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de Balmis, the Spanish court physician, its mission was to bring the new technology of Jennerian vaccination to the people of the vast Spanish empire in Latin America and the Pacific. On board were twenty-two foundlings, whose young bodies had never suffered the smallpox. Before setting sail, Balmis inoculated the first child with vaccine; as the expedition made its way across the seas, the doctor kept the “precious fluid” alive by vaccinating each child in succession, with pus from the vaccine sore of the previous child, in a continuous arm-to-arm relay. In this way, the Balmis expedition delivered “the beneficence of the King” to the Canary Islands, Puerto Rico, and Caracas, before breaking into two expeditions. One sailed to South America via Havana, the other to Vera Cruz and Mexico. Balmis picked up a fresh group of twenty-six children in Mexico before setting sail from Acapulco for the Philippines.59

In at least one respect, the official Spanish story cheated history. Balmis had arrived in Puerto Rico two months too late. With an epidemic of small-pox sweeping the island, a resourceful San Juan doctor named Francisco Oller (a military surgeon, no less) had procured some vaccine lymph from British St. Thomas. By the time of Balmis’s arrival, more than 1,500 residents of San Juan had already been vaccinated. The royal doctor promptly denounced Oller as a fraud and his vaccine as worthless.60

Under Spanish rule during the nineteenth century, Puerto Ricans grew accustomed to the occasional spectacle of public vaccinations. During smallpox epidemics, the public vaccinator would call the people of a barrio or village to assemble. Using virus secured from the Central Institute of Vaccination at San Juan, the vaccinator would inoculate a calf or two, drive them to the center of each village or barrio at an appointed date, and set about vaccinating the people with fluid taken directly from the animal. In the final years of Spanish rule there still existed much popular opposition to the medical practice, not least because the vaccine orders seemed so arbitrary and the operation itself so often proved ineffective. In the 1890s the Spanish compulsory vaccination measures, according to Colonel Hoff, had been “honored in the breach more than in the observance,” especially in the rural areas. The greatest number of vaccinations performed in a single year was fewer than 25,000 (in a population exceeding 900,000 people). American officials may have exaggerated the defects of Spanish “misrule,” but Puerto Rico did suffer a high incidence of smallpox during its final decade under Spain. In 1890, smallpox killed 2,362 people—accounting for 9 percent of the island’s deaths that year. For the decade, deaths from smallpox averaged 620 per year. A far greater number were left scarred or blinded by the disease. Lacking an effective measure against the disease, many Puerto Ricans regarded smallpox with a fatalism that Army medical officials too readily interpreted as indifference.61

The incidence of smallpox on Puerto Rico at the start of 1899 was not dramatically out of proportion with that of the last years of Spanish rule. Smallpox killed an estimated 522 islanders in 1898, somewhat below average for recent years. What was new was the presence of a regime determined to bring its full might to bear in fighting the disease.62

On January 27, 1899, the American governor general Guy Henry issued General Order No. 7. “The inhabitants of this island must be protected from smallpox,” it proclaimed. “Every resident who has not had this disease will be vaccinated, and hereafter all infants must be vaccinated before reaching the age of six months.” Hoff took charge. The order parceled the island into five geographical areas of roughly 200,000 inhabitants, each presided over by an Army medical officer designated as a director of vaccination. Each director, including Major Ames and Major Groff, would command a staff of surgeons, inspectors, and Hospital Corpsmen. The directors would report any neglect by Puerto Rican authorities to carry out the