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 rise 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.

According to the conventional understanding of the Constitution’s Tenth Amendment, police power—the right to interfere with individual liberty and property rights in order to serve the public welfare—was reserved chiefly to the states. During the constitutional firestorm of Reconstruction, the U.S. Supreme Court had breathed new life into that old understanding, almost as if the Civil War and the Fourteenth Amendment had left the federal system unaltered. The immediate losers in the Court’s jurisprudence were African Americans, whose civil rights Congress proved increasingly powerless (and unwilling) to protect. But the decisions reverberated in other areas as well. In the Slaughter-House Cases (1873), the Court’s majority reinvigorated the long-standing constitutional position that gave the state and local governments primary and, as far as the federal courts were concerned, well-nigh unlimited authority to restrain liberty and property in the name of the public health.¹⁶

In practice, the boundaries of local, state, and federal power frequently blurred. From time to time Wertenbaker did encounter smallpox in his work for the Service. On assignment in Chicago, he served as the federal sanitary inspector at the World’s Columbian Exposition of 1893. With Asiatic cholera spreading across Europe and visitors and performers arriving in Chicago from all corners of the globe, American officials braced themselves for an outbreak at the Exposition. Instead, smallpox struck the White City that summer and spread across the real-life Second City during the fall and winter, taking hold in the West Side tenement sweatshops and killing more than a thousand people. Wertenbaker assisted overwhelmed city health officials by searching for concealed cases on the hundreds of boats that had taken up winter quarters along the icy Chicago River. He surely heard about, if he did not witness for himself, the small riots that broke out as city vaccinators worked their way through the tenements. State Factory Inspector Florence Kelley, a Hull House social settlement veteran who knew the West Side well, would never forget “the feeling against vaccination in the tenements.” One young surgeon on the vaccination squad had been “disabled for life” when an agitated tailor shattered his elbow with a bullet.¹⁷

If Wertenbaker ever doubted the effectiveness of vaccination, as some physicians did, his work in Chicago and elsewhere gave him reason to believe. Vaccination as practiced in much of the United States during the 1890s was an unpleasant and risky medical procedure. Even under the best of circumstances newly vaccinated people often felt ill and achy for days. But in the vast majority of people, vaccination worked. As chief of the Service’s Delaware Breakwater Station in August 1896, Wertenbaker inspected the steamship Earnwell, just in from Colón, Panama. Three men on board had broken out with pox. Two of them had undergone vaccination before their voyage; they experienced mild attacks. The first mate had evidently escaped vaccination, and he suffered terribly from a severe confluent case. Wertenbaker could do little more than watch the seaman die from a preventable disease.¹⁸

In January 1898, Wertenbaker took command of the Marine-Hospital Service station at Wilmington, North Carolina, his first southern assignment in seven years. A bustling port located thirty miles up the Cape Fear River from the Atlantic Ocean, Wilmington was the state’s largest city. Roughly half of the city’s 21,000 inhabitants were African American. Most black residents worked in manual and domestic labor, but Wilmington had a sizable African American middle class of skilled tradesmen, physicians, lawyers, and—ever since a fusion campaign of Republicans and Populists won control of the government in 1894—several municipal officials. Wertenbaker arrived in the city at a moment of rising political tension. In the course of 1898, white Democrats would become increasingly well organized and violent in their determination to seize control of the government and bring an end to “Negro domination.”¹⁹

As a white southern Democrat himself, Wertenbaker must have had an opinion about these developments, but he did not express it in writing. The Virginian took Jim Crow for granted. He chose to continue the station’s practice of maintaining separate “white” and “colored” hospital wards. Apart from a white steward, the entire staff was black. Wertenbaker introduced a new level of discipline at the station, including weekly inspections, for which the surgeon turned out in his full dress uniform, sword and all. Wertenbaker moved into the station officer’s residence, on the first floor of the two-story main hospital building, with his wife, Alice Girardeau Wertenbaker, who descended from a prominent South Carolina family, and their infant daughter, Alicia. Alice would make a respectable household for the young family, and she and little Alicia toured the coastal area in the Service’s “station wagon,” a horse-drawn affair operated by a black driver in livery. Charles Wertenbaker himself never had a chance to settle in.²⁰

During Wertenbaker’s two and a half years at Wilmington, his telegraphic orders from Surgeon General Wyman sent him, over rail lines and dirt roads, to disease-stricken locales in Virginia, North Carolina, South Carolina, Georgia, Alabama, Kentucky, and Tennessee. Wertenbaker called this phase of his long career in the Service “my smallpox work.” And if, at times, that work seemed as cursed as smallpox itself, he could take some satisfaction in the fact that no one did it better.

He established himself as the Service’s foremost smallpox expert in the field, known to governors, mayors, and state and local health officials as a master diagnostician of the new “mild type” of smallpox, and a man with a proven strategy for stamping out the disease. Such was Wertenbaker’s stature in the field that he received temporary appointments to the staffs of the governors of Virginia, Georgia, and Nebraska. In 1899, Wertenbaker sent Wyman a long memo entitled “Plan of Organization for the Suppression of Smallpox.” The surgeon general published it as a supplement to the Service’s “Précis upon the Diagnosis and Treatment of Smallpox.” If the “Précis” presented the latest scientific knowledge of the disease, the “Plan” offered a comprehensive strategy—part medical intervention, part military operation—for suppressing local outbreaks. The highest demand for both pamphlets came from the southern states, and though the tactics Wertenbaker outlined should have worked just as well anywhere, they were distinctly the product of his own experience fighting smallpox in southern cities, towns, plantations, and work camps.²¹

Wertenbaker had been on the job at Wilmington for only a few days when North Carolina’s first reported case of mild type smallpox arrived in the city. On January 12, 1898, a local physician informed Mayor S. P. Wright that Stephen Johnson, an African American brakeman who worked the Atlantic Coast Line between Wilmington and Florence, South Carolina, had contracted smallpox. City health officials hung a yellow quarantine placard outside the Johnson home on Hanover Street and quarantined three neighboring houses, vaccinating all the residents. Mayor Wright posted two policemen on the block to prevent residents from leaving. Wertenbaker had no jurisdiction in the matter. But he offered his assistance to the local government, ordered a hundred points of vaccine, and told Wyman he would vaccinate “all persons applying.” During the next three weeks, Wertenbaker watched Wilmington turn into a battleground over public health.²²

On the first day of the outbreak, Wertenbaker accompanied Dr. William D. McMillan, the city superintendent of health, as he searched for a suitable site to establish a pesthouse. McMillan planned to remove Johnson from his thickly settled neighborhood as soon as possible. The doctors chose a three-room house on Meares Street, amid the sandy lots in the far southeastern section of the city. The place seemed ideal. It occupied a block by itself, the nearest house being three hundred yards away, and the caretaker said his tenant would be happy to move out so he could rent it to the city. But the area was not as deserted as it looked. Unlike Johnson’s neighborhood, inhabited almost exclusively by African Americans, the blocks around the Meares Street house were overwhelmingly white. When the Wilmington Messenger announced the opening of the pesthouse, twenty or thirty armed white men assembled at the property, warning that they “meant business” if an ambulance wagon showed up carrying Stephen Johnson. Under pressure from his neighbors, the tenant decided to stay put.²³

Dr. McMillan reset his sights on the northeastern corner of the city. He found a house on Nixon Street, located between the railroad tracks and one of Wilmington’s largest African American sections. The house had recently served as a barracks for a gang of convict laborers employed grading a link line for the Wilmington and New Bern Railroad. As soon as African American neighbors got wind of McMillan’s plan, they did just what the white residents of Meares Street had done. They formed a mob. But theirs was larger. Three hundred men, women, and children turned out at the property when Mayor Wright and Dr. McMillan paid it a visit. The crowd threatened to burn the house if the authorities brought Johnson there. That evening, Nixon Street teemed with men carrying pistols, shotguns, and, as one policeman commented, “some old time war muskets with muzzles big enough for rats to run into.” According to one witness, the many women in the crowd were even “more vehement” than the men. White men joined the crowd and “took a hand in the defiance.” Men and women blocked every avenue to the house; a hundred men stood guard along the railroad tracks to prevent the authorities from delivering Johnson by that route. No ambulance or train carrying Johnson materialized that night. But the crowd burned the house to the ground anyway. A smaller two-room house stood on the same property. The next day, a rumor spread that officials planned to move Johnson there. That evening a crowd set the second house on fire.²⁴

The authorities decided to let Stephen Johnson recover or die in his own home. (He survived.) A few days later Wilmington officials discovered a second man with smallpox, an African American stevedore named James Harge. Determined to remove him from his home, they settled on a remote site three miles from the city.²⁵

The Wilmington board of aldermen did not rush to order vaccination in the city. They debated the question for nearly two weeks. Several aldermen, including A. J. Walker, one of the body’s African American members, opposed the idea. Finally, on January 24, the board adopted an order requiring all residents to show proof of recent vaccination. Violators were subject to a $5 fine or ten days in jail. (Mayor Wright had called for stiffer penalties.) The mayor appointed five city vaccinators, including two African American physicians who were assigned to the black neighborhoods.²⁶

On January 27, some five hundred citizens of Wilmington, including about fifty African American men, assembled at city hall to protest the vaccination ordinance. They carried a protest document that had been drawn up earlier that day outside of J. T. Smith’s store on Front and Castle streets. The men took their stand as breadwinners, acting, as their petition announced, “[o]n behalf of ourselves, our wives and our children, and the thousands of our citizens and their families, who provide their livelihood by manual labor.” Two cases of smallpox did not justify a measure that threatened the arms and livelihoods of Wilmington’s wage earners. “[C]ompulsory vaccination will inflict an unnecessary hardship,” the petition said, “especially upon the poor who have to labor for their living.” The petitioners vowed to “resist to the uttermost with all our influence and manhood the enforcement of this iniquitous law.” The group’s leaders included an African American doctor named Bill Moore, who claimed that the document represented “the sentiment of two-thirds of the people of Wilmington.” According to the Wilmington Messenger, the physician’s statement was “greeted with applause by white and black.” In an impressive display of biracial local democracy, the committee appointed a jury-sized delegation of six white men and six black men. Together they presented the petition to the mayor and board of aldermen.²⁷

The aldermen did not rescind the ordinance. They did not have to. The city vaccinators met with such widespread resistance in Wilmington’s neighborhoods and workplaces that the board of health suspended the entire campaign just a few days after it had begun. All of the vaccinators had found the work dispiriting. The city’s strategy of sending black doctors into African American neighborhoods had not overcome the residents’ concerns about vaccination. One African American woman drove a black physician from her doorstep with an axe. An African American man brandished a gun to defend his threshold from a city vaccinator and two policemen, all of them black. White vaccinators hadn’t fared much better in white working-class neighborhoods. As the city hall protest had shown, compulsory vaccination was perceived as dangerous and unjust by many people, regardless of race.²⁸

By the time the city vaccinators ceased their unfinished work, Johnson and Harge had begun to recover. No further smallpox cases had come to light.

The Wilmington smallpox skirmishes of 1898 would be overshadowed in the city’s memory by the bloody race riots that came just ten months later during the November elections. The riots left more than ten blacks dead in the streets of Wilmington, caused thousands to leave the city, and put Democrats in control of the city government. Soon after that tragic episode, the North Carolina Board of Health issued its annual report. Citing the Wilmington smallpox outbreak as a cautionary tale, the board lamented that the city government’s efforts to stamp out the disease had been “so violently resisted by the negroes as to cause the abandonment of the attempt.” Absent from the report was any mention of the white and black pesthouse mobs, or the biracial coalition of Wilmington men, some five hundred strong, who had together taken a stand at city hall as workingmen and breadwinners opposed to compulsory vaccination.²⁹

For C. P. Wertenbaker, the pesthouse fires and antivaccination protests marked the beginning of an education in the contentious politics of southern smallpox control. Wherever Wertenbaker went, he saw smallpox engender intense conflict between “the public health” as a political ideal and “the public” as a fractious social reality. The public health implied a unity of purpose and interests—within the medical profession, between physicians and the state, and between state and society—that Wertenbaker rarely encountered. Instead, he found governments that wouldn’t govern and citizens who wouldn’t let them when they tried.

He witnessed this conflict in Wilmington in January 1898. He saw it that February in Charlotte, where white cotton mill workers, fearing vaccine poisoning, refused to comply with the city government’s vaccination order. He saw it again in March in Middlesboro, Kentucky, where local officials rebelled against their own legal duties as keepers of the public health. When Wertenbaker returned to Wilmington in April, Wyman forwarded to him a letter that J. W. Babcock of the Columbia, South Carolina, Board of Health had sent to Senator Benjamin R. (“Pitchfork Ben”) Tillman. As smallpox raged in the capital city, the board had ordered a general vaccination. “My private opinion,” Babcock told the senator, “is that we shall not get much cooperation from the white people, and none at all from the negroes.” Babcock asked Tillman to secure “the services of a competent officer of the Marine-Hospital Service, who would come here to advise and act with the Board in stamping out the disease.” Dispatched to Columbia, Wertenbaker reported that he found “much the same condition of affairs” as he had “in so many other places.” There was so much difference of opinion about the disease among doctors and so much concern about vaccination among the working people that health officials had “great difficulty in inducing the people to take necessary precautions.”³⁰

Wertenbaker’s experiences in the field would make him into an advocate for reform in the field of public health administration. He pushed for better, safer vaccines. He promoted official candor and public education as the best remedies for the pervasive “prejudice” against vaccination. And though Wertenbaker never discarded the racial beliefs of his time and place, he would, in an era of overwhelming white indifference to African American health, call for the government to mobilize rural blacks to organize their own fight against infectious disease. Ultimately, Wertenbaker’s smallpox sorties led him to conclude that there was only one way to stamp out infectious disease in the South—by increasing the scale and scope of federal police power.³¹

If late nineteenth-century American jurists were certain about anything it was this: the states could take any action necessary to protect their citizens from the “present danger” of a deadly infectious disease. Since the dawn of the republic, state and local governments had wielded powers both plenary and plentiful to defend the people from outbreaks of smallpox, yellow fever, cholera, and other pestilences. Individual liberty and property rights melted away before the state’s power—indeed its inherent legal duty—to defend the population from peril. Under the broad authority of the police power, state and local governments confined suspected disease carriers against their will, established armed quarantines on land and at sea, seized private homes for smallpox pesthouses, removed infected persons by force from their homes, and enacted, in the approving words of the U.S. Supreme Court, “health laws of every description.” Considering the case of a merchant from Burlington, North Carolina, who had refused to submit to his town’s vaccination during the epidemic winter of 1899, Justice Walter McKenzie Clark of the state supreme court drew a ready analogy between public health and the sovereign’s power of self-defense. “[I]t is every day common sense,” he said, “that if a people can draft or conscript its citizens to defend its borders from invasion, it can protect itself from the deadly pestilence that walketh by noonday, by such measures as medical science has found most efficacious for that purpose.” Like war, it seemed, epidemic disease was the health of the state.³²

But in the cities, towns, and rural hamlets that C. P. Wertenbaker visited across the South, convalescent people with infectious smallpox scabs on their faces and limbs moved freely about the streets, ran country stores, and went to work in the fields and mills. Meanwhile, local physicians engaged each other in front porch debates about the nature and provenance of this mysterious eruptive disease. When alarmed public health officials called for strong measures, local government agents often hesitated to act, not wanting to interfere with business or upset the electorate. When officials finally did act, as Wertenbaker wrote in a report to Surgeon General Wyman, time and again the people “revolted.”³³

Health officials met with resistance to every form of action they took. African Americans were said to be particularly quick to hide sick relatives and friends from health inspectors and the police, but whites did it, too. Shotgun quarantines on the public roads proved to be a weak defense against rural folk who knew their way through the woods. “We had just as well undertake to quarantine against red foxes and jack rabbits,” said one Kentucky health official. Pesthouses that had been hastily built were just as swiftly torched or torn asunder by crowds of people, white and black, who refused to let their neighborhoods be turned into smallpox dumping grounds. “We were totally unprepared to take care of a contagious disease,” recalled Dr. J. M. Manning, superintendent of health of Durham, North Carolina. Dr. Manning rode with the mayor across Durham, looking for a suitable place to pitch an isolation tent, but they were “met with shot-guns” wherever they stopped. Where officials did manage to establish pesthouses, they had to find a way to keep people in them. Even with armed guards and gasoline torches, most pesthouses and detention camps could not hold people who had the will and energy (as patients with mild smallpox often did) to escape. Local newspapers that a generation earlier had published notices of runaway slaves now ran stories about African American pesthouse fugitives who had broken loose from their confinement and fled into the night.³⁴

No public health measure inspired more ill will than compulsory vaccination. Some of the opposition came from the top of the political order—from state lawmakers, who almost everywhere maintained that if compulsory vaccination were to exist at all it must be by local mandate. Even in the midst of the regional epidemic, efforts to enact uniform statewide vaccination legislation failed in several states, including Alabama (despite strong support from the medical profession), Florida (where rural representatives killed a bill favored by their urban colleagues), and North Carolina (where a bill drafted by the state board of health was “treated with absolute contempt”). Even in those few states that did enact new vaccination laws—such as Mississippi, a yellow fever state with an exceptionally well-funded board of health—lawmakers merely authorized local governments to compel vaccination and impose penalties. Compulsory vaccination of public schoolchildren could be attempted under state legislation or local authority, but in a region with almost no compulsory school attendance laws, such measures had limited reach. As Secretary Richard H. Lewis of the North Carolina Board of Health commented, “One practical difficulty on educational lines now is to get the children to go to school at all.”³⁵

In the absence of state statutes, during smallpox epidemics local governments often ordered vaccination under their own general police powers, performing their legal duty to protect their populations from immediate danger. The orders usually resembled the one issued by the Wilmington aldermen: they required everyone in the community to show proof of a recent successful vaccination. The penalties ranged dramatically—with fines from $5 to $100, jail terms from ten to forty days. Some judges ordered violators to work on the public roads. In one North Carolina town, a man who refused to be vaccinated and threatened to spread smallpox among his “political enemies” had “three buggy whips worn out on him.” By contrast, some state and local measures created exemptions for specific classes of people. The city of Nashville made exceptions for people aged seventy or over, for women more than five months pregnant, and for individuals who, “in the opinion of the vaccinating physicians, are too ill to submit to the procedure.” Wertenbaker took a dim view of such exemptions. Only two classes of people should be allowed to neglect this duty, he wrote in his “Plan”: those who have had smallpox already and “those who are dead.”³⁶

Local or not, compulsory vaccination orders engendered strife. Much the same drama played out across the South, from High Point, North Carolina—where Wertenbaker arrived to find that the furniture factory employees had “closed their houses, and gone into the country to avoid being vaccinated”—to Sherman Heights, Tennessee, where a crowd of citizens drove off county vaccinators with stones, curtain poles, and guns. Some people loudly protested the measures as violations of their personal liberty. Others tried to shrug off the health officers’ authority. The health officer of Russell County, Alabama, complained bitterly to a Service surgeon that when he tried to enforce vaccination without the aid of police “the negroes laughed at him.”³⁷

In carrying out a policy that frequently targeted blacks, officials did not hesitate to use physical force. The sort of actions that Wertenbaker had heard about in Middlesboro (where African Americans were handcuffed and vaccinated at gunpoint) were echoed in official actions elsewhere. The phrase “equal protection of the laws” had little meaning in southern public health. Authorities in smallpox-ridden Thomson, Georgia, made sure that “all the colored population that could be caught were vaccinated” before they pressed the issue with whites. When they met “bitter opposition on the part of the white element,” the authorities decided to ask for an “outside opinion” before “forcing the matter.” They appealed for the aid of a Service surgeon. Racist pride was probably enough to stop white Thomson officials from asking Uncle Sam to help them handle “their” colored people.³⁸

Beleaguered southern health officials had a concise explanation for popular resistance to their authority: the people were “ignorant.” After the rebellious citizens of Laurel County, Kentucky, caused the local health board to withdraw its vaccination order, one officer sent a plea to Secretary J. N. McCormack: “you alone know how much unjust, unreasonable and criminal censure these ignorant people are heaping upon us.” Other health officials pointed out that the common people had no monopoly on ignorance. Physicians, judges, and county officials were clueless, too. When the opposition came from white farmers or mountain people, some officials inclined toward more charitable, if no less condescending, theories. “Our people are unaccustomed to the restraints and duties incident to the proper management of them according to the principles of modern hygiene,” Secretary Lewis of the North Carolina board gently explained. Meanwhile, African Americans who pushed back against white health authority were disparaged as not just “ignorant” but “criminally careless.”³⁹

As the southern smallpox epidemic wore on, Wertenbaker and some of his state and local peers developed a set of deeper explanations for why both smallpox and popular antipathy to public health authority had gotten so out of hand. Knowledge remained the crucial piece in these explanatory schemes. But Wertenbaker and others realized that a community’s understanding of disease depended on something more personal than a public health circular or a family doctor’s advice. Medical beliefs rested upon shared experience and memory. On this score, smallpox posed a special problem.

Outside the urban centers and port cities such as Charleston and New Orleans, most communities had not seen smallpox in a generation. People old enough to remember the Civil War recalled the epidemics that had raged in both armies. C. C. Wertenbaker probably told his son about the pox that burned through the Army of Northern Virginia during the Maryland campaign. Union and Confederate soldiers wrote in their diaries and letters of the wonders and horrors of arm-to-arm vaccination: the common practice of inoculating men with pus taken from another soldier’s vaccination sore or, worse, from an actual smallpox lesion. Some troops expressed gratitude for the protection their vaccinations afforded, while many more recounted stories of terrible fevers, poisoned arms, amputations, and death. During the battle of Chancellorsville in May 1863, five thousand Confederate soldiers were deemed unfit for duty after being vaccinated with material taken from the arm of a soldier who, as luck would have it, had syphilis.⁴⁰

The civilian population did not have it much better. “Colonel” A. W. Shaffer of North Carolina recalled the desperate measures taken by local communities when vaccine ran out. “Everything having the semblance of a scab or pus passed for vaccine; anything with two hands and a blade or point, for a vaccinator; and every filthy sore at the point of abrasion, for a successful vaccination.” So shocking had been the side effects that Shaffer blamed them for the outpouring of antivaccination sentiment in his state some thirty-five years later. “No wonder that the memory of that harvest of vile diseases still burns in the hearts and perverts the brains of the fathers and mothers of this later generation!”⁴¹

If Shaffer was right, the horrors of wartime vaccination burned more brightly in the memories of the people than did smallpox itself. Many places had not seen a single case since the war’s end. Like other rural Southerners, the people of Monroe County, Kentucky, had come to think of smallpox, in the words of a local physician, as “a disease confined to cities . . . a disease to be read about in the newspapers.” North Carolinians could boast of the “blessed fact that epidemics of infectious disease of any magnitude have been extremely rare in our State.” But the downside of this “wonderful immunity” was that in the Tar Heel State, as in more plague-prone areas of the South, a generation had come of age with no clear memory of how the symptoms of smallpox compared with those of the common childhood eruptive diseases such as chicken pox or measles. It did not seem to matter how much publicity heralded the spread of smallpox across the region. Each new outbreak seemed to catch the infected community by total surprise, like the unexpected return of some obnoxious but long-forgotten relation.⁴²

Southern physicians suffered from the same memory deficit. “Many physicians have never seen a case of smallpox, and are unfamiliar with the methods necessary for its suppression,” Wertenbaker wrote in May 1898 after visiting Columbia, South Carolina—which was, after all, a state capital, not a one-horse town. Old-timers in the profession remembered small-pox all too well: Dr. M. H. Young recalled treating hundreds of cases during his service as a surgeon in the Fourth Kentucky Volunteer Infantry during the war. But a generation of younger men had entered the field who had never laid a compress on a smallpox-rubbled face, never inhaled the sickening odor of an infected person’s room, or, for that matter, never received much college instruction on the subject.⁴³

Vaccination, meanwhile, had fallen by the wayside. The procedure, though simple, took time and care to perform correctly, and it normally garnered the physician a nominal fee. In the decades since the war, the once standard practice of arm-to-arm vaccination had been largely abandoned in favor of bovine vaccine, cowpox or vaccinia lymph harvested from cows and dried onto ivory points. The shift from so-called humanized virus to bovine points was hailed by most scientific authorities as a great innovation that reduced the transmission of human diseases, such as syphilis. But for a small-town physician, the changing technology imposed a new burden. If he chose to offer vaccination as part of his regular practice, he had to keep a stock of fresh vaccine on hand. In the absence of either much risk of smallpox, or much reward for performing the procedure, many physicians decided vaccination was not worth the bother. The practice had become, in the words of Secretary McCormack, “one of the ‘lost arts’ to the majority of country physicians.” To laypeople, it became an exotic and dodgy procedure, best left alone.⁴⁴

And so, when the disease returned in the late 1890s, Southerners in general—and African Americans and poor whites in particular—were caught almost uniformly unprotected. Service surgeon Joseph J. Kinyoun, a North Carolina native and the first director of the National Hygienic Laboratory, warned that “Small-pox is more of a menace to the Southern people than to the northern people,” because in the South vaccination was “practiced but little, and only in places of large population.” In North Carolina, scarcely 10 percent of the population had ever been vaccinated. In Georgia, a Service surgeon placed vaccination levels closer to 25 percent, but that was after smallpox had been back for a few years. At the outset of the Middlesboro epidemic in the winter of 1898, Kentucky officials estimated that “only” two thirds of the state’s residents had ever undergone the procedure. But as local reports came in from across the state, the officials had to revise that figure. Two thirds of Kentuckians had never taken the vaccine. Among African Americans, vaccination status varied with age. Many of the older former slaves had been vaccinated; their masters’ self-interest, if not their vaunted paternalism, had seen to that. But the overwhelming majority of younger blacks, raised in an era of almost total neglect from the white-dominated medical profession, had never been inoculated.⁴⁵

In his travels, C. P. Wertenbaker learned that ignorance, like knowledge, was a product of history. Medical knowledge—in both its popular and professional forms—still depended upon firsthand experience with illness. As far as smallpox was concerned, the wellspring of experience had (blessedly) dried up in the decades after the Civil War.

Any epidemic of smallpox would have caught most southern communities off guard. But the epidemiological profile of these end-of-the-century epidemics made them particularly difficult to manage. Smallpox struck African Americans first. And the disease took an exceptionally mild form. These two facts shaped how the scientific claims and political demands of public health officials would be received by the South’s many publics.

Addressing a white Mississippi audience in the early twentieth century, Booker T. Washington told his listeners, as he so often did, that “the destiny of the southern white race” was “largely dependent on the Negro.” The eminent African American educator drew upon recent history to make his point. “You can’t have smallpox in the Negro’s home and nowhere else,” he said. “You need to see that the cabin is clean or disease will invade the mansion. Disease draws no colour line.”⁴⁶

Several years earlier, C. P. Wertenbaker stood outside a grocery store in Richland, Georgia, a whistle-stop town of nine hundred souls not far from the Alabama border. As people came and went from the store, a crowd of children, white and black, loafed outside. One African American boy caught Wertenbaker’s eye. Judging by the scabs on his face, Wertenbaker figured the boy to be in the convalescent stage of smallpox known in the medical literature as “desquamation.” Smallpox experts considered desquamation, when the scabs crumbled and fell from the face and body, to be the most contagious phase of the disease. The boy, Wertenbaker recalled, was “scattering infection everywhere he went.” No one paid the boy any mind.⁴⁷

It was never easy to get rural people to take mild smallpox seriously, but when the disease appeared to infect “none but negroes” the task proved far more difficult. Federal, state, and local health officials, reporting from points across the South, uniformly identified the African American population as the reservoir for this disease. Newspapers, too, traced local outbreaks to particular African American individuals, families, or settlements. Even after the disease made its appearance among whites, the great majority of reported cases were in black people. In Tennessee and North Carolina, African Americans accounted for three quarters of all reported cases, far exceeding their proportion in the population. In particular locales, officials recorded far greater disparities. In Greenwood, Mississippi, a town of three thousand inhabitants where blacks outnumbered whites by a narrow margin, more than five hundred people contracted smallpox in the winter of 1900; just twenty-three of them were white.⁴⁸

Wertenbaker observed that many white Southerners, including some physicians, called mild smallpox “nigger itch” and claimed that whites could not catch it. Often, the first whites to contract the disease aroused contempt. When a group of young white men in Stanford, Kentucky, broke out with the “itch,” their neighbors had a ready explanation: the boys had made “indiscreet visits” to the “Deep Well Woods,” an African American settlement on the outskirts of town. The first white patients identified in health board reports were usually marginal figures such as tramps, half-witted women, and promiscuous girls—fixtures of the era’s eugenics-inspired literature on southern “white trash.” That some rural whites covered their faces before allowing health board photographers to take their pictures attests to the shame they felt at being caught with this “loathsome negro disease.”⁴⁹

Southern health officials admitted that a large percentage of smallpox cases went unreported in their states. How, then, could they speak with such certainty about the racial origins of these epidemics? Those in a position to produce official accounts of epidemics have often blamed their occurrence on subordinate social groups. But this is not to say that all such narratives are works of pure fiction. To dismiss the official accounts out of hand—or to read them only as elite ideology—is to forgo all hope of recovering the social experience of disease. The wonderfully idiosyncratic epistolary form that public health reports took in this era inspires at least some confidence in their contents. State reports consisted mainly of letters and telegrams, peppered with chatty detail, sent in by local health officers. Even assuming broad agreement regarding matters of race and class, it would have taken a racial conspiracy of an implausible scale to make all of these reports tell a common story of the epidemic’s prevalence among African Americans and poor whites, if there were not some basis for this in fact. With an infectious disease such as smallpox, which spread most easily among people without regular access to medical care and who lived in close proximity to one another, the poorest members of society were exceptionally vulnerable. Inadequate nutrition made poor people susceptible to all sorts of diseases. Public health officials made a revealing leap, however, when they concluded from such epidemiological facts that “irresponsible negroes” (or “ignorant” whites) were morally culpable for the spread of smallpox.⁵⁰

Smallpox patient at the Tampa pesthouse, 1900. COURTESY OF THE STATE ARCHIVES OF FLORIDA

In his personal papers and public writings, C. P. Wertenbaker was serious, dispassionate, and reserved—a gentleman scholar of the Service stripe. In his field reports to Washington, he dutifully noted whites’ belief that they had a natural immunity to the disease they called “nigger itch,” but he considered this popular belief a sign of ignorance and a bane to scientific smallpox work. He did not normally indulge in expansive statements of racial ideology, “scientific” or otherwise. But in one letter, which he sent to a Mississippi health official in 1910, the federal surgeon revealed some of his assumptions about the state, and fate, of African American health. “There is no question in my mind,” Wertenbaker wrote, “but that the negro constituted the gravest menace to the country in which they lived, from a sanitary standpoint.” “The negro is like a child,” he continued, “incapable of carrying on any effectual sanitary work unless guided and directed by the white people.... Unless there is a marked change in sanitary conditions among the negroes, I believe that within the next 100 years the negro will be almost as scarce in this country as the Indian now is. I believe that the extinction of the race is imminent.”⁵¹

With those few lines Wertenbaker revealed a cast of mind entirely conventional among white medical authorities of his time and place. Such theories had a long lineage. In the antebellum period, southern medical writers had used just such claims to defend the institution of slavery. Observing that African American slaves were less prone than whites to contract malaria and yellow fever (because, we now know, of an inherited genetic resistance to the mosquito-borne viruses that caused those diseases), slaveholders lauded their chattels’ natural fitness for back-breaking labor in the coastal rice and cotton fields. Ideologues claimed the intelligence and moral dispositions of African Americans were so deficient that slaves needed their white masters’ protection and restraint. In the post–Civil War era, white medical experts ridiculed the freed people’s claims to equal citizenship. During the 1890s and 1900s, physicians interpreted African Americans’ high mortality and morbidity rates as evidence of black people’s supposed biological inferiority, insisting that they brought disease upon themselves by sexual vices and intemperance. Using the flawed late nineteenth-century census returns to bolster their case, white experts claimed that the health of African Americans had plummeted since emancipation. This proved, the authorities claimed, that blacks had benefited from slavery and were so ill suited to freedom that they were now destined for extinction. Such medical racism led leading life insurance companies to refuse policies to African Americans.⁵²

In The Philadelphia Negro (1899), his pathbreaking work of urban sociology, the young African American scholar W. E. B. Du Bois calmly showed that the prevailing theories of African American health rested on sloppy science and wishful thinking. Since little reliable data existed regarding African American health during slavery, Du Bois pointed out, claims that the health of the race had undergone a dramatic decline since emancipation were, at best, unsubstantiated. Of the myth that blacks were doomed for extinction, Du Bois wrote that it represented “the bugbear of the untrained, or the wish of the timid.” But such medical falsehoods had devastating consequences. They inured the nation to the real—and substantially preventable—health problems of poor African Americans in the North and South. The average life expectancy for blacks was thirty-two, compared to nearly fifty for whites. Infant mortality rates were shockingly high. Black men and women were disproportionately struck by many chronic and infectious diseases, including heart disease and consumption (pulmonary tuberculosis), a major killer in the African American population. “In the history of civilized peoples,” Du Bois wrote, rarely had so much “human suffering” been viewed with “such peculiar indifference.”⁵³

That indifference was not just a cultural phenomenon. It was a systemic feature of the white-dominated medical profession, especially in the South. Reputable physicians refused to treat African Americans. As southern cities built new public hospitals in the late nineteenth century, most excluded blacks or relegated them to inferior Jim Crow wards. Such demeaning treatment, Du Bois observed, intensified the “superstitious” fear of hospitals and medicine that he considered “prevalent among the lower classes of all people, but especially among Negroes.” As a consequence, most poor blacks did not seek medical aid from a white physician until they were desperately ill. “Many a Negro would almost rather die than trust himself to a hospital.”⁵⁴

The best hope for African American health care lay with the black medical profession. By 1900 more than 1,700 black physicians practiced in the United States, up from about 900 a decade earlier. African American medical schools, nursing schools, and hospitals opened during the same period. Industrial schools such as Booker T. Washington’s Tuskegee Institute instructed poor blacks in the use of toothbrushes and everyday hygiene. As significant as these developments were, they could not quickly correct a pattern of institutional neglect so long in the making. As late as 1910, the entire state of South Carolina had only 66 professional black physicians, or one physician for every 12,000 black people. The ratio for white people was about 1 to 800. African American professional medicine existed mainly in urban areas. In the rural South, where most African Americans lived, black physicians were scarce. When rural blacks took ill, they still relied, as they had during slavery, on the informal medical knowledge of friends and relatives, root doctors, and practitioners of magical medicine. In a period of explosive growth in the American medical profession, it remained all too common for African Americans to take ill, suffer, and die without receiving any medical attention.⁵⁵

Even in an era of such systemic neglect, the realization that smallpox was spreading among African Americans across the South was bound to cause alarm among white public health officials. White officials understood from their own observations in the field that smallpox spread like wildfire through unvaccinated populations, regardless of their color. Since the majority of Southerners, white and black, had never been vaccinated, officials made some effort to explain the early prevalence of the disease among blacks.

White medical commentators marveled at African Americans’ sociability: their “gregarious habits,” their fondness for going on “excursions” and mingling “promiscuously,” their “close association and intermixing.” And the commentators were not just talking about sex. Many fretted about “religious negroes,” who seemed ever to be gathering in one meeting or another. During an outbreak, African American churches were usually among the first places quarantined—right after the black schools. Even the playfulness of African American children was deemed a threat to the public health. In the autumn of 1899, as sharecroppers in Concordia Parish, Louisiana, brought in the harvest, piling the seed cotton high in their cabins, one white official worried that children would pollute the cotton with smallpox: “On this inviting heap the darky children romp by day and sleep by night with that habitual disregard of cleanliness characteristic of the race.” The writer knew he could count on his readers’ imagination to complete the scenario. With the infected cotton bound for market, and from there to the mills, and from the mills to the homes of unsuspecting white consumers, who could say how far smallpox would travel from those sharecroppers’ shacks?⁵⁶

Racial anxieties permeate the official record of the southern epidemics. But the record also contains clues about the deeper causes of the prevalence of smallpox among African Americans. While poor nutrition and overcrowded living conditions made black people especially susceptible to smallpox, institutionalized racism fostered African Americans’ long-standing distrust of white doctors. Neglected and mistreated by the medical profession, the vast majority of southern blacks had never been examined by a physician, let alone been vaccinated, and would just as soon keep it that way. African Americans were understandably reluctant to report cases of smallpox in their homes or neighborhoods to white authorities. As the Atlanta Constitution noted during the Birmingham epidemic, “[T]he negroes there have a great dread of the pesthouse and use every effort to avoid having their friends and relatives taken there.” In other places, the physical or cultural distance from white medical authority was so great that such subterfuge was unnecessary. Traveling through Georgia in 1899, Wertenbaker kept stumbling upon African American settlements or sections of towns with names like “Hell’s Half Acre,” where smallpox had spread for four or five months, sometimes longer, without attracting the least notice from whites. “The disease became epidemic before it was known,” he said.⁵⁷

The close living conditions of African American laborers, even in the most rural of settings, aided the spread of smallpox. Especially efficient carriers, it seemed, were itinerant laborers in the fast-growing rural nonagricultural sector, including men who worked at turpentine stills, in phosphate and coal mines, and on the railroads. Unvaccinated African Americans who slept in crowded cabins, shared tents in mining camps, or huddled for warmth in railroad boxcars were extraordinarily vulnerable to airborne germs. Transient black workers, forbidden by law, custom, and their own poverty from sleeping in a white-owned tavern or inn, frequently stayed overnight in the home of a black family, where they shared rooms and often beds with children and other family members. In February 1899, a white Carrollton, Kentucky, physician named F. H. Gaines examined a transient African American man with a “suspicious eruption on his forehead and wrists.” Dr. Gaines diagnosed the eruption as smallpox. He learned from his patient that he had been put off the Madison and Cincinnati packet three days earlier and had spent the next three nights with three separate black families. When the man realized Gaines intended to take him to a pesthouse, he made a quick escape. Two weeks later, smallpox erupted in all three families.⁵⁸

A truism holds that in the Jim Crow South, whites and blacks lived side by side, while in the “promised land” of the urban North de facto racial segregation prevailed in the housing market. But the history of the southern smallpox epidemics suggests just how much social distance actually existed between the races in southern places. Jim Crow laws, which proliferated in the 1890s, stripped most African Americans of the suffrage, forced them into separate compartments on trains and streetcars, and relegated black children to the most poorly funded schools. For all of their flaws, the public health reports reveal some of the collective impact of this emerging regime of white supremacy, even as they attest to the vitality of black social institutions. Reports traced smallpox clusters to African American boardinghouses, schools, churches, restaurants, opera houses, and a few houses of ill fame—including one in Richmond, Kentucky, whose keeper served well-attended court-day dinners to the community.⁵⁹

Booker T. Washington had it right. Infectious disease drew no color line. People did—with their customs, practices, institutions, and laws. The color line, in any event, rarely held. Even when local authorities tried to keep smallpox at bay by ordering quarantines of African American sections—as officials did in 1900 in Wertenbaker’s native Albemarle County—smallpox crossed that line. When whites did catch smallpox, a disease that had in some places gone unnoticed for months suddenly attracted public attention. The formerly invisible disease became visible.⁶⁰

Which is not to say it became intelligible. For at that point, as Wertenbaker observed time and again, another problem presented itself. The public refused to believe mild type smallpox was the real thing.

The smallpox came to Stithton, Kentucky, on a winter’s day in 1899, when the Barker boy rode home from Louisville on a bicycle. A peculiar rash speckled the young cyclist’s face, and the town physician who examined him feared the worst. He instructed the boy to ride home and stay there, and then rang the Hardin County health officer. Accompanied by several excited physicians, Dr. C. Z. Aud took a ride out to the Barker place. Aud looked the boy over, ran his fingers over the papules, and in the presence of his attentive colleagues and the boy’s father, diagnosed smallpox. Mr. Barker did not gasp with alarm, he did not plead for a second opinion, he did not ask what could be done to save the boy. He just let the Hardin County health officer know that his opinion wasn’t worth all that much at the Barker place. “I was not very politely told by the old man,” Aud recalled, “that he had had small-pox himself, and knew a great deal more about it than I did, and he would not submit to vaccination.” Barker’s two daughters refused to bare their arms, either. Mrs. Barker said she had already been vaccinated. So Aud and his entourage left. When he got back to his office, Aud learned that Mr. Barker had already called a lawyer to see if he could “get damages from a doctor for saying his son had small-pox when it was a lie.” To Barker, Aud’s diagnosis amounted to libel. Time would tell that Barker did not know so much about smallpox. Two weeks later, he and his daughters broke out in pox.⁶¹

Though most rural Southerners had never come near a case of small-pox, they expected to know it when they saw it. And when their expectations were not met, they did not, as a rule, defer to the professional expertise of public health officers. Dr. J. R. Burchell of Clay County, Kentucky, found himself the object of “many a cursing” when he warned his neighbors that smallpox was spreading among them. “One gentleman’s idea of smallpox,” this health officer reported, “was that when a man had small-pox he was in a hell of a bad fix, and as no one had been in that condition, therefore there had been no small-pox.” It proved a difficult position with which to argue. Public health officers at points across the South agreed that one of the greatest obstacles to smallpox control was the doubt that existed in people’s minds as to the true nature of this new disease. Frequent bouts with naysayers led some officers to wish, in published government health reports, for the appearance of a “fool-killer”: a fatal case of smallpox. As one North Carolina official put it, the best cure for a doubting public was “a good first-class case of small-pox.”⁶²

That even a second-class case of smallpox could arouse so little public concern speaks to the amount of physical suffering that Americans raised in the nineteenth century expected to endure during their lives. Even in ordinary times, southern newspapers advertised patent medicines promising relief from all kinds of fevers and “itching skin diseases.” It took something stronger than mild smallpox to make people welcome government doctors into their lives. Even in a “mild” outbreak, Wertenbaker might see as many as a dozen grotesque confluent cases and one or two deaths. In December 1900, one of Wertenbaker’s Service colleagues, Assistant Surgeon John D. Long, inspected a gang of African American railroad workers in a Washington train station. The men had just finished digging a tunnel for the new West Virginia Short Line Railroad and were making their way south. For months, a disease—variously called “Cuban itch,” “nigger itch,” or “black measles”—had been spreading among white and black workers in the Short Line construction camps. As Long questioned the men, he jotted down their symptoms: “headache, fever, general weakness, vomiting, and pain in the neck and back,” followed by a rash that went through the usual stages of “vesiculation, pustulation, and desquamation.” Most of the men had been unable to work (or collect wages) for up to two weeks. The camps they had left behind had seen at least 140 cases of smallpox, with 4 deaths. That was “mild” smallpox.⁶³

Clusters of severe cases occurred during otherwise mild epidemics often enough to keep Wertenbaker in an almost constant state of apprehension. In each fatal outbreak he envisioned smallpox regaining its historical virulence. From a public health perspective, though, the most dangerous thing about mild type smallpox was that it did not lay people low enough. Some people recovered without ever taking to their beds. Particularly in the convalescent stage of the disease—when patients would ordinarily be confined under close quarantine—people with mild type smallpox often felt well enough to go about their business. Children with infectious scabs on their faces and hands played in the streets. Contagious men and women worked in the fields and factories, ran grocery stores, and mingled in the crowd on court day. Secretary Lewis of the North Carolina Board of Health complained that a man with mild smallpox was “exactly in the right condition for visiting around among the neighbors, or loafing at the railway station, or above all, attending a gathering of any kind—political preferred.” The eruption might be so insignificant as to attract no notice. Nevertheless, it was “the genuine article,” Lewis warned, “and capable of causing in the unvaccinated the most virulent and fatal form of the disease.”⁶⁴

The turn of the century is remembered today as the advent of the modern expert, when university-trained professionals in medicine, the sciences, and law acquired a new authority in American life. But southern health officials often found the public, business interests, and even their own local governments unwilling to accept their warnings or yield them the diagnostic ground. Like Mr. Barker of Stithton, many citizens saw no reason to elevate the medical opinion of a health official above their own.

Like other Americans of the period, blacks were accustomed to experiencing any number of fevers and skin eruptions during their lives. Their first inclination in naming a new disease was to compare it with others they had known. After inspecting a confluent black patient in a room crowded with “eight or ten negroes” in Princeton, Kentucky, a physician found his diagnosis of smallpox challenged by an “old negro” who said he had survived smallpox himself. “Dat nigger nebber had no small-pox,” the man declared, insisting that the “little bumps on him” were caused by “big-pox” (syphilis).⁶⁵

As local health authorities raised the pressure—making proclamations, ordering quarantines, calling for compulsory vaccination—critics raised their protests. Some citizens denounced the government officials as capricious and corrupt. Others relied, as rural blacks had since slavery, on the power of rumor. As Wertenbaker frequently witnessed in the field, nothing outran a rumor. Communities of cotton mill workers, who notwithstanding their claims to white privilege were among the most exploited and marginalized of southern laboring people, were deeply distrustful of medical authority. In Charlotte, Danville, and other places in the throes of industrial change, Wertenbaker found the expert claims of health authorities undone by rumors circulating among the mill workers that no smallpox existed.⁶⁶

Much of the diagnostic dissension came from the medical profession itself. Some local doctors readily conceded their “inexperience” and “distress” at the spread of this bizarre eruptive disease, and they welcomed the expertise of county and state health officials. But others openly dissented against the medical claims of the local officers of the board of health, who were after all physicians like themselves who had been given their extraordinary powers by virtue of a political appointment. Public health officers called their uncooperative peers “kicking doctors” (invoking the ultimate rural symbol of stubbornness: a kicking mule). State health officers openly mocked their local opponents in the medical profession, describing in published reports their encounters with many a “low grade” physician who was “as positive as he was ignorant.” When Inspector B. W. Smock arrived in Jackson County, Kentucky, a community in central Appalachia, a local physician informed him that (as Smock described the conversation) “they had a ‘breaking-out disease’ that was mighty ‘ketching’ up in what is known as Horse Lick Creek.” The local doctor reckoned it was measles. But Smock retorted that this disease was nothing less than “seven-day-in-a-week, stay-with-you-forever small-pox.” City-based state health officials such as Smock wrote up their travels into the heart of Appalachia as if they were conducting anthropological fieldwork. They marveled at the practices of local institutions, recorded (or mocked) local dialects, and cataloged medical folkways. For these state experts, the unruly subjects of their inquiry were not just the (by their lights) primitive mountain folk but also their “ignorant” physicians.⁶⁷

Local physicians took exception to the increasing interference of government-appointed health officials in their practices. But more than interests were involved. Mild type smallpox simply did not conform to physicians’ expectations. The disease differed in several respects from the classical smallpox described in their medical textbooks, which given the long quiescence of the disease in the South were for many physicians the only source of knowledge on smallpox available. Compared with text-book smallpox, the pocks of the new disease were few and superficial (and usually not confluent). Physicians examining patients for smallpox expected them to have a secondary fever, but mild type smallpox frequently brought none. And smallpox was supposed to be a winter disease. The mild type could prevail during an Alabama summer.⁶⁸

Wertenbaker had learned in Middlesboro how difficult it could be to pry smallpox funds from a parsimonious and skeptical county government. To get anything done, health officers needed the support of their local government institutions: vaccination orders (where state law did not give that authority to health boards), money for vaccine and vaccinators’ fees, cash to pay the pesthouse guards, and so on. In the larger towns, health officials had to win over the city council. In small towns and rural areas, health officials had to make their cases to county governments—boards of supervisors or, in some states (including Georgia and Kentucky), judicial bodies such as county courts and grand juries. The interests and medical understandings of those government bodies often clashed with those of health officers. For the lay officials, who, as Wertenbaker pointedly observed, were typically merchants, farmers, and other men “unfamiliar with matters pertaining to general sanitation and public health,” the smallpox question came down to taxpayer dollars and common sense. Unlike appointed health officials, most aldermen, county supervisors, and judges had to answer to the electorate. If they strayed too far from the common sense of the community, they risked losing their jobs.⁶⁹

Some of the most dramatic clashes between health authorities and lay officials took place in crowded courtrooms, the center stage of local political life at the turn of the century. When the modern expertise of medical science collided with the old-fashioned legal authority of judges and juries, the law won. Having given up on persuading local physicians that the “ketching disease” troubling Jackson County was really smallpox, Inspector Smock made his case to the county court. The state health official delivered a two-hour speech. As a reporter from Louisville described the scene, things seemed to be going well for Smock until a preacher stood up and addressed the assembly. “The Lord has sent this affliction upon us, and the Lord will take it away in His own good time,” he said. At that point the county attorney, an elected official in a room full of voters, declared that there was no proof that smallpox existed in the community and he was opposed to any measure that would cost the taxpayers their hard-earned dollars. In a remarkable gesture to rural democracy, the judge decided to take a vote of all those present, asking the courtroom crowd to decide whether the disease was smallpox. “[T]o a man they voted that small-pox did not exist,” the journalist reported, “notwithstanding the fact that two men with distinct pustules on their faces were in the crowd.”⁷⁰

Like Inspector Smock, C. P. Wertenbaker learned that to fight smallpox in a southern community he had to make his case in the court of public opinion. The politics of smallpox control was a politics of knowledge, as well as interests. Local government officials had many motives for requesting the aid of a Service surgeon. As in Middlesboro, some hoped to persuade “Uncle Sam” to pick up the tab for an epidemic they had allowed to spin out of control. After that debacle, though, Surgeon General Wyman had made clear that the Service would be supplying only expertise, not largesse. More opinions would seem the last thing needed in these local communities, where health officers had run into so much trouble trying to arouse public concern.

But to his surprise, Wertenbaker often found that by the time he arrived in a place, the people were ready to listen to a surgeon from the U.S. Marine-Hospital Service. Evidently, southern suspicion of federal authority had its limits. For Wertenbaker found that the quarreling parties in a community—the “kicking doctors,” the health officers, the county officials, and the public—seemed prepared to consider the diagnosis and recommendations of an agent of the U.S. government. Perhaps the Service’s years of yellow fever work had left a legacy of trust in the region. Maybe the Service’s reputation for medical expertise preceded it. Though local relationships generally mattered a great deal in these communities, it worked to Wertenbaker’s benefit that he had neither personal ties to these places nor private interests at stake. Sometimes he arrived to find that the quarreling parties had agreed in advance to accept the federal surgeon’s “diagnosis and advice.” In any case, he always came prepared to persuade.⁷¹

And to perform. There was a theatrical, even scripted, quality to Wertenbaker’s appearances in southern cities, county seats, and small towns. In an age of Chautauqua assemblies, traveling circus shows, and political debates in the open air, Wertenbaker’s impending arrival was heralded in advance in the local newspapers and by word of mouth. The public seemed hungry for information about smallpox and vaccination—or at least eager for a good show. The medical man gave it to them.⁷²

The show began the moment he stepped off a train, packet, or wagon. Greeted by the local health officers and officials, he asked them to take him directly to see the smallpox suspects. Before making his inspection, he put on his smallpox outfit—the overalls, head wrap, and respirator. Typically, the men, women, and children he examined had already been diagnosed with chicken pox or “elephant itch” or something else. It rarely took Wertenbaker long to make his own diagnosis, and it was usually smallpox.⁷³

Wertenbaker would then call a public meeting. At first he held his meetings in county courthouses, but the audiences soon grew too large and he moved with them into the public square or streets. The crowds sometimes numbered a thousand people or more. Entire communities turned out for the show: farmers and factory workers, businessmen and representatives of local women’s clubs, parents and schoolchildren, whites and blacks. Wertenbaker announced to the audience that smallpox existed in their midst and, be it ever so mild, it could kill. He instructed the people in the clinical features of smallpox, explaining how mild type smallpox differed from chicken pox, measles, and other common diseases.⁷⁴

Next he would explain the importance of vaccination, and how it worked. And that’s when folks got edgy. Wertenbaker’s audiences always included many people who were strongly opposed to vaccination. It was during these moments, as he stood in his Service blues preaching the virtues of vaccination to workingmen in overalls and women in homemade dresses, that Wertenbaker would listen to their complaints and their fears. He came to appreciate the extent to which antivaccination sentiment grew from reasonable fears of the procedure. Whether he was speaking in Charlotte or Columbia, Danville or Lumpkin, the surgeon heard the same objection from mill workers, farmers, and other manual laborers: vaccination caused “sore arms,” and that interfered with business.⁷⁵

This common fear of a vaccine-disabled arm was at least as old as the Civil War epidemics. “I have been in the habit of preaching vaccination for the last thirty or forty years,” one North Carolina physician said in 1898. “I never saw a fiddler vaccinated in my life.” The bad batches of “dry point” vaccine flooding the South in 1898 and 1899 turned a lot of people into fiddlers.⁷⁶

Even under the safest conditions—an aseptic procedure, using vaccine free of harmful bacteria—smallpox vaccination typically caused some constitutional disturbance, a fever, and a painful inflammation at the site of the vaccination. That’s how a physician knew the vaccine had taken: it “set up a fire.” But mass vaccinations during epidemics rarely afforded the safest conditions, and the results of the dry points caused physicians and health officers to voice concern.⁷⁷

In an era when almost everyone earned their living with their hands—farming the land, working wood, laying track, mining coal, tanning hides, rolling tobacco—the prospect of losing a few weeks’ wages to a “sore arm” brought on by tainted vaccine was reason enough to dodge the lancet. The belief that this new mild smallpox (if it actually was smallpox) was unlikely do serious harm only strengthened the perceived risk of vaccination. Secretary Lewis of the North Carolina Board of Health noted that opposition to vaccination seemed to be strongest among cotton mill workers. Although he favored compulsory vaccination, Lewis acknowledged the workers’ “natural reluctance” to lose the use of their hands. No system of social insurance existed in the 1890s (or for many years thereafter)—no policy of the state or the mill owners that would compensate men, women, and children who worked in the mills for their loss of wages due to bad vaccine. Lewis urged all large employers in the state to promise their workers half pay during any vaccination-induced disability.⁷⁸

In his public speeches and writings, Wertenbaker tried to dispel the worst rumors about vaccination: “Rumors of arms, legs, or life lost as the result of vaccination, have, as a rule, no foundation in fact,” he said. But, like Lewis, he developed a real empathy for the predicament of breadwinners. And as he realized how much harm vaccination as it was currently practiced could do, he became an advocate for reform.⁷⁹

He turned into a strong proponent of “glycerinized lymph,” a newer form of vaccine in which glycerin was used to kill the bacteria that proliferated in vaccine material (which was, after all, an animal virus harvested on the skin of cows). Glycerinized or “glycerinated” vaccine had been in use for several years, but the old, glycerin-free dry points were more widely distributed in the South during the first years of the epidemics. Wertenbaker was not the first public health officer to suggest that it was the dry points—not vaccination in general—that caused so many sore arms in the South. But the issue became a cause for him. He wrote letters to vaccine manufacturers, complaining about impure products. He sent samples of vaccine, including two dry points and two tubes of glycerinized lymph, to the Service’s National Hygienic Laboratory in Washington for testing. Passed Assistant Surgeon Milton J. Rosenau extracted the vaccine material from the samples and heated the material in his laboratory. The tests showed that both of the dry points crawled with bacteria, including virulent Staphylococcus pyogenes aureus, with which Rosenau inoculated a mouse. It died. The samples of glycerinized virus were hardly models of purity. They, too, yielded thousands of colonies of bacteria. But at least these proved nonvirulent.⁸⁰

Explaining the superiority of the new glycerinized lymph became a regular feature of Wertenbaker’s smallpox lectures. By speaking so candidly about the hazards of the dry point, he won a measure of trust from his audiences. As a regular feature of his performances, he offered to vaccinate volunteers with a tube of glycerinized lymph he carried with him. If all went well, leading citizens would step forward and roll up their sleeves to be scraped before the attentive crowd. On his best days, Wertenbaker told Wyman, “the persons who have been loudest in proclaiming that they will never, never be vaccinated, come up and ask that I vaccinate them at once.” Wertenbaker probably exaggerated when he claimed that, as a result of his talks, “the opposition to vaccination almost entirely disappears” and “the people usually readily acquiesce in any measure directed by the authorities.” But in their own reports local health officials praised his visits, one calling a Wertenbaker performance “of inestimable benefit.” And even when Wertenbaker failed to win over hearts and minds, his talks gave local health officials the leverage they needed to persuade mayors, county supervisors, and judges to appropriate money and take action.⁸¹

Wertenbaker always concluded his talks by presenting his plan for wiping out smallpox in the community. In the published version of “The Plan,” which Wertenbaker gave to his official hosts, he noted such details as the appropriate window shades for the smallpox hospital, pondered the relative merits of formaldehyde versus sulfur disinfectants, and specified the daily routines of numerous physicians, guards, and inspectors. (“By 8 a.m., the officer in charge is at his desk. . . .”) He advised (as if such advice were necessary) that in communities “where race feeling is strong,” separate smallpox hospitals be set up for whites and blacks. The Marine-Hospital Service surgeons forced local governments to take the health of African Americans seriously, which was in itself a real achievement. But the federal agents showed no interest in upsetting Jim Crow.

Wertenbaker’s plan was a model of “military authority”: house-to-house inspections by physicians and police, compulsory vaccination of everyone who could not show a recent vaccination scar, the relocation of all suspected disease carriers into detention camps, and treatment of all small-pox patients in an isolation hospital. Wertenbaker leavened this litany of logistics with aphorisms drawn from his experience in the field. “A policeman is of great assistance to an inspector.” “Measures, good or bad, half done are worse than useless, as they give a fancied security.” “Smallpox cannot be suppressed without the expenditure of money. The more promptly you act the less it will cost.” Middlesboro could not have been far from his mind as he wrote those last lines.⁸²

Like all measures of health policing since the invention of the quarantine in fourteenth-century Venice, Wertenbaker’s “Plan” had a draconian streak. But for all of Wertenbaker’s frustration with southern political institutions and officials—who, in his view, had let an eminently manageable pestilence run wild—his smallpox work instilled in him a certain optimism that those officials often lacked about the potential of the people. The people might be ignorant. They might spread false rumors. But in his travels through the southern states, Wertenbaker had learned from them. Above all, he had come to appreciate the ethical and political value of candor. Public health work required a big stick, to be sure, but it achieved little in the long run if the public remained unconvinced. Wertenbaker advised local health authorities to leaven force and discipline with education and persuasion. “If these facts are explained to the people by someone in whom they have confidence,” he promised in the “Plan,” “much of the opposition to vaccination will disappear.”⁸³

As Wertenbaker’s faith in the southern people grew, his opinion of their local institutions continued to diminish. In February 1900, after more than two years of smallpox work, Wertenbaker sent Surgeon General Wyman a memorandum. Not only did epidemic smallpox continue to plague many of the southern states, but now reports of new outbreaks of mild type smallpox (and, occasionally, its more terrifying ancestor) were reaching Washington from locales in the Middle West, the urban North, and the far West. The epidemics had become a national problem, making a coordinated federal response imperative.

“As matters now stand,” Wertenbaker wrote, “the suppression of the disease is left to individual communities, where action is but rarely taken until after smallpox has made its appearance.” Not only were the present methods expensive, but they allowed smallpox to spread endlessly from one community to another. “It is only by a general concerted action, embracing all the infected territory that we can hope to arrest the spread of the disease, and [guarantee] its ultimate suppression,” Wertenbaker told Wyman. “The Marine-Hospital Service, being the guardian of the Public Health, seems to be the proper source for the inauguration of such measures.” Wertenbaker had always believed that a successful smallpox eradication effort on any scale necessitated having a single “officer in charge.” And he let Wyman know that if his proposal for nationalizing smallpox control met with the surgeon general’s approval, he, C. P. Wertenbaker, would be willing to be that man.⁸⁴

Wertenbaker surely knew better than to expect any such sudden sweeping change in existing institutions. If the smallpox epidemics of the end of the century had shown anything, it was that democratic institutions and the political communities they governed often moved slowly, especially when official claims to expertise and visions of social control collided with the interests, beliefs, and values of the people. Walter Wyman did not put Wertenbaker’s plan in place on the national level, nor did he make Wertenbaker “officer in charge.” Seven months later, he transferred Wertenbaker to take command of the Service’s station in the huge southern port of New Orleans—a promotion, to be sure, but not the one Wertenbaker had once asked for.

In 1907, Wertenbaker happily returned with his family to his native Virginia to run the Service station at Norfolk. In the final years of his career, he would become well known to African American educators, ministers, physicians, and nurses for his efforts to organize rural black farmers and church groups into state and local “anti-tuberculosis societies.” In classic Wertenbaker fashion, he wrote up a detailed “Plan of Organization” for creating these societies. But the essence of the plan was to mobilize African Americans at the grassroots to fight a deadly infectious disease. By the time of Wertenbaker’s death, of kidney disease, in 1916, southern blacks had founded five state leagues and numerous local societies.⁸⁵

C. P. Wertenbaker’s grave lies in a well-shaded area of the University of Virginia cemetery, not far from the resting places of the eleven hundred Confederate soldiers buried there during the Civil War. The remains of C. C. Wertenbaker, who outlived Charlie by two years, lie nearby. The words on Charles Poindexter Wertenbaker’s tombstone remember a son of the Confederacy who, along with hundreds of other traveling medical men of the United States Marine-Hospital Service, carried the influence of the national government across the South. The inscription reads: “As Soldier, Doctor, and Officer for Twenty Eight Years of the National Health Service His Good Works are Imperishable.”⁸⁶

In the years after Wertenbaker left Wilmington, he saw many of the reforms he had advocated come to pass. Local, state, and federal health authorities placed a greater reliance on public education in their work. A new federal system, established in 1902 and run by the U.S. Public Health and Marine-Hospital Service’s National Hygienic Laboratory, regulated the manufacture of smallpox vaccine and the proliferating array of new vaccines, sera, and antitoxins on the market. And Congress gave the Service greater authority to standardize and coordinate the control of infectious disease at the local and state levels. No revolution had taken place. But reform surely had come.

At the turn of the century, there existed as yet only a few areas of the American domain where the authority of the nation reigned supreme in the field of public health. Foremost among them were the new colonial possessions acquired by the United States in the Spanish-American War of 1898. In those distant spaces, medical officers of the United States Army exercised powers of a scale and scope that C. P. Wertenbaker could scarcely have imagined.