Valedictory Address TO THE GRADUATING CLASS OF THE ARMY MEDICAL SCHOOL. WASHINGTON, D.C. DELIVERED MARCH 13, 1896. BY JOHN H. BRINTON, M.D., Profeasor of the Practice of Surgery, and Clinical Surgery, in the Jefferson Medical College of Philadelphia; Late Surgeon U. S. Volunteers. Valedictory Address. TO THE GRADUATING CLASS OF THE ARMY MEDICAL SCHOOL, WASHINGTON, D.C. DELIVERED MARCH 13, 1396. BY JOHN H. BRINTQN, M.D., Professor of the Practice of Surgery, and Clinical Surgery, in the Jefferson Medical College of Philadelphia; Late Surgeon U. S. Volunteers. In 1863, just a third of a century ago, the speaker was honored by instructions from the Surgeon Gen- eral of the Army to prepare an address to be delivered at the inauguration of a proposed Army Medical School. The Medical Museum had been founded, preparations were accumulating and a lecture room had been fitted up to receive the expected class of Medical Cadets and junior medical officers. The plan of instruction had been elaborated, and the chairs and names of the possible occupants were being discussed. All was ready, but the project did not receive final official approbation, and failed to become a reality. The disappointment was great to those who had anticipated much from the proposed school and who believed that, once established, its influence would be most happy and far-reaching. No one felt this regret more deeply than the speaker, but at the same time ever with the earnest hope and firm conviction that the establishment of an Army Medical School was but a matter of time; that sooner or later its necessity would be recognized, and that the day would come when the Medical Department of the Army of the United States would stand, as regards medical educa- tion, fully abreast with the medical services of nations, beyond the seas. 2 And it has come. How, you know. By the wise direction of the Secretary of War, at the recommen- dation of a Surgeon-General, who combines true mili- tary zeal with the highest scientific professional attainments. These efforts of the chief of the depart- ment to elevate and maintain the professional status of the medical corps have been nobly seconded by the President and Faculty of the Army Medical School. There is no more difficult and responsible post than that of teacher, and our country is most happy in commanding in this school the services of a faculty who to past experiences in active warfare, add the judicial influences of thought and study. That under such impulses the school has prospered and has assumed its true position, this public gathering, this official presence bear ample witness. Through personal kindness, and I fear unwise par- tiality, I have been asked to say to you, members of the graduating class, a few words. Let me at once confess that in accepting this flattering and delicate duty, I have been influenced by the recollection of many kindnesses I have received from cherished friends in the old army and by the desire, almost crav- ing, to renew with them, or their successors, my past associations. In the presence of such an audience I scarce know how to choose my words, yet it must not be forgotten that we come here to assist in the closing exercises of a session and to commemorate the passing out of you graduates into the active duties of your calling. Your functions as military medical officers will be discharged under circumstances widely differing from those of your predecessors, and these conditionshave doubtless been bettered to some extent by the lessons of a past experience. Are they not in some degree due to the practical and varied teaching of the great war through which our nation passed thirty years ago? What has been for the Medical Department of the Army the professional output of the war of 1861 ? Apart from the vast and wide-spread individual experiences, the 3 example and memory of which can never die, we have the Army Medical Museum, its catalogues and litera- ture, and the Circulars, medical and surgical, of the Surgeon-General's office; above all we have the mas- sive volumes of the Medical and Surgical History of the War, known, read and studied the world over. I think, too, that the* library of the Surgeon- General's office may fairly be regarded as one of the secondary results of the war, and from the library under the supervision of its accomplished Director, Dr. Billings, and its learned Librarian, that courtly man of letters, Dr. Fletcher, sprung its inestimable catalogue and I may venture to add the Index Medi- cus, the value of which to medical writers now and in all time can not be overrated. With all of these pro- ductions of the war you are conversant. I trust, nev- ertheless, that it will not be tedious to you if I briefly refer to the small beginnings of one (the Museum) and consider in a few words its influence upon the army surgeon and his work. The official history of the Army Medical Museum has long since been published and its catalogue pre- pared under the direction of the Surgeon-General in 1866, is familiar to you all. It is not, however, gen- erally known that in January, 1863, a preliminary cat- alogue was issued, setting forth the character of 1,349 objects which had been collected for the Museum in the five months since its establishment in August, 1862. Of these, 985 were surgical, 106 medical, and 133 were missiles. The curator of the Museum at that time stated in his prefatory report that the cata- logue was offered simply as a numerical list of objects in the Museum, and that no attempt had been made to classify or describe them; that work must be de- ferred for the future when it would demand volumes. On the title page of the original copy of this cata- logue is the manuscript entry: "Many specimens from battle-field sources are in this catalogue credited to medical officers in the field who were opposed to the collection of specimens. By this means opponents 4 often become later enthusiastic contributors to the Museum." This undoubtedly was a pious fraud, harmless, but useful. The proposed establishment of the Museum was announced in Circular No. 2, Surgeon-General's Office, May 21, 1862. Its title at first was the "Military Med- ical Museum," but in the catalogue published Jan. 1, 1863, the name "Army Medical Museum" appears, and since that time the collection has been so designated officially. When its foundation was decided upon circular letters were sent to medical officers of the regular and volunteer corps and to all medical officers in charge of field and permanent hospitals setting forth the object of the Museum and inviting their earnest and intelligent cooperation. It was not intended to impose upon them the labor of prepara- tion, but only to command their services in preserving and forwarding to the Surgeon-General's office as many specimens as could be procured and saved from the vast number of daily casualties in the Army. By many of the most intelligent officers these orders were received and executed in good faith; by others they were neglected, and not a few looked upon the project with derision and stigmatized the future Museum as "a collection of old bones." At first, too, there was some natural aversion on the part of the wounded sol- diers and their friends. The topic was a ghastly one, yet often a streak of humor would appear. I can rec- ollect one instance of a very rare and carefully studied case of leg injury. The patient died and was buried in soldier fashion. His bosom friends sat up and watched to prevent the much-feared desecration. The nefarious collector came. So great was his earnest- ness, so deep his sympathy, so moving his eloquence, so unanswerable his argument that patriotic bones rest better in Goverment cases than in a Virginia trench, that the stony hearts of the watchers were softened. Slowly and mournfully the former com- rades marched to the burial spot. The leg was exhumed, the bone taken out and carefully inspected 5 by the mourners, the chief of whom remarked, as the procession sadly moved campward, "After all, John would rather be of some use to the very end." Qu is custodiet custodes f It was no easy matter to popularize, if one may use the expression, the surrender to the Surgeon-General's office human specimens. It was only when medical officers in field and hospital felt tliat the Medical Department was really in earnest, that a great work was in progress that objects of the highest interest to military surgery and to the wounded of the future, were in contemplation, then only was the work of preservation and collection efficiently carried on. To obtain specimens accruing after action on the field, and in field, division and corps hospitals, the curator and his assistants were constantly sent to the front. The find, the aggregate of the operating tables roughly cleaned, were packed in barrels and forwarded to Washington. By General Order No. 116, May 22, 1863, Headquarters Military District of Washington, the schoolhouse on H street, between Thirteenth and Fourteenth, owned by Mr. Corcoran, had been taken possession of by the government and turned over to the Medical Department for the use of the Army Museum. This edifice and the outbuildings attached were immediately fitted up by order of the Acting Surgeon-General as a museum and working laboratory, and on Sept. 1, 1863, the Secretary of War authorized the transfer of the specimens from the room of the Surgeon-General's office to the newly selected Museum. The beginning of the Museum in August, 1862, was very modest, consisting of three dried and varnished specimens placed on the little shelf above the ink stand on the desk of the recently appointed curator. These were duly inspected and admired by the office officials and for a while, as a novelty, they had numer- ous visitors from the surgeons on duty in and around the city. "How is the Museum?" was the joking question of the day, and I doubt if anyone seriously believed that from this apparently ridiculous begin- 6 ning would arise the magnificent Military Medical Museum which I believe influences and will influence to no slight degree the future of American military surgery. But a start had been made, professional zeal had been excited, and the idea got around that perhaps after all there was samething in the notion that even "dry bones may live.'' Soon kegs and boxes from the field and general hospitals began to arrive. The pre- parer of the bones, Friederich Schafhirt, who under the unpretentious name of hospital steward, had been procured from the University of Pennsylvania, where he had long labored as an assistant to the immortal Leidy, was overworked. And here let me pay my tribute of respect to the memory of one who at this time did so much for the Museum, and without whom, perhaps, the collection had not then taken shape. When specimens were gathered at the front their preservation and transportation were no easy matter. The former involved the use of alcohol or whisky, at all times, within army lines, a fluid most apt to suffer mysterious leakage. " Tapping the Admiral " is a well-known nautical phrase, and it is said that in 1848 or 1849 when certain bodies of Russian Cossacks camped near the museum of Professor Hyrtl the alco- holic exosmosis from his jars was difficult, or perhaps easy, to explain. With us, indeed, it often happened that whisky on its way to the front, even though in barrels marked benzine or petroleum, was sure to leak, and kegs reaching their destination would show ingen - iously plugged gimlet holes. How and why this was done I learned only the other day from a tottering vete- ran who had once been on duty on the line of the Aquia Creek Railroad. His explanation of the gimlet hole, and inserted pipestem seemed credible, and the twinkle of his eye, suggested the motto: " Experto Crede." But the stimulant had other than preserva- tive qualities and the Museum was well supplied with it in this wise: In war times, in Washington the provost marshal's department confiscated all wines 7 and liquors brought to the city save on official permit, and all confiscated and condemned packages were turned over to the Museum for the distillation of pure alcohol, which was carried on in a lot adjoining the laboratory. So many a basket of champagne and box of Rhine wine and dozen of liqueurs found their way into Schafhirt's insatiate still. Now and then a keg of cherry brandy or the like, peculiarly soothing to military nerves, was saved and served as a ready pass- port for the Museum Messenger in search of patho- logic specimens. In fact, in most commands he was a welcome guest and a dispatch announcing his coming was honored as if it were the order of a secretary of war. Ah, I can see now the honest face of Sergeant K., who, with the compliments of Captain M. of the 105th Cavalry, had ridden down with two or three led animals to serve as escort and guide. How carefully the kegs were lashed on the pack saddle of the old roan, "and this keg is for the officers' mess, and this for the men's, and sure, sor, we must be riding now, if ye would reach camp and be getting something warm before taps." Occasionally it would happen that a specimen would be contributed to the Museum by its former owner. No. 1335, resulting from a leg crushed by a twelve-pound shot at Gettysburg, and for which thigh amputation was performed, was forwarded to the Museum in an extemporized coffin on which was tacked a visiting card "with the compliments of Major General D. E. United States Volunteers." But all were not so complaisant. On one occasion a man from the ranks demanded the return of a limb, an arm, I think. He was informed that the member in question could not be given up. " But it is mine," said he, "part of myself," earnestly enforcing his claim, and his demand to the lay mind seemed reason- able. Yet to surrender a specimen was very much like yielding a principle. " Stop," said the quick-witted young assistant curator to the claimant, " for how long have you enlisted?" "For three years or the war." 8 " Then," replied the official " the contract is not yet terminated, come back at the end of the war or at the expiration of your three years' service and you can have your bone. In the meantime one detachment of you is stationed in this Museum on government duty, the other wherever you may be ordered. Such is the opinion of the Attorney General." The reply and its reason seemed conclusive, and the bone remained in its place. But enough of old-time anecdote. Let us consider the Museum, not as a collection of curiosities or objects of historic interest, but rather as a teaching school of the first grade. For in it, I believe that les- sons of much value in military medicine and surgery may be learned, which nowhere else in this country can be so fully illustrated. As an adjuvant to the Army School its influence must be potent, for among its contents can be found exhibitions of pathologic conditions of most of the diseases and injuries met with in the warfare of the past. Look at the jars in which are shown the lesions which marked the so-called typho-malarial fevers. How mutely elo- quent they are, how much they tell you of the soldiers of our great war, how they lived, how they suffered, how and why they died. Study these preparations in the light of our recent knowledge of sepsis and bac- teriology, and we can almost see the country through which these men marched, and we fancy we can inhale the air they breathed, and taste the water which they drank. Indeed, we can imagine every noxious influence by which they were surrounded. Then we cease to wonder that so many perished; we rather marvel that so many lived through it all. The thoughtful student of to-day will ask himself how these unhappy conditions can be minimized or warded off hereafter, and the professors in youi' school will fell you and impart to you a knowledge which we never had. Look at that gunshot splintering near the knee condemned at first sight because of the joint fissure; then amputation was the only remedy. 9 Now, thanks to Sir Joseph Lister and the outcome of his teachings, wrought out by busy brains, and by none more patiently and successfully than by him who heads your corps, the limb fares otherwise. Salvation, not destruction, is the motto to-day. Com- pare the small-arm missiles of the past with those of the present time, the leaden bullet with the jacketed projectile. Consider their relative velocities, ranges, penetrative powers and modes of flight, and almost at a glance their wound tracks will be understood. The Museum makes easy of comprehension the phenomena of the modern gunshot injuries. The past helps us to judge the present, and almost foresee the future. These truths, too, are easily learned, for they are taught as objective lessons. In the quaint language of three centuries ago: " For speech, how perspicuous and eloquent soever it be, it can not so vividly express anything as that which is subjected to the faithful eyes and hands." As for the military surgery of the future, no one, however great his experience, may speak with certainty, he can but forecast, basing his guess upon deductions from the relics of past wars. These are even better than books since they permit, indeed invite, an individual judgment. Nowadays the teachings of books in our profession soon merge. The ink of an edition is scarce dried ere its doctrines become obsolete. New modes of study are found out and even as I write, the magic subtlety of Rontgen's ray would seem to banish touch and substitute the sense of vision. What next? In an elaborate address by one who has shed much luster on American surgery, Professor Senn, the conser- vative character of the surgery of future battle-fields is strongly dwelt on. In his opinion the dangers of hemorrhage and infection will be lessened by improved hemostasis and by the enforcement of more thorough asepsis and antisepsis. It is quite probable that the hemorrhage caused by the modern projectile will be greater than that produced by the old-fashioned round or elongated Minie ball, as it was called. The greater 10 velocity of the former and its increased axial rotation will give to the resulting wound more of an incised nature. However, as it will cause less bruising and laceration, the risk of secondary bleeding will be di- minished. To prevent the infection of battle wounds doubtless every immediate precaution will be taken, but I fancy that the fighting line must be much as in the past, and'despite the soldiers' antiseptic package that the real, effective surgical antisepsis will be exerted at the field hospitals in the rear. Here the wounds will be carefully examined, their diagnosis arrived at, the prognosis established and the opera- tions, treatment and dressings deliberately and defi- nitely entered upon to be persistently carried out. Many of the sad results which have followed the inju- ries of war must be avoided in times to come. This humane tendency will grow greater with fresh knowl- edge and with that increased and more efficient skill which knowledge brings, and so the condition of the wounded will be ameliorated. Think what it was in 1535 when Pare writes of the campaign of the French against the army of the German Emperor at Turin: "We entered the throng in the Citie and passed over the dead bodies and some of which were not yet dead. We heard the cry under our horses' feet which made my heart relent to hear them, and probably I repented to have forsaken Paris to see so pitiful a spectacle. Being in the Citie I entered a stable thinking to lodge my own and my man's horse, where I found four dead soldiers and three which were leaning against the wall, their faces wholly disfigured and neither saw nor heard nor spoke, and their clothes did yet flame with gun powder which had burned them. Beholding them with pity, then happened to come an ould soldier who asked me if there were any possible means to cure them. I told him no. He presently approached to them and cut their throats without anger. Seeing this great cruelty I told him he was a wicked man. He answered me that he prayed to God that whenever he should be in such a case that he might find some 11 one that would do as much to him that he might not miserably languish." And here at Turin, Pare obtained by gifts and pres- ents from a surgeon famed above all others for curing gunshot wounds, the recipe for his excellent balsam. He thus gives it: " Boil young whelps newly pupped, in oil of lillies, prepared earth worms with turpentine of Venice," and adds, "then was I joyful and my heart made glad that I had understood his remedy." Great stress in those old days was laid upon the com- position of these " vulnaria," or wound powders, oint- ments and balsams from which much healing value wms expected. I would have you note that in the decoctions of worms, puppies and geese there was a plentiful admixture of turpentine, aloes and myrrh, poppy, hyoscyamus and gentian, tolu, red wine and oil of juniper, and here we have articles of real ther- apeutic and almost antiseptic value. Such were the accompaniments of war three centuries ago; such was the surgery at the hands of one of the princes of our craft who, conferring great gifts on humanity, was destined to professional immortality. Think of the import of this sentence regarding amputations: " The ends of the vessels lying hid in the flesh must be drawn forth. To conclude, when you have so drawn them forth, bind them with a strong double thread." Quite recently I was told by an aged and venerable friend this, which may not be irrelevant: Fifty years since in the Philadelphia library was a small medical folio on the side of which was stamped the royal arms of England. It had been bequeathed to the library by a book collector, but a visitor from London recog- nized it as the former property of the British Museum, from which it had been stolen, and it was returned. In it was the following: "Take three blind puppies, put them in a mortar and pound them up, add" so and so, what at this long interval ray informant had forgotten. In a marginal manuscript note, identified as the handwriting of King Charles I., were these words: " Tried this on the Prince. It did his business." 12 As one with the experience of later years walks through the National Military Museum, he can not fail to be impressed with the lessons which confront him on every side. He feels that the mutilating am- putations and resections once so common must in future wars be greatly diminished in proportion. The new projectiles are far more humane in their effect upon the bony system. They penetrate rather than crush, and shattered wounds even when they occur will be, thanks to antisepsis, far more amenable to conservative treatment than of old. A limb may be saved and a joint preserved when once it would have gone as a matter of course, and our attempts at pres- ervation now cease to -be experimental, and have become recognized treatment. Professional opinion has changed, old judgments are reversed, new lines of study opened, new conclusions arrived at. These changes have been gradual but steadily progres- sive. In the aggregate they amount to revolution. I have often wondered what would be the impression of those of our brethren who have gone to rest twenty, fifteen, ten years ago, if they could now arise from their dust and view the existing state of the art once theirs. They would indeed find old manners changed, old customs gone, and realize that the greatest savant of yesterday would be the merest tyro of to-day. Following out this idea of incessant and bewilder- ing change, let me ask you to reflect for one moment on the marvels which have marked the onward strides of abdominal surgery, for in this direction perhaps first and most decisively has antisepsis achieved her victories, and these successes have been reached through the practice of an aggressive surgical inter- ference, guarded by a strict precautionary antisepsis. Years ago, and not so many either, the unfortunate recipient of a penetrating wound of the abdomen was looked upon as little less than a dead man, his way was through that portal at which those who enter leave all hope behind. Look at these well-weighed figures of our Otis in the Surgical History of the Rebellion, 13 3,717 cases, 3,031 deaths, a mortality of 87.2 per cent. In the British army of the Crimea the death rate was over 92 per cent, and in the French army of the East this rate was almost the same; in the German army at the siege of Paris, the rate was 94 per cent., and in the French army at Sedan an equal ratio. It is, of course, impossible now in times of peace to make comparison with the results above quoted, but I feel assured that hereafter when comparisons may be prac- ticable the finding will be very different, for have we not laparotomy and all of the abdominal technique, washing and drainage, intestinal anastomosis, and the ectomies? From the practice spring fresh confidence and firm convictions and a new born courage, the off- spring of these convictions. We know how great a success has crowned the endeavors of civil surgeons and we may rightly conclude that when the time comes a like result will be attained in military prac- tice, for there must be a new surgery of the battlefield. How different was it in pre-antiseptic days. I can recall memories far too sad to dwell upon. I can almost see before me the phantoms of the many who have perished from just such injuries as those alluded to. With every wish to help them and with every known effort so little in reality was done. The best knowledge of that day could not even accomplish a respectable diagnosis; the treatment was expectancy with folded hands. The quoted figures speak for the results. The idea of searching for a bullet in a pene- trating abdominal wound was not entertained. In the solitary recorded instance in which a world-famed operator asked "why not open the cavity and search for the ball," the very question was regarded as an evidence of genius gone astray and the suggestion was not even considered. Yet to-day the medical student in his second year could rightly formulate the treat- ment, now laparotomy, hemostasis, packing, drainage. So, too, in regard to chest injuries. The experience of the last few years has shown that portions of the ribs and chest walls can be raised or even removed 14 without injurious consequences. Estlander's opera- tion is familiar to every surgeon and it can not .be doubted that this operation may be so modified as to permit access to the pleura and the subjacent lung. I believe that deeply placed foreign substances will be traced, detected and removed and that hidden abcesses may be aspirated and emptied. Indeed the surgery of the chest is in its infancy, and when developed must prove life-saving. Instances of gunshot wounds of the chest occur to me, in which postmortem exam- inations revealed the presence of bullets which I am sure could have been found and removed by the methods of thoracotomy alluded to. The pity was that we did not know; you do. The internal study of the skull cavity is not beyond our powers, and when the cranial walls are perforated by gunshot or otherwise a suitable craniectomy is indi- cated. The sources of internal bleeding can be ascer- tained and arrested by ligation, pressure or otherwise, and at the same time foreign bodies may be taken away. In more chronic cases, abscesses may be located and opened and all this can be done, as many recent brain operations have shown, without unjusti- fiable risk to life. More could be added but time and place forbid. Thus in a few words I have sought to indicate something of the progressive nature of your art and show you what great changes are being gradually but surely wrought in surgery, and that by these the character of the military surgery of the future must be largely altered. You, as its servants, will be expected to know far more than your predecessors. You will be required to have a deeper knowledge of the modem doctrines of pathology and to comprehend their practical application in your every day work. All of these matters have been exhaustively presented to you by able teachers. When you leave this school and enter upon your active duties, you will assume higher responsibilities than those which usually fall to young medical offi- cers. In addition to the instruction which in civil 15 life precedes the acquisition of your professional degree, you have been especially taught many details which will affect your military life. You will thus be spared some of those hard lessons of laborious and dearly bought experience which have fallen to your predecessors. You now know to some extent, what is before you, what you have to do and how it is to be done. In a professional point of view, you have had exceptional opportunities. You have enjoyed time for reflection and have been able to weigh well the teachings of the civil school and under the supervision of your military professors to adjust your previously acquired information to the exigencies and changing phases of military life and I believe, moreover, that perhaps for some of you there may be a new function not yet covered by any paragraph of regulations. I mean a teaching function. I think that going hence, rightly having used your opportunities, you may be instrumental in disseminating the garnered experi- ences of many lives. You may become missionaries of military medical science. I pray God, that one day some great Apostle may issue from this school who may by practice and by precept, so spread its name and reputation that men shall turn and look hither with reverence. Ah, graduates, young officers, I almost doubt whether you fully estimate the advantages of your position. You enter upon your professional life at a moment when the bright rays of advancement illum- inate the whole horizon. We know and see enough to feel that a future which no man can foretell, is dawning upon our profession. Oh, that I could throw from my shoulders the burdens of the last forty years and be among you and with you and of you; for I see, and not darkly, that your corps has a glori- ous future, a future which it deserves and has earned in the past, by self sacrifice and conscientious devo- tion to duty. As a result, great institutions, the Museum, the Library and now the Army Medical School have grown 16 up, they have called forth the admiration of the pro- fessional world and stand as enduring moments to the zeal, industry and learning of the Department. In this good report of your corps you will share. Do more, contribute to its advancement. Be jealous of its good name. In every proper way, seek to further its interest. Especially let your professional work be earnest, persistent and well directed so that your names may not pass away. Do not live in vain. There was something noble in the last words of that good old surgeon, Perceval Pott: "My lamp is almost extin- guished, I hope that it has burned for the benefit of others." Let such be your life purpose. Remember that you have a triple duty before you: As members of our no- ble profession, let suffering humanity be your care. As officers, serve faithfully and devotedly, thus hon- orably will you uphold the flag of your country. As physicians, officers and gentlemen, be ever true to the dear old medical Department of the Army of the United States. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, MA RCH 38, 1896.