Sources and critique.-"The Medical Department of today owes more to the Civil War than most of its members realize," wrote Col. Percy M. Ashburn, MC, in 1929 (118). He might well have included, among the unappreciative and disparaging critics, most of the past authors who dealt with the history of that war, and some of the future historians who were destined to write about it.

Weakness of the Army Medical Department at start.-The contributions which Ashburn regarded as especially important were: increased organizational proficiency; the establishment of Letterman's model system of ambulance corps and field hospitals; and improvements in the care of the sick and wounded. He found little to praise in the Medical Department's performance in sanitation and military hygiene, at least during the first year of the war, when the Department was not only small, weak, and unorganized, but was a fossilized relic of the Mexican War in the hands of old, reactionary, unprogressive, rigid, superannuated officers. He attributed much of the inefficiency to lack of knowledge-"not much progress had been made in the prevention of disease, which is fully explained by the fact that bacteriology and its twin, modern hygiene, were yet unborn." Re-echoing this theme, General Sim-

mons allotted only 16 lines to the Civil War in his draft of an introduction. He mentioned a few positive gains: "The Civil War of 1861 was also fought before the advent of preventive medicine [meaning the coming of the "bacteriological era,"] and as usual the disease casualties were enormous, both in the Union and Confederate Forces."

There was indeed much sickness in the Union Army, especially in the first year of the war, when the forces were being increased from about 15,000 regulars to nearly 500,000 men by induction of unseasoned volunteers. But the records of succeeding years, though incomplete, show contrasting periods of relatively good health and a gradual improvement during the last 2 years, partly as a result of seasoning of the troops and partly as a result of improvements in all phases of military activity, including sanitation and hygiene. There were no severe epidemics and no serious hindrance of military operations by communicable diseases. On the whole, conditions of health were considerably better than they were in the Mexican War and among British troops in the first year of the Crimean War.

In the preparation of this monograph, the author has studied many documents, reports, and publications, of which the more important are cited (119). Selecting certain topics, he will not rehearse the oft-repeated narrative of the northern armies in the Civil War, but will deal particularly with certain events which influenced the evolution of preventive medicine in the United States Army-matters of primary concern for this volume. As will become evident, some of the specifically important events arose within the reorganized Medical Department. Others of even greater significance had their origins within the medical services of the field armies, or through the influential activity of a civilian organization-the United States Sanitary Commission.

Morbidity and mortality rates from disease and battle.-The following quotation from pages 27-28 of Duncan's Seaman Prize Essay (120) is a fair and brief summary of the statistics of morbidity and mortality:

During this war [American Civil War], lasting from April 15, 1861, to June 30, 1865, the average strength of the Union armies was 806,755 officers and men. The total number of deaths was 359,528 (Fox); 67,058 were killed in battle and 43,012 died of wounds; giving a total of 110,070 deaths from battle casualties; equivalent to a rate of 33 per 1,000 per annum. The number dying of disease is estimated at 224,586, or 65 per 1,000 per annum. These numbers are from the latest revised statistics and are all larger than those given in the M.[edical] and S.[urgical] History of the War. The death rate from sickness, while it appears high, was actually very creditable as compared with the rates of previous wars, usually waged by regular troops. While there was a great deal of sickness much of it was of a mild nature. Of 6,000,000 cases [the total enlistments and reenlistments is estimated to have been approximately 2,800,000], but 200,000 died, or 3.4 per cent. The death rate in the regular troops was 32; in the white volunteers 55; and in the negro troops 133 per 1,000 yearly. Of the wounded 14.6 per cent died, which was the average rate at that time. About two-thirds as many men died of wounds as were killed in battle. Twice as many men died of disease as from battle wounds.

In addition to the deaths named there were 24,877 from accidents, injuries and unknown causes. More than 250,000 were discharged for disability and 200,000 deserted.

Diseases in the Union Army.-Although the catalogue of the diseases that occurred among the Union troops is a long list, only a few groups of them will be mentioned here, and these are selected because of their actual or potential importance, and because the occurrence of some of them (diarrheas and dysenteries, and respiratory diseases) in the armies of the Civil War were prophetic of their recurrence in the Spanish-American War, World War I, and World War II.

Acute and chronic diarrhea and dysentery (121) "occurred with more frequency and produced more sickness and mortality than any other form of disease." In the period covered by the statistics, 1 May 1861 to 30 June 1865, there were 1,739,135 reported cases of diarrhea and dysentery and 44,558 deaths. Occasionally, there were also outbreaks of typhoid fever.

The control measures employed were the usual ones of cleanliness, disposal of wastes and excreta, policing of

camps, and some attempts to purify water or to secure clean sources.

Smallpox was present to a considerable extent in the United States during the war, but at no time could it be considered a prevalent disease among white troops serving in any of the armies or departments. A total of 12,236 cases with 4,717 deaths were reported. There were no serious outbreaks of smallpox, but at times, as in the period from January to April 1864, sporadic cases occurred in all commands. Isolation and vaccination were recognized as efficient means of protection, but often the troops were not satisfactorily vaccinated. Many of the volunteers had never been vaccinated before induction into the army (122).

Malaria, prevalent in the Atlantic and southern coastal regions, was not especially serious. The usual empirical methods of attempted prevention of the "miasmatic" group of diseases subsumed under the term "malaria" were employed routinely; namely, avoidance of the vicinity of swamps and marshes as campsites; avoidance of exposure to noxious airs of night, when feasible; avoidance of chilling and great fatigue, when not in battle, etc., etc.

In addition, quinine sulphate, when available, was used as a prophylactic against malaria. The drug was customarily given by mouth in alcoholic solution-3 grains in a gill of whiskey per day to each soldier in a malarious region-an alcoholic bitters that became the soldiers' favorite medicine and one that they did not spit out. The practice was based on both British and American experiences.

In both the Union and Confederate medical services, a number of authorities were aware of the prophylactic use of quinine by English seamen stationed in tropical regions, especially off the malarious coast of West Africa even as early as 1749, and they were convinced of its value. The administration of quinine to prevent malaria was recommended by the United States Sanitary Commission in July, 1861, and, Van Buren, in his monograph on the subject recorded that he had employed the method with good

results among troops in Florida in 1840. Surgeon General Hammond reported that he had frequently used it with success, especially throughout the unhealthy season of 1862. The deliberate introduction of chemoprophylaxis against malaria, by oral administration of quinine sulphate, marked the development of a new principle in military preventive medicine in the United States Army. This deserves special notice as one of the most valuable lessons from the Civil War (123).

Diseases of the respiratory organs (acute catarrh, bronchitis, and pneumonia, both primary lobar and bronchopneumonia secondary to measles, etc.) were important causes of ineffectiveness and mortality among the soldiers. As usual for armies in the field, fighting during fall, winter, and early spring, many thousands of cases of respiratory disease occurred, especially during the first years of the war (124).

Measles caused 67,763 cases and 4,246 deaths in white troops. Most of the mortality was due to secondary pulmonary infections, chiefly pneumonia. In camps, there were recurrent waves of measles, involving the susceptible persons through successive additions to the strength of the command (125).

There was little or no yellow fever among the troops, a result attributed to active measures of sanitation and the strict quarantine regulations imposed by military government at all of the main ports in the South (126).

Among the "camp diseases," outbreaks of jaundice, apparently infectious hepatitis, were numerous, incapacitating, but not highly fatal. Among the white troops there were no fewer than 71,691 cases of probable infectious hepatitis (127).

Venereal diseases, chiefly syphilis and gonorrhea, were more frequent at the beginning and close of the war than in the intermediate period. The control measures applied were mainly reporting of contacts of infected soldiers, treatment of diseased prostitutes, and licensing of prostitutes. It was the opinion of authorities that reduction of

venereal diseases took place under these regulations, at least in Nashville in 1863 (128).

The United States Sanitary Commission.-Immediately after the outbreak of the Civil War the inadequacies of the small and unprogressive Medical Department of the Army were shown up by catastrophies of sanitation, shortages of medical and sanitary supplies, and lack of provision for preservation of the health of the soldiers-both regulars and the new volunteers pouring into the Army of the Potomac and other commands. Responsible civilian citizens, aroused by the reports of these conditions, secured the approval by President Lincoln of an order of the Secretary of War, on 9 June 1861, appointing the United States Sanitary Commission, modeled somewhat after the British Sanitary Commission of the Crimean War. At first the President gave the Commission only limited powers of inspection and advice on medical, surgical, and sanitary matters in camps and hospitals, and in connection with certain nonmedical military activities in the Army. The Commission was authorized to communicate directly with The Surgeon General, medical officers, commanders of troops, the Secretary of War, and even the President. It was not long, however, before the Commission found that it could not get results without more power. Increased authority was granted, and the Commission became a pseudomilitary operating agency. Among its ideals and policies was the establishment and conduct of a "preventive service" in and for the Army (129). When the Commission became operative, it functioned in much the same manner as did the Preventive Medicine Service in the Office of The Surgeon General in World War II, although during the Civil War there was no such specialized division, nor, indeed, any specialized organization in the Surgeon General's Office. He seems to have looked after all the business of his office personally, with little delegation to others.

This civilian commission, operating in the midst of military formations, came into conflict with the military and other officials of the government. Some of the conflicts

were over jurisdictional matters; others were conflicts of personalities. On the whole, however, as Surgeon General Hammond noted in 1864, good relations existed between medical officers and the Sanitary Commission and its agents, and service of inestimable value was rendered by the Commission.

Among other activities, these services were concerned with the hundreds of details involved in the preservation of the health of soldiers, and in provisions for their care, their welfare, and their comfort. From the point of view of preventive medicine the most important division in the Commission's organization was its Camp Inspection Service. Throughout the war, the Commission recognized that prevention was far more effective than relief.

Reorganization of the Medical Department.-The Sanitary Commission soon recognized that the Medical Department of the Army had to be thoroughly reorganized and vitalized. By April 1862, it had assisted in securing the passage of an Act of Congress reorganizing the Medical Department, and after the retirement of Surgeon General Alexander Clement Finley on 14 April 1862 it had stepped in and dictated the appointment of Surgeon, 1st Lt. William Alexander Hammond (q.v.) as Surgeon General, on 25 April 1862, to the disgruntlement of the old regime. Also through the Commission's influence, Surgeon Jonathan Letterman was appointed by General McClellan as medical director of the Army of the Potomac. Both Hammond and Letterman were men of superior ability and the appointments had the direct result of immediate improvement and future development of preventive medicine in the army.

Publications by the Commission and health education.-During the war, distinguished American physicians and surgeons, members of the Sanitary Commission, prepared monographs, or military medical and surgical essays; and these were published by the Commission and issued to medical and line officers. They were received with favor; there was an immense demand for them. Among these monographs, a number were of special interest as docu-

ments of and involving preventive medicine. These subjects included: (1) Military Hygiene and Therapeutics, (2) Control and Prevention of Infectious Diseases, (3) Quinine as a Prophylactic against Malarious Diseases, (4) Scurvy, (5) Rules for Preserving the Health of Soldiers, and (6) pamphlets on various communicable diseases, including venereal diseases. In July 1864, Surgeon General Hammond, in view of "The favor with which they have been received both at home and abroad, and the wish expressed in many quarters that they might be arranged in a more permanent form," collected and published 17 of these essays in a single volume (130).

"These pamphlets are a historical landmark, for they initiated a special technique of health education which, in later years, developed into enormous proportions and became one of the standard procedures of health education in America." In making this evaluation, Smillie (131) was thinking particularly about civilian public health. From military experience, however, it can be said that the procedure is equally valuable in the practice of preventive medicine in the army.

Surgeon General Hammond starts a new era.-Surgeon William Alexander Hammond (1828-1900) (fig. 20), 34 years old, was moved up from the grade of first lieutenant to the rank of brevet brigadier general in one lift and appointed Surgeon General of the United States Army on 25 April 1862, thanks to the powerful influence of the United States Sanitary Commission, which recognized that he had talents even surpassing the mass and vigor of his physique. He was a man of prodigious energy, vision, originality, force, courage, productivity, learning, and literary skill. From studies, reading, and experience, he was extraordinarily well informed. Intensely interested in all phases of the medical service and the activities of the army, he lost no time in starting needed reforms and new undertakings. His entrance upon the stage marked the beginning of a new era in the history of the Medical Department. He gave to developments an impetus which carried

FIGURE 20.- William Alexander Hammond (1828-1900), Surgeon General of the United States Army (1862-1864), and a strong proponent of civilian public health and military preventive medicine. Founder of the Army Medical Museum and sponsor of the "Medical and Surgical History of the War of the Rebellion," he proposed the establishment of an Army medical school and an Army general hospital. (Portrait photograph, courtesy of the Armed Forces Institute of Pathology, photograph negative No. 61-4774.)

into advances, even though they were checked unfortunately by his personal feud with Secretary of War Stanton toward the end of the Civil War (132).

Surgeon General Hammond was fortunate in having several intelligent, able, pragmatic idealists as associates. Among those especially to be mentioned were Surgeon Jonathan Letterman, Medical Director of the Army of the Potomac, deviser of the system of field hospitals, originator of the new Ambulance Corps, and reorganizer of the

whole field of medical service; Surgeon John Shaw Billings, also a medical inspector under General Grant during the Wilderness Campaign, later to become the chief public health authority in the Army Medical Service and builder of the Surgeon General's Library, greatest medical bibliographer; and Surgeon Joseph Janvier Woodward, chief compiler and author of the great "Medical and Surgical History of the War of the Rebellion," one of the first to be concerned in the buildup of the Army Medical Museum, pioneer microscopist and pathologist, originator of Army medical laboratories, and forerunner of Sternberg. In many ways, these men contributed importantly to the evolution of preventive medicine in the United States Army.

Hammond and Letterman; improvements and innovations.-Shortly before Hammond was appointed Surgeon General, Congress, influenced considerably by depositions made by the United States Sanitary Commission, and recommendations made by Surgeon General Finley, as mentioned previously, passed the Act of 16 April 1862, which reorganized the Medical Department of the Army (133).

Among the numerous specifications in this Act, two sets of regulations were particularly important for the advancement of military hygiene in the Army. These were substantially as follows:

1. Increased rank (to general officer grade) for The Surgeon General; enlargement of the staff of the Medical Department; and a strengthened administrative position for the Medical Department through which authority was wielded, orderliness of procedure acquired, and confusion reduced methodically.

2. Eight (later increased to 16) Medical Inspectors were authorized, and subsequently appointed. These officers were charged with the duty of carrying out in the name of The Surgeon General supervision over every sanitary matter that affected the health of the troops. [These were the forerunners of sanitary inspectors in the Army in the 20th century.] Renewed and expanded requirements for monthly sanitary reports were specified.

It must be admitted that most of the Medical Inspectors became concerned chiefly with conditions in hospitals and with the care of the sick and wounded. Nevertheless, a principle was established, and emphasis upon the management of sanitation was increased. The Medical Inspectors, and all medical officers, were charged with responsibilities for making inspections and for furnishing advice and recommendations on sanitary matters. This charge was frequently stated in the instructions from highest headquarters. Numerous examples might be cited, but the following statements published by Jonathan Letterman (134) are quoted as representing the best thinking of the time:

The prevention of disease is the highest object of medical science.

*                                                       *                                                       *                                                       *                                                       *

* * * A corps of Medical officers was not established solely for the purpose of attending the wounded and sick; the proper treatment of these sufferers is certainly a matter of very great importance, and is an imperative duty, but the labors of Medical officers cover a more extended field. The leading idea, which should be constantly kept in view, is to strengthen the hands of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation, and for fighting.

*                                                     *                                                         *                                                          *                                                          *     

[The Medical Director should direct his Inspector] to instruct Medical officers in the proper mode of performing their duties, and particularly to impress upon them that the duties of Medical officers are not confined to prescribing drugs, but that it is also their duty, and one which is of the highest importance, to preserve the health of those who are well * * *.

Army Medical Museum established (1862); Army Medical School and General Hospital proposed.-Immediately after he was installed in office, Surgeon General Hammond set in motion many new proposals, recommendations, and activities (135). When, in time, these became actualities, they greatly increased the efficiency, productivity, and prestige of the Medical Department. Several of them which influenced particularly the evolution of preventive medicine in the United States Army are summarized below, with comments:

1. An increase in the medical inspection corps by two medical inspectors general and eight medical inspectors.

2. An appropriation for the Army Medical Museum, which had been proposed in Circular No. 2 (136). "Considerable progress has been made in the establishment of an army medical museum. The advantages to the service and to science from such an institution cannot be over estimated." A large part of the Army's laboratory system had its beginning in the Army Medical Museum, especially laboratories of pathology and bacteriology, and the Armed Forces Institute of Pathology.

3. The establishment of a central laboratory for chemical and pharmaceutical preparations for use by the Medical Department.

4. "An Army medical school, in which medical cadets and others seeking admission into the corps, could receive such special instruction as would better fit them for commissions." It was not until 1893, after Brig. Gen. George Miller Sternberg became Surgeon General, that the Army Medical School, the first school of preventive medicine in the United States, was established. Surgeon General Hammond noted that such a school might well be set up in connection with a general hospital and he recommended further that:

5. A permanent general hospital be constructed in Washington. "If this is done, the medical school and museum will be important accessories to it." From this conception, the Army General Hospital and the Army Medical School, in Washington, were united after the Spanish-American War to form the Walter Reed Army Medical Center.

6. Required surgeons to include in monthly reports case records, post mortem examination protocols, and much medical and surgical data, with notes on the relation of sanitation to prevalent communicable diseases. "Soon after my appointment I issued circulars [Circular No. 2, for example, cited above] to medical officers inviting them to cooperate in furnishing material for a medical and surgical history of the rebellion." In response, a large number

of memoirs and reports of great interest to medical science were received at the Office of The Surgeon General, collected and systematically arranged. This formed the substance from which the voluminous "Medical and Surgical History of the War of the Rebellion, 1861-65" was developed, and published during the period 1870 to 1888.

Treatise on military hygiene.-When Hammond became Surgeon General, there was no contemporaneous text in English dealing comprehensively with civilian public health or military hygiene. The only extant American publications on the subject were those of Benjamin Rush, John Jones, and Cutbush. In the first year of the Civil War, a small but useful handbook by Ordronaux (137) became available. Hammond noted that there were many excellent treatises in French and German, but recognized that they would not be serviceable for medical officers and others who could not read those languages. Therefore, to make up for this deficiency he wrote and published, in the midst of his almost overwhelming military-medical duties, devoting to it "the hours which would otherwise have been passed in rest," a 600-page volume on general and military hygiene (138).

Hammond's "Treatise" antedated Parkes' "Manual of Practical Hygiene," (110) by a year and was highly informative for its time. As this work appeared before the bacteriological era its sanitary philosophy was based upon the older ideas about cleanliness, policing and quarantine, etc., often referred to in previous sections of this volume. Nevertheless, the book has a breath of vitality. It contains also a considerable amount of autobiographical material about Hammond himself and statements of his opinions. In producing this book, Hammond became the first of a succession of United States Army medical officers who wrote and published comprehensive treatises on military hygiene and preventive medicine.

Demobilization.-At the close of the Civil War in April 1865, although Hammond and Letterman had been out of the Army about a year, many of the promising undertak-

ings which they had initiated were well underway and were being supported by Hammond's successor, Bvt. Maj. Gen. Joseph H. Barnes (1817-1883), who had been appointed Surgeon General on 22 August 1864. As usual, however, in American military administration following a war, the United States Army, including its Medical Department, was drastically reduced. Most of the young men in the service left the Army for more interesting and profitable positions in civilian medical schools or in private practice. With a few notable exceptions, to be mentioned later, those who remained in control of the Surgeon General's Office were older men of the conservative or reactionary "clique," who appeared to believe that the peak of perfection of military science had been reached in the Civil War. The gadfly United States Sanitary Commission was disbanded soon after the close of the war, and the Medical Department's concern with military hygiene and preventive medicine reverted to a low level of routine application of old practices applied on a scale commensurate with the reduced and dispersed Army. This concern was lifted to a higher energy level by events that occurred from time to time, especially by the advent of the bacteriological era beginning in the second half of the 19th century.

The 33 years from the end of the Civil War in 1865 to the beginning of the Spanish-American War in 1898 have been called by most historians of the period (139) "the day of small things in the United States Army." The Regular Army was reduced to about 25,000 men, stationed in small isolated posts, mainly in the Indian country in the Far West. The Medical Department consisted essentially of The Surgeon General with a small staff in Washington, a medical director for each geographical department, and a surgeon with a few assistants at each military post. In the field, brief but severe skirmishes with the hostile

Indians were frequent. There were epidemics of cholera and yellow fever in the Army, as among the civilians, in 1866, 1867, 1868, and 1873. In Washington, affairs pursued an almost peacetime course of military quiescence.

However, the appearance of smallness and lethargy were superficial. Actually, beneath the surface there was a seething of administrative and intellectual activity. In contrast with the ordinary affairs, several extraordinary movements and events, promoted by notable men, made the period one of the most significant in the history of preventive medicine in the United States Army. By the end of the period, modern preventive medicine had been created.

Before that stage is described, however, it will be advisable to notice briefly the progress made in several related activities.

Sanitary reporting monthly.-Increased attention was given to military hygiene at posts, stations, and camps. The consequential good results were shown in the decrease in the mortality from disease among troops to the low rate of 7 per 1,000 mean average strength for the year 1885. This was attributed to the strengthening of inspection, recommendations, and reporting by post surgeons which followed two vigorous reports by Assistant Surgeon John Shaw Billings (140), and by new imperatives embodied in War Department General Orders No. 125, dated 17 November 1874, and a revision of Army Regulations 2315, dated 15 July 1885, reaffirmed as Army Regulations 1642, in 1889.

By this change in Army regulations, the monthly sanitary report, which was formerly only a requirement of the Office of The Surgeon General, was made a mandatory official procedure by the highest military authority. The post medical officer was required to submit to his commanding officer a report in writing, with recommendations. The commanding officer was required to indorse his actions on the report, whether approved or disapproved, and the indorsed report, with a copy of the indorsement given to the post medical officer, was sent to the Department Com-

mander, and thence to The Surgeon General. Army Regulations 1642 comprehended everything relating to the hygiene of the post or command to which the medical officer was attached. The stated examples of items to be covered were intended to be illustrations of the more important subjects for sanitary inspections and were not to be interpreted as restricting the scope of the sanitary report. The results were salutary. The reports submitted, resembling somewhat the comprehensive reports included in the "Medical and Surgical History of the War of the Rebellion," were often abstracted copiously or reproduced in full in the annual reports of The Surgeon General, swelling each report from a meager fasciculus to a respectable volume, packed with interesting information about the living conditions of the troops and about sanitary problems.

Although reiteration of recommendations and hammering on principles and cases was necessary to get action, this system of reporting and of procedures for handling the reports became respected and continued in effect into World War II. The multiplication of reporting units then caused desks to be piled to the ceiling with reports which could not be read in a lifetime, and the system sank under its own weight!

Medical Museum and the Surgeon General's Library.-The Army Medical Museum and the Surgeon General's Library, located in Ford's Theatre building on 10th Street near E Street, N.W., in Washington, appreciably increased their holdings and activities, each representing a type of organization and service which aided preventive medicine in the Army. During this period, the Museum, under Assistant Surgeon Joseph Janvier Woodward (who could not accept the germ theory of disease), became a world renowned center of photomicrography of microorganisms and tissues. The Library of the Surgeon General's Office, under the nurturing direction of Dr. John Shaw Billings, Assistant Surgeon, appointed librarian in 1865, greatly enlarged its collection of books, making available to Sternberg and others nearly all the foreign

literature of microbiology, particularly publications on the relationship of microbes to disease. The scientific support and influence upon preventive medicine provided by both of these great institutions has been continuous.

Physical standards and statistics.-Preventive medicine, concerned with human beings as individuals and as populations, has had an abiding interest in physical standards and in the relationship between anthropometric statistics and such matters as performance, durability, and susceptibility (of man) to disease. In 1875, through the efforts of the Surgeon General's Office and the Office of The Provost Marshal, an enormous collection of such statistical material, with calculations of rates, was issued (141) in two mammoth folio volumes. Similar colossal reports have been issued from time to time in connection with the characterization and management of troops in World Wars I and II.

Although the germ theory of disease was very old and had had vogues of favor, it became generally discounted between 1800 and 1850. This occultation occurred in spite of the acquisition and spread of a considerable amount of microscopically established knowledge of pathogenic bacteria, fungi, intestinal worms, and the itch-mite in scabies. In 1840, Jacob Henle (1809-1885) announced the theory of a contagium animatum, and at about the same time he formulated designs of experiments in pathogenicity which later, in the hands of his famous pupil, became "Koch's postulates." The classical taxonomic atlas of C. G. Ehrenberg (1795-1876), "Die Infusionsthierchen als vollwommene Organismen" (1838), was known in the United States to physicians who became military surgeons. Notably among these was Dr. Joseph Jones, Surgeon in the Provisional Army of the Confederate States, who during the Civil War observed bacteria in the lesions of hospital gangrene and

in the mesenteric lymph nodes and Peyer's patches in typhoid fever (undoubtedly seeing the typhoid bacillus fully 20 years before Eberth made similar observations). As early as 1846 and 1847, in Philadelphia, John Kearsley Mitchell had lectured medical students on his theory that malarious and epidemic fevers were caused by microorganisms. The expanded lectures were published in a book (142). The remarkable "Treatise on the Practice of Medicine," by George B. Wood, M.D., Professor of Materia Medica at the University of Pennsylvania, published first in 1847 and republished in revised and enlarged editions until 1858, contained two large sections about animalculae in relation to diseases of men. Copies of this book were issued to regimental surgeons in the Union Army during the Civil War.

Through verbal dialectics, the anticontagionists got the upper hand over the contagionists, and the beliefs that miasmas, filth, and environmental factors were the chief causes of communicable diseases became firmly implanted in the lay and medical mind, although some diseases, such as venereal diseases, measles, and smallpox were admitted to be contagious. The experimental observations of microbiologists had not yet become sufficiently clear to be convincing (143).

Beginning of the bacteriological era (1876).-Following the work of Louis Pasteur (1822-1895) (fig. 21) on spontaneous generation, fermentation and putrefaction, on diseases of silkworms and of beer and wine, and on anthrax, during the period 1857 to 1877-and following the investigations, technical innovations, and announcement of postulates as criteria for judgment by Robert Koch (1843-1910) (fig. 22), during the period 1876 to 1881, etiological discoveries were made in rapid succession. Reviewing these accomplishments, Dr. William Henry Welch, himself a contributor to them, said in 1914 (144): "At the end of that wonderful decade, 1880-1890, perhaps the most wonderful decade in the history of medicine, there had been a revolution in medical thought through the discovery of the agents causing infectious diseases * * *.”

FIGURE 21.- Louis Pasteur (1822-1895), founder of modern microbiology and immunology, and producer of experimental proofs of causes of infectious diseases. (Portrait photograph, courtesy of the National Library of Medicine, photograph negative No. 59-332.)

Lister's "System of Antiseptic Surgery."-Disinfection and the antiseptic treatment of wounds were of interest to American surgeons in the late 1870's as they were to Pasteur, Koch, and Lister (who began his work in this field in the 1860's). Some years before 1876, carbolic acid and salicylic acid were being used in surgery in the United States Army to prevent or mitigate wound infections. In 1876, however, two events of crucial importance occurred. Capt. A. G. Girard, Assistant Surgeon, attached to the Office of The Surgeon General, visited Europe where, in the clinics of Nussbaum and Volkmann in Germany and

FIGURE 22.- Robert Koch (1843-1910), discoverer of etiological agents of communicable diseases. The "bacteriological era" is arbitrarily dated from his demonstration in 1876 of the bacterial cause of anthrax. (Portrait drawing after a photograph, courtesy of the National Library of Medicine, photograph negative No. 3968.7.)

Austria, he saw the spectacular results obtained by the application of Lister's system of antiseptic surgery. Shortly after his return to Washington, his full account of the technique, materials and methods used, and evaluation of results was published in a circular by order of Surgeon General Charles Henry Crane (145) "for the information of Medical Officers of the Army." In 1876, the sprays, carbolized dressings, carbolized sutures, etc., were made articles of issue upon requisitions approved by The Surgeon General.

The other event of primary importance in this chain of circumstances was the attendance of Sir Joseph Lister

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FIGURE 23.- Lord Lister (1827-1912), inventor of the "System of Antiseptic Surgery," which revolutionized surgical practice and furnished a spectacular example of preventive medicine. (Portrait photograph, courtesy of the National Library of Medicine, photograph negative No. 35904.)

(fig. 23) at the International Medical Congress held in Philadelphia in 1876 (146).

Lister, who was president of the section on surgery at that congress, made forceful scientific statements, and took part in the vigorous discussion of his system of antiseptic surgery at the meeting. He said, among other things: "The germ theory of putrefaction is the foundation of the whole system of antiseptic surgery, and, if this theory is a fact, it is a fact of facts that the antiseptic system means the exclusion of all putrefactive organisms."

Not all were convinced that the wound infections were caused by bacteria, but the discussion powerfully influ-

enced opinion toward acceptance of Lister's opinion that the antiseptic system meant the exclusion of bacteria from wounds by a chemical disinfectant barrier. The conception was essentially one of prevention. Hence, this system marked an advance in the practice of preventive medicine (including surgery) in both the civilian and military context. Undoubtedly, the success of antiseptic surgery, by supporting ideas about germs as causes of disease and about how to prevent their harmful activities, was a foundation pillar in the upbuilding structure of scientific preventive medicine.

George Miller Sternberg, pioneer bacteriologist.-The man who more than any other in the Army moulded events in preventive medicine (147) in the second half of the 19th century was George Miller Sternberg (1838-1915) (fig. 24), who after 32 years of service was appointed Surgeon General on 30 May 1893, and who held that position until he was retired for age on 8 June 1902. The decade of his surgeon generalcy was one of extraordinary accomplishment in preventive medicine. Most notable were the establishment of the Army Medical School, the establishment of a number of laboratories, the conception and skillful use of special scientific boards and commissions, particularly the Reed-Vaughan-Shakespeare Board on typhoid fever in the Spanish-American War, the Yellow Fever Commission in Cuba in 1900-1901, led by Walter Reed, and the Medical Section of the Philippine Board of Science.

General Sternberg, pioneer bacteriologist of North America, was self-taught. When he began his work, there were no bacteriological laboratories in the United States and no one on this side of the Atlantic to instruct him. He met Pasteur in Paris and Koch in Berlin only briefly in 1875. He began to study bacteria about 1870, if not somewhat earlier-possibly in the late 1860's, when he began to make photomicrographs at the Army Medical Museum where Assistant Surgeon Joseph Janvier Woodward was perfecting the technique.

In 1878, while stationed at Walla Walla, Washington, Sternberg began experiments to test the practical value

FIGURE 24.- George Miller Sternberg (1838-1915), Surgeon General of the United States Army (1893-1902). As a pioneer American bacteriologist, he helped to usher the "bacteriological era" into the United States. He founded the Army Medical School in 1893, appointed and supervised the Reed-Vaughan-Shakespeare Typhoid Board in 1898, and the Walter Reed Yellow Fever Commission in 1900. He established boards for the investigation and control of tropical diseases in the Philippines and Panama. (Portrait photograph, courtesy of the Armed Forces Institute of Pathology.)

of disinfectants, using cultures of putrefactive bacteria. From this, he went on through the next 20 years in work on cholera, yellow fever, septicemia (during which he discovered the pneumococcus in 1881), and in many ways exerted a new scientific influence upon attempts to prevent and control infectious diseases.

In his general writings, he was also extremely influential. In 1880, he published his translation of Antoine Mag-

nin's volume entitled "The Bacteria," which had been published first in Paris in 1878. This was the first systematic book of its kind in English. It was followed in 1892, by editions of Sternberg's classical "Manual of Bacteriology," and in 1896 and 1901, by editions of his "Text-book of Bacteriology." In 1895, in the vanguard of thinkers of the time, he published "Immunity: Protective Inoculations in Infectious Diseases and Serum Therapy," and in 1903, "Infection and Immunity with Special Reference to the Prevention of Infectious Diseases."

Sternberg's most prolonged, and apparently disheartening, bacteriological investigations were his attempts to find a bacterial cause of yellow fever. He found nothing etiological, but disproved the claims of several who thought that they had found the microbial cause of this disease. His results were so clearly negative that, as it turned out, they constituted a positive contribution. In showing that something besides a bacterium or protozoan parasite should be looked for, he cleared the way for Walter Reed and his associates in their quest which led to an invisible filterable virus.

Surgeon General Sternberg establishes the Army Medical School (1893).-On 24 June 1893, within a month after he had been appointed Surgeon General, Sternberg (148) obtained from the Secretary of War authorization to establish an Army Medical School in the city of Washington for "the purpose of instructing approved candidates for admission to the Medical Corps of the Army in their duties as medical officers."

Thus was implemented the recommendation that had been made by Surgeon General Hammond in 1862. By 22 September 1893, the school was organized and its first faculty announced. These were medical officers who were to teach in addition to their other duties. The first session of 4 months was commenced, with six students, in several rooms in the building of the Army Medical Museum and Library at 7th Street and B Street, S.W. (later Independence Avenue).

The first faculty of four professors included Maj. John Shaw Billings (later replaced by Maj. Charles Smart), professor of military hygiene, and Capt. Walter Reed, professor of clinical and sanitary science, and director of the pathological laboratory at the Army Medical Museum. There were courses also on "Duties of Medical Officers" and on "Military Surgery" in which information was given about Lister's system of antiseptic surgery. Among the special sessions, General Sternberg lectured on bacteriology, and Dr. Charles Wardell Stiles gave lectures on "Parasites in Man." In concordance with General Sternberg's leadership of the bacteriological era in America, strong emphasis was placed upon environmental sanitation, the microbial causes of communicable diseases, and upon scientific methods of prevention and control. Capt. Walter Reed's course was especially effective along these lines. It presented up-to-date exercises in experimental observations upon bacterial cultures, the inoculation of animals, and the recovery of bacteria from experimentally produced lesions (149).

The Army Medical School was suspended in May 1898 because of the Spanish-American War. Reopened in the fall of 1902, it has continued since then in an uninterrupted progression of teaching, research, and service. As the first and oldest school of preventive medicine and public health in the United States, it has provided much of the precise knowledge which General Sternberg knew must form the core of modern scientific preventive medicine.