S. troops, the first case of smallpox was diagnosed early in September 1898. By 31 March 1899, when the danger was considered to be over, 236 American soldiers had contracted the disease and 77 had died of it. Fresh smallpox vaccine had proved difficult to obtain. The effectiveness of matter sent from San Francisco did not survive the long voyage, and new supplies obtained from Japan deteriorated in the heat. When a former Spanish vaccine farm was reactivated, it became possible to revaccinate the entire command-along with all 13,000 Spanish prisoners of war who had surrendered at Manila the previous summer-with matter fresh, not from the cow, but from the water buffalo.⁴⁵

Skin problems were also often seen, since soldiers fighting in the Philippines were sometimes constantly wet for days. Ringworm, a fungal infection that usually responded to treatment with sulfur, was common. Sometimes, however, it was mistakenly diagnosed as the "doby itch," a form of contact dermatitis that could cause legs to swell "and large knots and tumors [to] cover them until walking [became] extremely painful." The most effective remedy against this condition proved to be having all clothes boiled during laundering. Doctors also encountered contagious pemphigus in a potentially fatal form most often found in the Philippines and characterized by blisters in the groin and armpits. It was apparently first encountered in troops en route to the Philippines when their ship stopped at Guam. When sodium hyposulfite became available, doctors were successful in curing most of these patients.⁴⁶

Mental illness was also encountered in the Philippines, but the rate of psychoses was not high. Most often seen were cases diagnosed as "nostalgia," or homesickness, an understandable and predictable problem for young men far from home in a strange country with a difficult climate and a hostile population. This problem disappeared with arrival back in the United States, but it was considered by some to be "undoubtedly the most severe affection in the command, affecting officers as well as enlisted men. Some regimental medical officers are badly infected with this com-

plaint, and such naturally sympathize with the men. The result is a sick list wholly out of proportion to the real disease present." Some soldiers also apparently took up smoking opium while in the Philippines, although reports that many became addicted were disputed.⁴⁷

Improved hygiene and sanitation were high among the measures favored in the effort to prevent many ills that afflicted men in the tropics. The debate over the virtues of woolen versus cotton underclothing in hot climates continued, and, in particular, the value of the woolen abdominal bandage in preventing diarrhea caused much argument. There was no disagreement over the need for lightweight uniforms. Such clothing was not available to the first arrivals in the Philippines, and the khaki cloth that was being issued by the Quartermaster's Department by the spring of 1900 was regarded as too heavy. Lippincott also urged in his 31 March 1899 report that the Army issue a "light, broadbrimmed, khaki-covered helmet," in addition to the campaign hat, which was highly regarded for wear in the rainy season. Even the troops' shoes failed them in the Philippines, where "the extremely plastic, adhesive mud" ripped soles apart, making both marching and resupply difficult. On one occasion 230 of 240 men in a battalion were without shoes. By July 1901 the official uniform for those serving in the Philippines was the khaki blouse and trousers, with the choice of underwear being left up to the individual.⁴⁸

While medical officers debated the nature of the most appropriate clothing, they were agreed on the management of sanitation. Failures to maintain standards usually resulted either from overconfidence that led to neglect or from battlefield necessity, since local water sources often proved to be polluted. Much emphasis was placed upon the need to boil all water, even when it had been filtered. For the most part, earth closets continued to be the usual means of dealing with excreta, great care being taken in maintaining latrines and in disposing of their contents in a sanitary manner.⁴⁹

In general, most supply shortages were temporary, and Army hospitals located on navigable waters or along the rail line rarely experienced problems, although the insurgents sometimes destroyed sections of track. Quinine was hard to find for a few weeks in early 1900, possibly because doctors were also treating sick Filipinos in the communities near their posts. Some temporary local shortages inevitably resulted from the inability of physicians to anticipate their needs well in advance, especially at the front. Investigation in one instance revealed that while hospitals were complaining of shortages, large supplies of many needed items had accumulated in Manila warehouses, presumably because of transportation problems. Delivering supplies became impossible when water levels fell and supply boats could no longer get through to troops serving along many rivers. When heavy rains washed out bridges, moving supplies by land became particularly difficult. In the rainy season in those areas where wheeled vehicles could not go, surgeons learned to accumulate supplies as much as six months ahead of the time they were needed to avoid shortages. At least one surgeon found himself for a time forced to rely upon "native leaves and roots for medicines," and soldiers fighting in the jungle occasionally had to exist on half rations.⁵⁰

For a time in the summer of 1900, a misunderstanding developed concerning orders for supplies from the Philippines. The desire to respond to pleas for help from indigent Filipinos may have been behind what both the Medical and War Departments regarded as excessive demands. Surgeon General Sternberg threatened to halve Colonel Greenleaf's quarterly requisition for medical supplies and hospital stores, but General MacArthur strongly supported his chief surgeon's insistence upon the reasonableness of his orders, thereby apparently preventing any severe cutbacks.⁵¹

Problems with diet often resulted from difficulties with supply, although surgeons continued to debate the ideal amount of meat and fat in the tropical diet. Many authorities believed that a higher proportion of sugar would be advisable because of the energy it provided and that the usual allowance of meat and fat, basically intended for men serving in cold climates, was larger than was necessary in the tropics. Some concluded that to maintain health in the tropics the soldier must eat much less than he would in a cooler climate to avoid producing too much heat. Others disagreed strongly, saying that the U.S. soldier was a meat eater, that in the tropics he needed to eat more than ever, and that the problem of heat should be managed by increasing the ability to lose heat through wearing lighter clothing.⁵²

Time made it apparent that the ration found acceptable in the United States would be satisfactory in the Philippines, but delivering meat, vegetables, and fruits unspoiled to the soldier in the field was at times "totally out of the question," according to one surgeon. Meat and even hard bread deteriorated rapidly in the climate of the tropics. Canned meat went "soft and disgusting" in the heat, and canned vegetables weighed too much to be carried far, although frozen beef could be sent fifty miles inland before it thawed out. Troops at the front, unable to carry adequate supplies with them without the use of wheeled vehicles, suffered from a shortage of food.⁵³

In late June 1900, despite misgivings about weakening his force in the Philippines, General MacArthur ordered the 9th Infantry to prepare to embark for China as the first Army contingent of the China Relief Expedition, which sought to protect U.S. interests and citizens threatened by the Boxer Rebellion. With the later addition of the 14th Infantry and an artillery battalion from the Philippines, as well as still more units coming directly from the United States, the China Relief Expedition would eventually number 2,500 and include 800 marines with their Navy doctors. Adna R. Chaffee, who received his promotion to major general in the volunteers on 19 July, assumed command of the China Relief Expedition when he arrived in China on the thirtieth, three weeks after the landing of the first U.S. troops there. The expedition became part of an international force composed of troops from several major powers, including Great Britain, France, Russia, Germany, and Japan, that were seeking to subdue the Boxers, to intimidate the Dowager Empress, and to make China again safe for foreigners. Because most of the U.S. soldiers who eventually served in China were sent from the Philippines, the responsibility for the medical care of the expedition fell upon the shoulders of Army Medical Department leaders there.⁵⁴

U.S. Volunteer surgeon Maj. William B. Banister, assigned to the 9th Infantry, served

as chief surgeon of the China Relief Expedition from the date of its formation until 25 September 1900 and assumed the ultimate responsibility for the medical care of U.S. troops going to China, although Navy surgeons serving under him did not submit reports to the Army Medical Department. Two contract surgeons were detailed to assist Banister in his preparations, but one did not report until 25 June, the day before embarkation, and the second never materialized. Thus the chief surgeon had to prepare for the expedition with little assistance, and only four medical officers, including regimental surgeons, initially accompanied the first 1,300 men to sail for China. Under these physicians served a hospital steward, three acting hospital stewards, and sixteen Hospital Corps privates, but the steward and four of the privates also arrived only the day before embarkation.⁵⁵

The men of the 9th Infantry were already worn down by eighteen months of service in the Philippines. Since many were suffering from malaria and chronic dysentery, Major Banister concluded that the regiment was "in extremely bad condition for field service." Nevertheless, some were so eager for service in China that they did their best to conceal any ailment that might prevent their going.⁵⁶

Although U.S. troops in China did not encounter humid and tangled jungles, they did face hot summers and familiar diseases presenting familiar threats. Hoping to reduce the incidence of malaria to a minimum, Major Banister prepared for the landing by dosing each man with a daily gram of quinine for three days before he set foot for the first time on Chinese soil. The traditional filth-borne diseases, too, again threatened U.S. troops. In Chinese communities, instead of a sewage system, "the pail system [was] generally in vogue," but because night soil was highly regarded as fertilizer for crops, it was piled up at selected sites outside the city, awaiting "its ultimate transportation to the country." The towns were in an "indescribably filthy condition" because of poor drainage and the tendency of the poorer male members of the population to relieve themselves wherever they were. Despite efforts to have soldiers drink only water known to be safe, dysentery took a high toll, and typhoid rates were higher than they had been in the Philippines.⁵⁷

After arriving near Tientsin on 10 and 11 July, Army and Navy physicians worked together to unload their equipment and set up an operating room in the building they shared outside the city. Major Banister assigned an acting hospital steward and four privates to each of the two battalions that landed in time to take part in the first battle of the Boxer Rebellion, the Battle of Tientsin on 13 July. The multinational

force was rapidly successful in taking the city. Of the wounded, 77 were U.S. soldiers, some of whom received their initial care in ditches, where the polluted water soaked their injuries and caused a particularly high rate of infection among those with shrapnel wounds. Since none of the Army's ambulance wagons had yet arrived before the city, the casualties were evacuated by litter-bearers who were forced from time to time to put down their burdens to return fire. Banister himself went into the city with the most advanced units, and the two hospital corpsmen with him never left his side. Supplies were brought up to him after he had set up an aid station behind the city's inner wall. As soon as the enemy left the city, Banister and his Navy colleagues entered to set up their facilities. Some Army patients shared the Marine hospital, and Banister took over a hotel for the remainder. By midnight every wounded man had received care and been moved into a bed within the newly surrendered city.⁵⁸

The interservice cooperation among U.S. units continued long after the battle had been won. With his sick and wounded divided among three locations, the regiment, the Marine hospital, and the hotel, Banister's hospital attendants were spread so thin that he was forced to supplement them with details from the line. He was soon able to concentrate his resources by moving all his patients from the Marine hospital, although the Army facility continued to receive occasional Marine casualties. After a few days Banister began to evacuate patients to the Navy hospital ship Solace; by 24 July she was sheltering 64 Army patients. She then departed for the United States via Japan, where the Japanese had made hospital space available at several cities, including 500 beds at Nagasaki.⁵⁹

Not surprisingly, given the condition of the troops when they were sent to China, the number of ill among them grew as the summer continued. By 26 July 215 men were sick with their units and another 61 were ill on board a transport, most of them with diarrhea and dysentery. Major Banister decided to establish a base hospital in a private home surrounded by enough land to permit pitching tents. Here the wounded could also recuperate until the expected arrival of the Relief, then on her way to China, and supplies could be accumulated for the advance on Peking. By this point, more supplies, equipment, and personnel were coming in to Tientsin. Four acting hospital stewards and thirty-two Hospital Corps privates were sent to the Tientsin hotel. The arrival of six more physicians made it possible to assign three to the base hospital. The eleven female nurses who had volunteered for China service while en route to Manila arrived in early August. Five more and a professional male nurse, plus more contract surgeons, disembarked a short while later.⁶⁰

A few days after General Chaffee took command of the China Relief Expedition, 2,500 U.S. soldiers joined British and French troops to march on Peking. The U.S. contingent now included the 14th Infantry with its four regular medical officers, two contract surgeons, twenty-one hospital corpsmen, and equipment. Each regiment had "Chino" litter-bearers, but they were trusted so little that they were kept "under guard to prevent their running away." A Regular Army assistant surgeon also accompanied the artillery battalion that was a part of the expedition. Marching with the soldiers were U.S. Marines with their three physicians, attendants, and litter-bearers. Although supply wagons were available for the Medical Department, Major Banister,

who continued in the position of chief surgeon, had his medical chests carried in his ambulances so that they would be immediately available.⁶¹

Shortly after leaving for Tientsin, the expedition encountered the enemy at Yangtsun, suffering an estimated 61 casualties in the engagement that followed. The ambulances moved forward just behind the troops, out of the line of fire, and picked up the wounded, taking them to the dressing station and then moving them forward to the campsite chosen for the night. Except for a surgeon who remained with the ambulances, all physicians stayed with the troops. A junk took 11 of the wounded back to the Tientsin base hospital that evening, with the rest of the wounded and several sick men making the same trip the next day. When the troops resumed their march, the heat took a heavy toll. Heatstroke and even convulsions were common, and ambulances were filled to overflowing. Fortunately, since it was impossible to keep all the disabled with the expedition as it moved forward, the number of surgeons with the troops was large enough to permit one to be left behind with the sick at each campsite.⁶²

The pattern set at Tientsin was generally followed at Peking. A multinational force handled the attack, which began with an unsuccessful Russian assault on 13 August. On the fourteenth U.S. troops scaled the wall around the Outer City and provided cover for the British soldiers who followed them. The next day U.S. artillery destroyed the gates in the wall around the Inner City, opening the way to the occupation of the entire city. American doctors with the attacking force provided medical care at Peking as they had in Tientsin, setting up a 150-bed field hospital as soon as the city fell. Here the sick and the 30 wounded received excellent care until they were evacuated by water back to the Tientsin base hospital. Whenever possible, the wounded and the seriously ill were then placed on the Relief for evacuation to Nagasaki, which became a second-level base for the expedition. On 29 September a second Army hospital ship, the Maine, was assigned the responsibility for taking patients to Nagasaki, where the Relief was to pick them up for the trip to Manila, which remained the primary base for American forces fighting in China.⁶³

The Peking hospital initially lacked an adequate supply of standard hospital bedding and furniture, but surgeons found Chinese bedding satisfactory on a temporary basis. In the fall a permanent hospital of 85 beds was established for the brigade to be garrisoned at Peking; existing Chinese buildings were used because the arrival of cold weather allowed no time for new construction. Some modifications were deemed necessary in these buildings, including lowering high ceilings and replacing many paper-covered lattice-work windows and doors with glass. For a few months a second and smaller hospital was set up at Peking, together with a residence for the female nurses who worked at the larger hospital.⁶⁴

By the end of September 1900 almost 4,000 soldiers were serving in China. A second brigade was stationed at Tientsin, where, like the garrison at Peking, it was served by a large hospital in the city. Many detachments were serving at other locations, and two of them had their own small hospitals. Since the railroad from Peking to Tientsin was still not operative, supplies had to be moved by river, and because junks covered no more than twenty miles a day, garrisons also had to be stationed along the waterway until December, when the railroad was at last reopened. For troops thus scat-

tered about a land of almost nonexistent sanitation, typhoid remained a particular danger, even when the greatest of care was taken, since flies could carry the disease to food and water supplies that were otherwise safe. Fortunately for their health, many of the U.S. troops occupying China left in the spring of 1901, and many of the remaining men left the following autumn. By 1904 the only Army troops in China were the men of the company guarding the embassy at Peking, and the rates of typhoid, malaria, tuberculosis, venereal disease, and alcoholism among them were higher than those among men stationed in the United States.⁶⁵

Service with the multinational force enabled medical officers to compare their work and equipment with that of the world's major military powers. Major Ives, who succeeded Major Banister in September 1900, commented unfavorably upon the transportation available to U.S. medical officers, blaming the situation largely upon the Medical Department's dependence on the Quartermaster's Department and the slow response time that resulted. He admired the Japanese litter as particularly well suited to battlefield use, though by no means as sturdy and comfortable as the American model. He was particularly enthusiastic about the disinfecting plants and laboratories of the German hospitals, but his observations led him to conclude that "the medical department of the United States Army is the best and most intelligently equipped of any service there represented."⁶⁶

Although U.S. forces encountered astoundingly unsanitary conditions both in China and in the Philippines, the two campaigns were otherwise a study in contrasts. The refusal of the Filipinos to accept American occupation resulted in a prolonged guerrilla war that challenged medical officers to adjust to the demands of innumerable small-unit operations, most of which were conducted in a hostile environment, and at times to work in comparative isolation. The Boxer Rebellion, on the other hand, involved conventional warfare and required U.S. physicians to work in proximity with medical officers of other nations in a situation where they could observe firsthand the way in which the medical services of other nations functioned. The campaigns over, physicians with both occupation forces were swept up in the effort to prevent the destruction of U.S. garrisons by disease.

Like the Spanish-American War, the Philippine Insurrection and the Boxer Rebellion reacquainted the U.S. Army with the potentially devastating effects of disease upon the effectiveness of armed forces and also placed U.S. troops in the midst of disease-ridden civilian populations living under conditions of incredibly poor sanitation. Unlike the Filipinos and the Chinese, who, U.S. observers believed, had accepted widespread disease and the deaths that resulted as inevitable, Army physicians were convinced by what they already knew that high morbidity and mortality rates were preventable. This conviction gave added strength to their struggles to guarantee the benefits of modern medicine to American soldiers and also to the people of the lands they occupied.⁶⁷

1. War Department, [Annual] Report of the Secretary of War, 1899, 1(pt.4):ix (hereafter cited as WD, ARofSW, date).

2. Ibid., l(pt.5):115 (quotation); War Department, Five Years of the War Department Following the War With Spain . . . , pp. 8-11; Brian McA. Linn, "The War in Luzon," Ph.D. diss., pp. 30-31.

3. WD, Five Years, pp. 11-14 (quotations), 79-85, 172-75, 207-08, 256; Linn, "War in Luzon," Ph.D. diss., pp. 33-34. MacArthur had been commanding officer of the 1st Brigade of the 2d Division.

4. War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1900, pp. 94, 118-19 (hereafter cited as WD, ARofSG, date).

5. The departments were the Department of Northern Luzon (six districts), the Department of Southern Luzon (four districts), the Department of the Visayas (four districts), and the Department of Mindanao and Jolo (four districts). In December 1901 the Departments of Northern and Southern Luzon were consolidated as the Department of North Philippines and the remaining departments as the Department of South Philippines. See WD, ARofSW, 1900, 1(pt.3):26, 45-50; idem, ARofSG, 1902, p. 45; AGO GO 38, 29 Mar 1900, and GO 49, 13 Apr 1900.

6. WD, ARofSG, 1900, p. 117, and 1902, p. 45; WD, Five Years, p. 79.

7. WD, Five Years, pp. 173-75, 177, 207-08; Frederica M. Bunge, ed., Philippines, p. 27; Linn, "War in Luzon," Ph.D. diss., pp. 33-34.

8. WD, ARofSG, 1898, p. 264, 1899, pp. 99-100, and 1900, p. 109; "Medical and Sanitary History of the Troops in the Philippines," p. 828.

9. In addition to a network of division, base, brigade, field, post, and camp hospitals, five general hospitals were serving troops in the Philippines by February 1900: the First Reserve, the Second Reserve, Hospital No. 3, Santa Mesa, and the facility for convalescents on Corregidor Island. See WD, ARofSG, 1900, pp. 97-98.

10. Ibid., pp. 104, 109-10, and 1901, p. 128; idem, ARofSW, 1900, l(pt.3):125; Henry Lippincott, "Reminiscences of the Expedition to the Philippine Islands," p. 172; Simon Flexner and L. F. Barker, "The Prevalent Diseases in the Philippines," p. 523.

11. WD, ARofSG, 1899, pp. 99-100 (first quotation), 110, and 1900, pp. 105, 111, 115-16; idem, ARofSW, 1900, l(pt.3):124-25; William O. Owen, "Some of the Trials and Tribulations of a Medical Officer of the United States Army," pp. 388-89, 392 (second quotation); War Department, Correspondence Relating to the War With Spain . . . , 2:847, 1014; Flexner and Barker, "Prevalent Diseases," p. 523; "Medical and Sanitary History," p. 828.

12. Rpt, John Kulp, in United States, Army, 3d Reserve Hospital, "Manila Report," pp. 3 (quotation), 8, National Library of Medicine, Bethesda, Md.; WD, ARofSG, 1900, p. 112.

13. WD, ARofSG, 1900, pp. 97-98, 113-14; idem, ARofSW, 1900, 1(pt.3):125; idem, Correspondence, 2:756; United States, Congress, Senate, Report of the (Dodge) Commission To Investigate the Conduct of the War Department in the War With Spain, 2:1318, 1320 (hereafter cited as Dodge Commission Report); N. N. Freeman, A Soldier in the Philippines, p. 32; William T. Sexton, Soldiers in the Sun, p. 148.

14. WD, ARofSG, 1899, pp. 110, 116, 195, 201-02, 1900, pp. 71-73 (quotation), 97, 106, and 1901, pp. 126-27; idem, Correspondence, 2:884, 1022, 1221; Dodge Commission Report, 2:1308-09, 1322; Ltr, H. O. Perley to Ch Surg, Div of Philippines, 30 Jun 1900, in Ms 4889, Entry 52, Record Group (RG) 112, National Archives and Records Administration (NARA), Washington, D.C.; William J. L. Lyster, "The Army Surgeon in the Philippines," p. 32; Flexner and Barker, "Prevalent Diseases," p. 523.

15. WD, ARofSG, 1901, pp. 78, 135, and 1902, p. 145; John M. Gates, Schoolbooks and Krags, pp. 112, 128, 233-36; WD, Correspondence, 1:442, 455, and 2:1245, 1253; idem, Five Years, p. 177.

16. WD, ARofSG, 1899, pp. 193 (quotation), 194, and 1901, pp. 78, 136; idem, Correspondence, 2:766; Henry S. Kilbourne, "The Medical Department of the United States Army Transport Service," pp. 4-5, 8; Louis M. Maus, "Military Sanitary Problems in the Philippine Islands," p. 28.

17. WD, ARofSG, 1899, p. 109.

18. WD, ARofSW, 1899, 1(pt. 5):26, 68, 78-79, and 1900, 1(pt.3):117 (quotation); "Medical and Sanitary History," p. 826; Gates, Schoolbooks, pp. 40, 76; Sexton, Soldiers in the Sun, p. 221.

19. WD, ARofSG, 1900, pp. 90 (first quotation), 149, 159; idem, ARofSW, 1899, l(pt.5):114-16, 1900, 1(pt.3):509 (remaining quotations), and 1901, l(pt.4):292-94; William F. Strobridge, "Chinese in the Spanish-American War and Beyond," in The Chinese American Experience: Papers From the Second National Conference on Chinese American Studies 1980, ed. Genny Lim (San Francisco: Chinese Historical Society of America and Chinese Culture Center, n.d.), pp. 14-15; Questionnaire, Richard Johnson, in Spanish-American War, Philippine Insurrection, and Boxer Rebellion Veterans Research Project, Military History Research Collection, U.S. Army Military History Institute, Carlisle Barracks, Pa.

20. WD, ARofSW, 1900, 1(pt.4):679 (quotation); idem, ARofSG, 1900, pp. 90, 142, 147; Frederick Funston, Memories of Two Wars, pp. 329-30; Franklin M. Kemp, "Field Work in the Philippines," p. 77.

21. Funston, Memories, pp. 194 (first quotation), 329-30; WD, ARofSW, 1899, 1(pt.4):527-28 and 1(pt.5):115 (second and third quotations), 116, 565-69, and 1900, l(pt.3):130 and l(pt.4):522; idem, ARofSG, 1899, pp. 110, 112-13, and 1900, pp. 90-92, 107, 123; Ltr, H. E. Wetherill to Ch Surg, Div of Pacific, 13 Apr 1900, in Ms 4888, Entry 52, RG 112, NARA; "Medical and Sanitary History," p. 830.

22. WD, ARofSG, 1899, pp. 110, 112-13, and 1900, pp. 90-92, 107; idem, ARofSW, 1899, 1(pt.5): 566-68.

23. WD, ARofSW, 1899, 1(pt.4):385, 395; idem, ARofSG, 1900, pp. 90-91, 93.

24. Lippincott was replaced as chief surgeon in April 1899 by Colonel Woodhull, who was, in turn, replaced by Colonel Greenleaf in January 1900. See WD, ARofSG, 1900, p. 95.

25. WD, ARofSW, 1899, 1(pt.5):116, and 1900, l(pt.3):124 (quotation); idem, ARofSG, 1900, pp. 97-98, 121-22, 138, 142, 163; Lippincott, "Reminiscences," p. 172; "Medical and Sanitary History," p. 826; Martha L. Sternberg, George Miller Sternberg, p. 232.

26. WD, ARofSG, 1900, pp. 97-98, 122, 132-33 (quotation), 138; idem, ARofSW, 1900, 1(pt.3):125; Sexton, Soldiers in the Sun, p. 198; Joseph I. Markey, From Iowa to the Philippines, pp. 241-42.

27. WD, ARofSG, 1900, pp. 97, 121; idem, ARofSW, 1900, l(pt.3):124; Lyster, "Army Surgeon," p. 30.

28. WD, ARofSG, 1900, pp. 97-98, 133, 135-37; idem, ARofSW, 1900, 1(pt.3):125.

29. WD, ARofSG, 1900, pp. 97-98, 150; idem, ARofSW, 1900, 1(pt.3):125.

30. Glenn A. May, Battle for Batangas, p. 83; WD, ARofSG, 1900, pp. 150, 155-56; idem, ARofSW, 1900, l(pt.3):125.

31. WD, ARofSG, 1900, pp.98, 158-59, 161-62, 164-65.

32. Ibid., pp. 23 (first quotation), 24, 90, 105, 110, 134; idem, ARofSW, 1900, 1(pt.3):128-29; Gilbert E. Seamen, "Some Observations of a Medical Officer in the Philippines," p. 181 (second quotation); Lyster, "Army Surgeon," pp. 30-31; "A New Course of Instruction for the Army Hospital Corps," p. 375.

33. WD, ARofSG, 1899, pp. 21-23, 111 (quotations), and 1900, pp. 25, 106, 109-10; idem, ARofSW, 1900, l(pt.3):129-30; idem, Correspondence, 2:837.

34. WD, ARofSG, 1899, pp. 111-12, and 1900, pp.24, 95-96, 105, 120-21, 127-28, 134, 142, 151; idem, Correspondence, 2:1192 (quotation), 1261; idem, ARofSW, 1899, l(pt.5):114-15, and 1900, 1(pt.3):117, 128.

35. John C. Brown, Diary of a Soldier in the Philippines, pp. 197, 210; Lyster, "Army Surgeon," p. 31; WD, ARofSW, 1900, 1(pt.3):117, 127-28; idem, ARofSG, 1899, p. 112, 1900, pp. 94-97, 105, 120, 129, 138, 144, and 1901, pp. 141-42.

36. WD, ARofSG, 1900, pp. 118-20.

37. Ibid., p. 95; Sexton, Soldiers in the Sun, pp. 268-72; Ltr, Clarence R. Edwards to George H. Penrose, 6 Nov 1899, in Ms 4888, Entry 52, RG 112, NARA.

38. Funston, Memories, p. 373 (quotations); Freeman, Soldier in the Philippines, p. 51; United States, Congress, Senate, Charges of Cruelty, Etc., to the Natives of the Philippines, pp. 3, 6, 19; WD, ARofSG, 1899, pp. 110-11, 1900, pp. 91, 93, 108, and 1901, p. 142; idem, ARofSW, 1899, l(pt.4):512, and 1900, 1(pt.4):542; Sexton, Soldiers in the Sun, pp. 79-80, 81-83, 240-42; Thomas McD. Fairfull, "General Nelson A. Miles and His Charges of Army Brutality in the Philippine Insurrection, 1902," M.A. thesis, pp. 27, 53-54; Gates, Schoolbooks, p. 86; Lippincott, "Reminiscences," p. 173; Kenton J. Clymer, "Not So Benevolent Assimilation," p. 550; James H. Blount, The American Occupation of the Philippines, 1898-1912, pp. 202-05; Leon Wolf, Little Brown Brother, pp. 306-07; Linn, "War in Luzon," Ph.D. diss., p. 208.

39. WD, ARofSG, 1900, p. 102; Sexton, Soldiers in the Sun, p. 238; John M. Banister, "Surgical Observations in the Philippines," pp. 1118-19.

40. Charles E. Woodruff, "The Soldier in the Tropics," pp. 772 (quotation), 779; WD, ARofSG, 1898, pp. 114-15, 1899, pp. 100, 110-11, 114-15, 1900, pp. 89-90, 92, 102-04, 126, 141, and 1902, pp. 105, 107; idem, ARofSW, 1900, 1(pt. 3):119; Sexton, Soldiers in the Sun, pp. 58-59, 140, 152-54; Maus, "Military Sanitary Problems," pp. 22-23; "Medical and Sanitary History," pp. 826-27, 830; Dodge Commission Report, 2:1247; Flexner and Barker, "Prevalent Diseases," p. 525. See also in Entry 561, RG 94, NARA: Ltr, Edward T. Comegys to Mil Sec, U.S. Army, 23 Oct 1904; Telg, Elwell S. Otis to AG, 5 Jan 1899, and Statement, Edward J. Wagnitz, 11 Jun 1907, Henry Lippincott Papers; Med Certificate, H. O. Perley, 21 Dec 1899, William D. Crosby Papers; and Div of Philippines SO 322 (copy), 18 Nov 1900, Henry F. Hoyt Papers.

41. WD, ARofSG, 1899, p. 173, and 1900, pp. 151-52 (first quotation), 163; Freeman, Soldier in the Philippines, p. 52 (second quotation); Maus, "Military Sanitary Problems," p. 6; Sexton, Soldiers in the Sun, pp. 152-54, 162; in Entry 52, RG 112, NARA: Ltrs, Greenleaf to All Divs and Dists in Dept, 26 Mar 1900, and W. F. Lewis to SG, 17 May 1900, Ms 4888, and Ltr, D. Glennan to Ch Surg, Div of Philippines, 21 May 1900.

42. WD, ARofSG, 1899, p. 113, and 1900, pp. 87, 89, 114, 148, 163; R. W. Andrews, "Tropical Diseases as Observed in the Philippines," pp. 86-87.

43. Sexton, Soldiers in the Sun, p. 58; WD, ARofSG, 1900, pp. 92, 131, 143; Andrews, "Tropical Diseases," p. 21; United States, Bureau of the Census, Census of the Philippine Islands . . . , 1:371-73.

44. WD, ARofSG, 1899, p. 136 (first quotation), 1900, p. 141 (fourth quotation), and 1902, pp. 48-49 (third quotation), 94-96; Seamen, "Some Observations," p. 188 (second quotation); Louis M. Maus, "Venereal Diseases in the United States Army," pp. 131-32.

45. WD, ARofSG, 1899, pp. 106, 136, 141-42, 244, 249-50, and 1900, pp. 89, 125, 134; idem, Correspondence, 2:1247; Maus, "Military Sanitary Problems," pp. 16-18, 25, 28-29; William T. Sexton, Soldiers in the Philippines, pp. 34, 56-57; "Medical and Sanitary History," p. 827; Gates, Schoolbooks, p. 58; Lyster, "Army Surgeon," p. 33; Brief Summary of the Military and Civil Services of Colonel L. M. Maus, Medical Corps, United States Army, Retired, p. 5, Louis M. Maus Papers, Entry 561, RG 94, NARA.

46. Freeman, Soldier in the Philippines, p. 73 (quotations); Lippincott, "Reminiscences," p. 171; "Medical and Sanitary History," p. 829; WD, ARofSG, p. 131.

47. WD, ARofSG, 1899, pp. 100, 102-03 (quotations); "Insanity in the Army," p. 586; "Medical and Sanitary History," pp. 826-27; Maus, "Military Sanitary Problems," p. 19; Sexton, Soldiers in the Sun, pp. 184-85; Woodruff, "Soldier in the Tropics," p. 779; L. G. Anderson, "Notes of an Army Surgeon in the Recent War," p. 477; P. J. H. Farrell, "Our Sick and Wounded in the Philippines," pp. 334-35; David T. Courtwright, Dark Paradise, pp. 96n, 100-101, 202-03.

48. WD, ARofSG, 1899, pp. 111 (first quotation), 134-36, 229, and 1900, pp. 127, 134-35, 140; idem, ARofSW, 1900, 1(pt.4):523 (second quotation); Div of Philippines GO 1, 22 Jul 1901, file 6355/45, Entry 22, RG 159, NARA; Woodruff, "Soldier in the Tropics," p. 776; G. W. Richardson, "Intestinal Fever, Causes and Prevention," p. 817; Sexton, Soldiers in the Sun, p. 230.

49. WD, ARofSW, 1900, 1(pt.3):122; idem, ARofSG, 1898, p. 262, and 1900, pp. 89, 92, 103, 133-34, 136, 139, 152, 155-56.

50. Ltr, IG to SG, 10 May 1902, file 6355/106, and Newspaper Clipping, 1 May 1902, file 6355/107, both Entry 22, RG 159, NARA; WD, ARofSG, 1900, pp. 98, 107, 128 (quotation), 138, 164; Lyster, "Army Surgeon," p. 31; Sexton, Soldiers in the Sun, pp. 119, 180.

51. WD, ARofSG, 1900, p. 107; idem, Correspondence, 2:1180, 1198.

52. Louis L. Seaman, "The U.S. Army Ration, and Its Adaptability for Use in Tropical Climates," pp. 381, 389; Edward L. Munson, "The Ideal Ration for an Army in the Tropics," p. 343; Sexton, Soldiers in the Sun, pp. 85, 183; Woodruff, "Soldier in the Tropics," pp. 770-72, 775; Maus, "Military Sanitary Problems," p. 9; WD, ARofSG, 1900, pp. 140-41, and 1902, p. 50; United States, Philippine Commission, 1899-1900, Report of the Philippine Commission to the President, 2:238; "Medical and Sanitary History," p. 827.

53. Quotations from Woodruff, "Soldier in the Tropics," pp. 770-71; ibid., pp. 772, 775; WD, ARofSG, 1899, pp. 226, 228, and 1900, p. 127; Seaman, "U.S. Army Ration," pp. 387-88.

54. WD, ARofSG, 1901, pp. 150-51; idem, Correspondence, 1:421, 426; idem, ARofSW, 1901, 1(pt.6):434, 508; Percy M. Ashburn, A History of the Medical Department of the United States Army, p. 228.

55. WD, ARofSG, 1901, pp. 150, 152, 155; idem, Correspondence, 1:412, 418-19; William B. Banister, "Succinct Account of Services," n.d., William B. Banister Papers, Entry 561, RG 94, NARA; Fred R. Brown, History of the Ninth U.S. Infantry, 1799-1909, pp.473-74.

56. WD, ARofSG, 1901, p. 152 (quotation); Banister, "Succinct Account of Services," Banister Papers, Entry 561, RG 94, NARA.

57. First quotation from Frederick M. Hartsock, "Military Medical Conditions Relating to the American Legation Guard in Pekin, China," p. 252; ibid., p. 253; remaining quotations from WD, ARofSG, 1901, pp. 158-59; ibid., p. 160.

58. William B. Banister, "The Medical Reserve Corps," pp. 34-35; WD, ARofSG, 1901, pp. 150-52; idem, Correspondence, 1:429; Rpt Extract, Charles A. Coolidge, 13 Jul 1900, Banister Papers, Entry 561, RG 94, NARA.

59. WD, ARofSG, 1901, pp. 151-52; idem, Correspondence, 1:427, 435, 442, 456; "Hospital Ship in Service at Taku," p. 276.

60. WD, ARofSG, 1901, pp. 152-55; idem, Correspondence, 1:444; Ltr, SGO [unsigned] to Miss Brennan, 4 Oct 1900, Entry 103, RG 112, NARA.

61. WD, ARofSG, 1901, p. 153 (quotations); idem, Correspondence, 1:426, 442; James A. Huston, The Sinews of War, p. 303.

62. Banister, "The Medical Reserve Corps," pp. 34-35; WD, ARofSG, 1901, pp. 153, 155; idem, Correspondence, 1:449.

63. William G. H. Carter, The Life of Lieutenant General Chaffee, p. 180; WD, ARofSG, 1901, p. 154; idem, Correspondence, 1:452, 455, 459-60; idem, ARofSW, 1901, l(pt.6):518.

64. WD, ARofSG, 1901, pp. 157-58; idem, ARofSW, 1901, l(pt.6):521, 539.

65. WD, ARofSG, 1901, pp. 155, 158, 161, 168, 1903, p.113, 1904, p.113, 1905, pp.99-102, and 1917, p. 218; idem, Correspondence, 1:464, 480; Huston, Sinews, p. 303.

66. WD, ARofSG, 1901, pp. 161 (quotation), 162-65.

67. Ibid., pp. 150, 152; idem, Correspondence, 1:438.