Armed Forces Institute of Pathology: Its First Century 1862-1962/Chapter XIII

by Robert S. Henry

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 numbered more than eight million men and women. 1^[1]

Such an increase in the military population, which was the primary constituency 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 In August 1942, AR 40-410 was superseded by another bearing the same number which was shorter, broader, and sharper than the original 1922 regulation.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, saying rather that autopsy, biopsy, and specified surgical materials "will be forwarded" as directed. 2 ^[2]

The combined effect of a rapidly increasing Army and more positive directions 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 specimens." 3^[3]

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^[4] Colonel Ash spoke truly when he said, "the trickle of materials of a decade ago has swollen into a torrent." 5^[5]

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 modified 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 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.6^[6]

To these centers, nearby posts and installations sent materials on which diagnostic assistance was required. After screening out those cases on which there were no serious diagnostic doubts or difficulties, the regional centers forwarded to the Medical Museum "such surgical cases as have a possible future administrative or 'followup' 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^[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 laboratory, usually at the principal general hospital in the area, to serve as its histopathologic 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

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] 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 desirable 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^[9]

Increase in Personnel

The tremendously increased workload at the Museum made necessary substantial 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. 10^[10]

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^[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 currently underway were in the field of pathology, while 11 of the 17 projects shown as having been recently completed dealt with pathology. 12^[12] " 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." 13^[13]

A New Name for a New Organization

This authorization, made informally in the closing weeks of 1943, is reflected 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 Lucké, 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 Professional Service, which was primarily the pathological division of the Museum

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 specimens 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 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. 14^[14]

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." 15^[15] 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 compared 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 Museum had completed its special study of three early fatal cases of hepatitis- one each from Fort Belvoir, Va.; Camp Callan, Calif.; and Walter Reed General 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. 16^[16]

"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 Lucké (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

Figure 79.—Maj. Gen. Norman T. Kirk, The Surgeon General of the Army, presents to Col. Balduin Lucké the Legion of Merit for distinguished service to the Museum-Institute, as Mrs. Lucké looks on.

Colonel Lucké'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.^[17]

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 "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 possibilities in this special field." 18^[18]

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 consisted of blocks of tissues of organs affected by a dozen diseases, ranging alphabetically 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 Museum prepared and, during the last week of December 1943, sent out 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 materials, it was hoped that the students might receive more thorough instruction in tropical medicine, and that future medical officers of the Armed Forces would have more adequate training in the subject. 19^[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 and records from military sources was supplemented by contributions from the civilian medical world. Action to this end was started at a meeting of a subcommittee 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 Pathologists 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, gunshot 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 Association 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 ^[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 Museum * * * 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 leishmaniases, the rickettsial diseases, yellow fever, cholera, plague, and yaws. On application 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 misunderstandings 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." 21^[21]

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 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." 22^[22]

The practice of having medical officers detailed for brief periods of observation and training at the Army's center for pathology continued through the war period. Pressure of duties at their home stations and the worldwide dispersion of the Army, however, combined with the crowded conditions at the Museum 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 illustrations, 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, dermatology, 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 encephalitis, 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 remainder to civilian doctors." 23^[23] 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 malignancies in the gastrointestinal tract. In fact, tumors of various types were found to be more prevalent than had theretofore been realized.24^[24]

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 significant numbers of cases of each type. 25^[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 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, and 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 undetermined 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 analyzed 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. 26^[26]

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

Figure 80.—Pencil, pen, brush and camera: The medical illustrator uses many media in his task of presenting the picture of trauma and disease.

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 Service—the MAMA's—but until as late in the war as mid-1943, no Plan for 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 circular 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.^[27]

Figure 80.—Continued.

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 Replacement 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 instructions 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 lithographing. On 6 November, the plant having the largest portion of the production 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^[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 attached 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

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 11 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 apparently 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.^[29]

Figure 81.—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 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 eliminate 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 inadequacy of a building which was "tremendously overcrowded," the "tissues received for diagnosis or review" were "handled promptly," and reports were sent out by mail, air mail, telegraph or radio, "in accordance with the emergency 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^[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' Administration in much the same way as it did for the Army. 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 continuing "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. Omar N. Bradley, Administrator of Veterans' Affairs, wrote the Secretary of War, on 12 June 1946, that the veterans' organization was "in need of certain forms of immediate assistance which it is believed could be provided by the Army Institute of Pathology." These were consultation and review as to pathological materials, assistance in training specialists in pathology and in studies of disease processes. General Bradley advised that informal conversations with The Surgeon General of the Army, Maj. Gen. Norman T. Kirk, and the Director of the Institute, indicated that the Institute was willing and capable of providing the assistance needed, if the Veterans' Administration would furnish personnel to cover the added workload. "This," General Bradley said, "we will be able to do." Use of the Institute's facilities, he added, would avoid needless duplication of facilities, while the Institute would "benefit through the accession of a great deal of additional material, much of which would be correlated with previous specimens received while patients were in military service."

On 8 July 1946, Secretary of War Robert P. Patterson approved a plan so obviously desirable and in the best interest of both organizations, and of the patients whom both served. 31^[31]

Only a month before the consummation of the plan to have the Institute perform the central pathological service for the veterans' organization, Colonel Ash saw another of his projects come to pass when, on 7 June 1946, a new War Department Army Regulation was issued, amending AR 40-410 so as to make the "Army Institute of Pathology" the official designation of the whole operation, with four departments — the Department of Pathology, the Army Medical Illustration Service, the American Registry of Pathology, and the Array Medical Museum. The head of the organization was to bear the title of "Director"; the heads of the pathology department and the registry were to be "Scientific Directors"; the head of the illustration service bore the title of "Chief" ; and the head of the Museum section, the title of "Curator." A Scientific Advisory Board of Consultants was provided for, with not more than 25 members, serving 5-year terms, to be appointed by The Surgeon General upon recommendation of the Director.

Words of Appreciation

The year 1946, the last of the 10-year tour of Colonel Ash, saw an unusual tribute to the retiring director in the publication of an entire issue of The Military Surgeon devoted to Colonel Ash and the Army Institute of Pathology. The issue opens with a Foreword from Surgeon General Kirk, in which he wrote that Colonel Ash's "diligence, foresight, professional knowledge, and undeterred devotion to duty have led to the organization of the most extensive service in tissue pathology ever known in the world."

General Kirk's Foreword is followed by an Appreciation by Col. James M. Phalen, long associated with the Library; by a sketch of the Institute during World War II by Col. Balduin Lucké; by an account of the American Registry of Pathology and its relation to the Army Institute of Pathology, by Dr. Howard T. Karsner; by a paper on the dental and oral pathology registry, by Dr. Henry A. Swanson and Lt. Col. Joseph L. Bernier; and by 10 scientific papers prepared by 16 scientists connected with the Institute and published as a tribute to the retiring director.

After summing up the advantages favoring an institute located in the National Capital as a site for the registries of national scope, Dr. Karsner summed up the situation of the organization in 1946 in his Military Surgeon article. "This Institute," he said "is unique in the world. 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 continues to be true, such a close scientific liaison between medical officer and civilian doctor." 32^[32]

From a civilian source, the Journal of the American Medical Association, comes confirmatory comment on the place of pathology in the accomplishments of medicine in wartime. "The startling accomplishments of surgery, medicine, physiology, bacteriology and epidemiology as they partake in the war effort tends to obscure the significant part played by pathologic anatomy," said the Journal. "In man, and in animals with natural or experimentally induced disorders, the final identification of disease, indispensable in investigation, depends on pathologic anatomy. Through the medium of autopsies and surgical specimens, pathologic anatomy serves the Army in its usual unpretentious manner. The organization now operating in the Army is such that careful examinations can be made in the field; central facilities provide for skilled controls and permanent files. Surgeons are aided in their operative work, internists in their investigation of patients and all medical officers in diagnosis, treatment and prevention not only of internal diseases, but of injuries on land, on sea and in the air." 33^[33]

1. 1 Figures for June 1940. December 1941. and August 1945. on file in the Adjutant General's Office Department of the Army.
2. 2 (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. 3 (1) 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 file in historical records of the AFIP. (Hereinafter cited as American Urological Association Address.)
4. 4 Lucké, Balduin: The Army Institute of Pathology During World War II. The Military Surgeon 99: 365, November 1946.
5. 5 Ash. J. E: 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.
6. 6 Histopathologic centers were established at: Lovell General Hospital, Fort Devens, Mass.: the Second Service Command Laboratory, Federal Office Building, New York City; Valley Forge General Hospital, Phoenixville, Pa.; Lawson General Hospital, Atlanta, Ga.; Stark General Hospital, Charleston, S.C.: Station Hospital, Fort Bragg, N.C.: Thayer General Hospital, Nashville, Tenn.: Billings General Hospital, Fort Benjamin Harrison, Ind.; the Sixth Service Command Laboratory, Fort Sheridan, Hl.; 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. 7 Circular Letter No. 141, Surgeon General's Office, 20 July 1943.
8. American Urological Association Address.
9. 9 Ash, Southern Medical Journal, 37 (1944), pp. 261-266.
10. 10 (1) Lucké, The Military Surgeon, 99 (1946), p. 367. (2) Brochure, Army Institute of Pathology- Army Medical Museum, prepared by Technical Information Division, Surgeon General's Office, first printing 1 July 1945 : reprinted December 1945 and 1 July 1946, p. 1. (Hereinafter cited as Brochure, AIP-AMM.)
11. 11 (1) Correspondence, Colonel Ash to Surgeon General's Office, 21 August 1944 and Surgeon General's Office to Colonel Ash. 25 August 1943. (2) Lucké, The Military Surgeon, 99 (1946). p. 367.
12. 12 Memorandum to Officers, Army Medical Museum, Army Institute of Pathology, and Photographic and Medical Arts Service, 3 January 1944. On file in historical records of AF1P.
13. 13 Ash, Southern Medical Journal, 37 (1944), PP. 261-266.
14. 14 Brochure, AIP-AMM, 1 July 1946.
15. 15 Karsner, Howard T.: Army Medical Museum; Army Institute of Pathology. Journal of the American Medical Association 124: 711, 11 March 1944.
16. 16 Memorandum. Col. J. E. Ash, to Chief of Laboratory Services, 22 July 1942. Copy on file in historical records of AFIP.
17. (1) Lucké, B.: Pathology of Fatal Epidemic Hepatitis. American Journal of Pathology 20: 471-593. May 1944. (2) Lucké, 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 color and black-and-white was made possible by a grant to the Journal from the International Health Division of the Rockefeller Institute. 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. Volume 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 II Volume V. Communicable Diseases Transmitted Through Contact Or By Unknown Means. Washington: U.S. Government Printing Office, 1960, pp. 411-432.
18. 18 Ash, J. E.: In Memoriam: Sophie Spitz; An Appreciation; 1910-1956. American Journal of Clinical Pathology 30: 553, December 1958.
19. 19 (1) Circular Letter to Professors of Pathology, undated. (2) Letter, Col. J. E. Ash to The Surgeon General, 30 June 1943, with 1st Indorsement, The Surgeon General, to Colonel Ash, 1 July 1943. (3) Report of Army Medical Museum Activities to 31 December 1943. On file in historical records of AFIP.
20. 20 Correspondence on file in historical records of AFIP.
21. 21 (1) Correspondence, Col. J. F.. Ash to Lt. Col. E. S. Robinson, Laboratory Branch, Preventive Medicine 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.
22. 22 Editorial: Seminars at Army Medical Museum. Bulletin of the U.S. Army Medical Department 74: 106, February 1944.
23. 23 Brochure, AIP-AMM. 1 July I945.P. 3.
24. 24 Ash, Bulletin of the U.S. Army Medical Department, 4 (1945), pp. 718-723.
25. 25 (1) Idem. (2) Brochure, AIP-AMM, 1 July 1945, pp. 4, 5. (3) Typescript of Memorandum, "Armed Forces Institute of Pathology: Status in a Future War," dated 8 September 1950. On file in historical records at AFIP.
26. 26 (1) Draft of Report of Inspection. Army Medical Museum (Army Institute of Pathology), with covering letter. Col. J. E. Ash to Assistant Commandant, Army Medical Center, 3 January 1945. Photostat copy in AFIP files. (2) Karsner, H. T.: The American Registry of Pathology and its Relation to the Army Institute of Pathology. The Military Surgeon 99: 369, November 1946. (3) American Urological Association Address.
27. Correspondence on file in historical records of AFIP.
28. 28 (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
29. (1) Typewritten memorandum in AFIP files dated 1 March 1949, signed R.A.S. (the initials of Maj. 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. Journal of Technical Methods 25: 91-101, December 1945.
30. 30 (1) Christmas Message, Army Medical Museum, 1944, preserved by Mr. H. C. Kluge, Medical Illustration Service. (2) Report of inspection, 3 January 1945. Photostat on file in historical records of AFIP.
31. 31 Copies of the correspondence on file in historical records of AFIP.
32. 32 Karsner. The Military Surgeon, 99 (1946), p. 369.
33. 33 Kariner, Journal of the American Medical Association, 124 (1944), pp. 710-711.