Back in Washington, Surgeon General Wyman saw the events in Middlesboro as a cautionary tale. The epidemic had cost the federal government a great deal of effort and $3,500 in cash. In his 1898 annual report, Wyman issued a terse statement titled “Principles Governing the Extension of Aid to Local Authorities in the Matter of Smallpox.” The surgeon general railed against the shortsightedness of local and state officials who, he believed, had allowed smallpox to rage out of control in Kentucky and elsewhere in the southern states. The spread of smallpox, Wyman thundered, “is so easily prevented under proper management that it is a disgrace to the sanitary authorities of any State, municipality, or locality whenever this disease is permitted to get beyond their control.”78
Henceforward, Wyman declared, the role of the Marine-Hospital Service in local smallpox control would be strictly limited, in keeping with the constitutional principles of American federalism. Local governments were the first line of defense against epidemic disease, supported, when things got out of control, by state institutions. The Marine-Hospital Service’s surgeons in the field, Wyman explained, would not lightly assume responsibilities that were so clearly local. They would merely furnish “expert assistance” to local and state authorities, settling differences of opinion about whether a particular infectious disease was smallpox. The surgeons would also offer “advice” regarding smallpox suppression. But the Service would take full control of an epidemic only when doing so was “necessary to prevent the spread from one State to another.” Monetary aid would be withheld “except under the most urgent circumstances.”79
Stern language. Given the nature of the southern outbreaks, however, the surgeon general surely understood that his “Principles” enabled the exercise of federal power as much as they restrained it. The spread of “mild type” smallpox placed an elite corps of federal officers—the medical men of the U.S. Marine-Hospital Service—in the almost unheard-of position of exercising police power in local communities. For the right to name a local outbreak of “Elephant itch” or “Cuban itch” a bona fide epidemic of small-pox was the very act that set the machinery of disease control in motion. Once that happened, the federal “advisor” who diagnosed the disease was well placed to take charge of operations on the ground. And when did smallpox ever respect national borders or state lines? As smallpox made its way across the southern states at the end of the nineteenth century, with little regard for political boundaries or man-made laws, the hundreds of urgent requests from local communities for federal assistance would put the old constitutional principles to the test. All of which is how C. P. Wertenbaker and the medical men of the U.S. Marine-Hospital Service became the vanguard of federal power in the American South.
THREE
WHEREVER WERTENBAKER WENT
Though he never went to war, C. P. Wertenbaker lived his entire life in uniform. As a boy, he donned the outsized epaulets and tasseled shako cap of the Warrenton Rifles, a company of the Virginia Volunteers that was legendary in Charlie Wertenbaker’s world for its stand at Fairfax Court House on June 1, 1861. (The Rifles’ commander, Captain John Q. Marr, lost his life that day, the first Confederate officer to fall in the Civil War.) While a medical student at the University of Virginia, and during his half-dozen years as a practicing physician, Wertenbaker turned out for militia duty in the resplendent garb and sergeant’s insignia of the Volunteers’ Third Infantry. At twenty-eight, he put on yet another uniform, the one he would wear with honor for the rest of his career. The simple navy-blue field suit of a commissioned officer in the U.S. Marine-Hospital Service, meant to suggest military-issue without quite being military-issue, consisted of dress pants and a fly-front coat, the only adornments a pair of gold Service insignia—a fouled anchor and caduceus—on the coat’s upright collar. For ceremonial occasions, he sported the Service’s full dress uniform, a double-breasted suit with two rows of big brass buttons, golden epaulets, white gloves, and, at his side, a sword etched with the Great Seal of the United States of America. It was this national uniform, rather than the state regalia of his younger self, in which Wertenbaker would one day choose to be buried.1
But the most memorable outfit Wertenbaker ever wore, and the one most truly his own, was the one he contrived for his southern “smallpox work” in the late 1890s. Before he stepped, uninvited and unannounced, across the threshold of a sharecropper’s cabin or a mill worker’s wood-framed house, he pulled on a pair of crisp, sterile overalls and a coat that reeked of formalin disinfectant. He wound cloth around the top of his head, looking like a soldier with a head wound. And over his mouth and nose he tied a respirator that he fashioned from a yard of cheesecloth and a piece of thick cotton. It was not until Wertenbaker completed his inspection—after he had posed his last question, examined the last squirming child, and scraped his lancet against the very last arm—that the subjects of his attentions finally got a good look at him. Their eyes followed the U.S. government man as he stepped outside, doffed his cap and respirator, and set them aflame.2
The road that carried C. P. Wertenbaker from his privileged childhood on Virginia’s upper Piedmont Plateau to the humblest homes of laborers in the Deep South ran through Richmond, New York, Norfolk, Galveston, Chicago, Washington, and a great many points in between. The Marine-Hospital Service surgeon had at least one thing in common with the railroad workers, rivermen, agricultural laborers, miners, drummers, minstrel performers, and machine tenders who ferried smallpox across the South in their bodies and on their clothes: he never stayed put for long. For many laborers in the end-of-the-century South, the ability to pick up and go was the only form of mobility their lives offered. To aging former slaves and their children, freedom of movement was a cherished right, one exercised, sometimes, for the sake of exercising it, to demonstrate to an exploitative boss or landlord that their bodies and labor could not, in fact, be owned. For the Service surgeon, member of an elite cadre of some two hundred mobile federal medical men, transience was part of the job description.3
And, as Wertenbaker would learn, it was more than that. The surgeons’ readiness to move, the very portability of their federal medical expertise, made them a force for the integration and bureaucratic standardization of public health in the United States. Wertenbaker and his colleagues were the vanguard of a modern, national public health system. That such a system would not reach fruition in their lifetimes does not diminish the significance of their work.
C. P. Wertenbaker as a young surgeon with the U.S. Marine-Hospital Service in 1888. COURTESY OF THE ALBERT AND SHIRLEY SMALL SPECIAL COLLECTIONS LIBRARY AT THE UNIVERSITY OF VIRGINIA
A half century before the establishment of the federal Communicable Disease Center (now the Centers for Disease Control and Prevention) in Atlanta in 1946, public health was still an explicitly coercive form of social regulation, or “police power.” As one early twentieth-century authority observed, “The famous Roosevelt doctrine to ‘speak softly, but carry a big stick’ is particularly applicable to public health work.” For the most part, local and state governments still wielded that authority, or neglected to, with little interference from Washington. But the mobility of the Service surgeons—premised upon the fact that smallpox and other infectious diseases did not respect borders—enabled the U.S. government to deploy scientific expertise and project an extraordinary measure of national authority across a vast region, a far-flung nation, and into new colonial possessions in the Caribbean and the Pacific. For a growing number of people across America and many other parts of the world, a medical man in a navy suit was the first representative of the U.S. government they ever encountered. In 1891, Congress had assigned the Service a new role as sentinels at the nation’s borders and overseas ports, to ensure that immigrants did not carry foreign diseases onto American soil. Though virtually forgotten today, the intervention of Service officers like Wertenbaker at the scenes of local outbreaks—often deep in the American interior—may have been just as important as border control to the long process by which the U.S. government
learned to govern its territory and people like a modern nation-state.4
The smallpox years of 1898 to 1900 were the busiest in the history of the Marine-Hospital Service to date, and those years were also the most mobile of Wertenbaker’s career. The surgeon’s sorties to smallpox-stricken locales across the American South afforded him an exceptionally broad regional perspective on the tangle of factors—the institutional constraints and conflicts, the clash of interests and beliefs, and the unpredictable behavior of a once-familiar disease and the individuals affected by it—that made small-pox control such an intractable political problem in southern communities. Middlesboro, Wertenbaker learned, had been just the beginning, an extreme example of the social dissension and political failure he would find everywhere. His experiences in the field would turn him into something of an extreme case himself, a strong advocate for greater national control in this traditionally local realm of law and governance, public health.5
Like most Americans born before the Civil War, Charles Poindexter Wertenbaker’s first loyalties were to family, community, state, and God. Born in Charlottesville, Virginia, on April 1, 1860, Wertenbaker descended from a long line of soldiers, scholars, and scribes, whose generations of service to the Old Dominion he traced back to a distant ancestor, a colonel who sat on the Bacon’s Rebellion court-martial in 1676. A great-great-grandfather on his mother’s side had received one hundred acres of Virginia soil for his service in the Revolutionary War, a fact Wertenbaker used to establish his right to membership in the Sons of the American Revolution. His grandfather, William Wertenbaker, fought while still in his teens in the War of 1812 and was appointed by Thomas Jefferson in 1825 to be the first librarian of the University of Virginia, a position he held for more than half a century. In his application to the Sons of the American Revolution, C. P. Wertenbaker failed to mention that his father, a cigar manufacturer named C. C. (Charles Christian) Wertenbaker, had spent his prime in a very different war. He fought with General Robert E. Lee’s Army of Northern Virginia during the bloody 1862 invasion of Maryland and was wounded himself two years later. C. C. Wertenbaker stood with his regiment when it surrendered, with the rest of General Lee’s forces, at Appomattox Court House on April 9, 1865, eight days after Charlie’s fifth birthday.6
Charlie Wertenbaker grew up in relative privilege, in a household with three or four servants, white and black. But illness and death were as familiar to his childhood landscape as the green lawns and white columns of Mr. Jefferson’s university. Charlie was the eldest of the eleven children born to C. C. and Mary Ella Wertenbaker. Seven of his siblings died in infancy or childhood; his mother died before he turned thirteen. Such family tragedies were common in nineteenth-century domestic life, with influenza, tuberculosis, and other infectious diseases causing most of the misery. But the relentless rhythm of loss in the Wertenbaker home would have been unusual even in the tenement districts of the disease-ridden northern cities. The mortality in the Wertenbaker family exceeded that found among nineteenth-century American slave children, more than half of whom died before reaching the age of five.7
This legacy of loss may partly explain why, when Charlie Wertenbaker came of age, he not only signed on with the Virginia Volunteers, in the family tradition, but enrolled in the medical department at the University of Virginia. At the time, a career in medicine promised neither high status nor great wealth. Still, it was a respectable calling, and by the 1870s educated people were beginning to think of medicine as a powerful science, capable of preventing the spread of infectious diseases, not just treating the symptoms that ravaged the human body. Wertenbaker earned his doctor of medicine degree in 1882. After graduation, he moved to the rebuilt capital city of Richmond, where he worked as an intern at the Retreat for the Sick under the eminent surgeon Hunter McGuire, erstwhile medical director of General Thomas J. (Stonewall) Jackson’s Second Corps (and future president of the American Medical Association). From 1884 to 1888, Wertenbaker moved north to work in hospitals in and around New York City. He entered the U.S. Marine-Hospital Service, as an assistant surgeon, in August 1888.8
The federal bureau, with its Washington headquarters and its uniforms of blue, must have seemed to some of his militia buddies a curious career choice for the eldest son of a proud old Confederate. But given the straitened southern economy after the Civil War, many young university-trained physicians from the region competed for positions in the federal government, particularly in the medical services of the Army and Navy and in the Marine-Hospital Service. Southern men would predominate at the Service’s entrance exams until the 1930s. Wertenbaker’s alma mater was known in the corps as “The University.”9
From its humble origins in 1798 as a federal fund to support sick and disabled seamen, the Marine-Hospital Service had grown after 1870 into an increasingly centralized and professional federal bureaucracy. Overseen by the secretary of the treasury, the Service modeled itself after the medical corps of the Army and Navy. It adopted a system of rigorous examinations, commissioned ranks (rising from assistant surgeon to passed assistant surgeon to surgeon), merit-based pay grades, and uniforms for the surgeons assigned to its many hospitals and relief stations at ports along the nation’s coasts and major inland waterways.10
The presence of the national government in the South had receded after the collapse of Reconstruction and the removal of the last federal troops from the South Carolina statehouse in 1877. But in the control of epidemic disease, the political current flowed in the opposite direction. As Congress expanded the Service’s scope of action, and the bureau’s cadre of mobile medical officers moved into areas of governance hitherto dominated by the state and local authorities, the South proved the greatest recipient—sometimes solicited, sometimes not—of federal aid. The National Quarantine Act of 1878, enacted during the devastating yellow fever epidemic that killed twenty thousand people in the Mississippi and Ohio river valleys, empowered the Service’s officers to enforce quarantine regulations in the region, a major expansion of federal authority in the realm of internal police power. The yellow fever work made the institution and its officers more familiar to Americans in the South than in any other region.11
The scale and scope of the Service’s activities continued to grow after Wertenbaker joined it, and not only in the South. In 1890, Congress gave the bureau permanent authority to administer interstate quarantine regulations. The following year Congress put the Service in charge of medical inspection of immigrants at the nation’s major border crossings and ports, including Ellis Island. Among the many things the U.S. medical men demanded of arriving immigrants was proof of a recent successful vaccination against smallpox—preferably in the form of a fresh vaccination wound on the upper arm. After war broke out with Spain in 1898, the Service followed the flag, administering quarantine at the coastal ports of Puerto Rico, Cuba, and the Philippines. By the time Congress renamed the institution in 1902, calling it the U.S. Public Health and Marine-Hospital Service, the bureau had already achieved that position in fact, with its hospitals, stations, state-of-the-art National Hygienic Laboratory, and traveling surgeons. In the eyes of Surgeon General Walter Wyman, who presided over this institutional growth, the United States finally had “a sanitary structure worthy of this nation.”12
The manly martial and scientific culture of the Service offered Wertenbaker a way of living in the world that he must have found both familiar and exotic. Wyman, a St. Louis native who bore a passing resemblance to Theodore Roosevelt, recognized that enforcing maritime quarantines and traveling to epidemic zones was lonely and dangerous work. And though the surgeon general could be an overzealous enforcer of bureaucratic edicts, he cultivated camaraderie in the ranks. This esprit de corps rested upon a soldierly discipline and the faith that, as one officer put it, “scientific investigation at the bench and in the field would yield eventually the knowledge to deal with the diseases of man.”13
Wertenbaker’s Service career, from 1888 to 1916, coincided with the meteoric ris
e of scientific medicine. Professionals in medicine, the biological sciences, and public health were dramatically reducing Americans’ rates of mortality and morbidity from infectious diseases. Wyman encouraged his surgeons to think of themselves as men of science working at the front lines of this historic campaign. He dispatched them to medical conferences. He published their field reports in the Service’s journal. And when his surgeons fell in the line of duty, he honored them in words redolent of the values of the institution they had served. Yellow fever killed Assistant Surgeon John William Branham, a young husband and father, in Brunswick, Georgia, in 1893. The surgeon general praised him for his “education and medical attainments, . . . manliness of deportment and gentlemanly bearing.”14
As Wertenbaker rose in the Service and built a small family of his own, he kept that eulogy in his personal files, not far from his two life insurance policies. He must have wondered if he, too, would one day be remembered as an honored citizen-soldier in Walter Wyman’s war against disease.15
C.P. Wertenbaker could not have foreseen that he would spend several years of his life fighting smallpox. Until 1898, the Service’s work consisted chiefly of running its 22 hospitals and 107 relief stations for American seamen on the coasts and interior ports, manning immigrant inspection stations, and administering maritime quarantines when yellow fever threatened. Suppressing a smallpox epidemic was a different proposition from inspecting vessels and passengers at port. Fighting smallpox involved close control of entire local populations, on their own turf. To do the job right meant compelling men, women, and children to undergo an unpleasant and unpopular medical procedure, vaccination. With the exception of the major entry points for immigrants into the American nation, such intervention was still viewed as a matter of police power, like punishing criminals and regulating noxious trades.
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