TWO

THE MILD TYPE

A peculiar new form of smallpox invaded communities across the American South during the last three years of the nineteenth century. The mysterious disease brought little of the horror people expected from smallpox. For every hundred people infected, only one or two died. Physicians and lay-people often mistook the symptoms for chicken pox, measles, or some other eruptive disease. The eruption passed through the normal stages, but the pustules typically remained superficial and discrete. Miraculously, most people recovered without pockmarks. At first the new pox reportedly spread almost exclusively among African Americans. Because of its unprecedented mildness and its reputation for infecting “none but negroes,” the new smallpox was allowed to gain a beachhead in the southeastern United States. Local governments were slow to respond until someone died or the disease crossed the color line. In this way, isolated cases became outbreaks, outbreaks became full-scale epidemics, and a disease whose ultimate capacity for destruction no one could foretell made its way from place to place.¹

As the disease spread back and forth along the rivers, roads, and rails of the southern states, a growing inventory of popular sobriquets traveled with it. “Cuban itch,” some called it, or “Porto Rico scratch,” “Manila scab,” “Filipino itch,” “Mexican bump,” “Nigger itch,” “Italian itch,” “Hungarian itch,” “Camp itch,” “Army itch,” “Elephant itch,” “Kangaroo itch,” “Cedar itch,” “Bean pox,” or simply “Bumps.” These invented diagnostic names, which some physicians adopted, expressed the lack of alarm with which ordinary people greeted this highly contagious, obviously itchy, and occasionally fatal eruptive disease. They’d seen worse.²

Like the rumors that everywhere circulated about the new disease, the made-up names traced its origins, in a matter-of-fact way, to particularly salient features of the social and political landscape of end-of-the-century America. Americans continued the practice, already old when smallpox first exploded across Europe, of ascribing the foul scourge to rival powers, the wandering poor, and other scapegoats. Surely, the Americans said, the “itch” came from the exotic colonial frontiers opened by the war with Spain. Or from the rowdy work camps that had sprung up across the southern countryside, wherever logs needed cutting, tracks laying, or coal hauling. Or from the bodies of a formerly enslaved people, now moving about the region in search of work and a greater measure of freedom. Or from the new immigrants who steamed across the Atlantic from unfamiliar parts of southern and eastern Europe. But behind all of these names, and the tales of origin they told, lay an old foe. “In nine out of ten cases,” said Passed Assistant Surgeon C. P. Wertenbaker of the U.S. Marine-Hospital Service, “these prove to be smallpox.”³

The full scope of these southern outbreaks may never be known. Many localities—and even some state governments, such as Arkansas’s and Georgia’s—had no public health board, much less any system for tracking the incidence of infectious diseases. Even where active health boards existed, the diagnostic confusion caused by the new “mild type” of smallpox ensured that many cases went unreported. The people most vulnerable to smallpox, unvaccinated African Americans and poor whites, were the members of southern society least likely to receive professional medical care—or to volunteer information about kinfolk and neighbors to police and health officials. When health authorities declared an epidemic, the public record thickened, because that declaration obliged local governments to seek out and isolate all infected people and their known contacts. But the efforts of state health boards and the federal Marine-Hospital Service to keep tabs on smallpox invariably came up short. The vast majority of Southerners who contracted smallpox during these years probably went uncounted.⁴

Still, a visitation of this magnitude did not go unrecorded. Local newspapers, state health boards, and the federal Marine-Hospital Service tried to survey the damage to people, commerce, and local reputations. Smallpox struck every southern state from 1896 to 1900, affecting hundreds of local communities. The first reported outbreak of the mild type began in Pensacola, in the Florida Panhandle, on November 20, 1896: 54 people caught the disease, and no one died. The first major epidemic began in the summer of 1897, some 250 miles north of Pensacola, in the manufacturing center of Birmingham and the surrounding coal camps of Jefferson County. Within a year, Alabama reported 3,638 cases with 51 deaths (a case-fatality rate of just 1.4 percent). Meanwhile, smallpox broke out in every state in the old Confederacy, as well as West Virginia, Kentucky, and a few northern and western states. A Kentucky Board of Health bulletin observed, early in 1898, that the disease showed “an unusual tendency everywhere to break over official control and assume an epidemic form.” By the end of 1901, the board had counted 394 separate outbreaks; only 9 of the state’s 119 counties escaped infection. All told, Kentucky reported 11,279 cases with 184 deaths (1.63 percent). From January 1898 to May 1903, North Carolina reported 11,735 cases and 331 deaths (2.82 percent). In other states the story was much the same. Almost everywhere, health officials wondered at the exceptional mildness of smallpox—and the fact that they seemed unable to get rid of it.⁵

Leading health officials, including Surgeon General Walter Wyman of the U.S. Marine-Hospital Service, warned local governments and the public that they could not afford to take mild smallpox lightly. Smallpox was smallpox. Mild or not, the disease still caused suffering and occasional death, and epidemics slowed local industry and commerce. No one knew what made the mild type mild, and no one could predict how long it would remain so. Given the scientific knowledge available to them, responsible health officials proceeded under the reasonable assumption that smallpox could regain its full lethal force at any moment. Trying to convey this concern to a skeptical and predominantly rural public, North Carolina health officials warned that mild smallpox might be planting the “seeds” for a truly horrific epidemic.⁶

The wisdom of such predictions seemed confirmed by localized outbreaks that claimed many lives. The experience of New Orleans, the South’s largest city, was worrisome. The mild smallpox reached the city, reportedly in the body of a “negro steamboat laborer,” in February 1899. (The theory of origin would have shocked no one: almost every epidemic to reach New Orleans since its foundation had been traced to a sailor or riverman.) That year, the New Orleans Board of Health reported 283 cases and only 6 deaths (2.1 percent). But the following year, during what city health officials described as “an almost incessant battle” with smallpox, New Orleans recorded 1,468 cases and 448 deaths (30.5 percent). Mississippi weathered deadly winter epidemics in 1900 and 1901. In just the first six weeks of 1901, the state reported 2,066 cases and 456 deaths (a 22 percent fatality rate)—a greater toll, noted the Atlanta Constitution, than the dreaded yellow fever had taken there in any year since the great epidemic of 1878. Outside the South, lethal outbreaks occurred around the turn of the century in New York, Philadelphia, Boston, Cleveland, and other cities. In Boston and Cleveland, these epidemics, in which hundreds died, came fast on the heels of outbreaks of mild smallpox.⁷

The slow accumulation of epidemiological experience would eventually persuade public health officials that mild type smallpox was a distinct disease entity. In 1913, Charles V. Chapin of the Providence Health Department, one of the preeminent American health officials of the early twentieth century, published the first major scientific article on the history of mild type smallpox in the United States. Basing his article on the evidence from public health reports, Chapin suggested that the mild type “seems to be a true mutation” with a marked tendency to “breed true.” That is, mild type smallpox begot more of the same. Mild smallpox could still give rise, in susceptible individuals, to horrifying confluent smallpox; it could even kill. Infants, the elderly, and people with preexisting health problems were especially vulnerable. But, said Chapin, “tho it is possible that a few outbreaks of the severe type may have developed from the mild type, there is no conclusive evidence that they have been numerous, or extensive.” Twenty years later, Chapin stated his claim in stronger terms. Citing the belief of “practically all epidemiologists and health officers who have had experience with smallpox in the United States,” he wrote, “there is no proof that, during the more than thirty years the mild type has been with us, it has ever given rise to a permanent strain of the severe type.” That remains the consensus of smallpox scientists today.⁸

Experts now believe that two strains of mild smallpox appeared for the first time at the tail end of the nineteenth century. One probably arose in the southeastern part of North America (the Pensacola strain), the other a bit earlier in southern Africa. Laboratory studies would eventually show that the two regional varieties of smallpox had different DNA, but their clinical and epidemiological characteristics were so similar that scientists created one term to cover both: variola minor. Classical smallpox was given a new name: variola major. Until the advent of genetic testing, the only sure way to tell variola minor from variola major was to count bodies. Variola minor was defined in the scientific community as that form of the virus that killed between 0.1 percent and 2 percent of its victims.⁹

Since the 1910s, the North American strain of variola minor has been referred to by its Brazilian name, alastrim, a Portuguese word that means “burns like tinder, scatters, spreads from place to place.” The name encapsulates its global history. Since many of its victims remained ambulatory, and because so much of the U.S. population at the turn of the century moved around the country in pursuit of work and profit, alastrim spread with unusual speed over great distances. From its likely southern origin, it traversed the United States from 1896 to 1902, slipped into Latin America, England, and Europe, then made its way around the world. In other words, the disease so many Americans called “Cuban itch” was almost certainly a U.S. export.¹⁰

Variola major did not go away. The classical form of the virus apparently caused those deadly epidemics in New Orleans, New York, Boston, and elsewhere in 1900 and afterward. The virus in its deadliest form continued to infect and kill millions of people around the globe until the 1970s. In the United States, however, the incidence of variola major declined sharply after 1905. (The last major epidemic struck Ohio, Michigan, and western Pennsylvania in 1924–25.) After the turn-of-the-century epidemics, then, the mild type became the only form of smallpox most American communities would ever know.¹¹

Government officials must often act in tight situations with imperfect knowledge. It’s part of the job description. Health officials in the late nineteenth-century South were fighting, in real time, against a mysterious disease whose capacity for taking human life no one could predict. In their eyes, there was only one sure way to permanently reduce the dangerous threat of smallpox: universal vaccination. Experience quickly confirmed that Jennerian vaccination worked just as well against the new smallpox as it did against the old—which was all the proof most health officials needed that the two diseases were, in fact, one and the same.

Because of the diagnostic confusion that followed “the mild type” wherever it went, public health officials found themselves fighting a hard public campaign on many fronts. They had to persuade town and county officials, who held the purse strings, to appropriate scarce funds for smallpox control. They had to convince skeptical physicians that this new disease was smallpox at all. They had to protect their own communities from infection by neighboring towns where lax or inept officials let epidemics spiral out of control. And they had to get the people vaccinated. This last task would prove the most intractable. Public health officials used every available tactic to secure universal vaccination among citizens who detested the procedure and feared its results. Those political tactics included education, intimidation, and, with the aid of local police, criminal sanctions. Especially when they confronted opposition from African Americans, the authorities readily resorted to violent force.

Public health imperatives alone did not determine the impact of smallpox in the South. Particular features of the region’s social and political landscape eased the spread of the mild smallpox and made its eradication extraordinarily difficult. Faced with an escalating public health disaster of regional scope, many local and state governments would turn for assistance to an unlikely ally: the federal government.

Smallpox burned across the South, without respect for such man-made boundaries as county lines and state borders. Even the color line, which for a while seemed to hopeful whites to hold the virus at bay, proved an ephemeral barrier. As indifferent as smallpox was to such political and ideological boundaries, they did shape how Southerners and their governments experienced and battled the disease. The smallpox epidemics of the end of the century constituted an event of regional and, ultimately, national significance. But in a more fundamental sense, they happened locally. And mild smallpox proved at least as adept as the most devastating variola major of the past at revealing the true boundaries and character of a community.

One place in particular—Middlesboro, Kentucky—showed the nation in the winter of 1898 just how much damage even the mild type of smallpox could do under the right social and political conditions. An Appalachian mountain city of 3,500 souls, Middlesboro occupied a shallow valley at the northern end of the fabled Cumberland Gap, just a few miles from the spot where the borders of Kentucky, Tennessee, and Virginia met. The “Magic City,” as local boosters called it, was just ten years old. Already it stood as a stark monument to the creative destruction of industrial capitalism. Before the epidemic there ended, the city would stand for failings of a decidedly more personal nature.¹²

Middlesboro was “west” before it was “south.” In the late eighteenth and early nineteenth centuries, thousands of westering Americans passed through Cumberland Gap, the natural passageway in the Appalachian range made famous by Daniel Boone, on their way to the Kentucky bluegrass and the North American interior. But few stopped long in the three-mile-wide geomorphic basin known as Yellow Creek Valley. Railroad construction bypassed the area in the early nineteenth century, and the traffic through the Gap reversed itself; the historic gateway to the West became a muddy conduit for men driving hogs to market in Tennessee and North Carolina. During the Civil War, Union and Confederate forces fought for control of the Gap. The mountain people of neutral Kentucky would not soon forget how troops from both sides had stripped their hills and homes. After the war, Yellow Creek Valley and its hillside grew isolated again, home to sixty farm families who lived close to the land and seemingly beyond the reach of the industrializing society of the United States.¹³

In 1886, a Scottish-born Canadian named Alexander Arthur prospected the area for a railroad company and found the place rich in hardwoods, iron ore, and coal. A distant relative of former president Chester A. Arthur, Alexander Arthur fit the type of the mutton-chop-wearing, fast-talking capitalist who earned the Gilded Age its name. With capital from New York and North Carolina, he started buying up options to the land. He then approached investors in London and sold them on the idea that Yellow Creek Valley had the makings of a great iron and steel manufacturing center, a place where surplus British capital could be brought to bear upon untapped American natural resources to generate extraordinary wealth. Arthur had arrived in London at an opportune moment, the very peak of British investment in U.S. enterprises. The economic potential of such boom-towns had already been demonstrated elsewhere in the “New South,” most notably in the coalfields and steel mills of Birmingham, Alabama, established in 1871. With Arthur running the U.S. side of the operation, the London investors incorporated in 1887 under English law as the American Association, Ltd. The association secured title from the mountain people to eighty thousand acres of land. A separate Arthur entity, the Middlesborough Town Company, launched construction of the physical city, named after the iron center in northern England. A local postmaster, as if to announce the presence of federal authority in this new community, lopped off the last three letters. Arthur’s secretary later told the tale of Middlesboro’s birth in terms not far from the mark: “[A]lmost a hundred years after England lost her colonies, ‘conquistadores’ from Albion came out to a still crude and unsettled quarter of the United States for the purpose of further colonization.”¹⁴

By 1890, twenty million dollars’ worth of British capital and the muscle of thousands of American and European workers had turned Yellow Creek Valley into a boomtown of five thousand people. Railroad workers dug a tunnel under the Gap, connecting Middlesboro to Tennessee and the markets and ports of the southeastern United States. A rail beltway circled the town, with spurs shooting off to the hillside collieries that various companies operated under leases from the Association. The Appalachian skies grew thick with the smoke and smells of ironworks, blast furnaces, tanneries, sawmills, brickyards, and breweries. The early encampment of tents gave way to a well-ordered grid of wide streets filled with streetcars, stores, saloons, hotels, banks, schools, churches, sturdy wooden houses for the workers, and stone Victorians for their bosses. Middlesboro even boasted an opera house and one of America’s first golf courses. And the American Association and its distant investors controlled it all. ¹⁵

The bust came as swiftly as the boom. In the spring of 1890, a fire leveled the Middlesboro business district. The buildings were quickly rebuilt, but at great expense to the Association and the local government it controlled. Later that year, the Bank of Baring Brothers in London declared bankruptcy, taking many of Middlesboro’s British investors down with it. As the town’s sources of capital dried up, the realization dawned that the area’s reserves of commercial grade iron ore were thinner than expected. Then came the American financial panic of 1893. All four of the town’s banks failed. Merchants closed their stores. Employers laid off workers. People drained out of the place. The Association mortgaged seventy thousand acres of land to a New York bank for $1.5 million and then, in October 1893, declared bankruptcy. And yet, Middlesboro survived. With its rail connections, its coal reserves, its furnaces, and its hungry labor force, the city still had the stuff of a scaled-down industrial city where profits could be made. In 1894, a federal court ordered a public auction of the mortgaged acres. A new company, incorporated under U.S. law, snapped up the land for a mere $15,000. The company’s name had a familiar ring: American Association, Inc. Its roster of investors looked familiar, too. They were mostly the same London capitalists who once called themselves American Association, Ltd. ¹⁶

Middlesboro shed its most grandiose aspirations (along with most of its wealthier residents) and settled down to the hardscrabble life of an Appalachian company town. The place more closely resembled a remote settlement of impoverished wage earners than a conventional urban or rural place. The local government carried a heavy debt; without a penny in the treasury, the city routinely paid its schoolteachers and other employees in devalued city scrip. The rest of Middlesboro’s breadwinners, with the exception of the factory superintendents and a small professional class, scratched out a living where they could, doing day labor and working for the mines, works, and factories that still operated. European immigrants had helped build Middlesboro, but almost everyone who stayed was a southern-born American. More than one fifth of the city’s 3,500 residents were African American.

Middlesboro heeded southern racial norms, with segregated schools and much of the black population consigned to work in the meanest jobs and to live in the thickly settled sections known as “Alabama Row” and “Over the Rhine.” (The latter name recalled a defunct German brewery that had once perfumed the area with the sweet stench of hops.) In the fall of 1897, the everyday life of Middlesboro was tied more closely than ever to the furnaces and the mines that fed them. In mid-November, the local newspapers buzzed with the first really good news that anyone had heard in a long time. The Ducktown iron mines over Cumberland Mountain were set to reopen. Soon trains would carry ten cars a day loaded with ore to Middlesboro. The furnaces would run at full blast again: “Prosperity is certainly coming to this section,” the Middlesboro Weekly Herald promised.¹⁷

Prosperity never came. Smallpox did.

It started in the Over the Rhine section. In late October, an African American miner named Scott had left the smallpox-infested coal camps around Birmingham and traveled more than three hundred miles for a new job in the Mingo Mines, located just across the border from Middlesboro in Tennessee. He found housing in the Over the Rhine section. Scott was a member of a fast-growing occupation. The number of black miners and quarrymen in the United States doubled during the 1890s. Like the vast majority of African Americans (roughly 90 percent), most of them lived in the southern states. And like roughly one third of all African American breadwinners at the end of the nineteenth century, they worked at least part of the year in nonagricultural occupations, often in rural industries such as mining, turpentine production, and lumbering. The age of Carnegie generated enormous demand for coal. And the rapidly expanding southern railroad network brought southern coal reserves within easier reach of the national market. In southern Appalachia, the coal-rich region stretching from central Alabama to West Virginia, one third of all miners were African American. The work was dirty and dangerous, the jobs mostly nonunion, the bosses white. Typically the first let go when business slowed, a black miner like Scott had to be ready to move.¹⁸

Although he had no way of knowing it, he carried a bit of Birmingham with him when he did. A Marine-Hospital Service surgeon stationed in Birmingham during the smallpox epidemics of 1897–98 described black miners as “the great disseminators of infection. Essentially itinerant, they travel from mining camp to mining camp, from town to town, carrying the disease with them.” About a week after his arrival at Mingo, Scott came down with a fever and chills. A week later came the eruption. Someone called for a doctor.¹⁹

On November 14, a white Middlesboro physician named Dr. F. P. Kenyon examined Scott. He found the miner lying ill in a building in Over the Rhine. Located across the tracks and the lazy Yellow Creek from the heart of Middlesboro, the section was notorious for its rowdy saloons and bawdy houses where whites and blacks mixed. The building where Scott lay had once housed John Hughes’s saloon, remembered locally, in the words of a white newspaperman, as “the scene of many a bloody coon scrap.” Dr. Kenyon recognized Scott’s condition, but just to make sure he called in a second physician, who confirmed his diagnosis: a “well developed case of smallpox.”²⁰

That simple act of naming Scott’s condition brought the miner and the physicians into the orbit of the law. A Kentucky statute required all physicians and heads of household to report any contagious and infectious diseases to their local board of health. In most communities in this predominantly rural state, “local” meant the county. But under state law, a city of Middlesboro’s size (more than 2,500 residents) was supposed to have a board of health and a health officer of its own. Middlesboro had no hospital in 1898, let alone a functioning board of health. But two of the three members of the Bell County Board of Health, Dr. T. H. Curd and Dr. L. L. Robertson, lived in the city, and they, too, confirmed the diagnosis, estimating that roughly fifteen people had come into contact with Scott. That night, residents clustered in the streets to discuss the rumored outbreak, the latest insult in a long run of bad luck. Some said it was time to leave Middlesboro for good. Meeting in an emergency session, the city council ordered the police to enforce a quarantine against the Over the Rhine district. Priding itself on its healthy mountain air, Middlesboro had no pesthouse. Scott and several African American residents known to have been exposed to him were placed under guard in the old Hughes saloon.²¹

Politically, the city council’s strategy for thwarting a smallpox epidemic had two things going for it: it didn’t inconvenience the white citizenry much, and it was cheap. Kentucky law held local governments liable for the cost of managing an epidemic. In a legal case arising from the Bardstown smallpox outbreak of 1883, a Kentucky court noted that this obligation went further than “the ordinary social duty to care for the helpless.” “If the poor man is neglected he may starve or freeze, but the calamity is personal, and his grave hides it; but if, having an infectious disease, which poisons the air, he is left where he lies, the entire community is menaced.” Whether this fiscal responsibility properly fell on Middlesboro, Bell County, or both would become a heated issue. For now, the city council decided that local police, already on the payroll, would enforce the quarantine. A more aggressive approach—a targeted quarantine and a well-run pesthouse coupled with compulsory vaccination of the entire population—would have been much more expensive. A pesthouse cost money: fees for the physician, wages for the guards, and food for the indigent patients. A general vaccination order posed other problems.²²

Vaccination was not popular in Kentucky. Although state board of health rules required that public schoolchildren submit to vaccination, the board estimated that at least one third of the state’s white residents and a larger part of its African Americans had never been vaccinated. In Middlesboro, according to one estimate, nine tenths of the population had never undergone the procedure. And when a local government ordered a general vaccination, it was liable under state law for the cost of providing vaccination free to the poor. In a place as impoverished as Middlesboro, that meant paying a lot of doctor’s fees and buying a lot of vaccine.²³

Another factor weighed into the political calculus. A good many Middlesboro residents, including the editors of the local newspapers, greeted the news of a smallpox outbreak with skepticism. The Weekly Herald described Scott’s illness as “a malady something like smallpox.” Scott had a relatively mild case, and it may have looked just like chicken pox to the few people who got a look at him. Economic self-interest and civic pride strengthened medical doubts. To call the “malady” smallpox would threaten the reputation and livelihood of Middlesboro. The city council of neighboring Pineville, the county seat, had already ordered a quarantine against Middlesboro, forbidding anyone from the mountain city to enter the town. The Middlesboro newspapers, which agreed on little else, warned citizens not to spread “wild exaggerated reports” that might lead other towns to choke off the flow of people and goods to and from Middlesboro. In Middlesboro’s straits, the spread of rumors seemed more dangerous than the spread of smallpox itself.²⁴

And then the smallpox “scare” ended. Scott recovered. No new cases had come to light. On December 9, the city council declared victory and lifted the quarantine. And so, as life returned to normal in Middlesboro, the population remained almost entirely unvaccinated.²⁵

Weeks passed before the white officials of Middlesboro realized their quarantine had failed. A smallpox outbreak often begins slowly. Due to variola’s long incubation period, two weeks may pass between the initial discovery of a single smallpox case and the appearance of the next cluster, or “generation,” of cases. The medical logic of the quarantine is that by waiting out the incubation period, keeping potential carriers—“suspects”—apart from everyone else, officials can contain an outbreak and eventually snuff it out. But for those who must live on the other side of the quarantine line, the medical rationale is not always its most salient feature. When Pineville had announced its quarantine against the entire city of Middlesboro, city leaders had cried foul. The historical record mentions no such public outcry from the African American residents of Middlesboro’s own quarantined district, who were confined to a territory ostensibly justified by the public health but drawn explicitly by race. But the unanticipated consequence of this policy was that African Americans in the district did not notify the white authorities when more people in their community broke out with smallpox.²⁶

This failure or outright refusal to cooperate with the local white power structure had its own unintended political effect. For when the authorities realized that smallpox had spread in the Over the Rhine section, the discovery merely reinforced their belief in the legitimacy of their quarantine. The Middlesboro Weekly Record ran a series of satirical dialect pieces that purported to represent the “niggahs’ ” point of view on the smallpox situation. In one piece, an old “aunt” tells a reporter that the only way to stop “dem low down niggahs from spreading smallpox is for de perlice” to “scrub that’ol Alabama dirt . . . off’n ’em.”²⁷

In late December, a second case was reported in the Over the Rhine district, followed by several others. At first the city council did nothing, reluctant to spend money it did not have in the absence of public alarm. Although the Bell County Board of Health called upon the county government to provide funds, the county Fiscal Court, in charge of such appropriations, said it viewed this as a Middlesboro matter. Among the people of Middlesboro, rumors still circulated that the disease was not smallpox. A winter surge of chicken pox added to the diagnostic confusion: many people had trouble distinguishing one disease from the other. Some Middlesboro blacks were calling the mild smallpox “Elephant Itch,” a name that, according to some accounts, old-timers, former slaves, had long used for smallpox. Another name, “African Itch” (the polite, newspaper euphemism for “Nigger Itch”), expressed the belief of many local whites that this disease, whatever it was, wouldn’t trouble them as long as they kept their distance from blacks. For well over a month, the disease did in fact remain confined entirely to African Americans. And when the city government finally got around to setting up a pesthouse, in mid-January, all of the patients and suspects detained there were black. In early February, the Weekly Record made a plea for calm: “Up to the present, no white people have been attacked and there is positively no occasion for alarm.”²⁸

One nearby community after another instituted shotgun quarantines against Middlesboro. Given the city’s border location, the epidemic inflamed interstate politics. Lee County, Virginia, quarantined against Middlesboro. A Tazewell, Tennessee, newspaper called the Middlesboro authorities “criminally negligent.” Officials in Claiborne County, Tennessee, home to Tazewell and the Mingo Mines, promised to enforce their quarantine against Middlesboro “if there is any virtue in a Winchester.” The Middlesboro council denounced these actions as “unwarranted, uncalledfor, unprofessional, ungentlemanly, and unworthy.” The quarantines cost local businesses thousands of dollars.²⁹

A series of events in mid-February finally spurred the local officials to take serious measures to stop the epidemic. The first was the long-anticipated arrival, on February 12, of Dr. J. N. McCormack, secretary of the Kentucky Board of Health. Students of American government use the term “federalism” to describe the distinctively decentralized operation of political power in the United States before the New Deal. The states, especially in the South, had their own form of federalism: localism. Controlling infectious diseases—like policing the streets, running public schools, and administering poor relief—was the indisputable province of local authority. And where that authority rested, so did liability for the cost of disease control. The Kentucky Board of Health, a body of prominent physicians with a small staff of inspectors and the power to issue statewide regulations, only intervened in local affairs when local officials let local matters get totally out of hand. Which is exactly what McCormack’s presence in Middlesboro signified.³⁰

Joseph Nathaniel McCormack of Bowling Green knew the Kentucky health laws as well as anyone. He’d written most of them himself. The fifty-year-old Kentucky native held medical degrees from the Miami Medical College in Cincinnati and the University of Louisville. He had served on the state board since 1879, holding the position of secretary for most of that time. He would remain as the state’s top health officer until his death, in 1912, when the Kentucky political leadership passed that office on to his son, Arthur Thomas McCormack. Joseph’s Kentucky pride did not extend to its communities’ fierce independence in matters vital to the health of the entire state. He devoted much of his life to the quixotic project of building a unified state health system.³¹

Arriving in Middlesboro, McCormack inspected the pesthouse, examined all of the known cases in the city, about twenty in all, and interviewed the health officers. What McCormack saw convinced him, as he said later, that “the parsimony and incapacity of the city and county officials” had laid “the foundation of an epidemic.” Standing before a special session of the city council, McCormack testified that every case he had examined was smallpox. He “recommended” that the council order compulsory vaccination.³²

Up to this point, the half-dozen private physicians and company doctors working in Middlesboro had vaccinated a few hundred people, but most residents remained unprotected. The councilmen had a strong incentive to carry out the secretary’s recommendation. If they did not, the state board would exercise its full quarantine power against the city. The state board had the power to forbid anyone to enter or leave the city and to prevent any transportation company from delivering freight (coal, iron ore, food) without the board’s written permission. The board could bring Middlesboro’s already beleaguered economy to a standstill. Before adjourning that afternoon, the council passed a compulsory vaccination ordinance and ordered the edict published on posters and distributed about the city.³³

That same afternoon, a man named Will Sheffly died in the pesthouse—the outbreak’s first fatality. The next day smallpox crossed the color line. The first white patient was Charles Dudley Ball, a saloon-keeper, gambling den operator, and deputy sheriff whose brother happened to be the chief of police. Charley Ball was not allowed to suffer the indignity of being the lone white man in the pesthouse. The authorities moved him to a deserted house on the outskirts of town. During the next forty-eight hours, eight more people with smallpox were discovered, four of them whites. Even more than Dr. McCormack’s visit, the infection of white Middlesboro residents, apparently by their black neighbors, gave the city vaccination campaign a sense of urgency among the city’s white leadership.³⁴

The compulsory vaccination of Middlesboro began peacefully, as the overwhelmed city and county physicians attended first to the many residents, white and black, who came forward voluntarily. But after the initial rush subsided, the vaccinators began the slower work of house-to-house vaccination in the neighborhoods, where they met resistance with threats of arrest, jail, and fines. The vaccination order was part of a raft of emergency ordinances enacted by the council. The councilmen closed the schools, churches, and saloons. They forbade the public to assemble in the streets and children to go out at all unless accompanied by a parent or guardian. Inmates of the city jail were put to work cleaning up the city—an act of urban renewal that shows the hold upon medical thinking of the old notion of smallpox as a filth disease, an association that even the ascendance of the microbe in medical science did not dispel. Meanwhile, the postmaster, still the lone agent of federal authority in Middlesboro, set up a fumigating apparatus for all outgoing mail; punching holes in letters and packages, he sealed them in a box for five hours with burning sulfur. Citizens could purchase their own personal disinfection devices from enterprising local merchants. S. R. Sneed Co. touted the Pasteurine Pocket Disinfectant and Deodorizer—“A deadly foe to Contagion.”³⁵

Given how long they had waited to take action, the city officials should have known the epidemic would get worse before it got better. More people with smallpox surfaced almost every day. By the end of February there were fifty-two known cases among African Americans and poor whites from various parts of the city. Several people suffered from confluent smallpox, and a second patient died. To make matters worse, Middlesboro officials were still haggling with Bell County over which government would pay for all of the guards, doctors, and food. The Bell County Fiscal Court continued to reject requests for aid, reasoning that so far the epidemic was confined to Middlesboro, and Middlesboro should take care of its own mess. As a result, the smallpox control effort slowed to a virtual standstill. ³⁶

On February 28, three months after Scott brought smallpox to Middlesboro, the Kentucky Board of Health stepped in. Secretary McCormack sent his son, Dr. A. T. McCormack, the state’s chief sanitary inspector, to run the operation. The younger McCormack, who was just twenty-five, brought along two deputy state inspectors, Dr. Austin Bell and Dr. B. W. Smock, and on his father’s request, the Bell County health officer, Dr. Samuel Blair, moved into the town, too. Most of the manpower—police, inspectors, guards, and vaccinators—were provided by the city government. The state board made clear at the outset that although it was taking control of the epidemic, it would not be paying the bills.³⁷

A. T. McCormack quarantined the entire population of Middlesboro, posting armed guards day and night on the eight roads leading out of town. He took over a deserted row of buildings called “Brown’s Row” and established a new pesthouse and detention camp there, under the charge of Dr. Blair. The city was divided into eight districts; inspectors and vaccinators canvassed each one. As they found people with symptoms, they moved them immediately to the pesthouse. The inspectors disinfected the homes of “the infected” by burning sulfur in the closed rooms. When they found a house too leaky to hold the sulfur gas, they burned it to the ground. “Suspects” were placed under quarantine in their own houses and were visited daily by one of the health officers.³⁸

McCormack put Dr. Bell in charge of the vaccination corps. The medical men entered the neighborhoods with health inspectors and police in tow. The men returned to the same homes later, to make sure the vaccine took. For some residents, the vaccine took toowell. In February and March, the newspapers ran four stories about citizens who became sick or temporarily disabled following vaccination. The arm of one mail clerk, according to one newspaper report, “swelled to three times its normal size.”³⁹

African Americans in the Over the Rhine district learned how a smallpox epidemic could transform years of official indifference and neglect into coercion and violence. Racial tensions had risen during the winter, as white officials and newspapers blamed black townsfolk for the events that brought shame on the community. The Weekly Record called for a public law, like the Louisiana separate coach law the U.S. Supreme Court had upheld in Plessy v. Ferguson (1896), to “keep the colored people in a separate section of the town. If it cannot be done by process of law, it can be accomplished by public sentiment.”⁴⁰

The thin line between process of law and white public sentiment vanished when Dr. Bell’s vaccination corps moved back into the Over the Rhine section in early March. Entering crowded wooden houses and shanties, they confronted the consequences of black distrust of white health authority. The inspectors found twenty or more adults and children suffering from smallpox, who had hidden (or been concealed by their parents) from the authorities. As the inspectors removed the patients from their homes and hauled them to the pesthouse, the physicians examined the arms of the other residents, finding many that had never been touched by a vaccinator’s lancet. As they attempted to enforce the vaccination order, the physicians were met, according to the Weekly Record, with “the greatest opposition.” That was what the police were for. This time there would be no arrests or fines. All who resisted were handcuffed and vaccinated at gunpoint.⁴¹

McCormack and his men brought a new measure of expertise, discipline, and violence to Middlesboro. In the ten days after the state took control of the epidemic, the health authorities handled 169 cases of smallpox. Thirty-four of the patients were white, the rest black. The youngest was an infant just one day old when the eruption appeared simultaneously on mother and child. Miraculously, the baby survived. By March 10, many of the patients had recovered, and no further deaths had occurred. Dr. Bell’s vaccination corps had scraped the arms of 1,968 people—the exactness of the count offered as a testament to the state officers’ efficiency. Earlier reports had put the number vaccinated by the city officials somewhere around a thousand. And others had been vaccinated by their own physicians. But the epidemic was not over. There were still seventy people packed into the pesthouse on Brown’s Row. And they were running out of food.⁴²

One thing McCormack and his deputies had not brought to Middlesboro was money. The state board didn’t have much in the first place; its annual appropriation was just $2,500, and half of that went to pay J. N. McCormack’s modest salary. The state was counting on city and county officials to pay for the guards and the pesthouse supplies. But squeezing money from the local governments proved even harder than getting people vaccinated. The Bell County Fiscal Court still refused to contribute a penny, and the scrip (called “warrants”) that the city had been using to cover expenses had become so devalued as to be all but worthless. As a consequence, the guards were virtually working without pay. When A. T. McCormack wired the news to his father, the secretary resorted to the only weapon at his disposal: the threat of a total quarantine against Middlesboro. J. N. McCormack wired Mayor John Glasgow Fitzpatrick: “Unless city or county can arrange [to pay the expenses], will be forced to release you and local Board from duty, stop all trains and advise adjoining counties to protect themselves.”⁴³

Secretary McCormack underestimated the political acumen of the local officials. Shortly after receiving his telegram, Mayor Fitzpatrick, a lawyer and businessman connected to local mining interests, sent a telegram of his own. He wired Middlesboro’s congressional representative in Washington, a favorite son of Yellow Creek Valley named David Grant Colson. A Republican, Colson had served as mayor of Middlesboro for four years before taking his seat in Congress. He understood the situation there better than anyone else in Washington. Fitzpatrick wrote: “County refuses aid; city has no funds. Can Federal aid be had?”

It was a good question. The United States in 1898 had no federal welfare state as such. But since 1790, Congress had on roughly one hundred occasions used its spending powers under the Constitution’s “general welfare” clause to appropriate relief for the hapless victims of wars, floods, fires, famines, cyclones, grasshopper invasions, and other disasters. Yellow fever epidemics and Mississippi floods had aroused Congress to send aid to southern communities on more than one occasion since the Civil War. But long-standing practice dictated that such appropriations be reserved for cases in which blameless people had been overwhelmed by circumstances beyond their control. The Middlesboro smallpox epidemic did not meet that test. The misguided parsimony of public officials, rather than an act of God or some other uncontrollable force, had caused the “disaster” in the mountain city. And how would Congress have responded to the Middlesboro leaders’ racial theory of the epidemic? Were African Americans a force beyond their control? Was this “African” epidemic an act of God? Congress never had an opportunity to ponder such questions. Rather than make the hard case for congressional relief, Colson contacted Walter Wyman.⁴⁴

Colson may have been aware that Wyman’s federal health bureau, the U.S. Marine-Hospital Service, had for the past two months been working with local authorities in Birmingham, Alabama, to control a smallpox epidemic there. In his message to the surgeon general, the congressman narrated the Middlesboro epidemic as an emergency. “The situation is a very grave one,” he wrote. “Neither the municipal, county or state authorities are able to control the epidemic.” But Colson astutely crafted his case for Marine-Hospital Service intervention in the political language of federalism. “All Southwest Kentucky, East Tennessee, and Southwest Virginia are involved, or liable to be.” Middlesboro’s location on the border made an uncontrolled epidemic there a danger to other states. This fact alone made direct federal intervention plausible. For good measure, Colson enclosed a note from Rep. Walter P. Brownlow, a fellow Republican whose district lay in northeastern Tennessee, just across the border from Middlesboro. “I fully concur in the above,” Brownlow said. “Smallpox is spreading in my district. I ask for immediate action.”⁴⁵

Passed Assistant Surgeon C. P. Wertenbaker was working at his station in Wilmington, North Carolina, later that day when the telegram came in. “Proceed to Middlesboro, Ky,” Wyman ordered. “Report on situation there and neighborhood with recommendations.” The surgeon general added a word of caution to his officer before he embarked upon his five-hundredmile journey from the Carolina coast to the heart of Appalachia: “Local authorities should meet expenses, [federal] government expenditures are interstate only.” Wertenbaker caught the next train west.⁴⁶

It was dark by the time the surgeon reached the mountain city, the high wooded ridge of Cumberland Mountain a presence more felt than seen in the cool March night. A clock had only just tolled eight, but the broad streets were virtually empty, the saloons shuttered, the trains dead on their tracks. Out on the public roads, men toting lanterns and shotguns guarded the quarantine line. No one in, no one out. The guards at the train station, though, had made an exception for Wertenbaker. They’d been expecting him.

In his crisp blue uniform, Charles Poindexter Wertenbaker was the very model of a Marine-Hospital Service physician during Walter Wyman’s long tenure as surgeon general (1891–1911). A university-trained medical man with the discipline of a soldier and the bearing of an officer, Wertenbaker knew how to handle a microscope, a pen, and a gun. Wertenbaker was thirty-seven years old. An inch or two shy of tall, he had fair skin, light eyes, and a thick mustache that in his younger days he had waxed into a fashionable pair of handlebars. He had spent ten years in the Service, working the federal outposts in a succession of American ports: Norfolk, Galveston, Chicago, and Lewes, Delaware. He took over at Wilmington just days before the smallpox arrived there, reportedly in the body of an African American railroad hand. Now, three months later, he was still figuring out the politics of smallpox control. For him, Middlesboro would be an object lesson.⁴⁷

When daylight broke on March 14, Wertenbaker toured Middlesboro on foot with A. T. McCormack. As they walked, Wertenbaker noted the Old World character and surprising sturdiness of the Appalachian boomtown: the broad streets with their English names, the imposing bank buildings and substantial storefronts of the business district, the Victorian mansions of the finer neighborhoods. Even the wood-framed houses constructed for the workers looked built to last. On many of those houses hung the telltale placards or yellow flags. McCormack told him that four hundred residents, roughly one ninth of the population, were now under domestic quarantine—prisoners in their own homes. Another seventy-two people were in the pesthouse. So far, McCormack told Wertenbaker, his men had vaccinated nearly two thousand people. At this point, anyone who had not been vaccinated probably aimed to keep it that way. In any event, as Wertenbaker reported to Wyman later that day, “forcible vaccination is still progressing.”⁴⁸

McCormack did not hide his resentment at Wertenbaker’s presence in Middlesboro. McCormack was a young man, but he was no country doctor. He had a medical degree from Columbia University. The Kentucky Board of Health was, in a sense, the McCormack family business. He was his father’s most trusted man in the field. He did not intend to let the Middlesboro debacle tarnish the board’s honor and reputation. The physician assured Wertenbaker that he had wasted his time in coming all the way to Middlesboro. The state had everything “under control.”⁴⁹

Next the men arrived at the pesthouse. The crowded structures, located in a thickly settled part of the city, housed seventy-two men, women, and children. As he moved through rooms thick with the sickening sweet smell of smallpox, Wertenbaker kept a running tally. Forty-nine of the inmates had already broken out with clear cases. The rest showed some early symptoms or were being detained as “suspects.” According to the standard Service practice, the suspects should have been kept apart from the patients, to avoid unnecessarily spreading the disease. Most of the inmates were African American; seeing Middlesboro from the perspective of smallpox, Wertenbaker mistakenly concluded that half of the city population was black. From his experience in North Carolina during the past few months, Wertenbaker couldn’t have been surprised that smallpox and Jim Crow had conspired in Middlesboro, too. But something else did surprise him. The inmates were not just sick, or in imminent danger of becoming so. As he wired Wyman later that day, “the patients are without food.”⁵⁰

Months of haggling between city and county authorities had come to this. Without the backing of the Bell County Fiscal Court, the city scrip was worthless. A few days earlier, the grocer who had already supplied the pesthouse with $500 worth of food refused to provide any more until he was “satisfied of reimbursement.” While Wertenbaker traveled to Middlesboro, the last of the food had run out. Some guards now refused to work until they were properly paid. The strategy of the McCormacks, father and son, was to exploit the public embarrassment of the pesthouse crisis and the threat of a county-wide quarantine in order to finally squeeze an appropriation from the county government. It must have seemed a sensible strategy to the McCormacks; thanks to the wire reports coming out of the city, newspapers as far away as Grand Forks, North Dakota, and New York City were running stories on the “starving” pesthouse inmates of Middlesboro, Kentucky. But locals knew better than to underestimate the fiscal parsimony of Judge James Neal of the Bell County Fiscal Court, whom the Middlesboro Weekly Record described as “a little, one-horse, whipper-snapper of a judge with a brain about as big as a mustard seed and a soul infinitely smaller.” And so while government officials engaged in a standoff over funds, the pesthouse inmates went hungry. If more guards abandoned their posts, could anyone expect the inmates to stay in the pesthouse?⁵¹

That afternoon Wertenbaker and McCormack addressed a roomful of indignant local businessmen and political leaders at the Middlesborough Hotel. Speaking for the state board, McCormack told the assembly that national government aid was unnecessary, the epidemic was already under control, and the county “could and would be made to pay.” Wertenbaker told the men that he could not take control of the epidemic unless the state board of health appealed to the surgeon general for assistance. Upon hearing this, several of the locals constituted themselves as a Citizens’ Committee. They drafted a telegram to Governor W. O. Bradley and J. M. Mathews, president of the state board of health, asking them to call on the national government. The decision to appeal to Mathews, the political appointee who presided over the board, rather than J. N. McCormack, who actually ran it, no doubt stoked the indignation of both McCormacks.⁵²

The Citizens’ Committee’s telegram was but the opening salvo in a war of the wires—a clash of rhetorical performances that would last three days and reverberate for months afterward. The entire discussion centered on cash, control, and, in an indirect way, the Constitution. The McCormacks blamed the episode on Wertenbaker, whom they came to see as an arrogant interloper who had usurped their authority by promising the citizens of Middlesboro a bag full of United States currency. As A. T. McCormack recalled bitterly, “A number of citizens who had given us little or no aid during our hard work consulted and reconsulted with the Service surgeon, and, inspired by either his talk or their dreams of government pelf, they kept the wires hot with messages appealing for government assistance.”⁵³

J. M. Mathews wired back to the Citizens’ Committee that, after consulting with the governor, he would happily authorize Dr. Wertenbaker to take charge—“if the Federal Government will defray expenses. There is no money in our treasury and no law to appropriate any for this purpose.” Having no doubt received a copy of Mathews’s telegram, Secretary McCormack then wired to Chief Inspector McCormack and told him to gather his men and leave Middlesboro at once. Once J. N. McCormack recalled the state officers, Wertenbaker was eager to take control, wiring the surgeon general that the state withdrawal left Middlesboro “absolutely unprotected.” “If authority in Mathews’ telegram is sufficient, I recommend that I be authorized to take charge to-night.... Please authorize necessary immediate expenditures for provisions, guards, etc.”⁵⁴

Walter Wyman was furious. He ordered Wertenbaker to notify both McCormacks that he had not been authorized to take control, and the state officers should not be recalled. “The [federal] government’s interest is in protecting other states,” he said, “and nowhere is the whole expense borne by the government. Every municipality should have enough pride in itself to suppress this ordinary contagious disease.”⁵⁵

But the men who had controlled the Middlesboro epidemic for the past two weeks had already caught the night train out of town. The Bell County Board of Health was back in charge—without any funds. A. T. McCormack and his men had barely left town before Judge Neal announced, again, that the county would not appropriate a dime.⁵⁶

The same message arrived soon from Frankfort, as the governor and Kentucky lawmakers abdicated responsibility for the Middlesboro debacle. After receiving the Citizens’ Committee’s telegram on March 14, Governor Bradley had wired his fellow Republican, Representative Colson, to intercede with the surgeon general. His confusion about the legal authority of the federal government in such a situation was evidently total. “Act of Congress not in library,” Governor Bradley said. “I do not know what the law allows. Am told Surgeon-General of the United States may be appealed to take charge immediately. If such can be done, request him in my name to take charge.” The next day, Bradley appealed to the state legislature for an emergency appropriation, but the lawmakers adjourned without granting his request.⁵⁷

Meanwhile, Mayor Fitzpatrick wired Surgeon General Wyman with a direct appeal. The mayor framed the Middlesboro situation as a relief crisis. “Middlesboro has 3,500 people dependent for support on wages of working people,” Fitzpatrick said. “People poor; business suspended; request for immediate assistance.” The mayor’s language was telling. He appealed not in the name of the city government, which he headed, but in the name of the deserving wage earners of Middlesboro and their families. He was trying, belatedly, to craft a narrative about a blameless community deserving of federal aid. Significantly, he left race out of his story.⁵⁸

For Walter Wyman, the request from Governor Bradley was enough. On March 16, Wyman wired J. M. Mathews and told him the Marine-Hospital Service was prepared to “furnish medical officers, attendants, guards, inspectors, and attend to vaccination and disinfection.” The local authorities would still be expected to “care for poor not sick” and to furnish the pesthouse with food “so far as possible.” Wyman did not want to open up a massive federal relief effort in Middlesboro. It was J. N. McCormack who wired back to accept Wyman’s offer, so long as the Service intended to “aid and co-operate under our regulations.” Wyman agreed to this face-saving language. But he added a condition of his own: “All expenditures . . . must be supervised and accounted for by our own officer.” A reasonable condition, to be sure. But also a brisk slap in the Kentuckian’s face.⁵⁹

All of these niceties did not disguise the new political reality in Middlesboro. As the Lexington Morning Herald reported, “Uncle Sam is in charge of small-pox now.”⁶⁰

There was one recent precedent for a federal takeover of a local small-pox epidemic. On January 8, 1898, two months prior to Wertenbaker’s arrival in Middlesboro, another Marine-Hospital Service surgeon named George M. Magruder had taken control of the smallpox epidemic in Birmingham and Jefferson County, Alabama. This was the same epidemic the miner named Scott thought he had left behind as he made his way north to the Mingo Mines. Built on a swampy valley floor, the manufacturing and mining boomtown with its highly transient population was a public health disaster waiting to happen—and never waiting very long. The area had weathered one epidemic after another since its founding in 1871, including serious bouts of Asian cholera in 1873 and typhoid in 1881. Alabama laws, enacted during the 1870s, established a state board of health and authorized the creation of county health departments. But at the moment smallpox broke out, not a single full-time county health organization existed in the entire state.⁶¹

Smallpox had been raging since July 1897 in Jefferson County, an area of a thousand square miles and 110,000 people. Half of the residents lived in Birmingham, the rest in mining camps, small towns, and manufacturing settlements outside the city. By the time Magruder arrived on the scene, more than 400 cases of smallpox had been reported in the area, with 15 deaths. As it would be in Middlesboro, the disease was confined almost exclusively to the African American population. The Atlanta Constitution assured its readers, “There is no danger of a spread of the disease among the white people.”⁶²

So far the disease had proved exceptionally mild, but also exceptionally expensive. The city and county governments spent the huge sum of $30,000 fighting the epidemic. They set up quarantine camps, enforced vaccination, and furnished 75,000 tubes and points of free vaccine. City officials strictly enforced vaccination: at least seven people were arrested in the first weeks of the epidemic for refusing to be vaccinated. But outside Birmingham, enforcement was spottier, and by December 1897, more than twenty towns and camps reported smallpox. In January, the local authorities called on the Marine-Hospital Service for aid. Surgeon General Wyman extended to Birmingham and Jefferson County the same offer he would later make to Middlesboro: the U.S. government would take general control of the quarantine camps, provide free vaccine, and organize a corps of men to inspect and vaccinate the population. But the city and county must “bear all other expenses.” The local authorities readily accepted.⁶³

From his headquarters in Birmingham, Magruder organized a corps of thirty inspectors, recruiting local physicians and medical students. He assigned each to a territory within the city, in which they inspected all homes and their occupants. Magruder advised the inspectors to extend courtesy to everyone—the “refined and rough, reasonable and unreasonable, crank and sage.” But under no circumstances would the Service honor certificates of vaccination. “In all large towns,” he explained, one could find “some physicians who will give false certificates for a small fee.” Magruder’s instructions show his awareness of the urban tradition of resistance to compulsory vaccination, abetted by local doctors who were supposed to be the front line of public health. He told his inspectors to check every person’s arm for a fresh vaccine scar—the only real proof of a successful recent vaccination. The inspectors were to make a thorough search of every room they visited, “especially in negro quarters,” looking for concealed people with smallpox. Ambulance wagons carried the sick to one of the quarantine camps. All suspects found living in a house with a smallpox sufferer were vaccinated at once and sent to the detention camp to be kept under watch for sixteen days. At the camps, Magruder introduced an innovation of which he was particularly proud. He surrounded each camp with a high fence of barbed wire. Thirty feet inside of this line he marked out a “dead line,” beyond which no “patient” was allowed to tread. At night the entire area was illuminated with gasoline torches, “enabling a small number of guards to effectually prevent the escape of convalescents.” Even with the doctors moving to and fro, to the detainees the federal quarantine facilities must have invited comparisons to Alabama’s notorious convict labor camps.⁶⁴

The mining camps outside of the city posed a special problem. Magruder believed the disease was spread chiefly by itinerant African American coal miners, who avoided vaccination whenever they could. Since they lived in unincorporated camps, none of the local compulsory vaccination ordinances applied to them. When superintendents of mining companies tried to enforce vaccination, “the men would leave in such numbers as to cause serious embarrassment from lack of laborers.” The men just picked up and moved to another camp where vaccination was not enforced. As a consequence, those mining superintendents who had tried compulsory vaccination on their premises gave up the effort.⁶⁵

Magruder had an idea. He called together the owners and superintendents of the mining companies. These men ran mines and furnaces that employed thousands of workers, including many with families. Magruder persuaded the company men to cooperate—with each other and the federal government. They posted notices at their mines and furnaces, stating that no one would be allowed to work who refused to have himself and his family vaccinated. The notices listed all the area companies that had entered into the agreement. Once employers tightened control over their workforce, Magruder reported, the phenomenon of vaccination-induced walkouts “almost entirely ceased.” The surgeon’s plan merged government and private authority in an ingenious solution to a seemingly intractable problem of industrial management and public health. Magruder’s account makes one wonder if the cooperative agreement he engineered among the employers might have laid the foundation for future agreements to control the organization and conditions of labor in their industries.⁶⁶

Other southern communities watched the Marine-Hospital Service’s work in Jefferson County with great interest. In short order, the mayor of nearby Talladega, Alabama, where smallpox had spread in the cotton mills, asked the Service to step in there, too. During the three months after the Marine-Hospital Service took over at Birmingham, the Service’s corps of inspectors had paid more than 41,000 visits to private residences, many of them the poorly constructed houses and cabins of African American workers and their families, where they had found a great many concealed cases. The corps had vaccinated nearly 39,000 people. The Service had treated 352 patients in its three quarantine camps, with only nine deaths. Among the 225 patients at the Birmingham Quarantine Hospital, all but six were African American; more than two thirds were male; nearly half were in their twenties; and nearly half had never been vaccinated .⁶⁷

By March 10 (the very date that Representative Colson asked Surgeon General Wyman to intervene at Middlesboro), George Magruder announced that the epidemics in Birmingham, Jefferson County, and Talladega had ceased—at least “for the present.” Magruder had no illusions about the permanency of his achievement in Alabama. Barbed wire, gas torches, armed guards, and men with lancets could only accomplish so much in this industrial frontier, where “large numbers of the unvaccinated persons are daily coming in.” And there were several towns and mining camps where the inspectors had met with such intense local opposition that Magruder had withdrawn them, leaving behind large unvaccinated communities. As he prepared to pull up stakes from Birmingham, Magruder had to concede that despite all his efforts, and the support he had received from employers and citizens’ groups in Birmingham, there were still enough unvaccinated people in the area to “keep the disease alive for some time.” He was right. In 1899 alone, 9,150 cases of smallpox were reported in the state of Alabama. Significantly, 5,265 of those cases were white—a number roughly proportional to the percentage of whites in the state population. In Alabama as elsewhere, the early promise of a special dispensation for whites did not last.⁶⁸

On March 17, C. P. Wertenbaker officially took over smallpox control at Middlesboro, Kentucky. He set up his headquarters, complete with a telephone, in a suite of offices in the business district. He hired five inspectors and twenty-five guards outfitted with Springfield rifles. He had four physicians on his medical staff, including Dr. Blair from Bell County, who would head up the inspector corps. A crew of nurses, cooks, attendants, and ambulance drivers rounded out the operation. Wertenbaker kept the mountain city under strict quarantine. Armed men guarded the public roads and the train depot, allowing no one to enter or leave the city without a pass signed by Wertenbaker. Within a week, one local newspaper reported, the federal surgeon had the smallpox control operation “running smooth as oil.”⁶⁹

For all of the similarities between the Jefferson County, Alabama, and Middlesboro, Kentucky, epidemics, the crisis Wertenbaker inherited from A. T. McCormack was far less intractable. The field of action was small by comparison—ten square miles against one thousand, a population of 3,500 against 110,000. And the Middlesboro population had been forcibly contained; unlike Jefferson County, which had laborers coming and going throughout the epidemic, Middlesboro had been under armed quarantine for weeks. Thanks to the efforts already made by local authorities and the state, the vast majority of the population had been vaccinated. In fact, if one believed everything printed in the state reports and the local newspapers, the total number of vaccinated people exceeded the actual population of Middlesboro.

Wertenbaker’s inspectors, under the charge of Dr. Blair, set out immediately into the streets and neighborhoods of Middlesboro. Wertenbaker divided the city into five districts, assigning one inspector to each to make a house-to-house canvass. A local newspaper boasted awkwardly that the Service’s inspection showed that “outside of small-pox this is the healthiest town on the globe.” They examined everyone, vaccinating the few unscarred people they found. Anyone who refused the vaccination order was promptly turned over to the city authorities, who gave the violator the option of being vaccinated or taken to jail. As Wertenbaker reported to Wyman, it was something of a moot question, because if the uncooperative person chose jail, “they are vaccinated as soon as they enter, under a law requiring all inmates of jails to be vaccinated.” The violence of compulsory vaccination at gunpoint in the Over the Rhine district had given way to something different, more orderly but still highly coercive.⁷⁰

Wertenbaker took steps to separate the smallpox patients from the smallpox suspects. He turned a row of twelve houses near the old Brown’s Row pesthouse, where patients and suspects had been confined, into a detention camp for suspects. He placed the camp under the charge of Dr. W. N. Shoemaker of Birmingham, who had become acquainted with Service methods from the epidemic there, and a staff of attendants and guards. For a smallpox hospital, Wertenbaker rented the old Biggerstaff boardinghouse, a two-story building on the city’s western outskirts, and fitted it out with beds and supplies. Someone christened it the South Boston Hospital, after the nearby South Boston Iron Works, once a major supplier of cannons and armaments to the U.S. government. Wertenbaker’s men moved the ninetyone people who had been languishing in the Brown’s Row pesthouse into the hospital and placed them under the charge of Dr. W. C. Duke, a physician from Memphis who had been trained in Service work. It was a simple facility, but Duke had the assistance of nurses and attendants, and no patient would go hungry for lack of provisions.

In all smallpox epidemics, good nursing care—including the provision of such basic human needs as warmth, proper food, water, and clean sheets—had a major influence on mortality rates. A poorly run or ill-provisioned pesthouse (and many turn-of-the-century pesthouses were both) could be far worse for a patient’s chances of recovery than care at home with family, which is one reason why so many families hid their sick from the health authorities. During the Service’s operation at Middlesboro, the hospital treated 103 patients. About three quarters of them were African American, and the males outnumbered the females 64 to 39. The patients’ ages provided a very rough measure of the vaccination status of the general population before the epidemic. All but six of them were under forty. Dr. Duke’s staff treated twenty-two children under ten years old, including seven younger than a year. All of the patients in the hospital, including the infants, survived. Even in an epidemic of mild smallpox, that was no small achievement.⁷¹

Given the strong contemporary belief that smallpox could be spread by contaminated objects, or fomites, a critical component of any state-of-the-art smallpox eradication effort was disinfection. Wertenbaker’s Disinfecting Division, under Acting Assistant Surgeon Ira W. Porter and his crew, traveled the city equipped with two large autoclaves for sterilizing objects, another disinfecting apparatus for burning sulfur, and a third for hosing rooms down with bichloride. In all, the division disinfected nearly one hundred houses. All clothing and bedding was destroyed. Houses too ramshackle to be disinfected were burned.⁷²

From the date the Service took over, only seven new cases developed in Middlesboro. Each day the Smallpox Hospital released more recovered patients. First they underwent a regimen of baths, while hospital staff washed their clothes in bichloride of mercury. The last smallpox case surfaced on April 6. Wertenbaker had returned to Wilmington the previous day, leaving the cleanup operation in Middlesboro in the hands of a Service officer named Hill Hastings. By April 14, only two cases of smallpox remained in Middlesboro. Hastings had them transferred to the Bell County pesthouse. (It was the very least Bell County could do.) On April 15, on Surgeon General Wyman’s orders, Hastings and his men broke up the Marine-Hospital Service’s camp at Middlesboro. Five months after it began, the Middlesboro epidemic finally came to an end.⁷³

For J. N. and A. T. McCormack of the Kentucky Board of Health, the Middlesboro epidemic had been a disaster—a disaster that threatened to overtake the entire state, one ill-governed community at a time. Political fecklessness and pound-foolishness had allowed Kentucky’s first encounter with mild type smallpox to spiral out of control. On March 25, Secretary McCormack issued a state bulletin, warning that the Middlesboro epidemic would be repeated everywhere if local authorities did not take its two main lessons to heart.

The first lesson was legal: under Kentucky laws, the expense of smallpox control had to be quickly met by the affected counties and cities. The price of inaction in Middlesboro amounted to thousands of dollars in government funds, “very many thousands in loss of business,” and the sheer “mortification of clamoring for outside aid.” In the future, McCormack said, the state board would not hesitate to order a quarantine against cities and counties that failed to do their duties.⁷⁴

The second lesson was racial: Kentucky communities could no longer ignore the spread of smallpox among African Americans. “The exemption of the white race” from the new smallpox was coming to an end. In a chilling statement, McCormack advised that “visiting and strange negroes be hunted, vaccinated, and kept under observation.” As the Kentucky epidemic spread, McCormack redoubled his efforts to control the movement of African Americans. At the October 1898 meeting of the board, he warned that the unrestricted travel of unvaccinated colored persons constituted “a menace to the health and lives of the people of this state.” The secretary proposed a resolution, which the board swiftly adopted. The new regulation made it unlawful for any person exposed to smallpox—and any African American, period—“to leave Cincinnati, Louisville, Memphis, Evansville, or any other point or place where small-pox now or may hereafter prevail,” for any point in Kentucky by train, steamboat, or other conveyance without a certificate of vaccination issued by a public health officer. A vaccination certificate had become a kind of internal passport, required of all blacks, as well as those whites who had actually been exposed to smallpox, for travel into, or within, the state of Kentucky. The most basic freedom of all—freedom to move—which African Americans had exercised in extraordinary numbers in the late nineteenth-century South, redefining the national map in the process, was now made dependent upon their vaccination status.⁷⁵

In the aftermath of the local outbreak that launched a four-year-long epidemic in the state of Kentucky, costing county and municipal governments more than $300,000, the officials of Middlesboro and Bell County seemed no more inclined than before to assume the legal obligations that came with local autonomy. Dr. Samuel Blair of the Bell County Board of Health sued the county to recover payment for his services at Middlesboro. A local jury ruled in his favor, and he received a judgment of $250. But Bell County appealed. The county suggested that because two members of its own board of health (Drs. Robertson and Curd) were taxpayers in Middlesboro, they had “fraudulently acted with the intention to charge the county and relieve the city from the burden.” An appellate court ruled in favor of the county, declaring that a city of Middlesboro’s size was not only empowered to fight contagious disease but also liable for the costs.⁷⁶

Remarkably, in all of the paper left behind during this five-month episode, there is not a single word of any effort by local officials to seek relief from the men of capital who had created Middlesboro and still owned its coal and its future. An ocean away, the American Association, Inc., did not lift a hand to aid the citizens of Middlesboro during their hour of need. Some Middlesboro citizens, though, seemed able to find a joke in everything. When reports reached the mountain city that a smallpox epidemic of more than five hundred cases had struck Middlesborough, England, one local newspaper asked if the disease had been carried there by “a negro from Kentucky.”⁷⁷

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.