[Gathering and spreading knowledge: publications

and the Army Medical Library around World War 1; 2015]

[Ken Koyle:] Good afternoon, ladies and gentlemen. Thank you for coming to this

afternoon's History of Medicine lecture. I'm Ken Koyle. I'm the Deputy Chief of the

History of Medicine Division here. And before I introduce today's speaker,

I'd like to let everyone know that our next History of Medicine lecture will be January 28th,

2016 when Doctor Eric Boyle from the National Museum of Health and Medicine.

Will examine the history of complimentary and alternative medicine

at the NIH. In a presentation co-sponsored by

the National Center for Complimentary and Integrative Health

and by the Office of NIH History. And I hope that you will all mark your calendars and join us on

January 28th for that lecture. But on for today's lecture. Our speaker today is a friend and

a longtime colleague of mine, Doctor Sanders Marble. Doctor Marble earned his undergraduate

degree at the College of William and Mary. And his graduate degrees at King's College

University of London. And he's worked for and written

for ehistory.com, for the Smithsonian's National Museum of American History and

for the Army Medical Department, both in the Office of Medical History and previously as the command

historian for the Walter Reed Army Medical Center and the North Atlantic Regional Medical Command.

Since 2010, he has held the post of Senior Historian with the Office of Medical

History at Fort Sam Houston, Texas, a position that has included a tour in Afghanistan collecting

the history of medical support to military operations in that region.

Doctor Marble has written or edited about half a dozen books and numerous

articles and chapters on artillery, military medicine, and military personnel,

including Skilled and resolute History of the 12th Evacuation Hospital and the 212th MASH.

From 1917 to 2006, which was published in 2013 and Rehabilitating the Wounded,

Historical Perspectives on Army Policy, published in 2008. Doctor Marble is a volunteer with

the US World War One Centennial Commission and is helping to organize

an international conference on on the medical history of the Vietnam War,

which will take place in Texas in March of 2016. And Doctor Marble is actively seeking

proposals for that that program. You have to get them in soon, though I think the deadline

has already passed. Doctor Marbles topic for today is Gathering and spreading knowledge

publications and the Army Medical Library around World War One. There will be time for some

questions and answers at the end. If you have questions for Doctor Marble,

please use the the mics in front of you by pushing the button on the

desk which will light up your mic so you'll know that it's active. Doctor Marble.

[Dr. Marble:] Thanks for that very generous introduction and there's a sign

over here saying please make an announcement if you didn't notice the three signs on the way in.

There's no food or beverage in here.

I work for the Department of Defense. I have to make a disclaimer that these views are are mine.

They are not the official position of the Department of Defense, Department of the Army,

or any other part of the US government. Don't worry about that. It's just pro forma.

Today I'm going to talk about how the Army Medical Department gathered and distributed.

I got to be careful with my gestures and not hit the mics knowledge around

the time of World War One, before, certainly during and a little bit after.

And I I want to focus on the Army Medical Library's role in that.

And now the doors are closed and you're in here.

The library was actually not the key node,

so we'll have to see what the

Army did to to replace that. I should thank various of my

colleagues in San Antonio who helped me refine ideas

and sat through a rough presentation of this.

More than most history projects, this really actively engaged my librarian and archivist

colleagues instead of just using the wonderful resources they have.

I need you to think about an anachronistic term, but think about this and then

not pay it too much attention. Before, during and after World War One,

the Army Medical Department had to collect, categorize, and then distribute

information. That is knowledge management. And while there were Hollerith cards

and and other IT technologies of the day, I'm really not going to focus

on information technology. So who here is a librarian?

Yeah, quite a few historians?

Yeah, okay, one loner. Physicians? Okay,

I think you'll all have different perspectives on this knowledge management

from your professional backgrounds. Now, the Surgeon General's library

started in 1836. At first, I don't think it was very much of a library.

It was a bookcase with books on it.

Yeah, they collected material about medicine, especially military medicine,

and it was a repository of information. You could use it if you visited. If you were an army doctor,

you could write in and say, hey, I'd like some information about X or I'd like to borrow book Y.

And they would do that. And they would also send information out. They would push out orders.

They would send advice by letters around the Army. But of course, this is 1830s,

1840s fifties. There's not a whole lot of good advice to send out.

The Army starts producing some

medical information, but there's no expectation of a quick turnaround.

This circular is produced this sorry, this published four months of data,

but it's two years into the war, so it's not, you know it not particularly useful.

It's also descriptive data. Without prescriptions about what you should do.

Individual doctors would look at this if they chose to, and then see how to best they

thought to use it. Now it is part of William [Alexander] Hammond's efforts to gather information in the

Surgeon General's library and the Army Medical Museum that he created. Now Hammond is expanding and

establishing repositories for knowledge, but I don't think the mid 19th century

circumstances are really great for pushing prescriptive information outwards.

The Army sends out material for information. You know, again, you can decide what to

do with the doctor and especially given how loosey-goosey medical diagnosis are,

surgical surgery is different from medicine. Medicine is much more loosey-goosey

in this time. The data would have had relatively little value you could interpret.

You know whether whether patient has recurring fever or intermittent fever.

Differently from another doctor. I'll give them credit for trying.

But then this may have been more of a public relations public document

and the Army Medical Department was under fire for the the rate of

sickness and the the certainly the number of deaths from sickness.

And they may have wanted to publish some statistics to make it look less bad.

1863 sorry, 1865, this is one of the first books in the

world to have surgical photographs. And again, the Army Medical Department

is gathering and creating knowledge. You know that depends on your perspective

and making it available and the museum is hugely important in this period.

I think Shauna Devine has talked behind

this very podium about that topic. And the in peacetime,

you can just see the dates there that they continue publishing in peacetime.

The Army is publishing this four years after a Lister publishes his article on antiseptic surgery,

and if so, my point being this isn't a time when the Army is not doing a lot of surgery,

so a few years is needed to get a robust data set.

They continue gathering information and passing it around, but it's quite slow.

Data collection for this publication began in the spring of 1868.

And this information is finally being used for an argument.

The main body of the report is descriptive, but the introduction by Doctor John Shaw Billings

points out that better ventilation reduces respiratory diseases and that

money spent on barracks reduces the Army's sick rate and thus keeps troops fit

for duty and reduces medical expenses. He's trying to make an economic argument

to Army leadership and to the Congress. That to get better facilities and he he

reaches into the medical data for that. This report, also overseen by Billings,

was rather quicker. This is all done in about 6 months.

Data call went out in October of 74. It also covers a lot of things

that we don't call hygiene today. The food of the Army, its quantity,

quality and mode of preparation. Is the food of the men's inspected daily?

Military punishments and their effect on the health and morale of the men.

Personal cleanliness of the men. What are the post regulations, if any, with regard to bathing?

What facilities are afforded? How often are the men's blankets washed?

Again, the medical department is looking at making the Army healthier,

looking for the best ways to do that, and literally airing the Army's dirty laundry.

Both of these circulars were quite hefty, #4 was over 500 pages and

this one is over 600 pages. Now these are being researched and

published from the Army Medical Library. The librarian,

Billings is converting it from a repository

where information sits to a locus for the intellectually curious. There's of course a good

literature on Billings. He could be probably has been the subject of a talk just by himself.

And I'm not going to try and tease apart what portion of the the change in the

late 19th century is due to Billings. What portion is due to

surgeons general that come and go. My my point is that the AMED, the Army Medical Department used its

library as an applied research tool. Now that may have been where the because the library was where

underutilized hands were. You know the Surgeon General's

office had only about six officers and 20 clerks and they were busy with routine administration.

Billings had more time on his hands. That's not to take anything away from Billings.

I have enormous respect for the variety of things he did. And the medical library was not alone.

The medical surgical history was produced mostly from the museum.

The six volumes are published over 1870 to 88. They are quite valuable,

but there's clearly a long lag between the events and the publication.

Now that's fine for history. That's probably important for history to get some perspective.

But it's not a good way to pass around anything that's time sensitive.

From 1880, Billings at the medical library was also producing the index catalog.

I'm not going to belabor that for the audience here, but it not only organized knowledge

by publishing that organized volume and soliciting more publications using doctor's vanity.

I think doctor's vanity is the reason that the Army Medical Library became

the world's largest medical library. The medical library brought together

more and more knowledge and made itself more and more useful. And then it's also pushing,

It's organizing this knowledge and pushing it back out. The catalog is not just available on site,

but print runs are well over 1000 volumes. It's a print runs it by World War One,

or about between 1000 and 1500 copies a year. Now the Index Medicus will be a worthy companion,

the monthly review of publications rather than the much slower, much slower,

but more comprehensive Index Cat. In 1893,

the Army establishes a school. You can guess what it's called to train doctors.

Some of it's in Army related topics like equitation. Dr. has to ride with his troops,

some of it's in Army clinical matters like sanitation that a civilian Dr.

wouldn't necessarily worry about, and some of it's in clinical things that are

not necessarily common in medical school, like microscopy.

The Army had a baseline standard for not just medical not just military topics,

but medical topics that were not necessarily taught in schools. But the school is sized for

the number of doctors that come into the Army any given year. There's no correspondence

courses for anybody else. There is no follow up courses for guys

10 or or so years into their career. This is, I think really the only place the Army

pushes medical knowledge to doctors. They they will send out a circular letter

occasionally.  They can do that, but this is the formal place

to make people smarter. Skipping and hopping ahead.

Nothing to do with the medical library now, but this is a case of of the Army

producing and disseminating knowledge. Reed, Vaughan and Shakespeare

discover how typhoid is communicated, including the aha moment of well

moments of the asymptomatic carrier and indeed the very idea of a carrier state.

This is the 239 page preliminary report. Four years later they come out with

the 1600 page doorstop report.

I think this is a time when book type publishing met the information cycle.

Nothing could be published before the date is analyzed, so getting at a really good preliminary

report in 18 months is very good, with other things going on in the background,

Reed himself is busy with yellow fever. The Surgeon General's office is busy with political fallout

from the Spanish American War.  You're going to have a lag in publishing the full report.

And I'm also not entirely sure what that full report gets you. More data to hit people over the head?

Okay. The circulars on posts and hygiene 25 years in the past.

But they're also correlative this and what we get around the turn of the century is that the the

doctors have step by step science to back up what they're arguing and

and what the army doctor is then. Saying to a unit commander, hey, you need to put the latrines

downstream from the water supply because here's the science, not just because we have correlative

data that that says it's smarter.

Let's go 10 years forward. These bulletins started in January 1913

under Surgeon General George H. Torney. I don't know that he had a personal impact on creating them.

But he did build up the medical school at the time. He may well have been involved in this.

There was some hope that these would be quarterly, but that never happened.

They turned out to be enormously erratic. There are 10 / 36 months.

Most of these would also be monographs. 45 pages, 133 pages, 97 pages.

So they don't fit as an article, they don't fit as a book,

and they can't get published any other way. But, it's a publishing route that

is under the Surgeon General's control.  And I have to apologize. I took some bad images along the way.

Now the Army, not the, not the medical department, but the Army certainly had

ways to push out information. There's a there is a book of Army regulations at this time.

It is a book and it is enormously thick. Getting something changed around

that applied across the Army. It meant that it had to be staffed through the whole army you had.

You had to get everybody to agree that it didn't bother them. I meant, you know,

the analog here would be getting HHS to approve everything that you have to do.

So, but if it's something that only applies in your sphere, so in the medical department,

something that applies there, you don't have to ask the rest of the army.

Especially so for clinical things the the medical department can move much quicker.

The circular letter, an arcane term, that, that's what they called it. Still,

the circular letter was the main route. So that's background, probably too much background.

So World War One, what does General Gorgas need? He knows his medical department is going to expand,

but he doesn't know how big it's going to get. Ultimately, it's going to grow from 450 regular

Army doctors to over 30,000 doctors, so.

95% of of the guys are going to be new. Gorgas knows that, that he's going to have to push out

information on all sorts of topics, but he doesn't know what those topics are

yet or what the information is going to be. He does know that he needs it soon.

So how's he going to get information out? So far I've talked about

institutionalization and publications and that was a major route for the Army.

But there were also person to person channels, which in the great Army way

they institutionalized. Consultants was what they called it there another way the

Army manages knowledge. For the first time the Army has to grapple with the

many facets of medicine that have become more and more specialized even in the interval since 1898.

And it and at the time, the Army has essentially no specialists.

The Surgeon General's office, for instance, is still about eight officers.

What they do is they quickly reach into civilian circles to get the technical experts.

The lead actually comes from the American Expeditionary Force,

the AEF over in France in the summer of 1917. They pick John Finney,

JMT Finney out of Baltimore who was the 1st President of the American College of Surgeons as

their Chief consultant in surgery. They reach grab Harvey Cushing and George Crile

as another couple of consultants. The lead medical consultant was William Thayer,

clinical professor out of Hopkins. They end up with 19 senior consultants.

I'm not going to run all the names past you, but these are the most recognizable.

Now, a consultant supervised and coordinated professional work, but they also were not an

inspector in an Army sense. They might catch you out on doing something

in that's clinically inappropriate but they're they're not there with a

checklist of of how to do it just right. They're also and they're more interested

in are you doing the right thing then are you doing it by the book.

They also become personnel advisors. Who are the good neurosurgeons?

Well I don't know let's ask Crile he knows.

And they also I think it makes a big difference in the AEF

that they are imminent practitioners because they and not inspectors

because they can more easily, talk to the British and French to get their clinical developments

than they could if their job was to inspect American facilities.

In the US, consultants had similar duties. These brothers Mayo were the

co-chief consultant in surgery. Each one of them ends up as a Brigadier General.

So it takes a moment to look at some of the nontraditional knowledge in processes. In the past,

the Army Medical Department had pulled information from its own doctors, those circular letters that

tell us about your post. They've done literature searches the that the the library did.

There are certainly friendly contacts between the military and civilian doctors,

especially once the Medical Reserve Corps established in 1908. As an

example when the medical department wanted validation that typhoid vaccination was the right thing.

They assembled a board of reservists, including civilian luminaries like Victor Vaughan, biochemist,

bacteriologist, and Dean of medicine at Michigan. William Thayer at Hopkins, Simon Flexner,

a professor of experimental pathology at Penn and director of the Rockefeller Institute.

Those guys are willing to serve in the Army as very junior officers,

first lieutenants. But before US belligerence in World War One,

so between 1914 and early 17. The Army had first permitted and

then pushed medical observers to Europe to gather both clinical and administrative information.

And also the army had pumped the civilian doctors that had gone over

under Red Cross auspices to volunteer in mostly French civilian hospitals.

Those doctors would also publish articles, and I'll touch on those later.

Most of the observers are senior men, so they're have credibility in the army.

The guy in London, for instance, is a full Colonel who would become the first

surgeon of the American Expeditionary Force. So the Army Medical Department

is preemptively trying to get information and which is good, it now has to organize it

and send that back out. I'm not going to underplay getting information from its own doctors

in World War One. There were certainly inspection tours by those consultants that both

gathered and disseminated knowledge. There are also medical liaison officers that come to

the AEF from the British and French. British and French also push medical

officers over to Washington to work at the Surgeon General's office.

Gorgas had the medical library which

does a wonderful job of publishing the Index cat and the the people working nights and weekends and

get out the index medicus as well, but that is not his main route to

push information during the war. Part of that was staffing during the the border flap with Mexico,

which in those days it was Poncho Villa coming from the the South. Nowadays, of course,

it's Donald Trump going from the north. The surgeon General's office had pulled

the most active library clerks to work on other projects since that was in night.

You know, we had troops in Mexico into 1916, by 1917, those guys, and they're mostly guys,

still haven't returned to the library. The library is increasingly left

with the old grumpy, infirm clerks. One was nearly blind, which was a

great qualification for library work. They do get to hire more, but there's serious morale

problems in the library. The librarian has to write a note to all staff saying knock it off.

I'm sure things have changed tremendously. They do. They do get to hire some more during the war,

but they're simply not able to work fast enough. Administratively, the library and museum are

lumped together under one guy, but the museum's wartime responsibilities start to dominate his time.

Champ McCulloch spends more time finding histopathology technicians

than working on the index catalog. He possibly spends more time going

over to France in in his mind, in support of his responsibilities,

than either than actually working on the the library.

A few people were given desks in the library, but they're not working on library projects.

There's a publications branch that gets started and there's some. So there's some people that

that work in the library, that don't work for the library, but with more doctors and also the

specialists, those consultants sitting in the surgeon general's office,

those are the ones that are tapped to select and organize the important literature, the librarians.

Are just the the the view of them changes to. They're just clerks that

that catalog the books. These doctors who have the specialty

knowledge are the ones that we look to for that specialty knowledge. In the A EF there is no library.

We did, we didn't duplicate everything and send it to France. So the chief surgeons staff

and the consultants select and organize the information. So I'm going to spend a lot of time

on how they get that information out. The peacetime dissemination routes were inadequate.

I don't think an index of the, sorry, an issue of the index catalog is

really going to be much used to a doctor in the trenches who's dealing

with trench foot or shell shock. It's just the wrong sort of

source of sorted information.

Now regulations had to be coordinated around the Army, so that's slow.

Manuals were apparently more technical

and decentralized how to pieces. They could be very basic. What is the right way to pick up a litter?

They told you what the right way was. It could be a manual of laboratory methods.

This is how we do lab to dark field smears.

If that's an actual thing. A circular letter could be issued across lines of command.

These would be technical guidance on how to do things, I think.

A good analogy would be when the Library of Congress changes cataloging methods.

They published that and they don't tell you how to do it, but they tell you what their standard is,

and you get to choose whether to adopt it or not. They could also,

because they cut across command lines, that's important. In the Army, they could,

so they can spread information laterally instead of just from the

Surgeon General's office to anything that's directly under his control.

You can also use them for information, so they publish more morbidity

and mortality data that way. So that the bulletins are apparently unchanged from before the war.

It's a publication that the Surgeon General controls. They were very erratic before the war,

though. They will be what really changes. And knowing the small capacity

of the medical school, the Army had been starting some

correspondence courses before the war, but timings wrong. They start them in 1914.

Nobody has graduated by the time of the war and they get absorbed. So some of the unofficial routes.

Messrs. Lea and Febiger published eight of

these medical war manuals in 1917 and 18. I don't know what they charged for it.

I think the Army ended up buying a bunch of these as textbooks. I don't know how they handled

royalties for doctors who, you know, government employees who published

this and then have the Army buy it. These are the topics. Again, I think these fall into the

textbook category. They're not critically quick or topical, but they're good for things

that don't change very quickly. You know, ophthalmology is not going to change

enormously over the course of a year. Some of these are purchased by the

army and issued as textbooks at the medical officer training camp.

And the Army organized special schools

on some of these topics, and that's where these were especially important manuals. #2 is actually

written by a British officer, one of the liaison officers in Washington.

I think he was probably asked to give us a quick manual on everything we need to know.

Independent committees are also doing things that help the war effort.

I don't know if the Army asked the National Committee for Mental Hygiene

to publish this, or if Salmon asked them to? Salmon was a member. I don't know if he said, hey,

here's an important thing, can you guys publish this more widely?

The government had sent him over to Britain and France to observe shell shock.

He'd gone over from Britain to France to see up close to the front.

So this is essentially a government report, but it's published at no cost to the government.

I think, but I also think that the the committee here and Lea and Febiger shows

that there is a market for these things.

This is cutting edge information and this is something that is

actually brand new during World War One and doctors want it.

30,000 doctors end up in the army. Some of them are, you know, are going to be seeing shell shock.

They're going to want to buy it. Civilians may well want it as well.

Here's the Army writing something in the AMA publishing it for them. According to the Army,

this was popular with civilian practitioners and it's taken over by

the Public Health Service after the war. So the knowledge is organized by the Army,

published by the AM A, and then could perpetuated by elsewhere in the government.

I think this is a completely independent product, but it's a medical library creating,

you know, organizing the knowledge, creating bibliography, and then pushing it out.

This was sent to military bases so their hospitals could have a reference guide.

I don't think the AML did that. The Crerar are was willing to

interlibrary loan the the books that they had and they would also make

photocopies of journal articles at cost, which is pretty big of them. Here's a nice effort to help.

It's, you know, unlike the National Committee for Mental Hygiene this is not a one off.

This is a supplement, obviously. October 1918 is not going to

be enormously useful with the war ending the next month, but you know their information

technology was just not as quick as up to date or the databases we have now.

This went through additions and publication or and reprints in 1917 and 18.

Again there's a market for this sort of thing probably helps

that Keene was really well known.

This is a special neurosurgery volume. The contents come from those those big

brains in the certain general's office. But this is a 360 page literature

review and you can imagine how frequently this would be useful. I know you have to be a

neurosurgeon to actually use this, so maybe they could get one to everybody,

but you can't really update it. And preparing something officially

doesn't necessarily mean that it actually gets published officially. Again,

they publish this gets published privately. There's different editions of this

506 pages about how to shoot X-rays. $4.00 for some editions,

$5 for others at the time. So I think you know a lot of civilians, physicians

I've never worked with X-rays before. A GP really wouldn't.

So there's an interest in the American medicine. Now,

Gorgas had excellent relations with the medical profession,

and the AMA quickly began to help the Army. For instance,

they sent 69,000 letters to doctors, not one guy getting 69,069 thousand--

69,069 thousand doctors getting a letter each. And it would tell them, Dear Doctor Jones,

this is how you volunteer for the Army. Wouldn't you like to do that in our time of national need?

JAMA begins to publish this column. The very first issue after the US

declaration of war and the Army liked this. The Army really appreciated it.

The propaganda published in the Journal of the American Medical Medical

Association and the printing done for the medical department by that journal

were of great importance and value. Credit is also due to other medical journals and the American

Medical Editors Association for the use of space and editorials in placing the needs of the medical

department before the profession. Practically all the leading medical

societies of the country rendered assistance in this connection.

But Gorgas doesn't control the AMA or JAMA. It's also not a perfect route to doctors.

Not every doctor is a member. They're still not. And getting JAMA through the through

the mail is going to be a trick. Getting it over to France is going to be a trick.

And also JAMA had never paid

much attention to the military. In 1916, from 1916 to

in, in all of 1916, it published

eight articles on wartime medicine. None of those was a particularly quick turnaround from the events

it was describing to a publication. By the fourth quarter of 1917, US had been at war for six months,

and JAMA is publishing 11 articles in that quarter.

But that's only 5.5% of their articles.

Now the AMED had excellent relations with the Association of Military Surgeons.

AMSIS had started in 1893 mostly for National Guard doctors,

but it had expanded to the to include the Regular Army and the Medical Reserve Corps.

The journal was run by a retired Army doctor and articles were on military medicine.

There's also multiple columns of administrative news, administrative changes, how to get things done.

Moreover, at the time, they were so flush financially that they had recently expanded the number of

pages and size of pages so they could. They doubled the space available for articles.

They even sent free copies to every Army hospital. There's actually a reference in the official,

the Army's official history saying this was an official publication.

And they're also people that are so useful to the Army their their desks are

in the Army Medical Library building. But this is a monthly.

This is not an "as I need it" to be published, and the Army could

not require doctors to join a private organization to get the information they needed.

And if you know this also goes out through the mails. AMSIS had had problems for all the

reservists that have been mobilized to go down to the Mexican border in 1915 and 16.

Those guys were not necessarily getting their copies of this in the mail and then they knew that

that was going to be a problem. In the US, when the army moves you from point A to point B,

and certainly a problem if you go overseas. Now, they do pay more attention to war medicine.

They had brought people more up to date. 1916 they published 28 articles on World War One,

which was about 1/4 of their total articles. But these journals have to be independent.

They cannot be let themselves be taken over by the Army and then try and come back out later.

So, I hope you can see where this is led. The Army needs a publication and

need a way to push out information. They have to do it themselves.

This review of war surgery and medicine is a fortnightly push of

abstracts and special articles. And they can choose. The Army can choose what goes into

this for for topicality keeps the doctors abreast of what the army thinks they need.

And it can also travel in supply channels. Though it's not considered mail,

it's considered an official publication. That's not to say it's necessarily prompt,

but it stands a better chance. And ahead articles on things that civilian

doctors would simply never have seen. It would never, civilian doctors don't see trench foot,

so they they publish a 10 page article on trench foot in March of 1918. If they also make it available

later to civilian medical libraries, only $0.10 an issue cheap at the price.

It ran for about 18 months through volume 2 #6 in June of 1919.

It slows down from fortnightly to monthly, but it's, you know,

it is the Army Medical Department's own and owned publications channel.

Again, I'm sorry this isn't more legible. It's abstracts, translations and reviews

of literature, reconstruction and reeducation of the disabled soldier.

So the Army was facing new questions about rehabilitation of the severely

wounded and also guys who've gotten sick. So they both they first established

policy spearheaded by a former AMA president and then it starts a rehabilitation bulletin.

This and it again, it has abstracts, translations, reviews,

articles on various facets of reconstruction that their their catchall term.

Including vocational training. This is a publication headed not for publication,

and that's something I thought only the Air Force could do.

Now I'm going to talk about what this guy, Major General Merritte Ireland wanted to do. He's surgeon,

the chief surgeon over in France for the American Expeditionary Force for the key part of the war.

There's a guy before him, but General Bradley doesn't have,

is in poor health and doesn't get much done. Ireland has liaison officers

out to the British and French. They have liaison officers in. He also writes to officers

saying keep your eyes open, talk to people, listen to people.

Sent back reports to my office. He had different ways to push information out.

He used circular letters, for instance. Some of these are administrative,

some of them are very clinical, he tells hospitals. If you have a pneumonia patient,

don't evacuate them back to the next hospital up out of the chain of evacuation that kills them.

He also used the Red Cross to print at

least one manual and a journal for him. He also published a weekly bulletin.

I don't know if any copies of this have survived. It would be great if you guys

could find some. It was 5 inches. It was a 5 by 8 sheet.

6 to 12 pages included not only data

on epidemics in the over in France, but the causes and treatment of wounds,

notes on health conditions back in the states, references and extracts from medical literature,

charts and drawings. They even said that they wrote it to be interesting.

I don't know how it was received, but they tried to make it readable. As I mentioned,

they have consultants staying abreast, professional developments and advising,

you know, so those guys are the ones who are really managing the the knowledge in there.

Ireland also sets up a school called the Army Sanitary School. Only a very small percentage

of doctors would go through, but he did use it to spread information to they sent the

classes up to the front lines, not literally in the front trenches, but up close.

They brought in British and French lecturers to the school, so they're using that as a

means for knowledge exchange. This is published by the published by the Red Cross.

They, the Red Cross also publishes a second thing, a medical bulletin,

which was focused on research. Now there's an unusual category of

information we don't see anymore. Army general hospitals. These are the referral centers,

not the community hospitals. And because they are seeing the more complex longterm patients,

they're going to be, the patients are going to be there for months. These hospitals are

encouraged to have newspapers. These are a mix of humor,

local news, you know, sports teams, administrative information.

So for instance, how the Army has changed its discharge policy lately and something

that would apply to to patients and encouragement for patients.

TB patients were a particular concern. [dramatic voice] It was planned to control the thought,

attitude and conversation of patients so far as possible, by means of personal talks and pamphlets,

and by building up in them some cheerful philosophy of life. Hospital newspapers were active

morale agents, considerable thought being devoted to suggestive titles as "Ward

Healer, The Comeback" and "Carry On", and to contents that would be encouraging,

stimulating and attractive. I think Jeff Resnick would cheerfully

throttle me if I didn't highlight "Carry On." It was the longest lasting hospital

newspaper and probably by by virtue of being printed in DC, had articles ghosted for

the great and the good. You'll even notice that that this official

publication is paid for by the Red Cross. These are are definitely

government communication routes. The Army sent out notes to the editors

saying do not contradict official policy. [dramatic voice] For the information of the patients,

their relatives and friends. The hospital newspaper should contain some authoritative statements

furnished by the Bureau of War Risk Insurance and by the Federal Board of Vocational Education,

which embrace the benefits provided by the government of convincible disabled soldiers and

sailors after their discharge. --And while I'm looking at

patient directed literature, health advice is another category. Enlistment data.

You know, medical screening of recruits had showed how wide STD's were.

And the progressives were progressive. They wanted to make things better. This is a short booklet on

how to lead a clean life, part of a multiformat campaign that was unleashed on soldiers.

You can also see how the various agencies are involved.

The War Department had set up the CTCA, the Commission on Training Camp Activities.

They were a bunch of no funs. They didn't like red light districts,

which is, you know, from the Army's perspective to keep soldiers healthy.

So okay, so the Army sets up the CTCA. The CTCA then publishes this--

Once the war is over, the Public Health Service are going to be the guys who are

keeping the effort going, but while you know, but if you're directing information

as people in the Army, soldiers, then the Army is probably the best means to get this job done.

So the Army actually sends this out. Here's another part of that propaganda information campaign.

They made a movie. It would be great if a copy survived, but apparently none did.

It was it would have been really, really interesting. Now I mentioned Index Medicus. Index Cat

Series 2 ran from 1916 and then Series 3 picks up in 1918 and

I think that reflects some of the the big issues that the medical library is having at the time.

The medical library certainly contributes to this 260 page summary of

international literature on military hygiene, medicine, surgery, ophthalmology, ear, nose, ear,

nose, throat, naval medicine and surgery and related matters. It includes psych that's

categorized under military medicine, but this is published sometime after one July 1918.

All I could find out that it was published was in. It was published in fiscal 1918,

so sometime after the the middle of the year. So it's a a nice thing to do,

but it's not particularly timely. Those semi official publications continued after the war.

I think this came out after the war because that's when the AMED had shifted

focus on keeping them healthy, keeping them alive to reconstructing them.

Now it's a good thing that lunch is over, because I don't think you really

want to flip through the 256 figures. But this was 442 pages,

so it's a it's quite a compendium. Military journals were not the only

route for knowledge to move around. They certainly used civilian journals.

Military officers were encouraged to prepare articles for publication

so it they would inform the the profession,

not just those in the military, and the Army would then abstract these

articles to get another feedback loop. This was a supplement to the Army's bulletin

that stopped in June 1919. This starts in December 1919

continues into 21.

I think it was sent to organizations, not to individual doctors.

Later on, it is supposed to be sent out to every doctor in the regular Army,

the Guard and the Reserve, and a few civilian libraries and

individuals and a few journal offices were put on the distribution list.

It's published not by the library. But by the laboratories and infectious disease division and

it includes article abstracts, notes on investigations that are going on clinical investigations,

not anything else and all statistics.

Hospital capacity, how many beds are full, how communicable diseases were going at that time.

I think that's why it's coming out of the, the infectious disease division.

So this is largely clinical. The Army Medical Bulletin starts up

after the war instead of the review. Initially it's not a regular publication, but as needed,

just like the prewar bulletin. And it ditches the fortnightly disease and hospital stuff

because not every doctor needs it, and also if you're coming out irregularly,

then having that data isn't really, really useful. Later, the Bulletin would become regular

as the Interwar Army refines its intellectual infrastructure. The consultants cling by

their toenails after the war, and by 1921 the Army Medical Department had lonely,

had gone back to generalized hospitals, not really general hospitals.

There are a couple general hospitals, but only really two.

They only one or two officers in the Surgeon General's Office are overseeing the specialized

wards that hospitals have. So in both facilities and personnel,

the Army Medical Department is really back to its prewar condition. And actually handling those

specialists is mostly just a personnel matter as far as they see it.

There's a restructuring of Army regulations after the war from one big book to a lot,

a lot, a lot of small books. The Army Medical Department had its own

index to all the regulations that covered it.

These are. These are an important way to get information out, although I'm not sure they

were necessarily a timely one. The time to revise these could be quite long. And I'll close with

a long term knowledge project, the Official History. This was remarkably completed in 1929.

The original plans for the history were laid by the surgeon, the librarian,

Colonel Champe McCulloch, and the bulk of the editing work was done

by somebody sitting in the medical library. Contract surgeon Loy McAfee,

who I think is one of the profiles in medicine somewhere on your website.

With my knowledge theme. The post war reorganization split the

medical museum in the Medical library. They've been together since the 1860s.

Now the library is paired off with the historians while the museum is put in with the laboratory,

which was appropriate for an organization that was leaving medical

curiosities and becoming a pathology collection and Pathology Organization.

And I'll conclude, The Army Medical Department diversified its ways to gather, organize,

and disseminate knowledge around World War One. It paid far more attention to

what other countries were doing, trying to learn from example rather than learn from experience.

Lacking good existing routes, Gorgas also used a large number of

unofficial routes to spread knowledge. He created some official routes because

the unofficial ones were not sufficient. New routes were pioneered and

new audiences were targeted.

The medical library played little role in this until after the war.

I think it's prewar specialization in producing a long cycle publication.

The index catalog meant that it was simply not flexible enough to handle

the volume of work or the deadlines. And library clerks also were not

probably the right people to stay up with the current clinical literature.

Thanks very much and I look forward to questions.

[applause]

Use the light please. Sure.

[Ken Koyle:] Thank you. So, thank you Doctor Marble I really appreciate your your talk and

this analysis of the the publications really from the end of the Civil War

all the way up through World War One. So my question is about what the

publication that you closed with the the histories of the the Great War.

How did since this was a a publication primarily of the library,

how did they gather the the content

for it they you know how did they get doctors to write the the essays that

became these remarkable histories?

[Dr. Marble:] A lot of what they did was pull the

monthly reports that had been filed during the the war and they actually

enforced filing monthly reports. During the war, people got in trouble for not doing monthly reports.

And it's a whether it's a hospital in the USA, hospital in France,

a regimental surgeon with, you know,

the 123rd Infantry Regiment in the whatever it was division. They were all supposed to file

reports and and then and they did. Those were enormously useful.

They also bring in people that oversaw

that particular function during the war. The guy overseeing it would

probably be a regular who was still

in the army in 19/23/25 and and he would know the things to highlight

and the things to that that were certainly present in the reports

but less important. McAfee I think actually writes it the you know I don't.

I think Lynch and Reed and and all the other senior officers have plenty

to do as senior officers and they

work with her to put it together and then she figures out what you

know what sentence to quote from a report and there's a lot of of-- unquoted quotes.

So they they take chunks out of reports.

But they they use the existing reports. They bring in the officers that had overseen something,

including some of the clinicians who had gone back into civilian practice.

So Salmon is involved in the Neuropsychiatry Volume,

Crile is writing parts of the Neurosurgery Volume.

But then McAfee does most of the writing. I think they're more content

with her because she is an MD. They wouldn't hire a historian to do it, but they would hire a Doctor

who was willing to write.

[Audience:] Thank you for a really interesting

talk with lots to think about. So the for me at the moment,

the most interesting question was your point about the

distribution of information during the Civil War being mostly here's the information, you, the doc,

should make your judgment based on it, but you it's your judgment that's in charge.

And then it seems by the end of of the Great War, there's much more of a

standardized approach to things. What I can't tell because I think I'm just ignorant,

is whether there were certain turning points in just an emerging consensus

which then the Army built upon, or whether part of it is a top down kind of thing because they

had to run a system of hospitals or whether there's an interplay, that's a huge question

but I think you have at least the start of an answer?

[Dr. Marble:] Yeah, I'll give some answer and I will

also say that I it is a big thing and I don't know all of it.

I think you have the beginnings of medicine becoming a science in that period

and there is a clear answer on what is the best thing to do.

You also have a lot more specialization in medicine,

so not anything like what we've got

today with boards and fellowships and people that only do such and such,

either because it's more lucrative or because that's what they've specialized in.

But you know, there is a board of Ophthalmology, there is this that is the only board established.

It's established in 1914. But there are guys that have said I do eyes,

I don't do medicine, I do eyes. There are people that say, you know,

they're not organizers aboard yet, but there are neurosurgeons and you know, I don't do medicine,

I don't do surgery, I do neurosurgery. But in the bigger picture,

going back out to things like sanitation, we've gone from something

that that Von Shtoyben knew. In the Revolutionary War, which is if you,

you will have less disease in your troops if you pay that more attention to hygiene.

He knew this. He didn't know why. After 1898, you've got a lot of science

as to why don't poop where you drink. You're going to get dysentery, you're going to get typhoid,

and a lot of your people are going to die. And I think they're also haunted

by that the the medical department as an organization is haunted by

its professional failings in 1898, for which they get hammered in the

press and they are desperate to avoid another hammering in the press.

They also, you know, even in something they get hammered in the press for in in World

War One is childhood diseases. It's a much more rural population.

In the US in 1917 and you bring together

millions of young men a lot of them haven't been exposed to scarlet fever.

There is a big measles and scarlet and another scarlet fever epidemic

in the army and hundreds of deaths. Hundreds as opposed to millions of

men in the army but hundreds is bad enough and they they take the army

takes heat for that they but they have some science to to go on saying.

I told you the surgeon general testifies to Congress saying, I told the the the army we needed to

have more square footage per man in the barracks and better ventilation,

or we would have epidemics of communicable disease.

And they said we need to win the war. This does not win the surgeon General

friends for testifying in front of Congress that his bosses had overruled him.

But he has science to go on and and

exactly which piece of science or which piece of this whole topic, there's, you know,

there's a lot of different answers to that, but they, they had a lot more science to go on from,

you know, the antiseptic surgery from 67.

They had a lot of hygiene data to go on. And they've also got doctors that

are much more specialized and know what to what the right answer is. But they are also, yes,

they are more prescriptive. And I think it comes back to if I know what the right answer is,

I'm going to tell you what it is. [Audience:] That's what's interesting about the

way you framed the question though is that it's in both an in and and out flow.

And so they're gathering the information which makes the science,

maybe not in the sense of scientific law, but also partly about

local conditions in this war, but at the same time they have to run

a system and so it's very interesting to see it move in the direction of

you know here you go make your own decision to this is the proper way to.

[Dr. Marble:] And I think there may also have been a changed expectation in the

public and if I'm a family, you know if if I have lent the

the government my son in 1862, I want them to take the best

possible care for of him, but I don't know what that is. And I know that nobody is

certain what that is. In 1917 there's a whole lot more certainty about what the right care is,

and if the Army doesn't do that, then that great big hammer of public opinion is going

to come down on their head.

--Thank you.

I scared everybody else off?

Well, thanks very much.

[applause]

[graphic and program end]