Thursday, July 16, 2015

From Appomattox to Havana


The period that followed [the Civil War] was a contradictory time for military medicine. The Medical Department, like the rest of the Army, declined in numbers. The special laws that had been passed for the prosecution of the Civil War expired when the war ended, and along with them the wartime structure of the Ambulance Corps, the general hospitals, and the hospital transports and trains disappeared. The Medical Department forfeited the progress it had made toward establishing commissioned officers in medical administrative specialties. The law that created the Ambulance Corps expired in 1866. There were two commissioned U.S. Army Medical Storekeepers in 1888, but there were none ten years later when the United States went to war with Spain.

There were efforts to counter those unfortunate events. In 1885 the surgeon general, Brig. Gen. Robert Murray, said the department had plans for the reestablishment of an ambulance system in the event of war. General Murray also argued that the department needed soldiers trained to provide medical care and treatment in the hospitals, and his efforts led to the creation of an enlisted hospital corps in 1887. Those medical soldiers were charged with performing "all necessary hospital services in garrison, camp, or field." Some militia organizations began to experiment with dedicated medical units that would continue to exist during peacetime as well as during wars. Massachusetts established an ambulance corps for its militia in 1885, but without the provision of ambulance corps officers.

Above all, the period that followed the Civil War was the time when the revolution began that transformed medicine into a science. The germ theory of disease was gradually worked out by European researchers and slowly (and in some cases reluctantly) adopted by American doctors. Army medical officers provided some leadership in the new science, notably Brig. Gen. George Miller Sternberg, who served as surgeon general from 1893 to 1902. Maj. Walter Reed studied the new science and began training others at the Army Medical School, established in 1893. Treatment modalities had also improved. The clinical thermometer, hypodermic syringe, and ophthalmoscope were in common use, as was the "Roentgen Ray," the x-ray, which permitted noninvasive viewing within the body. This new technology was used by the Medical Department in Cuba. Both anesthesia and aseptic surgery were accepted practices, and orthopedic surgery beyond amputation was possible.

The war against Spain in 1898 demonstrated the difficulties facing a fledgling world power as it quickly raised and moved ground forces in its first overseas deployment. Public support for Cuban independence and growing sentiment against Spanish influence in the Western Hemisphere turned to passion when the U.S. battleship Maine sank at anchor in Havana harbor on 15 February 1898. The United States declared war on the twenty-fifth, and the "splendid little war" was on. A hastily assembled expeditionary force arrived off Santiago, Cuba, on 21 June with seventy-one medical officers and eighty-nine reporters, "the former to experience many troubles, the latter to cause many." Santiago surrendered on 17 July, and Spain signed the Treaty of Paris in December, withdrawing from Cuba and ceding Guam, Puerto Rico, and the Philippines to the United States.

The mobilization was anything but efficient, but national policy dictated speed, and that policy was effective even though the war was over before the logistic support was fully organized. The weaknesses included medical support, and, as Major Reed put it, the Medical Department got a "black eye."

After declaring war with Spain, Congress acted to increase the Regular Army and to create a volunteer force, and the Army grew from 28,000 to nearly 275,000 personnel. Despite this dramatic growth, Congress did not increase the hospital corps, which numbered 791. General Sternberg, unable to expand the corps, did obtain authority to transfer soldiers from the line. But, as one chief surgeon complained, "they palmed off on the Medical Department the most undesirable element in the companies, men whom the captains wanted to get rid of." On the brighter side, hospital corps volunteers included medical students, pharmacists, and recent medical school graduates, an infusion of talent embraced as a welcome asset.

Lessons From the War With Spain

The war with Spain brought into sharper focus some of America's inadequacies in providing medical support to its military forces, part of the larger difficulty in projecting military power. The irony of organizational problems in the U.S. military at a time when the nation prided itself on its talent for business was not lost on those who sought to learn from the conflict. It moved Theodore Roosevelt to reflect that "it was curious that when war came we should have broken down precisely on the business and administrative side, while the fighting edge of the

troops left little to be desired." In most cases, the cure for the Medical Department's deficiencies required the addition of commissioned officers in administrative and scientific specialties necessary for a modernized military force.

The Medical Department's problems were thrashed out by a presidential panel. Called the Dodge Commission for its head, Grenville M. Dodge, it began hearings in September 1898. President William McKinley asked the panel to investigate charges of "criminal neglect of the soldiers in camp and field and hospital and in transports."

Medical logistics was a major source of complaint. Theodore Roosevelt, who would parlay his wartime exploits into the governorship of New York, testified that medical supplies were insufficient at the front. There had been no cots for the wounded and no ambulances at San Juan Hill. He later wrote that "the condition of the wounded in the big field hospitals in the rear was so horrible, from the lack of attendants as well as of medicine, that we kept all the men we possibly could at the front. One field hospital in Cuba consisted of little more than a few tents without cots, mattresses, or clothing for the patients. When Clara Barton of the American Red Cross visited the hospital at Siboney, she found wounded lying on the ground. Brig. Gen. William R. Shafter, who complained that the surgeon general "does not seem to appreciate the situation," had halted because his force could no longer handle the casualties. Stateside camps also had problems. Col. William A. Pew, Jr., commander of the 8th Massachusetts Infantry at Chickamauga Park, Georgia, pointed out that his surgeon had requisitioned drugs but never received any.

General Sternberg testified that shipping of medical supplies and equipment to Cuba had been outside the Medical Department's control. Much was late and much was lost, including an entire 200-bed hospital. Seventeen ambulances had been loaded at Tampa for Shafter's corps; three landed in Cuba. Other medical vehicles, supplies, equipment, and even animals loaded at Tampa were never seen again. The ambulance service, such as it existed, had been decimated by an ineffectual supply system.

In some cases medical logistics difficulties had been ameliorated by detailing line officers to serve as quartermasters and commissary officers for medical units. But problems remained. At the heart of the situation was the structural weakness of the Medical Department in its lack of a dedicated medical logistics organization and specially trained officers, and this deficiency had inevitably led to shortages in needed supplies and equipment where they were needed most. The surgeon general's lack of executive power underlay the failures, a point made by one of General Sternberg's defenders. "Our experience has taught us in a most forcible way that the Medical Department should have charge of everything pertaining to the sick and wounded."

Closely related to the lack of medical logistics officers was the absence of officers dedicated to medical administration, a subject that received attention by the Dodge Commission. Certainly the unfamiliarity of military physicians with Army procedures had complicated matters, but the administrative duties expected of physicians were counterproductive. Physicians assigned to field hospitals were saddled with numerous tasks ranging from the maintenance of patient records to the supervision of food service operations. Physicians commanded ambulance units because the Medical Department had lost its ambulance corps officers.

Sternberg recommended simplification of administrative procedures so that physicians could concentrate on their professional duties, but the problem went further than that. Witnesses repeatedly observed that many medical officers were good physicians but incompetent administrators. The situation had become so muddled in the II Corps that the chief surgeon, frustrated with the volunteer medical officers, had taken direct action in selecting commanders of the hospital enlisted detachments.

The inability of medical officers to grasp the company organization and its papers and lack of mental force or training to control the men led finally to my requesting authority to place one of the officers of the line, who are allowed as quartermasters in the division hospitals, in command of the Hospital Corps companies, and gradually matters became systematized.

That solution went to the heart of the matter by attempting to include in the structure of medical units officers dedicated to specific administrative functions.

The need for management expertise was also evident in the administration of Army hospitals. The commander of the hospital at Camp Wikoff, a rest camp hurriedly constructed at Montauk Point, Long Island, for soldiers returning from Red Cross nurse helps a sick soldier at the railroad station at Camp Wikoff, Montauk Point, New York

Cuba, was battered by his experience. He said one of the lessons he learned was the need for "experienced executive men" on the hospital staff. Maj. Jefferson R. Kean, commander of the 2d Division hospital at Camp Cuba Libre, Florida, believed that the lack of hospital administrative staff was the principal deficiency during the war. He suggested two administrative officers for hospitals under 300 beds, three for those over that size: "Without such staff assistance it is impossible for the commanding officer of a large hospital to keep his property and money secure, and, what is even more important, to carefully supervise the medical administration and see to it that the patients are properly cared for."

Another witness proposed two surgeons for every headquarters, one for administrative duties, the other for clinical responsibilities. More than one military surgeon suggested that since good physicians were not necessarily good administrators, the administrative part of the work could and should be handled by a line officer detailed for that purpose. Brig. Gen. Joseph P. Sanger, a former inspector general of the Army and a division commander in Cuba, included the duty of hospital commander in that category.

General Sternberg also came under fire for shortcomings in preventive medicine and sanitation. Line commanders were responsible for the state of sanitation in their units, while the surgeon general was responsible for the setting of standards and policy. Sternberg had acted upon his responsibilities by issuing a circular directing medical officers to undertake a series of sanitation measures, as well as "buck-up" circulars when the first directive failed to make a dent in the ubiquitous sanitation problems. Unfortunately, a small regular army might be expected to respond to directives, but not so with a hastily formed army of volunteer officers and recently enlisted conscripts, and Army camps remained smelly pestholes. Sternberg was a distinguished scientist with an international reputation as a bacteriologist. Nevertheless, preventive medicine measures were ignored while he "rested on the power of his circular."

The results were unfortunate: 932 soldiers were killed in action or died from wounds, yet 5,438 died of disease. In some cases, as with typhoid, the mechanics of transmission were known; in others, such as yellow fever and malaria, they were not. In any event, disease took its toll of lives and affected national strategy. Fear of disease, particularly yellow fever, was intense. A round-robin letter, signed by all but one of Shafter's commanders after the fall of Cuba, was sent to President McKinley demanding the withdrawal of American forces before yellow fever killed them. Part of the remedy lay with better application of existing preventive medicine doctrine. However, part of the remedy resided in medical advances that would increasingly provide medical officers with effective tools.

Image: Frederic Remington's drawing, Field Hospital at the "Bloody Ford" of San Juan Creek


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