The Armed Forces Institute of Pathology The Armed Forces Institute of Pathology The Armed Forces Institute of Pathology Its First Century 1862-1962 by Robert S. Henry, A.B., LL.B., Litt.D. OFFICE OF THE SURGEON GENERAL DEPARTMENT OF THE ARMY WASHINGTON, D.C., 1964 THE ARMED FORCES INSTITUTE OF PATHOLOGY Advisory Editorial Board Colonel John Boyd Coates, Jr., MC, USA, Chairman Colonel James E. Ash, MC, USA (Ret.) Brigadier General George R. Callender, USA (Ret.) Brigadier General Raymond O. Dart, USA (Ret.) Major General Elbert DeCoursey, USA (Ret.) Howard T. Karsner, M.D. Rear Admiral William M. Silliphant, USN (Ret.) Library of Congress Catalog Card Number: 63-60060 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price $4.25 (Buckram) Foreword As the Armed Forces Institute of Pathology approached its centennial year in nineteen hundred and sixty-two, it seemed appropriate to pause for a brief recapitulation of its accomplishments during its first one hundred years. To this end, a fitting ceremony was held in November 1962 to mark this event. The program was further enhanced by a 2-day scientific program that not only summed up what had been accomplished in the past but attempted to glimpse the future of the study of disease. In addition to holding these programs, it was considered that the completion of the first century of the Institute would also be an appropriate time to compile a more detailed study of the people and events that had made the Institute one of the Nation's leading scientific institutions from its very inception. With the approval of the Board of Governors, the Surgeons General of the Army, Navy, and Air Force, and with the assistance of the staff of the Institute, its Scientific Advisory Board, and the Institute's many devoted consultants, a project to compile a history was initiated. The assistance and support of The Historical Unit, U.S. Army Medical Service, and of The Surgeon General of the Army were requested, and they enthusiastically joined in the effort to assem- ble this record. The role of The Historical Unit in the compilation of this volume is but a continuation of the long and intimate association of this Unit and the Institute. One of the two original missions of the Army Medical Museum, the forerunner of this Institute, was to prepare the great "Medical and Surgical History of the War of the Rebellion," the other being "to collect and to forward to the Office of the Surgeon General, all specimens of morbid anatomy, surgical or medical, which may be regarded as valuable; together with projectile and foreign bodies removed, and such other matters as may prove of interest in the study of military medicine or surgery." This first effort of The Historical Unit, while it was still an integral part of the Army Medical Museum, moved Rudolf Virchow, the great German pathologist and the father of modern pathology, to comment, "From this time dates a new era in military science. Whoever reads these publications will be constantly astonished at the wealth of experience, the exactness of detail, the careful statistics and scholarly Vi FOREWORD statements embracing all sides of medical experience which preserve to pos- terity the knowledge bought at so vast an expense." With the passage of time, The Historical Unit became a separate organiza- tion. The Army Medical Museum kept its original name until after World War II when, in 1946, it was deemed appropriate to rename it the Army Insti- tute of Pathology. At this time, the Scientific Advisory Board was organized. Through the years since then, the dedication of the outstanding scientists who have served on the Board has been a landmark of strength to the Institute in the guidance of its professional developments. In 1949, the U.S. Navy and Air Force joined forces with the Army, so that the Institute became a total effort of the armed services under the executive management of The Surgeon General of the Army and the Secretary of the Army. It was redesignated the Armed Forces Institute of Pathology. Through the years, many curators and directors and the staff of the Museum-Institute had a continued interest in, and intuition of, the history that they were making. Documents and records were carefully prepared and pre- served. From the outset, the Institute played a leading role in national medical developments as well as being an integral part of the Washington medical scene. Its close association, throughout its history, with the medical schools of George Washington University, Howard University, and Georgetown Uni- versity attest to its leadership in medical affairs of the area. From its beginning, the value of the Institute as a means of instruction of young military physicians was apparent. A photographic department was added to the Museum in 1863, and the pioneer work in America in medical photography and photomicrogra- phy was accomplished by the Museum staff. From its early days, the Museum-Institute had been housed with the Army Surgeon General's Library, and the two remained under the same roof until 1955, when the latter, after a brief period as the Armed Forces Medical Library, became the National Library of Medicine. At the same time, the Institute acquired new quarters at the Walter Reed Army Medical Center. The location of the Institute at this great medical facility seemed appropriate, since Walter Reed had been for almost a decade, until his death in 1902, Curator of the Medical Museum. It was during his tenure that the Army Medical School was formed in the Museum building. In 1910, the School secured quarters of its own and eventually grew to become the great institution known today as the Walter Reed Army Institute of Research. Out of World War I came the impetus for the training of pathologists and the growth of pathology in the United States to the status of world emi- FOREWORD VII nence this country has in this field in the present day. World War II saw the Museum as the leader in bringing about the standardization of diagnoses and teaching methods in pathology that has enhanced the science of the study of disease in the past two decades. The Institute's close relationship with civilian medicine also has origins in the very beginning of the Museum. The first formal arrangement between the Museum and civilian medicine took place in 1895, when the American Dental Association adopted the Museum as a repository for study materials in the field of dentistry. The next great step was the founding of the American Registry of Ophthalmology in 1921. The establishment of the American Reg- istry of Pathology under the auspices of the National Academy of Sciences- National Research Council and the Museum in 1933 gave signal impetus to the registry movement, and by the end of the centennial year in 1962 the number of Registries had grown to 27. Following World War I, the Museum also became the repository for the material from the Veterans' Administration hospitals. This was discontinued in 1929, but after World War II the Veterans' Administration designated the Armed Forces Institute of Pathology as its "Central Laboratory for Anatomic Pathology and Research." Since that time, the Veterans' Administration has played a key role in the affairs of the Institute. Its employees make up a portion of the professional, technical, and clerical staff. This liaison between the Armed Forces and the Veterans' Administration permits former patients to be fol- lowed after they leave the service and greatly enhances the repository of case material available to the Institute. Through the aegis of the American Registry of Pathology, civilian pathologists also contribute cases to the Institute files that are valuable in filling gaps in the overall knowledge of disease; this infor- mation cannot be acquired from the military population alone. Beginning with the work of Walter Reed and the Museum staff in the 1890's on yellow fever, the Institute has had a continued interest in tropical diseases and other disease entities that occur throughout the world. This collection of material was invaluable in the beginning of World War II in the preparation of manuals and textbooks used in the training of physicians who were to accompany our troops to the remote corners of the earth during that conflict. The Institute has continued this interest in global medicine, with members of its staff collect- ing material from all corners of the world. Contributions of cases by patholo- gists of other countries have added significantly to the collection of disease entities, which now exceeds one million cases. From this vast storehouse of Viii FOREWORD cases, much teaching material is prepared and made available for loan to gov- ernmental and nongovernmental pathologists. Starting soon after World War II, the Institute embarked on the publication of the fascicles of the "Atlas of Tumor Pathology," in conjunction with the Division of Medical Sciences of the National Research Council and, specifically, the Committee on Pathology and its Subcommittee on Oncology. To date, some 33 of the 39 fascicles of the Atlas have been completed and are available at nominal cost through the American Registry of Pathology. These fascicles have been enthusiastically received by pathologists throughout the world. It is through the fascicles that the Armed Forces Institute of Pathology is known by practically every pathologist and other medical workers in all countries. While the authors of these fascicles are outstanding authorities throughout the United States and the United Kingdom, it has only been through the efforts of the staff of the Institute, the American Registry of Pathology, the Institute's Medical Illustration Service, and the National Research Council that the publication and dissemination of the fascicles has been made possible. With the designation of the Institute as an Armed Forces activity, the U.S. Public Health Service also began to play an active role in the Institute and has had pathologists assigned to the staff since that time. This Public Health Service participation was endorsed during the centennial year with the estab- lishment of the Radiation Pathology Registry ; additional financial and personnel support was given to this important endeavor so vital within the framework of the Institute's organization. The greatest problem that confronted the Institute and The Historical Unit in beginning the compilation of this history of the Museum-Institute was securing an author who could sift through the mountain of records and other historical material that would tell the story of the organization. It was desired that the story be told in such a manner that it would have appeal to the lay reader but still preserve the scientific content. In Robert Selph Henry, Litt.D., of Alexandria, Virginia, such a man was found. Dr. Henry is one of the leading American historians and famed for his writings of the Mexican War and the American Civil War. He is a man of varied interests who has served many years as Vice President of the Association of American Railroads and has prepared numerous treatises on railroading. In addition to being a member of the Board of Regents of Vanderbilt University, his alma mater, Dr. Henry was also one of the consultants in the preparation of the third edition of "Webster's New International Dictionary." Within a brief period of 2 years, Dr. Henry sorted through the voluminous document file of the Institute and FOREWORD IX many other varied sources, and this book is a testimony to his ability to recognize the high points of the story of the Institute during its one hundred years of existence. Of necessity, attention had to be given to routine coming and going of personnel and other administrative changes that are a part of the story of any organization. He has maintained reader interest with accounts of in- dividual accomplishment, and with many vignettes that lend fascination to the narration and make events of the past come alive. This brief look back over the century seems a fitting milepost and spring- board for this unique organization as it enters its second hundred years. With its ever-expanding program of research, education, and consultation, the Institute gives promise of being of even greater service to the Armed Forces and to the Nation in the years to come. As the century from the 1860's to the 1960's can be classified as the era of cellular pathology, so can the next few decades be expected to see the development of studies within the cell, or so-called molecular pathology. With its rich heritage from the past, the Institute today finds itself in the forefront of these newer developments. A glimpse into the future is revealed in the last chapter of Dr. Henry's history. One can be sure that the record of the past will serve as an inspiration to those individuals responsible in the future for the destiny of the Armed Forces Institute of Pathology and its important role in advancing military medicine. Leonard D. Heaton, Lieutenant General, The Surgeon General. 713-028'— 64- Preface In the preparation of this book, I have had so much assistance and so many kindnesses from so many persons that I despair of making suitable acknowledg- ment to all to whom it is due. First and foremost, I am deeply obliged to the Director of the Armed Forces Institute of Pathology, Col. Frank M. Townsend, U.S. Air Force, MC; to the Deputy Directors, Col. Joe M. Blumberg, MC, U.S. Army, and Capt. Roger H. Fuller, MC, U.S. Navy; and to the Scientific Director of the Institute, Dr. Robert E. Stowell. They have provided every facility and all possible assistance for the work. Especially appreciated was the establishment of an Advisory Editorial Board, with Col. John Boyd Coates, Jr., MC, USA, Director of The Historical Unit, U.S. Army Medical Service, as chairman, and the following membership : Col. James E. Ash, MC, USA (Ret.) Brig. Gen. George R. Callender, USA (Ret.) Brig. Gen. Raymond O. Dart, USA (Ret.) Maj. Gen. Elbert DeCoursey, USA (Ret.) Howard T. Karsner, M.D. Rear Adm. William M. Silliphant, USN (Ret.) Whatever merit this book has is due in no small degree to the counsel and guidance received from the members of this Board. All departments, divisions, and branches of the Institute have helped in the preparation of the book, but special thanks are due Mr. Herman Van Cott, Chief of the Medical Illustration Service, and his staff, including Mr. Herbert C. Kluge, who rendered special service in going through the voluminous pic- torial records of the Illustration Service and finding many of the photographs which are used. Special thanks are due, also, to the staff of the Medical Museum, where most of the material for the volume was located and where most of the writing was done. Col. Albert E. Minns, Jr., MSC, USA (Ret.), Curator of the Museum when work on the book was started, and his successor, Col. John W. Sheridan, MSC, USA, have done all in their power to facilitate the work. X1I PREFACE In the processing of the manuscript, the Executive Officer of the Institute, Lt. Col. Vernon S. Oettinger, MSC, USA, and the Adjutant, Lt. Col. Russell Z. Seidel, MSC, USA, and their staff have been most helpful, for which I am grateful. The services of the Institutes' Ash Library and its Librarian, Mrs. Ruth Haggerty, have been numerous and varied, and are gratefully acknowledged, as are the services of the secretarial pool and the Reproduction Division of the Institute. The Library of Congress, the National Archives of the United States, the National Library of Medicine, and The Historical Unit of the U.S. Army Medical Service have obligingly responded to every call for information and assistance. I am particularly grateful to Dr. Esmond R. Long, author of "A History of Pathology," published in 1928, and "A History of American Pathology," pub- lished in 1962, for permission to quote from his books, and for his interest in the development of this book. Thanks are also due to Dr. W. Montague Cobb, professor and head of the Department of Anatomy of the College of Medicine of Howard University, for information concerning Dr. Daniel Smith Lamb's connection with that institution. Among the many individuals who have been helpful in the writing of this book, to all of whom I am grateful, there are a few whom I must mention with special appreciation: Mrs. Gwendolyn M. Evans, Mrs. Ida P. Gaylin, Miss Betty Krulack, Mrs. Genevieve Overmyer, Miss Helen R. Purtle, Mrs. Esther M. Stone, Miss Cleo A. Warren, M. Sgt. Julia S. Williams, Mr. H. E. Demick, Mr. Gordon T. Harrell, Mr. Myron Miller, Mr. James B. Smith, and Sgt. Bennett W. Thompson. Finally, I am deeply indebted to my associate in this work, Mr. Samuel Kier, Research Historian of the Institute, who has been most helpful in the or- ganization and writing of this book, and to Mrs. Cyrilla E. Hickey, Editor, of the Editorial Branch, The Historical Unit, U.S. Army Medical Service, who has shepherded the manuscript through the press. Robert S. Henry Contents Pag, FOREWORD V PREFACE XI Chapter I. The Institute and Its Ancestry 1 The Threefold Mission 1 The American Registry of Pathology 2 "Unique in the World" 5 II. Background and Beginnings Some Medical Problems of the 1860's 8 A New Surgeon General 9 The Scientific Approach 11 The First Curator 13 Collecting Specimens 17 New Quarters for the Museum 23 Grounds for Anxiety 26 Plans for an Army Medical School 28 The Museum's Collections Grow 29 Hammond in Exile 30 The Second Curator 32 Reorganization of the Museum 32 Pioneering in Microscopy 34 Woodward, Curtis, and the Camera 36 The Museum and the Lincoln Tragedy 41 III. Second Wind 51 Supply and Funding for the Museum 51 Increasing Activities of the Museum 53 The Museum's Fourth Home 54 Praise from Foreign Visitors 60 The Museum and the Medical Profession 63 The Museum and the Congress in the 1870's 63 Enlarging the Aims of the Museum 65 Varied Uses of the Museum 66 Scientific Skepticism as to Bacteria 66 The Third Curator 68 The Museum and the Garfield Tragedy 68 xnt Xiv CONTENTS Chapter Pagt IV. Broadening the Base 73 Inadequate Quarters 73 Support From the Medical Profession 76 A New Surgeon General Presses for a New Building 77 Objections to Proposed New Building 78 John Shaw Billings Becomes Curator 79 The Museum Moves 82 A Shift in Emphasis 84 The "Old" and the "New" Museums 84 Dr. Billings' Appraisal 85 V. An Ending and A Beginning 89 The Museum and the Army Medical School 90 Walter Reed, Curator 93 Problems With Space 95 The Prime Source of Specimens 98 Bacteriology and Roentgen Rays at the Museum 100 Services of Dr. Billings 101 Animal Experimentation at the Museum 103 The Spanish-American War 105 VI. The Walter Reed Chapter 107 Yellow Fever Epidemics 107 Studies on Transmission 109 The Yellow Fever Board at Work 112 Dr. Finlay's Mosquito Theory 118 Human "Guinea Pigs" 119 The Death of Dr. Lazear 1 20 Studies at Camp Lazear 122 Soldier Volunteers 124 Testing the " Fomites" Theory 125 Transmission by Mosquitoes Established 127 Search for a Cause 130 Nil. Triumph Over Typhoid 133 Typhoid and the Medical Museum 134 The Typhoid Board's Report 135 A New " Villain"— The Fly 137 Changes in the Museum Command 139 Volunteers for Vaccination Against Typhoid 139 European Experience 142 Compulsory Vaccination Introduced 143 CONTENTS XV Chapter P"gi VIII. The "Pickle Factory" Period 147 The Army Medical School Moves Out 148 Changes at the Museum 150 Changes in Classification 153 The Devotion of Dr. Lamb 156 IX. The Museum in a World at War 159 Making Pathologists in a Hurry 160 Dr. James Ewing's Mission 161 The Autopsy Question 162 Procurement of Specimens 163 Two Museums in One 165 Launching the Movement for a New Building 167 Applying the Graphic Arts to Medicine 170 Motion Pictures 171 Pictures as Training Methods 174 Use of Animated Drawings 176 The Museum Goes Abroad 179 Necropsy Service in the AEF 180 Medical Photography in the AEF 183 The Museum's Major Aim 186 X. The Institute Idea 189 The First Practicing Pathologist to Become Curator 191 Space Problem Intensified 191 Plans for a Great Medical Center 194 American Registry of Pathology 197 Working in a New Direction 198 Varied New Activities of the Museum 201 Possible Courses of Action 203 XL The Registry Movement 207 Objective of the Registry 209 Organized Civilian Cooperation 212 Histopathology and the Museum 214 Inescapable Housekeeping 216 The Museum at Threescore Years and Ten 218 The Dental and Oral Registry 220 More Registries Formed 221 Publications of the Registries 222 Advantages of the Registry System 224 XVI CONTENTS Chapter XII. Between the Wars 227 Deterioration at the Museum 228 Inadequate Space, Insufficient Personnel 230 Working Under Handicaps 231 The Edgar Bequest 234 Gaining Ground 235 Prospects for a New Home 236 A New Building— Where and When? 239 Action Delayed 241 XIII. Pathology Worldwide 245 Regional Centers for Histopathology . 246 Increase in Personnel 249 A New Name for a New Organization 250 Scientific Investigations 251 The Attack on Tropical Diseases 254 Use of Materials for the Study of Pathology 256 Study Sets 257 The Army Medical Illustration Service 259 Storage of Museum Collections 264 Veterans' Administration and the Museum 265 Words of Appreciation 267 XIV. The Immediate, Imperative Objective 269 Continued Efforts To Get a New Building 270 Changes in Role of the Museum 271 Problems of Location 272 Building Plans Reviewed 277 Scientific Advisory Board of the AFIP 280 The Hawley Board 283 XV. New Name, New Home, New Responsibilities 287 Legislative Tangles 289 Congressional Hearings 289 A Bomb-Resistant Structure 292 Going Ahead on the New Building 293 Breaking Ground 295 Laying the Cornerstone 302 Dedication 307 XVI. Carrying On in the "Old Red Brick" 3J1 The Cooney Committee 315 Atomic Bomb Research Unit 318 Atlas of Tumor Pathology 320 CONTENTS XVII Chapter Page XVI. Carrying On in the "Old Red Brick" — Continued The American Registry 324 The Medical Illustration Service 326 Rebirth of the Medical Museum 330 Research Programs 332 TriService Administration 334 XVII. Life in the New Building 337 Shortage of Space 344 Expanded Facilities and Services 346 Program of Education 351 The American Registry of Pathology 356 The Medical Illustration Service 357 Television 361 The Museum's Movements 366 International Efforts 369 Aerospace Pathology 371 XVIII. Into the Second Century 373 Organization 373 The Four Departments 377 Extramural Monetary Support 386 Scope of the Institute's Activities 390 Emphasis on Research 391 APPENDIXES A. A Chronologic Synopsis of Events 395 B. Board of Governors, Armed Forces Institute of Pathology 403 C. Scientific Advisory Board Members, Armed Forces Institute of Path- ology 405 index 407 Illustrations "Figure 1. Brig. Gen. William Alexander Hammond, The Surgeon General, U.S. Army, 1862-1864 10 2. Circular No. 2, Surgeon General's Office, 21 May 1862 12 3. Circular No. 5, Surgeon General's Office, 9 June 1862 14 4. Group of U.S. Army medical officers prominent in the history of the Army Medical Museum and the Library of The Surgeon General . . . 15 5. Maj. John Hill Brinton, U.S. Volunteers, first Curator of the Army Medical Museum, 1862-1864 16 xvm CONTENTS 6. Surgeon John H. Brinton, with a group of Union Army officers in the field 18 7. A page from the first Catalogue of the Army Medical Museum. ... 21 8. The first home of the Museum 9. The second home of the Museum 10. The third home of the Museum 11. The "Incredible" General Sickles and his leg bones 31 12. Lt. Col. George A. Otis, the second Curator of the Army Medical Museum, 1864-1881 33 13. Lt. Col. Joseph J. Woodward, MC 35 14. Maj. Edward Curtis, U.S. Volunteers 37 15- Photomicrography spreads 16. Pioneer photomicrography 17- Photomicrography by artificial light 42 18. Diatom, a form of unicellular life of microscopic size, magnified by 2,540 diameters 43 19. Bullet that ended President Lincoln's life, instrument used to locate i t, and bone fragments which adhered to it 45 20. Hermann Faber 46 21. Sketch made by Hermann Faber 47 22. Reward poster, revised 48 23. Maj. Gen. Joseph K. Barnes, The Surgeon General of the Army, 1864- 1882 52 24. The fourth home of the Museum 55 25. Museum visiting rules 57 26. Main exhibit hall of the Museum, Ford's Theater building, 1866-1887 58 27. Early "dry" exhibits in comparative anatomy 61 28. Wet specimens on display enclosed in glass 64 29. Surgeon David Low Huntington, U.S. Army, third Curator of the Museum, 1881-1883 69 30. Bullet from the body of President Garfield 70 31- Maj. Charles Smart, Surgeon, U.S. Army 74 32. Dr. John Shaw Billings, famed Librarian, fourth Curator of the Museum, 1883-1893 80 33. Fifth home of the Museum 82 34. Foundation and evolution of the microscope collection 86 35- Medical and Surgical History of the War of the Rebellion 91 36. Brig. Gen. George M. Sternberg, The Surgeon General of the Army, 1893-1902 92 37. Maj. Walter Reed, fifth Curator of the Museum, 1893-1902 94 38. Army Medical School laboratories, located in the Museum-Library building in the first decade of the 20th century 96 39. Early X-ray apparatus at the Medical Museum 102 40. Early dental equipment 104 CONTENTS XIX F'g"" Pag, 41. Dr. Carlos Juan Finlay Ill 42. Lt. James Carroll, a member of the Yellow Fever Board, became sixth Curator of the Army Medical Museum, 1902-1907 114 43- Dr. Jesse W. Lazear, a member of the Yellow Fever Board 115 44. Dr. Aristides Agramonte, Cuban member of the Yellow Fever Board . . 116 45- Camp Lazear 123 46. Maj. Frederick F. Russell, seventh Curator of the Museum, 1907-1913 . 140 47- Maj. Frederick F. Russell vaccinating volunteers against typhoid . . . 144 48. World War I typhoid vaccination 145 49. Rented quarters of the Army Medical School in 1910 149 50. Maj. Eugene R. Whitmore, eighth Curator of the Museum, 1913-1915 . 151 51. Dr. Daniel Smith Lamb I55 52. Col. Champe C. McCulloch, Jr., ninth Curator of the Museum, 1915- 1916 158 53. Col. William O. Owen, tenth curator of the Museum, 1916-1919 . . . 168 54. Colonel Owen's "dream" of a new Museum and Library building, as pictured by Lt. Morris L. Bower, October 1918 169 55. Laboratory of Dr. William M. Gray 170 56. Instruction Laboratory, World War I 172 57- Film dealing with venereal disease, produced by the Instruction Labora- tory 173 58. Establishment of Anatomical Art Department is announced 177 59- Headquarters for medical art in the Army Medical Museum, World War I 178 60. Samples of scenes and messages from lantern slide sets developed for instructional use by the Army Medical Museum 181 61. Col. Charles F. Craig, eleventh Curator of the Museum, January- September 1919 190 62. Maj. George R. Callender, twelfth Curator, 1919-1922, and fourteenth Curator, 1924-1929, of the Museum 192 63- The "Great Hall" of the Museum in the 1890's 195 64. Gross pathological laboratory, Army Medical Museum 196 65- President and Mrs. Eisenhower congratulate Mrs. Helenor Campbell Wilder 200 66. Maj. James F. Coupal, thirteenth Curator of the Museum, 1922-1 924 . . 208 67- Dr. Howard T. Karsner 210 68. Title page and an illustration from volume XII of "The Medical Depart- ment of the United States Army in the World War" 213 69. Col. James E. Ash, fifteenth Curator, 1929-1931; twentieth Curator, 1937-1946; and first Director, Army Institute of Pathology, 1946-1947 . 215 70. Maj. Paul E. McNabb, sixteenth Curator of the Museum, 1931-1933 . . 217 71. Maj. Virgil H. Cornell, seventeenth Curator of the Museum, 1933-1935 • 219 72. Maj. T. C.Jones, VC, Registrar, Registry of Veterinary Pathology, Army Institute of Pathology 223 xx CONTENTS Figure Pa i' 73- Brig. Gen. Raymond O. Dart, eighteenth Curator of the Museum, 1935- 1936; second Director, Army Institute of Pathology, 1946-1949; and first Director, Armed Forces Institute of Pathology, 1949-1950 ... 229 74. Capt. Hugh R. Gilmore, Jr., nineteenth Curator of the Museum, 1935- 1937 232 75- Maj. Harry A. Davis 2 37 76. Architects' drawing of a new home for the Library and Museum, author- ized by Congress in September 1941 2 43 77. Schematic representation of the flow of pathological materials during World War II 248 78. A unit of the Museum and Medical Arts Department of the Museum photographing a diseased native of a tropical isle 251 79. Maj. Gen. Norman T. Kirk, The Surgeon General of the Army, presents to Col. Balduin Lucke the Legion of Merit 253 80. Various methods used by the medical illustrator to present the picture of trauma and disease 260 81. " Wounds" for training purposes 263 82. Main exhibit hall of the Medical Museum in the 1930's 272 83. Maj. Gen. Norman T. Kirk outlining, to a press conference, plans for a new medical center 277 84. Colonels James E. Ash and Raymond O. Dart look over an exhibit pre- pared for the American Medical Association Meeting in 1946 . . . . 278 85- Sixth home of the Museum, Chase Hall, 1947-1960 281 86. Materials awaiting inventory as the Medical Museum moved from warehouse storage to Chase Hall 281 87. A corner of the exhibits of the Museum as shown in Chase Hall .... 282 88. Scale model of the new building as planned before the requirement that the structure be blast-resistant 291 89. Brig. Gen. Elbert DeCoursey, second Director, Armed Forces Institute of Pathology, 1950-1955 294 90. Lt. Col. Colin F. Vorder Bruegge 296 91. Programs for the three ceremonial steps in the erection of the AFIP building 298 92. Turning of the sod 301 93. Clearing the site of the new building 303 94. Excavation troubles 304 95- Cornerstone laying ceremony 305 96. Typical floor plan of new Armed Forces Institute of Pathology building . 307 97. Coverage of the dedication ceremonies in the Service Stripe 308 98. President Dwight D. Eisenhower dedicates the new building 309 99. Quarters in the old red brick building in the 1940's 312 100. Mary Frances Gridley 314 101. Samples of the fascicles 321 CONTENTS XXI Figure Page 102. Diagnostic consultation, under the direction of Dr. Hugh G. Grady, Scientific Director, American Registry of Pathology, 1949-1957 . • • • 323 103- A sample study kit 325 104. President Harry S. Truman inspects an Institute exhibit on U.S. Govern- ment hospital services, shown at an American Hospital Association meeting 327 105. Antonio Cortizas 328 106. Roy M. Reeve 329 107. Aerial view showing the location of the Institute building in relation to the Walter Reed Army Medical Center 335 108. Dr. Ernest W. Goodpasture, first Scientific Director, Armed Forces Insti- tute of Pathology, 1955-1959 338 109. Capt. William M. Silliphant, MC, USN, third Director, Armed Forces Institute of Pathology, 1955-1959 340 110. Col. Joe M. Blumberg, MC, USA, Deputy Director, 1957-1963, and Director, Armed Forces Institute of Pathology, 1963- ; Scientific Director, American Registry of Pathology, 1960- 341 111. Capt. Roger H. Fuller, MC, USN, Deputy Director, Armed Forces Insti- tute of Pathology, 1959-1963 342 112. Col. Frank M. Townsend, USAF, MC, fourth Director, Armed Forces Institute of Pathology, 1959-1963 343 113. Dr. Robert E. Stowell, second Scientific Director, Armed Forces Institute of Pathology, 1959- 345 114. Specimens in storage and on display 346 115. Dr. Elson B. Helwig, Chief, Department of Pathology, Armed Forces Institute of Pathology 349 116. Optical and electron microscopes 351 117. Educational sessions 353 118. Handling radioactive materials 356 119. The evolution of an emblem, for the Institute 359 120. Award-winning exhibits of the Medical Illustration Service 361 121. War surgery told largely in pictures 363 122. Printing the fascicles of the Atlas of Tumor Pathology 364 123. Modern photomicrography apparatus 365 124. Television camera mounted in ceiling of Armed Forces Institute of Pa- thology autopsy room 366 125. Col. Joseph L. Bernier lectures with the use of visual aids 367 126. Threefold mission of the Institute 374 127. The Institute Organization, 1962 375 128. The three Surgeons General and The Director, AFIP, participate in the unveiling of a plaque on 19 July 1962 376 129. Executive officer and administrative staff 377 130. Organizational chart, Department of Pathology, 1 February 1962 ... 378 131. Department of Pathology staff, Professional Divisions 379 XXII CONTENTS F>i-rc Page 132. Administrative staff, Department of Pathology 380 133- Lawrence W. Ambrogi, Chief, Histopathology Laboratories 381 134. American Registry of Pathology staff 388 135- Medical Illustration Service staff 389 136. Curator and staff of Medical Museum, 1962 390 137. Building erected for the Army Medical Museum and the Army Medical Library in 1887 391 138. The Institute's expanding research program 392 CHAPTER I The Institute and Its Ancestry On 21 May 1962, the Armed Forces Institute of Pathology entered upon the second century of its life. It had started one hundred years before as an item in Circular No. 2, of the Surgeon General's Office, in which Brig. Gen. William Alexander Hammond, The Surgeon General, announced his intention to estab- lish an Army Medical Museum, for which medical officers were directed to collect specimens of morbid anatomy. The collections with which the Museum started consisted of three dried and varnished bones resting on a little shelf above the inkstand on the desk of Brigade Surgeon John Hill Brinton, the young medical officer who was to be- come the first curator of the Museum which was to be established. The Museum thus launched evolved into the Army Institute of Pathology which became the Armed Forces Institute of Pathology— a veritable treasure house of medical knowledge and an active center for consultation, research, and education in the effects of disease and injury upon the form and function of living cells and tissue. For back of the announcement in Circular No. 2 was an idea— the idea that by careful collection, comparison, and study of the anatomical wreckage of the great war in which the United States and the Confederate States were then engaged, there might emerge a body of knowledge and understanding which would, in time, lead to the lessening of human suffering and the saving of human life. To that end, the Museum and its successor Institutes have followed General Hammond's admonition, "diligently to collect" specimens of morbid anatomy and other materials of value and interest to the study of military medicine or surgery until, at the opening of the second century of its life, the Institute had in its collections more than 1,000,000 specimens— and is continuing to re- ceive such specimens at the rate of 200 per day. The Threefold Mission The institution which has grown to such proportions in its first century is unique in its organization and mission. It was founded and for 87 years 2 ARMED FORCES INSTITUTE OF PATHOLOGY existed as an Army installation, and still is administered under the authority of the Secretary of the Department of the Army, acting through The Surgeon General of that Department, but it is not now an organization of and for the Army alone. It is truly a triservice organization, established as such by the joint action of the Department of Defense and the Departments of the Army, the Navy, and the Air Force, with its broad policies determined by a Board of Governors, the members of which are the Surgeons General of the three Armed Forces. It is thus a military organization, but one with so strong an infusion of the civilian in its makeup and mission that the medical profession — the term "medical" as here used being broad enough to include the dental and veterinary professions as well — has come to accept and rely upon the Institute's work and findings as a distinct, indeed a unique, contribution to the advancement of medical science and practice, civilian as well as military, throughout the Nation. Nor are the services of the Museum-Institute limited to the boundaries of the United States, for they have followed wherever the American soldier, sailor, and airman have gone — to the western plains in the 19th century Indian cam- paigns; to Cuba, Puerto Rico, the Philippines, and the Canal Zone at the turn of the century; to Europe in the first war, known simply as the World War until a second world war of even greater dimensions took the American forces back to Europe, and to the continents of Africa, Australia, and Asia, to Japan, and the islands of the Pacific; and, at the halfway mark of the 20th century, to Korea. From all these campaigns, as well as from the American Civil War during which the Museum was founded, lessons learned in the diagnosis and treatment of disease and trauma have been reported to the Museum-Institute in the form, principally, of specimens taken from surgical operations and from autopsies, together with the relevant medical history and records of each case. The American Registry of Pathology In addition to this flow of materials from military installations in all parts of the world, the Institute receives the organized cooperation of civilian medicine, acting through the American Registry of Pathology, an arm of the National Research Council of the National Academy of Sciences. The American Registry of Pathology, which now includes 27 constituent registries sponsored by the appropriate national societies of the various medical specialties, is both an arm of the National Research Council and also one of the four main operating departments of the Armed Forces Institute of Pathology. Thus, the Registry THE INSTITUTE AND ITS ANCESTRY 3 constitutes a living link between the operations of the Institute and civilian practitioners in regard to matters of pathology. Pathology has been defined "as that specialty of the practice of medicine dealing with the causes and nature of disease, which contributes to diagnosis, prognosis and treatment through knowledge gained by laboratory applications of the biologic, chemical or physical sciences to man, or material obtained from man." ' Broad as it is, the definition is not broad enough to cover all the activities and contributions of the Institute. Being limited to man, it does not cover the work of the Institute in veterinary science, a field in which what is probably the largest staff of veterinary scientists in the country is engaged. Nor does it cover much of the work of the Medical Illustration Service, one of the four departments which make up the Institute, and one which is called upon for many services outside the perimeter of pathology. The heart and core of the Institute is in its work of consultation, research, and education, carried on largely by its Department of Pathology. To this Department goes the daily intake of specimens sent in by medical officers in the field, pathologists at military hospitals, and civilian practitioners seeking light on some puzzling piece of pathological material. No matter whence it comes, the sender is asked to designate the degree of urgency which attends its sending by the use of code words which tell the staff at the Institute whether the utmost in expedition is required, or whether the specimen may safely be given ordinary expedited attention, or if it may go into the backlog of cases awaiting opportunity to be worked over by the Institute's pathologists. In numerous instances, review of the original diagnosis by the Institute has profoundly altered the therapy applied. In other instances, materials have been submitted to the Institute too late for treatment to be affected by the revised diagnosis. Such was the case of a 22-year-old air cadet who developed a growth, upon an eye, which though actually benign was mistakenly diagnosed in the first instance as "malignant melanoma." The eye was removed, and the enucleated eye, along with the benign nevus, was sent to the Institute—too late to save the young cadet's eye. More fortunate in its outcome was a similar case in which the nevus, mistakenly diagnosed as malignant, was submitted to the Institute in time for a telegraphic report to save the patient's eye from enucleation. Review of diagnoses by the Institute staff has prevented unnecessary oper- ations, including amputations of limbs, in a number of cases. Such cases are 1 Directory of Medical Specialists. Chicago: Marquis-Who's Who, Inc., I9<»- vo1 - X - P- 82 3- 4 ARMED FORCES INSTITUTE OF PATHOLOGY an infinitesimal percentage of all cases reviewed, but to the individual whose limb or whose sight is saved or lost, nothing could be more important. Institute review of diagnosis is important, also, in preventing possible imposition on the Government or injustice to the serviceman in cases involving line-of-duty questions as to responsibility for death or disablement. Thus, Institute review has forestalled the collection of compensation for nonexistent disease and, on the other hand, has altered erroneous diagnoses of the causes of deaths which, if allowed to stand, would have denied benefits due the serviceman's family. To many, and perhaps to most, of those outside medical circles, pathology is vaguely recognized as a special sort of medical activity, and the pathologist is a dim and remote background figure. This attitude was reflected in an aside from President Dwight D. Eisenhower when he was called upon to dedicate the new building of the Institute in May 1955. Turning to his friend and physician, Lt. Gen. Leonard D. Heaton, just before making the dedicatory address, the President said, "Leonard, what am I doing getting up to dedicate a building for pathology, when I don't even know what pathology is?" In telling of the incident, General Heaton adds the comment that however little the President knew then what pathology is, "he would soon know" — having in mind the medical and surgical experiences that lay ahead of him. President Eisenhower, indeed, began to learn about pathology that same after- noon of the dedication, "For the enlightenment of this audience," he said in his opening remarks, "it is indeed fortunate that Dr. [Brig. Gen. Elbert] DeCoursey saw fit (in his address of welcome) to tell us about pathology. Because for myself, I can assure you that I have learned more in the last 5 minutes than I knew in my entire life before." The most common picture of the pathologist in the popular mind — insofar as there is such a picture — is probably that of the specialist who advises the surgeon as to whether the tissues to be removed are, or are not, malignant. That, indeed, is an important part of what the specialist in pathology does, but it is, after all, a part only. As Dr. James Milton Robb, of Detroit — not himself a pathologist — put it in his presidential address before the American Academy of Ophthalmology and Otolaryngology, in 1952: * the study of pathology in its relatively short life has grown from an investiga- tion or the changes found in the human body after death and their correlation with the signs of disease which had been observed during life to include almost anything which had to THE INSTITUTE AND ITS ANCESTRY 5 do with disease, etiology, pathogenesis, morbid anatomy, microscopic histology, parasit- ology, functional changes, chemical alterations, indeed any topic except treatment.- Or, to put it more briefly and even more broadly, Dr. Esmond R. Long, practitioner and historian of pathology, describes pathology as "the basic in- formational science in the understanding of disease" and "a science that makes use of all other biological and medical disciplines in its development." ! In arriving at this broader concept of pathology and the place of the pathologist in the scheme of things medical, the Institute has played a major part. During the first half-century of its life, while it still was the Army Medical Museum, it contributed to medical research and education through compiling and publishing the massive "Medical and Surgical History of the War of the Rebellion," and through the introduction and development of such techniques as photomicrography and the use of aniline dyes in staining slides for microscopic study. Through its Curator, Maj. Walter Reed, it contributed to the conquest of yellow fever, and through another curator, Maj. Frederick Fuller Russell, it helped mightily in stamping out typhoid fever. Under the curatorship of Maj. George Russell Callender, the Museum broadened its work of education and research through its linkage with civilian medicine in the Registry movement. Through the work of more recent curators, the Museum, while retaining its distinctive character as a place for exhibition of medical lore and historic materials to a large and increasing number of visitors, has had its greatest growth through the enlargement of its services of education and, increasinglv of late years, of research. ''Unique in the World' ' Writing in 1946, when the Institute was still an Army organization and had not taken on its triservice character, Dr. Howard T. Karsner, then of Western Reserve University, described it as "unique in the world." He continued: ' * * * Nowhere else has there ever been a concentration of pathological specimens that is comparable. Nowhere else is the pathology of the entire Army of a great country so concentrated. Nowhere else have the civilian pathologists and other interested physicians taken such a great part in organization and operation. Nowhere else has there been, as " Transactions of the American Academy of Ophthalmology and Otolaryngology, September-October 1952, p. 715- 3 Long, Esmond R.: A History of American Pathology. Springfield, 111.: Charles C Thomas, Publisher, 1962, pp. 133, 147. karsner, Howard T.: The American Registry of Pathology and Its Relation to the Army Institute of Pathology. The Military Surgeon 99: 368-369, November 1946. 6 ARMED FORCES INSTITUTE OF PATHOLOGY continues to be true, such a close scientific liaison between medical officer and civilian doctor. In the years since this was written, the Institute has not only taken on its triservice character; it has also become the central laboratory of pathology for the Veterans' Administration, the Atomic Energy Commission, and the U.S. Public Health Service, and has furnished informal consultation to the Civil Aeronautics Board and the Federal Aviation Agency. All in all, as Dr. Esmond R. Long says in his recent (1962) book, "A History of American Pathology," the Armed Forces Institute of Pathology has "become in fact the hub of activities in the nation's pathology," in a period of activity since 1949 that "has never been matched by any organization for research and instruction in pathology." ° The sweep and scope of these activities of the Institute are indicated by the fact that its latest annual report, that for the last year of the first century of its life, requires 254 pages in order to outline the working organization and list in briefest form the activities undertaken and carried forward during the year. These activities included 194 registered research projects, 91 publications by staff members, n postgraduate courses with an attendance of 1,105, tne distribution of 27,000 copies of fascicles published as part of the "Atlas of Tumor Pathology," and the creation of 55 new visual exhibits— to mention but a few items of work done in but one year out of the one hundred years of the life of the Museum-Institute. In the opening years of the second century of its life, the Institute is carrying forward studies that range from the nature and behavior of the in- finitesimally small subcellular particles that are revealed only in the stream of electronic waves of the electron microscope to the inconceivable vastness of outer space. For wherever man may go, and whatever he may see, pathol- ogy — the scientific cornerstone of medicine — goes with him, and its evidences are to be seen. This volume does not undertake to treat in detail the history of the first century of the Museum and its offspring, the Institute— a multi-volume task — but seeks to tell in brief compass the story of the soil and the seed from which a great medical service has grown, with some account of the men and women who have made great the century-old Armed Forces Institute of Pathology. 'Long, op. cit., pp. 379, 381. CHAPTER II Background and Beginnings In May 1862, the United States had been at war with the Confederate States for a year and a month. After early defeats at Bull Run and Wilson's Creek, the course of the war had been marked by great victories and wide conquests. In the western theater, Fort Donelson had fallen to "Unconditional Surrender" Grant, Nashville had been occupied by Buell, the battle of Shiloh had resulted in victory for the Union, the great port of New Orleans had been taken by Farragut. In the East, the mountain counties of western Virginia had been detached from the Old Dominion, the defenses of the North Carolina sounds had been breached, the deep water harbor of Port Royal in South Carolina had been occupied to provide a safe base for the blockaders of the Atlantic ports, and, most conspicuous of all, General McClellan's mighty Army of the Potomac had advanced up the Virginia Peninsula, pushing the Confederate defenders back almost into the outskirts of Richmond itself. For the Union, the war had gone well in its first year, but it had been at a cost in suffering and death from wounds and disease at which the people were appalled. The Nation had gone to war in traditional hip-hip-hurrah fashion, with little regard for the visible dangers of the battlefield and even less regard for the invisible but more deadly dangers of the diseases that lurked in the unclean camps. Indeed, even if there had been a more realistic appreciation of these risks and dangers, there was not in the existing state of medical knowledge and military organization a great deal that could be done about them. Though anesthesia had been introduced in America some 15 years earlier, methods were still crude, and it was used with considerable misgiving. Bacteria were known to exist but had not yet been accepted as a cause of disease. Antiseptic surgery was still in the future, and asepsis was not yet even an ideal to be sought. The occurrence of pus in wounds or as a result of surgery was looked upon as part of the process of healing, a necessary suppuration. 8 ARMED FORCES INSTITUTE OF PATHOLOGY Some Medical Problems of the 1860's Medical men were still divided into dogmatic schools of thought, according to the theoretical basis on which they practiced. The dominant school, the allopaths, depended upon the administration of powerful dosages of drugs to combat the suppositious causes of sickness or to neutralize its effects; the homeopaths believed in small doses of medicine, operating on the theory that "like cures like." The nature of the curative agents largely relied upon by the medical profession led Dr. Oliver Wendell Holmes to observe, in an address before the Massachusetts Medical Society in May i860, that "if the whole materia medica, as now used, could sink to the bottom of the sea, it would be all the better for mankind — and all the worse for the fishes." Dr. Holmes granted that there were exceptions to his sweeping condemna- tion, but his opinion as to the efficacy of much of the orthodox treatment of disease was warranted by the fact that methods of treatment were derived more from speculation and theory than from directed and controlled experimentation. Even if there had been a more general recognition of the importance of experiment and scientific observation, there was, in America in the early 1860's, little of the apparatus or equipment for observation of even simple symptoms. Even such familiar tools of the physician as the clinical thermometer and the stethoscope were all but unknown and little used, and it was not until the war was half over that the headquarters of the Medical Department of the Army enjoyed the possession of an achromatic microscope, the basic working tool of the pathologist. Not because of these lacks — for at the time they were not recognized as such— but because of the almost total lack of organized readiness for the removal and treatment of the wounded, the Medical Department of the Army came under criticism and condemnation. To many, the suffering of the sick, and especially of the wounded, seemed unnecessarily severe because of the failure of the Department to foresee the mounting needs of war and to organize to meet them. The charge against the Department was "stiff adherence to anti- quated forms and modes of action outworn even for peace conditions." l Whether the deficiencies of the Medical Department were greater than those of other staff departments of the Army may be questioned, and certainly the framework of the governing law, under which the Medical Department was compelled to rely on the quartermaster for transportation and hospital construction and upon the Commissary Department for subsistence, was faulty. 'Duncan, Louis C: Evolution of the Ambulance Corps and Field Hospital, p. 4. In The Medical Department of the United States Army in the Civil War. Washington, 1911. BACKGROUND AND BEGINNINGS 9 But the fact that medical shortcomings, real or supposed, manifested them- selves in the sensitive area of human suffering and death made all the more glaring every instance of ineptitude, inadequacy, inefficiency, or just plain indifference. That there were such instances goes without saying. How could it have been otherwise, when a department set up to care for the medical needs of an army of 16,000 men, with all its methods geared to the slow tempo and small- scale demands of peacetime, suddenly found itself called upon to care for an army rapidly growing to the million mark and engaged in an active and hard- fought war? A New Surgeon General On 15 May 1861, the 80-year-old Thomas Lawson, Surgeon General of the Army since 1836, died. To succeed him, Clement Alexander Finley, veteran of more than 40 years' service in the Department, was named Surgeon General, to face the problems of an ever-expanding and hugely demanding war. In the opinion of the United States Sanitary Commission, an unofficial body with official recognition which was, in a sense, a forerunner of the American Red Cross, the new Surgeon General was too much devoted to routine, and lacked the flexibility of outlook, the largeness of concept, and the vigor in action which the situation required. The Sanitary Commission pressed for passage by Congress of a bill en- larging and reorganizing the Medical Department of the Army, and likewise sought to have the 64-year-old Finley replaced as Surgeon General. In March of 1862, Finley fell afoul of the new Secretary of War, the imperious and irascible Edwin M. Stanton, and was forced to resign. In April, Congress passed, and President Abraham Lincoln signed, the bill reorganizing the De- partment and, on the 25th of the month, a new Surgeon General, William Alexander Hammond, was appointed (fig. 1). The new Surgeon General, who was to become the father of the Army Medical Museum and, through it, of the Armed Forces Institute of Pathology, was less than 34 years old at the time of his appointment. His selection over officers who were his seniors in age, rank, and experience was due in large measure to the recommendation and persistent pressure of the Sanitary Com- mission, which had been impressed by the tireless energy and high adminis- trative ability he had exhibited in the organization and operation of hospitals in Maryland and western Virginia. 2 2 Adams, George Washington: Doctors in Blue: The Medical History of the Union Army in the Civil War. New York: Henry Schuman. Inc.. 1052, pp. 28-31. 10 ARMED FORCES INSTITUTE OF PATHOLOGY Figure i. — Brig. Gen. William Alexander Hammond, The Surgeon General, U.S. Army, 1862-1864. Dr. Hammond was born in Annapolis, Md., on 28 August 1828, was reared in Pennsylvania, and studied medicine in New York, where he received his degree at the age of 20. He passed the examination for entrance into the Army Medical Service and in 1849 became an assistant surgeon. In the next 10 years, he served as medical officer at various frontier posts and also at West Point. He took advantage of a sick leave spent in Europe to study in the medical BACKGROUND AND BEGINNINGS II centers there. Returning to duty, he submitted a report on a nutritional research project of his own which won for him an American Medical Association prize in 1857. In the report on this study, in which Dr. Hammond had used himself as one of his "guinea pigs," he described himself as 6 feet 2 inches in height; from 215 to 230 pounds in weight; of a rather full habit of body; and disinclined to exercise for its own sake. In the autumn of i860, the future Surgeon General resigned from the Army to take the chair of anatomy and physiology at the medical school of the Uni- versity of Maryland in Baltimore, but upon the outbreak of hostilities he had resigned his professorship and re-entered the Army, coming in as a lieutenant at the bottom of the promotion list, without credit for his 10 years of previous service. 3 The Scientific Approach The new Surgeon General faced a mountain of problems of medical supply and administration, but he saw beyond these to the basic questions of the practice of military medicine and surgery. Within less than a month after taking office, therefore, the new Surgeon General, seeking more complete and accurate knowledge of actual conditions, issued his Circular No. 2 on 21 May 1862 (fig. 2). This circular prescribed in detail the requirements of the "remarks" which were to accompany the monthly Reports of Sick and Wounded. Full informa- tion was called for as to fractures, gunshot wounds, amputations, and exsections by the surgeons. On the medical side, information was sought not only as to symptoms and treatment of fevers, diarrhea and dysentery, scorbutic diseases, and respiratory diseases, but also as to shelter and sanitary conditions, and as to the character and cooking of the ration, rightly regarded as factors in the causation and severity of sickness. Almost as an afterthought, the circular announced in its closing paragraph the intention to create a medical museum. "As it is proposed to establish in Washington, an Army Medical Museum," the circular read, "Medical officers are directed diligently to collect, and to forward to the office of the Surgeon General, all specimens of morbid anatomy, surgical or medical, which may be regarded as valuable; together with projectiles and foreign bodies removed, and such other matters as may prove of interest in the study of military medicine or surgery. These objects should be accompanied by short explanatory notes. "Drayton, Evelyn S.: William Alexander Hammond, 1828-1900; Founder of Army Medical Museum. The Military Surgeon 109: 559-565, October 1951. 713-028' — 64 3 12 ARMED FORCES INSTITUTE OF PATHOLOGY SURGEON GENERAL'S OFFICE, Washington Citt, May 21, 1862. [ ll>cl'U> No. i ] In the monthly Report* of Sick and Wounded, the following details will be briefly mentioned in accompanying remarks : SURGERY. fractures. — The date of reception, the situation, character, direction, treatment and resvJt in all cases. Gunshot wound*. — The date of reception, the situation, direction, and character; the foreign matters extracted ( if any ) ; and the result in all cases. Amputations — The period and nature of the injury ; the character of the operation ; the time, place, and result. Eisections — All operations for, with a statement of the injury demanding them ; the date of injury, the date of operation ; the joint or bone operated upon, and the result. MEDICINE. Fevers. — Their character and symptoms; an outline of the plans of treatment found most efficient, with remarks on the location and sanitary condition of camps, or quartern, during the prevalence of these disorders. Diarrhoea and Dysentery. — Grade, and treatment, with remarks on the character of the ration, and the modes of cooking. Snrbutic Diseases. — Character and symptoms, with observations on causation, and a statement of the means employed to procure exemption. Respiratory Diseases.— Symptoms, severity, and treatment, with remarks on the sheltering of the troops, and the atmospheric conditions. Similar remarks on other preventible diseases. Important cases of every kind should be reported in full. Where post-mortem examinations have been made, accounts of the pathological results should be carefully prepared. As it is proposed to establish in Washington, an Army Medical Musnm, Medical officers are directed diligently to collect, and to forward to the office of the Surgeon General, all specimens of morbid anatomy, surgical or medical, which may be regarded as valuable ; together with projectiles and foreign bodies removed, and such other matters as may prove of interest in the study of military medicine or surgery. These objects should be accompanied by short explanatory notes. Each specimen in the collection will have appended the name of the medical officer by whom it was prepared. WILLIAM A. HAMMOND. Surgeon General NOTE -Medie.1 Dmc,.,. .m ft™,. „„ CQfy of , w , cimUaI ,. mwy ^^ ^ fa ^ .^^ ^ ^^ "?T ' Dd "* 7 WU1 ""**"" '•"""' to ""• offi " wkh •* ■"""" ■ " — «* "P—. au .he monthly „J, of the _*». -Seen under their Hpnl*a T*v .ill „,.. lou-dU-t, ...nsmu, aD Uck m<raUllv repOT „. „„„ **— "*■ * b °" "**"" ""*"- "* -W- "«* ~» »™ ««*M in their respective ofc,,^, * commencement of the rebellion. we Figuge 2. — Surgeon General Hammond announces his intention to establish the Army Medical Museum, 21 May 1862. BACKGROUND AND BEGINNINGS T , Each specimen in the collection will have appended the name of the medical officer by whom it was prepared." * Three weeks earlier, on i May, General Hammond had procured, from the Adjutant General of the Army, orders for Assistant Surgeon Joseph Janvier Woodward, on duty with the Army of the Potomac, and Brigade Surgeon John Hill Brinton of the Volunteers, on duty with the Army of the Mississippi, to re- port to the Office of the Surgeon General for special duty. The nature of this duty was disclosed in part, on 9 June 1862, in Circular No. 5 (fig. 3). "It is intended," the circular read, "to prepare for publication the Medical and Surgical History of the Rebellion," with responsibility for the medical portion of the work assigned to Dr. Woodward and for the surgical part to Dr. Brinton, and with all medical officers called upon for cooperation (fig. 4)." The First Curator Meanwhile, The Surgeon General was maturing his plans for a medical museum, and on 1 August 1862, he gave to Surgeon Brinton the go-ahead sign, directing him "to collect and properly arrange in the 'Military Medical Museum' all specimens of morbid anatomy, both medical and surgical, which may have accumulated since the commencement of the Rebellion in the various U.S. hos- pitals, or which may have been retained by any of the Medical officers of the Army." Dr. Brinton was also directed to "take efficient steps for the procuring hereafter of all specimens of surgical and medical interest that shall be afforded in the practice of the different hospitals" and to report the name of any officer who might decline or neglect to furnish such materials. 6 The 30-year-old Brinton had been a demonstrator of anatomy at the Jeffer- son Medical College in Philadelphia and had served with General Grant in the West. At Fort Donelson, under the direction of Surgeon H. S. Hewitt, he had put together the first combination of regimental hospitals and ambulances into brigade organizations, foreshadowing the broader and more comprehensive groupings for evacuation and treatment of the wounded to be worked out later in the same year of 1862 by Surgeon Jonathan Letterman, Medical Director of the Army of the Potomac. 7 'Circular No. 2, Surgeon General's Office, Washington City, May 21, 1862. On file, National Archives, Accession No. 421, Circulars/SGO/1862-1865. 5 (i) Special Orders Number 98, War Department, Adjutant General's Office, 1862. (2) Circular No. 5, Surgeon General's Office, Washington, D.C., June 9, 1862. On file, National Archives, Accession No. 421, Letter Book No. 30. March 7 to May 30, 1862/SGO, p. 319. " Brinton, John Hill: Personal Memoirs. New York: The Nealc Publishing Co., 1914, pp. 180-181. ' (1) Duncan, op. cit., The Battle of Bull Run, p. 21. (2) Duncan, op. at., Evolution of the Ambulance Corps and Field Hospital, pp. 2-4. I4 ARMED FORCES INSTITUTE OF PATHOLOGY Oit'eulai' No. .">. Washington, D. 0., June It, 1862. It is intended to prepare for publication the Medical and Surgical History of the Rebellion. The Medical portion of this work has been committed to Assistant Surgeon J. J. Woodward, United States Army, and the Surgical part to Brigade Surgeon John H. Brinton, United States Volunteers. All medical officers are therefore requested to co-operate in this under- taking by forwarding to this Office such sanitary, topographical, medical and surgical reports, details of cases, essays, and results of investigations and inquiries as may be of value for this work, for which full credit will be given in the forthcoming" volumes. Authority has been given to both the above named gentlemen to issue, from time to time, such circulars as may be necessary to elicit the desired facts, and the medical officers are defired to comply with the requests which may thus be made of them. It is scarcely necessary to remind the medical officers of the regular and volunteer services that through the means in question much may be done to advance the science which we all have so much at heart, and to establish landmarks which will serve to guide us in future. It is therefore confidently expected that no one will neglect this oppor- tunity of advancing the honor of the service, the cause of humanity, and his own reputation. WILLIAM A. HAMMOND, Surgeon Ucnrrah V. S. Army, Figure 3. — Circular No. 5, Surgeon General's Office, 9 June 1862. Dr. Brinton (fig. 5) warmly welcomed the order to collect, for study, speci- mens of damaged or diseased tissues. Indeed, he had anticipated the order of 1 August by writing on 28 July to the medical officers in charge of hospitals at St. Louis, Mo., Cincinnati, Ohio, Baltimore, Md., Philadelphia, Pa., Mound City, 111., and Winchester, Va., directing that all specimens be collected and for- warded. Immediately after the issuance of The Surgeon General's order, he addressed similar letters asking the cooperation of the officers in charge of BACKGROUND AND BEGINNINGS '5 Ficure 4. — This group of U.S. Army medical officers includes several who were to be prominent in the history of the Army Medical Museum and the Library of The Surgeon General. Standing (left to right): Lt. Col. William G. Spencer, Assistant Surgeon Alfred A. Woodhull, Surgeon General Joseph K. Barnes, Assistant Surgeon Edward Curtis. Seated (left to right): Assistant Surgeons George A. Otis, Charles H. Crane, John S. Billings, and Joseph J. Woodward. (From an original glass negative dated 1864 in the AFIP files.) hospitals at Alexandria, Falls Church, and Culpeper Court House, Va., and at Memphis, Tenn. s "My whole heart was in the Museum," he wrote afterward, "and I felt that if the medical officers in the field, and those in charge of hospitals, could only be fairly interested, its growth would be rapid and the future good of such a grand national cabinet would be immense. By it the results of the surgery of this war would be preserved for all time, and the education of future generations of military surgeons would be greatly assisted." During his period of service as Curator, Dr. Brinton visited the field hospitals after the great battles in the East — Antietam or Sharpsburg, Fredericksburg, 8 Record of John Hill Brinton's Action in the Matter of the Military Medical Museum. On file in historical records of AFIP; letters of 28 July, 7, 9, 12, 18, and 19 August 1862. i6 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 5. — Maj. John Hill Brinton, U.S. Volunteers, first Curator of the Army Medical Museum, 1 862-1 864. Chancellorsville, Gettysburg — seeking to enlist the interest of the surgeons with the armies, to develop a "true professional interest" in the Museum as an opportunity to contribute to the "common stock of surgical knowledge" and BACKGROUND AND BEGINNINGS 17 to convince the skeptical that the formation of a "great National Surgical and Medical Museum was not for the collection of curiosities, but for the accumula- tion of objects and data of lasting scientific interest, which might in the future serve to instruct generations of students, and thus in time be productive of real use." 9 Dr. Brinton could hardly have foreseen that future generations of students would come to look upon many of the medical and surgical practices of the Civil War as curiosities carried over from the Middle Ages of medicine, but in his prediction that the institution which he was launching would "in time be productive of real use" he was abundantly correct— for the Medical Museum has broadened into the Institute of Pathology, serving not only the Armed Forces but, through its unique relation with the civilian specialist, serving the needs and pacing the progress of all pathology. Collecting Specimens Many of the Army surgeons of 1862 "entered into the scheme of the Museum with great zeal and earnestness," Dr. Brinton wrote afterward, "but some few there were, and these mostly the least educated, who failed to see its importance." In time, however, the project received "active and faithful co-operation" from the medical staff generally. The chief difficulty encountered at first was in the field hospitals where, after battles, the medical forces were overwhelmed with the bloody work of operating under conditions and pressures which did not permit the preparation of specimens with their accompanying case histories. "It really seemed unjust," Dr. Brinton noted, "to expect [under such cir- cumstances even] the rough preparation necessary to preserve for the Museum the mutilated limbs." Consequently, the Curator adopted the practice of visit- ing the battlefields (fig. 6) where he had dug out of the trenches in which they had been buried "many and many a putrid heap" of legs and arms on which he went to work "amid surrounding gatherings of wondering surgeons and scarcely less wondering doctors." All saw, he said, that he was in earnest and as his infectious example spread from corps hospital to corps hospital, "active co-operation was eventually established." In his visit to the Army of the Potomac, after the battle of Fredericksburg, Dr. Brinton was accompanied by Dr. William Moss, the Assistant Curator, the purpose of the trip being to assist in caring for the wounded and also to "look * Brinton, op. at., pp. 181, 186. i8 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 6. — Surgeon John H. Brinton (front row, center), with a group of Union Army officers in the field. after the interests of the Museum." On the afternoon of 15 December, Dr. Brinton "encountered Dr. Moss, my assistant, bringing with him an immense number of surgical specimens for the Museum, some of these in boxes, which we sneaked over in the wagons; the remainder were carried in great bags on the backs of one or two very black negroes." Upon his return from the field, the Curator sent his assistant back "down to the army for more" specimens. "By this time," he said, "the surgeons generally were becoming interested in the Museum project, and were taking pains to get and preserve what they could for the collection." 10 To spare the field surgeons as much as possible in the preparatory work, the Museum issued "Suggestions to the Medical Officers of the Army as to the Preparation and Forwarding of Specimens to the Army Medical Museum, Sur- geon General's Office, Washington, D.C." After a listing of the types of "speci- mens illustrative of surgical injuries and affections" and the "specimens of diseases" which were desired, the Suggestions continued: "It is not intended to impose on medical officers the labor of dissecting and preparing the specimens 10 //'«</., pp. l86, 187-188, 214 220, 222. BACKGROUND AND BEGINNINGS 19 they may contribute to the Museum. This will be done under the super- intendence of the Curator." Instructions for forwarding "such pathological objects as compound frac- tures, bony specimens, and wet preparations generally, obtained after ampu- tation, operation or cadaveric examination" included rough removal of all unnecessary soft parts, wrapping in cloth so as to preserve all spicula and frag- ments, attaching a tag of wood or sheet lead bearing the number of the specimen and the name of the officer sending it, and immersing the object in a keg or small cask of diluted alcohol or whisky. When filled, the cask was to be forwarded to the Office of the Surgeon General by express, collect. At the same time, a corresponding list or history of the cases was to be mailed to The Surgeon General. To facilitate the collection of specimens, the following medical officers at major hospital centers were designated to receive and forward them: Surgeon Lavington Quick, U.S. Volunteers, Baltimore Acting Assistant Surgeon Edward Hartshorne, U.S. Army, Philadelphia Acting Assistant Surgeon George Shrady, U.S. Army, New York Surgeon M. Goldsmith, U.S. Army, Louisville Assistant Surgeon F. L. Town, U.S. Army, Nashville Surgeon John S. Hodgen, U.S. Army, St. Louis Surgeon H. S. Hewitt, U.S. Volunteers, Army of the Mississippi " In acknowledging receipt of specimens submitted in response to circular letters and individual communications, Dr. Brinton, upon occasion, inquired as to particular cases of which he had knowledge. For example, in a letter of 17 December 1862, thanking Surgeon John S. Hodgen at St. Louis, Mo., for his contributions, Brinton mentioned that he had not seen among them "one of a gunshot wound of the ear which occurred at Fort Donelson and was treated in the Hospital under your charge last winter," and asked for the specimen and also for "the round ball which inflicted the injury should it be in your possession." Not every wounded man was willing to give up the severed portion of his anatomy or the projectile by which he was struck. As an instance of this occasional unwillingness, there is the case of Pvt. W. H. Knaup of the 2d New Jersey, who was struck by a shell fragment in the left cheek and lost the angle of his jaw. Brinton wrote the surgeon in charge of the hospital at Chester, Pa., to which Knaup had been removed, to "make him "Catalogue of the Army Medical Museum, Surgeon General's Office, Washington, January 1. 1963, pp. 5, 6. 713-028'— 64 » 20 ARMED FORCES INSTITUTE OF PATHOLOGY give up the shell by which he was struck and the loose angle of jaw for the Army Museum," adding, "Keep every specimen you can." Some of the operating surgeons, through ignorance or misunderstanding of orders, believed that the specimens resulting from their operations were their own to dispose of as they saw fit. One such instance was that of Surgeon R. B. Bontecou, of the hospital at Beaufort, S.C., who, while on duty in the Peninsula, collected between 70 and 80 preparations which he gave to Dr. Thomas M. Markoe of New York. Brinton wrote to the recipient of the gift, explaining that "all the specimens collected by medical officers belong to the national museum" and calling for the return of those which had been transferred to him by Surgeon Bontecou "under the mistaken impression that he possessed the right to part with them." There is no record of the receipt of anything from Dr. Markoe, but eventually Dr. Bontecou contributed 101 specimens. And then there was at least one case of outright theft of specimens by "the men who had charge of the dead house" at a general hospital, and the sale of the specimens to a New York physician. 12 In spite of early indifference and the very real difficulties of collection, the specimens came in, even though the case histories which were to have accompanied them were frequently lacking. Enough material had been re- ceived by the end of 1862 to warrant the issuance of a small catalog in January 1863 (fig. 7). In a covering letter to Surgeon General Hammond, the Curator noted that "all the contained specimens," numbering 1,349 objects, had been collected since the Museum's establishment in August and the number was "being daily augmented." Of the objects cataloged, 985 were surgical speci- mens, 106 were medical, and 103 were missiles, "for the most part extracted from the body." Through the cooperation of the Ordnance Department of the Army, the Museum was enabled to display also a series of projectiles for small arms, field and heavy guns, and a set of the bayonets in use in the United States and foreign countries. This first catalog of the Museum was "offered simply as a numerical list of the objects" in the collection with no attempt to classify the various injuries or to describe in detail the preparations included. Of the nearly 1,000 surgical specimens listed, all but a handful were the result of gunshot wounds, and the vast majority of those were from the "(1) Record of John Hill Brinton's Action in the Matter of the Military Medical Museum, pp. tj 22, 52, 59. On file in historical records of AF1P; letters of 28 July, and 7, 9, 12, 18, and 19 August 1862. (2) Lamb, Dr. D. S-: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, pp. 8, 9. BACKGROUND AND BEGINNINGS 21 12 No. or Brsc'tr, 72 • 73 * 71 § 78 79 ■ 60 CI 82 # 83 * 84 87 * 88 * 89* 90 91 " 92 • 93 " 94 95 96 97 98 99 * Descripi ion. Gunshol fracture of upper third s]i;ift of Tibia. Gunshot fracture, comminuted ; porforatiorj of Humerus. Shell contusion of Tibia; great suppuration. Surg..T.H.Brinton,U.S.V. A Asst. Surg. W. W. Keen, l\H A .«., n'\ Horn No. l. Fredvrick, Md. A. Asst. Surg. D. W.Chee- wr, l'. S. A., .In Hosp., Washington, l>(". Gunshot fracture, comminuted, of shafl of Dr. Bowles, Waters' Ware- Femur, house, Georgetow d,D. <.'. Gunshot fracture of Femur; perforation Surg. C. H. Pago, IT. S.A, above condyles. Gunshot fracture of condyles of Femur; de- 1 posit of callus. " ot fracture of upper half and neck ' Humerus, fracture of upper half Bhaft of Asst. Surg. B. A Storrow, 1 Fibula, L\S.A.,Eckiugtou Hosp., Washington, l>. C. Gunslmt^kLhiiv of Tarsus and tower ex- Dr. Warner, Waters' Ware- tremity Mp^tiljm auiUi^i^i^ mui. I > Gunshot In and Fibuli Gunshot •fartfiic'^B ' S.V tremity of Radio Gunshot fracture of H H 8 \ with deposit of <:l I Hosp. GlLllsln Gunshot fracture of of ball perpend ic Gunshot fracture of carpal bones and ( iinii-imi fracture of Gunshol fracture o with couoidal 1ml Gunshol fracture of carpal bones. Gunshot fracture, < U[<]»-r half Of I I il' Gunshot fracture of t lunshot fracture <■(' tors. Gunshot fracture : process an I head Gunshot fracture; inch of shaft ot ll| Gunshol fracture Ethmoid, and I'm Gunshol fracture "il Humerus. tliird, fourth, and mTWTfflinirff^TWff^^^iTnrrrT^TTr^^WPl F. S \ Gunshot fracture of Carpus; amputation. Asst. Snrg. .1 .). Wood* ward, f 8. A. Gunshot fracture of lower half of Femur. Burg. J. if. Brinton, [TJ8.V. Figure y. — A page from the first Catalogue of the Army Medical Museum. The specimen shown is the one listed as No. 76 in the catalogue. conoidal bullets devised by Capt. C. E. Minie of the French Army and widely adopted by both sides in the Civil War. Comparatively few American surgeons had had experience with gunshot wounds, and fewer still had so much as 22 ARMED FORCES INSTITUTE OF PATHOLOGY seen wounds made by Minie balls— hence the emphasis upon such specimens in what soon came to be the largest collection of such specimens in the world. Some 30 of the specimens other than gunshot wounds were from reampu- tations or other secondary operations. Two were from victims of radroad accidents; one was the result of a kick by a horse. Only two were saber wounds, and there were no instances of wounds by the bayonet. One specimen was from a case of gangrene of the face attributed to salivation— a condition resulting from excessive dosage of calomel or other mercurial drugs. The most numerous single disease listed as the cause of the lesions shown in the specimens was typhoid fever, designated in 17 cases. The most frequently mentioned disease was "Chickahominy diarrhoea," 10 cases. The Museum's specimens, as they may be observed in its original catalog, were illustrative of the effects of military action and camp conditions upon the life and health of the soldier. 13 The work of preserving the specimens and preparing them for museum purposes was done at the Museum by a professional anatomical "preparator," Frederic Schafhirt, assisted by his son, Adolph, and later, also by his son, Ernst. The senior Schafhirt, who bore the courtesy title of "Doctor," was born and trained in Germany and had been an assistant in anatomical work for Dr. Joseph Leidy of the University of Pennsylvania. The preservative commonly used was alcohol diluted in strength to 70 percent. This alcohol was secured by re-distilling the illicit liquors seized and confiscated by the provost marshal of Washington, a source of supply which was found adequate for Museum purposes for some years. Dr. Brinton recalled afterward that the side lot of the Museum was "piled with kegs, bottles, demijohns and cases, to say nothing of an infinite variety of tins, made so as to fit unperceived on the body, and thus permit the wearer to smuggle liquor into camp." Among the more ingenious of these containers, according to the recollec- tion of another officer assigned to the Museum, were false breasts, each holding a quart or more, worn by women who were arrested as they sought to cross the Long Bridge, carrying liquor to the camps. 14 13 Catalogue of the Army Medical Museum, Surgeon General's Office, Washington, January i, 1863, passim. " (1) Lamb, op. cit., pp. 4, 5, 25. (2) Krinton, op. cit., pp. 181-182, 191. BACKGROUND AND BEGINNINGS 2 3 New Quarters for the Museum During these early months of the Museum's life, its quarters were moved twice. The first move was from the "top of my desk," as Brinton wrote, to some "shelves put up for the purpose in my rooms in the Surgeon-General's office," then located in the old Riggs Bank Building (fig. 8) at the corner of President Place (now Pennsylvania Avenue) and 15th Street, NW., Washington, D.C. From these shelves, on the second floor rear of the bank building, the growing collection was soon removed to rooms in a building at 180 Pennsylvania Figure 8.— The first home ot the Museum. Avenue, NW., which stood on lots since numbered as 1719-1721 (fig. 9) . While in this building, the first catalog was issued, but as increasing numbers of speci- mens came in from the hospitals and the field, new and larger quarters were imperatively demanded. While he and Dr. Woodward were "pushing" on the medical and surgical history of the war, and compiling lists of sick and wounded, Dr. Brinton was scouting Washington, on the lookout for suitable quarters for the growing Museum. The only place he could find that was both suitable and available was a building on H Street, NW., between 13th and 14th Streets, opposite the New York Avenue Presbyterian Church. The building, which belonged to the Washington philanthropist, W. W. Corcoran, is variously described in con- 24 ARMED FORCES INSTITUTE OF PATHOLOGY MWUUUWWUWWWJWW^^ » UWUWM*^ Figure 9. — The second home of the Museum. temporary documents as a "mechanics' library," the "Library Building occupied by Miss Middleton's School," and "the Art Gallery Building." It might have been intended for use by the subsequently famous Corcoran Gallery of Art, but BACKGROUND AND BEGINNINGS 25 it was in use as a school and was known as "Mr. Corcoran's School House" when it was taken over by the Government. Mr. Corcoran agreed to put the building in repair and rent it for $1,000 a year. The proposition was accepted by the Curator, and on 16 May The Surgeon General asked permission of Secretary Stanton to rent the building on these terms, the rent to be paid out of an appropriation of $5,000 for the Museum which had been made at the closing session of the Congress. On 21 May, the Secretary of War directed that the Military Governor of Washington, Maj. Gen. Ethan Allen Hitchcock, take possession of the building and turn it over to the Medical Department of the Army for the use of the Medical Museum, which was done in Special Orders No. 116, Headquarters, Military District of Washington, on 22 May 1863. Dr. Brinton stated in a letter of 24 August to Col. Joseph K. Barnes, Medical Inspector and Acting Surgeon General, that Secretary Stanton had ordered that "no rent will be paid for the building" owned by Mr. Corcoran, but re- gardless of rent or no rent, the Medical Department took possession of "the building known as Corcoran's School House near Dr. Gurley's Church, to- gether with its outbuildings thereto, having been turned over to this department by order of Secretary of War" and on 1 June assigned the quarters to the Museum, directing Surgeon Brinton to "take charge thereof, and make such alterations and repairs as may be necessary to fit it for the purpose of the army Medical Museum." Brinton was cautioned, however, to "avoid all useless alterations or expense." 15 Acting under this authorization, the Museum occupied the Corcoran build- ing (fig. 10) as soon as the school term was over and put it in complete repair at a cost, including new cases for exhibits, of nearly $2,000. On 24 August, the Curator reported the building "as ready for the reception of the collection" which by that time had grown to an estimated 3,500 specimens. Already, Dr. Brinton reported to the Acting Surgeon General, "the collection of gunshot injuries alone is the largest in the world, exceeding in number and value that of the British Government at Netley (formerly at Fort Pitt, Chatham), and far sur- passing the French Museum at Val-de-Grace, founded by Baron Larrey." ' 15 (1) National Archives, War Department Records, Adjutant General's Office, Miscellaneous 204, Accession Number 421, SG Letter Book Number 4, Surgeon General's Office, p. 108. (2) Rrinton. op. at., pp. 182-184. (3) Lamb, op. at., pp. 16, 17, 19-21. (4) Lamb, D. S.: Army Medical Museum. Washing- ton, D.C. The Military Surgeon 53: 99, 101, August 1923. (5) W. W. Corcoran Papers. On file in Manuscript Division, Library of Congress, Letter Press Copy Book, volume 22, pp. 269, 410. M (1) Original letter, John Hill Brinton to Joseph K. Barnes, 24 August 1863. On file in historical records of AFIP. (2) Lamb, op. at., pp. 19, 20. (3) Lamb, The Military Surgeon. 53 (1923). pp. IOI, 102. (4) Brinton, op. at., pp. 183, 184. 26 ARiMED FORCES INSTITUTE OF PATHOLOGY — -~- — — -^t^— ~ == : B\ I .'-J f*T7\ T"-^ A ^*-»- Figure io. — The third home of the Museum. Picture is from an engraving by H. H. Nichols of the Museum staff. Grounds for Anxiety Apparently, judging from the anxious tone of Brinton's letter of 24 August 1863 to Col. Joseph K. Barnes, the Acting Surgeon General, there was some apprehension that the Museum project might be caught in the backwash of the increasingly bitter differences between Surgeon General Hammond and the Secretary of War. These differences between two men of powerful personality and clashing temperament had progressed to the point, by 2 July 1863, that a special commission of three civilians was appointed to scrutinize The Surgeon General's papers, seeking cause for his removal. The Surgeon General had added to the ranks of his opponents by the issuance, on 4 May 1863, of his Circular No. 6 striking calomel and tartar emetic from the list of Army medical supplies — an action which outraged many physicians who were accustomed to use calomel as a standard medication, if not as a sovereign remedy. Before the month of August was out, Hammond was ordered out of Washington on a vague and ill-defined mission of inspection in the South with headquarters at New BACKGROUND AND BEGINNINGS 27 Orleans, whence he was to report to the Secretary every 10 days, while Colonel Barnes acted as Surgeon General. 1 ' It was obvious that the Secretary of War was determined to be rid of tlie innovating and independent Hammond, and it might well have been appre- hended that this determination extended beyond the person of the unwanted Surgeon General to all his works, as well. At any rate, Curator Brinton, while disclaiming any need for such representations, urged upon Acting Surgeon Gen- eral Barnes that the plan for the Museum be carried out. "It is unnecessary for me, Colonel," he wrote, "to urge upon you the value of our National Medical Museum. Its claims to usefulness are recognized by the civil profession through- out the country and it is by them weekly and almost daily considered. The cabinet as it stands is not a mere Museum of curiosities. It is a collection which teaches." "It is practical," he continued, "and has already powerfully influenced for the better the treatment of the wounded soldier." In confirmation, he called to mind the lessons to be deduced, from the study of the specimens of the Museum, as to injuries of the joints from conoidal balls, "a class of injuries previously almost unknown and the treatment of which, at the commencement of the war, was unsettled." The proposed arrangement of the Museum in its new quarters, he added, would open the collection to the study of every surgeon, civil as well as military. Only in this way, he said, could a true knowledge of the treatment of wounds caused by modern projectiles be diffused. Concluding, he referred to the loss which would occur if the plans for the Museum should be changed. "I know of no other suitable building for the purposes of the Museum," he wrote, "and even should one be found, the fund at command would be utterly insufficient to make a second time the alterations and repairs which would be absolutely necessary." Dr. Brinton's argument against scuttling the plan for removal of the Museum to its new and larger quarters was successful, for on 1 September Colonel Barnes was notified that the Secretary of War had "authorized the transfer of the specimens from the room in the Surgeon General's office to the Museum newly selected." 18 " (1) Duncan, Louis C: The Strange Case of Surgeon General Hammond. The Military Surgeon 64: 107-108, January 1929. (2) Ashburn, Percy M.: Gleanings from Medical Department History. Military Surgeon 64: 449, March 1929. (3) Drayton, Evelyn S.: William Alexander Hammond, 1828-1900; Founder of Army Medical Museum. The Military Surgeon 109: 563, October 1951. 18 (1) Original letter, John Hill Brinton to Joseph K. Barnes, 24 August 1863. On file in historical records of AFIP. (2) Lamb, op. cit., pp. 19-21. (3) Lamb, The Military Surgeon, 53 (1923), pp. 101-102. 2 8 ARMED FORCES INSTITUTE OF PATHOLOGY Plans for an Army Medical School Dr. Brinton was less successful in the attempt to establish a school of military medicine and surgery in the Museum. On 24 September 1863, four young Army medical officers then on duty in Washington, some of them being con- nected with the Museum and "wishing to make that institution at once practi- cally useful," asked Acting Surgeon General Barnes for "permission to deliver a course of lectures on military medicine and surgery in the hall of the Museum." Such a course would be particularly advantageous, they suggested, because of the large number of medical cadets and junior medical officers on duty in the hospitals in the Washington area. It was proposed to deliver the lectures in the evening so that they "would in no way interfere with the official duties of any- one concerned." The proponents of the course had all had experience in lectur- ing on medical subjects. "These lectures of course will be delivered free," the letter read, "and with the facilities afforded by the Museum would not be a source of any expense whatever to the Government." The officers who thus proposed what would nave been the first school of the sort were: Doctors Brinton and Woodward, Dr. Roberts Bartholow, and Dr. D. W. Bliss. Others who were to have lectured included Surgeons John A. Lidell and A. C. Hamlin, Assistant Surgeon William Thomson, of the Volun- teers, and Surgeon Richard H. Coolidge of the Regular Army, who was to have taught the customs of the service and military medical ethics. The Acting Surgeon General submitted the proposition to the Secretary of War, who said he would decide the matter the next day. Surgeon Brinton tells the story : On the morrow, about nine o'clock, on his drive from his home to the war office, he [the Secretary] stopped at the Museum Building, descended from his carriage, ran hastily through the Museum rooms, looked angrily at the dear little lecture room, stamped his foot, growled, "Ugh," drove to his office, sent for Acting Surgeon General Barnes and said sharply to him, "Are these lectures to be given in the evenings?" To an affirmative reply, he growled, "They will go to the theatre and neglect their duties. It shan't be," and thus was the end of a favorite plan for doing some good for the Medical Corps of the Army, and for disseminating a more correct and general knowledge of military medicine and surgery. 19 And, it might be added, it was to be another 30 years before the idea of an Army Medical School was to come to fruition. 19 (1) Original letter, John Hill Brinton to Joseph K. Barnes, 24 September 1863. On file in historical records of AFIP. (2) Lamb, op. cit., pp. 23-25. (3) Lamb, The Military Surgeon, 53 (1923), pp. 103, 104. (4) Brinton, op. dr.. pp. 258—259. BACKGROUND AND BEGINNINGS 29 The Museum s Collections Grow However disappointed Brinton and Woodward may have been at Secretary Stanton's brusque dismissal of their promising plan, they still enjoyed the sup- port of Acting Surgeon General Barnes both in their work on the "History" and on the Museum project. On 25 November 1863, and again on 24 June 1864, Dr. Barnes issued circular letters to all medical officers in aid of the Museum. In the first letter, he invited attention to the possibilities of illustrations and representations of the results of surgical operations by means of plaster casts which, it was said, could "in many instances be conveniently obtained — with- out subjecting the patient to the slightest inconvenience." It was suggested that cases in which the results of the operation had been unfavorable would be as "instructive and valuable for future reference and study" as those which had resulted favorably. The 1864 circular of Acting Surgeon General Barnes directed medical offi- cers in charge of hospitals "to diligently collect and preserve for the Army Medical Museum all pathological specimens which may occur in the hospitals under their charge." Listing the types of objects desired, the circular contained directions for forwarding them to the Surgeon General's Office, substantially repeating and reinforcing the "Suggestions" printed in the 1863 Catalogue of the Museum. 20 Under the stimulus of these orders, and as a result of the missionary efforts of the Museum staff, specimens continued to come in, particularly after the great battles. Two barrels, filled with the gruesome materials resulting from the work of the surgeons, were sent in by a member of the Museum staff after Gettysburg. One specimen from that battle which came in, without need of orders from The Surgeon General or solicitation by Museum staff members, was an amputated leg, received in a small coffin-like box, bearing the visiting card of the donor with the message, "With the compliments of Major General D. E. S." Gen. Daniel E. Sickles, whose leg it was or had been, combined a keen sense of self-advertisement with a high estimation of the importance and interest attached to the severed anatomy of the commanding general of the III Corps. That he was correct in his estimate is evidenced by the fact that even today 20 (1) Circular Letter, Surgeon General's Office, June 24, 1864. On file in National Archives, War Department Records. (2) Lamb, op. at., pp. 25A, 25B, 28, 20. (3) Lamb, The Military Surgeon, 53 (1923), pp. 105-109. 30 ARMED FORCES INSTITUTE OF PATHOLOGY the fractured bones of the Sickles' leg attract the interest of visitors to the public exhibits of the Museum (fig. n)." 1 Hammond In Exile Throughout the last half of 1863, the Medical Department of the Army was in the anomalous state of having two heads— the titular Surgeon General Hammond, who was in official exile away from the seat of government, and Acting Surgeon General Barnes, in charge of affairs at the Capital. Determined to put an end to this situation, Hammond demanded reinstatement in his office or trial by court-martial. Permitted to return to Washington, he arrived on 15 January 1864, to be placed in arrest on the 17th, and ordered to trial, be- ginning the 19th, on charges of irregularities in the procurement of supplies and falsehood. Hammond sought a postponement to allow preparation of his de- fense, but it was denied him, and he was forced to proceed to trial in 48 hours on charges and specifications which had required 6 months to prepare. The ensuing trial ran for nearly 4 months, accumulated a record of 2,500 pages, and resulted in a verdict of guilty and a sentence of dismissal from the Service, approved by the implacable Secretary of War and promulgated on 18 August. Dr. Hammond, far from being crushed by the sentence, retained the respect of the medical profession, and went on to win new honors as one of the founders of the developing specialty of neurology, with a large and lucrative practice in New York City. Fifteen years after his dismissal, on 27 August 1879, by Act of Congress and action of the President, he was restored to the retired list of the Army with his rank of brigadier general, though, at his own re- quest, without pay for the past, present, or future. In its report recommending such action, the Senate Committee summed up the evidence as follows: A careful, unbiased and searching scrutiny of the evidence * » * forces irre- sistibly the conclusion that the gravamen of all the charges save one (that of falsehood) was either disproved by the defense, abandoned by the prosecution, or eliminated by the findings of the court. The single charge of which the gravamen was not found wanting by the Court, was in itself trifling, if not frivolous, and certainly insufficient in character and importance to arraign, try, convict, and pronounce sentence thereon, in the manner and form set forth. Referring to Hammond's request that he not be awarded pay but only vindication, the Committee wrote: Dearer and more precious to him than untold gold, the priceless treasure of reputation restored and reparation made at the hands of his countrymen; he was asked that his name n (1) Brinton, John Hill: Address to the Graduates of the Army Medical School, March 13, 1896. Journal of the American Medical Association 26: 602, March 28, 1896. (2) Lamb, op. at., p. 18. (3) Lamb, The Military Surgeon, 53 (1923), p. 100. BACKGROUND AND BEGINNINGS 31 Figure ii. — The "Incredible" General Sickles and his leg bones. 32 ARMED FORCES INSTITUTE OF PATHOLOGY be again inscribed upon the roll of honor in companionship with those brave men who had fought the good fight and rested on their unstained laurels.- 2 The verdict of the Senate Committee, concurred in by the Senate, the House of Representatives, and the President, that William Alexander Ham- mond deserved well of his country, has been accepted by all who are acquainted with the achievements of his 15 months in actual charge of the affairs of the Medical Department and with the circumstances surrounding his dismissal. In the face of indifference, and even obstinate opposition, he had initiated reforms and launched institutions which were to be of lasting benefit, and even his unfulfilled recommendations were to come to fruition in later years. The Second Curator The change in surgeons general was followed, a month later, by the relief of Major Brinton from his duties in the Surgeon General's Office and also as Curator of the Medical Museum, and by orders for him to report to Assistant Surgeon General Robert C. Wood at Louisville, Ky., for assignment in the West. On 3 October, Dr. George Alexander Otis (fig. 12), who had been Brinton's assistant since July, was named as his successor and was to serve as Curator longer than any other individual. 23 The new Curator, 34 years old, was from Massachusetts but had received his M.D. degree from the University of Pennsylvania, had studied in Paris, and had practiced for 2 years in Richmond, where he had founded and edited the Virginia Medical and Surgical Journal. From 1854 to trie outbreak of the war, he had practiced in Springfield, where he had joined a Massachusetts regiment as surgeon. After 3 years' service, in which he had attracted the favorable attention of Charles Henry Crane, Assistant Surgeon General, he was assigned to the Museum." 4 Reorganization of the Museum Upon his designation as Curator, the Surgical and Photographic Sections of the Museum were assigned to Dr. Otis, while the Medical and Microscopic a (i) Duncan, Louis C: The Strange Case of Surgeon General Hammond. The Military Surgeon 64: 98-110, January 1929, and 64: 252-262, February 1929. (2) Phalen, James M.: William Alexander Hammond. Army Medical Bulletin, Number 52, pp. 42-46, April 1940. B (i) Special Orders Number 245, Adjutant General's Office. On file, National Archives, Accession Number 421. Letter Book Number 9, Military, Surgeon General's Office. (2) Brinton, op. at., pp. 307, "Hume, Edgar Erskine: Victories of Army Medicine: Scientific Accomplishments of the Medical Department of the United States Army. Philadelphia: J. B. Lippincott Co., 1943, p. 81. BACKGROUND AND BEGINNINGS B Figure 12. — Lt. Col. George A. Otis, the second Curator of the Army Medical Museum, 1 864-1 881. 34 ARMED FORCES INSTITUTE OF PATHOLOGY Sections were continued under the exclusive control of Dr. Woodward, an arrangement which, according to Otis's report of i July 1865, was to work with "entire harmony and concert of action" between the respective departments. This division of labor was not new, since during Brinton's curatorship, patho- logical work, as distinguished from the collection and preparation of specimens, had been largely assigned to Woodward. Like his associate, Brinton, Wood- ward was a Philadelphian, born in 1833, and a graduate in medicine at the University of Pennsylvania in 1853. He was a founding member of the Patho- logical Society of Philadelphia, organized in 1857, and had published several papers dealing with microscopic studies before entering the Army at the outbreak of war. In connection with his duties at the Museum, he had written "The Hospital Steward's Manual," published in 1862, a valuable guide for the work of the forerunners of today's medical corpsmen, and "Outlines of the Chief Camp Diseases of the United States as Observed During the Present War," published in 1863. 25 Pioneering in Microscopy It was in the study of "camp fevers and diarrheas" that Dr. Woodward (fig. 13) made the pioneer use in America of the newly discovered aniline dyes in staining tissue, so that certain parts become more visible under the microscope. The idea of staining specimens so as to cause particular features to stand out more clearly was as old as Van Leeuwenhock himself, but the unstable nature and the limited range of colors of most of the vegetable and animal dyes available had limited the use of the idea until the discovery, by the English youth, William Henry Perkin, of aniline dyes made from coal tar. The new dye industry flourished famously in Germany and it was there, in 1862 and 1863, that the new colors were used to stain specimens for microscopic examination. On 14 May, Dr. Woodward wrote to Rudolf Virchow, whose theory of the cellular origin of cellular tissues had been announced in 1858, asking if he had "used aniline or any of its derivatives for coloring microscopical specimens." There is no record of a reply from the great German investigator, if indeed he replied to his then virtually unknown American interrogator, but as early as July 1864, Woodward was using "aniline in histological researches," as reported in a paper in the American Journal of the Medical Sciences, published in 1865 under the title "On the Use of Aniline in Histological Researches With a Method ■ ( 1 ) 1 lume, op. at., pp. 141, 142. (2) Edmonds, Henry W.: Woodward and the Changing Concept of Cancer, 1 858-1873. The Military Surgeon 109: 314, 315, October 1951. BACKGROUND AND BEGINNINGS 35 Figure 13. — Lt. Col. Joseph J. Woodward, MC, who pioneered in America in the use of aniline dyes for staining microscope slides and in photomicrography "using the highest powers." of Investigating the Histology of the Human Intestine and Remarks on Some of the Points To Be Observed in the Study of the Diseased Intestine in Camp Fevers and Diarrheas." From the title of Dr. Woodward's paper and its opening statement that "the use of these colors for the purpose of staining certain parts of tissues and thus rendering them more visible appears to be unknown in this country and, so far as I can learn from the journals accessible to me, is imperfectly understood abroad," it appears that, working independently in the Army Medical Museum, 36 ARMED FORCES INSTITUTE OF PATHOLOGY young Dr. Woodward had hit upon and developed one of the great basic techniques of the pathologist. 26 Woodward, Curtis, and the Camera Another of the indispensable tools of present-day pathology in which Woodward did pioneer work was the photographing of objects visible only under the microscope. In this work, he was assisted by Dr. Edward Curtis (fig. 14), whom Woodward described in his letter to Virchow as a patient and dexterous young man (Woodward himself was 31; Curtis was 5 years younger) with preliminary training as a microscopist, who was capable of independent investigation in pathology. The work in photomicrography, first undertaken late in 1864 (fig. 15), was described in a report to The Surgeon General, published on 1 November 1865 as Circular No. 6, and again in the second part of the Catalogue of the Microscopical Section of the Museum, published in 1867." In these early experiments with microscopic photography, the source of illumination was the sun itself, ingeniously harnessed "to insure a perfectly steady and at the same time an intense light," according to the account of the process as given in the catalogue. The room in which the photograph was to be taken, darkened so as to dispense with a light-tight bellows, became the "camera" with a window fac- ing south as the "shutter," through which the direct rays of the sun, caught in the mirror of a heliostat mounted outside the window, were reflected upon the plane mirror of a microscope mounted horizontally just inside the window. From the mirror, the reflected rays of the sun were thrown upon the object to be photographed, placed upon the stage of the microscope, whence the light passed through the barrel of the instrument to the object-glass where it was magnified. The magnified image was brought to a focus upon the sensitive photographic plate, mounted upon a stand which was moved back and forth along a 10-foot track provided with a scale for measurement of distances from the microscope (fig. 16). When photographs were to be made at the higher ™ (1) Copy of letter, Joseph J. Woodward to Rudolf Virchow, 14 May 1864. On file in historical records of AFIP. (2) Leikind. Morris C: Aniline Dyes — Their Impact on Biology and Medicine. From the Report of the Smithsonian Institution for 1957, Publication Number 4330, p. 437. (3) Lamb, op. cit., p. 38. (4) American Journal of the Medical Sciences 49: 106-113, New Series, 1865. "(i) Circular No. 6, Surgeon General's Office, War Department, November 1, 1865, p. 148. (2) American Journal of Science and Arts, Second Series, Volume LXII, Whole Number XCII, New Haven, September 1866, pp. 189-195. (3) Catalogue of the Microscopical Section of the United States Army Medical Museum, Washington, 1867. BACKGROUND AND BEGINNINGS 37 Figure 14. — Maj. Edward Curtis, U.S. Volunteers, who collaborated with Dr. J. J. Woodward in photomicrography. 38 ARMED FORCES INSTITUTE OF PATHOLOGY jMt/t^i / /Lf.*6n£<J, fsC&e^&ms, &&Cct*/ etrt-teO /l/c-i , ■ TjtaiUj 97tx 6n*o c^rfu; £/t6*i_ ijji<t4t(_ Art/ //a_ V /xyyajt^uy &*ij*r*i/tj ■OmwJ W&mqJL' yfl*v**o /3~ fe ■&$?/ c/<n^>ttAi^ awt Mi (rt*(i-> ) /u >>ir>(w^t'>i> ttaj As / t* t iAf// h/ y y/ . (JUL wiwautu J2.Jrtu»a*.'i (£0rcjiy fe fymic/t, i^Je^e^ntm-^ 1 5 <*■ r j -4 '■*" / ^ >naAivr. A Figure 15. — Photomicrography spreads. A. The idea of photomicrography had spread from the Medical Museum to the general hospitals, as shown by this memorandum of its use in the Douglas Hospital in Washington. powers of magnification, or those requiring extended exposure, the beam of light was passed through a pane of greased ground glass giving a diffused "white cloud" effect or, where necessary, through an achromatic condenser placed below the stage. Photographs were made with violet light, separated from the mean white light of the sun by passing the beam through a blue ammonio-copper solution, which also aided the operator by absorbing the heat BACKGROUND AND BEGINNINGS 39 B Ficurh 15.— Continued. B. The miscroscopc shown is one of those issued by the Surgeon General's Office. rays of the solar beam. Pictures were "snapped" by opening an aperture in the light-tight shield with which the window was fitted. The apparatus with which Surgeon Woodward and Assistant Surgeon Curtis worked was, to a large extent, of their own devising. At that time, all plates used in photography had to be sensitized, exposed, and developed while wet with chemicals mixed and applied at the time and place where the picture was to be taken. Projection printing had not been perfected, so that it was still necessary to expose the bulky wet plates in the size desired for the final print. With all these complications in photography, experience showed that better pictures were obtained by the employment of a "practical photographer * * * to manage the dark room" while the microscopist focused his "whole attention to the optical arrangements." Despite difficulties and complications, the pioneer photomicrographers made pictures which suffer not at all in com- parison with those made today. 4° ARMED FORCES INSTITUTE OF FATHOLOGY 1 B Figure 16. — Pioneer photomicrography. A. By sunlight. B. The microscope is wedded to the camera. BACKGROUND AND BEGINNINGS 4 1 Despite the frustrating delays of overcast weather and the vagaries of pass- ing clouds even on sunny days and determined to make the "process wholly independent of the weather," experiments were undertaken in 1869, using electric lights and magnesium lamps (fig. 17), such as were used for "magic lantern" lectures. Both proved successful, but the electric light was superior. In fact, Woodward reported to The Surgeon General on 5 January 1870, that an electric lamp, powered by a 50-unit battery, gave better results with less trouble than sunlight, and claimed for the Museum and for himself the credit of having demonstrated the serviceability of artificial lighting as a source of illumination for making negatives of high powers. The use of artificial light- ing made it possible, as Dr. Woodward reported in 1870, "to sit down quietly of an evening, and during 4 hours of work to produce from 12 to 30 negatives, or more" — a casual reference to the working habits which, along with his zeal and enthusiasm, accounted for his prodigious output. But even before his successful demonstration of the use of artificial light, Dr. Woodward, assisted by Dr. Curtis, made negatives which were clear and well defined at the mag- nification of 2,344 diameters, and which retained their clarity and definition even when enlarged photographically to 19,050 diameters (fig. 18). 28 Making photomicrographs, however, was but one facet of the work carried on by Lieutenant Colonel Woodward and Major Curtis. There was always the work on the massive medical volumes of the Medical and Surgical History and on the voluminous and growing materials of the Record and Pension Division, which had been committed to Woodward's care. The Museum and the Lincoln Tragedy The most melancholy mission assigned to Doctors Woodward and Curtis was that of doing the autopsy upon the body of President Lincoln, who died at 7:20 a.m., 15 April 1865. The pathologists were summoned to the White House at n a.m. to perform the grievous task of finding and removing the bullet fired into Mr. Lincoln's head by the assassin, John Wilkes Booth. Wood- ward's laconic technical report, addressed to The Surgeon General, gives no hint of the emotional tension under which he must have labored. After de- scribing the bloodshot condition of the eyes and lids, and the condition of the wound and surrounding tissue, swollen with blood, he traces the course of the bullet, which entered through the occipital bone about an inch to the left of 18 (1) Woodward, J. J.: Report to the Surgeon General .... on the Magnesium and Electric Lights as applied to Photo-Micrography, Washington, January 5, 1870. (2) Lamb, op. cit., p. 27. 42 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 17.— Photomicrography by artificial light. A. Using the electric light. B. Using the magnesium light. the median line, and just above the left lateral sinus, which it opened. It then penetrated the dura mater (the outer sheath covering the brain), passed through the left posterior lobe of the cerebrum, entered the left lateral ventricle, BACKGROUND AND BEGINNINGS 43 K A B D B P k R THE NT, Surgeon General'! Office, Army Medical Museum. PLEUROSIGMA AXGULATOM. I Pliologrnphcd by D IABB i uni*. Aj By Ouutii or 1. ] II n J J. VYuobWARD. Hit I.l- Orf. umI A— I. Swg, C. 9 A Figure i8. — A diatom, a form of unicellular life of microscopic size, is magnified by 2,540 diameters. and lodged in the white matter of the cerebrum just above the anterior portion of the left corpus striatum where it was found. The ventricles of the brain were full of clotted blood. A thick clot beneath the dura mater coated the right cerebral lobe. There was a smaller clot under the dura mater of the left side. 713-028'— 64 5 44 ARMED FORCES INSTITUTE OF PATHOLOGY But little blood was found at the base of the brain. Both orbital plates of the frontal bone were fractured, and the fragments pushed up toward the brain. The dura mater over these fractures was uninjured. The orbits were gorged with blood. 29 A more colorful and emotion-packed account has been left by Dr. Curtis, who wrote: Eleven o'clock comes; the two designated pathologists are ushered into what was the bedchamber of the deceased, a room furnished in simplest style. There sit in solemn silence some officers in uniform and some civilians, while the Surgeon General paces nervously to and fro beside another silent occupant of the chamber, a shrouded figure, cold and motionless, lying outstretched upon two boards laid across trestles * * *. The shroud is laid back, and see! A smooth clear skin fitting cleanly over well-rounded muscles, sinewy and strong * * *. Next see at the back of the head, low down and a litde to the left, a small round blackened wound, such as is made by a pistol-shot at close range. There is no counter-opening, so the missile has lodged and must now be found * * *. The part is lifted from its seat, when suddenly, from out a cruel vent that traverses it from end to end, through these very fingers there slips a something hard — slips and falls with a metal's mocking clatter into a basin set beneath. The search is satisfied; a little pellet of lead. So impressed was Dr. Curtis with the historical interest attached to the autopsy on the martyred President, that when he found some drops of the blood of the President upon his cuffs, Mrs. Curtis cut them off and saved them. Ultimately, they were presented to the Medical Museum where they may be seen today, along with a tiny sliver of bone which evidently had been driven into Mr. Lincoln's brain by the bullet and had adhered to the surgical instrument used by Dr. Curtis (fig. 19) . 30 Another connection between the Museum and the events surrounding the death of President Lincoln was the preparation by Hermann Faber (fig. 20), " (i) This account is taken from a true copy of the original, certified by Maj. George A. Otis, in the collection of the Medical Museum. In Gilmore, Col. Hugh R., Jr.: Medical Aspects of the Assassination of Abraham Lincoln. Proceedings of the Royal Society of Medicine, London, 47: 103—108, February 1954. It is Dr. Gilmore's opinion that "it is doubtful if modern medical practice could have saved Lincoln's life." (2) In a lecture at Walter Reed Army Medical Center on 25 May i960 (reported in the Washington Post of 25 May), Lt. Col. George J. Hayes, M.C., Chief of Neurological Service, said that even with the best of modern medical service, the President would have had no more than a 50-50 chance of survival, and even if he had survived, he would probably have been completely paralyzed on the right side and possibly unable to talk. M (1) Personal Recollections of the War of the Rebellion: addresses delivered before the Commandery of the State of New York Military Order of the Loyal Legion of the United States, Fourth Series, A. Noel Blakcman (editor), New York, 1912, includes "Last Professional Service of the War," pp. 54-65, read on 7 October 1908 by Companion Edward Curtis, Brevet Major, Late U.S.A. (2) From the bloodstains on the cuffs preserved by Mrs. Curtis, Col. Joseph H. Akeroyd, MSC, U.S. Army (now stationed at Brooke General Hospital) was able to type President Lincoln's blood as Type A. BACKGROUND AND BEGINNINGS 45 m Figure 19. — The bullet that ended President Lincoln's life, the instrument used to locate it, and bone fragments which adhered to it. medical artist at the Museum, of the earliest and most accurate sketch of the scene at the deathbed of the President. Mr. Faber, a German artist enlisted as a hospital steward and assigned to the work of what would now be called medical illustration, entered the Petersen house, in which Mr. Lincoln had died, immediately after the removal of the body. Nothing had been disturbed, and the sketch made was approved for accuracy by Surgeon General Barnes, who had been one of the physicians attending the President and who was present at his death. The original of the sketch is among the exhibits at the Medical Museum (fig. 21). 31 31 (1) Purtle, Helen R.: Lincoln Memorabilia in the Medical Museum of the Armed Forces Institute of Pathology. Bulletin of the History of Medicine 32: 68-74, January-February 1958. Miss Purtle's article discusses interestingly the various Lincoln items in the Museum, and gives an account of the acquisition of each one, which was mostly by gift. (2) Original sketch was presented on 30 January 1933, by Erwin F. Faber, son of Hermann Faber, to the Army Medical Museum. Letter on file in historical records of AFIP. 46 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 20. — Hermann Faber, whose sketch of the Lincoln deathbed scene gives some idea of the throng in attendance. The pictorial resources of the Museum were also called upon in the search for the President's assassin and his accomplices. "During the month of April," says a report of 1 July 1865 from Dr. Otis to The Surgeon General, "there were printed 1,500 photographs of the assassins of the President, for the assistance of the officers of justice." 3 ~ Presumably, these photographic prints were used to illustrate the reward posters of the War Department, dated 20 April 1865. This 1 Lamb, op. cit., p. 35. BACKGROUND AND BEGINNINGS 47 i*. 1 Figure 21. — This sketch, made by Hermann Faber immediately after the removal of President Lincoln's body from the Petersen house in which he died, was approved for accuracy by Surgeon General Barnes. poster is illustrated with a familiar pose of Booth, but the picture of David E. Herold is that of a schoolboy, while the one supposed to represent John H. Surratt is of some other individual entirely. Later, after the conspirators had been captured, tried, and executed, the War Department revised the photo- graphic part of the poster, changing the Booth picture to another pose, the picture of Herold to one made after his capture, and the Surratt picture to one of Surratt made after his capture and return to the United States. 33 The poster exhibited at the Medical Museum is one of the revised edition (fig. 22). Still another contact of the Museum with the Lincoln tragedy was the examination of the cervical vertebrae and section of the spinal cord of the assassin, John Wilkes Booth. These specimens were removed from the body officially identified as that of Booth after it was brought to Washington on 29 April 1865, and show the course of a conoidal bullet through the third, fourth, "Roscoe, Theodore: The Web of Conspiracy. Englewood Cliffs, New Jersey: Prentice-Hall '959- PP- 334. 335- Inc., ARMED FORCES INSTITUTE OF PATHOLOGY War Department, Washington, April 20, 1865, '-»-ffi )0,000 REW ARD TIE MURDERER Of our late beloved President, Abraham Lincoln, IS STILL AT LARGE, $50,000 REWARD Will bo Mid bj this Dop&rtniuDt Tor his appreh Municipal Authorities or State Executives. •.•ward offered by $25.i in Will be paid for iho upprelie $25,i in REWARD I of JOHN H SURBATT, MU or Booth'* Accomplice*. REWARD Will be paid for the apprehension ot David C. Harold, another of Booth's acoomplioea, U HI IBM "ill hi («<•! km jh> IpJtaMiBi u»< tal wfa ba angel ■■' «<»" w "" **">**> Sfl p-r-ww hnri».rtns •" ir^ntkiat lh- -ai.l |f(v.,u- 01 vital i ■■! ili-m. ..( (Man*, •* i-i-im^ (h- i r .'..ii.valiii.tii Of n--apr. vill I>r lri-nl.il ». arHiitiplin- in t*. m-itrUr at th* rVailkat •'■•! lae MIMMpM *"**'»■ ''"" " f "» ^■•W»a/T of Ma, a** .ban he ->*>>•-( tu trial befi.r.- ■ Hlftii) "Tmi'^j nl the paafahiiiiH nl UMTH l*t lar Mail .rf mnon-tjl I^omI be IfniwwJ <•""> tlw '*<"* '•> lfc» •"•i -""' f"J»!-hin.-i>l "' ,,,, ' MM * "* *" \ll ifw.il ,-itiirn- ai» »ti.*1.J l<> aid paESr JMtfjcv '>n ihia nrrwiiili Brer* m-m hoaM roaaiaVf III- '"•» • •iti»"ioai» <a*f*Mt >iUi 'hi-. -'■U-rnn detv, and r»~4 Beitbel nL-l.i hi dav until n be ■MMRfHaM KIM* I * H. ST ASTO.V *4**rvtar) «f War. - DHa"KIITlH5x. *HTH h Hw Keel : at - batea Ugh, -i'-l-r bald, kM faneeed Mm* hdr, UhI ■■•-. aad <MH» a heart bleak laniahreji JollV U .' jil'RRAT i. ab™t i fret, if iaoW llair ratiu-r ihui hh) Auk: "■- rather !i«bt. on beard. Wogtd wele* 149 or 1M potman. t '^atrikw niter r pair anil <-lear, -ill. o..kw in be) iWk Wet* I i«hl clothe* i<f Bee •Mil*, ?*™leVr» aqeatv reeM hone* rather promier nl : alb nartaw ; MU iTO|e«linK at il«- l"p fan-head rather fee aad*eeerr. bat broad ParU hieJau? <>n dw rinhi alee: etci ™thw '""it- tii- lip- an- linuli ~et. V "liw meo, ll.iHK ' MAKMf.fi ., fee fret aft in.-hr* hiffh. liaic ilark •'•'- -lara, I pfcjWW rather lire*?, full tare. BOM abort, hand *b"»rt awl Beaky, fret -mall i„«,.|, hiL-l ratlt >|nlra ^if! aotlva, iUfftMl* "Iim« hi" ct™ whea IkaUajt at a prnoa !HTl(3t -In acUilHM :o th. above, StaU ami -Uhi aiilhttnu-- !«**•■ otfi-rtiJ i.-«af>la a Figure 22. — Reward poster, revised. BACKGROUND AND BEGINNINGS 49 and fifth cervical vertebrae and the perforated spinal cord, all of which are now on exhibition in the Museum. 34 With the surrender at Appomattox and the collapse of the Confederacy, the war which had been responsible for the birth and growth of the Museum was approaching an end. Soon the grand armies of the Union would march in review up Pennsylvania Avenue and would disband to their homes. Many of the war-born institutions would come to a close — but not the Army Medical Museum. It would continue its mission of showing, by specimens, preparations, and illustrations, the nature and form of disease and injury, and teaching ways and procedures to alleviate suffering and lessen mortality according to the medical lights of the time. M (1) Purtle, op. cit., p. 74. (2) Medical and Surgical History of the War of the Rebellion. Surgical History. Washington: Government Printing Office, 1870, pt. I, vol. II, p. 453. CHAPTER III Second Wind Fortunately for the future, while most other elements in the great complex of military organizations which had just won the war were shrinking back toward pre-war standards of size and activity, the Medical Museum was per- mitted to go on its way undisturbed. It had won the respect of the new Surgeon General, loseph K. Barnes (fig. 23), who declared in the Annual Report for 1864, wri il e tne war was stm being fought, that "the Army Medical Museum continues to increase in value, and is already one of the most instructive patho- logical collections in the world." Thus, early in its history, the ultimate direction of the development of the Museum was foreshadowed by the use of the word "pathological" to describe its collections. The term was repeated in The Surgeon General's Report for 1865, with mention of the Museum's "patho- logical collection," which had grown to 7,630 specimens. Continued support of the project by Surgeon General Barnes was further evidenced by Circular No. 6 of the Surgeon General's Office, issued on 26 lune 1865, directing that "when Hospitals shall be discontinued and their Libraries disposed of, the most valuable works, Scientific, Historical, etc., shall be care- fully selected, packed and turned over to the Quartermaster's Department for transportation to Surgeon George A. Otis, U.S.V., Curator of the Army Medical Museum." Supply and Funding for the Museum Besides books, The Surgeon General interested himself in supplementing the financial support of the Museum by securing from the War Department the authority to have all "slush funds" of discontinued hospitals turned over to Major Otis for the use of the Museum. lust how much these funds amounted to does not appear, but the transfer, ordered on 27 September 1865, did not escape the attention of the Comptroller of the War Department, to whom General Barnes addressed an explanation and an inquiry on 21 July 1866. "This Fund," The Surgeon General wrote, "accrued during the war at the various General Hospitals from the sale of soap, fat and swill, and upon their discon- 713-02S" — 04 6 52 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 23. — Maj. Gen. Joseph K. Barnes, The Surgeon General of the Army for 18 years, 1 864-1882, who carried forward much of the program initiated by General Hammond. SECOND WIND 53 tinuance, was transferred to Dr. Otis by authority of the Honorable Secretary of War, to be expended for the use of 'the Army Medical Museum.' As this fund resulted from the sale of refuse subsistence supplies, it is believed to be embraced in the exceptions to the Act of 1849, which are stated in the Act of 1850." Under the circumstances, The Surgeon General asked, were not the "slush funds" exempt from the requirements of the Act of 1849 that "all moneys received from the customs, and all other sources, are to be paid into the Treasury without abatement or reduction" ? 1 Expenditures from the Museum fund, whether augmented by the "slush funds" or not, were extremely modest. As reported by Curator Otis to The Surgeon General on 1 July 1865, "* * * about two-fifths of the annual appropriation" of $5,000 had been paid for new cabinets to contain the speci- mens and $1,200 had been spent for "apparatus of a high order of excellence" for the "commodious photograph gallery erected in the yard of the Museum by the Quartermaster's department, and supplied with water, baths, screens, shelving, etc." Increasing Activities of the Museum Over 50 of the more interesting specimens in the Museum had been photo- graphed, and 40 complete sets of this series of pictures, each accompanied by a history, had been prepared for issue to medical directors of armies and depart- ments. This project had involved the making of more than 1,000 photographic prints, this being before the day of the halftone process of reproduction. In addition, 150 photographs were made to guide the wood engravers in making a like number of woodcuts for use in illustrating catalogs or other oublications relating to the surgery of the war. Additional apparatus for Surgeon Joseph J. Woodwards microscopical work had been purchased, and "for several months" Assistant Surgeon Edward Curtis had been engaged in experiments in photomicrography, with results already attained that had been favorably received. In the surgical department, 997 additional specimens had been mounted and cataloged since 3 October 1864, while the medical side of the Museum had "very complete" illustrative materials on the principal camp diseases, with many valuable additions on parasitic diseases and morbid processes in general. *(i) Lamb, Dr. D. S.: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, pp. 34, 37. (2) On file, National Archives, Accession Number 421 , Letter Book Number 42, SGO, p. 347. 54 ARMED FORCES INSTITUTE OF PATHOLOGY Enough glass jars were on hand to meet the Museum's needs for a year to come, and a sufficient quantity of alcohol had been distilled from confiscated whisky turned over to the Museum by the major general commanding in Washington to mount the wet preparations suitably. 2 The Museum, according to Dr. Otis's report, had not only enough glass jars and alcohol; it had also an appropriation for the coming year that was "ample." The fact that an annual appropriation of $5,000 was "ample" was explained later by Dr. Woodward in an article in Lxppincott 's Magazine for March 1871. "The building is already the property of the government, the officers and attaches all belong to the army; no extra-duty pay, no special allow- ances of any kind are awarded to any of them." Hence, as Dr. Woodward put it, "the total additional outlay * * * in consequence of the existence of the museum is so small that it may fairly be regarded as insignificant in comparison with the good to be obtained." 3 The Museum's Fourth Home In its 3 years of life, the Museum had been housed in three different build- ings and now, in its fourth year, it was to be moved again. Its new quarters were in the building (fig. 24) formerly occupied by Ford's Theater, on 10th Street, NW., where, on Good Friday of 1865, President Lincoln was shot. The building had been closed as a theater immediately after the assassination and had been in the possession of the Government since 8 July 1865. The purchase of the building "for the deposit and safekeeping of documentary papers relative to the soldiers of the army of the United States and of the Museum of the Medical and Surgical Department of the Army" was provided for by Act of Congress approved 6 April 1866, and on 7 May 1866, the building was assigned by Secretary of War Edwin M. Stanton to The Surgeon General. 4 Its interior fittings had been torn out and replaced with three floors, of which the upper floor was assigned to the Museum, the second floor to the surgical records of the Surgeon General's Office, and the ground floor to the Record and Pension Division of the same office. There had been an effort to fireproof the building by putting in brick floors resting on iron arches, sup- ~ (i) Lamb, op. at., pp. 35, 37. (2) Lamb, D. S.: Army Medical Museum, Washington, D.C. The Military Surgeon 53: 109-111, August 1923. 3 Woodward, J. J.: The Army Medical Museum at Washington. Lippincott's Magazine, Philadelphia, VII: 241, March 1871. *(l) Statement of Gen. Joseph K. Barnes. On file, National Archives, War Department Records, Letter Rook No. 14, SCO, 1878, p. 15. (2) U.S. Statutes at Large, volume 14, p. 23. SECOND WIND 55 Figure 24. — The fourth home of the Museum. ported by columns of iron. Stairways between floors were also of iron. The building had a front of 71 feet on 10th Street, and a depth of 109 feet. Museum workshops and a chemical laboratory were housed in small wings on each side. Into this building, "the scene of the assassination of the lamented Lincoln," in the words of Dr. Woodward, the collections of the Museum were to be moved. "What nobler monument could the nation erect to his memory," the doctor asked, "than this sombre treasure house, devoted to the study of disease and injury, mutilation and death?" 5 The movement of this "sombre treasure" from the building on H Street began on 12 November 1866, and continued until 8 December. The removal of the records, and that portion of the collection which had been housed at 180 Pennsylvania Avenue, followed between 11 December and the 21st of the month. On the 22cl, General Barnes advised the Quartermaster General's 'Woodward, Lippincott's Magazine, VII (1871), pp. 233, 242. 56 ARMED FORCES INSTITUTE OF PATHOLOGY office that the former quarters had been vacated, and transmitted the keys. 6 For the next 20 years, the life of the Museum was to be centered in the Ford's Theater building. From the beginning, the Museum had attracted an increasing number of visitors. Within a year of its establishment, its usefulness had been recognized by the civilian medical profession as well as by the military, and it was "weekly and almost daily" consulted by them. 7 To the medical profession, there was added another class of visitors with a special interest. In Dr. John H. Brinton's phrase, "officers and soldiers who had lost a limb by amputation would come to look up its resting place, in some sense its last resting place." Then, too, as Dr. Brinton wrote, "the public came to see the bones, attracted by a new sensation." While the Museum was still at the H Street address, Curator Otis reported, more formally, "the number of visitors to the collection constantly increases." 8 With the removal to the Ford's Theater building, and its tragic associations with the great appealing figure of Lincoln, the number of visitors mounted to such an extent that rules, approved by order of The Surgeon General and issued on 25 April 1867, were posted (fig. 25) .* Between mid-April of 1867 and the end of the year, some 6,000 persons, an average of about 25 for each day the Museum was open, had been registered in the visitor's book. Within the next 4 years, the number of visitors had trebled, 10 and the Museum had become established as one of the "sights" of Washington. When extra crowds came to the city, as upon the occasion of Lt. Gen. Ulysses S. Grant's inauguration as President in 1869, the visiting hours were extended — opening at 9 a.m. and closing at 4 p.m.; and at his second inauguration, in 1873, from 8 a.m. until 4 p-m. 11 The collections viewed by these visitors were divided into six groups or sections — surgical, medical, microscopical, normal human anatomy, compara- tive or animal anatomy, and miscellaneous articles (fig. 26). * (1) Lamb, op. cit., p. 41. (2) Lamb, The Military Surgeon, 53 (1923), pp. 112, 113. (3) National Archives, Accession Number 421, Letter Book Number 13, Military, p. 452. 'Original letter, John Hill Brinton to Joseph K. Barnes, 24 August 1863. On file in historical records of AFIP. *(i) Brinton, John Hill: Personal Memoirs. New York: The Neale Publishing Co., 1914, p. 189. (2) Lamb, op. cit., pp. 35-37. (3) Lamb, The Military Surgeon, 53 (1923), p. no. * War Department Records, Office of the Surgeon General. On file in National Archives. 10 (1) Lamb, op. cit., p. 44. (2) Woodward, Lippincott's Magazine, VII (1871), p. 239. "Original letters, George A. Otis to Charles H. Crane, 2 March 1869 and 28 February 1873. On file in historical records of AFIP. SECOND WIND 57 r ■ mo Mu 5f bLo C$nwM oM^djLXLoL W'JJLUvntL xr ;zzn jU>A '^yv^^^db "tew *^a> jq^^o^uu j o^Zd ^ oU|o^a>ob C^dU/J.^. rv^y-^o AaaJUL a-"yv<. sJajuJc^ tUY /ttvj- <AXa~-«^ . Figure 25. — The Museum adopts visiting rules. In addition, there was the beginning of a collection of crania, chiefly of American Indians, together with specimens of Indian weapons, dress, imple- ments, diet, and medicines, started in response to Circular No. 2 of the Surgeon's General's Office, issued on 4 April 1867. The chief purpose of the collection, officers of the Medical Department were informed by Assistant Surgeon General 58 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 26. — Main exhibit hall of the Museum, Ford's Theater building, 1 866-1 887. SECOND WIND 59 Charles H. Crane in a memorandum of September 1868, was "to aid the progress of anthropological science by obtaining measurements of a large number of skulls of the aboriginal races of North America." For that purpose, it was necessary "to procure sufficiently large series of adult crania of the principal Indian tribes to furnish accurate average measurements." 12 The articles relating to Indian archeology and anthropology, received along with the skulls and skeletons, belonged more appropriately in the Museum of Natural History, administered by the Smithsonian Institution. Professor Joseph Henry, Secretary of the Smithsonian, accordingly proposed to Surgeon General Barnes an exchange of the Smithsonian's anatomical materials for the Medical Museum's materials relating to the manners and customs and the archeology of the Indian tribes. The Surgeon General agreed, and over the next several years numerous exchanges were effected. The craniological collection was to have been the most important feature of a proposed catalog of the anatomical section of the Museum, to accompany the catalogs of the surgical, medical, and microscopical sections. In a letter of 18 January 1873, to the Honorable John Coburn, chairman of the House Committee on Military Affairs, Surgeon General Barnes strongly urged such a catalog as "simply a necessity" to make the collections accessible to students. "Anthropologists in different parts of the world," he wrote, "are anxious for the data * * * for comparison with similar data published in Sweden, Russia, Germany, Italy, France, and England. The French Government, through its Legation here, after making repeated applications for the tables of cranial measurements, employed an artist to make casts and take photo- graphs of a series of typical skulls; and a professor of Bonn made the study of the collection the object of a trip across the Atlantic." The Military Affairs Committee reported favorably on the bill authorizing the publication of the catalog at a cost for 1,000 copies estimated at $26,200, but the bill was not passed and the catalog was not published. 13 After some 30 years of medically unfruitful measurement of the cubic capacity, the length and breadth, the facial angle, and other characteristics of skulls, it was decided that such determinations pertained more properly to anthropology than to medical study. On 8 May 1898, therefore, the Museum's "(i) War Department Records, Office of the Surgeon General. On file in National Archives. (2) Lamb, op. cit., pp. 43, 50, 51. (3) Lamb, The Military Surgeon, 53 (1923), pp. 117, 118. "House of Representatives Report 56 (421! Congress, 3d session), 4 February 1873, "The Army Medical Museum." 6 ARMED FORCES INSTITUTE OF PATHOLOGY collection of crania, by then numbering 2,206 specimens, was transferred to the Museum of Natural History." Exchanges of duplicate and supernumerary specimens with other institu- tions and individuals, and purchase of private collections increased the hold- ings of the Museum. Among the former was the exchange of pictures and models, suitable for class demonstration, which had been prepared for use in the projected Army Medical School, vetoed by Secretary Stanton, for a cabinet of pathological specimens collected by professors of the National Medical Col- lege of Washington, which had taken over the buildings on H Street vacated by the Museum and which, under its present name of the School of Medicine of George Washington University, still occupies the site. Among the latter was the purchase at Richmond, Va., on 22 April 1868, from the widow of Prof. William Gibson, University of Pennsylvania, of a collection of 413 specimens, 54 casts and wax models of human anatomy, and 42 oil paintings by Sully of various diseased conditions. 15 Still another source of specimens for the Museum's collection was the medical staff of the Bureau of Refugees, Freedmen, and Abandoned Lands, better known as the Freedmen 's Bureau. Col. L. A. Edwards, chief medical officer of the Bureau, appealed on 6 June 1868 to "all Acting Assistant-Surgeons in the employment of the Bureau, and especially those who are in charge of Freedmen's Hospitals, [to] avail of every opportunity of contributing to the Anatomical and Pathological collections of the Army Medical Museum." Offi- cers were especially urged to make, or have made, autopsies and to forward to the Museum "all pathological specimens of interest thus obtained." ' Praise From Foreign Visitors By 1871, when Dr. Woodward's description of the Museum was published in Lippincott's Magazine, the surgical section consisted of about 6,000 mounted specimens and 350 plaster casts, the medical section of 1,150 specimens, and the microscopical section of more than 4,000. The anatomical section included nearly 1,000 human skulls and skeletons, of which 376 had been transferred by the Smithsonian in exchange for Indian weapons, utensils, and other arti- facts, while a still larger number had been contributed by medical officers. 17 The section of comparative anatomy (fig. 27) included more than 1,000 animal " (1) Lamb, op. cit., pp. 52-54, 56, 57, 75, 76, 81, 89, 91, 97, 108, 114. (2) Lamb, The Military Surgeon, 53 (1923), pp. 118, 119. ,s (1) Lamb, op. cit., pp. 48, 49, 56. (2) Lamb, The Military Surgeon, 53 (1923), pp. 116, 117. '" War Department Records, Office of the Surgeon General. On file in National Archives. 17 (1) Woodward, Lippincott's Magazine, VII (1871), pp. 235-238. (2) Lamb, op. cit., p. 56. SECOND WIND 61 Figure 27. — Early "dry" exhibits in comparative anatomy at the Medical Museum included skeletal remains of a variety of mammals, birds, and reptiles. 62 ARMED FORCES INSTITUTE OF PATHOLOGY skulls and skeletons, with special attention paid to the anatomy of the horse. The majority of the 6,000 surgical specimens were, as was to be expected, illustrative of military surgery, though other surgical cases were already well represented. Over 400 missiles extracted from wounds were included, while sabers and other cutting weapons were responsible for 22 specimens. "Altogether," wrote Dr. Woodward, "it may safely be asserted that in the illustration of military surgery this section not only exceeds any other surgical museum in the United States, but surpasses any similar collection hitherto made in the Old World — a fact that has been frequently and willingly admitted by foreign savants well acquainted with the subject who have visited Washington." 18 Dr. Woodward doubtless referred to statements by Dr. Berenger-Feraud of Paris, published in the Gazette des hopitaux civils et militaires, Paris, and Saint George Mivart, published in Nature, London, in 1870. In the Paris pub- lication, Dr. Berenger-Feraud said that the United States had done as much in the building of an anatomicopathological museum in 5 years as had been done in Europe in a century, and that the three catalogs which had been published — surgical, medical, and microscopical — contained more specimens than were in all the like museums in Europe combined. In recognition of the fact that the materials in the Museum had been chiefly collected during the American Civil War, Mr. Mivart said in the London publication that "the Americans are a wonderful people. There are few other nations which would have been capable of so utilizing the results of a protracted internecine war as to make them available in after years toward the advancement of medical science and alleviation of human pain." 19 Some foreign visitors, according to Dr. Woodward, were not only impressed by the scope of the collections of the Museum, but "seem to have been par- ticularly struck with the free access given to the general public and to private soldiers, who in less enlightened communities would be excluded from such an institution." While the majority of the 1,150 specimens in the medical section of the Museum illustrated "morbid conditions of the internal organs in fever, chronic dysentery and other camp diseases," Dr. Woodward reported, "the number of preparations which exhibit the morbid anatomy of the diseases of civil life" had been constantly increasing since the war. These included "pathological '* Woodward, Lippincott's Magazine, VII (1871), p. 236. "(i) Gazette des hopitaux civils et militaires, Paris, XLIII: 293, and Nature, London, 11 August 1X71., p. 290 (.is cited by Lamb, op. cit., pp. 57, 58). (2) Lamb, The Military Surgeon, 53 (1923), p. 120. SECOND WIND 63 pieces" relating to the diseases of women and children — which, after all, were not foreign to the practice of medicine by army doctors responsible for the health of dependents as well as for that of military personnel. The iSAuseum and the Medical Profession Many of the post-war contributions to the Museum were from physicians and surgeons in civil life who, as the institution became better known after the war, gave specimens developed in their practice — the beginning of the close relationship between the Museum and its successor, the Institute, and the medical profession, the results of which have been so fruitful." Among the more interesting of the early contributors to the collections were former Confederate surgeons, including three presidents of the American Medical Association, Dr. Henry F. Campbell of Augusta, Ga., Dr. Paul F. Eve of Nashville, Tenn., and Dr. Hunter McGuire of Richmond, professor of surgery in the Medical College of Virginia, but perhaps better known as the chief surgeon of "Stonewall" Jackson's Corps in the Army of Northern Virginia. 21 The collections of the Museum, housed on the third floor of the building, were lighted by windows front and rear and by a large central skylight. Beneath the skylight was an oblong opening in the floor which let the light fall into the space below. All available wall space was covered with display cases, which also stood in ranks on the floor. In these cases, which were of pine and painted white, the specimens were exhibited. Most of the surgical specimens were mounted "dry," while almost all the medical specimens were "wet" preparations, preserved in wide-mouthed jars, closed with ground glass stoppers to the undersurfaces of which were attached glass hooks from which the specimens were suspended in the preservative fluid (fig. 28)." The ISAuseum and the Congress in the 1870' s While supplies of alcohol distilled from confiscated whisky remained ample, at least until 1876, with the growth of the Museum and its work, the annual appropriation of $5,000 — which had seemed ample to Dr. Otis in 1865 — ceased "° Woodward, Lippincott's Magazine, VII (1871), pp. 236, 237, 239. 21 (1) Otis, George A.: Notes on Contributions to the Army Medical Museum by Civil Practitioners. Boston Medical & Surgical Journal 98: 163-169, 1870. (2) Lamb, D. S.: The Army Medical Museum — A History. Washington Medical Annals 15: 9, January 1916. (A paper presented before the Medical Society of Washington, 1 November 191 5.) 22 Woodward, Lippincott's Magazine, VII (1 871 ), pp. 234, 236. 64 ARMED FORCES INSTITUTE OF PATHOLOGY W s± Figure 28. — Wet specimens on display enclosed in glass. to be sufficient. The Surgeon General accordingly addressed a letter to the Honorable James A. Garfield, chairman of the Committee on Appropriations of the House of Representatives, on 6 January 1872, justifying an estimate of $10,000 for the Museum and also the Surgeon General's Library. "No insti- tution," he said, "has reflected greater credit upon its Government both at home and abroad than the Army Medical Museum and its present size and steady increase render the expense of keeping it in good order and preservation larger than heretofore, although still small when compared with the cost of other institutions of similar character." The request was looked upon with favor, but the Senate Appropriations Committee cut the item from $10,000 to $5,000 whereupon, on 15 May, General Barnes wrote Chairman Cole, urging recon- sideration and stating that the lesser sum was not sufficient to maintain the growing collection and "to make some of the more valuable results known to the profession of the country, a course which has been pursued so far as means would allow." The appeal for restoration of the House figure was not success- ful, and the next year's appropriation remained at $5,ooo. 23 An interesting sidelight is thrown on the problem of the congressional relations of the Museum by a bit of correspondence between Curator Otis and Brevet Lieutenant Colonel John Shaw Billings of the Surgeon General's Office, preserved in the Armed Forces Institute of Pathology records. On 7 May 1870, "On file, National Archives, Accession Number 421, Letter Book Number 50, SGO, pp. 37, 245. SECOND WIND 65 Otis wrote, "I have on hand about thirty volumes of surgical photographs. Is it practicable to have them bound at the Congressional Bindery ?", to which inquiry Dr. Billings responded on the same day, "Dear Doctor: I do not think it will be well to try to get any binding done at the Gov't, office until Congress adjourns. It wouldn't be done I am sure and I doubt whether the attention of the Committee on Printing would not be called to it— which thus far has been avoided." 2i Enlarging the Aims of the Museum Despite limited financial support, the Museum continued to grow. By 1876, in its 10th year in the Ford's Theater building, the surgical section con- tained 6,539 specimens, the medical section 1,279, the microscopical section 7,275, the human anatomical section 1,254, tne comparative anatomical section 1,522, and the section for miscellaneous articles 240. The primary emphasis remained on preserving specimens illustrative of the wounds and diseases which produced death and disability in the military forces, with the purpose of reducing mortality and alleviating suffering among soldiers, but by 1876, Dr. Woodward wrote, it had become "the desire of the Surgeon General that so far as the means placed at his disposal will permit, the collection shall be extended so as to embrace all forms of injuries and diseases, so that eventually it shall become a general pathological Museum, accessible for study to all medical men who are prosecuting original inquiries That the original purpose remained uppermost is indicated by the reports of foreign observers, who were struck by the richness of the collections in gunshot and arrow wounds, and were impressed with the diligence and de- votion which had permitted the making of such collections in the midst of a great war. "Among the foreign visitors, whose wide experience made their commendation peculiarly gratifying," said The Surgeon General in his annual report for 1875, "were Baron Schwartz-Sanborn, Director of the Vienna World Exposition of 1873, and Professor John Eric Erichsen, of University College, London." Professor Erichsen, who visited the Museum in the fall of 1874, said in a lecture on American surgery at the University College on 9 November of that year: There is one Museum which is so unique, so admirably arranged, and so interesting, that I must direct your attention to it for a few minutes. It is the Museum of the Army Medical Department at Washington. This magnificent collection, illustrating not 2t Original letters on file in historical records of AFIP. * (1) Lamb, op. cit., p. 76. (2) Lamb, The Military Surgeon, 53 (1923), p. 125. 66 ARMED FORCES INSTITUTE OF PATHOLOGY only every possible variety of gunshot and arrow injury, but also those diseases which are more fatal than the bullet to an army in the field or in camp, has under the able superintendence of Surgeon General Barnes, and of Drs. Otis and Woodward, been most admirably arranged and catalogued * * *. Many of the specimens in this Museum are quite unique * * *. 26 Varied Uses of the Museum The Army Medical Museum became somewhat of a focus for the intellectual and scientific life of the Washington of the 1870Y The fortnightly meetings of the Philosophical Society, the leading intellectual group of Washington, were held at the Museum, and the charter meeting of the now famous Cosmos Club, and its first election of officers, was held at the Museum on 13 December 1878. 27 When the American Medical Association met in the Capital in 1868, the Museum was the scene of a reception to its members given by The Surgeon General. A like courtesy was extended to the members of the National Academy of Sciences in 1870. Upon both occasions, as well as at other times, Dr. Woodward showed transparencies of some of the remarkable photomicro- graphs made at the Museum. Another notable visitor for whom The Surgeon General had a reception at the Museum, on 11 December 1872, was Prof. John Tyndall of London, whose studies in sterilization by heat had not yet reached their culmination but who, already, had dealt mighty blows to the theory of spontaneous generation. 28 Scientific Skepticism As to Bacteria Just a month before the reception at the Museum for one whose careful re- searches were to do so much toward establishment of the theory of bacterial in- fection, Dr. Woodward paid his respects to the theory, in a letter to the editor of the Washington Evening Star, published on 13 November 1872. "During the last few years," the letter read, "it has been a favorite speculation in certain quarters, that epidemic diseases are produced by the presence in the atmosphere of vegetable germs, so minute as to be visible only with the microscope. Con- siderable labor has been bestowed upon microscopical work in this direction, but the results which have been confidently announced from time to time by M (i) Annual Report, Surgeon General Barnes, 1875, p. 12. (2) The Lancet, London, 1874, II: 720 (quoted in Lamb, op. at., pp. 67, 68). "' Cosmos Club Bulletin, Washington, volume 13, Number 3, March i960, p. 4. 38 Lamb, op. cit., pp. 49, 51, 54, 55, 57, 62. SECOND WIND 6 7 enthusiasts have been either contradicted or so materially modified by subse- quent observations that the question still remains in the domain of mere speculation." Referring to the opportunities for "charlatanism" and for honest mistake in this field, he added, "nevertheless I certainly regard the microscopical forms which exist in the atmosphere and their possible effect on man as a proper matter for scientific study, and by way of contributing my mite to the difficult subject * * * I have collected the organic forms from a quantity of air of a stable in this city where there are a number of sick horses, and sub- mitted them to the highest power of the microscope, without finding any which are not usually encountered when no epidemic is prevailing * * *."" His opinion had undergone little change when, 7 years later, in part II of volume I of the "Medical and Surgical History of the War of the Rebellion," he used with approval the derisive term "bacteriafanatics" and, speaking of the persistence of the "general hypothesis that bacteria are in some way disease- producers," said that Virchow's "splendid rhetoric has lent plausibility to argu- ments which appeal almost as much to faith as to reason." Dr. Woodward was well aware of the presence of inconceivable numbers of bacteria, but he was doubtful of the disease-producing effects of what he referred to, somewhat slightingly, as "those convenient bacteria which have played so conspicuous a part in modern pathological speculation." 30 Ironically, the expressions of scientific skepticism on the part of Dr. Wood- ward were published 2 years after Capt. A. C. Girard, stationed at Fort Randall, Dakota Territory, had reported enthusiastically on the results of Joseph Lister's technique in antiseptic surgery, which he had observed on a trip to Europe. Captain Girard was willing to "leave to other pens the task of elucidating" the nature of bacteria and how they acted upon the body, but he stoutly main- tained "the indisputable fact that there are germs or ferments in the atmosphere which will produce putrefaction in wounds, and that by preventing their ingress we can in most cases avert the complications which cause the greatest fatality in surgery * * *. This is the key to Lister's system." Captain Girard's report was published to the Medical Corps in Circular Orders No. 3, Surgeon General's Office, 20 August 1877, but, perhaps because the report and the Lister system dealt with surgery while Dr. Woodward was concerned with medicine, neither the Girard report nor Lister himself is mentioned in the 1879 volume of the History. 29 (1) Lamb, op. cit., pp. 61, 62. (2) Lamb, The Military Surgeon, 53 (1923), pp. T20. lai, 123. 30 Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Gov- ernment Printing Office, 1 879, pt. II. vol. 1 , pp. 370, 374, 595. 68 ARMED FORCES INSTITUTE OF PATHOLOGY The Third Curator The stupendous task of compiling and writing the Medical and Surgical History was drawing to its close when, in May 1877, Dr. Otis suffered a stroke of paralysis, and in May 1880, Dr. Woodward was compelled by the state of his health to go to Europe. On 23 February 1881, Dr. Otis died, at the early age of 51, and was succeeded as Curator of the Museum by Surgeon David Low Huntington, U.S.A. (fig. 29), who also took over the task of completing the third and final part of the surgical volumes of the great History upon which Dr. Otis was engaged at the time of his disability and death. 31 Back from Europe, Woodward suffered a broken leg on 1 January 1881, when his horse slipped and fell on him, but he was able to resume work at the Museum in time to be one of the physicians attending President James A. Garfield, when the President was shot and fatally wounded by Charles J. Guiteau on 2 July 1881. The shooting took place in the waiting room of the Baltimore & Potomac railroad depot in Washington, where the President had gone to board a train to join his wife on the New Jersey seashore. The first shot from Guiteau's pistol grazed the President's arm; the second entered his back and was not located until after his death on 19 September 1881. Probing failed to find it, as did an "induction-balance" device of Prof. Alexander Graham Bell which was supposed to locate metal objects by an electrically induced sound. Every- thing known to the medical art of 1881 was tried, but in the prevailing state of medical knowledge, there was nothing that could be done to save the President's life. The Museum and the Garfield Tragedy Eighteen hours after his death, in a seaside cottage at Elberon, N.J., where the President had been taken to escape the heat of Washington and the miasmas of the swamplands south of the White House, an autopsy was performed by Dr. Daniel Smith Lamb, pathologist of the Museum, with Dr. Woodward acting as recorder (fig. 30). The autopsy disclosed the course and location of the fatal bullet, which had entered the victim's back about 4 inches to the right of his spine ; had broken the eleventh and twelfth ribs to the right of the spine ; passed through the first lumbar vertebra, missing the spinal cord; grazed the splenic artery; and stopped behind the pancreas, some 10 inches from the point of 31 (1) Lamb, op. cit., pp. 77, 80-82. (2) Lamb, The Military Surgeon, 53 (1923), p. 127. SECOND WIND 6 9 Figure 29. — Surgeon David Low Huntington, U.S. Army, third Curator of the Museum, 1881-1883. entrance. 1 " The President's vertebrae are preserved in the Medical Museum, with the course of the bullet traced through them by a plastic rod. Dr. Woodward's health failed early in 1882, and in February he left for Europe — to return no more to the Museum. He did not participate in the " (1) Lamb, D. S.: Official Record of the Postmortem Examination of the Body of President James A. Garfield. American Journal of the Medical Sciences 82: 583-590, 1881. (2) Lamb, op. at., p. Si. 7" ARMED FORCES INSTITUTE OF PATHOLOGY / ' \ 111 S • . ft, 0) (J r ■ . V 6i ^ urn* ' 9j Figure jo.— Bullet from the body of President Garfield, located at autopsy by Dr. Daniel Smith Lamb, pathologist of the Museum. SECOND WIND 7 1 autopsy performed by Dr. Lamb on Guiteau, the assassin, who was executed on 30 June 1882. Special attention was given to the brain, sections of which were parceled out to eminent alienists for examination, but no evidence of unusual pathological change was found. 33 Thus it was, that in the first 20 years of its life, the Museum attaches were called upon to participate in the activities growing out of the assassinations of two Presidents of the United States, and the Museum itself became the repository of the melancholy medical memorabilia of two great national tragedies. 33 (1) Lamb, op. cil., p. 83. (2) Lamb, Washington Medical Annals, 15 (1916), p. II. (3) Medical News, Philadelphia, volume 41, p. 13, 1882. CHAPTER IV Broadening the Base The Ford's Theater building was at best a makeshift home for the Museum, the Library, and the historical records of the Surgeon General's Office, and with the passage of time and the growth of the collections, it became less and less suitable. By 1880, it has ceased to be adequate for the Museum alone, even if all its space had been available for museum purposes. As it was, the Museum was confined to the crowded and cluttered third floor, the books of the Library were packed two and three rows deep on the shelves on the second floor, and the hospital records of the Civil War, with the clerks at work on them, filled the ground floor to overflowing. "In time," wrote Maj. Charles Smart, Surgeon, U.S. Army (fig. 31), who was assigned to complete the work on the medical volumes of the History after Dr. Joseph J. Woodward's disability, "there came to be no room for even the storage of books and specimens, not to speak of facility of reference or advantageous display." 1 There was, moreover, distinct danger of utter destruction of irreplaceable records and materials by fire. The floors were of noncombustible materials, it is true, but the roof was not, and the walls were so weak and so much out of plumb as to threaten imminent collapse in case of fire. Indeed, the ordinary use of the building was limited by a prohibition "against putting heavy articles in the upper floor for fear of pushing out the west wall." " Inadequate Quarters In his annual report for 1880, Surgeon General Barnes "invited attention to the overcrowded and unsafe condition" of the 10th Street building. Growth of the collections, he wrote, had made "the space available for their preservation quite inadequate, not merely for their proper display, but even for satisfactory 1 Smart, Charles: The Army Medical Museum and the Library of the Surgeon-General's Office. Journal of the American Medical Association 24: 577, 20 April 1895. 2 Congressional Record, 48th Congress, 2d session, p. 1767. [That fears for the safety of the Ford's Theater building were not exaggerated was demonstrated on 9 June 1893, when the floors fell through to the basement with a loss of 22 lives and 68 injuries.] 74 ARMED FORCES INSTITUTE OF PATHOLOGY Ficure 31.— Maj. Charles Smart, Surgeon, U.S. Army. storage." The Surgeon General earnestly recommended an appropriation for a building which should be "absolutely fireproof, but no expenditure for mere architectural display is required." Pursuant to The Surgeon General's recommendation, President Rutherford B. Hayes, in his last annual message to Congress, urged such an appropriation. The collection of books, specimens, and records constituting the Army Medical Museum and Library are of national importance," the President said. Their destruction would be an irreparable loss not only to the United States but to the world * * *. These valuable collections are now in a building which is peculiarly exposed to the danger of destruction by fire. It is therefore earnestly recommended that an appropriation be made for a new BROADENING THE BASE yc fireproof building, adequate for the present needs and reasonable future expan- sion of these valuable collections. Such a building should be absolutely fire- proof; no expenditure for mere architectural display is required. It is believed that a suitable structure can be erected at a cost not to exceed $250,000." :1 The movement for a new building was furthered by Surgeon General Barnes in a letter of December 1881, to Secretary of War Robert T. Lincoln, son of the President. The Library, he said, contained 51,500 volumes and 57,000 pamphlets, while the 22,000 specimens of the Museum were "unique in the completeness with which both military surgery and the diseases of armies are illustrated." These collections, he added, "although originally founded chiefly" for purposes of military medicine, "have proved to have manifold uses in con- nection with the general progress of medical science in the United States, especially in relations to the public health, uses which are perhaps of equal importance to the nation." As to the worth in money to be placed on the collections, The Surgeon General wrote that the value of that part of the Government property collected in the old building "which could be replaced by money" could not be less than $250,000, but that "much of it could never be replaced, either by time or money." Surgeon General Barnes had the satisfaction of seeing his recommendation approved by Secretary Lincoln on 6 January 1882, and made the subject of a special message to Congress by President Chester A. Arthur, on die 19th of the same month. 4 On 28 February 1883, almost at the end of the second and final session of the 47th Congress, and too late for further action, the House Committee on Public Buildings and Grounds reported favorably on the bill, H.R. 7681, ap- propriating $200,000 for a building in the vicinity of the National Museum and the Smithsonian Institution: The collections of records, books, and museum specimens, * * * in imminent danger of destruction, are of great national importance * * *. The Library now con- tains about 70,000 volumes * * *. The museum is by far the best collection of materials relating to military medicine and surgery in existence. They number over 20,000 speci- mens * * *. Some 40,000 persons visited the museum during the year 1881 * * *. The medical profession throughout the country have presented to the committee a large mass of testimony commending the unequaled collections, both of the Library and ""Documents with Reference to Proposed Building for the Army Medical Museum and Library of the Surgeon General's Office" — Copy of Report No. ioor, annex B, Committee on Public Buildings and Grounds, on H.R. 7681, 47th Congress, 2d session, 28 February 1883. 4 Senate Executive Document 65, 47th Congress, 1st session. 713-02S>' — 64 7 76 ARMED FORCES INSTITUTE OF PATHOLOGY Museum, and have earnestly requested that suitable provision be at once made for their preservation * * *. The building proposed is plain, fireproof, with a large amount of floor space the building would cover an area of about 21,000 square feet, contain about 1,350,000 cubic feet, and at a cost of $200,000, recommended by the bill, or about 15 cents per cubic foot. 5 Support From the Medical Profession Before the new Congress, the 48th, opened its first session, the medical profession made further representations favoring a new building for the Museum and the Library. Professors Samuel D. Gross of Philadelphia, Austin Flint of New York, and Oliver Wendell Holmes of Boston, three giants in American medicine, addressed a letter to members of the American Medical Association calling attention to the need for a new building as a subject of great importance to the medical profession and to the public welfare. They wrote: There has been formed at Washington, under the direction of the Medical Department of the Army, a Museum of Military Medicine and Surgery, and in connection with this, a Medical Library, each of which is believed to be the largest and best of its kind in the world. The building in which these invaluable collections are stored, collections which can never be replaced if destroyed, is insecure, not fire-proof, in the midst of highly inflam- mable buildings, and overcrowded. At the close of the last session of Congress, too late for action, a bill appropriating funds for a fire-proof building * * * was reported It appears to the undersigned in the highest degree desirable that this bill should become a law at the next session of Congress, and to further this end, that the physicians of the United States should explain to the members of Congress * * * the great importance of these collections of books and specimens, the propriety of granting the funds necessary for their maintenance and preservation, the inexpediency of separating them, or removing them from the management under which they have so successfully been conducted, and the necessity of a fire-proof building, that they may be handed down safely to coming generations. Responding to his communication, the American Medical Association, meeting at Cleveland, Ohio, on 5-8 June 1883, adopted a strong memorial and named a special committee to present the matter to Congress and to call the attention of State medical societies to the importance of action. To the dis- tinguished medical men who had originated the action, there were added on the special committee Doctors D. W. Yandell of Louisville, T. G. Richardson of New Orleans, and H. F. Campbell of Augusta — all three ex-Confederate sur- geons and future presidents of the American Medical Association. '' H.R. Report 1995 (H.R. 76S1), 47th Congress, 2d session. BROADENING THE BASE Action in support of the new building taken by local, county, and State medical societies in at least 19 States was reported to the Congress by the special committee of the American Medical Association, which also addressed its own communication to Congress on behalf of the national association, stressing "the urgent need to secure the preservation and full benefits" of the Museum and Library. "These collections," the committee said, "already the largest and most valuable of their kind in the world, are of the greatest importance, not only to the physicians of this country but to all whose welfare and lives depend on medical skill; and hence what we ask is emphatically for the general good." e A New Surgeon General Presses for a New Building Before further action toward a new building was taken, Surgeon General Barnes, who had retired in 1882, died in April 1883. His successor in office, Charles H. Crane, who had been Assistant Surgeon General since 1863, ^ so died in October 1883, and was succeeded as Surgeon General by Robert Murray. 7 General Murray continued to press the movement for a new building, filing with Congress a printed document setting forth the "imperative need of such a building" and the "pressing necessity of placing in security these collections, probably the most valuable of the kind in the world." 8 General Murray's submittal was in support of bills introduced in the Senate by Senator Joseph R. Hawley of Connecticut (S. 403) and in the House by Gen. William S. Rosecrans, Representative from California (H.R. 48), in December 1883, in the early days of the first session of the 48th Congress. 9 On 13 December 1883, Secretary Lincoln, renewed his recommendation, re- marking that he did so the more strongly because the appropriation of $200,000 6 (i) Congressional Record, 48th Congress, 2d session, p. 1768. Documents, Proposed Building, loc. cit., pp. 3-6. (2) Scrapbook of clippings. On file in historical records of AFIP. 7 In announcing General Barnes' death, the Adjutant General's office ascribed to him the founding of the Medical Museum and the launching of the History. Dr. Hammond called attention to the error, which resulted in a change in the general order, which was made to read "Under the fostering care of Edwin M. Stanton, Secretary of War, he (General Barnes) accomplished the successful establishment of the Medical History of the War and the Medical Museum." Taking the word, " 'accomplished' in its primary signification of 'completed'," Dr. Hammond was satisfied with the amendment. General Barnes, he said, " 'completed' their successful establishment." (From the official correspondence between Surgeon General William A. Hammond, U.S. Army, and the Adjutant General of the Army, relative to the founding of the Army Medical Museum, and the inauguration of the Medical and Surgical History of the War of the Rebellion, New York, 1883). * Senate Executive Document 12, 48th Congress, 1st session. "Congressional Record, 48th Congress, 1st session, pp. 37, 59. [General Rosecrans was in command in West Virginia where the future General Hammond, founder of the Medical Museum, made his first reputation in the Civil War.] „g ARMED FORCES INSTITUTE OF PATHOLOGY provided by the bill was $50,000 less than the amount originally proposed. On the 17th, President Arthur again submitted the documents in the case to the Congress, and the bills and the recommendations were referred to the respective Committees on Public Buildings and Grounds of the two houses of Congress, to which also went the numerous petitions and memorials of the medical profession. 10 On 28 May 1884, William Mahone, late major general in the Confederate service but then Senator from Virginia, reporting for the Committee on Public Buildings and Grounds, submitted an amended bill for S. 403, carrying an appropriation of $200,000, which the Committee recommended for passage and which, on 3 June, was passed by the Senate and sent to the House. 11 It was not until the second and final session of the 48th Congress was nearing its close, however, that final action was taken. On 16 February 1885, H.R. 48, the bill introduced by General Rosecrans, came before the House of Representatives. The bill, appropriating $200,000 recommended for passage by the Committee, was submitted by its chairman, Representative Strother M. Stockslager of Indiana. Objections to Proposed New Building Opposition was expressed on the grounds that the medical records of the Civil War should be housed in the Pension Building or in the State, War, and Navy Building, both of which were then under construction ; that the medical library should be merged with the Library of Congress in the building then in contemplation; and that the Medical Museum could be accommodated either in the new State, War, and Navy Building or in the Smithsonian Institution. One opponent, Mr. Potter of New York, went further, saying that he did not believe in "preserving the relics and bones or wounds caused by the war at any place in our capital" and expressing the wish that "they were all buried and covered all over with green grass and hidden from sight forever." To meet objections, proponents of the new building pointed out that the buildings then being constructed for other purposes would not be adequate to house the collections and the records of the Surgeon General's Office ; also, that these features should be kept together, and that the present building, in the words of Representative Stockslager, was a "mere tinder-box" and in an "absolutely dangerous condition." 10 Senate Executive Document 1 2, 48th Congress, 1st session. " Congressional Record, 48th Congress, 1st session, pp. 4603, 4766. BROADENING THE BASE 79 In the course of the debate, Representative Lyman, of Massachusetts, ex- pressed the views of an informed layman on the state of the medical art and the contributions of the Museum to medical progress. "Most of the progress" in medicine and surgery, he said, "has been made during the last half century, and the next fifty years promise a great advance * * *. There is no subject more baffling, and yet it is yielding to study. Already the studies of disease have rendered it highly probable that these plagues are caused by the fertili- zation of microscopic germs within the body; so that these diseases are a death struggle between man and a parasitic fungus. But already we discern a hope that these germs may be used for inoculation and may protect us from such diseases, just as vaccination protects against smallpox." "These profound studies, so essential to the welfare of our people, are carried on under the fostering care of our National Medical Museum, whose library, now the first in the world, and whose not less admirable collection of military pathology are placed at the disposal of all investigators." After an hour's vigorous debate, H.R. 48 was passed by a vote of 181 to 23. Transmitted to the Senate, the bill was recommended for passage by the Committee, which reported its action through Senator Lott Morrill of Vermont, and was passed without objection. On 3 March, the last day of the session, President Arthur reported to Congress that, on the day before, he had signed the bill, which thereby became law. 12 The bill, as finally passed, authorized the construction of a brick and metal building upon the government reservation in the vicinity of the National Museum and the Smithsonian Institution, the exact site to be selected by a commission composed of the Secretary of War, the Architect of the Capitol, and the Secretary of the Smithsonian. The building was to be in accordance with plans and specifications submitted by The Surgeon General of the Army and approved by the above Commission. Construction was to be under the direction and superintendence of the Secretary of War, and at a cost not to exceed $200,000." John Shaw Billings Becomes Curator During the years in which the matter of a new home for those institutions was before Congress, a noteworthy change in the organization and personnel of the Museum and Library took place when, on 28 December 1883, the two were consolidated into one division to be known as the Museum and Library 12 Congressional Record, 48th Congress, 2c! session, pp. 1767-1770. 2117,2177, 25 6 9- "(1) Public Law 62, 48th Congress. 2d session. (2) 23 VS. Statutes at Large, ch. 315. 8o ARMED FORCES INSTITUTE OF PATHOLOGY Ficure 32.— Dr. John Shaw Billings, lamed Librarian, fourth Curator of the Museum (1883-1893), and father of its collection of microscopes. Division of the Surgeon General's Office, and Maj. John Shaw Billings (fig. 32) was named as Curator of the Museum as well as Librarian." Dr. Billings was 45 years of age when he was detailed for the double duty of Librarian-Curator. Born in Indiana in 1838, he was educated at the "old" Miami University at Oxford, Ohio, and received his M.D. degree at the Medical College of Ohio in Cincinnati. Four years of wartime service as a brilliant operating surgeon and medical administrator led to his detail in the Office of the Surgeon General where, among other duties, he was assigned to the care of the little library of that office. This library, started in 1836, had grown, by 1865, to fewer than 2,000 volumes. When, 30 years later, Colonel Billings relin- quished his post as Librarian, the collection had grown to 115,000 bound volumes and 184,000 unbound pamphlets and papers. 15 Moreover, this vast collection of medical information had been made accessible and usable by the publication "National Archives, Accession Number 421, SGO Circular, 1881-1885, p. 162. ,a Smart, Journal of the American Medical Association, 24 (1895), pp. 579-580. BROADENING THE BASE 8l of the "Index-Catalogue," started by Dr. Billings in 1880, in which both subjects and authors are listed alphabetically and "every article from every issue of every journal from every country" was indexed. 16 On 17 August 1884, Dr. Woodward died in a hospital near Philadelphia at the early age of 51. In announcing his death, Surgeon General Murray outlined the highlights of a distinguished professional and scientific career which had culminated with his election as president of the American Medical Association for 1882, being the first medical officer of the Armed Forces to be so honored. The "confinement, anxiety and labor" to which he "was subjected in his attend- ance upon the late President Garfield during his long illness proved too much for a mind and body already over-strained by incessant labor," said The Surgeon General, "and precipitated the illness which finally terminated his life." 3 As was anticipated when the enabling legislation was before Congress, the Commission charged with responsibility for the erection of the new building for the records, library and museum, on 25 March 1885, selected a site fronting 270 feet on the north side of B Street, SW. (now Independence Avenue), and ex- tending back 170 feet on the west side of 7th Street. 18 Three weeks later, on 15 April, The Surgeon General was called upon to furnish plans and specifications. The plans (fig. 33) were drawn by Adolph Cluss, architect, according to the ideas of Dr. Billings, acting for The Surgeon General, and after Commis- sion approval, the contract was let, on 18 August, to the firm of Bright & Hum- phrey. Completion was, as usual, delayed beyond the contract date, making it necessary for the Government to pay rent for 2 additional months on quarters on F Street, occupied by 156 clerks of the Record and Pension Division, and to threaten heavy penalties if the rented quarters were not vacated by August 1887. In a letter to Col. John M. Wilson, the officer in charge of public building and grounds for the Secretary of War, the new Surgeon General, John Moore, on 20 June 1887, outlined a proposed schedule of partial completions with appro- priate moves of units into portions of the new building. He concluded with a proposal for a 3-month extension if by 1 August Bright & Humphrey had "so forwarded their work that there is a reasonable certainty" of carrying out the schedule proposed. Otherwise, Surgeon General Moore recommended that the Government take steps to have the work completed by others and be reim- 18 Hume, Edgar Erskine: Victories of Army Medicine: Scientific Accomplishments of the Medical Department of the United States Army. Philadelphia: J. B. Lippincott Co., 1943, pp. 48, 49- 17 (1) Memoir of Joseph Janvier Woodward, 1833-1884, by J. S. Billings. (Read before the National Academy of Sciences, April 22, 1885.) War Department Records, Office of the Surgeon General. On file in National Archives. (2) Biographical Memoirs, National Academy of Sciences, volume 2, 1886. 1S Original letters in File 4938, Office (if the Surgeon General, National Archives. 82 ARMED FORCES INSTITUTE OF PATHOLOGY -•*. iqrr: _i_L_Ui Figure 33.— Fifth home of the Museum. The view of the building shown here is from the architect's drawing. bursed for losses and extra charges incurred. Apparently, the work was "so forwarded" by the original contractors, and on 9 November Colonel Wilson formally transferred the building to Surgeon General Moore. 19 The Museum Moves From November 1887 until 15 February 1888, the Museum was in the process of moving into the new building. The process was somewhat compli- cated by the fact that the display cases were found to be a little too high to go through the doors and had to be taken through a large window on the front end of the second-floor Museum Hall. In copy prepared by or for Colonel Billings for use in a guidebook which was never issued, the building is described as "exceedingly plain, without orna- mentation," while to Major Smart is was "severely simple in style." To a lady writing for Godey's magazine in 1898, the building was a "plain red brick structure." The profusion of brick and terra cotta embellishment on the ex- " Idem. BROADENING THE BASE 83 terior of the building raises a question as to how much ornamentation would have been required in the 1880's and the 1890's to cause a building to be consid- ered elaborate. The structure, according to the proposed guidebook, consisted of a center building 112 by 55 feet, with wings 60 by 131 feet on either end. Thus the building had a front of 232 feet on B Street, with wings jutting back 81 feet be- yond the rear line of the center building. In the courtyard thus formed, there was an annex 52 by 24 feet, connected with the rear of the center building by a covered passageway. The central and western portions of the first floor were largely occupied by the clerks of the Record and Pension Division, while the east wing was given over to appanages of the Museum — a dissecting room, an anatomist's room, a darkroom, a room containing the outfit for a post hospital, and a room for genitourinary specimens considered unsuited for display in a museum open to all comers. The east wing on the second floor was given over to the specimens of the Museum, the west wing to shelf stacks of the Library, while the central portion of the floor was occupied by library offices and reading rooms. The Library and the Museum wings were built so as to form fireproof compartments separated from the other parts of the building. Both were open from the second story to the roof, forming halls 31 feet high to the eaves and 47 feet to the ridge of the lantern skylights by which they were ventilated and lighted. The Museum wing also had, on the level of the third floor, a gallery 14 feet wide, extending clear around the hall. Rooms on the third floor were used as offices, a microscopy room, and a room equipped for anthropometry. The fourth floor, found in the central building only, contained the photographic gallery and several storerooms, two of which were filled with appliances, for transporting the sick and wounded in the field, for which no space could be found in the exhibit hall of the Museum. The anatomical and biological laboratory was contained in the annex, in which were found also the utilities and the limited and somewhat primitive sanitary facilities. 20 20 (1) Lamb, D. S.: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, pp. 93-95. (2) Lamb, D. S.: Army Medical Museum, Washington, D.C. The Military Surgeon 53: 129, 130, August 1923. (3) Smart, journal of the American Medical Association, 24 (1895), pp. 579-580. (4) Smart, Charles: The Army Medical Museum and the Library of the Surgeon General's Office. Journal of the Military Service Institution of the United States 19: 277-279, 1896. (5) Kyle, Joanna R. N.: The Army Medical Library and Museum. Godey's Magazine 136: 408-418, 1898. 71.'i-028 v — 64 8 84 ARMED FORCES INSTITUTE OF PATHOLOGY The office rooms were graced with fireplaces and mantels, while the large library and museum halls were warmed by air passed over steam-coils in the basement and supplied by ducts, in addition to steam radiators. Corridors and stairways were heated by radiators. Such was the building which was destined to be for nearly 70 years the home of the Army Medical Museum and its successors, the Army Institute and then the Armed Forces Institute of Pathology, and which after an absence of 7 years was to be reoccupied by the Museum and the overflowing activities transferred from the main building of the Institute. A Shift in Emphasis With a new home and a new curator, there was a shift in emphasis in the work of the Museum. The new concept of that work attributed to Dr. Billings in a dispatch of 18 September 1886, in the Medical News of Philadelphia, was as follows: 1. To illustrate the effects, both immediate and remote, of wounds and of the diseases that prevailed in the Army. 2. To illustrate the work of the Army Medical Department; models of transportation of sick and wounded, and of hospitals; medical supplies; instruments; etc. 3. To illustrate human anatomy and pathology of both sexes and of all ages. 4. To illustrate the morphological basis of ethnological classification, more especially of the native races of America, including anthropometry, and craniology. 5. To illustrate the latest methods and apparatus for biological investigations and the various methods of preparing and mounting specimens. 21 Surgeon General Moore, in a circular letter issued 15 September 1888, after the move to the new building was completed, "respectfully invited" the attention of all physicians to the fact that the Museum was "now arranged in a convenient fire-proof building which affords means for the proper preservation and display of specimens" and requested their aid in making it "a complete representative collection covering all branches of medicine." To that end, the circular outlined in great detail the types of specimens especially desired and the methods of "preserving them so as to make them most useful." 22 The "Old" and the "New" Museums In keeping with this broader concept, there gradually developed a separation in the exhibits of the Museum, with lessening emphasis on the "missiles, weapons, ■' Medical News, Philadelphia, volume 49, p. 330. ^Memoir of Joseph Janvier Woodward, 1833— 1884, by J. S. Billings. (Read before the National Academy of Sciences, April 22, 1885). War Department Records, Office of the Surgeon General. On file in National Archives. BROADENING THE BASE 85 fractures, excisions, amputations, and other specimens of the Civil War," which tended to be placed in the gallery. "In fact," Major Smart wrote (in 1895) "the museum of the old Ford's Theater building may here [in the gallery] be recog- nized, while that on the floor of the hall is relatively a new institution." 23 The central space of this "new institution" was occupied by flat-topped glass cases in which were displayed various surgical instruments, including the begin- nings of the collection of microscopes, started by Dr. Billings in 1884 with 17 instruments obtained in Europe— a collection which has grown to number nearly 500 microscopes. These instruments date from the earliest times, in- cluding a replica of the single-lens microscope through which Van Leeuwen- hoek first saw the "little animals" in a drop of water— generally recognized as the beginning of the microscopic era — and extending to the most elaborate opti- cal types and the ultra-modern electron and phase-contact instruments (fig. 34). In a series of display cases projecting from the walls, the Museum displayed anatomical and pathological specimens so arranged as to tell, for each organ and region of the body and for the human organism as a whole, the story of normal development, abnormal deviations, disorders and diseases, and repairs and res- toration, including that by surgery. The displays of the Museum, together with the specimens held for study but not on display, were designed to broaden and deepen the lessons learned in the Library by adding to the reading of die printed word the impact of the tangible and visible object, the thing itself. Dr. Billings' Appraisal The Museum, which was moved into the new building, contained nearly 27,000 specimens, probably more than there were in any other like museum in the world. Comparison of the number of specimens, however, in the opinion of Dr. Billings, "would give an exaggerated and erroneous idea of the value of this collection" in relation to others. "The most important medical museum in the world," he said in his presidential address before the Congress of Ameri- can Physicians and Surgeons on 20 September 1888, "and the one which has exercised the greatest influence in giving direction to anatomical and pathologi- cal studies * * * is undoubtedly that of the Royal College of Surgeons of London, the foundation of which was the collection made by Jolin Hunter, purchased by the government in 1799 * # *. At first the Army Medical Museum was limited to military medical subjects, but of late years its scope has 23 Smart, Journal of the American Medical Association, 24 (1895), p. 580. 86 ARMED FORCES INSTITUTE OF PATHOLOGY Figure ments show of London. 7a. — Foundation and evolution of the microscope collection. A. The instru- n are from the original 17 sent by John Mayall of the Royal Microscope Society been greatly broadened, and is now clearly the same as that of the Royal College of Surgeons." Speaking "On Medical Museums, with special reference to the Army Medi- cal Museum at Washington," Dr. Billings declared that the "object of this address is not to boast of what we have, but to indicate what we want." The Museum, he said, had "only a beginning of such an anatomical collection as I have indicated is desirable * * *. We are accustomed to think that human anatomy is exhausted as a field for original research," a view to which the speaker did not subscribe. "There is ample material and scope for original work for half a dozen skilled anatomists for many years to come to supply the demands of this museum for illustrations of human morphology * * *," he added. "The pathological section of a Medical Museum is its main feature," he said. "No doubt much of the ancient pathology, and some of that which is quite recent, is comparable to the looking in the dark for a black spot which is not there, but those who despise pathology, and devote their entire time to BROADENING THE BASE 87 Figure 34. — Continued. B. A part of the famous microscope collection displayed in the Medical Museum. symptoms and treatment, err as much on one side as those who talk and act as if a knowledge of pathological anatomy could take the place of clinical ex- perience do on the other." Although Dr. Billings was the author of "A Report on the Hygiene of the United States Army," published by The Surgeon General in 1875, and be- lieved that "an ideal medical museum should be very complete in the depart- ment of preventive medicine, or hygiene," the collections of the Army Museum did not cover the subject except "in their immediate relations to the military medical service." Partly accounting for this was the existence of the Museum of Hygiene, under the direction of the Medical Department of the U.S. Navy. "The objects of a medical museum are to preserve, to diffuse and to increase knowledge," Dr. Billings said in his presidential address. "Its conservative function is to form a permanent record of what has been demonstrated and to fix the meaning of terms. Even in my brief experience of thirty years the terminology of anatomy, physiology, pathology, chemistry, and of most of the specialties has greatly changed * * *. To get useful results from the older 88 ARMED FORCES INSTITUTE OF PATHOLOGY literature we must know the precise significance of the old words and, in some cases, the best way to learn this is to examine the specimens prepared by those who use such terms in their descriptions." One of the advantages of the Medical Museum, which it enjoyed "in com- mon with several of the largest, and most important museums, more especially those of the Royal College of Surgeons and of the Faculty of Medicine of Paris," pointed out by Dr. Billings, was its close association with "a large medical library which is in the same building, and at present under the same direction. The increased utility and attractiveness which this gives to both library and museum are very decided." In the first place, in a "very condensed statement of the wants of our National Medical Museum," Dr. Billings listed "the intelligent interest and friendship of the medical profession * * *. To a very considerable extent it has had that; were it otherwise it would not be what it is, nor where it is. But it needs more of it, and it can never have too much." Referring to the fact that a large proportion of the pathological specimens "were gathered during a great war * * * when antiseptic surgery, as now understood and practiced, was unknown," Dr. Billings predicted that this group, showing the "effects of pyogenic microorganisms on gunshot wounds," would never be duplicated. These and other Civil War relics, he said, "have an interest beyond that which is purely professional * * *. The fact that we are physicians does not imply that we look upon them from a medical or scientific stand only. Those of the combatants who survive are now better friends than ever, and the museum specimens coming as they do from the sick and wounded of both armies, and contributed by both Union and Con- federate surgeons, enforce the lesson of the unity of the profession and of its interests, as well as that of our country." And, with prophetic vision, the Curator saw ahead to the idea of an institute of pathology cooperating with "earnest and well trained students" working on the museum's collections "so as to advance knowledge * * # To all such students we shall endeavor to afford opportunities for this work. Precisely how this is to be effected is not yet clear, but here is abundance to be done, and there are quite a number of men coming on the stage who want to do such work for its own sake * * *. Sooner or later, we shall have half a dozen or more of specially trained men busy in the laboratories and work-rooms of the museum, each engaged on his own problems, and the whole for the common good." 24 "Medical News, Philadelphia, volume 53, number 12, 22 September 1888, pp. 309-316. CHAPTER V An Ending and A Beginning Shortly after the new building was occupied, in 1888, the sixth and final "part," comprising the two "volumes" of the monumental "Medical and Surgical History of the War of the Rebellion," was published. From its inception this project had been, in all but name, an integral part of the Museum operation. The first Curator of the Museum, Dr. John H. Brinton, had been the first editor of the Surgical volume, and he was succeeded in the editorship by Dr. George A. Otis, the second Curator, who brought out part I of that volume in 1870 and part II in 1876, leaving part III to be brought out by still another Curator, Dr. David L. Huntington, in 1883. The first and second parts of the Medical volume were edited by Dr. Joseph Janvier Woodward, coming out in 1870 and 1879, respectively, and the third and concluding part was edited by Dr. Charles Smart, the Army surgeon detailed to complete the History. Each of the six "parts" is a massive volume in itself, averaging nearly 1,000 quarto pages of text, with an average of some 40 full-page plates, many in color, plus scores of black-and-white woodcuts. The volumes contain the reports of thousands of medical and surgical cases, usually in the words of the doctors who treated the wounds or diseases. In view of at least one unfriendly critic, indeed, the work was a "mere compilation of other people's writings," l but it is far more than that. The History contains an orderly arrangement and presentation of vital statistics, while the body of the text summarizes, analyzes, and comments on the specific cases in the light of the best medical literature and thought of the times in which it was published. Thus, Dr. Woodward's skepticism as to the bacterial origin of disease, expressed in the volume issued in 1879, was replaced with a more tolerant view by Dr. Smart in the 1888 volume. He was not yet ready to admit that the "causal relationship of a micro-organism to the disease" of typhoid fever had "been established" but he discussed at some length the researches supporting that view and concluded, "Although the typhoid germ 1 Sunday Herald, Washington, I April I i 90 ARMED FORCES INSTITUTE OF PATHOLOGY has not been recognized its existence is generally allowed, and many of the conditions needful to its development have been demonstrated." ; All in all, the History merited the high praise which it received, even from such an outstanding and keenly critical authority as the great Rudolf Virchow, who wrote: Whoever takes up and reads the extensive publications of the American medical staff will be constantly astonished at the wealth of experience therein found. The greatest exactness in detail, careful statistics even in the smallest matters, and a scholarly statement embracing all sides of medical experience are here united, in order to preserve and transmit to contemporaries and posterity in the greatest possible completeness, the knowledge pur- chased at so vast an expense. 3 The Museum and the Army Medical School With the completion of the Medical and Surgical History (fig. 35), there ended the last major link tying the Museum to its Civil War origins. True, the majority of its specimens were the result of Civil War wounds and sickness, and the interest in Civil War specimens persisted, but there was the strong infusion of more recent and different pathological material and, more importantly, there was the new direction of thinking typified in the launching of the Army Medical School. The idea of a medical school for Army personnel had been put forward as early as 1862, first informally by Brinton and his associates, and later by Surgeon General William A. Hammond in his report of 10 November to the Secretary of War, in which he recommended "an army medical school, in which medical cadets and others seeking admission into the corps, could receive such special instructions as would better fit them for commissions, and which they cannot obtain in the ordinary medical schools * * *". 4 Like so many other of the excellent recommendations in this report, nearly all of which were ultimately adopted, the idea was rejected at first, to remain dormant for over 30 years until, in 1893, President Grover Cleveland appointed Lt. Col. George Miller Sternberg (fig. 36) to succeed Charles Sutherland as = Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Govern- ment Printing Office, 1888, pt. Ill, vol. I, pp. 492, 493. 3 Hume, Edgar Erskine: Victories of Army Medicine: Scientific Accomplishments of the Medical Department of the United States Army. Philadelphia: J. B. Lippincott Co., 1943, pp. 152, 154, quoting, Morgan, William Gerry: Contributions of the Medical Department of the United States Army to the Advancement of Knowledge (With Particular Reference to Fields Not Directly Connected with the Practice of Military Medicine). The Military Surgeon 66: 779-790, June 1930. * Annual Report of the Surgeon General, U.S. Army, 10 November 1862. AN ENDING AND A BEGINNING 91 In B GUNSHOT SCALP WOUNDS AND CONTUSIONS OF THE SKULL Figure 35. — A. Medical and Surgical History of the War of the Rebellion. B. A page from the History. 92 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 36. — Brig. Gen. George M. Sternberg, The Surgeon General of the Army for 9 years, 1893-1902, turned the thought of the Museum toward bacteriology. The Surgeon General. The new Surgeon General was outstanding among American bacteriologists. Working independently, he had discovered the pneumococcus responsible for pneumonia in 1881, the same year in which, earlier, Louis Pasteur had described the same microorganism. In 1882, Stern- berg had photographed for the first time the tubercle bacillus, discovered in the same year by Robert Koch. Ten years later, in 1892, he had published "A Man- ual of Bacteriology," the first American textbook on the subject. He came into the Office of the Surgeon General bearing the reputation of being the Army Medical Corps' first man in scientific attainment. Within less than a month after taking office, the new Surgeon General secured authority of the War Department for the long-deferred Army Medical School set forth in General Orders No. 51, A.G.O., dated 24 June 1893. "By direction of the Secretary of War," the Orders read, "upon the recommendation of the Surgeon General of the Army, an Army Medical School will be estab- lished in the city of Washington for the purpose of instructing approved candi- AN ENDING AND A BEGINNING 93 dates for admission to the Medical Corps of the Army in their duties as medical officers." "The course of instruction will be for four months, and will be given an- nually at the Army Medical Museum, in Washington City, commencing on the ist day of November." As General Sternberg explained in his annual report for 1894, the new school, although affording "all the advantages that could be derived from one costing heavily for establishment and maintenance," would add nothing to the expense of the Army. Professors were selected from among the senior mem- bers of the corps stationed in or near the Capital, while the new Museum and Library building provided the necessary lecture rooms and "the accumulation of material for bacteriological and chemical study in the Army Medical Museum which furnished everything essential for laboratory work." Walter Reed; Curator The Museum, indeed, furnished more than laboratory facilities and class rooms, for one of the most useful members of the faculty of the school was the newly appointed Curator of the Museum, Capt. Walter Reed (fig. 37), soon to become Major Reed, who took over the office on 8 September. The appoint- ment was, in a sense, symbolic of the lessening of emphasis on the Civil War as the dominant theme of the Museum's activities. Born in Virginia in 1851, of North Carolina lineage, he was the first Curator of the Museum who had not served in the Union Army during the Civil War, and the first officer of Con- federate antecedents to become Curator, serving under Maj. John Shaw Billings who continued to hold the post of Director of both the Museum and the Library. Both Major Billings and Captain Reed were members of the faculty of the Army Medical School at its first session — Major Billings as professor of military hygiene, including practical instruction in the examination of air, water, food, and clothing from a sanitary point of view, and Captain Reed as professor of clinical and sanitary microscopy and director of the pathological laboratory. Other members of the faculty were: Col. Charles H. Alden, Deputy Surgeon General and president of the faculty, who lectured on the military duties of medical officers, including property responsibility, examination of recruits, cer- tificates of disability, reports, rights and privileges, customs of the service, and like topics; Lt. Col. William H. Forwood, attending surgeon at the Soldiers' Home, who was professor of military surgery, including care and transportation of the wounded; and Capt. Julian M. Cabell, instructor in Hospital Corps drill. In addition to the regular courses taught by the members of the faculty, there 94 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 37. — Maj. Walter Reed, fifth Curator of the Museum, 1893-1902. were lectures on bacteriology by General Sternberg; on military law by Mai. G. B. Davis of the Judge Advocate's Office; on comparative anatomy by Capt. J. C. Merrill; on medical jurisprudence by Dr. Robert J. Fletcher of the Library; on parasites in man by Dr. C. W. Stiles of the Department of Agriculture; and AN ENDING AND A BEGINNING 95 on head surgery by Dr. W. W. Keen, professor of surgery at the Jefferson Medical College and one of the most active surgeons of the Union Army in the Civil War. 5 The first annual session of the school closed with appropriate exercises on 28 February 1894, attended by most of the officers of the War Department. The distinguished Prof. William Osier of the Johns Hopkins University ad- dressed the graduating class of five assistant surgeons, as did Maj. Gen. John M. Schofield commanding the Army, briefly, and Colonel Alden more at length. The address of the President of the Faculty doubtless was directed more to the assembled spectators, which included ex-Surgeons General Hammond, Murray, and Sutherland, than it was to the graduating class. In his address, he outlined the many duties and responsibilities of the Army doctor which were outside the work of the physician and surgeon as ordinarily understood, and described the school's courses of study designed to fit the medical officer for these military duties. Referring to the work of the Department of Clinical and Sanitary Microscopy, the colonel said : Perhaps it is proper to say here to our non-medical friends that the day when bacteria were a scientific curiosity and their study a pastime or fad has passed. The investigation of these microscopic organisms and their effects lies at the very foundation of modern medicine and surgery, and of advanced medical and surgical practice. In this direction lies today our strongest hope and brightest prospect of preventing and arresting disease. 6 Thus there was launched, in quarters provided by the Army Medical Museum, and using facilities furnished by it, the school which was to grow and develop into the Medical Department Professional Service Schools in 1923 and, in 1947, into the Army Medical Department Research and Graduate School, with its own quarters and facilities in the Walter Reed Army Medical Center (fig. 38). Problems With Space Even before the inauguration of the School in the Museum quarters, and, in fact, within a year of the occupation of the new building, the old question of lack of space and overcrowding had already been raised. In his annual report for 1888-89, Surgeon General John Moore said : The question of space for the better accommodation of the present holdings of the Museum and for the additions which experience shows are to be expected, is already ob- 5 Ashburn, P. M.: A History of the Medical Department of the United States Army, lloston: Houghton Mifflin Co., 1929, pp. 149, 150. *(i) Army Medical School: Closing Exercises of the First Session. Journal of the American Medical Association 22: 352-354, 10 March 1894. (2) Ashburn, op. <•;>., pp. 149, 1 5". 96 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 38.— Army Medical School laboratories, located in the Mu in the first decade of the 20th century. A. Bacteriological laboratory. luseum-l-ibrary build ing truding itself. Some special and valuable exhibits * * * already suffer from insuf- ficient or unsuitable presentation * * *. In fact that is no avoiding the conclusion that the whole of the office rooms on the first floor * * * now occupied by the Record and Pension Division should pass into my control for the use of the growing Library and Mu- seum for which the whole building was originally constructed * * *. I therefore earnesdy recommend that provision be made elsewhere for the work of the Record and Pension Division of the War Department and that justice may be done to the intent for which this building was constructed. 7 In the report for the next fiscal year, 1889-90, the recommendation is repeated with equal earnestness, and a like lack of success in securing the use of the entire building for Library and Museum purposes. In support of his request, The Surgeon General said, erroneously, that the building had been erected at a cost of only one-half of the estimates, resulting in a reduction in its dimensions and facilities. 'Lamb, Dr. D. S.: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, pp. 103, 104. AN ENDING AND A BEGINNING 97 Figure 38. — Continued. B. Chemistry laboratory. In the use of the building, unanticipated needs were encountered and had to be dealt with as part of the regular operation of the Museum. For example, on 28 August 1888, within a few months after occupation of the building, Dr. Billings found it necessary to ask for bids on the construction of a "cremating furnace," sufficiently powerful to consume the body of an animal of the size of a large Newfoundland dog without leaving obnoxious odors. s Another lack of the building was a dependable source of electricity for the light necessary to carry on continuously photomicrographic work without hav- ing to depend upon the vagaries of the weather, and also for lighting the Library hall on the "rare occasions when it is necessary to use this room at night." One such occasion was the anticipated opening of the Museum at night during the meeting of the American Medical Association, which was held in Washington in the first week of May 1891. In a letter of 14 April to The Surgeon General, 8 Circular Letter, J. S. Billings. On file in historical records of AFIP. 98 ARMED FORCES INSTITUTE OF PATHOLOGY Dr. Billings asked authority to purchase, for not more than $410, a dynamo to be driven by an 8-horsepower steam engine, already connected with the boilers, and urged action in time to have the lights working during the evenings when 1,500 members of the A.M.A. were expected to be in the city." Special and specific authority had to be sought from the Office of the Surgeon General for items of far less consequence than the dynamo needed to replace one which had been borrowed from the National Museum and had been recalled by its owner. "I have the honor to state that the following articles are required for use at the Army Medical Museum and request authority to buy them as emergency purchases to be paid for from the Museum appro- priation: 5 gallons of Benzine, Estimated cost, $.75" read a typical formal letter of the sort, duly signed by "Your obedient servant, John S. Billings, Major and Surgeon, U.S. Army, Curator Army Medical Museum." Other such letters re- quest authority to purchase items as minute as 30 cents' worth of flour, 10 cents' worth of resin, and a half a dozen washers for a dime. 10 The degree of financial stringency involved in operating the Museum on an annual appropriation of $5,000— and that not always forthcoming without a struggle— is indicated by a letter of 30 December 1890 from Major Billings to M. Jules Talrich, Officier de l'lnstruction Publique in Paris, from whom Billings had purchased some anatomical models during a visit to Paris, and who had offered others for sale. I greatly appreciate your kind offer to let me have the two figures: "Une premiere attaque d'hysterie chez une jeune femme de la race caucasique" and "une jeunne fille de Zouzouland," for the sum of $4,000.00 but the means at my disposal will not allow me to purchase them. The yearly appropriation made by Congress for this Museum is very small, and after reserving the amount absolutely necessary for the current expenses of this Institution, there remains less than a thousand dollars available for the acquisition of new preparations and specimens. 11 The Prime Source of Specimens How nearly complete was the reliance placed on contributions for speci- mens is shown by the pamphlet catalog of the Museum's portion of the Army Medical Department's exhibit at the World's Columbian Exposition in Chicago in 1892-93. 12 In its "Description of Selected Specimens," the pamphlet lists 82 "Letter Book, J. S. Billings, October 1890 to June 1891, pp. 360, 361. On hie in historical records of A I'll'. 10 Ibid., pp. 33, 200. 11 Ibid., p. 70. - Pamphlel catalog, World's Columbian Exposition, Chicago, 1892-93. On file in historical records AFIP. AN ENDING AND A BEGINNING 99 medical and surgical specimens, contributed by 60 physicians and surgeons, with only three specimens identified as having been purchased. In a foreword to the pamphlet, Dr. Billings described the purposes and collections of the Museum. Its primary object was, he said, to illustrate wounds and diseases of armies as a "step in the study of the best means of diminishing disease and mortality among soldiers," but it had soon been found necessary to extend the scope of the collection to include all forms of injuries and diseases, and also to form collections of means of transportation of the sick and wounded, of surgical instruments, and of instruments for diagnosis and research, including microscopes. The Museum had, in 1892, a total of 29,486 specimens, including 3,439 of normal anatomy, 1,717 of comparative anatomy, 10,746 in the pathological section, 12,270 in the microscopical section, and 1,584 instruments and pieces of apparatus. "Large as these numbers may appear," he said, "there yet remain many gaps in each series * * *." And since Congressional appropriations left little margin for the acquisition of additional specimens, The Surgeon General appealed to all medical men to "aid, by contribution of specimens, an institu- tion which is already of great value and interest, having an enviable reputation both in Europe and in this country, and which, it is believed, is destined to be of great importance in the advancement of medical science." Increasingly, he added, contributions were being received from practitioners in civil life, as the "facilities afforded by the Museum for the permanent preservation of pathological specimens, and of the records connected with them, are more and more appreciated" — a trend which Billings sought to strengthen by his earnest appeals for cooperation from all medical men, civilian as well as military. The appeal for civilian cooperation was not a one-sided seeking of help without corresponding mutual benefits, for it had long been the settled policy and practice to open the facilities and collections of the Museum to qualified investigators and students — a policy which was made explicit by the passage of a joint resolution of the Congress, approved 12 April 1892, declaring it to be the policy of the Government to make available to students the facilities of the Army Medical Museum and other scientific and literary institutions in the Nation's Capital, as a measure for the promotion of research and the diffusion of knowledge. 13 While this action was in the nature of a ratification of existing policies and practices, it constituted congressional recognition of the scientific character of the Museum. 13 27 U.S. Statutes 395. 100 ARMED FORCES INSTITUTE OF PATHOLOGY Recognition of the character of the institution by others was abundantly forthcoming. Thus, Dr. Henry W. Bettmann, Curator of the Cincinnati Hos- pital, wrote the Curator of the Army Medical Museum on 13 July 1895, seeking information as to the literature dealing with the best methods of preserving and mounting anatomical and pathological material, or a detailed account of the "methods employed in your own famous collections." Dr. Billings, who replied on 20 July, observed that the literature on the subject was "very limited, consisting principally of isolated hints scattered in various medical publications," but gave, in a nine-page memorandum, a "general summary" of the methods employed at the Museum which "after many futile experiments, have to some extent proved successful." " The memorandum describes the steps in the process of cleaning, degreasing, and mounting bones showing disease or injury, and in even greater detail the processes of preparing wet specimens, preserved in ethyl alcohol or formalin. Special precautions were taken with specimens intended for microscopic or bacteriological work. For the latter, tissues were kept apart, handled as little as possible and with every care to prevent access of foreign bacteria. Bacteriology and Roentgen Rays at the Museum With George Sternberg as Surgeon General and Walter Reed as Curator, bacteriology was bound to expand in importance in the world of the Museum, but the main emphasis of the laboratory work, if we may judge by the cor- respondence files of the period, continued to lie in the pathological examination of specimens sent in from Army posts and Indian agencies. Indeed, when the Health Officer of the District of Columbia asked Major Reed if he could con- veniently make bacteriological examinations of specimens of water from public wells of which the health officer was suspicious, Major Reed was compelled to reply that "with every desire to assist" it would be impossible to "give you at present any material assistance," his own time and that of his assistants being "so completely taken up with the routine Museum work." 15 Routine work of the Museum did not, however, keep Major Reed from taking a keen interest in medical developments. For instance, Wilhelm Roent- gen's discovery of X-rays was announced to the world on 6 January 1896. Within 3 months, Reed had applied to The Surgeon General for authority to obtain apparatus for the purpose of experimenting with the new rays, and had been turned down on the ground that it was "not probable that any u In correspondence files, AFIP. * In correspondence files, AFIP, 30 January and 1 February 1895. AN ENDING AND A BEGINNING I0I experiments you would find time to make would add anything of importance to our knowledge of these rays and their practical application in medi- cine * * *. Later, when the exact practical value of photography by these rays has been determined, we may want the necessary apparatus in order to assist in the diagnosis of cases occurring in the District, to which the new method may be applicable." 1G That the Museum got its apparatus within 3 months after being turned down, is indicated by a letter of Dr. Joseph S. Wall of Washington, in which he describes an early clinical use of the X-ray. On 10 June 1896, as Dr. Wall recalls, and as the admission records of the Garfield Hospital showed, "a girl of seven- teen was admitted to the hospital because of a .22 calibre penetrating gunshot wound of the hip, accidentally inflicted by her brother." It became the duty of Dr. Wall, as a young "externe" of the hospital, "to accompany the patient in a horse-drawn ambulance to the Army Medical Museum to obtain the services of Dr. William Gray," who had been engaged in microscopic and bacteriologic work for the Museum since 1884, and who, Dr. Wall said, had the only Roentgen tube in Washington at that early date (fig. 39). "After the orderly-driver and myself had struggled up four flights of stairs to Dr. Gray's laboratory," he con- tinued, "carrying a rather plump young lady on the stretcher, she was exposed to the X-ray for a period of one hour in order to secure a picture showing the location of the bullet." A satisfactory plate was secured, "even though the tube was activated by a kind of static grindstone," the girl was taken back to the hospital, and the bullet was successfully extracted. 17 Services of Dr. Billings Midway in the closing decade of the 19th century, in 1895, Dr. John Shaw Billings retired from the Army, after 34 years of service, of which 30 years had been spent in building up the Library, with 12 years of concurrent service to the Museum. Dr. Billings, a mighty man of medicine, went on to a postretire- ment career of rare distinction. From the University of Pennsylvania, where he occupied a chair in the medical school for a year after retirement from the "(1) Castiglioni, Arturo: A History of Medicine. Translated from the Italian and edited by E. B. Krumbhaar, 2d ed. New York: Alfred A. Knopf, Inc., 1947, p. 1065. (2) Letter, George Stern- berg to Walter Reed, 6 March 1896. Letter, Dr. Joseph S. Wall to R. A. Sloan, Army Medical Museum, 13 January 1950. From a story in the Washington Times Herald, 6 October 1954, it appears that there was an earlier use of the X-ray, in the District of Columbia, to locate a bullet accidentally fired into the hand of Carl A. Loefflcr, as reported in the Washington Post, 24 April 1896. 102 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 39. — Early X-ray apparatus at the Medical Museum. A. Roentgen ray tube. B. Static electric apparatus. AN ENDING AND A BEGINNING 103 Army, he was called to New York where he worked out the consolidation of the Astor, the Lenox, and the Tilden Libraries to form the great New York Public Library, of which he became the first director, heading not only the main library, housed in a building erected in accordance with his ideas, but also the whole library system with some 80 branches in Greater New York. 18 Among Dr. Billings' last official services to the Museum was his initiation of a movement to have the dental profession adopt the Museum as a repository for study materials in the field of dentistry (fig. 40), "just as other sections of the Museum and Library are considered to be their national collections by the physicians, surgeons, and specialists of the country," as Dr. Billings wrote Dr. Williams Donnally, D.D.S., of Washington, on 10 December 1894. The sug- gestion bore fruit when, in 1895, the American Dental Association accepted the suggestion when offered by Dr. Donnally. This action, the first such formal acceptance of the Museum as a national repository, may be regarded as a step toward the system of national registries of pathological materials and case his- tories of the various specialized medical groups which is such an important factor of today's Armed Forces Institute of Pathology. 19 Animal Experimentation at the Museum Upon the retirement of Lieutenant Colonel Billings, Col. David L. Hunt- ington, Deputy Surgeon General, was placed in charge of the Museum and Library Division, with Major Reed continuing as Curator of the Museum. As Curator, he was called upon to deal with charges of unnecessary cruelty to animals, said to have taken place in the Museum some years earlier. These charges were contained in a letter from Dr. L. E. Rauterberg to the Senate Committee on the District of Columbia, in connection with an investigation of the practice of vivisection in the District. Dr. Rauterberg wrote : It was my lot for a number of years to be engaged in the Microscopical Division of the Army Medical Museum, and I saw practiced the most inhuman and barbarous mutilations of the dumb animal, under the supervision and with the sanction of the United States of- ficers in charge. A desired part or section of the animal would be removed, not under anesthesia, and the poor beast would be then placed back in its cage or vessel until it suited the convenience of the operator to help himself to another portion, so long as the animal " Who Was Who in America, 1943 edition, "Billings, John Shaw." "Lamb, op. cit., pp. 109-1 11. The invitation extended by Dr. Billings through Dr. Donnally was published in Dental Cosmos, June 1895, p. 519- Dr. Donnally's eloquent and persuasive presentation of the reasons for acceptance of the invitation appears in the Transactions of the American Dental Association, 1895, pp. I34-I49- 104 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 40. — Changes in the concepts of dentistry since the time when this type of equipment was familiar have been quite as profound as the change in the equipment and instruments used. would survive these tortures. I have thus seen animals with eyes, section of brain and other parts removed, and kept in reserve for future experiments for a number of days, and all for the verification and repetition of results obtained and published years ago. Since the practices alleged were ascribed to a time before he became Curator, Dr. Reed asked Dr. J. C. McConnell, who had been connected with the Museum AN ENDING AND A BEGINNING 1 05 from about 1870 to the end of 1895, about the truth of the charges. Dr. Mc- Connell replied on 8 June 1896, "That a very wonderfully distorted, inaccurate and false description has been given of work conducted at the Army Medical Museum some twenty years ago." He continued : Those who were practically engaged in the Microscopical Division should know better than anyone else the character of the work that was performed, and that all animals ex- perimented upon were under the influence of an anesthetic. One who was not in any manner connected with the Microscopical Division of the Museum, as was the case with Dr. L. E. Rauterberg, could draw upon his imagination very satisfactorily, and write a vivid description of what might have been done with animals, the remains of which he saw under alcohol in specimen jars. I, however, testify that at no time during my connection with the Army Medical Museum, from about 1870 to the end of the year 1895, have any experiments been performed upon animals in which an anesthetic was not used, unless some of the ordinary inoculation experiments, which are practically painless, nor were animals kept in a mutilated condition. 20 Dr. Reed did not appear before the Senate Committee, that function being performed for the Army by General Sternberg, who vigorously opposed passage of the bill which, in the opinion of most doctors, would have so restricted animal experimentation as to have the practical effect of prohibiting the use of this avenue to increased medical knowledge. Dr. Reed did, however, appear in opposition to the bill at a preliminary hearing before the commissioners of the District of Columbia, as is mentioned in an account in die Washington Post of 10 February, and reproduced in the transcript of the Senate Committee hearings. The Spanish- American War The major military event of the nineties, the war with Spain, seemed at first to have passed the Museum by. Col. Dallas Bache, who had been ap- pointed Director of the Museum and Library Division on 31 January 1898, as the war clouds were thickening, made a report to Surgeon General Sternberg on 17 October, after the brief war had been fought and won, in which he said: The contributions to this Museum from the active theatre of the recent war with Spain and from the extensive field of subsidiary operations, have been so few and unimpor- tant that it seems desirable to renew the attention of Medical Officers to this important subject. The hurry and peculiar military conditions of the Santiago campaign, and the amount of work imposed upon Medical Officers in our large camps of instruction would naturally obscure the more remote interests of the Museum; but from our large General Hospitals and Hospital Ships, and the more deliberate methods of our forces of occupation may well be demanded a return to the systematic collection of specimens illustrating the M Senate Report 1049, to accompany S. 1552, 54th Congress. 1st session, 20 May 1896. 106 ARMED FORCES INSTITUTE OF PATHOLOGY bone and tissue injuries produced by modern firearms and explosives, and a careful preser- vation of such illustrations of disease as may be obtained upon cadaveric examination. Colonel Bache's observations, with accompanying renewed directions as to methods of preparation and preservation of specimens and their delivery to the Museum, were published to the Medical Corps in the Surgeon General's Cir- cular No. 10, 20 October 1898; 21 with what response does not appear. But the Spanish-American War, with its record of nearly seven times as many deaths from disease as from enemy bullets, with more than half the deaths from disease from one cause, typhoid fever, and with the specter of yellow fever lurking in the background, sounded a challenge to the best brains and the most devoted dedication to medical advancement. The history of the Spanish-American War was, in a way, a repetition of that of the Civil War, in that a Medical Department, barely adequate for peacetime and actually forbidden by law to store up reserve supplies, was suddenly called upon to care for a tenfold increase in army numbers. Moreover, General Stern- berg had been denied his request for allotment of a reasonable share of the emergency funds voted for defense purposes before the start of actual hostilities, and so was not permitted to anticipate his increased needs before the flood of raw volunteer troops fell upon his slender medical resources. Typhoid soon became epidemic in nearly nine out of ten of the new regi- ments, and about one soldier in five contracted the disease. The reasons as- scribed for these epidemics were numerous but, in the language of Col. P. M. Ashburn, "fundamentally they are one, ignorance." " To the task of dispelling the prevailing ignorance of the transmission of typhoid, and the equally un- known method of transmission of yellow fever, and so to make a beginning in the control of two of the major diseases of man, the Army Medical Museum was called. 21 (1) Lamb, op. cit., pp. 112, 113. (2) Lamb, D. S.: Army Medical Museum, Washington, D.C. The Military Surgeon 53: 131, 132, August 1923. 22 (1) War Department Records, Office of the Surgeon General. On file in National Archives. (2) Ashburn, op. cit., p. 169. CHAPTER VI The Walter Reed Chapter In three tremendous years of achievement, from 1898 to the end of 1900, Maj. Walter Reed, Curator of the Army Medical Museum, and professor in the Army Medical School, wrote imperishable pages in the history of medicine. First, as president of an Army Board of medical officers set up to investigate the typhoid fever epidemic in the camps within the United States, he helped to broaden the understanding of the ways in which typhoid spreads — an essen- tial step in the triumph of the next decade over that disease, to be dealt with in a subsequent chapter of this story. And then, after the field work of the Typhoid Board was completed but before its report was compiled and published, Reed was called upon to head another board of medical officers to investigate infectious diseases in Cuba, which was to discover, and prove beyond a doubt, the method of transmission of the most dreaded disease of the Tropics— yellow fever. Yellow Fever Epidemics Yellow fever, indeed, was more than a tropical disease. Endemic in the American tropics, it had an unaccountable and disconcerting way of breaking out in epidemic form in the cities and villages of the Temperate Zone of North America. In at least 35 years of the 18th century, yellow fever invaded the United States, extending as far north as Nantucket Island, where 259 persons died of it in 1763, and New York, where there were 2,300 deaths in 1798, and raching a climax of destructiveness in 1793, with 4,041 deaths in 6 weeks among the 40,144 inhabitants of Philadelphia, then the Capital City of the Nation. The 19th century was even worse, with invasions in at least 77 years, rising upon occasion to great epidemics such as those of 1853, which took 7,848 lives in New Orleans; of 1855, with 2,670 deaths in New Orleans and 2,000 in Norfolk; of 1878, when 4,046 died in New Orleans and 5,150 in Memphis; and as many more in smaller and scattered communities in the Mississippi Valley. 713-028*— 64 !) I08 ARMED FORCES INSTITUTE OF PATHOLOGY Altogether, in the years since 1793, New Orleans had suffered more than 40,000 deaths, Philadelphia more than 10,000, Memphis more than 7,500, Charleston more than 4,500, and New York almost 3,500, while the total for the United States exceeded 100,000 deaths. 1 Perhaps worse than the sickness, which attacked from three to five persons for every one who died of the disease, and certainly worse than the economic disruption, was the sheer terror of the deadly infection which struck no one knew how and against which no precautions, no defenses, seemed to avail. Writing of the Philadelphia epidemic of 1793, eyewitness Mathew Carey says in his "Short Account of the Malignant Fever Lately Prevalent in Phila- delphia," that the "consternation of the people * * * was carried beyond all bounds. Dismay and affright were in the countenance of almost every person." Flight from the city was sought by many, including some of the representa- tives of the Federal government while "of those who remained many shut themselves in their houses and were afraid to walk the streets * * *." The "marks of terror" seen on every hand included burial of "the corpses of the most respectable citizens, even those who did not die of the epidemic * * * unattended by a friend or relative, and without any sort of ceremony." Pedestrians kept to the middle of the streets "to avoid being infected in passing by houses wherein people had died." The custom of shaking hands was discon- tinued, and it became common practice to try to keep to the windward of persons met abroad in the streets." Nearly a century later, when the great epidemic of 1878 struck the Mis- sissippi Valley, causing a loss of 16,000 lives, J. M. Keating, who lived through them, wrote of the scenes in Memphis. "Men, women and children," he said, "poured out of the city by every avenue of escape * * * by every possible conveyance — by hacks, by carriages, buggies, wagons, furniture vans, and street- drays; by bateaux, by anything that could float on the river; and by the rail- roads * * *. The aisles of the cars were filled and the platforms packed * * *. The ordinary courtesies of life were ignored, politeness gave way to selfishness, and the desire for personal safety broke through all social amenities." ' (1) Yellow Fever: A Symposium in Commemoration of Carlos Juan Finlay. The Jefferson Medical College of Philadelphia, 22-23 September 1955, pp. 4, 5. [Hereinafter cited as Symposium.] (2) Kelly, Howard A.: Walter Reed and Yellow Fever, 2d edition. Baltimore: Medical Standard Book Co., 1906, pp. 83, 84, 204, 210, 221, 233, 238. (3) Reed, W., and Carroll, J.: The Prevention of Yellow Fever. Medical Record (New York) 60: 641, 26 October 1901. "Carey, Mathew: A Short Account of the Malignant Fever Lately Prevalent in Philadelphia, Phila- delphia. 1703, quoted in Kelly, op. cit., pp. 212-215. THE WALTER REED CHAPTER 109 Twenty-five thousand persons, half the population, left the city and 5,000 more went into camp to escape the city's streets where "trade and traffic were suspended" and "death was everywhere triumphant." The terror of the time was heightened by the fact that "neither cleanliness nor right living were a shield to stay the hand of the destroyer. He invaded the homes of the most chaste and the den of the vilest. He took innocence and infamy at the same moment and spread terror everywhere. Where sorrow was so general there could be no parade of it. There were no funerals and but little demand for funeral services * * *. Not infrequently bodies were left in the cemetery unburied for a night, so hard pressed were the managers for labor, and so numerous were the demands upon what they had * * *." 3 For every act of depravity or inhumanity there were, doubtless, deeds of devotion and unselfishness, but the overall effect of an epidemic attack of yellow fever — and any outbreak might develop into epidemic proportions— was the utter demoralization of community life. The direat that hung over the cities and villages of the United States was ample warrant for the creation of a special commission to visit the West Indies and study yellow jack in its home haunts. Such a commission was formed in 1879, with Maj. George M. Sternberg, a future Surgeon General of the Army, as secretary. After 6 months' study in Cuba and Brazil, the Commission reported, on 16 November 1879, that "yellow fever is an epidemic, transmissable disease and the agent capable of transmitting the disease must be in the air." 4 Studies on Transmission The suggestion of an airborne agency of transmission of the disease found lodgment in the mind of Dr. Carlos Juan Finlay of Havana (fig. 41). Dr. Finlay was Cuban-born, of Scottish and French parentage, educated in France and Germany, a graduate of the Jefferson Medical College of Philadelphia, fluent in four languages, a student of the classics, and a man of scientific attain- ments. He was first connected with the study of yellow fever when he was named, by the Spanish Governor General of Cuba, to work with the United States Commission of 1879 on the subject. The most meaningful consequence of the work of that commission, as it turned out, was the idea implanted in the mind of its Cuban collaborator. 3 Keating, J. M.: History of the Yellow Fever Epidemic of 1878 in Memphis. Tcnn.. quoted in Kelly, op. cit., pp. 223-228. * Symposium, p. 5. II0 ARMED FORCES INSTITUTE OF PATHOLOGY On 14 August 1881, Dr. Finlay read before the Royal Academy of Medico- Physical and Natural Sciences in Havana a paper entitled "The Mosquito Hypothetically Considered as the Agent in the Transmission of Yellow Fever." This was not the first suggestion of the possibility of the mosquite as a carrier of yellow fever — Dr. Josiah Clarke Nott, of Mobile, Ala., had speculated upon the possibility as early as 1848 — but Dr. Finlay was the first to go beyond specu- lation to the working out of a definite theory of the method of transmission, based upon experiments with a particular species of mosquito, then called Culex fasciatus, later known as Stegomyia fasciata, and now classified as Aedes aegypti. Dr. Finlay 's theory was not ignored — he was too respected a figure for that — but it met with almost universal disbelief, and even encountered ridicule as the theory of "that crazy Cuban doctor." For this, there were more than the usual reasons for nonacceptance of a new idea. Perhaps the most potent reason of all was the lack of positive proofs resulting from Dr. Finlay's own continued experiments in which he was never able to produce a clear-cut and undoubted case of experimental yellow fever from the bite of a mosquito. ' In the very spirit of the time, there were reasons why the Finlay mosquito theory did not receive the attention it merited. It was propounded in a period when bacteriology, in the first flush of widespread acceptance of its basic premise, was announcing with almost breathtaking frequency discoveries of new bacteria as the specific causes of particular diseases — tuberculosis among them, and tetanus, pneumonia, typhoid fever, anthrax, and diphtheria, to name a few of the scourges for which a disease-causing microorganism was found. Naturally, the eyes of the scientific world were focused on the minute organisms which were being made visible by improved instruments and pro- cedures, and inevitably, bacteriologists saw organisms which were taken to be the cause of yellow fever. Such "discoveries" were announced in Brazil, Mexico, and Cuba during the 1880's but further investigation by Dr. Sternberg, outstanding among American authorities on the subject, demonstrated in each instance that the supposed causative agent was not, in fact, related to yellow fever. The specific agent of the disease, according to Sternberg's report, in 1890, of his investigations carried on in Havana, Vera Cruz, and Rio de Janeiro, had not been discovered and demonstrated. There matters stood until, in 1897, Dr. Giuseppe Sanarelli, an Italian bacteriologist of the University of Bologna, who had worked in Montevideo '*' ( 1 ) Symposium, pp. 96—IOI. Dr. Nott's suggestion as to mosquitoes was published in the New Orleans Medical Journal, volume IV, pp. 563 ff., under the title "Yellow Fever Contrasted with Bilious Fever: probably insect or animalcular origin." Dr. Finlay's theory first appeared in the Annales dc la Real Acadcmia. volume LVIII. pp. 147-169. THE WALTER REED CHAPTER III - Figure 41. — Dr. Carlos Juan Finlay, whose theory of transmission of yellow fever by the bite of mosquitoes was tested and proved by Walter Reed. and Rio de Janeiro, announced his discovery of die cause of yellow fever as an organism which he called Bacillus icteroides. The announcement created great interest in America, where studies were promptly undertaken to check and, if possible, to confirm the reported finding. One such investigation, ordered by Surgeon General Walter W. Wyman of the Marine Hospital Service — now the United States Public Health Service — resulted in a report, in 1899, which accepted Dr. Sanarelli's claim in the fullest.' Sternberg, by this time Surgeon General of the Army, assigned the task of checking the Sanarelli discovery to two members of the staff of the Army Med- ical Museum — Walter Reed and James Carroll — who performed the work in the laboratories of the Museum. In a "Preliminary Report," published in the Medical News of 29 April 1899, they reported that the Sanarelli bacillus was apparently a strain of the bacillus of hog cholera rather than a cause of yellow 'Reed. Walter: The Propagation of Yellow fever: Observations Based on Recent Researches. (An address given before the 103d Annual Meeting of the Medical and Ohirurgical Faculty "I the State "1 Maryland, held in Baltimore, 24-27 April 1901.) Published in the Medical Record (New York) 60: 201-209, I0 August 1901. I Hereinafter cited as Baltimore Address.] 112 ARMED FORCES INSTITUTE OF PATHOLOGY fever. Dr. Sanarelli hotly resented the Reed-Carroll findings in a communi- cation in the Medical News of 12 August, in which he charged his "obstinate opponents" with "hiatuses of observation and inexactness in * * * ex- periment," leading to "gross and inexcusable error." Reed and Carroll made reply in the same journal of 9 September, refuting the charges and outlining the careful procedures of the respected laboratories of the Museum. 7 By 1899, the subject of yellow fever was of all the more pressing interest because on 1 January of that year the American Forces had formally taken over from Spain the occupation of Havana, a city which had not been entirely free of the pestilence for 140 years. Yellow fever, feeding on the non-immune per- sonnel of the occupation forces, again broke out in epidemic form, in 1900. The opportunity and the need for a fresh, thorough, and searching investi- gation of the source and the spread of yellow fever had come together — and the Army, fortunately, had the men who could make the most of the opportunity and could meet the need. The Yellow Fever Board at Work The Surgeon General again turned to Major Reed, who had so ably directed the investigations of the Typhoid Board, and to James Carroll, his second in command at the Army Medical Museum, who had participated in the investi- gation of the Sanarelli bacillus. These two, with Dr. Jesse W. Lazear and Dr. Aristides Agramonte, were designated as a board to investigate infectious diseases in Cuba, set up by War Department Special Orders No. 22, 24 May 1900. All four members of the Board were happy, one might say almost inspired, choices. Walter Reed was born on 13 September 1851, in Gloucester County, Va., s where his father was a Methodist minister, and was reared in Farmville, Va., and Charlottesville, seat of the University of Virginia. After a year at the University in the study of the classics, Reed, compelled by slender family finances to curtail his education, managed to compress the 2-year course in medicine into 1 year, graduating third in his class before his 18th birthday. A year later, in 1870, he received a second M.D. degree from the Bellevue Hospital Medical College in New York. After 5 years as a hospital intern and a health department inspector in Brooklyn, he took the examinations for the Medical Department of the Army, partly because he wished to ask Miss Emilie Lawrence 7 Medical News, Philadelphia, 74: 513-514, 29 April 1899; 75 : '93-199, 12 August 1899; 75: 321- 329, 9 September 1899. 8 A piece of one of the original logs of which the house at "Belroi," where Walter Reed was born, was constructed, is exhibited at the Medical Museum, AFIP. THE WALTER REED CHAPTER 113 of Murfreesboro, N.C., to marry him and felt that the prospects of establishing a sufficiently assured private practice, which he said depended "more on his beard than on his brains," were not sufficiently promising to sustain the venture. He succeeded in passing the examinations, was commissioned a first lieutenant, and won his bride. There followed 4 years of frontier service in Arizona, and a year at Fort McHenry, Baltimore, where he took advantage of the opportunity to study physiology at Johns Hopkins. The next 5 years were spent in Nebraska, after which he had a tour of 2 years at Mount Vernon Barracks in Alabama. In 1889, Reed was back in Baltimore as attending surgeon and examiner of re- cruits, with permission of Surgeon General Jedediah H. Baxter to pursue such courses at Hopkins as would be of practical benefit to any army surgeon, but not to take laboratory courses. After General Baxter's death, Captain Reed was permitted to take courses in pathology and bacteriology — subjects which were to determine the direction of his future career. After 2 years more of frontier service in the Dakotas, Reed was named to the positions in the Medical Museum and the School which he held at the time of his appointment to investigate yellow fever— the appointment which he was to make of such shining service to medicine and mankind. 9 James Carroll (fig. 42) was born in England in 1854, emigrated to Canada at the age of 15, and enlisted in the U.S. Army in 1874 at the age of 20. Twelve years later, he took advantage of a tour of duty in New York to begin his medical education, which he finished with the degree of M.D. from the University of Maryland, earned while stationed in Baltimore in 1891. Postgraduate work in bacteriology and pathology at the Johns Hopkins Hospital followed, in 1892 and 1893. In the latter year, he was assigned to the Museum, where he served with the rank of Hospital Steward until 1898, when he became Acting Assistant Surgeon. 10 Jesse William Lazear (fig. 43), the third member of the Yellow Fever Board, was born in 1866 in Baltimore, where he graduated in academic studies "Reed's career up to the time of the creation of the Yellow Fever Board is based on Kelly, op. at., chapters I, II, and HI, and upon Maj. Jefferson Randolph Kean's memoir, included in Senate Document 822, 61st Congress, 3d session, 1911, pp. 14-16 and 38-40. Maior Kean refers in these memoirs to a little Indian girl who had been so badly burned in a campfire that she had been abandoned to die by her people, but whom Dr. Reed had rescued and saved, taking her into his home for rearing. The story is told in greater detail in an account of an interview, with Miss Blossom Reed, the major's daughter, at her home at Blue Ridge Summit, Pa., on the 109th anniversary of his birthday, which appeared in the Washington Daily News of 14 September 1960. 10 (1) Kelly, op. cit., pp. 262, 263. (2) Lamb, D. S.: A History of the Army Medical Museum. 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, p. 114. ii4 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 42. — Lt. James Carroll, a member of the Yellow Fever Board, who contracted the disease in its experiments, became sixth Curator of the Army Medical Museum, 1 902- 1 907. at the Johns Hopkins University in 1889. He took his medical degree at Columbia University in 1892, served at the Bellevue Hospital in New York for 2 years, and studied in Europe for a year, including time in Italy and a period at the Pasteur Institute in Paris. Back in the United States, he became bacteriol- ogist on the staff of the Johns Hopkins University and assistant in clinical microscopy in the medical school, until he was selected by the Surgeon General's Office to go to Cuba as a bacteriologist at Camp Columbia, where he arrived in February 1900." Aristides Agramonte (fig. 44), the youngest member of the Board and the only member who was an "immune" to the disease which was to be inves- tigated, was born in Puerto Principe, Cuba, in 1868, the son of a Cuban patriot "(1) Kelly, op. a:., pp. 281-283. (2) Truby. Albert E.: Memoir of Walter Reed: The Yellow Fever Episode. New York: Paul B. Hcebcr. Inc.. 1943, pp. 61, 73, 82. THE WALTER REED CHAPTER "5 Figure 43. — Dr. Jesse W. Lazear, a member of the Yellow Fever Board, who lost his life in its experiments. insurgent against the rule of Spain. After the death of General Agramonte in battle, in 1872, the family moved to New York, where Aristides graduated from the College of the City of New York and received his M.D. in 1890, at the College of Physicians and Surgeons of Columbia University. In May 1898, at the outbreak of the war with Spain, he was appointed acting assistant surgeon in the U.S. Army, and participated in the Santiago campaign of that summer. At the time of his appointment to the Yellow Fever Board, he was in Havana, making bacteriologic studies of yellow fever cases. * Major Reed was acquainted with all three of the other members of the new Board. Carroll was his close associate at the Museum, Lazear he knew through their connections with the Johns Hopkins school, and Agramonte had done work in the laboratories of the Museum. When appointed, Doctors Lazear and Agramonte were already at work on yellow fever in Cuba, where Reed had renewed his acquaintance with them in the early spring of 1900, 12 Kelly, op. at., pp. 2KX-2<ji>. 713 028* 04 10 u6 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 44. — Dr. Aristides Agramonte, Cuban member of the Yellow Fever Board, was its only "Immune.'' when he was there investigating the germicidal qualities of an "electronzone" product being offered to the Army. The personalities and capabilities of the Board which was to be created in late May were well known to its president. 13 The senior members of the Board, Reed and Carroll, arrived in Havana on 25 June 1900, and work was undertaken immediately. Headquarters was established at Columbia Barracks in the suburban village of Quemados de Marianao, 6 miles west of Havana. Quemados, as it happened, was in the grip of an outbreak of yellow fever, with 50 cases and 12 deaths, despite an almost ideal situation from the standpoint of general sanitation. The first work undertaken was a further investigation of the Sanarelli bacillus, making use of the wealth of yellow fever materials available in Cuba. Blood drawn from 18 yellow fever patients and autopsies performed on 11 who 13 (1) Truby, op. cit., pp. 73-77. (2) Lamb, op. cit., p. 118. (3) Senate Document 822, 61st Con- gress, 3d session, p. 26 (Dr. Agramonte's statement). THE WALTER REED CHAPTER 1 17 had died of the disease yielded no trace of the organism so, quite early in the investigation, the Sanarelli theory as to the cause of the disease was discarded. 14 Reed, in fact, was to be criticized, in the clear light of knowledge after the fact, for the time spent on disproving the Sanarelli theory. With the un- solved problem before him, however, and especially with the knowledge that the Marine Hospital Service accepted Sanarelli's claims, it is hard to see how Reed could have done otherwise than make the most thorough test possible of all approaches to the mystery of the cause and propagation of yellow fever. At any rate, little time was lost, for even while the cultures were being tested and the autopsies performed, preparations went ahead for trying other approaches. The "search for the specific agent of yellow fever," in Dr. Reed s words, was not to be abandoned but was "to be given secondary consideration, until we had first definitely learned something about the way or ways in which the disease was propagated from the sick to the well." It was regarded "as of the highest importance that the agency of an intermediate host, such as the mosquito, should either be proven or disproven." l0 Reed's attention had been drawn to the possibility of the mosquito as a transmitter of disease by the then recent work of Ronald Ross, of the British Indian Medical Service, in demonstrating that the Anopheles mosquito carried the plasmodium causing malaria between birds, while Sir Patrick Manson demonstrated that the bite of an infected mosquito could cause malaria in man. To the "brilliant work of Ross and the Italian observers"— Grassi, Bastianelh, Bignani, and others — Reed expressed his indebtedness. 10 Coming closer to the problem of an intermediate host for the cause of yellow fever, Dr. Reed was impressed by the observations of Surgeon Henry Rose Carter of the Marine Hospital Service, made during an outbreak of yellow fever in Mississippi in 1898 and published in the New Orleans Medical Journal "Reed, W., Carroll, J., Agramonte, A., and Lazear, J. W.: The Etiology of Yellow Fever. A Pre- liminary Note. Philadelphia Medical Journal 6: 790-796, 27 October 1900. a Baltimore Address, p. 203. M (1) Reed ct al., Philadelphia Medical Journal, 6 (1900), p. 791. (2) Reed, W.: Recent Researches Concerning the Etiology, Propagation and Prevention of Yellow Fever, by the United States Army Com- mission. Journal of Hygiene 2: 107, April 1902. Ross had demonstrated the role of the mosquito as die intermediate host to the plasmodium of malaria in 1897. The year before, 1896, Major Reed had reported to The Surgeon General upon a malaria epidemic at Washington Barracks (now Fort Lesley J. McNair) and Fort Myer, Va. By careful epidemiological investigation, he had ruled out the possibility of drinking water as a cause and concluded that the fevers were due to "emanations from the Potomac flats. As Col. Hugh R. Gilmore, Jr., Curator of the Medical Museum, put it, Reed "correctly implicated airborne •emanations 1 — but the 'emanations' had wings!" In Gilmore, H. R., Jr.: Malaria at Washington Barracks and Fort Myer: Survey by Walter Reed. Bulletin of the History of Medicine 29: 34^-351 (July-August) '955- n8 ARMED FORCES INSTITUTE OF PATHOLOGY in May 1900. These observations showed that between the occurrence of the first cases at isolated farmhouses and of the first succeeding groups of cases at the same houses there was a lapse of 2 or 3 weeks, while subsequent cases de- veloped in a shorter period of incubation of from 1 to 7 days. To Dr. Carter, this indicated that there was in a life cycle of the infecting organism an inter- mediate host, such as the mosquito, which harbored the cause of the disease for a period before passing it on. 1T To the work of Ross and of Carter, Reed added a perspicacious observation of his own at Pinar del Rio, 100 miles west of Havana, where yellow fever broke out in the American garrison. One of the victims was a general prisoner, under confinement in the guardhouse since 6 June 1900, who fell sick on 12 July and died on the 18th, and was autopsied by Dr. Agramonte on the 19th. The fact that this guardhouse prisoner, effectively in quarantine insofar as yellow fever exposure by ordinary means was concerned, should sicken and die of yellow fever, led to the conjecture "that, perhaps, some insect capable of conveying the infection, such as the mosquito, had entered through the cell window, bitten this particular prisoner, and then passed out again." This, Dr. Reed added, was only a supposition, but it was a supposition no doubt strengthened by the reflection that iron bars at the windows and armed guards at the door could keep the prisoner from visiting places of infection, but would not keep infected mosquitoes from visiting the prisoner. ls Dr. Finlay' s Mosquito Theory And then there was Dr. Finlay and his long-held mosquito theory which he had "ingeniously discussed," as Reed put it, as early as 1881 and had repeated since, notably in papers published in 1891, 1894, 1895, and as recently as 1899. Although the Cuban doctor had "no results in support of his theory" Reed wrote, * * * the argument in favor of an intermediate host seemed so strong * * * that investigation along this line was determined upon." '" Already, around the 1st of July, members of the Yellow Fever Board had called upon Dr. Finlay and had received his most cordial cooperation, for which Reed expressed "sincere thanks." The doctor turned over larvae and eggs of the suspected species of mosquito, which became the foundation of the breeding stock used in the experiments. Dr. Lazear, who had had entomologic training and experience with mosquitoes in Italy, was placed in charge of the work of " Reed ct al., Philadelphia Medical journal, 6 (1900), pp. 791, 792. 18 Baltimore Address, pp. 202, 203. " Reed et al., Philadelphia Medical Journal, 6 (1900), p. 792. THE WALTER REED CHAPTER II 9 breeding, rearing, and caring for Dr. Finlay's mosquitoes and those obtained from other sources. Hospital Steward John S. Neate, of the staff of the Medical Museum, who was sent to Cuba in June for service with the Reed Board, had the hazardous and exacting task of the daily care and feeding of Dr. Lazear's "birds." 20 To carry out the contemplated experiments, however, there had to be more than a theory and a breeding stock of mosquitoes. There had to be money, for one thing — precious little money by comparison with modern expenditures or in relation to the results accomplished, but money just the same. And there had to be experimental "animals" — and so far as anyone then knew, the only animal subject to yellow fever was the genus Man, himself. This disturbing fact led to another problem — not where to get the men necessary for the experiments, for that problem was to be solved by ready volun- teers, but whether to authorize experiments on human subjects. In the light of the results accomplished, that question does not seem as thorny now as it must have seemed to Dr. Reed, who had the responsibility for proposing such a course to Surgeon General Sternberg, and to Maj. Gen. Leonard Wood, Governor General of Cuba, who had the final responsibility for authorizing human experimentation. It happens that the experiment was brilliantly successful, and that the only life lost was that of one of the experimenters, but it is easy to imagine, if things had turned out differently, the outcry that would have assailed those responsible. Fortunately, the United States was represented in Cuba in 1900 by a governor general who, being a medical officer himself, had the understanding of the problem and the courage to face it in his own responsibility — and Walter Reed got the necessary authority ami backing. Before all arrangements for the mosquito tests could be set up, Reed was compelled, on account of the death of Dr. Edward O. Shakespeare of the Typhoid Board, to hasten back to the United States to work on the preparation of the report of that board for publication.' 1 He left Cuba on 2 August, and did not get back to Quemados until 4 October. In his absence, there had been developments both tragic and triumphant in the work on yellow fever. Human e( Guinea Pigs" One of the conditions upon which the Yellow Fever Board had recom- mended the use of human "guinea pigs" in its work was that the members of "" ( i) Truby, op. cit., pp. 92, 93. (2) Lamb, op. at., p. 1 [9. " Ireland, M. W.: The Conquest of Yellow Fever. The Military Surgeon 64: 244-251, February 1929. 120 ARMED FORCES INSTITUTE OF PATHOLOGY the Board should themselves be the subject of experiment. Consequently, in the first group of eight inoculations by the bites of mosquitoes hatched from Dr. Fin lay's eggs, administered between i August and 19 August, Dr. Lazear was included as Case No. 6. The result in all eight cases, listed in the report by number only, was negative — no yellow fever. The same thing was true of Case No. 9, that of Dr. A. S. Pinto, bitten on 25 August by a mosquito infected 10 days earlier." 2 But on 27 August, Dr. Carroll was bitten by a mosquito infected 12 days before — and on 31 August, Dr. Carroll sickened with a well-defined and very severe case of yellow fever, the first such case traceable to the bite of an infected mosquito under experimental conditions. Dr. Carroll's case came very near to proving fatal and, in its aftereffects, undoubtedly shortened his life. The second case of experimental yellow fever was that of Pvt. William H. Dean of the Seventh Cavalry who, on 31 August, the day that Dr. Carroll was taken sick, was bitten by the same mosquito which had infected him, and also by three others which 12 days before had fed on the blood of yellow fever patients. Dean, referred to in the original reports of the investigation as "XY," had a mild but definite attack of yellow fever. 23 Up to this time, there had been eleven "bitings" by the experimental mos- quitoes, with but two cases of fever resulting — a circumstance which was after- ward found to be due to the fact that only the female of the species could trans- mit the disease, and she could not do so until at least 12 days after becoming herself infected, and that the first nine "bitings" had been too soon after the mosquitoes had been fed on yellow-fever blood. Moreover, there was a shadow of doubt as to whether Major Carroll's case was of experimental or accidental origin, since he had been in infected areas before and after being bitten. As to the case of Private Dean, however, there was no doubt, since he had been a patient in the post hospital at Columbia Barracks, and had not been exposed to any source of infection other than the four experimental mosquitoes. The Death of Dr. Lazear In addition to the two cases of Carroll and Dean, there was the tragic case of Dr. Lazear, who was stricken on 18 September and died a week later. After his death, a notebook containing entries about his experiments was found in the pocket of a uniform which he had been wearing. This little notebook, when analyzed by Reed, furnished the clue to the secret of mosquito transmis- 23 (1) Rcec] ct al., Philadelphia Medical Journal, 6 (1900), p. 792. (2) Truby, op. cit., pp. 126, 220. 23 Rccd ct al., Philadelphia Medical Journal, 6 (1900), p. 792. THE WALTER REED CHAPTER 121 sion of the disease— namely, that it was a matter of timing of the bites, both of the original patient from whom the disease was transferred and also of the transferee. To become infected, the mosquito must bite the sick patient within the first 3 days of illness; to transfer the infection, at least 12 days must have elapsed since the infection was acquired by the mosquito. The nine unsuccess- ful attempts to produce the disease were explained by the recorded fact that the original patient was bitten after the third day of his illness, or that the attempt to convey the disease was made less than 12 days after the mosquito was infected. Dr. Lazear's own case presented a puzzle. Reed had no doubt that it was due to the bite of a mosquito but could not be sure that the mosquito was one of those reared in the laboratory. Dr. Lazear told Major Carroll and Maj. William C. Gorgas that, while engaged in letting his experimental mosquitoes bite yellow- fever patients at the Las Animas Hospital in Havana, a stray mosquito had landed on his hand, and he had permitted it to drink its fill. Obscure and un- finished notations in Lazear's pocket memorandum book, however, indicated that he might have applied some of the laboratory mosquitoes to his own arm, knowing by that time that there was every chance of infecting himself with a possibly fatal disease. This raised a question as to how the case of Lazear would be treated in the report. There was no doubt in Reed's mind of his illness and death from the bite of a mosquito, and there is persuasive evidence that he believed that the mosquito was actually one of the purebred laboratory strain which Lazear had deliberately applied to himself, and not the stray insect which Lazear hail men- tioned during his illness to Carroll and Gorgas. The reason for the discrepancy, it is surmised, was possibly an apprehension on the part of the sick man that his life insurance might be forfeited if he deliberately infected himself with a possibly fatal disease."' 4 Reed decided to list the cause of Dr. Lazear's lamented death as the bite of the mosquito in Las Animas Hospital, as related by Lazear. but he accepted the case as evidence of the validity of the mosquito theory, adding strength to the Carroll and Dean cases. While analyzing the evidence resulting from the preliminary experiments, Reed was intensely occupied in setting up arrangements for further experiments "(I) Trubv, op. at., pp. .23-127. (2) Hench, Philip S.: Conquerors of Yellow Fever. Hygeia (The Health Magazine) October ,941, p. 5. Dr. Hench. of the Mayo Clinic, has found in the stud, ol the Walter Reed epic an absorbing avocation. In 1940. he visited the rcma.ns of Camp Lazear, accom- panied by John J. Moran. one of the original volunteers, who identified the "infected bedding and clothing building," falling into decay. Efforts to have the building restored and preserved failed. . York Times, 4 November 1951. 122 ARMED FORCES INSTITUTE OF PATHOLOGY under controlled conditions designed to test the truth of the theory beyond any question. Meanwhile, Reed felt warranted in making a report of results as far as the work had gone. This he did, in person, in a paper, "The Etiology of Yellow Fever: a Preliminary Note," read before the American Public Health Associa- tion, meeting at Indianapolis from 22 October to 26 October 1900, and published in the Philadelphia Medical Journal of 27 October. The "Preliminary Note" disposed of the bacillus icteroides of Sanarelli, and drew the flat conclusion that "The mosquito acts as the intermediate host for the parasite of yellow fever." Reed's preliminary report got a rather cool reception, and aroused some opposition, notably from Dr. Eugene Wasdin of the Marine Hospital Service, who was committed to the Sanarelli thesis, and who attacked Reed's conclusions in the Medical Journal of November 17. 20 Studies at Camp Lazear Before that time, Reed was back in Cuba and had plunged into the work of planning and providing a camp— Camp Lazear, it was appropriately called— where tests of the transmission of yellow fever could be carried on under con- ditions controlled with certainty. A site was picked near Columbia Barracks but far enough away from habitation to insure isolation. The distinguishing feature of the camp, located at Quemados de Marianao, a suburb of Havana, was two small frame buildings, each 14 by 20 feet, located on the opposite slopes of a little valley about 80 yards from each other and the same distance from the camp proper. One, the "Infected Mosquito Building," was designed to test the mosquito theory; the other, the "Infected Clothing Building," was designed to test the currently accepted theory of infection by contact with the clothing, bedding, and other articles which had been in close contact with yellow fever patients (fig. 45). 2G Camp Lazear was put in operation on 20 November 1900, manned by a service detachment of volunteers— two doctors, one an immune; one hospital steward, an immune; nine privates of the hospital corps, one of whom was immune; and an immune ambulance driver. A strict quarantine was estab- lished, with no one except the four immunes permitted to enter or leave the isolated camp. K Dr. Wasdin's article appears in: Philadelphia Medical Journal 6: 951, 952, 17 November 1900. "Reed, W., Carroll, J., and Ajrramonte, A.: The Etiology of Yellow Fever. An Additional Note. Journal of the American Medical Association 36: 431-440, 16 February 1007. THE WALTER REED CHAPTER 123 Figure 45.— Camp Lazear. A. The small cabins in the distance are the "Infected Mosquito Building" and the "Infected Clothing Building." The tents housed the detachment. B. Building in which the fomites theory was disproved. For subjects upon whom the experiment was to be carried out, the original reliance was placed upon securing the services of some of the numerous new Spanish immigrants to Cuba who, in the language of the agreement which each one signed, understood "perfectly well that in case of development of yellow fever in him, that he endangers his life to a certain extent but it being entirely impossible for him to avoid the infection during his stay in this island, j 24 ARMED FORCES INSTITUTE OF PATHOLOGY he prefers to take the chance of contracting it itentionally in the belief that he will receive * * * the greatest care and the most skillful medical service." A further consideration was the payment of $100.00 in American gold and, in case of contracting yellow fever, an additional $100.00, to be paid to the subject if he survived; otherwise, to the person whom he designated. The subject bound himself not to leave the camp during the period of the experi- ments, forfeiting all benefits if he should do so. 27 Some of the Havana newspapers "have abused us soundly and have charged us with all kinds of inhumanity and barbarity," Reed wrote General Sternberg on 26 November, but, he added, "the Spanish consul, a most courteous and intelligent gentleman, assures us that we shall have his support, as long as we do not use minors and the individual gives his written consent * * *." ' Soldier Volunteers Although no United States soldier was asked to submit to the inoculation tests, Pvt. John R. Kissinger, of the hospital detachment, and John J. Moran, a civilian clerk in the headquarters of Brig. Gen. Fitzhugh Lee, astonished and delighted Reed by volunteering, upon the condition that they receive no money. There is an apocryphal story that Major Reed, upon receiving their unsolicited offer, which was renewed after the risks they ran had been carefullv explained to them, rose, touched his forehead, and said, "Gentlemen, I salute you." The story of the salute is probably not true in detail, but he did say in his published account of the experiment that "in my opinion this exhibition of moral courage has never been surpassed in the annals of the Army of the United States." " The remark was made of Private Kissinger, who was the first to become the subject of experiment and to contract yellow fever, but the same remark would apply to Moran, who volunteered along with him, and to the other 12 who volunteered to subject themselves to inoculation with fever — Dr. Robert P. Cooke of Virginia, James A. Andrus of Pennsylvania, Thomas M. England of Ohio, Levi E. Folk of South Carolina, Wallace W. Forbes of Illinois, James F. Hanberry of South Carolina, James Hildebrand of Georgia, Warren G. Jernegan of Florida, William Olsen of Wisconsin, Charles G. Sontag of - An original contract, in Spanish, signed by Walter Reed and Vicente Presedo, with an English translation, is displayed in the Medical Museum of the Armed Forces Institute of Pathology. : " Truby. op. cit., p. [53. "' Baltimore Address, p. zt>^. THE WALTER REED CHAPTER 1 25 South Carolina, Edward Weatherwalks of New Jersey, and Clyde L. West of Indiana. 30 The first inoculation by mosquito bite which produced yellow fever was that of Kissinger, who was bitten on 5 December, and fell sick on the night of the 8th. "As he had been in our camp 15 days before being inoculated," Reed exultantly wrote his wife, "and had no other possible exposure, the case is as clear as the sun at noonday, and sustains brilliantly and conclusively our con- clusions." 31 Between the 10th and the 15th, the proof was strengthened by the development of three more cases, after which there were no cases for 10 days, due to a cessation of inoculations— a hiatus which demonstrated that the four cases in 1 week did not mean that the camp itself was infected. "" While continuing his experiments with mosquito bites, Dr. Reed was carry- ing on a rigorous test of the theory that infected clothing and bedding was the transmitting agent of the fever — a theory unquestioningly accepted by the medical profession and acted upon in framing and enforcing quarantine regu- lations. The very name given to these infected articles, supposed to be capable of passing on the flame of infection— "fomites," a word derived from the Latin term for "tinder" — indicates how seriously they were regarded as a means of spreading the flames of the fever. The fomites theory, as Reed remarked, was "not disputed by anyone." 33 To establish the mosquito-infection theory was not enough so long as the theory of infection by fomites was left undisturbed. Testing the "Fotnites" Theory Consequently, on 30 November the testing of the infective power of fomites was begun in the "Infected Clothing Building"— a tight little structure, proofed against the entrance of mosquitoes, with a minimum of ventilation, and heated ■"'The names of the "Participants of Yellow Fever Investigations in Cuba" appear annually in a special "Role of Honor" in the Army Register, in compliance with an Act of Congress approved by President Calvin Coolidge on 28 February 1929. In addition to those who took part in the first series of experiments, the Roll of Honor includes those who volunteered in 1901 to undergo injection of blood from infected persons, as follows: Assistant Surgeon Roger P. Ames of Louisiana, John R. Bullard of Massachusetts, Albert Coyington of North Carolina, Wallace W. Forbes of Illinois, and Paul B. Hammann of Illinois (born in Germany). In special category was Gustaf E. Lambert, male nurse, born in Sweden, who cared for the fomites in the infected clothing experiment. Not to be forgotten also are the five Spanish volunteers, who stayed to the end of the first series of experiments, four of whom developed yellow fever — Jacinto Mendez Alvarado, Antonio Bcnigno. MicanoT Fernandez, Jose Martinez, and Vicente Presedo; and two others who participated in the 1901 experiments — Pablo Ruiz Castillo and Manuel Guttcricz Moran. 31 Kelly, op. cit., pp. 140-142. M Rced ct al., Journal of the American Medical Association, 36 (1901), p. 435. 33 Baltimore Address, p. 202. 126 ARMED FORCES INSTITUTE OF PATHOLOGY above 90 ° F. Into this environment, there were introduced four large locked boxes of sheets, blankets, pillowslips, and other articles "contaminated by con- tact with cases of yellow fever and their discharge * * * purposely soiled with a liberal quantity of black vomit, urine and fecal matter * * *." Dr. Cooke and Privates Folk and Jernegan, all nonimmunes, entered the building, unpacked the boxes, handled and shook out their contents so as to "disseminate through the air of the room the specific agent of yellow fever, if contained in these fomites * * *," used the fomites to make their beds, and lay down to sleep upon the beds so made— and continued to do likewise for each of the next 19 nights, after which they were quarantined while other soldiers— Eng- land, Hanberry, Hildebrand, and Weatherwalks — repeated the horrible ex- perience, even adding to it the macabre touch of sleeping in the shirts which had been worn by yellow fever victims.' 14 Summing up the ordeal of the fomites, Major Reed said, in his address at Baltimore, that these volunteers, sleeping every night in a building into "which no sunlight ever came" and which was purposely designed to lack air ventila- tion, "engaged in the morning in packing boxes with garments much soiled by contact with the bodies and excreta of yellow fever patients, and at night unpacking these same boxes in order to obtain articles for their beds and cloth- ing for their bodies; in other words, sleeping in the very beds and garments just vacated by cases of yellow fever * * * averaging each 21 nights amid such surroundings, came out of this pesthouse * * * none the worse for their exposure. Not one had contracted the disease." 35 "Yellow fever can no more be transmitted in that way than intermittent fever," Dr. Reed wrote his wife, while the experiments were still underway. Later, in an address before the American Public Health Association, meeting at Buffalo on 18 September 1901— a year after he had presented his "Preliminary Note" to the same organization— Reed declared that the doctrine of the spread of yellow fever by fomites "burst like a bubble" at the first touch of "actual experiment upon human beings." 3G In clearing up theories, there was another that called for attention— the theory of infection from a contaminated house. To test this, there was the "Infected Mosquito Building"— well ventilated, tightly screened, with a mos- quito-proof screen dividing its interior into two parts, differing only in that one side of the building was free from mosquitoes, while infected insects were released in the other side. In this side, Mr. Moran allowed 15 mosquitoes to "Reed ct al.. Journal o/ the American Medical Association, 36 (1901), pp. 431-440. " Baltimore Address, pp. 207, 208. M (i) Kelly, op. cit., p. 149- (2) Reed and Carroll, Medical Record, 60 (1901), p. 642. THE WALTER REED CHAPTER 1 27 bite him during three visits, while two other nonimmunes, acting as controls, occupied the other side of the building, free of mosquitoes. Moran, who had been in quarantine for 32 days before being bitten and had had no other chance to catch yellow fever, sickened on Christmas morning. The controls, who spent 14 nights in the room protected by the wire screen, but who had breathed the same air as Moran, remained well. The demonstration was complete that a house is infected with yellow fever only if it contains infected mosquitoes.'' To insure that the particular species of mosquito which possessed this infective potency should be accurately depicted for surer identification, Major Reed asked General Sternberg, on 22 December, to have Dr. J. C. McConnell of the Medical Museum sent to Cuba to "make drawings of the mosquito and larvae from live specimens." Dr. McConnell, who had returned to the Museum as anatomist and who acted, in addition, as a one-man Medical Illustration Service, came down bringing his camera lucida and paper, and by the end of the year was at work on his sketches. 38 Transmission by Mosquitoes Established As the year ended, Reed had every reason for gratification. The fomites experiment was still underway, as were experiments with the transmission of yellow fever by direct infusion of infected blood from an active case to non- immune volunteers. These experiments, mostly carried out in January and February 190 1, proved that the presumptive "parasite" of yellow fever circulates in the bloodstream and is directly transmissible from man to man without the necessity of an intermediate host. These experiments, however, in no way vitiated the conclusion that the only method of propagating yellow fever in nature is by the bite of a mosquito which has drunk the blood of a yellow fever patient— a conclusion which was to be presented by Reed, on behalf of himself, Carroll, and Agramonte, and with a tribute to Lazear, before the Pan American Medical Congress, meeting in Havana on 6 February 1901. This, and the other conclusions of the report, backed by the unimpeachable testimony of unassailable research techniques, were to be almost immediately accepted by the medical world and the world at large. To Dr. Finlay, as Reed said, "must be given full credit" for the original idea and for the persistence with which it was maintained in the face of indifference and even ridicule. But to Walter Reed, James Carroll, Aristides Agramonte, and the lamented Jesse W. n> Baltimore Address, pp. 204, 205. m Truby, op. at., pp. 166, 172. 177. 128 ARMED FORCES INSTITUTE OF PATHOLOGY Lazear, and to the corps of intrepid and dedicated volunteers who offered them- selves for experiment, must go the credit for demonstrating and establishing the fact that explained the mysterious behavior of yellow fever and offered a method of successfully combating it. As Dr. Agramonte wrote in his biographical sketch of Dr. Finlay, speaking of the parts played by the Cuban doctor and the U.S. Army Board, "the great credit due the one robs not the other of a particle of his glory." ' Already, even before the experiments were concluded and the results pre- sented, the findings had begun to be put into effect in the American Forces occupying Cuba. At the suggestion of Maj. Jefferson Randolph Kean, Acting Chief Surgeon, General Wood issued General Orders No. 6 on 21 December 1900, prescribing mosquito-control methods for application at all posts on the island, "the Chief Surgeon of the Department having reported that it is now well established that * * * yellow fever * * * (is) transmitted by the bites of mosquitoes * * *." 40 Reed himself had been positive ever since Kissinger came down with yellow fever that, as he wrote Lt. Albert E. Truby on the 10th, "the theory is all right." 41 The theory, as he wrote his wife on 9 December, was Finlay's, "and he deserves great credit for having suggested it, but as he did nothing to prove it, it was rejected by all, including General Sternberg. Now we have put it beyond cavil * * *." 42 Writing to his wife again, in the closing minutes of the closing year of the 19th century, Reed expressed feelingly the glow of modest exultation at this great accomplishment: Only ten minutes of the old century remains. Here I have been sitting, reading that most wonderful book, La Roche on Yellow Fever written in 1853. Forty-seven years later it has been permitted to me and my assistants to lift the impenetrable veil that has surrounded the causation of this most wonderful, dreadful pest of humanity and to put it on a rational and scientific basis. I thank God that this has been accomplished during the latter days of the old century. May its cure be wrought in the early days of the new! The prayer that has been mine for twenty years, that I might be permitted to do something to alleviate hu- man suffering has been granted! * * * Hark, there go the twenty-four buglers in concert, all sounding "taps" for the old year. 13 " Agramonte, A.: Dr. Carlos J. Finlay: A Biographical Sketch. Transactions of the American Society ot Tropical Medicine 10: 27-31, 1916. " Truby, op. cit., pp. 187, 224, 225. 41 lhid. t figure 26. '" Kelly, op. cit., p. 141. " Ibid., pp. 152, 153. THE WALTER REED CHAPTER 129 On February 9, 1901, 3 days after he had presented to the Pan American Medical Congress the results of the experiments at Camp Lazear, Major Reed sailed for home, leaving Carroll behind in Havana to finish up certain details, including winding up the affairs of Camp Lazear, which was closed on 1 March 1901." In Havana also were Dr. Finlay, the theorist whose theories had been vindicated by experiment, and his friend— and Reed's— Maj. William Craw- ford Gorgas, whose original skepticism as to the theory hat! been replaced by acceptance, and whose acceptance and resulting action was to give the theory its first practical application. Dr. Gorgas still was not convinced that the mosquito was the only means of natural transmission of the disease, but realiz- ing that the insects were effective carriers, he declared war on the Stegomyia fasciata in Havana. Yellow fever had claimed an average of nearly 500 lives in Havana an- nually for the 20 years, 1880-1899. In 1899 and 1900, the city was "cleaned up," with good effect as to general health, but still there were, in 1900, more than 300 deaths from yellow fever. In January 1901, there were seven deaths, and in February, five. In February, the new regulations as to mosquito control were put into effect. In March, four new cases were reported, with one death. In April, there were three cases and no deaths; in May, four cases and no deaths; in June, neither a case nor a death. In July, the disease was re- introduced into Havana from the interior, with three cases and one death. August saw eight new cases and two deaths; September, five cases and one death; October, two cases but no death— and thereafter, for the remainder of 190 1 and the entire year of 1902, neither new cases nor deaths from the scourge that for over 140 years had never been absent from Havana's streets and homes. 45 The task of mosquito control in a tropical city was prodigious in its diffi- culties and infinitely vexing in its details, but it was accomplished by the vigor, firmness, patience, and tact of the great health administrator, Gorgas. And in its accomplishment, it provided the perfect proof of the correctness of the conclusions of the great medical discoverer, Reed. Back in Washington, Reed continued his work for the Yellow Fever Com- mission, as well as his work as Curator of the Medical Museum and professor of bacteriology at Columbian (now George Washington) University. He was, 2 CO Ibid., p. ,63. (2) Reed, Journal of Hygiene, 2 (1902), p. 108. "(i) Reed, Journal of Hygiene, 2 (1902), pp . ioi, 102. (2) Kelly, op. cit., pp. 182-187. (3) Senate Document 822, 61st Congress, 3d session, pp. 221, 235, 236. !3o ARMED FORCES INSTITUTE OF PATHOLOGY for the season, relieved of his work as professor of the Army Medical School which had been suspended for the period of the Spanish War and was not to resume its sessions until October 1901. Meanwhile, Reed, as he wrote to Carroll, who was still in Havana, was "tied down to the Army Examining Board." 4C Search for a Cause The Yellow Fever Commission had succeeded in demonstrating to the satisfaction of the world the method of transmission of the disease, but the discovery of the activating cause of the disease itself was unfinished business. In 1898, Friederich A. J. Lomer and Paul Frosch had demonstrated that hoof- and-mouth disease in animals is due to something called, for want of a better name, a "virus." Prof. William H. Welch, who had taught Reed at Johns Hopkins, and who had been a fellow-pupil of Loffler's under the great Robert Koch, called Reed's attention to the LdfHer-Frosch findings in the early summer of 1901. To Reed and Carroll, it appeared possible that the same sort of substance might be the cause of yellow fever. A brief outbreak of tht disease in Santiago de las Vegas offered an opportunity to put the supposition to the test, so Carroll was sent back to Cuba in August 1901 to carry on the experiments. The tests showed that the infective agent was present in the blood and in the blood serum of fever patients, and that the power to produce fever persisted even after the serum had passed through "the pores of a filter which ordinarily serves to prevent the passage of all known bacteria." 1T It was to be yet another quarter of a century before it was finally established that the infecting agent of yellow fever is not a visible "parasite" such as Reed and Carroll sought, but is a virus which filters had not yet trapped nor microscopes revealed. In the little more than a year which remained of what has been described as the "fifty-one years of Walter Reed's industrious, blameless life," ,s Reed lost no appropriate opportunity to give the medical world the lessons learned in the work of the Yellow Fever Commission. Besides his appearance before die Medical and Chirurgical Faculty of Maryland at Baltimore in April 1901, and his second appearance before the American Public Health Association in September, both of which have already been referred to, he appeared before the Senate Document S22, fust Congress, 3d session, pp. 163, 164 (letter of 26 February 1901). (1) Ibid., p. 165. (2) Reed, Journal of Hygiene, 2 (1902), p. 106. "McCaw, Walter IX: Walter Reed: A Memoir. Washington: The Walter Reed Memorial Association, 1004. p. 1. THE WALTER REED CHAPTER 131 American Association of Physicians, meeting in Washington in July,"' and before the Society of American Bacteriologists, meeting in Chicago at the end of the year. 50 In addition, he published in the Journal of Hygiene, a British periodical, a summary article of recent researches concerning the etiology, propa- gation, and prevention of yellow fever by the United States Army Commission. 51 In these various papers and publications, he outlined in detail the experi- mental procedures followed and the results obtained, demonstrating to all who heard and read that both in its occurrences and its nonoccurrences at Camp Lazear, "yellow fever strictly obeyed the behests of the experimenters." Dr. Reed resumed his teaching, while continuing as Curator of the Medical Museum, but by the fall of 1902, it became evident that his strength was failing. In November, he suffered an attack which was diagnosed as appendicitis. On the 17th, at the Army General Hospital at Washington Barracks, he under- went an operation for removal of a ruptured appendix. "Maior Reed received the accepted treatment" of that period, according to Dr. Charles Stanley White, and "was in most competent hands." 5S Everything was done for him that medical experience dictated and the personal solicitude of affectionate associa- tion could suggest— but on 22 November 1902, Walter Reed, who "gave to man control over that dreadful scourge, Yellow Fever," 51 being but 51 years of age, died, to live among the medical immortals. "Reed, W.. Carroll, J., and Agramonte, A.: Experimental Yellow Fever. American Medicine. Phila- delphia 2: 15-23, 6 July 190 1. 50 Reed, W., and Carroll. J.: The Etiology of Yellow Fever. A Supplemental Note. American Medicine, Philadelphia 3: 3°i-305, 22 February 1902. 51 Reed, Journal of Hygiene, 2 (1902), pp. 101-110. '•"- White Dr Charles Stanley: The Last Illness of Major Walter Reed. Medical Annals of the District of Columbia '24: 396-398, August ,955- The surgeon in charge was Maj. William Cline Borden assisted by Lieutenants Ford and Conner, with Dr. White as anesthesiologist. Others in attendance were: Surgeon General O'Reilly, Mai. J. R. Kean, Cant F. P. Reynolds, and Doctors Wallace Ncff and Bovee. Dr. Borden, who was Reed's devoted friend, was more than any other one individual responsible for the creation of the Armv Medical Center which bears the name of Walter Recd-a project "known to his contemporaries as "Borden's dream'." In Ramsey, Herbert P.: Washington Medical Institutions: Walter Reed Armv Medical Center. Medical Annals of the District of Columbia 28: 225-231. A P nl ">5 9 - 53 (1) The quotation is from the citation accompanying the award of an honorar) MA. degree by Harvard University in 1902. (2) In .9.,. the U.S. Senate published Document 822. 6,st Congress, } d session, under the'title "Yellow Fever." The document includes tributes to Reed and his work among them the declaration of President Theodore Roosevelt that Reed left "mankind his debtor and the state- ment of Gen. Leonard Wood that "his was the originating, dieting, and controlling mind in this work • * *" The document also reprints seven of Reed's papers and addresses on yellow fever and three by Carroll on the same subject, together with cop.es of reports of the practical application of the discoveries of the Yellow Fever Board, by Col. Valery Havard, Chief Sanitary Ofhcer of the Department of Cuba, and by Maj. W. C. Gorgas, Chief Sanitary Officer in Havana. CHAPTER VII Triumph Over Typhoid Writing in 1906, Maj. Jefferson Randolph Kean declared that "Typhoid fever is today, on account of its wide dissemination, the persistent vitality of its infecting organism, the duration and severity of its attack and its large death rate, the most formidable infectious disease with which we have to contend in military life." * Of this fact, the Nation had had melancholy proof in 1898, during and after the war with Spain. Hostilities with Spain ended with the signing of the peace protocol on 12 August of that year, but there was no treaty of peace with a more insidious enemy, the Bacillus typhosus, as it was then called, or Salmonella typhosa, to give the microorganism its present-day name. Typhoid fever struck one out of every five soldiers in the national encampments within the United States, with a date rate of more than 7V2 percent of those stricken." To the study of this epidemic, Surgeon General George M. Sternberg as- signed Maj. Walter Reed of the Regular Army, Curator of the Army Medical Museum, and two surgeons of the Volunteers— Maj. Victor C. Vaughan, dean of the Medical School of the University of Michigan, and an epidemiologist and microbiologist of note, with special experience in the examination of water supplies, and Maj. Edward O. Shakespeare of Philadelphia who, as special commissioner from the United States, had studied cholera epidemics in Spain and India. The new Board, set up by General Orders No. 194, Adjutant General's Office, on 18 August 1898, lost no time in getting to work. On 20 August, they were at Camp Alger at Dunn Loring, Va., near Washington. There they found hundreds of cases of fever which they believed to be typhoid, but which most of the medical officers in attendance had diagnosed as malaria. 1 Kean, Jefferson R.: The Prevention of Disease in the Army (The Seaman Prize Essay). The Military Surgeon 18: 13, 1906. 2 Reed, W., Vaughan, V. C, ami Shakespeare, E. O.: The Origin and Spread of Typhoid Fever in United States Military Camps During the Spanish War of 1898. Volume 1. Washington: Government Printing Office, 1904, p. 674. 134 ARMED FORCES INSTITUTE OF PATHOLOGY Typhoid and the Medical Museum The question could be settled only by microscopic pathological examination, and there was not a microscope in the camp. Authority to set up a diagnostic laboratory in each camp was requested and was granted. Doctors William M. Gray and James Carroll of the staff of the Army Medical Museum were assigned to the laboratory at Camp Alger, the first to be established. Later, after the troops left Alger, the activity was transferred to Fort Myer, Va., and afterward to Jacksonville, Fla. 3 The Typhoid Board's first stop on its tour of inspection of campsites and surroundings was at Fernandina, Fla., reached on 26 August. By the end of September, the Board had visited camps at Jacksonville, Fla.; Huntsville, Ala.; Chickamauga National Park, Ga.; Knoxville, Tenn.; Montauk Point, Long Island; and Harrisburg, Pa.' On much of their journey, they traveled and lived in an office car provided for their use by the Southern Railway."' The early differences in diagnosis between the Board and the local medical officers, first evident at Camp Alger, persisted. At Jacksonville, where the VII Army Corps was encamped, the dominant diagnosis for the fevers was malaria for the milder cases, and typhomalaria for the more severe. The Reed- Vaughan-Shakespeare Board was convinced, from the clinical evidence, that many such cases were typhoid. They persuaded Brig. Gen. Fitzhugh Lee, in command of the camp, to order that 50 cases diagnosed by the camp medical officers as malaria or typhomalaria be sent to Fort Myer, where Dr. Carroll had set up his diagnostic laboratory, for microscopic tests. The tests, in every instance, showed the true diagnosis to be typhoid fever. Being still unconvinced by the tests of a microscopist working for the Typhoid Board, further tests were made on a larger number of men, sent to major civilian hospitals in Baltimore, Philadelphia, New York, Boston, and Cleveland— and again the tests showed that the correct diagnosis was typhoid fever.' 1 By September, the bacteriologic laboratory was in operation at Chicka- mauga National Park, where 60,000 soldiers had been encamped during the summer, and where camp fever had been so prevalent that there was a dis- "(1) Reed et al„ op. at., p. xiii. (2) VaugBan, Victor C: A Doctor's Memories. Indianapolis: Kobbs-Mcrrill Co., [926, pp. $69— 371. Reed ct al.. op. cit., p. xvi. " Vaughan, op. < it., p. 580. '/*/</.. pp. 572, 373. TRIUMPH OVER TYPHOID 1 35 position to term the disease "Chickamauga fever" and to ascribe it to "a miasma that arises nightly from the river and permeates the camp." ' The laboratory at this camp, in charge of Acting Assistant Surgeon Charles F. Craig, was supplied with materials for its tests from pure cultures furnished by the Army Medical Museum and the Johns Hopkins University. 8 In October 1898, the Board was back in Washington and at work on the laborious task of studying the detailed medical records of 118 regiments which were, or had been, in the national encampments. Leaving out of account the records of 20 regiments, which were so defective that they were discarded, the Board checked every man shown on sick report who might have been a typhoid case, tracing him through the regimental, division, and general hospitals, and even the civilian hospitals to which many men had been sent, in order to learn the course and the outcome of the disease. In 48 regiments, the subsequent medical history of every man with a short diarrhea or a supposed malarial attack was checked, in order to see whether they afterward showed a greater or a lesser susceptibility to typhoid fever. In all regiments studied, the analysis of the start and spread of the disease was localized by companies; in many regiments, it was carried down even to the squad, with the date and order of occurrence of the disease listed by individual tents. At the end of June 1899, the appropriation for the work of the Typhoid Board ran out, and Doctors Vaughan and Shakespeare were relieved from duty. They continued the work on their own account, however, dividing the sick reports and taking them to their respective homes for further analysis. On 2 June 1900, a meeting of the members of the Board was to have been held, but on the day before the appointed meeting, Dr. Shakespeare died. Three weeks later, Major Reed was on his way to Cuba to meet the menace of yellow fever; Dean Vaughan, however, had prepared an abstract of the findings of the Board, which was concurred in by Major Reed, and was pub- lished in 1900. The Typhoid Boards Report The abstract, however, did not carry the convincing authority of the sup- porting evidence, and in 1903, largely at the instance of Elihu Root, Secretary of War, the Congress provided the funds for publication of the full report. In the meanwhile, Major Reed had died, leaving the task of putting the full 'Ibid., p. 379. * Reed et al., op. cit., p. 136 ARMED FORCES INSTITUTE OF PATHOLOGY report into shape for publication to the surviving member of the Board, Dr. Vaughan. 9 As finally issued in 1904, the report is in a massive volume of text and tables, with a second volume of maps and charts, in the preparation of which Major Reed testified that C. J. Myers, longtime Chief Clerk of the Museum, had given "invaluable assistance for two years * * *." 10 From the data in the two volumes of the report, 57 conclusions were drawn. The conclusions are a succinct and nearly complete compendium of information on the course, transmission, and prevention of typhoid fever in military camps or, for that matter, in civil life as well. As Major Kean wrote in his Seaman Prize Essay of 1906, the report of the board "threw a flood of light on the subject * * * and remains a permanent monument to the vast labors and scientific acumen of the members of that board— Reed, Vaughan, and Shakespeare." u As to the cause of the disease, the report clears up several theories once widely held— the "obsolete theory," as it is termed— that the disease is caused by inhalation of gaseous emanations arising from certain soils, for one, and the more sophisticated theory that the disease is due to germs which spontaneously evolve, or "ripen," from microorganisms normally present in putrefying matter. Instead, the report firmly supports the specific origin of the disease by trans- mission, directly or indirectly, from an infected individual to a susceptible person. With the wide dissemination of typhoid at the turn of the century, the Board found that there were plenty of sources of infection, with 82 percent of the regiments studied developing typhoid within 3 weeks after reaching national encampments. Regardless of the section of the country from which the soldiers came, and even if they were encamped under perfect sanitary conditions, the chances were that one or more cases of typhoid would develop— and every case was a potential focus of infection. 12 Indeed, because of the disposition to diagnose all but clear-cut cases as malaria or typhomalaria— a term which the report recommended to be dis- carded—typhoid fever was found to be much more prevalent than had been supposed. In the camps, "Army surgeons correctly diagnosed about half of the cases of typhoid fever," in the opinion of the Board after checking clinical symptoms and bacteriologic findings. But even so, the Board added, the Army ' (r) Ibid., pp. xiii, xiv. (2) Vaughan, op. cit., pp. 391-394. "'Lamb. Dr. D. S.: A History of the Army Medical Museum, 1 862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, p. 119. " Kean, The Military Surgeon. 18 (1906), p. 13. 12 Reed et al., op. cit., pp. 659, 662, 663. TRIUMPH OVER TYPHOID T37 surgeon "in recognizing nearly half the cases of typhoid fever * * * probably did better than the average physician throughout the country does inh is private practice " 13 Typhoid fever, the report found, "is disseminated by the transference of the excretions of an infected individual to the alimentary canals of others." Infected individuals included those in the early and undiscovered stages of the disease, and also convalescents who had passed through the attack but continued to excrete typhoid bacteria." The existence of "carriers" who were not themselves suffering from the disease was not known until 1907, when the report on the original "Typhoid Mary" was published. 15 Contrary to the general belief— and a belief held by the Board itself at the outset of its investigation — that typhoid was primarily a waterborne disease, it was found that "infected water was not an important factor in the spread of typhoid in the national encampments in 1898." Transmission through the air in the form of dried dust carrying the bacilli of typhoid was regarded as "prob- able * * to some extent" and it was looked upon as "more than likely that men transported infected material on their persons or in their clothing" — a likelihood rendered all the more likely by the fact that "camp pollution was the greatest sin committed by the troops in 1898" and by the prevailing practice of detailing men from the ranks on a day-by-day basis to act as orderlies in the hospitals. 10 A New ''Villain" — The Fly A new villain in the transmission of the disease was fount! in the flies which served to convey the infected organisms from their source to a person. To the modern generation, living in a wire-screened and stableless environment, and trained from childhood to swat the fly, the idea of the fly as a carrier of disease is commonplace. In 1898, however, when schoolchildren were exhorted to emulate the fly in its supposed neatness, evidenced by constant rubbing of its wings with its legs— "washing" itself, it was thought to be— the idea that the common fly was a carrier of deadly disease was novel. General Sternberg, in his Circular No. 1, issued on 25 April 1898, had suggested the possibility of flies as a source of infection in typhoid, camp diarrheas, and perhaps yellow fever. The statistics gathered by the Typhoid Board showed that men who 13 ibid., p. 674. u Ibid., pp. 663, 667, 721, appendix 3. 15 Sopcr, George A.: The Work of a Chronic Typhoid Germ Distributor. Journal of the American Medical Association 48: 2019, 15 June 1907. " Reed ct. al., op. cit., pp. 666, 667. j 38 ARMED FORCES INSTITUTE OF PATHOLOGY ate in screened tents were less liable to typhoid than those whose mess tents were open to the flies. The finding of the Board was explicit and convincing — "Flies swarmed over infected matter in the pits and then visited and fed upon the food prepared for the soldiers in the mess tents." " The Reed-Vaughan-Shakespeare report takes on an even greater importance when the conditions existing in the camps in 1898, constituting the background into which the report was projected, are considered. Camp sanitation was still virtually an unknown subject to most line officers and men and, for that matter, was not well known even to many medical officers. Medical officers, moreover, lacked authority and could do little more than recommend. In some instances, the recommendations were vigorous, as in the case of the Third Nebraska Volunteer Infantry, in camp at Jacksonville. "As we were instructed to do," writes Dean Vaughan, "we found our way to the colonel's tent and asked him to join us in the inspection of his regiment. I can only say that we found the sanitary conditions no better than in other regiments. When we were through with the inspection Major Reed said to the colonel: 'Shake- speare and Vaughan are on this commission because they know something of camp sanitation. I am here because I can damn a colonel,' and he proceeded in plain terms to speak of the responsibility of a commanding officer in looking after the health of his troops." The colonel of the Third Nebraska was William Jennings Bryan. 18 The prevailing state of knowledge, or the lack thereof, is summed up by Col.P.M.Ashbum: There was ignorance of the epidemiology of typhoid, that it was conveyed in other ways than by polluted water, ignorance of sanitation in general and of camp sanitation in particular, ignorance of proper precautions to be taken in the preparation and handling of food, ignorance of the danger of having sick men in kitchens, ignorance of the accurate methods of diagnosis which are now employed as routine in camps and hospitals, ignorance of the existence of typhoid carriers. For this ignorance no one person was to blame, it was the characteristic of the day. 1 " Most of this prevailing ignorance the Typhoid Report dispelled, even though it did not suspect the existence of the carrier who is not himself at the moment a victim of typhoid, and did not bring out sharply the danger of infection from the convalescent or recovered typhoid patient. " (1) Ibid., p. 666. (2) Vaughan, op. at., pp. 384, 385. " Vaughan, op. at., p. 375. " Ashburn, P. M.: A History of the Medical Department of the United States Army. Boston: Houghton Mifllin Co., 1929, pp. 169-170. TRIUMPH OVER TYPHOID 1 39 Changes in the Museum Command In the interim between the accumulation of the data for the report and its publication, there had been changes in the Surgeon General's Office and in the Medical Museum. General Sternberg had reached the age of retirement in 1902, and had been succeeded by Brig. Gen. William H. Forwood who, after a service of only 3 months as surgeon general, had also retired in the same year, to be succeeded by Brig. Gen. Robert M. O'Reilly. Col. Alfred A. Woodhull had succeeded Col. Dallas Bache as Director of the Museum and Library Division in 1900, to be succeeded in the following year by Col. Calvin DeWitt, who in turn was succeeded by Col. Charles L. Heizmann in July 1903. On 1 November 1902, Maj. Walter Reed was put in charge of the Library of the Surgeon General's Office, in addition to his duties as Curator of the Museum, and Lieutenant Carroll was designated as Acting Curator. When Major Reed died, later in the same month, Carroll was the natural choice for his successor but, perhaps because he was already in performance of the duties of the office, it was not until July 1903 that he was formally appointed to the post. In 1906, Col. Valery Havard succeeded Colonel Heizmann in charge of the Museum and Library Division, with Lieutenant Carroll continuing as Cura- tor of the Museum. In March 1907, Carroll was promoted to the rank of major, and 6 months later, on 16 September, he died. 20 Upon the death of Major Carroll, Capt. (later Maj.) Frederick Fuller Russell (fig. 46) was named as Curator of the Medical Museum and professor of bacteriology and clinical microscopy at the Army Medical School. The new Curator, 37 years old, had done his premedical work at Cornell University, and had taken his M.D. degree at the College of Physicians and Surgeons of Columbia University in 1893. After serving an internship and a residency at Bellevue Hospital in New York, and studying in Berlin, he had received a commission in the Army as first lieutenant and assistant surgeon in 1898, being promoted to captain in 1903. He had served in Puerto Rico and, briefly, at the Museum in 1900. Volunteers for Vaccination Against Typhoid In the latter years of Major Carroll's tenure as Curator of the Museum, he undertook an experiment in vaccination against typhoid fever which, in its use of human volunteers as subjects, was reminiscent of the experiments with ' (1) Lamb, op. cit., pp. 122, 123, 133. (2) Senate Document 822, 61st Congress, 3d session, p. 20. 71 3-028* — 64 1 1 140 ARMED FORCES INSTITUTE OF PATHOLOGY Figurl 46. — Maj. Frederick F. Russell, seventh Curator of the Museum, 1907-1913, who introduced typhoid fever vaccination in the Army. yellow fever in Cuba. The typhoid fever experiment, started in May 1904, called for the oral administration of dead typhoid bacilli. After experiments with rabbits and guinea pigs had succeeded in producing an immune reaction, Dr. Carroll secured the permission of The Surgeon General to call for volun- TRIUMPH OVER TYPHOID l . l teers who would swallow doses of nutrient bouillon which had been inoculated with typhoid bacilli killed by heat. Carroll himself swallowed the typhoid dose, as did two officers detailed to assist— Lt. Edward B. Vedder !1 (later Col., MC, USA, and the discoverer of the cause and the prevention of beriberi) and Lt. Harry L. Gilchrist (later Maj. Gen. and Chief of the Chemical Warfare Service). Fifty soldiers volunteered for the experiment, from whom every fifth man was accepted— Sgt. Joseph I. Howe, and Privates William E. Lumley, George Dunn, George C. Williams, George S. Ward, Robert A. Eisemann, Merl Clifford, William J. Epps, Claud W. Powell, and Robert E. Bowman. Seven of the group developed undoubted cases of typhoid, and three others suffered attacks of a febrile disease which may or may not have been typhoid. This first attempt at a new technique in prevention failed in its purpose of producing immunity, resulting instead in attacks of the disease against which immunity was sought, but other and more successful experiments were to come. Undismayed by the failure of the first attempt with oral typhoid vaccina- tion, Dr. Carroll turned to a method of vaccination by hypodermic injection, first used by Sir Almroth Edward Wright, in British India in 1896, and re- ported in the British Medical Journal of 30 February 1897. Typhoid was even more destructive among British troops in the Boer War of 1899-1902, with 31,000 cases and 5,877 deaths, than it was among the Amer- icans in the war with Spain. Sir Almroth's vaccination was tried on a voluntary basis, with results so mixed that vaccination for typhoid was suspended in 1902 and, in 1903, its further use in the British Army was prohibited. The ban was removed, however, when the Royal College of Physicians, after full investi- gation, sustained the use of this method of prophylaxis. Both the oral and the hypodermic methods of vaccination depended upon killing the bacteria in the culture by heat raised to the death point for the specific microorganism. This thermal death point had been determined by General Sternberg for typhoid and many other bacteria. In determining these death points, he had used small glass bulbs with the narrow necks sealed, thus pre- venting evaporation. In making larger batches of vaccine, a i-liter flask was used, with the mouth stoppered by cotton, which permitted some evapora- tion. This left a ring of dried matter in the neck of the flask. Since it requires a higher temperature to kill dried typhoid bacteria than is required to kill them when moist, some of the dried organisms survived and, when the flask was handled, were washed down into the liquid where they began to grow Zl Vedder, Edward R., Col., MC (Ret.) : Typhoid Fever and Typhoid Inoculation in the United States Army. Unpublished typescript, made available through the kindness of Lt. Col. Henry Vedder, MC, USA. I42 ARMED FORCES INSTITUTE OF PATHOLOGY again, with the result that the vaccine was contaminated with living typhoid bacteria. To prevent this, Russell added to each flask a small quantity of tri- cresol disinfectant, sufficient to kill any bacteria left alive in the vaccine. 22 European Experience On io February 1908, Captain Russell wrote Lt. Col. W. B. Leishman, pro- fessor of pathology at the Royal Army Medical College at Millbank, London, advising that it was proposed to inaugurate antityphoid vaccination in the American Army and asking about the British experience. To this letter, Colonel Leishman cordially replied on 29 February, offering "most gladly" to give all the information he could on the subject, and sending him a culture of the strain of Salmonella typhosa employed by the British."" In the summer of 1908, Surgeon General O'Reilly sent Captain Russell to Europe to study at firsthand the methods and the experience of the British and German Armies. This assignment, carried out with "great industry and ability," as The Surgeon General put it, resulted in a report which The Surgeon General described as a "very valuable treatise on the epidemiology of this disease to date." ' 21 The experience of the German Colonial Army, which had tried vac- cination for typhoid in 1904 on a voluntary basis, was that the vaccinated soldier was only about one-half as likely to develop the disease as the unvaccinated soldier, and that the death rate was cut to one-fourth. 25 In the British experience, as described by Colonel Leishman, there had been among 6,610 unvaccinated soldiers 187 cases of typhoid, with 26 deaths, while among the 5,473 men at the same posts who had volunteered for vaccination, there had been only 21 cases and 2 deaths. 20 The history of vaccination as a method of protecting troops against typhoid fever, including the experience of the British and German Armies with voluntary vaccination, was considered by a special board of officers of the newly created Medical Reserve Corps. Members of the Board were eminent clinicians and ^dlThc explanation of the accident that left typhoid bacilli alive is that of Brig. Gen. Frederick Fuller Russell, MC. USA (Ret.). (2) Memorandum of conversation with General Russell at Louisville, Kv.. 28 April i960. (3) Letter, General Russell to Dr. Edward H. Vedder, George Washington Univer- sity Medical School, 25 October 1935. ^Original letter, W. B. Leishman to F. F. Russell, 29 February 1908. On file in historical records of AFIP. : * Annual Report of the Surgeon General, U.S. Army, 1909, p. 44. 3 Russell, F. F.: The Experience of the German Colonial Army with Anti-Typhoid Vaccination. The Military Surgeon 24: 53-56, 1909. M Journal of the Royal Army Medical Corps 12: 166, cited in: Russell, F. F.: The Prevention of Typhoid Fever by Vaccination and by Early Diagnosis and Isolation. The Military Surgeon 24: 484, June 1909. TRIUMPH OVER TYPHOID 143 pathologists — Doctors William T. Councilman, distinguished for his researches in amebic dysentery ; Simon Flexner, first director of the Rockefeller Institute for Medical Research; Alexander Lambert, a distinguished internist of New York; J. H. Musser, of the distinguished Philadelphia school of practitioners of internal medicine; William S. Thayer of the Johns Hopkins faculty; and Victor C. Vaughan, surviving member of the Reed-Vaughan-Shakespeare Board — with Capt. F. F. Russell as recorder. After studying the evidence, this Board concluded that "the practice of anti- typhoid vaccination is both useful and harmless and that it offers a practicable means of diminishing the amount of typhoid fever in the Army both in times of peace and war." The Board accordingly recommended that in time of war the practice be introduced in both the regular and volunteer forces, and that it be introduced immediately on a voluntary basis in the medical units, with an opportunity for volunteers from the Army as a whole to receive the protection of vaccination. 27 The findings and recommendations of the Board were ap- proved and published in 1909, in War Department General Orders No. 10. Meanwhile, Major Russell (he was promoted in 1909) was busy with prepa- rations for vaccinating the volunteers, the first of whom came from the Army Medical Museum and the Medical School (fig. 47). A "special room in the Army Medical Museum was fitted up as a vaccine laboratory," entirely separate from the School. The new laboratory, with "complete equipment of entirely new apparatus, specially planned for this particular purpose" of manufacturing vaccine, was completed in February 1909, and in March, vaccination on a whole- sale scale began. 23 Compulsory Vaccination Introduced Eight hundred and thirty volunteers were vaccinated by the time the 1909 report of the Surgeon General was issued, without untoward incident. By the end of the next year, 10,841 volunteers had received "shots." In March 191 1, be- cause of troubles on the Mexican border, an entire division of the Army was mobilized in Texas. For this mobilization, vaccination was made compulsory for military personnel — and with more than 10,000 men in camp, the only death from typhoid was that of a civilian teamster who had refused vaccination. "It is hard to credit the accuracy of such a record," declared President William Howard Taft, addressing the Medical Club of Philadelphia on 4 May 191 1. "But, as I have it directly from the War Office," he added, "I can assert it as one more instance of the marvelous efficacy of recent medical discoveries and practice — 27 Annual Report of the Surgeon General, U.S. Army, 19ml, pp. ^, 46. 28 Ibid., pp. 46—50. i 4 4 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 47. — Maj. Frederick Fuller Russell (extreme right) vaccinating volunteers against typhoid. in which he included "modern health regulations" as well as vaccination against typhoid."" In his Annual Report for 1913, Surgeon General George H. Torney ex- pressed the astonishment of a veteran Army medical officer. "It seems more than marvelous," he wrote, "that among the number of men in the camps at Texas City and Galveston, and among those in the numerous camps along the Mexican border, constantly exposed to infection, not a single case has occurred." On 30 September 191 1, vaccination for typhoid was made compulsory for the entire Army, and by the end of 191 1, 85 percent of all personnel had received the protection (fig. 48). The reduction in the incidence of the disease which followed was dramatic. In 1909, with fewer than 1,000 men vaccinated, there had been 3.35 cases of typhoid per thousand. In 1910, with 15 percent of the strengdr vaccinated, there had been 2.43 cases per thousand. In 191 1, with 85 percent vaccinated by the end of the year, there were 0.08 cases per thousand. In 1912, the rate was 0.03 per thousand, and in 1913, 0.004 cases P er thousand. In the Navy, where vaccination did not become compulsory until 1912, there were 361 cases of typhoid in 191 1; 92 cases in 1912; and 33 in 1913. " "President Tart and the Medical Profession. Journal of the American Medical Association 56: 1399- 1404, 13 May 1911. '"(1) Siler, J. F., and others: Immunization to Typhoid Fever: Results obtained in the Prevention of Typhoid lever in the United States Army, United States Navy, and Civilian Conservation Corps, by the TRIUMPH OVER TYPHOID 145 Figure 48. — In 1917, with the coming of World War I, typhoid vaccination scenes such as this were commonplace. Typhoid vaccination did not originate with the United States, but the American Army was the first to make vaccination a required prophylaxis against typhoid. For this step and the beneficial results which flowed from it, credit is due to the mass experiments conceived by Major Russell and carried out at the Army Medical Museum, and with vaccines at first produced in its laboratories.' 1 For such results, there was a multiplicity of interacting causes. Faster and more accurate diagnosis of cases helped to reduce the risk of infection, which was further reduced by more thorough and efTective disinfection — a procedure which Major Russell termed "really important" in his first article on "The Prevention of Typhoid Fever by Vaccination and by Early Diagnosis and Isolation." : '~ Use of Vaccines. The American Journal of Hygiene, Monographic Scries. No. 17. Baltimore: Johns Hopkins Press, September 1941, pp. 12, 13. (2) Annual Report of the Surgeon General, U.S. Army, 1910, p. 48. (3) Annual Report of the Surgeon General, U.S. Army, 1911, p. 51. 31 Afterward, the Army Medical School took over the preparation of antityphoid vaccine for the Army, the Navy, and the Public Health Service. An interesting account of the process and tl» ex- ponents of the vaccine used against typhoid and the two types of paratyphoid was published in: Callender, G. R., and Luippold, G. F.: The Effectiveness of Typhoid Vaccine Prepared by the United States Army. Journal of the American Medical Association 123: 319-321, 9 October 1943. 32 Russell, The Military Surgeon, 24 ( 1 909) , pp. 479-5 1 8. 146 ARMED FORCES INSTITUTE OF PATHOLOGY Writing in answer to an inquiry as to the propriety of using typhoid vaccine in civilian institutions, in November 1909, Major Russell said : I do not think that it is the only thing to be considered in the prevention of typhoid fever by any means; attention must be paid to all the usual sources of infection in addition to the use of vaccine. This is for the reason that the protection gained by vaccination is not absolute but only relative, and that if the infected material is present in sufficient quantities some people might develop typhoid in spite of previous vaccination. 33 Greater knowledge of medical officers and greater authority for the Medical Corps resulted in stricter sanitary controls. Broader knowledge of sanitation and disease prevention among officers and men of the line made such controls more readily enforcible. The combination of a lesser number of cases and lesser chances of infection from such cases as there were, created a diminishing spiral of morbidity. There was to be no repetition of 1898. By 1910, the chances of typhoid infection in the Army had been reduced to the point that the soldier was no more likely to suffer from the disease than the civilian. And then, into this already diminishing incidence of the disease, there was introduced the added safeguard of preventive vaccination, voluntary at first and then, for the military forces, compulsory. In the 5-year period 1911-1916, the chances of typhoid in the Army were further reduced to the point that the soldier was only one-fifth as liable to the disease as the civilian. 34 The English physician, William Budd, writing in 1874, stoutly maintained that typhoid was a "perfectly preventable plague" if pollution from alvine dis- charges of infected individuals could be checked. The Reed-Vaughan-Shake- speare study assembled overwhelming evidence to sustain the Budd theory, and outlined methods of prevention. The application of these methods, together with improved sanitary conditions generally, and the added protection of pro- phylactic vaccination of both civilian and military personnel, has brought measurably near Budd's prediction of perfect prevention. For tliis triumph over typhoid, many causes are responsible, but no small part of the responsibility rests upon three successive curators of the Medical Museum — Reed, who organized and carried forward the great study of the disease and its prevention; Carroll, who initiated experiments with the prophylactic vaccine; and Russell, who carried the experiments to successful conclusion and mass application. M Correspondence with John I. Armstrong, Kirkwood, Atlanta, Ga. On file in historical records of AFIP. 31 Siler ct al., op. tit., pp. 17, 18. CHAPTER VIII The "Pickle Factory" Period Five medical officers of the Army— Colonels Valery Havard, W. H. Arthur, and Walter D. McCaw, and Majors Carl R. Darnall and Frederick F. Russell, all of whom had special acquaintance with the work, the problems, and the situation of the Army Medical Museum or the Army Medical School, or both — met on 31 March 1909, to discuss the need for a new and suitable build- ing for the School. Their conclusion, arrived at unanimously, was that there was such a need. "The rooms which this school now occupy in the Museum and Library build- ing are inadequate and unsuitable," they said in a memorandum of their discussion. 1 "They have never been more than a makeshift * * * crowded and insufficient * * *" as well as encroaching upon the space and facilities desperately needed by the Library and the Museum. Two possible remedies were agreed upon: renting a building in Wash- ington or "simply the carrying out of the policy already decided upon" of providing a suitable building for the school in proximity to the Walter Reed General Hospital, then nearly completed. The conferees agreed that "the second solution seems decidedly preferable," as the next step in the normal development of the general plan, and strongly urged that $250,000, the esti- mated cost, "be included in the next estimates to be submitted to Congress, and that special efforts be made to induce Congress to appropriate it." With a lively sense of the uncertainty of congressional action, however, the conferees recommended that if it should be found that "there is no dis- position on the part of Congress to appropriate the necessary sum for the building" on the site already selected for it on the grounds of the Walter Reed Hospital, inquiries should be made so that "a suitable structure may be found and, if possible, rented." Memorandum, Office of The Surgeon General, 31 March 1909. On file in historical records of A I IP. 713-028'— 04- 148 ARMED FORCES INSTITUTE OF PATHOLOGY The Army Medical School Moves Out Almost a year later, on 2 February 1910, Curator Russell "respectfully invited" the attention of the officer in charge of the Museum and Library Division of the Surgeon General's Office, who was then Col. Louis A. LaGarde, to the history of the School's occupancy of quarters in the Museum and Library building. 2 The School, he recited, was established in 1893 in "two rooms which belonged to the Army Medical Museum, and Museum exhibits were put into the store-room to make way for the School. Each year as the institution has grown, the same encroachment on the exhibition and work rooms of the Muse- um has followed, and the growth of the School has been entirely at the expense of the Museum. This method * * * has reached its climax, since the Museum has absolutely no more room of any sort to give it * * *. As the School has grown the activities of the Museum have been more and more limited until we have arrived at a state in which something must be done." Something was done, and on 7 June 1910, Curator Russell informed The Surgeon General, through Lt. Col. Walter D. McCaw, then the officer in charge of the Museum and Library Division, that "the Army Medical School equipment is now being moved out of this building into the building at No. 721 Thirteenth Street, N.W., which has recently been turned over to the Medi- cal Department by the Quartermaster's Department." The move would be completed, he added, "towards the end of the present month" (fig. 49). The move of the School relieved somewhat the space pressure on the Museum, but at the same time it created other problems. Major Russel was in charge of, and did personally much of the technical work of, both the teaching laboratory of the School and the laboratory of the Surgeon General's Office, which carried on the work of the Museum in the fields of pathology and bacteriology, including the new procedure of making typhoid vaccine. Major Russell was also on the faculty of the Army Medical School and was to be moved, with his teaching laboratory, to the new school quarters. Unless both laboratories were under the same roof, he advised The Surgeon General, it would be practically impossible for him to continue to do the work of ex- amining water supplies, blood samples, and pathological materials required of the Surgeon General's laboratory. Authority was sought, therefore, and secured, for the removal to new quarters at the School of both laboratories, along with two experienced men to do the "considerable" clerical work. 'Letter, F. I'. Russell to L. A. LaGarde, 2 February 1910. On file in historical records of AMP. THE "PICKLE FACTORY" PERIOD I 49 Figure 49. — After 15 years of operation in the Museum building, the Army Medical School moved in 1910 to rented quarters on Louisiana Avenue. Major Russell also recommended that a branch of the Museum be estab- lished in the new building, "since a considerable part of the specimens, exhibits, etc., of the Museum has been set aside for and are regularly used in the instruc- tion of the classes of student officers" and it would be "impracticable to move articles of this character back and forth between the two buildings." Dr. John S. Neate, who had taken his medical degree since serving the Yellow Fever Board in Cuba and was then microscopist of the Museum, was recommended to have the custody and care of the branch. 1 1 Letter, F. F. Russell to The Surgeon General, 7 June 1910. On file in historical records of AFIP. !50 ARMED FORCES INSTITUTE OF PATHOLOGY Changes at the Museum On 15 October 1913, Major Russell's service as Curator of the Museum ended. His further Army service included distinguished work during the First World War in the field of preventive medicine, as head of the Division of Laboratories and Infectious Diseases of the Surgeon General's Office. In 1920, Colonel Russell, as he then was, resigned from the Army to be commis- sioned a brigadier general in the Medical Reserve Corps, and to become direc- tor of the International Health Board of the Rockefeller Foundation. He closed his career in medical science and administration by years of service as professor of preventive medicine at Harvard. Succeeding Russell as Curator of the Museum was Maj. Eugene Randolph Whitmore (fig. 50). The new Curator was an academic graduate of the University of Wisconsin and had received his M.D. degree at the University of Illinois in 1899. In 1910, while on duty in the Philippines with the Board for the Study of Tropical Diseases, he had established the Pasteur Institute in Manila. For almost two decades, during the administrations of three curators who had preceded Major Whitmore, the center of the Museum stage had been held by work in bacteriology and its related subjects of epidemiology and immu- nology. The resulting situation was recognized and described in a memoran- dum of 21 November 1913, addressed by Colonel McCaw, the officer in charge of the Museum and Library Division, to The Surgeon General of the Army. 4 "The Museum feature of the Museum and Library Division of the Surgeon General's Office," he wrote, "has for many years past been almost at a standstill. While the Army Medical School occupied a large part of the present building, the energies of the Museum staff in practically all the laboratory work were expended in teaching the class and in making original investigations, prin- cipally bacteriological, into questions of great importance for the Army at large and the Medical Corps in particular. The results have been so brilliant * * * that no excuse is needed for having temporarily ceased to develop the Museum feature proper — to wit, the collection, preparation and exhibition of specimens illustrating medicine in all its branches. This feature was necessarily neglected because of the preponderating importance of the brilliant work undertaken and carried out successfully." "Many new specimens have indeed been accumulated; the Museum has been added to in some new directions and much obsolete material has been ' Memorandum, It. Col. \V. I). McCaw, to The Surgeon General. On file in historical records of AFIP. THE "PICKLE FACTORY" PERIOD I5 1 Figure 50.— Maj. Eugene R. Whitmore, eighth Curator of the Museum, 1913-1915. taken from exhibition to give place to more valuable and up-to-date specimens. The only room in the building especially adapted to exhibition and built for that purpose is now much overcrowded and yet it contains only the pick of the collections. As space was gained by the removal of the School two large rooms were selected for exhibition purposes and promptly rilled * . In the space 152 ARMED FORCES INSTITUTE OF PATHOLOGY gained from the School the Library also overflowed just in time to save it from being choked in its own material * * *." As a temporary solution, or rather palliative, of the space problem, Colonel McCaw suggested the removal from the building of certain offices of the Adjutant General's Department so that the entire building would be given over to the Medical Department — a proposition reminiscent of similar proposals of a quarter of a century earlier, when the "old red brick building" was new. In spite of the difficulties imposed by the lack of space, and the lessened emphasis on anatomy and pathology by reason of the overshadowing achieve- ments in bacteriology, the Museum had continued to excite interest among the professionals as well as the lay public. Calling "the attention of the profession in a general way to the advisability of more frequently resorting to this store- house of pathology," one Washington doctor declared that instead of the speci- mens being looked upon "as so much 'embalmed beef,' they should be regarded as treasures of great value," to be consulted by the "earnest student of disease." Much remained to be done to fill the gaps, however, since "many phases of many diseases are still unrepresented in this magnificent collection." 5 As seen by a visitor from Germany, Staff Surgeon Dr. Paul Ehrlich, of Giessen, the collections were described as including "many rare pathological preparations of man and the lower animals," with "serial sections of organs displayed comprehensively between plates of glass, to give the spectator an idea of their growth and structure." ° Dr. Ehrlich's "lively interest" was awakened by the preparations of tropical diseases, but he found diem "unfortunately bleached out by being kept in alcohol, and have lost their natural color. I called the attention of the pathologist to the methods employed in Germany (e.g., Dr. Karl Kaiserling's method) of pre- serving specimens in saline solutions, which, it seems, are not generally known of in America." As to knowledge in America of the Kaiserling process, the German visitor was in error. Dr. Kaiserling announced his method, which included the use "Smith, Thomas C: The . . . Treasures of the Army Medical Museum (Presidential address de- livered before the Washington Obstetrical and Gynecological Society, 6 October 1899). In American Journal of Obstetrics and Diseases of Women and Children 41: 57-63, January 1900. Although Dr. Smith's address dealt with obstetric specimens, he declared that the "richness of the Museum" in this field applied with equal force to other branches of medical and surgical pathology. Ehrlich, Dr. Paul: A German View of the American Army Medical School, Library and Museum. Translated by Dr. F. H. Garrison, Assistant Librarian, Army Medical Library from the Deutsche mihtararztliche Zeitschrift, July 1904, p. 396, et seq. THE "PICKLE FACTORY" PERIOD 1 53 of a solution of formalin followed by alcohol, in Berlin on 8 July 1896.' The process, with some modification, was introduced into the Army Medical Museum in June 1897, and had been used for wet specimens "with much satisfac- tion" since that time. With the adoption of the Kaiserling method, the use of alcohol, except as part of that process, was almost entirely discontinued. 8 The stature of the Museum and of its Curator, Maj. James Carroll, was recognized by the election of Carroll as the first president of the Inter- national Association of Medical Museums, a new organization whose truly international character is evidenced by the election of professors at an American, an English, and a German university as vice presidents, and of Dr. Maude E. Abbott of McGill University, a Canadian institution, as secretary-treasurer. Major Carroll was unable to attend the meeting, at which he was elected, because of illness from which he never recovered sufficiently to enable him to serve actively as president of the new association. At the second stated meeting of the Association, deep regret was expressed at the death of "one of the heroic figures in the history of this country" whose passing was a loss to the scientific world. 9 Changes in Classification In the last year of Carroll's curatorship, a new classification of the Museum s materials was begun, under the direct charge of Dr. D. J. Healy, anatomist of the Museum. The new system followed closely that adopted in 1899 by the Pathological Museum of McGill University in Montreal. It superseded, largely, the system of classification which had been developed by Dr. Daniel Smith Lamb, the pathologist of the Army Medical Museum. 10 The advantages claimed for the McGill system of decimal numbers to designate classes were that it followed an anatomical classification, with "the different morbid processes affecting each organ subclassified under it, general and regional pathology being provided for by cross cataloguing." In criticism of the Army Medical Museum system, submitted with deference to that Insti- tution's general excellence, it was said that the arrangement of descriptive num- bers, made up of capital and lowercase letters and numerals, which was the 'Abbott, M. E.: On the Classification of Museum Specimens. (A paper read before the Canadian Medical Association, Montreal, on 18 September 1902.) In American Medicine. 4 April I9°3. P- 54 1 - "Lamb, D. S.: The Army Medical Museum — A History. Washington Medical Annals 15: 4, January 1916. (A paper presented before the Medical Society of Washington, 1 November 1915.) "Bulletin Number 1, International Association of Medical Museums, Washington, D.C., 15 May 1907. The death of Major Carroll was noted in Bulletin Number 2, Washington, D.C., 15 January I9°9- 10 Lamb, Washington Medical Annals, 15 (1916), p. 14. J 54 ARMED FORCES INSTITUTE OF PATHOLOGY basis of the system, was "not systematically carried out in its application, so that it does not altogether answer the purpose for which it was intended * * *. Not only is it difficult or even impossible to classify a specimen under the head- ings that the catalog numbers furnish, but also it is impossible to observe the numerical order in the different groups without disturbing the natural order in which the specimens should stand." 1X Before the new system could be fully installed, Major Carroll died, Dr. Healy resigned, the new classification was abandoned, and the older system was reinstated by Dr. Lamb, who was made custodian as well as pathologist. Under this system, there were "collected together in one place all specimens illustrating any one disease * * * the subarrangement being according to the organ involved." Under this plan, as an example, it had been possible to select in a few minutes specimens to be loaned to a Tuberculosis Congress meeting in Baltimore without having to look for specimens in "twenty or more places." 12 More responsible than anyone else for the classification and cataloging of specimens was Dr. Daniel Smith Lamb (fig. 51), who joined the Museum staff as a hospital steward in 1865, took an M.D. degree from Georgetown University in 1867, while still on duty at the Museum, was appointed Acting Assistant Surgeon in 1868, served the Museum in that capacity until the rank was abolished by Congress in 1892, and then became pathologist to the Museum, and continued as such until his voluntary retirement in 1920 — a total span of active service to the institution of 55 years, followed by occasional consulting assistance during the remainder of his long life of 86 years. Dr. Lamb commenced his service at the Museum under Dr. Joseph J. Woodward and continued it under Dr. George A. Otis and Dr. David L. Huntington. In 1883, when John Shaw Billings, the great administrator and bibliographer, was put in charge of the Museum as well as the Library, Dr. Lamb became, in effect though not in name, the active Curator of the Museum's collections, and so remained under the administration of Walter Reed, whose other responsibilities absorbed so much of his time and attention that the task of keeping up the Museum's pathological collections was largely left to the pathologist. 13 11 Abbott, American Medicine, 4 April 1903, pp. 541-544. (1) Letter, D. S. Lamb to V. Havard. In Lamb, D. S.: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, pp. '33-'35- (2) Lamb, Washington Medical Annals, 15 (1916), PP- M> '5- (1) Callcndcr, Maj. George R.: Doctor Lamb's Association With the Army Medical Museum. Copy of this memorial address on file in historical records of AFIP. (Hereinafter cited as Callendcr Address.) (2) Kobcr, George M., Dean of Georgetown University Medical School: Doctor Daniel Smith Lamb, A Man of Science. (An address delivered upon the occasion of Dr. Lamb's 50th anniversary as a THE "PICKLE FACTORY" PERIOD 155 Figure 51. — Dr. Daniel Smith Lamb. During die curatorship of Carroll, there seems to have been a slight change in the assignment of responsibilities in the work of the Museum. In a circular letter of 25 May 1905, the Curator informed sugeons of Washington, D.C., that teacher in the Howard University Medical Department, 7 June 1923.) Published by the Howard University School of Medicine, 1923. 156 ARMED FORCES INSTITUTE OF PATHOLOGY the Army Medical Museum was "now prepared to accept * * * pathological specimens of interest and preserve them after the method of Kaiserling, which is intended to retain the natural coloring * * *. In the absence of the Curator, any specimens turned over to Dr. Healy, the Anatomist, will be properly cared for." With reference to this circular, Lamb observed with some asperity that he, the pathologist of the Museum, had been using the Kaiserling process since 1899 "so that there was nothing really new in the circular, except the assignment of the Anatomist instead of the Pathologist to receive pathological material." The asperity was doubtless heightened by the fact that the anatomist had been on the Museum staff only 6 months, while the pathologist had already served 40 years, and had contributed more specimens to the Museum's collections "than any other has, or ever will, so contribute." u The Devotion of Dr. Lamb The devotion of Dr. Lamb to the interest of medical science extended beyond life into death. In his last will and testament, drawn in July 1928, in the last year of his life, he left specific instructions for the performance of an autopsy, even prescribing the formula for the solution in which his brain was to be pre- served for transmission to the Wilder collection at Cornell University, and directing that "such other organs as it may be desirable to preserve," including the skeleton, be "donated either to the Army Medical Museum, where I gave 54 years of service, or to the Howard University Medical School where I gave 50 years," first as professor of materia medica, but for 45 years as professor of anatomy. Dr. Lamb designated Maj. George R. Callender, then the Curator of the Medical Museum, to perform the autopsy, with Dr. Ales Hrdlicka of the National Museum as supervisor. Both were old and valued friends. To make the autopsy and examination of the organs more meaningful, Dr. Lamb filed with his will a complete statement of all illnesses and injuries from which he had suffered, including the "many times" he had had "infection from post-mortem examination" of which he had made "about 1,500 on nearly all diseased conditions." " The devotion and determination of Dr. Lamb helped to keep alive an inter- est in anatomy and pathology in a period of 30 years after 1883, when interest in microorganisms and parasite carriers of disease overshadowed that in morbid anatomy. In the latter years of the 19th century and the opening decades of the 20th, the fields of bacteriology and related studies were filled with "ardent 11 Callender Address, op, cit. Washington timing Star. 21 April 1929 aiul New York Times, 23 April 1929. THE "PICKLE FACTORY" PERIOD 157 workers who * * * all but forgot that while parasitology is of fundamental importance, certainly interesting, and approaches the exact in science, the orga- nisms themselves do not constitute disease but must be coordinated with morbid anatomical processes." In the prevailing neglect of morbid anatomy, Dr. Lamb retained his interest and "preserved specimens essential to the study of diseases including those caused by parasities." lb Major Whitmore was followed as Curator of the Museum on 4 August 1915, by Col. Champe Carter McCulloch, Jr. (fig. 52), who had been for 2 years previously librarian, and who combined the duties of librarian and curator until 23 June 1916, when he was succeeded as Curator by Col. William Otway Owen. Like Colonel McCulloch, the new Curator was a medical graduate of the Uni- versity of Virginia. He had been retired from the Army for disability in line of duty in 1905, after 23 years of service, but in 1916 was recommissioned and assigned to duty at the Museum. Through all changes of curators and all shifts of interest and emphasis, the collections of the Museum continued to grow. In 1906, when the abortive reclassification was undertaken, the collections numbered 34,338; 10 years later, they had grown to 47,313 specimens. But despite growth in the absolute size of the collections, the relatively reduced interest in morbid anatomy led to a decline in status of the Museum to such a point that it came to be called by the scornful appellation of "the pickle factory" 17 — a name which it bore until the events and demands of the Nation's next war demonstrated once more the vital need for a repository of materials for the study of pathological anatomy, physiology, chemistry, parasitology, and bacteriology in balanced relation to the prevention, diagnosis, and cure of disease. 10 Callender Address, op. cit. 17 Dart, Brig. Gen. Raymond O.: The Pathologist's Position in the Government Services. (An address before the College of American Pathologists and the Section on Pathology of the Southern Medical Associa- tion.) Typescript copy on file in historical records of AFIP. i 5 8 ARMED FORCES INSTITUTE OF PATHOLOGY Fi<;ure 52. — Col. Champe C. McCulIoch, Jr., ninth Curator of the Museum, 1915-1916. CHAPTER IX The Museum in a World at War With the entry of the United States into what was then called simply the World War, there being as yet no need to identify such conflicts by number, there came a profound change in the affairs of the Army Medical Museum. In his annual report for the fiscal year ending 30 June 1917— a report which reflected for the most part conditions before the declaration of war on 6 April of that year— Surgeon General William C. Gorgas noted that the Museum, with its nearly 48,000 specimens, was "one of the largest, most instructive, and valuable collections in existence." A year later, in a report prepared at about the time the "bridge of ships" was beginning to move American combat outfits into France in significant numbers, The Surgeon General reported that in the past year the Museum had "taken on new life." * At first, however, the rush of preparing for a war, which was to see the size of the U.S. Army increased nearly fortyfold, seems to have bypassed the Museum and left it in a quiet backwater, with its annual appropriation for the "preserva- tion of specimens and the preparation and purchase of new specimens held down to the $5 thousand-a-year figure which had come to be customary." "With this meager sum," Dr. Charles H. Mayo of Rochester, Minn., said in addressing the Surgery Section of the American Medical Association, the officers in charge of the Museum had, over the years, "accomplished much," maintaining a record of the "progress of medicine of past ages" and accumu- lating "many valuable historical specimens," while materials accumulated dur- ing the war would "make the collection modern, and one of the best in the world." These medical records of the war," he added, "will be of the greatest value, not only to the glory of medical accomplishment, but also as a means of interesting and educating the public in scientific matters pertaining to health and disease." 3 1 Annual Reports of the Surgeon General, U.S. Army, to the Secretary of War, for fiscal years ending 30 June 1917, p. 325, and 1918, p. 434. TT . , 2 War Department Bulletin Number 3", 22 May 1017. In The Medical Department of the United States Army in the World War. Washington: Government Printing Office. 1923. vol. I. p. 532- I " inafter cited as Medical Department History, World War I, volume I.] "Mayo, Charles H.: Educational Possibilities of the National Medical Museum. Journal of the Amer- ican Medical Association 73: 411-413,9 August 1919. 160 ARMED FORCES INSTITUTE OF PATHOLOGY The accumulations to which Dr. Mayo referred were the result of strenuous efforts to interest and instruct medical officers in the field, both in the camps at home and in the American Expeditionary Forces overseas, in the exacting work required in the proper preparation of anatomical and pathological speci- mens and forwarding them to the Museum in Washington. Despite such ef- forts, "most of the good material, and all the first-class specimens received at the Museum, with few exceptions, were brought there by men sent from the Museum to get them" — thus repeating, half a century later, the experiences of the staff of the early Museum in the Civil War. For this, there were plenty of real reasons as well as good excuses. Sum- ming up the situation, the eminent Dr. James Ewing of the Cornell University Medical School in New York, who is widely regarded as the "father" of oncology in the United States, and who, serving the Army as a contract surgeon in 1918, was assigned to the staff of the Medical Museum, said that this business of col- lecting pathological material was "one of the least urgent matters claiming at- tention in an army whose task was to win the war and win it quickly." A succession of epidemics, both at home and in the AEF, and the care of the wounded in the AEF overtaxed the laboratory forces and left "neither time nor force to collect suitable pathological specimens and preserve them according to modern methods." Furthermore, Dr. Ewing said, the "number of men in the American medical profession trained in the methods of the pathological laboratory, and especially in the methods of museum preparation, proved to be extremely small, and few of these were available to the army." 4 Making Pathologists in a Hurry The shortage of pathologists led to a certain amount of shortcut improvisa- tion, such as the way in which Maj. C. Judson Herrick of Grand Rapids, Mich., found himself in charge of the pathology department of the Army Medical Museum. As Dr. Herrick tells the story, he was commissioned as a major on 18 January 1918, and charged with the business of assembling personnel for assignment to Army hospitals to collect neuropathological materials for delivery, with their accompanying records, to the Museum. In April, when he had rounded up about 20 enlisted men with some training in histology and pathology, his original order was rescinded and shortly thereafter he was ordered to report for duty at the Medical Museum. Major Herrick continues: ' Ewing, James: Experiences in the Collection of Museum Material from Army Camp Hospitals. In- let-national Association of Medical Museums Bulletin VIII, December 1922, p. 27. [Hereinafter cited as Ewing.] THE MUSEUM IN A WORLD AT WAR l6l Upon reporting at the Museum to Col. W. O. Owen the only order I received was, "Go see Capt. Cattell." Henry W. Cattell was then in charge of pathology at the Museum. When Major Herrick reported for duty to Captain Cattell he was naturally disconcerted. The Captain knew that I knew very little about pathology and I knew that he knew very litde about neurology. Accordingly I suggested to him that he carry on exactly as before except that he deliver to me all neurological material for processing as it came in. Shortly after my arrival at the Museum, Col. Owen said to me, "Capt. Cattell has been transferred. You will take over his space and all his duties." "Very well, Sir. You understand that I am not a pathologist." "Perhaps you weren't yesterday," Colonel Owen replied. "You are today." •"' Dr. James E wings Mission The task of collecting suitable material and getting it to Washington in usable form was, in the opinion of Dr. Ewing, "almost insuperable," even though, in 1917, "orders had been given that all pathological materials received at camp hospitals should be sent to Washington. Under the existing conditions it was practically impossible to carry out such orders, and they fell down at nearly every point. At one time permission for the performance of autopsies was suspended, but this situation was shortly relieved by the Surgeon General's Office. Accordngly the only material from 1917 cases was sent by one or two pathologists whose attention to the needs of the museum had been specifically and urgently directed." Failure of material to arrive from most of the camps prompted Colonel Owen to send Dr. Ewing to visit some of the cantonments in the eastern part of the United States in the early summer of 1918. "On these visits," said Dr. Ewing, "it became apparent that the laboratories had been built, equipped and manned chiefly for clinical microscopy, and not for pathology. There was always an impressive array of test tubes, Wasserman trays, blood counters, urinometers, etc., and a rather superabundant personnel trained in their use, but I found the pathologist at only one of die seven hospitals visited, and he was busily engaged as admitting officer of the hospital. Autopsies had been performed, however, and at two camps efforts had been made to collect a local camp museum of interesting cases, but frequent transfers and changes of the acting pathologists had worked "against the effective preservation and control of material." The "most obvious" handicap to the success of Dr. Ewing's missionary efforts was "lack of knowledge of the methods of museum preparation." " As "Original letter, Maj. C. Judson Herrick, to Brig. Gen. Elbert De Coursey, 10 October 1953- On file in historical records of AFIP. 8 Ewing:, p. 28. 1 62 ARMED FORCES INSTITUTE OF PATHOLOGY a means of improving this situation, The Surgeon General issued a circular letter of instructions on preparation and shipment of materials for die Museum. Before such a circular of precise and detailed instructions was issued the question of military authority for the making of post mortem examinations had to be cleared up. The Autopsy Question In an opinion of the Acting Judge Advocate General of the Army, issued on 6 October 1917, it was held "that there can be no question but that military authority over all persons who are members of the Army of the United States is sufficient to authorize the performance of a necropsy * * * if there is sound military reason therefor." But, he added, "it is not within my province to express my opinion upon the question whether such military reason exists."' On 25 February 1918, The Surgeon General of the Army advised the War Department that while it was "impracticable to state in detail the specific circumstances which would justify post mortem examination in each case," he regarded such examinations as essential in the management of epidemics and in cases where medicolegal questions were involved, and as desirable in all cases. Even in cases where the cause of dealth was from well-recognized processes of disease, The Surgeon General said, an autopsy "almost invariably yields information which is instructive and of great value and importance in the treatment of the living," and that "great good to the service and [to] medi- cal science would result" if it were "practicable to hold post-mortem examina- tion after all deaths." In publishing this correspondence to the medical officers, on 1 March 1918, The Surgeon General added the requirement that commanding officers of hospitals would be held responsible for the determination of the necessity for performing post mortems, for the manner in which they were performed, and for the proper preparation of the bodies thereafter, as required by Army regulations. 3 The question of whether or not autopsies should be performed was dealt with again on 12 June 1918, in a circular letter from the War Department in which The Adjutant General, noting that there had been complaints that "autopsies have been held on [the] bodies of deceased soldiers in various camps and cantonments," ruled that while military authority was sufficient to au- thorize them, "if there be sound military reason therefor, they should not be ' Medical Department History, World War I, volume I, pp. 1020, 1021. 'Ibid., p. 1021. THE MUSEUM IN A WORLD AT WAR 1 63 resorted to, unless such reason exists." Commanding officers of hospitals or the senior surgeons present were charged with responsibility for compliance with the ruling. 9 On 18 June, 6 days after this promulgation from the War Department, The Surgeon General sent this further appeal for greater activity in preparing and shipping pathological specimens: 1. The Surgeon General expects that all medical officers will collect and ship pathological specimens to the Army Medical Museum, as provided in paragraph 135, Manual for the Medical Department, and in previous circulars from this office. The specimens should be accompanied by histories, and officers will receive credit for their contributions. 2. A statement is desired as to: (1) Whether your laboratory has already sent specimens to the museum. (2) Whether you have collected specimens and have them ready to ship to the museum. (3) Whether you have material on hand for making Kaiserling solutions. 3. Have you collected large containers for storing and shipping specimens, such as 5-gallon oil cans, crocks, and kegs? 10 Apparently there was some uncertainty in the minds of the hospital com- manding officers whose responsibility it was to authorize autopsies in individual cases, for on 30 September, The Surgeon General issued another circular letter which undertook to define more explicitly the "sound military reason" required for authorization of the procedure. This, said the circular, was the "same as the reason for performing an autopsy heretofore; that is, the study of the natural history of the disease in question * * * even when the cause of death in that particular case is known. It is essential from a military point of view that autopsies be performed until the causes of the prevailing diseases are wel understood and until suitable therapeutic and prophylactic measures have been elaborated to cure and prevent the lesions found at autopsy." Procurement of Specimens With the nature of the authority for making autopsies thus clarified and defined, and with the somewhat disappointing results of Dr. Ewing s mis- 9 Ibid., pp. 1021-1023. '"Ibid., p. 1296. 11 Ibid., p. 1 02 1. 164 ARMED FORCES INSTITUTE OF PATHOLOGY sionary journey to the camps in mind, it was decided to "issue a pamphlet containing explicit directions for collecting, preserving and shipping gross anatomical material." The resulting circular, which was reviewed and revised with the help of leading pathologists, stated explicitly what material was wanted by the Museum and how it should be prepared and shipped. It was undated, but was not distributed to the hospitals whose autopsy methods it sought to improve until December 1918, after the armistice. 1 " In its efforts to procure suitable specimens, the Museum did not depend wholly on either this definitive circular or the earlier promulgations of The Surgeon General or the War Department. Appeals had been addressed to "many camp pathologists personally known to members of the Museum staff," and such letters had produced some results. Dr. W. G. MacCallum, of the College of Physicians and Surgeons, for example, had sent in "a large number of pneumonic lungs which formed the sole representatives of the epidemic of 1917-1918." 13 At the same time, therefore, that it was seeking to enlist the interest and assistance of pathologists in the field, the pathology department of the Museum was building up and training its own staff in the work of receiving and caring for the specimens which were sought. Dr. Daniel Smith Lamb, who had stood "as a lone sentinel guarding the interests of pathological anatomy, crowded into two small rooms, but faith- fully performing his function day by day as he has been doing year by year," no longer stood alone. "With rare generosity," Dr. Ewing wrote, Dr. Lamb "placed at the disposal of the staff of new men his valuable museum collection of microscopes and laboratory utensils." More rooms were secured and were transformed into an active laboratory of pathology, a transformation due, says Dr. Ewing, to the efforts of Major Herrick, who had been so summarily meta- morphosed into a general pathologist by Colonel Owen. 14 In assembling and training a staff for the work in pathology, Major Herrick was fortunate in being able to use the services of some of the men whom he had previously enlisted for the Medical Department's section on brain surgery. Ten of these university-trained histologists, who had entered military service by voluntary induction for neuropathological laboratory work, were assigned to the Museum, and by the time hostilities ended were giving excellent service. ,J ( 1 ) Ewing, p. 28. (2) Surgeon General's Office: Review of War Surgery and Medicine, volume to. Number i, December 1918, p. 72. [Hereinafter cited as Surgeon General's Office Review.] ' Ewing, p. 2m. "Mem. THE MUSEUM IN A WORLD AT WAR 1 65 One of the nonmedical members of the staff, detailed to Camp Wheeler, Ga., during the period of the dread epidemic of influenza in 1918, "secured through the cooperation of the pathologist at the camp hospital, most of the really good specimens of influenza lungs that were in the Museum." This man, wrote Dr. Ewing, "was permitted to remove the organs from the body and preserve them before random incisions were made. He worked over them day and night until fixation was perfect, packed them himself, rode on the wagon that carried them to the station, and saw them off on the train." With the help of such devoted members of the staff, the Museum's pathology department was, in the opinion of the eminent Dr. Ewing, "in fair working order" by the date of the armistice, with "a constant flow of materials of all grades arriving." 1B Two Museums in One To take charge of the business of classifying and cataloging these accessions to the Museum, Maj. Robert Wilson Shufeldt, a retired medical officer who had served briefly on the staff of the Museum in the early i88o's while it was still housed in the Ford's Theater building, was recalled to active duty in January 1918. The major was a most prolific writer on a variety of subjects, and accordingly was charged with the additional "duty of publishing in medical and other journals of good standing articles describing those activities in the museum about which the medical profession at large and the general public may properly be informed." 1C He took up his task of publicizing the problems and the accomplishments of the Museum with enthusiasm as to the future but with a critical view and a caustic pen in reference to the past. He had made known his views as to the state of the institution in an article published in October 1917, in which he declared that "from the standpoint of antiquity and history, this collection will always be of enormous value, but from the viewpoint of a growing collection and up-to-date exposition of modern medicine in all its varied departments, it has, for only too long a time, been a supreme joke." ' This opinion of the Museum, as it existed before 1917, expressed before Major Shufeldt's recall to active duty, was repeated in varied language in the articles published by him while engaged in the work of classifying and catalog- ing its incoming accessions. The pre-1917 museum, he wrote, "was still a lj Ewing, pp. 29, 30. 18 Surgeon General's Office Review, p. 74. " Shufeldt, R. W.: Army Medical Museums. Medical Record 92: 664, f'65. 20 October 1917- 1 66 ARMED FORCES INSTITUTE OF PATHOLOGY teacher, to be sure, but a teacher of the past. It exemplified, with its many thousands of specimens, our knowledge of military medicine and surgery as practiced during the Civil War * * *. In the presentation of its specimens, casing, labeling, lighting and in numerous other matters and details, it is decidedly antiquated; and while it is, upon the whole, tidily kept, it is by no means an exponent of what a live, growing functional museum of the present time should be * * *. It required a World War to awaken this museum * * *. This somnolent institution of yore gradually came out of its lethargic state, and took on new life." The source of this new life, according to Major Shufeldt, was the appoint- ment to the Museum staff of several men who had had "long experience in museum affairs and management." The effect of "three or four heroic doses of vim injected into the vitals of this medical Morpheus, this sleepy old Museum" he described as "a revolution, a mild upheaval, and a readjustment with an increase in the Museum's staff in various old departments and the establishment of the new ones." 1S The sharp cleavage between the "new" and the "old" museums was exempli- fied in the scheme of cataloging adopted by the new custodian of the collections. All specimens in the Museum at the time of the declaration of war against Germany were left undisturbed, with their accession numbers unchanged, and were designated as Series A, while items received after 6 April 1917, were accessions under new and separate numbers, designated as Series B. This maintenance, in the same museum, of two separate series of numbers for materials of essentially the same kind was deemed by Major Shufeldt to be "radically absurd," but it was adopted as a temporary measure until such time as it might be possible to revise and reclassify the older materials accumulated over a period of more than half a century. When the time should come to merge all the exhibition materials into "one homogeneous collection," he felt that "no small part" of the Series A materials would have to be set aside and that all of it would be reclassified along "divisional lines * * * very dif- ferently drawn. Science will take a hand in the arrangement, and by the application of true principles of museology, material will be exhibited in an or- derly and scientific manner— properly cased, labeled, and classified * * *." 19 Shufeldt. R. W.: Value of the Army Medical Museum as a Teaching Factor. Proceedings of the American Association of Museums, 1918, p. 209. Shufeldt. R. W.: On the Classification Adopted for the Material Constituting the Collections in the Armv Medical Museum of the Surgeon General's Office at Washington. Medical Review of Reviews B, December [918. THE MUSEUM IN A WORLD AT WAR 1 67 Launching the Movement for a New Building This future reclassification, it was hoped, would be made in a new building for the Museum and the Library, which Colonel Owen (fig. 53) had proposed, first to The Surgeon General in 1916, and later to the medical profession at large in an article published in the New Yorh\ Medical Journal?" The time seemed ripe for such a project when it was launched. A special Public Buildings Commission had been set up pursuant to a 1916 Act of Con- gress, to "ascertain what public buildings are needed to provide permanent quarters for all the government activities in the District of Columbia." This Commission, reporting in December 1917, included in its plans a site on the south side of the Mall between 4 14 and 6th Streets, SW., for a building of 175,000 square-feet capacity, to house the Museum and the Library. Cost estimates for building and ground ranged from $2'/ 2 to $4 million. Preliminary plans for such a building, of classical design, were approved by the Fine Arts Commission as part of the move for a more beautiful Capital City. The zeal of Major Shufeldt, seconded by Colonel Owen, led the major to write letters to the deans of the principal medical schools of the country ; to state, county, and city medical societies; and to individual physicians and surgeons of prominence, soliciting their endorsement of the plan to provide, without delay, suitable quarters for housing the materials to be collected on the battlefields of Europe. With his letters, which went out in February and March 1918, he sent reprints of an article from his pen, published in the Medical Record of 2 Febru- ary, in which he described the existing Museum as a "mummy" stagnating in its "sarcophagus" but retaining still the "essential life spark" which made possible "revivification" and future usefulness." 1 The response to his letters was gratifying to him. The plan was endorsed by more than a score of medical college deans and faculties, a like number of medical societies, and three times as many individual practitioners, including some of the leaders in the medical world, representing in Major Shufeldt s some- what overly optimistic opinion, "the voice of practically all the profession in America." The letters were bound in a handsome volume placed on the desk of The Surgeon General, and were reproduced for wider circulation." The new building was part of Colonel Owen's dream of the Museum of the future, which should be not "merely a collection of medical history of the United 20 Owen, W. O.: The Army Medical Museum. New York Medical Journal 107: 1034-1036. ' J unc " ,8 - a Shufeldt, R. W.: War Material at the Army Medical Museum. Medical Record 93: l8n ' 2 Fcb 22 (1) Mimeographed copies of letters on file in historical records of AFIP. (2) Shufeldt, R. W.: The New Army Medical Museum on the Map. Medical Review of Reviews 24: S90-599. October 1918. 1 68 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 53. — Col. William O. Owen, tenth Curator of the Museum, 1916-1919. States but should also be a teaching center in the truest sense * * * housed in a building with a dignity commensurate with the service to be demanded of it." "The Museum of 1861-1865, and later," he said, "was all that could have been hoped for in that day. I am trying to make preparation for the study of medical material of this war upon a modern, scientific basis * * *. I do not THE MUSEUM IN A WORLD AT WAR f 7JUL . 169 •(US- Figure 54.— Colonel Owen's "dream" of a new Museum and Library building, as pictured by Lt. Morris L. Bower, October 191 8. believe that a mere collection of anatomical and pathological curiosities for exhibit to the curious and the prurient should be permitted. A medical museum should be, in my judgment, a great library of history and pathology, where the student of medicine may come and study the history of disease and its pathology, for the benefit of himself, his patients, and his nation." * With a war to be won, however, and with money, materials, and manpower in short supply, the time was not propitious for the construction of new perma- nent buildings in Washington, and the project for a new home for the Museum joined the other deferred dreams— not to be realized for yet another 40 years, and then in an entirely different form and at a different place from the pro- posals of 1918 (fig. 54). The unrealized dream of a new building, however, in no way diminished the drive of the Museum in expanding its activities to meet the demands of the war of 1917-18. "The present war," said Major Shufeldt, "has had the effect of waking up the old-time spirit in this erstwhile slumbering institu- tion * * *. It is now an active medical concern, reaching out in all direc- tions and absorbing every possible means to become a medical research and teaching center in the broadest sense of those words." ; 23 Owen, New Yorl{ Medical Journal, 107 ( 1918), p. 1036. "Shufeldt, R. W.: Vertebrate Types Below Man in the Collections of the Army Medical Museum. Medical Review of Reviews 24: 274, May 1918. ijo ARMED FORCES INSTITUTE OF PATHOLOGY Applying the Graphic Arts to Medicine One of the new directions in which the Museum was "reaching out" in the war years of 1917 and 1918 was in the extension of its informational services through the wider use of the graphic arts — photographic, pictorial, and plastic. Medical illustration in the Armed Forces of the United States was not some- thing new in 1917. It had been developed during the Civil War period, when the Museum staff included such medical artists as Hermann Faber and Edward Stauch, and such clinical photographers as William Bell and E. J. Ward, whose graphic plates are vividly reproduced in the "Medical and Surgical History of the War of the Rebellion," in addition to Doctors Joseph J. Woodward and Edward Curtis, who pioneered in photomicrography. The tradition of these pioneers had been carried on by Dr. William M. Gray in photomicrography, and by Dr. J. C. McConnell whose careful drawings of mosquitoes were useful in the practical application to mosquito control of Walter Reed's discovery (fig- 55)- The World War I counterpart of these earlier illustration services was called the Instruction Laboratory of the Medical Museum, a name bestowed to dis- tinguish it from the division of the Museum devoted to work in pathology. Figure 55. — This laboratory of the nineties was that of Dr. William M. Gray, who carried on the tradition of achievement in photomicrography established by Dr. Woodward and Dr. Curtis. THE MUSEUM IN A WORLD AT WAR 171 The development of the new services may be dated from the employment, in June 1917, of Roy M. Reeve as photographer— an employment which was the beginning of a career of nearly four decades in the graphic depiction of military medicine by the use of the camera. 25 In November 1917, Lt. Thomas L. W. Evans, head of a New York firm of "commercial cinematographers" and a man of experience in the then young motion-picture industry, was put in charge of the new Instruction Laboratory (fig. 56). The operations of the Laboratory grew to include Mr. Reeve's section of still photography ; a section of motion pictures, headed at first by Lt. Robert Ross and later, after Lieutenant Ross had gone to France, by Lt. Charles W. Wallach ; an anatomical art service headed at first by Lt. William T. Schwarz, then by Lt. Morris L. Bower, and at the end of the war by Lt. Raymond O. Ellis; and a section of wax modeling under Capt. James Frank Wallis." 6 Through these various graphic methods the Instruction Laboratory sought to reach and inform a threefold audience — troops in training, medical officers, and the civilian world, including especially civilian medical men. Motion Pictures A major activity of the Laboratory was the production, reproduction, and distribution of motion-picture films. Altogether, 137 such films, including both those produced by the Laboratory and those produced by other organizations and distributed by it, were listed as available for showing in camps and canton- ments and through civilian outlets." 7 The films offered for showing to the various "publics" ranged in length from one-half reel to a nine-reel production on the diagnosis of tuberculosis. The picture most widely shown and frequently discussed was a four-reeler, "Fit to Fight," described as a "venereal disease photo play" which in three reels of dramatic action told a story and, in one reel showing clinical consequences, pointed a moral (fig. 57). "Fit to Fight" was designed primarily for showing in the training camps but was also shown, in a somewhat revised form, to selected civilian audiences. Such showings were arranged by the Commission on Training Camp Activities, by local departments of health and police authorities, by major industries, and by the U.S. Public Health Service, among others. E Creer, Ralph P.: Medical Illustration in the United States Army; Historical and Present Consider- ations. Journal of Laboratory and Clinical Medicine 28: 651-661, February 1943. M Memorandum, Colonel Owen to Lieutenant Colonel Fulton, 25 October 1018. On file in historical records of AFIP: Evans, Ross, and Schwarz. 27 Medical Department History, World War I, volume I, p. 515. 713-02S-— 64 IS 172 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 56. — Instruction Laboratory, World War I. A. Drying racks for motion-picture film. THE MUSEUM IN A WORLD AT WAR 173 Figure 56.— Continued. B. Cutting and polishing room for motion pictures. SOUND EDUCATION AND VARNINC The motion picture "FIT TO FIGHT" tolls the stoty c«f Vmereal Dtsoase its results. Figure 57.— The best known and most controversial production of the Instruction Labora- tory was the film dealing with venereal disease. '74 ARMED FORCES INSTITUTE OF PATHOLOGY The film was shown before the convention of Rotary International held in Kansas City in late June 1918, with the result that many of the constituent clubs arranged meetings at which the film was shown in their communities, usually for men and boys over 16. A typical example of such showings and the reaction to them is the experi- ence of the Rotary Club of Dallas, Tex. Showings were first planned for Sep- tember or early October, but the spread of the appalling influenza epidemic in city, country, and camps brought a ban on public gatherings and forced post- ponement until late November. The reaction to the film when finally shown is thus described in a report from W. C. Temple, secretary of the Dallas Rotary Club, upon returning the film to the Army Medical Museum: 28 The first showing, by invitation only, was made to about one hundred and fifty men. We did this to feel out the local situation, and after those invited had witnessed the film, they were unanimous in their opinion that it should be shown to as many males as possible, so we gave another showing of the picture, giving the matter publicity through the local press, at which time the film was shown to something like two thousand men and boys over fifteen years of age * * *. In my opinion this is just such education work as should be carried on throughout this country. Pictures as Training Methods Most of the motion pictures made by the Instruction Laboratory, however, were of an instructional nature, as the name of the organization implied, and were aimed at perfecting procedures and standardizing training methods. For example, Colonel Owen corresponded with both Brig. Gen. H. P. Birmingham, in command of the great Medical Officers Training Center at Camp Greenleaf, Fort Oglethorpe, Ga., and Col. W. N. Bispham, commanding the Medical Offi- cers Training Camp at Fort Riley, Kans., advising them of the availability of moving-picture production crews at the Museum and inquiring as to the desira- bility of having them make pictures of such training features as an ambulance company or a field hospital breaking camp, moving on the road, setting up a dressing station or a field hospital, bringing in and caring for the wounded, and making camp. Colonel Bispham responded with a letter approving the project, and on 1 May 1918, wired Colonel Owen asking for a man to make the pictures about the middle of that month. Lt. Robert Ross was sent to Fort Riley where, despite weather and lighting difficulties, he shot a satisfactory picture which was com- pleted by mid-June. 29 ** Letters. 11 October and 29 November 191 8. On file in historical records of AFIP. Correspondence between Colonel Owen and Colonel Bispham. On file in historical records o£ AFIP. THE MUSEUM IN A WORLD AT WAR 175 Meanwhile, in May 1918, Colonel Owen received a reply from General Birmingham in which he agreed that the moving picture suggested would be of "great value in giving ideal demonstration and the technically correct methods of foot drill, litter drill, with the loaded and unloaded litter, as well as the use of improvised litters and the handling of the wounded without any apparatus whatsoever, ambulance drill, Field Hospital dress, tent drill, gas defense, first-aid, principally dressings and splints, sanitation in camp and in the field, surgery and surgical treatment under field conditions, principally operating and preparation of patients and materials for same, the giving of hypodermic injections, and the use of the catheter." To this thoughtful letter Colonel Owen replied immediately, saying that the pictures covering base, evacuation, and field hospitals, and ambulance com- panies were being made at Fort Riley, but that the other subjects referred to in the general's letter would be made at Camp Greenleaf whenever the troops which it was intended to photograph would be ready for the shooting of the pictures. 30 Among the most successful and valuable of the films produced by the forces of the Instruction Laboratory at the camps, and with the aid of the Medical Department, was "Training the Medical Officer," directed at the thousands of new medical officers taken from civilian life and passing through the medical officers training courses. Two films directed at the practical matter of insect control, and reflecting the longtime preoccupation of the Museum with entomology, were "Mosquito Eradication" and "Fighting the Cootie." Each U.S. military post had received directions from The Surgeon General to collect mosquitoes in its vicinity, and to forward the specimens collected to the Medical Museum for identification. At the Museum, the mosquitoes— and other insect carriers of disease as well— were examined by the Museum's entomologist, Dr. Clara S. Ludlow, whose distinction in the field is indicated by the fact that two strains of anopheles mosquitoes bear her name as A. ludlowi. Identification of the mosquitoes, together with any information that might be useful in controlling the pests, was reported to the surgeon at the post from which the specimen was received. Compliance with the order was far from universal, and was not always in con- formity with the directions for collecting and forwarding the specimens. Fleas, 'Correspondence between Colonel Owen and General Birmingham. On file in historic .il « 31 Directions for Collecting and Forwarding Mosquitoes, Office of the Surgeon General, -i Marc Copy on file in historical records of AFIP. AFIP. 176 ARMED FORCES INSTITUTE OF PATHOLOGY lice, ticks and bedbugs" were asked for in one instance, but somehow only cock- roaches and flies were received, while from some posts nothing at all came in, but enough specimens were received to keep the entomology staff of the Museum busy in identifying them and making recommendations for their eradication or control. 32 Use of Animated Drawings Among the films prepared by the Museum's force were several made with what was described as "stop-motion pictures," producing the effect of animated drawings in which every step in an operation was reproduced by sketches. "The knife appears, without any hands, goes to the proper position and makes the proper incision; the retractors appear, holding the wound apart. The needle appears, armed with the thread, goes to the right place, puts the suture in the right position; the suture rises up and ties itself and sloughs off its own ends. Purely impersonal surgery, the patient being impersonal likewise * * * as the schematized operation proceeds, legends are thrown upon the screen ex- plaining the steps and pointing out the names of the essential structures as they are successively exposed to view during the operation" — this being just before the day of the motion picture with sound. 33 One of the skilled artists who worked on the production of animated pic- tures was Sgt. (afterward Lt.) Paul H. Terry who, upon his discharge after the armistice, opened an office in New York for the production of cartoon comedies and, in time, originated the famous "Terrytoons," to the delight of millions. 3 ' A third branch of the Instruction Laboratory, the Anatomical Art Depart- ment, grew out of this work of making sketches in series for use in animated cartoon moving pictures, in which the artists were at first largely engaged. In the spring of 1918, however, the brush and pencil came to be independent of the camera, with the issuance of an attractive announcement, designed by Sgt. V. B. Sisson, of "the establishment of an official department [in the Army Medical Museum] for the handling of such surgical and anatomical illustration as is required in the activities of the United States Army Medical Corps" (fig. 58). 35 ^Letter, Dr. Ludlow to Curator, Army Medical Museum, 21 August 1922. On file in historical records of AFIP. M Surgeon General's Office Review, p. 70. 31 Letters, Lieutenant Evans to Lieutenant Ross, 4 September 1919 and Lieutenant Ross to Colonel Owen, 18 December 1918. On file in historical records of AFIP. ao Shufeldt, R. W.: The Art Department of the Army Medical Museum. Medical Review of Reviews 24: 39i,Iuly 1918. THE MUSEUM IK A WORLD AT WAR l 77 ANATOMICAL ART DEPARTMENT Amgi<toal€*n» CING THE ESTABLISHMENT OF AN OFFICIAL DEPARTMENT FOR THE HANDLING OF SUCH * SURGICAL 222 ANATOMICAL ILLUSTRATION AS IS REQlJIRr ED IN THE ACTIVITIES OF THE UNITED STATES ARMY MEDICAL CORPS TTTTtTT t Anatomical Art Deft. IN THE ... Army Medical Mu seum Figure 58.— The Museum offers its services to those requiring assistance in the development of illustrative medical art. In charge of the Anatomical Art Department was Lt. William T. Schwarz, who had had 5 years of experience in medical illustration at Syracuse University, topped off by 2 years of study in Europe. He was assisted by Lt. Morns L. Bower, who was to become well known as a magazine illustrator. Both officers receive further training in the spring of 1918, under Prof. Max Brodel at Johns Hopkins. They and others added to the staff, which by May came to number a dozen artists, were given training in medical art on the job (fig. 59)- 11S 178 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 59.— Headquarters for medical art in the Army Medical Museum, World War I, with staff members dutifully posing for the photographer. included dissecting experience on cadavers in a dissecting room set up in the Museum. "" Additional experience was had in the making of a large number of drawings illustrating various stages in surgical operations at the Walter Reed General Hospital and elsewhere, and participation in performing numerous autopsies at the Government Hospital for the Insane (St. Elizabeths), in Wash- ington, D.C., where the pathological service had been taken over for instruction purposes by the Museum." The output of the Museum's staff of artists found use in the program of medical instruction of officers and men in the training camps, in the shape of lantern slides, for projection on the screen, to illustrate lectures on medical topics. Through these lectures, declared Major Shufeldt, the fitness and health of the army was vastly improved." This was probably an exaggerated estimate of the effectiveness of these educational efforts, 38 but there can be no doubt that the " (1) Letter, Lieutenant Schwarz to Dean John Heffern, Syracuse University, 28 May 191 8. On file in historical records of AFIP. ( 2 ) Shufeldt, Medical Review of Reviews, 24 (1918), pp. 391, 392. 37 (1) Annual Report of the Surgeon General, U.S. Army, fiscal year 1919, p. 1066. (2) Surgeon General's Office Review, p. y 2 . " Shufeldt. Medical Review of Reviews, 24 (1918), p. 392. THE MUSEUM IN A WORLD AT WAR 179 attempt to add to the medical knowledge of officers and men through anatomi- cally accurate medical art helped to make the army of 1917-18 the first in United States history in which deaths from disease were fewer than those from battle- field casualties (fig. 60). A separately organized branch of medical art in the Instruction Laboratory dealt with making casts and wax models of the lesions of wounds and disease. Capt. James Frank Wallis, a Washington dermatologist and an experienced modeler in wax, was in charge of the work and was assisted by Miss Eleanor Courtenay Allen of Milwaukee, who had studied at the Chicago Art Institute, and who joined the Museum staff in March 1918. 39 The Museum had had for many years a collection of several hundred wax models, for the most part produced by the famous Baretta studios in Pans, and part of the work of the new division was to rehabilitate some of the French models which had deteriorated from prolonged exposure to direct sunlight. The Museum Goes Abroad With all the new developments and extensions of the service of the Museum in the United States, the goal of the organization was to be of service overseas, whether in pathology, photography, or anatomical art. First steps to that end were taken in January 1918, when The Surgeon General at home sought from the Chief Surgeon overseas authorization to send over a medical museum unit. The oversea work of the Museum was to be in charge of Maj. (afterward Col.) Louis B. Wilson, in civil life pathologist and director of laboratories for the Mayo medical organization at Rochester, Minn. Dr. Wilson was ordered to England— first to study what was being done along the line of collecting specimens in the British and Colonial Forces, and then to France for duty with the AEF as an assistant director of the Division of Laboratories. In England, where he spent the last 3 weeks of April, Major Wilson con- ferred with Sir Walter Morley Fletcher, secretary of the National Research Committee; Prof. Arthur Keith of the Royal College of Surgeons; and Lt. Col. J. C. Adami, in charge of the historical bureau of the Canadian Medical Corps, with reference to methods of collecting pathological specimens. He talked also with officers in charge of military orthopedics, concerning casts, models, paintings, and drawings; with officers in charge of the cinema service; an with those in charge of the indexing and filing of medical records and their 38 Shufeldt, R. W.: Wax Modeling Department of the Army Medical Museum. Medical Record 94: 663, 19 October 1918. , vn'tarv "Wilson, L. B.: Museum and Art Service of the American Expeditionary Forces. The Surgeon 46: 165, February 1920. 713-02S V — 64 14 180 ARMED FORCES INSTITUTE OF PATHOLOGY statistical use. On i May 1918, he reported to Colonel Owen on his stay in London, with a separate memorandum covering each subject discussed, and proceeded on to France. 41 Before Major Wilson's arrival in France, the then Chief Surgeon of the AEF, Brig. Gen. A. E. Bradley, had issued Circular No. 17, 2 April 1918, "Instruction Concerning Autopsies," in which the attention of medical officers was called to the importance of the post mortem examinations and under which Major Wilson was to build up the necropsy service in the AEF. The circular, issued in order to "secure proper records of causes of death of American troops in France, and specimens of scientific value for the Army Medical Museum," gave directions as to procedures in autopsies, which "should be performed whenever possible." With this encouragement to the adoption of the autopsy as a routine procedure, to be done as a matter of course in all cases rather than as a special procedure to be done only on express authorization, the number of autopsies performed in the AEF rose from less than 25 percent of all deaths in hospitals, which it had been in 1917, to 57 percent in the early months of 1918, and 92 percent in August and September. It held up to 85 percent even in the peak month of the influenza epidemic, October 1918, when the laboratory facilities and staffs, like every other hospital facility, were "overwhelmed by the enormous number of deaths from influenza and the battle casualties of the Argonne offensive." *" Necropsy Service in the AEF Writing shortly after the event, Colonel Wilson pointed out that in May 1918 there were, in the AEF to serve 72 hospitals and laboratories, but "fifteen pathologists capable of making post-mortems and intelligently interpreting the results" — a condition due in part to the "long neglect of autopsies in many civil institutions in the United States" and in part to the "overshadowing status of bacteriology in military laboratories." He continued: The autopsy service in the Army in the United States had not been established as a routine procedure, but, on the contrary, autopsies were made only on the written authority of the commanding officer of the hospital. However, in the A.E.F. the need of a routine autopsy service, amounting in fact to professional inspection of the diagnostic and thera- Lctter, Maj. L. B. Wilson to Col. W. O. Owen, I May 191 8, with eleven memoranda attached. On file in historical records of AFIP. (1) Wilson, L. B.: The Pathologic Service of the American Expeditionary Force. The Military Surgeon 45: 700, 702, December 1919. (2) Medical Department History, World War I, volume II, pp. 918-919. THE MUSEUM IN A WORLD AT WAR 181 Figure 6o.-Samples of scenes and messages from lantern sl.de sets developed for in- structional use by the Army Medical Museum, using material furnished by the Office ot Surgeon General. peutic measures of medical and surgical officers, became rapidly »PF»"« du ™« * C ^ mer of 1918. Surgeons were called upon to diagnose and treat, with little tunc fo stud or reflection, many gunshot wounds with the like of which they had little or no prev ou experience. Even those who were well grounded in the general principles of surgery 1 82 ARMED FORCES INSTITUTE OF PATHOLOGY forced to make decisions and institute treatment thereon without sufficient basis or study. As a result, there were errors in diagnosis and errors in treatment. The worst of these could be determined only by the pathologist. In like manner, attending medical officers, e.g., in cases of war gas poisoning and especially in the widespread epidemic of influenza and pneumonia, were brought face to face with conditions with which they were totally unfamiliar, and were frequently forced to make diagnoses and institute treatment with a very meager knowledge of the facts. Here autopsies were of tremendous importance in securing for the attending man a knowledge of the pathologic lesions, which knowledge he could use in his diagnosis and treatment of subsequent cases. 43 The Director of the Division of Laboratories, AEF, Col. Joseph F. Siler, requested in June 1918, that 10 competent pathologists be cabled for from the United States, in addition to those coming over with organized hospital units. The needed pathologists, or rather eight of them, came over in due course and, with their help, centers for pathologic service were established at Baccarat, Toul, Souilly, and Paris, staffed by medical officers who acted as consultants in pathology for the surrounding areas. 44 Less successful was the request, made in May, for a museum unit of photographers and artists to be sent to France. This request was approved by General Bradley, Chief Surgeon of the AEF, but was turned down by the General Staff, AEF, "in view of the existing tonnage situation," and because it was believed that the "requirements of the Medical Corps could be met successfully in this particular by the personnel and facilities already available, in both the Signal and Engineer Corps." " 5 The interests of the Museum were not forgotten, however, for on 27 July 1918, Brig. Gen. Merritte W. Ireland, who had succeeded General Bradley as Chief Surgeon upon his retirement for disability, issued Circular No. 42 "for the information of those branches of the service whose cooperation and assist- ance are necessary to enable the Army Medical Museum to discharge its duty of collecting all those things which may be used for medical education and research, or which may be of historic interest." Circular No. 42 noted the responsibility of all medical officers to direct into proper channels all desirable material coming to their notice; stressed the duty of the pathologist in each unit to collect, preserve, and ship all such Wilson, The Military Surgeon, 45 (1919), p. 701. " (l) Ibid., pp. 701-702. (2) Letter, Maj. L. B. Wilson to Col. W. O. Owen, 5 October 1918. On file in historical records of AFIP. (1) Letter, Commander in Chief, G—i, to Commanding General, Services of Supply, 4 June 1918. On file in historical records of AFIP. (2) Medical Department History, World War I, volume II, p. 222. THE MUSEUM IN A WORLD AT WAR 1 83 material as was obtainable; and gave detailed directions for the fixation and preservation of pathological specimens. The circular covered a broad field, including microscopic materials as well as gross organs and tissues; such pathogenic bacteria as might be isolated in the American Expeditionary Forces; specimens of animal parasites, pref- erably alive; helmets and other bodily protections; instruments and apparatus; and paintings, drawings, and diagrams of medical interest. "For the psychic effect, a missile removed from the body of a wounded soldier may be given to him if he wishes to keep it," said the circular in para- graph 12. In view, however, of the desirability of securing such material for the Museum, the hope was expressed that when the scientific value of the comparative study of such missiles was explained to them, soldiers might be induced to give up these intensely personal souvenirs of service. Medical Photography in the AEF Reference was also made in the circular to General Orders No. 78, General Headquarters, AEF, dated 25 May 1918, in which the earlier prohibition against the use of cameras by anyone other than the Signal Corps was liberalized, and the Medical Department was given responsibility for "technical photography connected with the recording of photographic processes of surgical and patho- logical matters." 40 The change in the orders as to the use of cameras had little immediate effect. Only a few of the medical units in France had qualified medical photographers in their ranks. Because of the earlier ban on making photographs, still fewer units had suitable cameras among those which had been brought over in spite of the bar to their use. These were put to work; a few others were secured from the French; 3 were borrowed from the Signal Corps; and 24 were secured from the X-ray Department of the Medical Corps itself. This was enough to make a start on the business of securing a photo- graphic record for information and study. 4. Whether because of the relaxation of restrictions upon non-Signal Corps photography, or because of some easing of the ship-tonnage situation, or because of an increasing recognition of the value and importance of the Museum s program, or because of a combination of all three, the ban on Museum Unit No. i getting to France was lifted. This was done in Courier Cablegram No. 7, 20 July 1918, from the Com- " Ibid., pp. 961-964. " (1) Ibid., pp. 222-223. (2) Wilson, The Military Surgeon, 46 (1920), PP- 165-168. 184 ARMED FORCES INSTITUTE OF PATHOLOGY manding General, AEF, to The Adjutant General of the Army. Paragraph 2 of this message read: Request that the Museum Unit, one Cinema Camerist, one photographer and four artists with complete equipment and adequate supplies for at least six months be sent to France. Item M 941 K. Consult Curator Army Medical Museum. 48 It was the end of August before the unit asked for could be assembled and dispatched overseas, but by the middle of September, two groups sent from the United States arrived in France. Captain Ross and seven photographers reported to the headquarters of the Division of Laboratories, then at Dijon, and Lieutenant Schwarz, Lt. W. H. French, and Miss Allen, illustrators and modelers, who had come over attached to Base Hospital No. 115, were sta- tioned at the hospital center in Vichy. 49 Before the General Staff, AEF, allowed Major Wilson to ask for talent from the United States, he had "managed to scrape up in the Base Hospitals some fifteen to twenty men who had had more or less training in medical illustration," as he wrote Colonel Owen, on 5 October 1918. "A few of these," he continued, "such as Coleman and Jarrett, of whom you wrote, are good Brodel-trained artists. Most of them have been landscape painters, interior decorators or white-wash brush artists. A few of them we will be able to train to do fairly good work. I propose to do this by ordering them to Vichy, where Schwarz, French and Miss Allen will be permanently stationed." As to the photographic work, Major Wilson wrote Colonel Owen that "a number of units" had come to France with "fairly good amateur photog- raphers" but that most of them, "having nothing to do, had been put into work entirely foreign to photography" and "had to be blasted loose by slow and diplomatic methods. Some are still grown fast to non-photographic jobs but we are slowly getting the work in operation." Colonel Owen was intensely interested in the use of moving pictures for instruction purposes and doubtless had impressed his views upon Major Wilson. It must have been with some degree of disappointment, then, that the major reported, "up to date I have not been able to arouse any interest whatsoever in moving pictures in the Medical Department of the A.E.F. * * *. Most of the surgeons say they do not see any value in moving pictures of surgical operations except to advertise the operator and that they do not want them taken *. However, I am very far from disheartened, especially since " Copy of cablegram, on file in historical records of AFIP. "Medical Department History, World War I, volume II, pp. 224, 225. THE MUSEUM IN A WORLD AT WAR ^5 Captain Ross and other motion picture men have arrived and believe that before long this side of the work will be going satisfactorily." 50 Today's acceptance of moving pictures of operations as a familiar procedure in medical training has vindicated the interest taken in this technique by Colonel Owen and Major Wilson. Such pictures are shown as part of modern medical training, and have even made their appearance on television. They still in- escapably "advertise the operator," but this minor objection is more than counterbalanced by the greater facility with which the observer can see and understand what is done as it is done. By the end of September, the photographers were at work in the zone of the advance, covering the activities of the divisions at the front. With the signing of the armistice of n November 1918, and the cessation of hostilities, the Museum staff was concentrated at Dijon until 29 November, when Captain Ross, with three photographers, was ordered to Paris to set up a photographic bureau for the Medical Department of the AEF. The bureau was housed in the Elysee Palace Hotel, where three large bathrooms were converted into photographic darkrooms. 51 Despite difficulties and delays in securing sufficient supplies, some of which had to be procured from the French, the photographic staff made, captioned, filed, and cross-indexed about 10,000 still photographs and turned out some 40,000 feet of motion-picture film showing medical and surgical activities around the hospitals, in addition to prints of 20,000 feet of film made by the Signal Corps. In the same period, the artists and modelers produced 35 casts of surgical subjects, about 200 drawings and paintings, and 1,000 photographs of technical subjects. 52 Lieutenant Schwarz conceived the idea of making life masks of the prin- cipal figures at the Peace Conference then in session. Working with Miss Allen, he made a "bully mask" of Ambassador Sharp, who put him in touch with Col. E. M. House who, in turn, introduced the lieutenant to M. Andre Tardieu, the French High Commissioner for Franco-American affairs, whose mask was also made. Through M. Tardieu, Lieutenant Schwarz was presented to Marshal Joseph J. C. Joffre, who consented to have his mask taken on the evening of 7 January 1919, and who made arrangements for the taking of a mask of Marshal Ferdinand Foch on 9 January, and of President Raymond Poincare M Letter, Maj. L. B. Wilson to Col. W. O. Owen, 5 October 1918. On file in historical records of AF1P. "Memorandum, Maj. Robert Ross, 17 April 1919. On file in historical records of AFIP. S2 (i) Medical Department History, World War I, volume IF, p. 225. (2) Wilson, The Military Surgeon, 46 (1920), p. 172. 1 86 ARMED FORCES INSTITUTE OF PATHOLOGY and Premier Georges E. B. Clemenceau on the ioth. King Albert of Belgium was slated to have his mask taken on 13 or 15 January, while Field Marshal Douglas Haig, Prime Minister David Lloyd George, and Mr. Herbert H. Asquith were to be taken sometime between the 13th and 17th of the month. Whether any more of the masks were made, and what became of those which were, does not appear in the Armed Forces Institute of Pathology files other than the statement of Major Ross, in a letter of 21 January 1919, to Colonel Owen that he understood that Lieutenant Schwarz had "been pulled off the plaster masks proposition and it was turned over to an officer of higher rank to handle." 53 The Museum s Major Aim The major aim of the Museum was not, however, in the making of life masks of notables, nor in graphic presentation of Medical Department activities, nor even in the collection of weapons and other materials used by the armed forces of allies and enemy nations — important as these were. The major function of the Museum was the collection and preservation of pathological materials. As to this, Major Wilson, after he had been overseas for 6 months, wrote Colonel Owen that : It is of course useless to talk about collecting pathological specimens except through the men who are making the pathological examinations and there were very few such men over here when I came. Most of the work was centered on bacteriology. At the same time there was great need for the development of an autopsy service. One of the first steps, therefore, was to cable back for a supply of pathologists # * * Since then we have made a thorough combout of the A.E.F. for pathologists, placed good men in the most ad- vantageous positions, and talked the necessity of autopsies not only to laboratory men but also to clinicians and surgeons most insistendy, until today we have a very high grade necropsy service in smooth working order. We still are very short of competent patholo- gists but those that are here * * * are securing the fullest cooperation from the attending physicians and surgeons. 54 The severe influenza epidemic, coinciding as it did with the great final American offensive in the Meuse-Argonne, put such a strain on medical per- sonnel and facilities that "only relatively slight attention could be given to the collection of specimens." Nevertheless, despite the limited personnel and the lack of equipment, of supplies, of containers, and in fact of everything except "Letters, Lieutenant Schwarz to Colonel Owen, 23 December 1918, and Major Ross to Colonel Owen, 19 December 1918 and 21 January 1919. On file in historical records of AFIP. " Letter, Maj. L. B. Wilson to Col. W. O. Owen, 5 October 191 8. On file in historical records of AFIP. THE MUSEUM IN A WORLD AT WAR I°7 a multitude of specimens, upward of 6,000 pathological specimens were col- lected, preserved, and shipped to the Army Medical Museum. 1 "' With the signing of the armistice on 11 November, the tremendous flow of men and materials across the Atlantic had to be reversed, with consequent confusion and delays. Recognizing that the specimens being shipped home- ward would be subject to unpredictable delays, Col. Walter D. McCaw, who had succeeded General Ireland as Chief Surgeon of the AEF, when he had become Surgeon General on 14 November 1918, upon the retirement of General Gorgas, issued, on 2 December, his Circular No. 58 supplementing and reinforcing Circular No. 42, and giving specific directions as to methods of packing and shipping specimens so that they would not deteriorate even if they should not be delivered for a couple of years. 50 The flow of materials collected in France had little more than begun to reach the Museum, and most of the eager young men whom Colonel Owen had sent overseas were still over there, when the colonel reached the statutory age of compulsory retirement. Regretfully, in mid-January 1919, he yielded the curatorship to become, after his retirement, professor of anatomy at the Georgetown University School of Medicine. Succeeding him as Curator was Col. Charles Franklin Craig, who was to be called upon to deal with the problem of handling the incoming flood ot specimens and materials with no increase in the space in which they were to be processed and exhibited, and with a staff which, almost daily, was shrink- ing toward pre-war levels as the wartime additions were demobilized. M Medical Department History, World War I, volume II, pp. 223-224^ "(i) Ibid., p. 226. (2] in historical records of AFIP. Medical Department History, World War I, volume II, pp. 223-224. (!) Ibid., p. 226. (2) Letter, Maj. L. B. Wilson to Col. W. O. Owen, 2. December 19.8. On file CHAPTER X The Institute Idea "At no time during the war was there a sufficient number of trained pathol- ogists in the service," said Surgeon General Merritte W. Ireland in his annual report for the fiscal year ending 30 June 1919. "The same condition seems to exist in civil life," he added, "for it proved impossible to find a sufficient number of trained men." A start toward correction of this situadon was made when the position of the chief of the laboratory service in Army hospitals was made "coordinate in standing and authority with the chiefs of the medical and surgical services," thereby opening the previously blocked path to promotion for practitioners of pathology. During the year, also, special arrangements were made for the in- struction of medical officers in pathology at the Government Hospital for the Insane (St. Elizabeths), in Washington, D.C., at the Brady laboratories of the hospital in New Haven, Conn., and at the Army Medical Museum, where special instruction in neuropathology was given. "Pathology, however," as The Surgeon General said in his report, "is a subject in which a large experience is acquired slowly, and, in spite of efforts to train additional men by the arrangement of special courses of instruction, the number of qualified pathologists could not be greatly increased during the war." x Meeting the need for more and better-trained pathologists became, in the period following the First World War, a prime purpose of the Museum. Col. Charles F. Craig, the first postwar Curator (fig. 61), was not primarily a pathol- ogist but was distinguished for his studies of dengue fever, filariasis, the dysen- teries, and, most particularly, malaria and its control. The incidence of the last- named disease in the Army was reduced in the first quarter of the 20th century from more than 700 to less than 10 per 1,000. This control of malaria in the Army was not the result of any one man's efforts, but Colonel Craig's contribu- tion, through his "extensive investigations, writings, and advice" on the subject, was outstanding. He was chosen by a board of officers appointed by Surgeon 1 Annual Report of the Surgeon General, U.S. Army, 1919, p. 1043. 190 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 61. — Col. Charles F. Craig, eleventh Curator of the Museum, January-September 1919. General William C. Gorgas to prepare for the Army the compendious treatment of the subject entitled "The Prophylaxis of Malaria with Special Reference to the Military Service," published by the War Office of the Surgeon General as THE INSTITUTE IDEA l 9 l Bulletin No. 6, August 1914. This special interest, demonstrated ever since the time of the Spanish- American War, was further evidenced by his post-retirement career as professor and chairman of the Department of Tropical Medicine at Tulane University." The First Practicing Pathologist to Become Curator His successor at the Museum, in 1920, was Maj. George Russell Callender (fig. 62) , a native of Massachusetts and a graduate of Tufts Medical College, who had served as Assistant Curator during Colonel Craig's administration. Major Callender was the first practicing pathologist to head the institution which was foremost in the Nation in the collection, preservation, and presentation of the raw materials of pathology and which, a quarter of a century later, was to become in name as well as in function an institute of pathology. The problem which the Museum faced in the years after the First World War was three-pronged, with an enormous increase in the quantities of materials received, a diminishing work force to accession, catalog, and process the mate- rials, and rigid limitations in the space available. During and just after the First World War, the collections of the Museum more than doubled, rising from fewer than 48,000 to more than 100,000 speci- mens. The new specimens had to be accessioned and given numbers in a filing system which contemplated bringing together and keeping with each specimen all available pertinent information such as clinical histories, protocols of autop- sies, photographs, X-ray plates, tissue blocks, microscopic slides, and anything else which might shed light on the pathological condition of the specimen. Keeping up with the routine of accessioning and cataloging these materials as they came in "entailed a very large amount of work upon a very small clenca force," which was "the more difficult because of the constant decrease of personnel and the constant increase of work due to the material received from France, as well as that which came in from the hospitals in the United States as they were closed after the War. :1 Space Problem Intensified More difficult to deal with than the problem of doing more work with fewer people was the problem of finding space in an already overcrowd. 2 Ashburn, P. M.: A History of the Medical Department of the United States Army. Mifflin Co., 1929. pp. 267, 268. 'Annual Report of the Surgeon General. U.S. Army. 1919, pp. 1<> 6 3. '"'' 4 Boston: Houghton i 9 : ARMED FORCES INSTITUTE OF PATHOLOGY Figure 62. — Maj. George R. Callender, twelfth Curator, 1919-1922, and fourteenth Curator, 1924-1929, of the Museum. building for the display, or even storage, of the inflow of materials. This problem was further complicated by a slow delivery of museum glass jars, which made it necessary to store many specimens in 10-gallon stone crocks in the basement of the west wing of the Museum and Library building. Not being THE INSTITUTE IDEA J 93 fitted with airtight tops, the crocks allowed evaporation of the preserving fluids, so that it was necessary to inspect and refill the crocks at intervals to prevent spoiling of the specimens. 4 Some slight relief from the pressure for space was found in the discon- tinuance, on i March 1919, of the production of moving pictures, because of a lack of funds and personnel. This closing of the production end of the Mu- seum's motion-picture activity did not stop the circulation and showing of films already made, which was continued bodi by the Museum and by the U.S. Public Health Service. Much of the demand for showings came from civilian sources, including medical colleges, medical associations and societies, and educational institutions. Before 1 May 1919, exhibits in the Museum were open to all the public. Feeling that the lay public would neither understand nor profit by viewing many of these exhibits, the Museum began on that date a systematic rearrange- ment of exhibitions, insofar as available space permitted, under which prepara- tions and specimens not regarded as suitable for indiscriminate showing were to be removed from the floor of the main museum hall to the gallery and to rooms on the first floor which were to be open only to the medical profession, including students and research workers. 6 "It is hoped eventually," Colonel Craig wrote, "to replace all pathological material on the main museum hall floor with material of general public interest, as specimens of ordnance, missiles, gas masks, sanitary appliances and apparatus used in the Army in the prevention of disease." By the middle of 1920, gross pathological specimens, wax models illustrat- ing skin diseases, and anatomical models and sections, had been removed to die first floor, as part of the plan of segregating material ot interest rooms on primarily to physicians and medical students. At the same time, but for reasons involving the more effective use of available space, die exhibits illustrating the method of transmission and treatment of the hookworm disease, and the collec- tion showing the historical development of the microscope were also removec from the main hall to the first floor. The material removed from the main hall was replaced by material showing diseases from which both military and civil communities suffered, inclu ing malaria, typhoid fever, dysentery, and tuberculosis, displayed in such lasnion •Memorandum o£ Maj. J. F. Coupal: Activities of the Patholo S ical Section of the . Museum During the World War. On file in historical records of AFIP. 6 Annual Report of the Surgeon General, U.S. Army, 1920, pp. 246, 2 47- 6 Annual Report of the Surgeon General, U.S. Army, 1919, pp- ' o6 7. Io68 - ARMED FORCES INSTITUTE OF PATHOLOGY as to be "valuable in the instruction of the general public in hygiene and preventive medicine." ' No amount of shuffling and reshuffling of exhibits within the confines of the 30-year-old building occupied by both the Library and the Museum could produce enough space to permit either a proper display of the exhibit materials or an effective use of the study collections (fig. 63). It was estimated, indeed, that proper display and exhibit of the World War materials alone would take up the entire room of the building, while the whole of the Museum's materials would fill a building twice the size of the one occupied by both the Library and the Museum. Accordingly, The Surgeon General earnestly recommended construction of a new building at as early a date as was possible. 8 Plans for a Great Medical Center The first concrete step toward such a new building was the appropriation by the Congress, on 11 July 1919, of $350,000 "for the purchase of land con- tiguous to Walter Reed General Hospital, District of Columbia, 26.9 acres more or less, for the final location of the Army Medical Museum, the Surgeon General's Library, and the Army Medical School." Supplemental to this ap- propriation, was an additional grant, on 22 September 1922, of $44,109.22 "for the site of Medical Museum and Library." 9 The project contemplated a great medical center, with the School, the Library, the Museum, and the Hospital in mutual support of one another. The plan as projected was never to be carried out fully. The Army Medical School moved from its rented quarters on Louisiana Avenue to its new build- ing, in suburban Washington, in September 1923. The Museum, later trans- muted into the Armed Forces Institute of Pathology, was to remain in its downtown location for yet another 30 years before moving the greater part of its activities to the Walter Reed site; while the Surgeon General's Library, under its new name of the National Library of Medicine, was to stay on Inde- pendence Avenue for still another decade and then move — not to Walter Reed, but to the grounds of the National Institute of Health. At the time of the purchase of the land contiguous to Walter Reed, how- ever, there were plans for a new building for the Museum in which The Surgeon General could carry out more effectively the idea of making available 'Craig, Charles F.: The Army Medical Museum and the Medical Profession. Modern Medicine 2: 542, August 1920. * Annual Reports of the Surgeon General, U.S. Army, 1919, p. 1068, and 1920, p. 243. *(i) 41 U.S. Statutes, 122. (2) 42 U.S. Statutes, 1029. THE INSTITUTE IDEA 195 Figure 63.— The "Great Hall" of the Museum in the 1890's. to research workers facilities for the study of the Museum's rich resources in pathological materials (fig. 64). So long as the Museum was crowded into its half of the old building, however, it was "impossible to furnish working rooms for research purposes," and the Museum's materials could be used by others than its immediate staff only by sending out available materials on loan, upon re- quest by recognized research workers. 10 . Nevertheless, and despite the handicap of limited space and facilities, the Museum was, as The Surgeon General described it in his 1920 report, a very valuable connecting link between the Medical Department of the United States Army and the general medical profession of the United States, from the stand- point of scientific medicine and surgery." Every feasible encouragement was offered for the use of the Museum's collections by civilian physicians, it being "believed that only in this way will the Museum fulfill its larger function ot 'Craig, Modern Medicine, 2 (1920), p. 542 196 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 64.— A 1920 photograph of the gross pathological laboratory of the Army Medical Museum. being not only a place for the exhibition of pathological and other material, but a great instruction center in pathology and epidemiology." ] This concept of the Museum as a connecting link between military and civil medicine, expressed by The Surgeon General in 1920, was not new. It was foreshadowed by Surgeon General William A. Hammond in the very beginning of the institution and had been repeated by other medical men, both military and civilian. It had been most eloquently voiced by Col. John Shaw Billings in his address to the Congress of American Physicians and Surgeons, meeting in Washington in 1888. Billings, in fact, had gone a step further when, in 1895, he entered into an arrangement under which the Museum be- came the repository of the dental and oral collections of the American Dental Association. 12 "Annual Report of the Surgeon General, U.S. Army, 1920, p. 247. 12 Sec chapter V, pp. 89-106. THE INSTITUTE IDEA I97 American Registry of Pathology In June 1921, there was initiated another and more active form of cooper- ation between the Museum and important segments of the medical profession. The first such arrangement— there are now 27— was outlined in a joint letter of Major Callender, representing the Museum, and Doctors Harry S. Gradle and Ira Frank, of Chicago, representing the Academy of Ophthalmology and Otolaryngology. In substance, this undertaking reflected the realities of a situ- ation in which the Academy's members could furnish pathological materials which the Museum did not have, while the Museum could supply the home for the Academy's collections and the technical staff for the preparation of specimens. The arrangement thus entered into was confirmed by the Academy at its meeting in October 1921. It was noted that the Army Medical Museum, at that time, did not have on its staff anyone well versed in the pathology of the special fields covered by the Academy and qualified to do the consultative diagnosis, which was to be a major feature of the active cooperative work contemplated under the new arrangement. It was necessary, therefore, to set up a committee of the Acad- emy's specialists, to whom all specimens on which there was any doubt in diagnosis were submitted. Most active in this work were Dr. Frederick Her- man Verhoeff of Boston, the committee chairman, and Dr. Harry S. Gradle of Chicago. Both men were prompt in reporting on the doubtful cases and specimens submitted to them by Major Callender, who did much of the work on the easier specimens himself. 13 At first without a name or title, the new arrangement finally came to be called the Registry of Ophthalmic Pathology and became the first of the reg- istries which make up the American Registry of Pathology. This great col- laborative endeavor is housed and administered by the Armed Forces Institute of Pathology, but draws its strength and substance from the memberships of the 17 medical-specialty societies which sponsor the 27 individual registries now in operation. (1) The Atlases of Pathology. A symposium, presented at the Joint Session of the 57th Annual Session of the American Academy of Ophthalmology and Otolaryngology, in Chicago, 12-17 October 1952, and reported in: Transactions of the American Academy of Ophthalmology and Otolaryngology 57: 13-26, January-February 1953. (2) Zimmerman, L. E.: The Registry of Ophthalmic Pathology: Past, Present and Future. Transactions of the American Academy of Ophthalmology and Otolaryngology 65: 61-65, January-February 1961. (The 17th Jackson Memorial Lecture presented at the 65th Annual Session of the American Academy of Ophthalmology and Otoaryngology.) Dr. Zimmerman's lecture is as broad as its subject signifies and contains much of value, both historically and professionally. Ig g ARMED FORCES INSTITUTE OF PATHOLOGY The name "registry," which came to be applied to this form of cooperative medical endeavor, probably grew out of a case of suspected bone sarcoma in a patient of Dr. E. A. Codman of Boston. The patient's family wished to know of cases of recovery from what was, or was supposed to be, bone sarcoma, and the treatment which had resulted in a cure. Informally, Dr. Codman called on his personal acquaintances in the profession for such light as they could throw on cases, and their cures, if any. The first cases collected were placed in the Registry in July 1920, less than a year before the Museum and the Academy entered into their arrangement. Although the original patient for whose benefit the information had been gathered had died, it was realized that the information itself was too valuable to lose. Dr. Codman, therefore, took up the matter with Dr. James Ewing of New York and Dr. J. C. Bloodgood of Baltimore, with whose cooperation the Registry was informally organized. Other surgeons and pathologists became interested in the project, which was to be taken over, as part of its work, by the American College of Surgeons. On 3 January 1922, Dr. Codman, using a bound, blank book with the printed heading "Register," began the diary of "The Registry of Bone Sarcoma." The primary object was to "keep an up to date list of all supposed-to-be sarcoma cases" by registering "every case (1) of which we have a brief history and an X-ray picture or a slide or tissue. (2) certain interesting or unusual bone tumor cases which have been confused with sarcoma." The objectives were not greatly different from those of the almost con- temporary and still nameless arrangement between the Museum and the ophthalmologists, and the basic idea of the operation was so nearly the same and so well contained within the idea of a registry of pertinent information in individual cases, that it was most natural to call the Museum-Academy arrange- ment by the same name of a "registry." Particularly is this the case since Dr. Codman was a friend and patient of Dr. Verhoeff, chairman of the cooperative committee of the Academy, 14 to whom he might well have given the idea of calling the new alliance between military and civilian medicine a "registry." Working in a New Direction At any rate, and regardless of the name, the new movement was destined to give a largely new direction to the work of the Museum. At the first annual meeting of the American Academy of Ophthalmology and Otolaryngology, held after the new relationship between that organization and the Museum, "Zimmerman. Transactions of the American Academy of Ophthalmology and Otolaryngology, 65 (1961 1. pp. 6a, 69-71. THE INSTITUTE IDEA 1 99 the Museum exhibited some of its resources in the way of specimens of oph- thalmic pathology, most of which had been collected from members of the Academy during the year since the joint project was undertaken. The exhibit received high praise from the doctors in attendance, and was the subject of commendatory letters and expressions of appreciation from Dr. Walter R. Parker of Detroit, president of the Academy during the first year of its spon- sorship of the Registry. 15 The arrangement between the Museum and the professional sponsors of the Registry was strengthened by the subsequent addition of Dr. Jonas Stein Friedenwald of Baltimore and Dr. Georgiana Theobald of Chicago to its spon- soring committee. It was further advanced during its first year in operation by the gift, from Dr. James Moores Ball of St. Louis, of his entire collection of historical and operative ophthalmic materials. The Ball collection became, indeed, something of a cornerstone in the building of the Registry. It included 136 items of historical interest and value, which alone "would have been a generous donation" to the Museum. But this was only a portion of the gift, which included an interesting collection of ophthalmic instruments, large num- bers of microscopic slides and other items, nearly 500 gross pathological speci- mens, and more than 1,000 pictorial items."' While the movement for what came to be called the Registry of Oph- thalmic Pathology originated with the American Academy of Ophthalmology and Otolaryngology, and that organization continued to be its major support, it was soon strengthened by the affiliation of the two other groups of specialists in this field, the American Ophthalmologic^ Society and the Ophthalmic Section of the American Medical Association. The Registry was fortunate both in its professional sponsorship and m the Army personnel with which it had to deal. Surgeon General Ireland and Curator Callender were of one mind in feeling that the Medical Museum should, as Major Callender put it, "become a live activity in pathology in addition to its function of collecting, studying and reporting on the injuries and diseases of armed conflict." " 15 Ibid., pp. 65-67. . f pi,:], » (X) Dr. BaU's gift to the Registry was made at the instance of Dr £*£» M - £*£ delphia. Other major donors to the Registry in its early years included Dr. Harris 1 . mo who gave more than 600 specimens and Dr. E. C. Ellett of Memphis, whom General Callcn ^.^^ „ was "the largest single contributor and active supporter during the first ten years of the Registry s c (2) Coupal, James F.: Special Report: The Ophthalmologic Collections from the * m «£ n * mQ ' & Ophthalmology and Otolaryngology at the Army Medical Museum. American Journal ot p 853. 854, October 1923. . /)»o/«rvneo/ogv, » Callender, George R., Transaction* of the American Academy of Ophthalmology and Otolary g 57 (>953).PP- 14-15- 200 ARMED FORCES INSTITUTE OF PATHOLOGY And the movement was doubly fortunate in the member of the Museum staff assigned to the operation of the first registry— Miss Helenor Campbell, a young lady whose previous experience included 6 years as a technician in pathology at the Johns Hopkins Hospital. Miss Campbell, afterward Mrs. Wilder (fig. 65), joined the Museum staff in 1920 as a medical technician. In 1953, upon her marriage to Mr. Rudolf Foerster of San Francisco, she retired as an ophthalmic pathologist— justly renowned as "the famous Mrs. Wilder." Upon the occasion of her retirement, after more than 30 years of distinguished Figure 65. — President and Mrs. Eisenhower congratulate Mrs. Helenor Campbell Wilder (now Mrs. Rudolf Foerster) upon her achievements in ophthalmology which won for her the designation as "Woman of the Year in Science" by the Women's National Press Club in 1953. THE INSTITUTE IDEA 201 service, Mrs. Foerster, as she then was, was presented by her associates at the Armetl Forces Institute of Pathology with a bound collection of her published contributions to an increasing knowledge of pathology and ophthalmology. The collection covered a span of 32 years, from 1922 to 1954. It included 35 articles, appearing in 17 different publications. In 18 of the articles she was the sole author; in 17 she had as collaborators some of the outstanding author- ities in the field covered. Speaking in 1952 of the early days of what is now the oldest ^medical registry in the United States, General Callender gave the "highest credit" for its success to the woman who served it so brilliantly for so many years, and whose scientific attainments were such as to lead to her election to membership in professional medical societies, despite her lack of the college degrees ordinarily required for entrance. Mrs. Wilder made "two of the most eminent discoveries in ophthalmology of the past two decades" by her demon- stration of toxoplasmosis in many cases which had previously been diagnosed as tuberculous, and her finding that the larvae of nematodes are "a not infre- quent cause of endophthalmitis" or inflammation of the inner structure of the eye. By her outstanding achievements, she well merited the honorary degree of doctor of laws conferred upon her in 1955 by Mills College, Oakland, Calif. Varied New Activities of the Museum Another new service of the Museum, evidencing its increasingly close relations with the medical profession in general, was its designation as the institution entrusted by the Society of American Bacteriologists with the cus- tody and maintenance of its type cultures. Under this arrangement, which went into effect in May 1922, the Museum became the depository of the "purebred" strains of every differentiated bacterium of interest to medicine, from which subcultures of particular strains were supplied upon request. This arrangement, valuable alike to the medical profession and to the Museum, con- tinued for 3 years until, adequate funds having been obtained, the activity was transferred to the National Research Council, with the type cultures located at the McCormick Institute for Infectious Diseases in Chicago. During the time the cultures were maintained at the Medical Museum, the subcultures distributed came to number as many as 4,000 a year, in response to 700 re- " (0 Idem. (2) AFIP and Ophthalmology. Archives of Ophthalmology 67: 3>. M ^ ,<>61 - (i) AFIP Centenmal. Archives o£ Ophthalmology 67: 177-178, May 1962. (4) Lebenson, J. E.: The Armed Forces Institute of Pathology. American Journal of Opthalmologv 53: 695, April i'<<'- (5) Zimmerman, Transactions of the American Academy of Ophthalmology and Otolaryngology, 65 ("/">' PP- 78. 79- 202 ARMED FORCES INSTITUTE OF PATHOLOGY quests — a use which increased approximately eightfold while the work was being done at the Museum. 19 Still another new activity of the post-World War I period, which helped to intensify the turn taken by the Museum toward becoming an institute of pathology, was the designation of the Museum as the location of the central exchange for pathology specimens of the American and Canadian Sections of the International Association of Medical Museums. This work had been car- ried on, somewhat informally and in a limited way, as an addition to her other duties, by Dr. Maude E. Abbott of McGill University who, over the years, had been the mainspring of the work of the International Association. In the spring of 1921, Prof. James W. Jobling of the College of Physicians and Surgeons in New York, brought to a head the rather formless discussions of the subject of a central exchange by a letter to The Surgeon General of the Army suggest- ing the establishment of such an arrangement, to be housed and administered by the Army Medical Museum. The subject was submitted to Major Callender for his recommendation. Major Callender strongly urged the adoption of Dr. Jobling's suggestion, saying in a memorandum of 13 April to The Surgeon General, that the establishment of such an exchange at the Museum would be of material benefit "by bringing the Museum into the closest contact with our medical educational institutions" by rendering to them a most valuable service and, at the same time, would enable the Museum to strengthen its collections. The Surgeon General agreed, the Secretary of War approved and author- ized the issue of a revocable lease for the necessary quarters at the Museum, and 1 he Surgeon General authorized the officers at the Museum to undertake the administrative details. On 1 May 1922, the Museums Association authorized the removal of the central bureau for the preservation of results of medical research and the exchange for pathological specimens from Montreal to Washington. In an editorial in Bulletin VIII of the International Association of Medical Museums, Major Callender said: The central bureau for the preservation of the results of medical research will have a permanent file of records entirely independent from those of the Museum as a whole, and separate cabinets for slides and cases for specimens representing the result of original re- search. It will be kept carefully under suitable safeguards to prevent loss and will be open for consultation under adequate supervision to those qualified to consult it. 20 "Annual Reports of the Surgeon General, U.S. Army, for fiscal years 1922, p. 108; 1923, p 104- 1924, p. 161; 1925, p. 210. 30 (1) Letter, Major Callender to Professor Jobling, with memorandum to The Surgeon General 13 April .921. On file in historical records of AFIP. (2) Callender, G. R.: The Exchange of Museum Specimens. International Association of Medical Museums Bulletin VIII, December 1922, p. 12. THE INSTITUTE IDEA 203 Busy as he must have been with the launching of such a variety of new and valuable prospects, Major Callender was faced, in 1922, with proposals for combining the Army Medical Museum with the Smithsonian Institution. This movement had what probably was its fullest and most elaborate exposition in a letter from Dr. Arthur MacDonald of Washington, sent to many scientists and inserted in the Congressional Record by Representative Melvin O. Mc- Laughlin of Nebraska under the title "Consolidation of Government Science Under the Smithsonian Institution." 21 Dr. MacDonald's letter was not directed solely at the Army Medical Museum. His plan contemplated placing 33 bureaus of government organiza- tions having to do with scientific matters under the jurisdiction of the Board of Regents of the Smithsonian Institution. Among the agencies which would have been affected were the Geological Survey, the Reclamation Service, the Bureau of Mines, the Patent Office, the Census Office, the Bureau of Standards, the Bureau of Fisheries, the Public Health Service, the Army Medical Museum and Library, the Library of Congress, the Government Hospital for die Insane (St. Elizabeths), the Coast and Geodetic Survey, the Naval Observatory, and all the scientific bureau of the Department of Agriculture. The advantages claimed for this wholesale transfer of government agencies was that under it government science would develop to the highest efficiency, by correcting illogical and haphazard arrangement of bureaus or departments, and by reducing to a minimum political influence in scientific bureaus. The plan was likened to the administration of a university, with the Secretary of the Smithsonian Institution being analogous to the president of the university, and the Board of Regents, consisting of die Chief Justice, the Vice President of the United States, and three members each from the Senate and the House of Representatives, corresponding to the university trustees. Possible Courses of Action The movement for consolidation of all governmental scientific activity does not appear to have developed any great popular strength, but coming as it did, just as the Army Medical Museum was changing its direction so as to expand its services to medicine in general, as well as military medicine in particular, such public discussion of the plan led Major Callender to give serious and con- centrated thought to the position and the future course of the Museum. Possible courses of action, as outlined in a memorandum of 13 February 1922, for The Surgeon General, were fourfold: (1) The Army Medical Musuem 21 Congressional Record, 67th Congress, 1st session, volume 405, pp. 8833-8835, 26 October 1921. 713-028' — 64 15 204 ARMED FORCES INSTITUTE OF PATHOLOGY might continue "to be maintained as the only medical museum of national character as it has been for the past sixty years," with exhibits "for the purpose of educating the lay public in preventive medicine and hygiene" and an "en- tirely separate collection of a scientific nature" or (2) that the Museum should confine its activities to fields of general and preventive medicine as directly applied to the Army, leaving the broader field of medicine to be dealt with by another institution; or (3) that the Museum should "confine its activities to diseases particularly affecting troops;" or (4) that the Museum, as a temporary policy only, should continue to accept "temporarily the display of hygienic and preventive medicine, awaiting further developments." In analyzing the various plans, Major Callender put the cost of maintaining and operating the Museum proper, exclusive of rental and repairs to the build- ing, at about $40,000— an expense so small that the institution was being "run below par." Costs under plan 1, he estimated, would be about $100,000 more than the prevailing level of costs, in addition to the requirements of larger space. Plans 2 and 3 would have little effect upon costs, while plan 4 would mean that additional help from some source would be required, if exhibitions of preventive medicine and hygiene were to be done by the Museum. "The Army has had the only national museum worthy of the name in the United States * * *" Major Callender wrote, which "is one of our most valuable contacts with the civilian profession." Under Army control the facil- ities of the Museum had been offered "to other government services which might and should be interested in studying, particularly human pathology." Specifically, the U.S. Public Health Service and the Veterans' Bureau had been "apprised of our willingness to take care of their material for them." "In a similar way," he continued, "we are now cooperating with all societies who desire special representation in a museum of national character with the idea that one medical museum is sufficient for all." Because Army medical personnel are so mobile and are therefore subject to infection with diseases to which they are not accustomed, he added, "medical museums are absolutely necessary" for the education of medical officers in dealing with unfamiliar diseases. The same thing was "becoming important to the civilian profession because of the ease of travel throughout the world today" — truly a prophetic note to strike in 1922, when transatlantic flight had been achieved by only two stripped-down military planes, and the age of the jet airliner was not yet even on the most advanced drawing boards. Major Callender also pointed out that the Medical Department of the Army was in far better position to conduct a medical museum than was any other government service or an independent organization. "This is true," he said, THE INSTITUTE IDEA 205 "for preventive medicine and hygiene, as well as for pathology. Army officers have, since the advent of modern means of disease control, led the field in pre- ventive medicine and hygiene. This work is largely a development of the last 25 years and was first brought to notice by Reed. It has since been ably continued by Gorgas, Ashburn, Russell, Craig, and scores of others * * *." The compara- tive richness of the results of Army medical research was attributed, in part, to the fact that "the civilian profession, while frequently establishing the principles used as a basis for disease control, lack the opportunity to prove their worth which are offered the military by reason of the latter's contract with bodies of troops under discipline." The Medical Department of the Army, moreover, "by reason of its control over 1,400 officers, including dental, veterinary and administrative corps, is in a more favorable position to collect material illustrating disease conditions. Thus, it can direct the collection of pathological and other material as it now does disease bearing insects and thus obtain results impossible for an independent institution without the expenditure of enormous sums of money and the sending of details of scientific men to all parts of the globe." Balancing various considerations, without closing the door on any of the suggested plans, Major Callender concluded that under any plan of organization there still would be need for a museum aimed at both educating the lay public in preventive and hygienic measures and also at the further education of medical personnel. "I believe that eventually there will be a large national medical museum," he said in his memorandum for The Surgeon General, "and I am sure that the military medical aspects of such a museum must be an integral part of the Army Medical School. Otherwise it will be a curio shop appealing only to morbid interest while its real value is purely educational for graduates in medicine, more particularly officers of the Medical Department." 2 For yet another quarter of a century after Major Callender finished his first tour of duty as Curator, the Museum would continue in its same quarters, com- bining under one roof its functions as a place for professional study and research and as a place for interesting and informing the lay public in matters medical. But already, in the years just after the First World War, the differentiation in objective and function was emerging. The Museum was becoming, more and more, an Institute. 23 Memorandum, George R. Callender, Curator, for The Surgeon General, U.S. Army, 13 February 1922. On file in historical records of AFIP. CHAPTER XI The Registry Movement "The evolution of the pathology registries stands out as the most important organizational development in American pathology," declared Brig. Gen. Elbert DeCoursey, addressing the annual meeting of the American Academy of Oph- thalmology and Otolaryngology in 1952. 1 When General DeCoursey, then the Director of the Armed Forces Institute of Pathology, made his comment upon the importance of the registry movement, there were 21 registries in successful operation, with many thousands of cases registered and subject to the organized and systematic study of the manifesta- tions of disease and trauma, with provision for regular periodic followup to check on developments and responses to treatment. In the 1920's, however, the registry movement was quite limited in scope, being confined for the first 5 years to but two examples— the original arrange- ment with the American Academy of Ophthalmology and Otolaryngology, set up in 1921, and a second registry in lymphatic tumors, established in cooperation with the American Association of Pathologists and Bacteriologists in 1925. Two years later a third registry, in bladder tumors, was set up under the sponsorship of the American Urological Association. Succeeding Maj. George R. Callender as Curator of the Museum was another native of Massachusetts and graduate of Tufts Medical College, Maj. James Francis Coupal (fig. 66), who had been Assistant Curator under Callender. He was to serve from 1922 to 1924, in which year he was appointed White House physician during the administration of President Calvin Coolidge. Upon his withdrawal from the Museum, Major Callender returned to serve as Curator in the 5 years from 1924 to 1929. During the administration of Major Coupal, a start was made toward a reclassification of the contents of the Museum, using an adaptation of Dr. Maude E. Abbott's modification of the Wyatt-Johnson museum classification. 1 DeCoursey, Elbert: The Atlases of Pathology. A symposium, presented at the Joint Session of the 57th Annual Session of the American Academy of Ophthalmology and Otolaryngology in Chicago, 12 17 October 1952, and reported in: Transactions of the American Academy of Ophthalmology and Otolaryngology 57: 15, 16, January-February 1953. 208 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 66. — Maj. James F. Coupal, thirteenth Curator of the Museum, 1922-1924. Under the new system, the anatomical names and the pathological lesions which produced disease and death were listed, with a number assigned to each of the anatomical terms used. The numbers, listed in accordance with the International List of Causes of Death, were used as a code. The code was cross- filed, so that it was possible to locate specimens by their anatomical names, by THE REGISTRY MOVEMENT 209 their pathological classifications, and by the names of their contributors. By 1924, the new system had been applied to 5,000 protocols, 4,000 gross pathological specimens, and 4,500 miscellaneous items. 2 By the end of Major Calender's second tour of duty as Curator of the Museum, in 1929, the original ophthalmic registry had accumulated 2,000 registered cases, while the two tumor registries had about 200 each. The regis- tries, in Major Callender's opinion, were well established and had "reached that stage of development and activity which makes necessary more professional, technical and clerical work that can be given by the Army Medical Museum." To find adequate support and to insure that there should be continuity of policy in the registry movement, Major Callender took up with Dr. Ludwig Hektoen, Chairman, Division of Medical Sciences of the National Research Council, the matter of recognition of the registries as a joint activity of the Council, the Museum, and the sponsoring professional societies. As a result, and with the approval of the Council, the American Registry of Pathology was formed, in 1930, by a committee headed by Dr. Howard T. Karsner (fig. 67) of Cleveland as chairman and Major Callender as secretary. Other members of the committee included : Dr. James Ewing of New York, Dr. Stanley P. Reimann of Philadelphia, and Doctors Bowman C. Crowell, Harry S. Gradle, and Herman L. Kretschmer of Chicago, all of whom had been active in promoting the existing registries or were interested members of professional societies, such as the associations combating cancer, who were naturally interested in the project. Objective of the Registry The object of the American Registry of Pathology, which has grown to include 27 specific specialty registries, as outlined by Major Callender, 3 is to "collect data and specimens from patients, especially those with tumors, with a view to accumulating a sufficient number of instances of each disease to determine its characteristic course, the criteria for diagnosis, and to evaluate methods of treatment * * *. The cases preferred are those living at the time of registration, and that can be followed so that the outcome may be ascertained. The following up of these cases will constitute a considerable and important part of the Registry's activities." = Coupal, James F.: Modification of the Wyatt-Johnson Museum Classification in Use at the Army Medical Museum, Washington, D.C. International Association of Medical Museums Bulletin X, Apnl 1924, PP ' ^CaUcnder, George R.: Report of Committee on Ophthalmic and Oto-Laryngic Pathology, 35th Annual Meeting of the American Academy of Ophthalmology and Otolaryngology. Transaction; American Academy of Ophthalmology and Otolaryngology, 193°. PP- 53 0_ 535- 210 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 67. — Dr. Howard T. Karsner, pre-eminent pathologist who throughout the years, has been a discerning critic, a firm friend, and a staunch supporter of the Medical Museum and its offspring, the Armed Forces Institute of Pathology. Diagnosis in the early stages of disease "offers the best chance of cure," Major Callender said, but early and accurate diagnosis is not possible in the absence of opportunity to observe enough cases to form a basis for reasonable THE REGISTRY MOVEMENT 211 judgments. Except at large medical centers, there were too few cases of any one kind to afford such opportunity for study. By combining cases from the coun- try as a whole, Major Callender observed, "It will be possible to obtain con- siderable numbers of cases and specimens in a much shorter time." The Registry was not intended to replace the local pathologist and would "never serve as a diagnostic laboratory." Rather, it was to be "a clearing house in pathology to which will be sent cases already diagnosed and the obscure cases about which more can be learned by obtaining the opinions of several pathologists. In addition, by sending 'follow-up' letters to the physician regis- tering cases, the Registry will be a means of helpful stimulation." The success attained by the three registries already in operation when the American Registry was formed, had "been obtained in spite of a minimum of publicity effort because there has been insufficient personnel at the Army Medical Museum to conduct larger collections. As the registries have become better known, the 'follow-up' work alone is more than can be handled adequately in the time of the Museum personnel available for it." "The expense of these registries has thus far been borne entirely by the Museum, whose entire budget, inclusive of all personnel and upkeep of plant, is about $30,000. The expense for materials and equipment for the proposed registry can be handled by the Museum," he added, "but it is necessary to have additional help in the form of professional, clerical and technical personnel." Other activities of the Museum personnel included the handling of the tissues and histories of all cases of tumor or suspected tumor in the Army, and the review of the protocols of all Army necropsies, numbering about 800 a year. 4 With a staff of but one medical officer, two medical technicians, one sten- ographer, and one typist, it was obvious that additional help must be had if the registries were to realize their full potential. Another obstacle to securing con- tinuity of policy was the fact that the officer personnel on duty at the Museum was shifted every 4 years, usually, and in many cases after even shorter periods. In his outline of the operations and potentialities of the American Registry of Pathology, Major Callender paid particular attention to the possibilities offered by the registry in the earlier diagnosis of malignant growths. "It is generally acknowledged by pathologists," he said in his 1930 outline > " that many neo P lasms are difficult to diagnose. * * * The earliest changes which signify malignancy are not sharply defined. In fact, there is serious doubt if we know by sight the earliest malignant changes in any tissue. Unless cases are followed up we cannot * Army Regulations No. 40-410, 18 January 1922. paragraphs 19. 2". 713-028*— 64 16 2I2 ARMED FORCES INSTITUTE OF PATHOLOGY learn these changes. Even if a definite cause for cancer should be found, it will still be necessary to recognize the earliest change indicating its presence." In his outline of the American Registry of Pathology, he referred to the project for a new building for the Museum and the Library at the Army Medical Center, adjacent to the Walter Reed General Hospital as "being before the Bureau of the Budget. In the new building, as contemplated, there will be rooms available for research by scientists not on the Museum staff. Laboratory facilities will be available and all collections of the Museum will be more accessible for research." The dream of the new building was not to come to fruition for yet another quarter of a century after the American Registry of Pathology was set up by the National Research Council, an agency of the National Academy of Sciences, which was authorized to receive and administer any funds contributed to the Registry. Through the channel thus opened, the medical specialty societies could conveniently make financial contributions to the work of the Museum in pathology. Organized Civilian Cooperation These contributions have continued over the years, but the greater contribu- tion by far has been the active cooperation of the specialists in the registry work in what has been aptly called an "effective synergism." 5 The way in which the Museum and the civilian specialists worked together was well described in the 1927 report of Maj. Gen. Merritte W. Ireland, The Surgeon General of the Army, as follows: In the operation of a registry, case reports accompanied by specimens are sent in to the registrar. Slides of the specimen are prepared, and when the diagnosis is in doubt the entire case is circulated to a group of pathologists. The diagnoses furnished are studied and the case is classified by the registrar in cooperation with a committee appointed by the society conducting the registry. In so far as possible, only cases living at the time of regis- tration are accepted and every case is followed to its conclusion. In this way large numbers of cases are brought together, followed by subsequent reports to their decease, and classified and studied to determine the character of the disease process, the course of the disease, and to evaluate the methods of treatment. The emphasis of the registries, it will be noted, was on living cases to be followed to the end rather than on specimens resulting from post mortem cases important as they are. "The registries," said the 1927 report of The Surgeon 5 Dart, Raymond O.: The Army Medical Museum. International Association of Medical Museums Bulletin 27: 13, 1947. THE REGISTERY MOVEMENT 2I 3 T5he MEDICAL DEPARTMENT OF THE UNITED STATES ARM? IX THE WORLD WAR VOLUME XII n;\ hi- nil ACI IK RESPIRATORY ISES, AND "i LOWING WAR WOI NDS Figure 68.— Title page and an illustration from volume XII of "The Medical Depart- ment of the United States Army in the World War." The illustration shows the lung in a case of pneumonia following influenza. General, "are the source of the most valuable material now being received, and the museum is fortunate in being chosen to conduct them." Since the registries had been "accepted as offering the greatest aid in determining the best method of reducing the mortality from malignant disease," it was confidently predicted that "registries in other lines will follow as the years go by." ( Six years were to go by, however, before another registry was established- years in which Major Callender was to complete his second tour of duty at the Museum, in 1929, to be succeeded by Maj. James Earle Ash, whose first tour of duty covered the years to 1931 and who, in turn, was to be succeeded by Maj. Paul Edgar McNabb, who served until 1933 when Maj. Virgil Heath Cornell became Curator. The year 1929 was marked by the publication of volume XII of "The Medical Department of the United States Army in the World War" (fig. 68), which dealt with the two subjects chosen as the most important conditions of the war from the standpoint of pathology. The first section of the work, "Pathology of ° Annual Report of the Surgeon General, U.S. Army, 1927. PP- 22, < 222 ' 2I4 ARMED FORCES INSTITUTE OF PATHOLOGY the Acute Respiratory Diseases" was written by Major Callender; the second section, "Pathology of Gas Gangrene Following War Wounds," by Maj. James F. Coupal, former Curator of the Museum. The richly illustrated volume, with 24 plates in lifelike color and 312 black-and-white pictures, was based to a large extent on material in the Medical Museum, and made use of the photography and artwork produced by the Museum staff, including Maj. Theodore Bitterman, S.C., Capt. R. W. French, Inf., and Messrs. Roy M. Reeve, F. E. Prior, Garnet Jex, L. W. Ambrogi, Walter Parker, and Edward V. McCarten, to whom grate- ful acknowledgement was made.' Major Callender's successor, Major Ash (fig. 69), was a native of Philadel- phia and a medical graduate of the University of Pennsylvania. His 6 years of postgraduate experience in various hospitals had been supplemented by study in Vienna, where the young doctor and his slightly older colleague, Howard T. Karsner, both men destined to distinction, worked at the State Therapeutic Institute. Upon his return to the United States, Dr. Ash served 3 years on the staff of the Harvard University Medical School. There he became interested in tropical diseases — an interest which turned him to the Medical Department of the U.S. Army, which was outstanding in that field. He was commissioned in the Medical Corps in 1916. On his second tour of duty at the Museum, from 1937 to 1947, he was to become known as the principal protagonist of the spreading registry movement, but during his first tour, 1929 to 1931, there was no further increase in the roster of registries. This may be partially accounted for by the "greatly increased" work of the Museum staff in the fields of diagnosis and consultation, following the issuance of The Surgeon General's Circular Letter No. 2, on 12 February 1929. Histopathology and the Museum This circular called to the attention of all Medical Department officers the fourfold functions of the Museum with reference to tissue pathology. These were, the letter said, "to obtain material for instruction and research ; to preserve material permanently for reference purposes; to act as a consulting service; to examine and diagnose surgical, biopsy, and autopsy material for stations at which adequate laboratory facilities and personnel for such diagnostic work are not available." The cooperation of all medical officers in selecting and sending in to the Museum "specimens presenting interesting pathological conditions" was urged, but the greater stress was laid on the diagnostic and consulting functions. 7 The Medical Department of the United States Army in the World War. Washington: U.S. Govern- ment Printing Office, 1929, volume XII, pp. v, vi. THE REGISTRY MOVEMENT 2I 5 Figure 69.— Col. James E. Ash, fifteenth Curator, 1929-1931; twentieth Curator, 1937-1946; and first Director, Army Institute of Pathology, 1946-1947. The availability of this diagnostic service at the Museum "apparently is not fully appreciated by the surgeons of all military hospitals," the letter said, in announc- ing that certain hospitals had been designated as centers to which selected por- tions of tissue might be sent for emergency diagnosis "when the best interests ot 2l6 ARMED FORCES INSTITUTE OF PATHOLOGY the patient necessitate a microscopical diagnosis at the earliest possible moment and local facilities for such diagnostic work are not available." The hospitals so designated were Letterman General Hospital, for the IX Corps area; William Beaumont General Hospital and the Station Hospital at Fort Sam Houston, for the VIII Corps area; Fitzsimons General Hospital, for the VII Corps area; and the Army Medical Museum itself for the I through the VI Corps areas. The officer making the diagnosis was instructed to report by telegraph or radio when, in his judgment, such a course was required. In all cases, specimens were to be furnished to the Museum, together with a copy of the report. Explicit instructions were given for the preparation and shipment of specimens and the writing of autopsy protocols, all of which were to enter the collections of the Medical Museum for final study, review, and preservation. Inescapable Housekeeping "There is an enormous amount of work that should be done in rearranging exhibits and developing the material already on hand," said the annual report of the Surgeon General for 1929, "but it must be put aside for the more urgent current demands" of the consultation and diagnostic service which, as the Museum's most important function, "has precedence over all other activities." 8 Although the diagnostic and consultation functions of the Museum had first precedence, there were always inescapable housekeeping chores to be attended to. The Museum's material, stored in the basement, was surveyed, and the portions which had deteriorated and become useless were disposed of. The cleanup was hampered by the chronic shortage of personnel. The task of sorting material, and especially the "enormous amount of facio-maxillary material which had accumulated during the few years after the war" was perhaps made simpler by the adoption, in 1930, of straight alphabetical index- ing, which was described as "much simpler and more efficient" than the numer- ical system of coding adopted in the years just after World War I. Even though there were no new registries set up, "active interest" in the three existing ones was continued. In fact, nearly one-third of all accessions in 1930 were contrib- uted through the route of the registries. 9 In the fall of 1931, Major McNabb (fig. 70) succeeded Major Ash as Curator of the Museum. The new Curator, a native of Tennessee, received his M.D. degree at the University of Pennsylvania. His Army service had 8 Annual Report of the Surgeon General, U.S. Army, 1929, p. 267. 'Annual Report of the Surgeon General, U.S. Army, 1930, pp. 271-273. THE REGISTRY MOVEMENT 217 Figure 70.— Maj. Paul E. McNabb, sixteenth Curator of the Museum, i93i- : 933- included tours of duty in the Canal Zone and the Philippines, where he had been president of the Army Medical Research Board. During Major McNabb's administration, the photographic section of the Museum was particularly active in color photography of both gross and micro- scopic specimens for museum display and also for lantern-slide demonstration. 2l8 ARMED FORCES INSTITUTE OF PATHOLOGY There had been earlier efforts at the Museum to produce true color reproduc- tions of pathological specimens, as reported by Major Callender, Major Coupal, and Mr. F. E. Prior, in an article published in Bulletin No. X of the International Association of Medical Museums. Effective results were produced by a method which involved accurate photographic prints which were colored by hand, with the resulting picture reproduced by lithography. The 1932 experiment, carried on by Roy M. Reeve, photographer for the Museum, and Joseph Carter of the U.S. Department of Agriculture, sought to secure correct coloring by making three color separation negatives, from which prints were made in blue, red, and yellow. The prints were superimposed upon one another, checked for accurate registration, and true color values, corrected by differential printing of the three images, and then mounted — yellow image first, red second, and blue third, to complete the picture. The Reeve-Carter process produced effective color prints, even though it required much patience and a high degree of manipulative skills, and was a distinct advance in the development of today's simpler and more rapid systems of producing photographs in color. 10 The Museum at Threescore Years and Ten In 1932, the 70th year of the existence of the Army Medical Museum, its exhibits were viewed by 67,689 visitors. Because of a lack of space, only about half its collections could be placed on exhibition. The collections "com- bined exhibits of historical value and interest to the Medical Corps of the Army, to the medical profession at large, and to the general public." There was, however, a "great volume of material of a purely pathological character"— for it could never be forgotten that the Museum was, above all else, "the active central unit of pathology in the Army." As such, it received, in its 70th year, protocols and specimens from nearly 1,000 autopsies performed at Army hos- pitals, representing more than 56 percent of all deaths in these hospitals. 11 Major McNabb was succeeded as Curator by Maj. Virgil H. Cornell in IQ 33 (fig- 7 1 )- The new Curator was a native of Brooklyn and received his medical degree at the Long Island College of Medicine in 1913. Thirty years later, after serving as pathologist and chief of the laboratory service at major 10 (1) Callender, G. R., Coupal, J. F., and Prior, F. E.: True Color Reproduction of Pathological Specimens. International Association of Medical Museums Bulletin X, April 1924, pp. 38-41. (2) Reeve Roy M.: Color Photography in the Medical Museum. Journal of Technical Methods and Bulletin of the International Association of Medical Museums 19: 12-19 October 1939. (3) Reeve, Roy M.: Color Prints by the Carter-Reeve Color Process. The Journal of the Biological Photographic Association 4 - 132-136 1936. 11 Memorandum, Maj. P. E. McNabb, for The Surgeon General, U.S. Army, 1932. On file in historical records of AFIP. THE REGISTRY MOVEMENT 219 Ficure 71.— Maj. Virgil H. Cornell, seventeenth Curator of the Museum, 1933-1935- Army posts, including service in both World Wars, Major Cornell received from Harvard University the degree of doctor of public health. His Army service is further memorialized in the name of the Cornell Laboratory, the special section of the Medical Museum set aside for the use of medical research workers. 220 ARMED FORCES INSTITUTE OF PATHOLOGY The Dental and Oral Registry Major Cornell's administration as Curator was signalized by the establish- ment, in 1933, of the fourth of the registries and the first to be set up as a part of the American Registry of Pathology. The Dental and Oral Pathology Registry added in 1933 was, in a sense, a reactivation of the arrangement of 1895 under which the American Dental Association designated the Museum as the national depository for its dental and oral specimens and materials. Since this designation, there had been periods of activity, and also of inactivity, in carrying out the plan for the deposit of material in the museum. The action taken in 1933 contemplated a different and more active participation of the dental profession in the development of a full-fledged registry, with the work- ing support of a committee of the American Dental Association, headed by Dr. Henry A. Swanson of Washington. By the end of 1936, the Dental and Oral Pathology Registry had a total of 483 accessions, many of which had been transferred to it from the materials already collected in connection with the earlier registries. The dental registry, however, was not yet "actually functioning" to the same degree of activity as the other registries, even though there had been an official relationship between the Museum and the organized dental profession for 40 years. In a mimeographed statement, undated but apparently issued in 1939, when there were 808 cases in the Registry, the purposes and intentions of the committee of the Dental Association cooperating with the Museum were out- lined along general lines. It was intended to "collect material from, and com- pile data appertaining to, the pathological disturbances of the hard and soft tissues of the oral cavity * * *. All cases of definite or suspected malignancy * * * will be followed by annual inquiry addressed to the contributor for a period of five years." The purpose of the Registry was to furnish consultation service in such cases as could not be diagnosed locally, and to prepare loan collections consisting of microscopic preparations, photographs, lantern slides, and other material of illustrative cases for use in dental schools, societies, and study clubs. It was the expressed desire of the committee to enlarge and modernize the dental exhibit of the Museum "so that it will be of interest, educational value and historic record second to none." 12 "Ash, James E.: Data for the Preparation of Statement Requested by Dr. E. H. Bruening, undated. On file in historical records of AFIP. THE REGISTRY MOVEMENT 221 More Registries Formed Whether because of this appeal for more active cooperation on the part of the profession, or because of the general pickup in military activity following the near collapse of Allied defenses in Europe, the number of new cases received in the Dental and Oral Pathology Registry went up from 95, which it was in 1938, 13 to 226 in 1939, and to 692 in 1940 — a sevenfold increase in 2 years. While the dental and oral section of the American Registry was over- coming the degree of indifference which it met at the outset, two other reg- istries were being successfully launched. In 1935, the ear, nose, and throat cases in the original combined ophthalmic and laryngic registry were separated to become the Registry of Otolaryngic Pathology, under the sponsorship of the Academy which had started the registry system at the Museum. The addition of two more registries was reported in 1937— a Tumor Reg- istry sponsored by the American Society of Clinical Pathologists, and one in Dermal Pathology sponsored by the American Dermatological Association and now under the sponsorship of the American Academy of Dermatology and Syphilology. With these additions to the list, it appeared to Surgeon General Charles R. Reynolds that "practically all the special fields are covered except neuropathology, and it is possible that this will be taken care of in the near future." " The Surgeon General underestimated the extent to which subdivision of specialties would be carried in the next two decades, as well as the range of additional fields in which pathology would be found basically useful. Neuro- pathology was indeed "taken care of" in the formation of a registry in 1942, jointly sponsored by the American Association of Neuropathologists and the American Psychiartic Association. The registries in tumors, originally limited to the lymphatic tumors and those of the bladder, evolved into a total of six tumor registries through the addition of those on Kidney Tumors (1938), Prostatic Tumors (1943), and Testicular Tumors (1959), all sponsored by the American Urological Associa- tion; and that on Chest Tumors (1940), sponsored by the American Association for Thoracic Surgery. In the field of pathology of particular organs, areas, and systems there are, in addition to the registries already mentioned, registries covering Orthopedic Pathology (1943), the Female Reproductive System (i95 2 )> and the Gastr °- "Annual Report or the Surgeon General, U.S. Army, 1938. P- l % 2 - " (1) Idem. (2) Annual Report of the Surgeon General, U.S. Army, 1937. P- «7> 222 ARMED FORCES INSTITUTE OF PATHOLOGY intestinal Tract (1952), all sponsored by the American Society of Clinical Pathologists; Genitourinary Pathology (1947), sponsored by the American Urological Association; Cardiovascular Pathology (1948), with the American Heart Association as sponsor; Hepatic Pathology (1949), under the sponsorship of the American Gastroenterological Society; Pediatric Pathology (1956), with the American Academy of Pediatrics as sponsor; and one of Endocrine Pathol- ogy, organized in 1948 and currently unsponsored. In the broader fields of function and treatments, registries are found in Gerontology (1945), sponsored by the Gerontological Society; Radiologic Pa- thology (1947), jointly sponsored by the American College of Radiology, the American Roentgen Ray Society, and the Radiological Society of North Amer- ica; and Nutritional Pathology (1951), sponsored by the American Institute of Nutrition. The field of veterinary pathology is covered by a registry organized in 1944, with the American Veterinary Medical Association as sponsor (fig. 72). The specific disease of leprosy is the field of a registry, formed in 1950, under the sponsorship of the Leonard Wood Memorial. Most recent in the roster of registries are the ones on Forensic Pathology, formed in 1958, with the College of American Pathologists as sponsor and two formed in the centennial year of 1962 — one on Radiation Pathology, under the sponsorship of the U.S. Public Health Service, and another on Geographic Pathology, sponsored by the International Academy of Pathology. Both new registries were formed to meet the increasing need for accurate information as to radiation, in the one case, and as to diseases which may be encountered in lands other than the United States, particularly those in the Tropics. The registries are a living link between the practitioners of the various medical specialties and the staff of the Museum and its successor organiza- tions — first the Army, and then the Armed Forces Institute of Pathology, in the consultation, education, and research which are their common objectives. Publications of the Registries Brig. Gen. George R. Callender, in whose curatorship at the Museum the first of these links was forged, paid tribute to the civilian pathologists who, in the early days of the Registry, "taught the staff Ophthalmic Pathology, in which at the start we were profoundly ignorant." 15 The teaching process 15 Callender, George R., Transactions of the American Academy of Ophthalmology and Otolaryn- gology, 57 (1953). P- 15- THE REGISTRY MOVEMENT 223 Figure 72.— Maj. T. C. Jones, VC, Registrar, Registry of Veterinary Pathology, Army Institute of Pathology. worked both ways, with the Museum staff providing study materials for loan to responsible individuals and sets of lantern slides for group teaching. A combination of group and individual instruction were the seminars conducted for several years by the American Society of Clinical Pathologists for which the Institute of Pathology furnished, upon occasion, as many as 37,000 micro- scopic slides in sets of 25 slides to each of about 1,500 participants in the program. 16 From these loan sets of slides, the Museum evolved the atlases which were to become one of the strongest ties between the pathologists of the armed serv- ices and the medical profession. In addition to the "Atlas of Tumor Pathology," the Registry has published an "Atlas of Angiocardiography" dealing with ob- servation of the heart and great vessels after intravenous injection of an opaque liquid, and an "Atlas of X-Ray Myelography" dealing with X-ray examination "DeCoursev, Elbert, Transactions of the American Academy of Ophthalmology and Otolaryngology, 57 (1953). P- '6- 22 . ARMED FORCES INSTITUTE OF PATHOLOGY of the spinal cord. Other publications of the Registry include syllabuses on various disease conditions, issued in connection with courses of instruction. Most of the publications have gone through more than one edition, with revisions and reprinting. "Our original atlases were rather primitive," said Colonel Ash in the course of reminiscent remarks at the 1952 session of the American Academy of Ophthalmology and Otolaryngology. The pages of the first editions were mimeographed and had as illustrations actual photographs instead of printed reproductions. This limited the editions to about 100 copies of each. "I remember so well the job it was to collate the pages," said Colonel Ash. "We had the pages in a series of pigeonholes on the balcony of the old Museum and it was the habit of the few of us who were then at the Museum to stop and collate a book or two on our way back from the rest rooms on the first floor." Continuing, Colonel Ash said that "after this initial effort of using photo- graphs, we did manage to acquire a little offset reproducing machine with which the second edition was run off * * *. All the time, however, we had in mind atlases that were more comprehensive professionally and technically less amateurish." Advantages of the Registry System Speaking from his long experience with the Registry system, Colonel Ash expressed the conviction that "registries, properly sponsored and properly ad- ministered, can be very potent factors in education, in research, and in the advancement of the various clinical specialties." Speaking as a general pathologist, the colonel declared that "much of the pathology of several of the specialties has been developed by clinical specialists frequently not too well grounded in general pathology. On the other hand, general pathologists have very little notion of the eye pathology and not too much of skin, bone, teeth, and so on. Well, it is our idea that with these very specialized activities at the Institute we have helped the specialist in the pathol- ogy of his field, but at the same time have importantly stimulated the general pathologist to an interest in these special fields." Colonel Ash was speaking 30 years after the organization, by General Callender, of the first of the Museum's registries. In those years, 22 registries had been formed. Others were to be added in the decade which followed, bringing the total to 27 at the close of the first century of the life of the Museum and its successor, the Institute. The value of the Registry as an essential part of the activities of the Institute has been abundantly proved by the better THE REGISTERY MOVEMENT 225 understanding it has fostered between pathologist and clinical specialist and between civilian and military medicine. "Medicine," as Colonel Ash con- cluded, "owes a great debt to this Academy for being the pioneer in this activity. We should honor Dr. Gradle and General Callender for fostering the idea in its early stages. It has been a great privilege of the Institute and of the Army to have participated in it." 17 "Ash, James E., Transactions 0} the American Academy of Ophthalmology and Otolaryngology, 57 (1953). PP- 18. 19- CHAPTER XII Between the Wars Chronic difficulties of too little space and too small a staff continued to plague the operation of the Army Medical Museum in the years between the 1918 armistice and Hitler's invasion of Poland, 21 years later. "The rapid accumulation of materials * * * burdened the museum staff with the labor of preparation" of specimens for several years after the First World War, said Maj. Virgil H. Cornell, addressing the International Association of Medical Museums at its meeting in Washington in May 1933. The combina- tion of the volume of materials for display and the shortage of space had tended to bring about overcrowding of the exhibits, particularly since, "anticipation of the early erection of a new museum had led to the postponement of rearrange- ment" of materials in the existing building. By 1933, it had become apparent that the new building for which a site had been purchased 11 years earlier was, like many another hopeful project, a victim of the great depression. "In view of a rather indefinite postponement of any new construction," Major Cornell added, "we are attempting to improve the material accumulated with what facilities are at hand. Though no progress has yet been made in the new group- ing of exhibits, it is none too early to begin the assembling of materials so that it may be ready for transfer in group arrangement to the new museum when that time comes." The time when such a transfer and rearrangement was to be made was not to come about until after two wars, three temporary homes, and four removals of the Museum, so that it is no wonder that the idea of making ready in 1933 for an anticipated move to a new building might, in Major Cornell's words, "sound overoptimistic." But, he added, in extenuation of his seeming overoptimism, "we have lived too long in an atmosphere of pessimism, so it is time to reverse the trend." x In the discussion which followed Major Cornell's presentation of the current activities of the Museum, Dr. Howard T. Karsner of Cleveland, professor of Cornell, V. H.: Current Activities at the Army Medical Museum. Typewritten memorandum for remarks at International Association of Medical Museums Meeting, 13 May 1933. » °" file "> histor.cal records of AFIP. Published in: International Association of Medical Museums Bulletin 13: 183-185. 1934. 22 g ARMED FORCES INSTITUTE OF PATHOLOGY pathology at Western Reserve University, declared that it demonstrated what could be done by the U.S. Army Medical Corps "in the face of most distressing conditions." The oral presentation by the Curator was backed up by a tour of the Museum, in which the members of the Association had an opportunity to see in actual use the methods of mounting, lighting, and display which had been presented and discussed earlier in the day. The tour, according to the minutes of the Association, afforded "an extremely interesting and valuable time * * * in the examination of the treasures and resources of this great Collection." " Deterioration at the DAuseum The collections of the Museum were indeed great, but there can be no doubt that by the early 1930's, as a result of restricted space and reduced staff, they had deteriorated relatively, if not absolutely. This was made plain in a special report to The Surgeon General of the Army by Maj. (later Brig. Gen.) Raymond Osborne Dart (fig. 73), who had served as Major Cornell's Assistant Curator and who succeeded him. The new Curator was a native of Kansas, who received his academic education in the University of that State and took his medical degree at Rush Medical College of the Uni- versity of Chicago. He entered the Army in 1917, and started his first tour of duty as Curator of the Museum in 1935. Before his second tour of duty with the Museum ended, he was to affect profoundly its organization and direction. The purpose of Major Dart's special report of 19 July 1935 was to point out and make "recommendations for the correction of defects in the organization which have seriously handicapped the successful operation of the institution in the past." Continuing, he wrote: It is an easily verified fact that the Army Medical Museum has slipped steadily back- ward from the first rank of medical museums which it occupied immediately after the World War until it is no longer regarded as an important place for the dissemination of information concerning museum technique and display. Meanwhile the very fundamentals of museum display have been changed and other institutions have assumed the leadership in this field which was formerly held by the Army Medical Museum. The reasons for this state of affairs are quite obvious when one considers the history of the organization during the past few years. 3 "Ibid., pp. 184, 185. 3 Maj. R. O. Dart's report, 19 July 1935, Surgeon General's Office file number 024.9 (Army Medical Museum and Library). On file in historical records of AFIP. BETWEEN THE WARS 229 Figure 73.-Brig. Gen. Raymond O. Dart, eighteenth Curator of the Museum, 1935-1936; second Director, Army Institute of Pathology, m^W, and first Direc- tor, Armed Forces Institute of Pathology, 1949-1950. Taking up in turn the "four chief non-professional departments," he out- lined their condition and described its effects upon the professional work of pathology and scientific research. 2 , ARMED FORCES INSTITUTE OF PATHOLOGY The "department of museum display and gross technique" was, he said, the "most important non-professional department" and the one which had "gravitated to the lowest level of all." He continued : From 1919 to 1922 this department was in charge of Captain C. F. Silvester, Infty (Res), an excellently trained technician and administrator. During this period he not only supervised the preparation and display of a large amount of war material but published many articles on museum technique of such importance that the Army Medical Museum enjoyed an eviable position of leadership in this field. Since that time the work of this department has been done by a succession of enlisted men from the detachment at Walter Reed General Hospital or the Army Medical School who have been detailed temporarily to the Army Medical Museum for this purpose. Desultory efforts to supervise this work have been made by the Curator and his assistants when time could be spared from other duties, but only the mounting of rare and important specimens could be given this atten- tion and all others requiring more than the simplest technique have of necessity been either destroyed or dumped in large vats in duplicate storage. 4 Inadequate Space J Insufficient Personnel Even this attenuated attention to museum display had been further diluted by reduction in staff from three enlisted men to one, who was due to retire for age in a few weeks, with no trained replacement on hand. In the circumstances, preparation of special exhibits for display in the building and at various scientific meetings was "taking many hours of time from the more important duties of the curator and his assistants" and the "undertaking of modernizing the general museum exhibit" was "out of the question." On the clerical and administrative side, the loss of Capt. Theodore Bitter- man, principal clerk, through retirement in 1931 without replacement, "was probably the most serious handicap to the successful administration of the museum." The loss of this experienced administrator had imposed upon the Curator multitudinous details requiring attention. The Department of Photography, headed by Roy M. Reeve, was "inade- quately staffed by a succession of enlisted men of the Medical Department who as soon as they have become sufficiently trained to be of any real help in the advancement of the department have either been transferred elsewhere or have accepted more remunerative positions with civilian institutions." Mr. Reeve's advances in the field of color photography, keeping up the tradition of leadership in the photographic arts established by Dr. Joseph J. Woodward and Dr. Edward 'Among the published articles of Capt. Charles F. Silvester were: (i) Mounting War Collections at the Army Medical Museum. International Association of Medical Museums Bulletin, pp. 49-53, December 1022 (2) Typewriting Labels on Museum Jars. International Association of Medical Museums Bulletin, pp. 83-86 December 1922. BETWEEN THE WARS 23 1 Curtis, and carried on by Dr. William M. Gray, had been done, Major Dart noted, "entirely after office hours and on Sundays and holidays," since routine official duties had "occupied his entire government time." The Department of Histology, except for the loss of personnel, had "main- tained its former status," largely because of the publications and contacts of Mrs. Helenor Wilder and the training which she had given the other members of this unit. Comparing the period of 1924-26 with 1932-34, and taking the average number of accessions as a fair index of the volume of work accomplished, the special report found that the average had been 2,666 per year in the later period as against 1,990 per year for the earlier. The difference was widened by the fact that approximately 1,200 per year of the earlier accessions were not new cases but simply re-accessions from the old museum, requiring only the paperwork of entering them in the modern system of classification, while in the later period, lack of personnel had precluded the work of re-accessioning, so that the accession figures represented new cases, the majority of which were specimens sent in for diagnosis. The actual work in the 1930's was nearly double that in the period in the 1920's, while the personnel had been reduced from 31 to 21 in all categories. Major Dart continued: This is an insufficient number to carry on more than the routine and consequently the work on large projects essential to the orderly classification of the museum which have been started in previous years from time to time have been stopped and a large part of the vast museum collection still remains in a hopeless muddle. The very building has degen- erated into a shambles of cobwebs and dirt, filled with antique furniture and the debris of worn out equipment and broken exhibits. Working Under Handicaps The state of affairs in the Museum proper, characterized as a "breakdown," imposed such a handicap upon the work of the Curator and his professional assistants that they were able to accomplish the routine padiology only with difficulty and had "little time" for the "scientific research with which the officers on duty at the museum are charged by regulation." Major Dart's views on the state of the Museum were shared in large degree by his successor, Capt. Hugh Richmond Gilmore, Jr. (fig. 74) » who served as Acting Curator for a few months in 1935 and 1936. In a memorandum of 5 August 1936, for The Surgeon General, Captain Gilmore made the point that between 1926 and 1936 the volume of work in the institution had increased ARMED FORCES INSTITUTE OF PATHOLOGY Figure 74. — Capt. Hugh R. Gilmore, Jr., nineteenth Curator of the Museum, I 935" I 937- 50 percent while the size of the civilian staff had decreased by almost the same percentage. "Due to this decrease in civilian personnel the Museum exhibits have not been kept up to date," he wrote. "Instead of being a leader in its field the Army BETWEEN THE WARS 233 Medical Museum is rapidly becoming nothing but a storehouse of poorly ar- ranged and poorly exhibited pathological specimens * * *. Also the Museum's files and records are six months from being up to date." The situation of Mr. Reeve, chief photographer and the only civilian em- ployee in the department, was singled out. "If anything should happen to him," the memorandum read, "the department would collapse." ' More restrained in their language, but much the same in import, were the Annual Reports of The Surgeon General of the Army for this period in the life of the Museum. "The continued increase in routine pathological and administrative details has again prevented renovation of the museum exhibits which has been needed badly for a number of years," said Surgeon General Robert Urie Patterson in his annual report for 1934. "The changes made in the main museum in 1933 have but accentuated the need for further work of this type * *. An attempt to reduce and prevent overcrowding is continually being made but the present quarters necessitate removal of some portion of present exhibits when anything new is added." Personnel was not adequate, The Surgeon General said, to permit the making of the studies which should be made. In 1935, when the Museum was visited by 81,423 persons, the largest number which had done so in any year up to that time, Surgeon General Charles R. Reynolds spoke again of the great need for revision of the general museum, but said that because of insufficient personnel it could not be done.' The subject was discussed more at length in General Reynolds' report for 1936. "The routine pathology," he said, "is more than sufficient to fully occupy all of the [time of the] officers regularly assigned to duty. However, in addi- tion to the purely professional work, a large amount of time is required for the administration of the museum, the proper conduct of the registries and in teaching the course in pathology at the Army Medical School. All of the officers are required to spend additional hours of duty in the institution and to take part of the routine work to their homes to be done during the evenings and on Saturday afternoons and Sundays. As a consequence, very little time can be spent in the proper care and display of the permanent Museum exhibit." Revision of the "entire exhibit on a modern basis" was "sorely needed," The Surgeon General said, but shortage of trained technical personnel precluded such a possibility. •Memorandum, Capt. H. R. Gilmore, for The Surgeon General, 5 August 1936. On file in his torical records of AFIP. "Annual Report of the Surgeon General, U.S. Army, 1934. PP- '54. «57- 7 Annual Report of the Surgeon General, U.S. Army, 1935. P- '49- 2 , 4 ARMED FORCES INSTITUTE OF PATHOLOGY The entire permanent exhibit, he said, "must be reviewed, relabeled, and modernized as soon as funds and personnel are available * *. This Museum must be rearranged so as to tell the story of disease as well as to display its morbid processes. By so doing it would then become one of the greatest teaching institutions in its field." s The picture of the Museum, however, was not all dark. The photographic department, which had been "functioning under the handicap of worn-out equipment, leaky plumbing, and ineffective lighting" had been aided by the installation of new sinks and the rearrangement of its layout. The Edgar Bequest New cases for better display of the Museum's great collection of microscopes were procured, thanks to the William F. Edgar Bequest, a fund left to The Surgeon General of the Army, to be expended for the benefit of the Medical Museum and The Surgeon General's Library. The donor of the fund was Dr. William F. Edgar who, in 1849, traveled overland by covered wagon from the Missouri River to Oregon, and thence to California. There, in Los Angeles, he prospered and accumulated a substantial estate. In a will drawn in July 1893, ne made the Museum and the Library co-sharers in the residue of his estate, after the payment of numerous bequests to individuals and to charitable, educational, and civic organizations. In 1894, by a codicil to his will, he had changed the division of his bequest to The Surgeon General by providing that the Museum should be the beneficiary of four-fifths and the Library of one-fifth of the fund bequeathed. Dr. Edgar died in 1897, but his estate could not be settled until after the termination of a life estate left to his widow. In 1931, the trustees of the estate sought to make final settlement with the Army, but this could not be done until after the Congress passed a joint resolution author- izing acceptance of the bequest. This was not done until 1933, at which time the bequest amounted to $18,309, and the four-fifths going to the Museum, to $14,647. This amount was to be spent for equipment, supplies, and services outlined in War Department General Orders No. 5, dated 8 May 1933, and was to be "available until expended." The largest items of expenditure, by far, were for new display cases, but the Edgar funds made it possible to meet such peripheral expenses of the Museum-Institute as paying the inheritance tax of the State of Pennsylvania on the portrait of Dr. John H. Brinton, the first Curator, which was given to the Museum by Dr. Ward Brinton, his son. Annual Report of the Surgeon General, U.S. Army, 1936, pp. 145, 147. BETWEEN THE WARS 235 The fund dwindled over the years, as was inevitable, but it lasted for a quarter of a century before its final extinction in 1958, after the last $42.51 had been spent in December 1957." Lt. Col. James E. Ash returned to the Museum in 1937 for a second tour of duty as Curator — a post which he was to hold for 10 fruitful years. In the first of these years, the Museum attracted more than 97,000 visitors, making it, according to Surgeon General Reynolds' report for 1937, "one of the show places of the Nation's capital" — to which he added the wry comment that it was "about the shabbiest." The largest medical museum in the world "from the standpoint of amount of material," the report said, "suffers considerably by comparison with other museums in Washington, with their fine buildings and modern equipment." l0 The status of the Museum as the Army's "clearing house for pathology" and the "large number of cases sent into the various registries * * # ," said the report, "require the constant application and considerable overtime effort of the limited personnel to keep it moving at a reasonable pace. There is no time for the study and investigation that this material warrants, and the Museum itself can be given only perfunctory supervision." Many exhibits needed revamping and a large percentage of the labels, some of them actually illegible, needed replacing, but "with the present personnel it is possible to make scarcely any appreciable progress in this rejuvenation." Gaining Ground Nevertheless, progress was made. The collection of microscopes, ophthal- moscopes, hard-of-hearing aids, and stethoscopes — each collection as compre- hensive as any to be found in the world — were exhibited to "much better advantage than they have been heretofore," n using the new exhibit cases pur- chased out of the Edgar Bequest. During 1938, the main museum room was improved, the work being done by the staff using materials purchased from the limited funds available. To relieve some of the overcrowding, several of the old wooden exhibit cases were retired and the number of exhibits was "Just what led Edgar to make the Army Medical Museum the principal beneficiary of his will does not appear in the will and codicil thereto. Among his other bequests, however, there was one for ihe sons of Surgeon General Robert Murray, which might indicate an interest on the part of Dr. Edgar in The Surgeon General's office. Material on the Edgar Bequest is in the AFIP historical files, which contain legislative and court proceedings, accounting records, and correspondence between The Surgeon General and the trustees under the Edgar will. Uses made of the bequest are mentioned in the Annual Reports 'it the Surgeon General, U.S. Army, for 1936, pp. 145, 146, and for 1937, P- >7°- "Annual Report of the Surgeon General, U.S. Army, 193", PP- I7I-J7 2 - 11 Ibid., p. 170. 713-028'- — 64 17 6 ARMED FORCES INSTITUTE OF PATHOLOGY reduced, it having been found that the display had a "greater appeal to the laity if it is not confusingly overcrowded." The great bulk of the collections were relegated to storage, but in such form that the material was always avail- able for study. The Museum had taken its place "as one of the more popular sights in Washington," having had, for the first time, more than 100,000 visitors in a year. 12 Substantial evidences of ground gained were found in the number and distinction of the medical collections given to the Museum in the years of its resurgence (fig. 75). Important contributions during 1938 included a col- lection of models, pictures, and actual specimens covering comprehensively the history of appliances used in maxillofacial surgery, assembled by Dr. George Morris Dorrance of Philadelphia, and described as "an unique collection of great historic value"; a collection of historic and modern bronchoscopes and esophagoscopes devised by Dr. Chevalier Jackson of Philadelphia and his son, and of hundreds of foreign bodies removed by their use; a collection of models and drawings developed in the postgraduate course in otolaryngology at the Harvard Medical School under the supervision of Dr. Harris Peyton Mosher, together with material representing Dr. Mosher's original research in diseases of the esophagus; and several types of artificial larynxes, with which persons who have lost their larynx can talk, presented by Dr. LeRoy Allan Schall of Boston. The most notable gift of this period was the world-famous Huntington collection of anatomical material, perhaps the largest collection in the world in its field. The collection had been gathered by Dr. George Sumner Huntington of the College of Physicians and Surgeons of Columbia University, the first full-time professor of anatomy in this country, in the years between 1889 and his death in 1925. It includes some 5,000 specimens, illustrating the form, de- velopment, and evolution of most parts of the body in many species, including man. These specimens, presented to the Museum for display and study, were an important educational resource of the Museum, particularly in the field of comparative anatomy." Prospects for a New Home Still more encouraging for the days ahead was the passage by Congress of a bill authorizing the Secretary of War to construct a new building to "replace "Annual Report of the Surgeon General, U.S. Army, 1938, pp. 179, 181. 1:1 Memorandum. I.t. Col. J. E. Ash, for Colonel Harden, Surgeon General's Office. 5 January 1939, Copy on file in historical records of AFIP. BETWEEN THE WARS ^il Figure 75 .-Maj. Harry A. Davis, after 28 years of military service, served the Museum for 21 years, first as entomologist and later in historical work in the course of which he gave special attention to the Museum's collections of medical instruments. 2 ,g ARMED FORCES INSTITUTE OF PATHOLOGY the present Army Medical Library and Museum Building." The new building was to be put up in the District of Columbia, on a site to be chosen after consulta- tion with the National Capital Park and Planning Commission, and subject to approval by the National Park Service. The total cost of the new building was not to exceed $3,750,000, but the bill carried no appropriation for this or any other amount." The dream of a new building had persisted ever since Col. William O. Owen's time as Curator, and even before. In earlier days, the dream was for a building on the Washington Mall; in more recent times, as the great Army Medical Center developed around the Walter Reed General Hospital, the favored site had come to be one in the vicinity where, indeed, additional lands had been purchased for the purpose of housing the Museum and Library. This point of view was vigorously and thoughtfully presented by Dr. Howard T. Karsner in letters to congressional and executive department leaders. Writing in his capacity as secretary of the American Association of Pathologists and Bacteriologists, and as chairman of the National Research Council's com- mittee on the American Registry of Pathology, Dr. Karsner declared that even in their present state the Museum and Library "have proved of the greatest value to the medical profession of the United States" as "living, active, useful collections rather than mere repositories. Numerous medical research projects would have been sadly handicapped had it not been for the library and museum. The same would be true of the future if the work of these institutions were in any way limited." As to cost, Dr. Karsner said that "These great institutions" were operated at a "relatively much smaller cost than could be expected in any other circum- stances." His familiarity with the Library and the Museum and his extensive experience in university work convinced him that no possible combination with other national libraries and museums, unless they were of identical objectives, would result in any further economy, while it was his opinion that any such combination would lead to "deterioration of the collections and of their usefulness." The doctor strongly favored the Walter Reed site, feeling that it would form a highly desirable adjunct to the work of the hospital and would aid and improve the teaching in the Army Medical School and associated schools already located in the Walter Reed area. " H.R. 10455, approved 15 June 1938, Public Law Number 611, chapter 384, U.S. Statutes at Large, 75th Congress, 3d session, 1938, volume 52, p. 684. BETWEEN THE WARS 239 In concluding, Dr. Karsner wrote, "No words can overemphasize the importance to the Nation of the preservation of the integrity of these two institutions as part of the Army organization and of their proper and adequate housing at the Army Medical Center." 15 A New Building — Where and When? In the work of securing favorable action by Congress on the bill author- izing the new building, the medical profession of the country was foremost. Dr. Karsner's letter was typical of the more than one hundred letters, from distinguished doctors, which were submitted to the committees of the House and the Senate when, in 1938, those bodies had hearings on the identical bills introduced by the chairmen of the Committees on Military Affairs of the Senate and House. In addition to these individual recommendations, the American Medical Association "officially endorsed the movement by authority of the House of Delegates," a circumstance which recalled to the editor of the Journal of the American Medical Association the fact that the Association had "played a great part in obtaining the legislation for the old building" which had housed the Museum and the Library for 55 years and had "contributed with equal force in obtaining the new," — thereby treating the prospective new building as if it were an accomplished fact and not a project which was to take another 15 years of struggle and delay so far as the Museum was concerned, and an even longer time for the achievement of the new Library. On 18 June 1938, in an editorial published only 3 days after the Presidential approval of the authorization bill, the J.A.M.A. exulted that "at last the world's mightiest collection of medical literature and one of the largest of medical museums will be given adequate quarters. The medical profession," the edi- torial went on to say, "may congratulate itself on the enactment of the bill to authorize the new building." "But," the editor added, "this is not enough. Under our legislative proce- dure the appropriation called for by the authorization bills must be obtained. The Committee on Appropriations of the Senate and House of Representatives will shortly consider this. If we want the new building built now — and the need is nothing less than urgent — we must let our representatives in both houses of Congress know of our desire. The foundation for the building is already 15 Letters, Dr. Howard T. Karsner. various dates in August igj?. Copies on file in historical records of AFIP. ARMED FORCES INSTITUTE OF PATHOLOGY laid; not the foundation of stones and mortar but that of Congressional approval." 10 Efforts to build upon this foundation of congressional approval were promptly forthcoming, when President Franklin D. Roosevelt included in his budget for the fiscal year ending 30 June 1941, submitted on 4 January 1940, an item of $600,000 for preliminary expenses in connection with the new building. Support for the adoption of this item in the appropriation bill included an article by Joseph M. Lalley, in the Washington Post of 11 February 1940, entitled "Neglected Treasures," which thus described "the plight of the Army Medical Library and Museum": * * * Two years ago Congress authorized the expenditure of $3,750,000 for the construction of a new building for the Army Medical Library and Museum. This benig- nant gesture was merely an imprimatur. The Secretary of War is now free, within the limits of that sum, to have a new edifice built for the library and museum whenever and if ever he gets the money. He has not got it yet. The new War Department budget, how- ever, does contain, among the Surgeon General's estimates, a special item of $600,000 for the acquisition of a site. But with Congress in its present temper, and with the estimates for national defense tremendously swollen, the fate of this item appears precarious. All the same, it is unlikely that many high officers outside the Medical Corps, give any great attention to the concerns and difficulties of the library and museum. None of them, of course, would dream of parting with it. But when, in the course of the hagglings with the Congressional committee, it may mean the difference between a few extra tanks or bombing planes there may be a temptation to let the library wait another year for a new home. But it has already waited too many years, and can wait no longer. Adoption of the budget item in the War Department appropriation bill was urged by the Washington Post in an editorial of 10 February 1940, entitled "Priceless and Unique." The estimate of $600,000 for the purchase of a site and the preparation of plans for "a new building which will more adequately house the Army Medical Library and Museum" was termed "modest" in amount and pressing in importance. "Whatever the needs of other forms of national defense, there is no part of the current Army estimate more worthy of public support than this relatively tiny item," the editorial said. "Nearly two years ago Congress authorized a new building to replace the present antiquated Army Medical Museum, erected in 1887. Economy of a glaringly penny-wise pound-foolish variety has hereto- fore blocked action under this authorization. In view of the long delays and "Editorial entitled, "Army Medical Museum and Library." Journal of the American Medical Associa- tion 110: :<' 1 t8 June 1938. BETWEEN THE WARS 24I the urgent need in providing this new building, the least that can be done at this session is to make a start in a matter so patently overdue." ' Between the time of submission of the estimate and action upon it, the war in Europe passed from a period of comparative inactivity to the furious "blitzkrieg," with the German invasion of Denmark and Norway in April 1940, the invasion of the Low Countries in May, the disaster at Dunkirk in the last week of that month, all culminating in the fall of France in mid-June. Against this background of rapidly moving events and precipitately deteri- orating situations, the proposed appropriation was considered in the Congress. Action Delayed On 3 April 1940, the Appropriations Committee of the House of Repre- sentatives recommended the adoption of $130,000 of the budget item, being that portion of the expenditure proposed for the drawing of plans and pre- paring of specifications, and recommended against the $470,000 included for the purchase of a site for the new building. In the 1938 authorization, Congress had assumed that the new building was to be erected on Government-owned land, presumably adjacent to the Walter Reed Army Medical Center. When it became generally known that the site of the new building was to be in that region, then somewhat remote, "great opposition developed from the rank and file of the civilian medical profession of the country" and this influence, among others, led to "the aban- donment of the plan to move * * * to the Army Medical Center and a return to the idea of constructing it near its present location." The National Capital Park and Planning Commission had to be consulted under the terms of the act of authorization; it had other plans, however, and recommended a location east of the Library of Congress, and Surgeon General James C. Magee acquiesced in that decision. 18 The Appropriations Committee, however, felt that the whole question of a site was out of order, since the preceding Congress, in passing the authoriza- tion act, had not contemplated purchase of a site but had assumed that the building was to be put on Government-owned land. The House accepted the Committee's interpretation of the situation but the Senate, when the bill 17 The article and editorial are quoted in: Congressional Record, Appendix, 76th Congress, jd session, volume 86, part 14, pp. 1336, 1337. "Memorandum of Maj. Gen. James C. Magee. The Surgeon General, U.S. Army, 27 April 19 I file in Record Group 112. Surgeon General's Office file number 631.1 (Arm) Medical Museum and Library), from the records of the National Archives. incidi ARMED FORCES INSTITUTE OF PATHOLOGY 242 came before that body, restored the full $600,000 item by amendment 78. The matter came before the House again on 10 June, when Representative Ross Collins of Mississippi urged acceptance of the Senate amendment, while Rep- resentative John Taber of New York opposed its adoption, taking the stand that there were more pressing military needs. The House supported Mr. Taber's view and "disagreed to the amendment of the Senate numbered 78." n The bill, with its appropriation of $130,000 for getting on with the pre- liminaries of construction, passed and was approved on 13 June 1940— by co- knce, the day before the German armies entered Paris. 20 Acting under the authority granted, the Secretary of War and The Sur- geon General selected as architects for the building the New York firm of Eggers and Higgins, whose works included the National Gallery of Art, then nearing completion. Preliminary plans, submitted in February 1941, were gone over by a consulting board consisting of the incumbent Librarian, Col. Harold W. Jones, the incumbent Curator, Lieutenant Colonel Ash, a former Librarian, Col. James M. Phalen, a former Curator, Col. George R. Callender, and Lt. Col. John R. Hall of the Surgeon General's Office. Early difficulties as to the division of space between library and museum activities were ironed out and, at a meeting of the consulting board on 11 August 1941, the plans in general were approved. 21 As plans were developed and costs were rising, it became obvious that the amount authorized in the 1938 legislation was inadequate. Consequently, H.R. 5146 to authorize the purchase of a site and to increase the total authorized expenditure from $3,750,000 to $4,750,000 was introduced in and passed the House, and was amended by and passed the Senate. On 15 September 1941, the amended bill was brought up for action in the House, under the sponsor- ship of the chairman of the Military Affairs Committee, Andrew J. May of Kentucky. Representative Robert F. Rich of Pennsylvania asked whether it was "absolutely necessary" to erect the building "now, when materials cost so 19 Congressional Record, 76th Congress, 3d session, volume 86, part 7, pp. 789s if. " U.S. Statutes at Large, 76th Congress, 2d and 3d sessions, volume 54, part I, chapter 343, p. 363, 13 June 1940. "(1) Letters, Robert P. Patterson, The Assistant Secretary of War, to Mai. Gen. James C. Magee, 2 December 1940; Colonel Birdscye, for The Quartermaster General, to Messrs. Eggers and Higgins, 12 December 1040; Daniel Paul Higgins to Colonel Birdseye, 16 December 1940: and drafts of letters to Eggers and Higgins, approved by The Surgeon General, 3 January 1941. All on file in Record Group 112. Surgeon General's Office file number 631. 1 (Army Medical Museum and Library), from the records of tin National Archives. (2) Letters, Lt. Col. J. E. Ash to Col. H. W. Jones, 10 February 1941 and Lt. Col. I. V.. Ash to Mai. J- C. Magee, 13 May 1941; Office Order 119, Surgeon General's Office, 21 Ma} 1941: Report of Meeting of the Consulting Board, 11 August 1941. All on file in historical records ol \I IP. BETWEEN THE WARS 2 43 Figure 76. — Architects' drawing of a new home for the Library and Museum, author- ized by Congress in September 1941, just before Pearl Harbor, an event which brought an end to the plan. much and labor is so scarce," suggesting that construction "ought to be post- poned until some more appropriate time" after the national defense program then underway was ended. Mr. May urged the necessity of the new building but in effect accepted the position taken by Mr. Rich, pointing out that the bill was merely an authoriza- tion, without an appropriation, and expressing the belief that nothing further, other than the preparation of plans then underway, was to be done about the matter "until after the emergency is over." Unanimous consent was accordingly given to consideration of the bill, which was passed and, on 24 September 1941, was signed by the President (fig. 76). " Representative May's estimate of the lack of effect of passage of the increased authorization upon actual construction proved to be well founded. Work on plans continued until in December, when the events at Pearl Harbor transformed the "emergency" into active participation in full-scale, all-out, unlimited war— a state of affairs in which, by tacit consent, the Nation's medical treasures of the Library and Museum would continue to be housed in a "rather decrepit old red brick building" to whose "dingy halls * * * the world's foremost medical scholars" would continue to come — as they had been coming for more than half a century."' 1 " Congressional Record. 77th Congress, 1st session, volume 87, part 7, pp. 7122. 7-'4. 7 -17**. 74 1 5' 757 1 - ( 2 ) Public Law Number 256, chapter 418. a (l) Editorial: American Journal of Public Health and the Nation's Health 26: 930- 932, September 1936. (2) Editorial: British Medical Journal, 26 October 1935. (3) Editorial: The Military Surgeon. volume 78, April 1936. 713 028' 64 IS CHAPTER XIII Pathology Worldwide Decrepit the old building may have been, and dingy, too, but it was in its crowded and cramped quarters that Col. James E. Ash and the Museum staff somehow managed to carry the heavy wartime routine of pathology services for an Army which was expanding explosively, not only in numerical strength but also in geographic dispersion throughout the world, and at the same time to turn out a program of productive research which, in view of the conditions, was nothing short of prodigious. The rapid expansion of the Army dates from 16 May 1940, when President Franklin D. Roosevelt, addressing the Congress on the fast-deteriorating military situation in Europe, recommended the appropriation of an extra billion dollars for purposes of defense. The strength of the Army was then under 270,000. By the time of the attack on Pearl Harbor, it had grown to 1,680,000, a sixfold growth which continued until, at the end of hostilities in August 1945, it num- bered more than eight million men and women. 1 Such an increase in the military population, which was the primary con- stituency served by the Museum, was enough in and of itself to have called for an increase in the Museum's peacetime staff. To this multiplication of the numbers to be served, however, there was added another factor in the buildup of the pathological workload— a change in the applicable Army regulations. Since 1922, these had been set forth in the War Department's AR 40-410, which "solicited" the sending in of pathological materials and "requested" Medical Department personnel to "make special efforts to procure and forward the desired specimens." In August 1942, AR 40-410 was superseded by another bearing the same number which was shorter, broader, and sharper than the original 1922 regulation. The 1942 regulation did not "solicit" support or "request" Medical Department cooperation. Instead, it spoke in the imperative, 'Figures for lunc 11)40. December 1941. and August 1945. on file in the Adjutant General's Offic Department of the Army. 246 ARMED FORCES INSTITUTE OF PATHOLOGY saying rather that autopsy, biopsy, and specified surgical materials "will be for- warded" as directed. 2 The combined effect of a rapidly increasing Army and more positive direc- tions for the submittal of pathological specimens was to increase the workload of the Museum to 3,500 or 4,000 "cases" per month— as many as had been handled in a full 12 months before the expansion began. By 1943, autopsy materials and records were flowing into the Museum at the rate of 15 per day, a figure which increased before the end of the war to the point where "we were receiving at the Institute an average of over 50 autopsies a day and as many significant surgical » 3 specimens. In 1945, the year in which hostilities ended, records and tissues from nearly 19,000 autopsies were received at the Museum, along with more than 20,000 surgical specimens. 4 Colonel Ash spoke truly when he said, "the trickle of materials of a decade ago has swollen into a torrent." Regional Centers for Histopathology The "torrent" might have overwhelmed the Museum staff if, during the period of preparedness before the United States became an active belligerent, there had not been thought out a planned decentralization of the pathological facilities and activities of the Army. On 11 December 1941 — 4 days after Pearl Harbor — the new system was put into effect by The Surgeon General's Circular Letter No. 121, subsequently mollified in Circular Letter No. 141, of 29 July 1943, and repeated in the War Department's Technical Bulletin 99, issued 11 March 1944. The new system deployed the limited number of trained pathologists at the points where they would be able to serve most effectively. It was recognized that there simply were not enough pathologists to go around among all the medical installations, but there were enough to staff regional centers for his- - ( 1 ) Army Regulations No. 40-410, paragraphs 6, 8, and 9, 18 January 1922. (2) Army Regulations No. 40-410, paragraphs 3-7, 3 August 1942. 3 (i) Ash, James E.: The Army Medical Museum in This War. An address before the Section on Pathology, Southern Medical Association, 37th Annual Meeting, Cincinnati, Ohio, 16-18 November 1943. Published in Southern Medical Journal 37: 261-266, May 1944. (2) Ash, J. E.: Tumor Registries of the American Urological Association. An address before the Association, Cincinnati, Ohio, 25 July 1946. Copy on tile in historical records of the AFIP. (Hereinafter cited as American Urological Association Address.) 4 l.uckc, Balduin: The Army Institute of Pathology During World War II. The Military Surgeon 99: 365, November 1946. 'Ash. J. 1 ■..: The Army Institute of Pathology. (Tenth Annual Harrison S. Martland lecture delivered before the Essex County Anatomical and Pathological Society, Newark, N.J.) Abstract published in Bulletin of the U.S. Army Medical Department 4:718, December 1945. PATHOLOGY WORLDWIDE 247 topathology. These centers — there were 18 of them altogether, with one or more in each of the nine Service Commands into which the United States was then subdivided — were set up mostly in the laboratories of named general hospitals." To these centers, nearby posts and installations sent materials on which diagnostic assistance was required. After screening out those cases on which diere were no serious diagnostic doubts or difficulties, the regional centers for- warded to the Medical Museum "such surgical cases as have a possible future administrative or 'follow-up' value, particularly tumors and those cases requiring final or confirmatory diagnosis." Also forwarded to the Museum were all autopsy materials, including the protocols or records, as well as the tissues involved. 7 As American Forces spread to theaters of active operations, the system of channeling pathological materials and information spread with them, with the chief surgeon of each oversea theater designating a medical general labora- tory, usually at the principal general hospital in the area, to serve as its histo- pathologic center. These centers were called upon to gather and forward the same classes of materials as the regional centers at home, and in addition were asked to send in materials and information about the disease encountered among the peoples of foreign lands, "inasmuch as 'geographic pathology' has become of great importance to the armed forces." The materials sought in this connection included not only tissues from surgery and autopsies but also "insect species that act as disease vectors or are suspected of doing so, poisonous plants, poisonous snakes, and other material of medico-military interest" — a term which covered the vast variety of conditions to be encountered by an Army whose troops were serving in every sort of terrain and climate, all over the world. At the center of this worldwide network of channels, through which pathological materials and records flowed in and diagnostic information flowed out, was the Museum (fig. 77). "The U.S. Army is the only armed force in the world that had this centralization of pathology," said Colonel Ash, "and it has resulted in the largest single accumulation of material in the history of "Histopathologic centers were established at: Lovell General Hospital, Fort Devcns, Mass.: the Second Service Command Laboratory, Federal Office Building, New York City; Valley Forge General Hospital, Phocnixville, Pa.; Lawson General Hospital, Atlanta, Ga.; Stark General Hospital, Charleston, S.C.: Station Hospital, Fort Bragg, N.C.: Thayer General Hospital, Nashville, Tenn.: Hillings General Hospital, Fort Benjamin Harrison, Ind.; the Sixth Service Command Laboratory, Fort Sheridan, 111.; O'Reilly General Hospital, Springfield, Mo.; Fitzsimons General Hospital, Denver, Colo.: Brooke General Hospital. Fort Sam Houston, Tex.; William Beaumont General Hospital, El Paso, Tex.: Army and Navy General Hospital, Hot Springs, Ark.; LaGarde General Hospital, New Orleans, La.; Hoff General Hospital. Santa Barbara, Calif.; Letterman General Hospital, San Francisco, Calif.; and Barnes General Hospital, Vancouver, Wash. 7 Circular Letter No. 141, Surgeon General's Office, 20 July 1043. 2 4 8 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 77. — Schematic representation of the flow of pathological materials during World War II. A. Continental network, to and through Histopathologic Centers on the way to the Institute. B. Worldwide flow to and from the Medical Museum. medicine. It is particularly valuable because it has given us the opportunity to study not only the pathology incident to warfare but also that arising from the varied environments to which our soldiers were subjected — from the Arctic to the tropics." 8 " American Urological Association Address. PATHOLOGY WORLDWIDE 249 The basic idea, Colonel Ash said, was "to concentrate all the significant data and material pertaining to pathologic processes occurring in the Army at the Medical Museum, where it will be available for current professional use and future scientific investigations, for teaching, and for historical purposes." Still another value of this centralization of records and materials grows out of the exceptional mobility of military life. Frequently, it is necessary or desir- able to transfer military patients from one hospital to another— as for example, from a post hospital to a more commodious and better-equipped general hospital, or perhaps to a hospital with unusual facilities for the treatment of a particular disease. In any such case, the Museum would have the tissues, the diagnosis, and other pertinent facts, and could furnish from its files "a life history of such a patient's condition, a record of his treatment, and of the outcome of the disease," all readily and quickly available in a single file. 9 Increase in Personnel The tremendously increased workload at the Museum made necessary sub- stantial increases in the staff. From the prewar number of three, the number of professional pathologists at the Museum went up to more than 20. Twelve of them remained at the Museum for more than 2 years; eight for more than 3 years. The average number employed at any one time was 14. In addition to the staff of professional pathologists, the work of the several departments of the Museum required the services of some 30 enlisted men and Wacs, and about 60 civilians. 1 " Reinforcing this full-time staff was a succession of distinguished resident consultants who were invited by the Curator to participate in the work of the Museum for brief periods. Seventeen such consultants were at the Museum, first and last, staying for periods of from 2 weeks to 3 months, in which they acted as advisers in the workup of pathological materials and participated in the researches which were going forward. 11 Overwhelmingly, the greater part of the activities of the organization, still entitled the Army Medical Museum, had come to center in the pathology service. For example, in a list issued at the beginning of 1944, 37 out of 47 projects cur- rently underway were in the field of pathology, while 11 of the 17 projects shown 9 Ash, Southern Medical fournal, 37 (19.14), pp. 261-266. 10 (1) Lucke, The Military Surgeon, 99 (1946), p. 367. (2) Brochure, Army Institute of Path- Army Medical Museum, prepared by Technical Information Division, Surgeon General's Office, first printing 1 July i.j_|=5 : reprinted December 11)45 and 1 July 1946, p. 1. (Hereinafter cited as Brochure, AIP-AMM.) 11 (1) Correspondence, Colonel Ash to Surgeon General's Office, 21 August ic»4i and Surgeon General I Office to Colonel Ash. 25 August 1943. (2) Lucke, The Military Surgeon, 99 (1946). p. $67. ARMED FORCES INSTITUTE OF PATHOLOGY as having been recently completed dealt with pathology. 1 " As Colonel Ash said, the organization "suffered under the connotation museum, an institution still thought of by many as a repository for bottled monsters and medical curiosities. To be sure, we have such specimens. As is required by law, we maintain an exhibit open to the public but in war time, at least, the museum per se is the least of our functions, and we like to be thought of as the Army Institute of Pathology, a designation recently authorized by the Surgeon General." 18 A New Name for a New Organization This authorization, made informally in the closing weeks of 1943, is re- flected in the printed heading of Office Order No. 18 of the Curator, dated 1 January 1944, which outlines the functions of the organization and assigns responsibilities for the various segments of activities. On this heading, the new name of "Army Institute of Pathology" appears as a subordinate division of the Army Medical Museum— a relationship which was to be reversed 2 years later when the "Army Institute of Pathology" was to become officially and formally the general designation of the entire operation, with the Army Medical Museum as a subordinate division. Under the new dispensation, the head of the whole organization was known as the Director instead of the Curator. The organization outlined in Office Order No. 18 of the Army Medical Museum consisted of four divisions or "services"— Administrative, Professional, Photographic and Medical Arts, and Museum and Medical Arts. The Museum proper was relegated to the status of a subdivision of the Photographic and Medical Arts Service, headed by Capt. Frank H. Netter. Besides the Museum, this service included all forms of medical art, including photography other than clinical and motion pictures. The latter types of photography were assigned to the Museum and Medical Arts Service, headed by Capt. Ralph H. Creer. Organization and training of units to be sent over- seas were assigned to the Museum and Medical Arts Service — to be known for short as the "MAMA's" (fig. 78). Lt. Col. Balduin Lucke, in civil life a distinguished Philadelphia pathologist and professor of pathology at the University of Pennsylvania, was named in the office order as Deputy Curator and also as the officer heading up the Pro- fessional Service, which was primarily the pathological division of the Museum- '- Memorandum to Officers, Army Medical Museum, Army Institute of Pathology, anil Photographic anil Medical Arts Service, t, January 1944. On file in historical records of AF1P. " Ash, Southern Medical Journal, 37 (19-14), PP- 261-266. PATHOLOGY WORLDWIDE 2 5 I Figure 78. — A unit of the Museum and Medical Arts Department of the Museum, in World War II, is photographed while photographing a diseased native of a tropical isle. Institute. The division was responsible for reviewing and reporting on speci- mens sent in currently, and also for research and education in the field of pathology. Scientific Investigations Studies in progress and those recently completed, listed in a memorandum to officers issued by the Army Institute of Pathology and the Photographic and Medical Arts Service on 3 January 1944, indicate the wide range of the research and educational activities of the staff of what was still known officially as the Army Medical Museum. By the end of the war, the results of 62 of these investigations had been published — two of them in the new medical books, six in revisions and reissues of the Museum's atlases of the pathology of particular organs, and the others in articles in the scientific medical press. Fifteen of these published articles appeared in the American Journal of Pathology; 11 in The Military Surgeon; 4 each in the Archives of Pathology and the American Journal of Orthodontics and Oral Surgery; and the remaining 20 in 15 other medical journals. In ARMED FORCES INSTITUTE OF PATHOLOGY 252 addition to the articles which had been published by 1 July 1946, 14 others had been completed and were ready for publication, and 28 more were in progress. 1 * These scientific investigations were not "mere academic research projects," Dr. Howard T. Karsner wrote in 1944, but were in large part such studies as had "immediate application." " As an example of immediacy of application, Dr. Karsner cited the part played by the Medical Museum in scotching the subterranean rumor that the outbreak of hepatitis in the Army in the spring and early summer of 1942 was actually yellow fever following vaccination against that disease. Color of support for the rumor was found in the undenied fact that troops were being given "shots" for yellow fever, and the further fact that the most obvious and visible symptom of both yellow fever and hepatitis was the jaundiced hue cast by both over the sufferers. The diseases, however, were very different in their effects. Hepatitis, while it is exceedingly debilitating and distressing to its victims, is not a disease of high mortality, the death rate being less than three-tenths of 1 percent of hospitalized cases. In disablement and deadliness, hepatitis was not to be com- pared with yellow fever, but there was enough plausibility in the rumor that "yellow jack" had returned to the Army through the hypodermic syringe of the surgeon to make it damaging to morale. Fortunately, before the alarmist rumor was well spread, the Medical Mu- seum had completed its special study of three early fatal cases of hepatitis- one each from Fort Belvoir, Va.; Camp Callan, Calif.; and Walter Reed Gen- eral Hospital— and had circulated its findings to the laboratory chiefs of Army hospitals for the information of "officers who may not have had an opportunity to study at first hand the pathology of fatal hepatitis." The findings were accompanied by clinical notes and microscope slides. 10 "Because of the current interest in yellow fever," there went with the reports like information about an authentic case of yellow fever which had caused the death of a young man in Brazil in 1937. As Colonel Lucke (fig. 79), who had prepared the notes and materials on both diseases, pointed out, the differences between them, when seen under the pathologist's microscope, are so obvious that "it will be seen at once" that they are not the same. The putative epidemic of yellow fever was demonstrated to be hepatitis — a demonstration which was clinched by continued study, the results of which are embodied in " Brochure, AIP-AMM, i July 1946. ,= Karsner, Howard T.: Army Medical Museum; Army Institute o£ Pathology. Journal of the American Medical Association 124: 711, 11 March 1944. '" Memorandum. Col. J. E. Ash, to Chief of Laboratory Services, 22 July 1942. Copy on file in historical records of AFIP. PATHOLOGY WORLDWIDE 2 53 Figure 79.— Maj. Gen. Norman T. Kirk, The Surgeon General of the Army, presents to Col. Balduin Lucke the Legion of Merit for distinguished service to the Museum-Institute, as Mrs. Lucke looks on. Colonel Lucke's articles on "The Pathology of Fatal Epidemic Hepatitis," based on 125 fatal cases, and on "The Structure of the Liver After Recovery from Epidemic Hepatitis," based upon post mortem examinations of 14 patients who had recovered from the disease but had thereafter succumbed to some other disease or accident. 1. Yellow fever was but one of the tropical diseases which gave concern to the U.S. Army in the war. Indeed, as Colonel Ash wrote, tropical medicine IT (1) Lucke, B.: Pathology of Fatal Epidemic Hepatitis. American Journal of Pathology 20: 47i"593. May 1944. (2) Lucke, B.: The Structure of the Liver After Recovery From Epidemic Hepatitis. American Journal of Pathology 20: 595-619, May 1944- Publication of the 36 plates in « lur and black-and-white was made possible by a grant to the Journal from the International Health Division of the Rockefeller Insti- tute. The hepatitis was traced to certain batches of vaccine which used as a stabilizer human serum containing the virus of hepatitis. The epidemic stopped after the use of human serum was discontinued. In Medical Department, United States Army. Preventive Medicine in World War II. \ olume III. Personal Health Measures and Immunization. Washington: U.S. Government Printing Office, 1955, pp. 306-312, and Medical Department, United States Army. Preventive Medicine in World War Volume V. Communicable Diseases Transmitted Through Contact Or By Unknown Means. Washington: U.S. Government Printing Office, i960, pp. 411-432. __. ARMED FORCES INSTITUTE OF PATHOLOGY -M "held a place of special importance, not only medical but military, with our troops stationed in all quarters of the globe * *. Almost overnight, the diseases of the tropics became an urgent specialty, where previously the general pathologist had occasion for no more than superficial knowledge." "The medical personnel of the armed forces," said Colonel Ash, "had to be instructed in at least the basic features as quickly as possible." The Attack on Tropical Diseases To meet this emergency, Dr. Sophie Spitz, a brilliant young woman pathologist serving as a contract surgeon, "prepared comprehensive study sets from the large collection of material that had come to the Institute from wide- spread tropical installations, which were distributed particularly to the Army pathologists. In order to reach a wider circle, she prepared other collections of tissues from tropical diseases which went out to nearly all medical schools in the United States and Canada, as a means of alerting students to the possi- bilities in this special field." 1S This activity was undertaken by the Museum in mid-1943 at the request of the Committee on Pathology of the National Research Council, with funds supplied by the John and Mary Markle Foundation, through the American Foundation for Tropical Medicine. The purpose was to collect and distribute pathological material on tropical diseases to the undergraduate medical schools of the United States and Canada, with the hope that it would stimulate interest and facilitate teaching in tropical medicine. As part of a preliminary survey, a circular letter was sent to the professor of pathology of every American and Canadian school of medicine, listing the material available and asking that only items actually needed should be selected. The materials offered con- sisted of blocks of tissues of organs affected by a dozen diseases, ranging alpha- betically from amebic dysentery to yaws, together with case records and lantern slides or, in some cases, stained sections for microscopic examination. The response to the letter was enthusiastically affirmative, with 82 schools answering promptly and nearly every school stating that it had need for all the items listed. Under the direction of Colonel Ash and Dr. Spitz, the Mu- seum prepared and, during the last week of December 1943, sent ou t to the medical schools 2,312 lantern slides, 1,049 tissue blocks, 324 stained sections of tissue, and 794 sets of clinical records and autopsy protocols. Through these "Ash, J. E.: In Memoriam: Sophie Spitz; An Appreciation; 1910-1956. American Journal of Clinical Pathology 30: 553, December 1958. PATHOLOGY WORLDWIDE 255 materials, it was hoped that the students might receive more thorough instruc- tion in tropical medicine, and that future medical officers of the Armed Forces would have more adequate training in the subject. 19 So great was the demand for pathological materials, and so valuable was the concentration of such materials at a central point, that the flow of specimens anil records from military sources was supplemented by contributions from the civilian medical world. Action to this end was started at a meeting of a sub- committee of the Advisory Committee of the National Research Council, held in the same month as Pearl Harbor, at the suggestion of Col. George R. Callender, and was carried forward by the Council of the International Association of Medical Museums, and the secretaries of the American Association of Patholo- gists and Bacteriologists and of the American Society of Clinical Pathologists. These organizations approved a plan for the collection of pathological material, including pictorial records of diseases and injuries, that might come to the attention of civilian pathologists so that it might be added to the collections of the armed forces. The civilian materials to which attention was particularly called were those "arising from airplane crashes, civilian bombings, fires, gun- shot wounds, and specific epidemics, particularly the virus diseases, encephalitis, polio, Rickettsia, influenza and 'atypical' pneumonia." The Army Medical Museum was approved as the collecting point for all such material, which could there be "processed, correlated and studied with material from army activities and possibly from the other armed services" and be "available for training, teaching and scientific purposes." Pursuant to this plan, Colonel Ash, in his capacity as secretary of the Associa- tion of Medical Museums, on 5 March 1942, issued a circular addressed to civilian doctors, in which he outlined the plan and specified in greater detail the types of materials desired. 20 This appeal was reinforced by Surgeon General's Office Circular Letter No. 127 (1943), which read: In view of the need for pathologic material in undergraduate and graduate education, the Committee on Pathology of the National Research Council urges that all who have suitable anatomic specimens forward them to the Curator of the Army Medical Mu- seum * * * for correlation and distribution to other central agencies and to teaching institutions. Material from the following is particularly wanted: the malarial diseases, bacillary dysentery, endamebiasis, filariasis, the trypanosomiases, the relapsing levers, the " (1) Circular Letter to Professors of Pathology, undated. (2) Letter, Col. J. E. Ash to The Surgeon General, 30 June 1043, with 1st Indorsement, The Surgeon General, to Colonel Ash, 1 July 1943. (3) Re- port of Army Medical Museum Activities to 31 December 1943. On file in historical records of AMP. - 1 " Correspondence on file in historical records ol AMP. 6 ARMED FORCES INSTITUTE OF PATHOLOGY leishmaniases, the rickettsial diseases, yellow fever, cholera, plague, and yaws. On applica- tion to the Curator, arrangements for transportation will be made. Use of Materials for the Study of Pathology To take full advantage of the concentration of materials for pathological study at the Museum, the Surgeon General's Office issued, on 23 July 1943, temporary duty orders, for 10-day tours of duty at the Museum, on 34 medical officers, distributed over the nine service commands. The purpose was to give officers'in charge of the histopathologic centers and certain other key officers in the various regions an opportunity to observe at firsthand the available facilities and the procedures followed at the Museum and also at the laboratories of the Army Medical School. A large amount of material was being sent in daily, and the majority of the officers sending materials were conscientiously trying to carry out instructions, the letter said, but there were still a "number who through unfamiliarity were failing to comply. Hence, on the one hand, the facilities provided by the Army Medical Museum and the other central laboratories are not fully utilized, and on the other hand, much very valuable material is not submitted and thus is lost to the Army." The hope was expressed that by "thoroughly familiarizing a selected group of officers with the various activities, facilities and problems of the central laboratories in Washington, present mis- understandings may be corrected and future ones avoided." The officers to whom the orders were directed were expected to pass on to other laboratory officers in their respective service commands the information gained in the short tour of duty in Washington. The first group, 10 officers from the Third and Fourth Service Commands, were to report on 16 August 1943. They were to be followed by 15 officers The first group, 10 officers from the Third and Fourth Service Commands, reporting on 30 August, and they, in turn, by nine from the Ninth Service Command, reporting on 13 September." 1 Officers detailed for these temporary duty assignments had the opportunity of attending and participating in the staff conferences held daily at the Medical Museum, at which diagnostic problems were discussed and illustrative material was screened. Each Saturday afternoon, there was a seminar at which an out- 21 (1) Correspondence, Col. J. F.. Ash to Lt. Col. E. S. Robinson, Laboratory Branch, Preventive Medi- cine Division, Surgeon General's Office, 20 July 1943- ( 2 ) Memorandum, Lt. Col. E, S. Robinson to Chief, Military Personnel Division, 23 July 1943, approved by Brig. Gen. James S. Simmons, Director, Preventive Medicine Division, in which Service Commands were requested to issue temporary duty orders for the officers whose attendance was desired. PATHOLOGY WORLDWIDE 257 standing authority in pathology presented a topic, after which there was a free discussion. All medical officers stationed in Washington and vicinity were invited to attend the staff conferences and seminars." 2 The practice of having medical officers detailed for brief periods of obser- vation and training at the Army's center for pathology continued through the war period. Pressure of duties at their home stations and the worldwide disper- sion of the Army, however, combined with the crowded conditions at the Mu- seum itself to limit the number of laboratory officers who could receive such training. Altogether, some 150 officers were detailed to see the organization and operation of the Museum-Institute at firsthand, but other means had to be found to make the results of continuing study and research in pathology more widely available. Study Sets This was done, in part, through publication of articles of particular interest in the medical scientific press. For more detailed and intensive study, however, the printed word alone, even with photographic or photomicrographic illustra- tions, was not enough. For such students of particular topics, the Museum- Institute set up an extensive service, making study sets available to all Army laboratories, to keep medical officers throughout the Army informed about the pathology of the diseases prevalent during the war. These study sets consisted of slides for microscopic study, reinforced by printed syllabuses or atlases illustrated by photographs or photomicrographs of the diseases with which they dealt. The sets were of two sizes, 100 slides and 25 slides. The larger sets covered the pathology of major specialties such as ophthalmology, otolaryngology, orthopedic surgery, neurology, derma- tology, gynecology, serology, and dental and oral surgery— in general, the specialties in which active registries had been established by the time of the entrance of the United States into the Second World War. The smaller sets dealt, for the most part, with specific diseases, among them being lesions of the lymph nodes and the thyroid gland, tumors of certain organs, interstitial pneumonitis or viral pneumonia, the various types of en- cephalitis, and the several diseases traceable to different forms of fungus. During 1945, the last year of active hostilities, a total of 1,669 stud Y sets were sent out on loan, approximately 90 percent of which went to Army installations and the re- mainder to civilian doctors." ' "Editorial: Seminars at Army Medical Museum. Bulletin of the U.S. Arm} Medical Department ~y. 106, February 1944. 23 Brochure, AIP-AMM. 1 July I945.P-3- 2 _g ARMED FORCES INSTITUTE OF PATHOLOGY Both types of sets were designed to make available to medical men the information derived from the specimens and clinical records flowing into the Institute from medical installations all over the world. The emphasis, of course, was upon the pathology of the soldier— the military-age group roughly defined as from 18 to 38 years. "Never before," said Colonel Ash, "has there been an opportunity to learn so much about the pathology of this military age group; only now as a result of the Army policy of centralization have significant data been available to cover this presumably healthy span." In contrast with the knowledge of diseases at other times of life— infancy, childhood, middle life, and old age— information about young adults was scarce indeed. The pathological findings were, in many cases, surprising. For example, while it had long been known that fatal coronary disease is suffered by the young, the number of fatalities from this cause was unexpectedly large. Study of the first 80 cases received at the Institute showed that about one-third of these deaths were in men under 30 years of age, and that overweight was a common condition among those so stricken. Another unexpectedly large figure was that of malig- nancies in the gastrointestinal tract. In fact, tumors of various types were found to be more prevalent than had theretofore been realized." Among the disease conditions which were the subject of special studies by the Institute staff and its resident consultants were infections of the central and peripheral nervous systems, and the group of diseases transmissible to man by the bite of an infected louse, flea, tick, or mite, known generically as rickettsial diseases, named for Dr. Howard Taylor Ricketts who lost his life to typhus. Other special studies by the staff included malaria and the results of its treatment with Atabrine; heat stroke, a subject of particular interest to an Army which was to do much of its fighting in areas of high temperature; failure of the kidneys to function as a result of crushing injuries to other parts of the body, burns, or transfusions of incompatible blood; and tumors of various types and localization. These studies were carried on in conjunction with, or at the same time as, those of other agencies investigating like conditions, and all such studies were greatly furthered by the collection, in one central location, of signifi- cant numbers of cases of each type. 25 As an example of the prompt and expert diagnostic and consultative service offered by the Institute, as an aid in the reduction of health hazards, there was "''Ash, Bulletin oj the V.S. Army Medical Department, 4 (1945), pp. 718-723. ~'(i) Idem. (2) Brochure, AIP-AMM, 1 July 1945, pp. 4, 5. (3) Typescript of Memorandum, "Armcil Forces Institute of Pathology: Status in a Future War," dated 8 September 1950. On file in historical records at Al II'. PATHOLOGY WORLDWIDE 259 the case of soldiers serving in Alaska who died unexpectedly and inexplicably, insofar as the local medical officer could determine. Autopsy tissues sent to the Institute indicated that death was due to severe damage to the liver following inhalation of a toxic vapor. Investigation revealed that the soldiers had used a cleaning fluid containing carbon tetrachloride to clean weapons. A directive- was issued promptly to discontinue the use of the fluid indoors, anil pathologists in the field were alerted to the danger of its use in confined quarters. From such instruction, Army pathologists were enabled to explain the previously undeter- mined causes of death among crews of allied submarines which docked at Pacific ports. Studies of autopsy tissues revealed characteristic lesions, and investigation showed that the sailors had used toxic cleaning solutions within the close confines of submarines. Along with the work on specimens received through military channels, went the work done under the direction of the American Registry of Pathology, through which materials of pathological interest arising in civil life were ana- lyzed and studied. On account of wartime pressures, both upon the staff and the cooperating civilian physicians, the followup system had to be suspended for the duration of the war, and there was some slackening in the registration of tissues and clinical records contributed from this source. Interest in the registries continued, however. Five new registries were added during the war, bringing the total number to 13. The total number of accessions received by the Museum-Institute from this source by the end of the war had grown to more than 48,ooo. 20 The Army Medical Illustration Service While the study of pathology was the principal business of the Museum- Institute, it still was but part. Closely related was the graphic representation of the results of such study through the media of drawings and paintings, photography and photomicrography, and plastic medical art — all comprising the Army Medical Illustration Service (fig. 80). This Service included the Photographic Laboratory which, in an average month, turned out from its collection of 100,000 negatives of medical interest as many as 2,500 prints, prepared i,oco colored lantern slides, and made more than 2,500 photostats and 25,000 offset prints. Not all of this work, by any " (1) Draft of Report of Inspection. Army Medical Museum (Armv Institute of Pathology), with covering letter. Col. J. E. Ash to Assistant Commandant, Army Medical Center, , January n)45- 1'hotostat copy in AFIP files. (2) Karsner, H. T.: The American Registry of Pathology and its Relation to the Vrmy Institute of Pathology. The Military Surgeon 99: 369, November 1946. (3) American Urological Association Address. 260 ARMED FORCES INSTITUTE OF PATHOLOGY Capsular Zi f/eac/ of Femur- r / /■* i / / / ■ HlJ Figure 80. — Pencil, pen, brush and camera: The medical illustrator uses many media in his task of presenting the picture of trauma and disease. PATHOLOGY WORLDWIDE 26 1 means, was done for the Museum-Institute, as the Laboratory, presided over by Roy M. Reeve, became, in effect, the photographers for the Surgeon General's Office. The work of medical illustration in the oversea theaters was provided for by the detachments sent out by the other branch of the Medical Illustration Serv- ice — the MAMA's — but until as late in the war as mid-1943, no P^ an f° r central supervision of clinical photography in the hospitals in the Zone of the Interior, or the "homefront," had been adopted. On 15 June of that year, Colonel Ash proposed to The Surgeon General a plan for such supervision, with centralization of the resulting materials in the Museum, where they would be available for teaching, scientific, and historical purposes. Upon inquiry, it appeared that only 6 out of the 22 general hospitals queried had photographic equipment and supplies. In November, therefore, The Surgeon General approved in its essentials the plan for centralized direction of photographic activities in the Museum. This action was followed by a cir- cular letter of 22 December, directing that, beginning with 1 January 1944, monthly reports be made to the Museum, with prints of all photographs. When prints were found to be worthy of preservation or wider circulation, the Museum was to request the negatives for copying, after which the negatives were to be returned to the hospital. Under this plan, the Institute was to handle in an average month 5,000 still prints from 60 hospitals in the United States." 7 Figure 80. — Continued. O rrespondence on file in liistnric.il records ol All I". 2 5 2 ARMED FORCES INSTITUTE OF PATHOLOGY To help meet the demand for medical artists and clinical photographers both at home and abroad, The Adjutant General of the Army, in a telegram of 2 August 1943, directed the commanding general of the Medical Replace- ment Center at Camp Grant, 111., to submit to the Curator of the Museum the name, serial number, and experience record of clinical photographers reporting to the Center, and not to transfer such personnel elsewhere except upon instruc- tions from The Adjutant General's Office. As part of the education of Medical Department personnel, the Director of Training, Army Service Forces, Maj. Gen. Clarence R. Huebner, asked the Training Division of the Surgeon General's Office to prepare a graphic portfolio illustrative of first aid in battle. The project was turned over to the Museum in February 1943, and Captain Netter was assigned the job of producing 50,000 portfolios of 50 posters each. Sketches and a preliminary draft of the text were approved by The Surgeon General and the Training Division, Army Service Forces, by the end of March. Final photographs and paintings were completed in July. After a period of study and review by various officers of the Surgeon General's Office, the Training Division of the Army Service Forces, and the Publications Division of The Adjutant General's Office, the material was finally approved and turned over to the U.S. Government Printing Office for publication. In October, the Government Printing Office, for more rapid production, let the job on contract to five lithographic companies in New York. To save time, Captain Netter was ordered to New York to supervise the litho- graphing. On 6 November, the plant having the largest portion of the pro- duction ran out of paper — six carloads were required to do the whole job — and it was not until 9 December, more than 9 months after the project was started, that the lithographs were completed and ready for distribution. Such were the problems of production in wartime. 28 As an aid to more realistic teaching of emergency medical care and battlefield first aid. the Museum and the Medical Arts Section were called upon to produce sets of war-wound moulages, or models in synthetic rubber, of the types of wounds which might be expected. Each set consisted of eight pieces — two masks showing shell-fragment wounds of the forehead and gunshot wounds in the jaw, to be worn by the men representing the "wounded," and six plaques to be at- tached to the "wounded" men, showing wounds in the chest, the abdomen, the arm and hand, and the leg. The purpose was to "impart greater realism to casualties" in practice maneuvers, and to give better opportunity to demonstrate correct methods of wound treatment, as set forth in War Department Technical s * (1) Report of Army Medical Museum Activities to 31 December 1943. (2) Letters, Captain Netter to Colonel Ash, 12 November and 9 December 1943. Photostats on file in historical records of AFIP PATHOLOGY WORLDWIDE 263 1 A ^^^tfflMhft^l ^^r^^m Figure 81. — "Wounds" for training purposes. A. Moulages, produced by the Medical Illustration Service, represent types of wounds which might be expected. Bulletin 116, issued on 18 November 1944. When applied to soldiers in the field, the moulages were startlingly lifelike (fig. 81). More than 4,000 pieces, representing n different wounds, were prepared by the Medical Illustration Service, but none of the World War II moulages are to be found in the Museum today. In late 1944, after the moulage-making job was completed, the laboratory was cleaned up and turned to other uses, but appar- ently no attempt was made to accession a set or two or to salvage the original patterns or the plaster of paris molds. Instead, it is likely that all the excess moulage materials were included in a general cleanup of the Museum, in which nine truckloads of materials of various sorts were hauled off to nearby Army posts in Virginia and dumped. Diligent search of the basement of the Institute building and of Chase Hall — a temporary building into which the Museum proper was moved in April 1947 — failed to turn up any of the missing moulages of this particular lot. The use of moulages in training was continued, however, and they are still being made by the Medical Illustration Service."" = " (1) Typewritten memorandum in AFIP files dated 1 March 1949, signed R.A.S. (the initials ol M.ii. Ruell A. Sloan, Curator, Army Medical Museum, in 1949). (2) The production of these moulages at the Army Medical Museum is described in: Clarke, Carl D.: Rubber Moulages for First Aid Training, [ournal of Technical Methods 25: 91-101, December 1945. >64 ARMED FORCES INSTITUTE OF PATHOLOGY Figure 8 i.— Continued. B. When applied to soldiers in the field, moulages were startlingly lifelike. Storage of Museum Collections Even before the outbreak of the war, it had been necessary to store a major part of the collections of the Museum proper. With the onset of the war and the proliferation of new activities, still more material had to be withdrawn from exhibit, and storage space had to be found in a southwest Washington waterfront warehouse. Except for the main exhibit hall, all the exhibit rooms in the old building were given over to offices and laboratories. The number of rooms was increased by partitioning the large old-fashioned rooms into smaller cubicles. With it all, however, the Museum proper was kept open, and continued to draw visitors at the rate of 200,000 a year. Capt. Hans Schlumberger added to PATHOLOGY WORLDWIDE 265 his duties as a professional pathologist the task of making the most that could be made of the limited exhibit space remaining, and was successful to a remarkable degree. In this, he was assisted by the installation of new alternating-current lighting to dispel the "1885 gloom" of the decrepit direct-current lighting system in the old building. Testimony to the effectiveness of the captain's efforts is to be found in a staff letter at Christmas time, 1944, in which readers were told, "You'd never know the crusty old place." More formal evidence to the same effect is found in the draft of an inspection report, made in January 1945, which noted that "the museum display has been reset so that it is now more informative and instructive to the general public; it is still, however, of great interest to medical students and to physicians." The same 1945 inspection report pointed out that the present accession rate in the Institute-Museum was on the order of 20,000 per year, but that "because of the screening function of the histopathologic centers which elimi- nate such routine materials as tonsils and appendices, almost all of these 20,000 cases present diagnostic problems." In consequence, the case load had grown faster than the staff to handle it. Nevertheless, in spite of the fact that "the load * * * now exceeds the capacity of the present personnel" and the inade- quacy of a building which was "tremendously overcrowded," the "tissues re- ceived for diagnosis or review" were "handled promptly," and reports were sent out by mail, air mail, telegraph or radio, "in accordance with the emer- gency of the situation." The service of the Army Institute of Pathology, the report said, "has acted as a check on the correctness of diagnosis in all branches of the medical service." 30 Veterans' Administration and the Museum The end of hostilities in 1945 brought an uneasy peace to the world, but it saw no great slackening of the work of the Army Institute of Pathology. As the wartime hospitals were inactivated, and their laboratory material was forwarded to the Institute for screening and review, there was a spurt in cases handled. Before this was past, arrangements had been made to have the Army Institute act as the central laboratory of pathology for the Veterans' Adminis- tration in much the same way as it did for the Army. 30 (1) Christmas Message, Army Medical Museum, 1944, preserved by Mr. H. C. Klugc, Medical Illustration Service. (2) Report of inspection, 3 January 1945. Photostat on file in historical records of AFIP. rs ARMED FORCES INSTITUTE OF PATHOLOGY In a letter to The Surgeon General of the Army, written on 24 September 1945— less than 2 months after the surrender of the Japanese— Colonel Ash suggested such an arrangement as being beneficial to both parties, and to the Government as well. "We are now receiving daily requests from the Veterans' Administration for slides and diagnoses on cases that have been transferred to its facilities," Colonel Ash wrote, as evidence of the possibilities for a con- tinuing "followup" of patients from their days in active service through their periods of treatment in the facilities of the Veterans' Administration. "There are now 97 Veterans' Facilities * * *" he wrote, and "no doubt this number will be greatly augmented shortly." The additional load, he added, could be handled by having the Veterans' Administration assign to the Institute two pathologists, two technicians, and two clerks. After consultations and correspondence between the Administration and the Institute, Gen.