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

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Armed Forces Institute of Pathology: Its First Century 1862-1962
by Robert S. Henry
Chapter VII : Triumph Over Typhoid
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4134282Armed Forces Institute of Pathology: Its First Century 1862-1962 — Chapter VII : Triumph Over TyphoidRobert S. Henry

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CHAPTER VII

Triumph Over Typhoid

Writing in 1906, Maj. Jefferson Randolph Kean declared that "Typhoid fever is today, on account of its wide dissemination, the persistent vitality of its infecting organism, the duration and severity of its attack and its large death rate, the most formidable infectious disease with which we have to contend in military life." 1[1]

Of this fact, the Nation had had melancholy proof in 1898, during and after the war with Spain. Hostilities with Spain ended with the signing of the peace protocol on 12 August of that year, but there was no treaty of peace with a more insidious enemy, the Bacillus typhosus, as it was then called, or Salmonella typhosa, to give the microorganism its present-day name. Typhoid fever struck one out of every five soldiers in the national encampments within the United States, with a date rate of more than 7½ percent of those stricken.2[2]

To the study of this epidemic, Surgeon General George M. Sternberg assigned Maj. Walter Reed of the Regular Army, Curator of the Army Medical Museum, and two surgeons of the Volunteers— Maj. Victor C. Vaughan, dean of the Medical School of the University of Michigan, and an epidemiologist and microbiologist of note, with special experience in the examination of water supplies, and Maj. Edward O. Shakespeare of Philadelphia who, as special commissioner from the United States, had studied cholera epidemics in Spain and India.

The new Board, set up by General Orders No. 194, Adjutant General's Office, on 18 August 1898, lost no time in getting to work. On 20 August, they were at Camp Alger at Dunn Loring, Va., near Washington. There they found hundreds of cases of fever which they believed to be typhoid, but which most of the medical officers in attendance had diagnosed as malaria. ​

Typhoid and the Medical Museum

The question could be settled only by microscopic pathological examination, and there was not a microscope in the camp. Authority to set up a diagnostic laboratory in each camp was requested and was granted. Doctors William M. Gray and James Carroll of the staff of the Army Medical Museum were assigned to the laboratory at Camp Alger, the first to be established. Later, after the troops left Alger, the activity was transferred to Fort Myer, Va., and afterward to Jacksonville, Fla. 3[3]

The Typhoid Board's first stop on its tour of inspection of campsites and surroundings was at Fernandina, Fla., reached on 26 August. By the end of September, the Board had visited camps at Jacksonville, Fla.; Huntsville, Ala.; Chickamauga National Park, Ga.; Knoxville, Tenn.; Montauk Point, Long Island; and Harrisburg, Pa. 4[4] On much of their journey, they traveled and lived in an office car provided for their use by the Southern Railway." 5[5]

The early differences in diagnosis between the Board and the local medical officers, first evident at Camp Alger, persisted. At Jacksonville, where the VII Army Corps was encamped, the dominant diagnosis for the fevers was malaria for the milder cases, and typhomalaria for the more severe. The Reed- Vaughan-Shakespeare Board was convinced, from the clinical evidence, that many such cases were typhoid. They persuaded Brig. Gen. Fitzhugh Lee, in command of the camp, to order that 50 cases diagnosed by the camp medical officers as malaria or typhomalaria be sent to Fort Myer, where Dr. Carroll had set up his diagnostic laboratory, for microscopic tests. The tests, in every instance, showed the true diagnosis to be typhoid fever.

Being still unconvinced by the tests of a microscopist working for the Typhoid Board, further tests were made on a larger number of men, sent to major civilian hospitals in Baltimore, Philadelphia, New York, Boston, and Cleveland— and again the tests showed that the correct diagnosis was typhoid fever.6[6]

By September, the bacteriologic laboratory was in operation at Chickamauga National Park, where 60,000 soldiers had been encamped during the summer, and where camp fever had been so prevalent that there was a dis​ osition to term the disease "Chickamauga fever" and to ascribe it to "a miasma that arises nightly from the river and permeates the camp." 7[7] The laboratory at this camp, in charge of Acting Assistant Surgeon Charles F. Craig, was supplied with materials for its tests from pure cultures furnished by the Army Medical Museum and the Johns Hopkins University. 8[8]

In October 1898, the Board was back in Washington and at work on the laborious task of studying the detailed medical records of 118 regiments which were, or had been, in the national encampments. Leaving out of account the records of 20 regiments, which were so defective that they were discarded, the Board checked every man shown on sick report who might have been a typhoid case, tracing him through the regimental, division, and general hospitals, and even the civilian hospitals to which many men had been sent, in order to learn the course and the outcome of the disease. In 48 regiments, the subsequent medical history of every man with a short diarrhea or a supposed malarial attack was checked, in order to see whether they afterward showed a greater or a lesser susceptibility to typhoid fever. In all regiments studied, the analysis of the start and spread of the disease was localized by companies; in many regiments, it was carried down even to the squad, with the date and order of occurrence of the disease listed by individual tents.

At the end of June 1899, the appropriation for the work of the Typhoid Board ran out, and Doctors Vaughan and Shakespeare were relieved from duty. They continued the work on their own account, however, dividing the sick reports and taking them to their respective homes for further analysis. On 2 June 1900, a meeting of the members of the Board was to have been held, but on the day before the appointed meeting, Dr. Shakespeare died. Three weeks later, Major Reed was on his way to Cuba to meet the menace of yellow fever; Dean Vaughan, however, had prepared an abstract of the findings of the Board, which was concurred in by Major Reed, and was published in 1900.

The Typhoid Boards Report

The abstract, however, did not carry the convincing authority of the supporting evidence, and in 1903, largely at the instance of Elihu Root, Secretary of War, the Congress provided the funds for publication of the full report. In the meanwhile, Major Reed had died, leaving the task of putting the full ​ report into shape for publication to the surviving member of the Board, Dr. Vaughan. 9[9]

As finally issued in 1904, the report is in a massive volume of text and tables, with a second volume of maps and charts, in the preparation of which Major Reed testified that C. J. Myers, longtime Chief Clerk of the Museum, had given "invaluable assistance for two years * * *." 10[10]

From the data in the two volumes of the report, 57 conclusions were drawn. The conclusions are a succinct and nearly complete compendium of information on the course, transmission, and prevention of typhoid fever in military camps or, for that matter, in civil life as well. As Major Kean wrote in his Seaman Prize Essay of 1906, the report of the board "threw a flood of light on the subject * * * and remains a permanent monument to the vast labors and scientific acumen of the members of that board— Reed, Vaughan, and Shakespeare." 11[11]

As to the cause of the disease, the report clears up several theories once widely held— the "obsolete theory," as it is termed— that the disease is caused by inhalation of gaseous emanations arising from certain soils, for one, and the more sophisticated theory that the disease is due to germs which spontaneously evolve, or "ripen," from microorganisms normally present in putrefying matter. Instead, the report firmly supports the specific origin of the disease by transmission, directly or indirectly, from an infected individual to a susceptible person. With the wide dissemination of typhoid at the turn of the century, the Board found that there were plenty of sources of infection, with 82 percent of the regiments studied developing typhoid within 3 weeks after reaching national encampments. Regardless of the section of the country from which the soldiers came, and even if they were encamped under perfect sanitary conditions, the chances were that one or more cases of typhoid would develop— and every case was a potential focus of infection. 12[12]

Indeed, because of the disposition to diagnose all but clear-cut cases as malaria or typhomalaria— a term which the report recommended to be discarded—typhoid fever was found to be much more prevalent than had been supposed. In the camps, "Army surgeons correctly diagnosed about half of the cases of typhoid fever," in the opinion of the Board after checking clinical symptoms and bacteriologic findings. But even so, the Board added, the Army ​ surgeon "in recognizing nearly half the cases of typhoid fever * * * probably did better than the average physician throughout the country does in his private practice " 13[13]

Typhoid fever, the report found, "is disseminated by the transference of the excretions of an infected individual to the alimentary canals of others." Infected individuals included those in the early and undiscovered stages of the disease, and also convalescents who had passed through the attack but continued to excrete typhoid bacteria. 14[14] The existence of "carriers" who were not themselves suffering from the disease was not known until 1907, when the report on the original "Typhoid Mary" was published. 15[15]

Contrary to the general belief— and a belief held by the Board itself at the outset of its investigation — that typhoid was primarily a waterborne disease, it was found that "infected water was not an important factor in the spread of typhoid in the national encampments in 1898." Transmission through the air in the form of dried dust carrying the bacilli of typhoid was regarded as "probable * * to some extent" and it was looked upon as "more than likely that men transported infected material on their persons or in their clothing" — a likelihood rendered all the more likely by the fact that "camp pollution was the greatest sin committed by the troops in 1898" and by the prevailing practice of detailing men from the ranks on a day-by-day basis to act as orderlies in the hospitals. 16[16]

A New "Villain" — The Fly

A new villain in the transmission of the disease was fount! in the flies which served to convey the infected organisms from their source to a person. To the modern generation, living in a wire-screened and stableless environment, and trained from childhood to swat the fly, the idea of the fly as a carrier of disease is commonplace. In 1898, however, when schoolchildren were exhorted to emulate the fly in its supposed neatness, evidenced by constant rubbing of its wings with its legs— "washing" itself, it was thought to be— the idea that the common fly was a carrier of deadly disease was novel. General Sternberg, in his Circular No. 1, issued on 25 April 1898, had suggested the possibility of flies as a source of infection in typhoid, camp diarrheas, and perhaps yellow fever. The statistics gathered by the Typhoid Board showed that men who ​ ate in screened tents were less liable to typhoid than those whose mess tents were open to the flies. The finding of the Board was explicit and convincing — "Flies swarmed over infected matter in the pits and then visited and fed upon the food prepared for the soldiers in the mess tents." 17[17]

The Reed-Vaughan-Shakespeare report takes on an even greater importance when the conditions existing in the camps in 1898, constituting the background into which the report was projected, are considered. Camp sanitation was still virtually an unknown subject to most line officers and men and, for that matter, was not well known even to many medical officers. Medical officers, moreover, lacked authority and could do little more than recommend.

In some instances, the recommendations were vigorous, as in the case of the Third Nebraska Volunteer Infantry, in camp at Jacksonville. "As we were instructed to do," writes Dean Vaughan, "we found our way to the colonel's tent and asked him to join us in the inspection of his regiment. I can only say that we found the sanitary conditions no better than in other regiments. When we were through with the inspection Major Reed said to the colonel: 'Shakespeare and Vaughan are on this commission because they know something of camp sanitation. I am here because I can damn a colonel,' and he proceeded in plain terms to speak of the responsibility of a commanding officer in looking after the health of his troops." The colonel of the Third Nebraska was William Jennings Bryan. 18[18]

The prevailing state of knowledge, or the lack thereof, is summed up by Col.P.M.Ashbum:

There was ignorance of the epidemiology of typhoid, that it was conveyed in other ways than by polluted water, ignorance of sanitation in general and of camp sanitation in particular, ignorance of proper precautions to be taken in the preparation and handling of food, ignorance of the danger of having sick men in kitchens, ignorance of the accurate methods of diagnosis which are now employed as routine in camps and hospitals, ignorance of the existence of typhoid carriers. For this ignorance no one person was to blame, it was the characteristic of the day. 19[19]

Most of this prevailing ignorance the Typhoid Report dispelled, even though it did not suspect the existence of the carrier who is not himself at the moment a victim of typhoid, and did not bring out sharply the danger of infection from the convalescent or recovered typhoid patient. ​

Changes in the Museum Command

In the interim between the accumulation of the data for the report and its publication, there had been changes in the Surgeon General's Office and in the Medical Museum. General Sternberg had reached the age of retirement in 1902, and had been succeeded by Brig. Gen. William H. Forwood who, after a service of only 3 months as surgeon general, had also retired in the same year, to be succeeded by Brig. Gen. Robert M. O'Reilly. Col. Alfred A. Woodhull had succeeded Col. Dallas Bache as Director of the Museum and Library Division in 1900, to be succeeded in the following year by Col. Calvin DeWitt, who in turn was succeeded by Col. Charles L. Heizmann in July 1903.

On 1 November 1902, Maj. Walter Reed was put in charge of the Library of the Surgeon General's Office, in addition to his duties as Curator of the Museum, and Lieutenant Carroll was designated as Acting Curator. When Major Reed died, later in the same month, Carroll was the natural choice for his successor but, perhaps because he was already in performance of the duties of the office, it was not until July 1903 that he was formally appointed to the post. In 1906, Col. Valery Havard succeeded Colonel Heizmann in charge of the Museum and Library Division, with Lieutenant Carroll continuing as Curator of the Museum. In March 1907, Carroll was promoted to the rank of major, and 6 months later, on 16 September, he died. 20[20]

Upon the death of Major Carroll, Capt. (later Maj.) Frederick Fuller Russell (fig. 46) was named as Curator of the Medical Museum and professor of bacteriology and clinical microscopy at the Army Medical School. The new Curator, 37 years old, had done his premedical work at Cornell University, and had taken his M.D. degree at the College of Physicians and Surgeons of Columbia University in 1893. After serving an internship and a residency at Bellevue Hospital in New York, and studying in Berlin, he had received a commission in the Army as first lieutenant and assistant surgeon in 1898, being promoted to captain in 1903. He had served in Puerto Rico and, briefly, at the Museum in 1900.

Volunteers for Vaccination Against Typhoid

In the latter years of Major Carroll's tenure as Curator of the Museum, he undertook an experiment in vaccination against typhoid fever which, in its use of human volunteers as subjects, was reminiscent of the experiments with ​

Figure 46.—Maj. Frederick F. Russell, seventh Curator of the Museum, 1907-1913, who introduced typhoid fever vaccination in the Army.

yellow fever in Cuba. The typhoid fever experiment, started in May 1904, called for the oral administration of dead typhoid bacilli. After experiments with rabbits and guinea pigs had succeeded in producing an immune reaction, Dr. Carroll secured the permission of The Surgeon General to call for volun​ teers who would swallow doses of nutrient bouillon which had been inoculated with typhoid bacilli killed by heat. Carroll himself swallowed the typhoid dose, as did two officers detailed to assist— Lt. Edward B. Vedder 21[21] (later Col., MC, USA, and the discoverer of the cause and the prevention of beriberi) and Lt. Harry L. Gilchrist (later Maj. Gen. and Chief of the Chemical Warfare Service). Fifty soldiers volunteered for the experiment, from whom every fifth man was accepted— Sgt. Joseph I. Howe, and Privates William E. Lumley, George Dunn, George C. Williams, George S. Ward, Robert A. Eisemann, Merl Clifford, William J. Epps, Claud W. Powell, and Robert E. Bowman.

Seven of the group developed undoubted cases of typhoid, and three others suffered attacks of a febrile disease which may or may not have been typhoid. This first attempt at a new technique in prevention failed in its purpose of producing immunity, resulting instead in attacks of the disease against which immunity was sought, but other and more successful experiments were to come.

Undismayed by the failure of the first attempt with oral typhoid vaccination, Dr. Carroll turned to a method of vaccination by hypodermic injection, first used by Sir Almroth Edward Wright, in British India in 1896, and reported in the British Medical Journal of 30 February 1897.

Typhoid was even more destructive among British troops in the Boer War of 1899-1902, with 31,000 cases and 5,877 deaths, than it was among the Americans in the war with Spain. Sir Almroth's vaccination was tried on a voluntary basis, with results so mixed that vaccination for typhoid was suspended in 1902 and, in 1903, its further use in the British Army was prohibited. The ban was removed, however, when the Royal College of Physicians, after full investigation, sustained the use of this method of prophylaxis.

Both the oral and the hypodermic methods of vaccination depended upon killing the bacteria in the culture by heat raised to the death point for the specific microorganism. This thermal death point had been determined by General Sternberg for typhoid and many other bacteria. In determining these death points, he had used small glass bulbs with the narrow necks sealed, thus preventing evaporation. In making larger batches of vaccine, a I-liter flask was used, with the mouth stoppered by cotton, which permitted some evaporation. This left a ring of dried matter in the neck of the flask. Since it requires a higher temperature to kill dried typhoid bacteria than is required to kill them when moist, some of the dried organisms survived and, when the flask was handled, were washed down into the liquid where they began to grow ​ again, with the result that the vaccine was contaminated with living typhoid bacteria. To prevent this, Russell added to each flask a small quantity of tricresol disinfectant, sufficient to kill any bacteria left alive in the vaccine. 22[22]

European Experience

On 10 February 1908, Captain Russell wrote Lt. Col. W. B. Leishman, professor of pathology at the Royal Army Medical College at Millbank, London, advising that it was proposed to inaugurate antityphoid vaccination in the American Army and asking about the British experience. To this letter, Colonel Leishman cordially replied on 29 February, offering "most gladly" to give all the information he could on the subject, and sending him a culture of the strain of Salmonella typhosa employed by the British."23[23]

In the summer of 1908, Surgeon General O'Reilly sent Captain Russell to Europe to study at firsthand the methods and the experience of the British and German Armies. This assignment, carried out with "great industry and ability," as The Surgeon General put it, resulted in a report which The Surgeon General described as a "very valuable treatise on the epidemiology of this disease to date." ' 24[24] The experience of the German Colonial Army, which had tried vaccination for typhoid in 1904 on a voluntary basis, was that the vaccinated soldier was only about one-half as likely to develop the disease as the unvaccinated soldier, and that the death rate was cut to one-fourth. 25[25] In the British experience, as described by Colonel Leishman, there had been among 6,610 unvaccinated soldiers 187 cases of typhoid, with 26 deaths, while among the 5,473 men at the same posts who had volunteered for vaccination, there had been only 21 cases and 2 deaths. 26[26]

The history of vaccination as a method of protecting troops against typhoid fever, including the experience of the British and German Armies with voluntary vaccination, was considered by a special board of officers of the newly created Medical Reserve Corps. Members of the Board were eminent clinicians and ​ pathologists — Doctors William T. Councilman, distinguished for his researches in amebic dysentery ; Simon Flexner, first director of the Rockefeller Institute for Medical Research; Alexander Lambert, a distinguished internist of New York; J. H. Musser, of the distinguished Philadelphia school of practitioners of internal medicine; William S. Thayer of the Johns Hopkins faculty; and Victor C. Vaughan, surviving member of the Reed-Vaughan-Shakespeare Board — with Capt. F. F. Russell as recorder.

After studying the evidence, this Board concluded that "the practice of anti-typhoid vaccination is both useful and harmless and that it offers a practicable means of diminishing the amount of typhoid fever in the Army both in times of peace and war." The Board accordingly recommended that in time of war the practice be introduced in both the regular and volunteer forces, and that it be introduced immediately on a voluntary basis in the medical units, with an opportunity for volunteers from the Army as a whole to receive the protection of vaccination. 27[27] The findings and recommendations of the Board were approved and published in 1909, in War Department General Orders No. 10.

Meanwhile, Major Russell (he was promoted in 1909) was busy with preparations for vaccinating the volunteers, the first of whom came from the Army Medical Museum and the Medical School (fig. 47). A "special room in the Army Medical Museum was fitted up as a vaccine laboratory," entirely separate from the School. The new laboratory, with "complete equipment of entirely new apparatus, specially planned for this particular purpose" of manufacturing vaccine, was completed in February 1909, and in March, vaccination on a wholesale scale began. 28[28]

Compulsory Vaccination Introduced

Eight hundred and thirty volunteers were vaccinated by the time the 1909 report of the Surgeon General was issued, without untoward incident. By the end of the next year, 10,841 volunteers had received "shots." In March 1911, because of troubles on the Mexican border, an entire division of the Army was mobilized in Texas. For this mobilization, vaccination was made compulsory for military personnel — and with more than 10,000 men in camp, the only death from typhoid was that of a civilian teamster who had refused vaccination. "It is hard to credit the accuracy of such a record," declared President William Howard Taft, addressing the Medical Club of Philadelphia on 4 May 1911. "But, as I have it directly from the War Office," he added, "I can assert it as one more instance of the marvelous efficacy of recent medical discoveries and practice" — ​

Figure 47.—Maj. Frederick Fuller Russell (extreme right) vaccinating volunteers against typhoid.

in which he included "modern health regulations" as well as vaccination against typhoid."[29]

In his Annual Report for 1913, Surgeon General George H. Torney expressed the astonishment of a veteran Army medical officer. "It seems more than marvelous," he wrote, "that among the number of men in the camps at Texas City and Galveston, and among those in the numerous camps along the Mexican border, constantly exposed to infection, not a single case has occurred."

On 30 September 1911, vaccination for typhoid was made compulsory for the entire Army, and by the end of 1911, 85 percent of all personnel had received the protection (fig. 48). The reduction in the incidence of the disease which followed was dramatic. In 1909, with fewer than 1,000 men vaccinated, there had been 3.35 cases of typhoid per thousand. In 1910, with 15 percent of the strength vaccinated, there had been 2.43 cases per thousand. In 1911, with 85 percent vaccinated by the end of the year, there were 0.08 cases per thousand. In 1912, the rate was 0.03 per thousand, and in 1913, 0.004 cases per thousand. In the Navy, where vaccination did not become compulsory until 1912, there were 361 cases of typhoid in 1911; 92 cases in 1912; and 33 in 1913.[30] ​

Figure 48.—In 1917, with the coming of World War I, typhoid vaccination scenes such as this were commonplace.

Typhoid vaccination did not originate with the United States, but the American Army was the first to make vaccination a required prophylaxis against typhoid. For this step and the beneficial results which flowed from it, credit is due to the mass experiments conceived by Major Russell and carried out at the Army Medical Museum, and with vaccines at first produced in its laboratories.[31]

For such results, there was a multiplicity of interacting causes. Faster and more accurate diagnosis of cases helped to reduce the risk of infection, which was further reduced by more thorough and effective disinfection—a procedure which Major Russell termed "really important" in his first article on "The Prevention of Typhoid Fever by Vaccination and by Early Diagnosis and Isolation."[32]


​ Writing in answer to an inquiry as to the propriety of using typhoid vaccine in civilian institutions, in November 1909, Major Russell said :

I do not think that it is the only thing to be considered in the prevention of typhoid fever by any means; attention must be paid to all the usual sources of infection in addition to the use of vaccine. This is for the reason that the protection gained by vaccination is not absolute but only relative, and that if the infected material is present in sufficient quantities some people might develop typhoid in spite of previous vaccination. 33[33]

Greater knowledge of medical officers and greater authority for the Medical Corps resulted in stricter sanitary controls. Broader knowledge of sanitation and disease prevention among officers and men of the line made such controls more readily enforcible. The combination of a lesser number of cases and lesser chances of infection from such cases as there were, created a diminishing spiral of morbidity. There was to be no repetition of 1898. By 1910, the chances of typhoid infection in the Army had been reduced to the point that the soldier was no more likely to suffer from the disease than the civilian. And then, into this already diminishing incidence of the disease, there was introduced the added safeguard of preventive vaccination, voluntary at first and then, for the military forces, compulsory. In the 5-year period 1911-1916, the chances of typhoid in the Army were further reduced to the point that the soldier was only one-fifth as liable to the disease as the civilian. 34[34]

The English physician, William Budd, writing in 1874, stoutly maintained that typhoid was a "perfectly preventable plague" if pollution from alvine dis- charges of infected individuals could be checked. The Reed-Vaughan-Shakespeare study assembled overwhelming evidence to sustain the Budd theory, and outlined methods of prevention. The application of these methods, together with improved sanitary conditions generally, and the added protection of prophylactic vaccination of both civilian and military personnel, has brought measurably near Budd's prediction of perfect prevention.

For this triumph over typhoid, many causes are responsible, but no small part of the responsibility rests upon three successive curators of the Medical Museum — Reed, who organized and carried forward the great study of the disease and its prevention; Carroll, who initiated experiments with the prophylactic vaccine; and Russell, who carried the experiments to successful conclusion and mass application.

  1. ↑ 1 Kean, Jefferson R.: The Prevention of Disease in the Army (The Seaman Prize Essay). The Military Surgeon 18: 13, 1906.
  2. ↑ 2 Reed, W., Vaughan, V. C, and Shakespeare, E. O.: The Origin and Spread of Typhoid Fever in United States Military Camps During the Spanish War of 1898. Volume 1. Washington: Government Printing Office, 1904, p. 674.
  3. ↑ 3 (1) Reed et al„ op. cit., p. xiii. (2) Vaughan, Victor C: A Doctor's Memories. Indianapolis: Bobbs-Merrill Co., 1926, pp. 369— 371.
  4. ↑ 4 Reed et al.. op. cit., p. xvi.
  5. ↑ 5 Vaughan, op. cit., p. 380.
  6. ↑ 6 Ibid. pp. 372, 373.
  7. ↑ 7 Ibid., p. 379.
  8. ↑ 8 Reed et al., op. cit., p.
  9. ↑ 9 (1) Ibid., pp. xiii, xiv. (2) Vaughan, op. cit., pp. 391-394.
  10. ↑ 10 Lamb. Dr. D. S.: A History of the Army Medical Museum, 1862-1917, compiled from the Official Records. Mimeographed copy in historical records of AFIP, p. 119.
  11. ↑ 11 Kean, The Military Surgeon. 18 (1906), p. 13.
  12. ↑ 12 Reed et al., op. cit., pp. 659, 662, 663.
  13. ↑ 13 ibid., p. 674.
  14. ↑ 14 Ibid., pp. 663, 667, 721, appendix 3.
  15. ↑ 15 Soper, George A.: The Work of a Chronic Typhoid Germ Distributor. Journal of the American Medical Association 48: 2019, 15 June 1907.
  16. ↑ 16 Reed et. al., op. cit., pp. 666, 667.
  17. ↑ 17 (1) Ibid., p. 666. (2) Vaughan, op. cit., pp. 384, 385.
  18. ↑ 18 Vaughan, op. cit., p. 375.
  19. ↑ 19 Ashburn, P. M.: A History of the Medical Department of the United States Army. Boston: Houghton Mifflin Co., 1929, pp. 169-170.
  20. ↑ 20 (1) Lamb, op. cit., pp. 122, 123, 133. (2) Senate Document 822, 61st Congress, 3d session, p. 26.
  21. ↑ 21 Vedder, Edward B., Col., MC (Ret.) : Typhoid Fever and Typhoid Inoculation in the United States Army. Unpublished typescript, made available through the kindness of Lt. Col. Henry Vedder, MC, USA.
  22. ↑ 22 (1) The explanation of the accident that left typhoid bacilli alive is that of Brig. Gen. Frederick Fuller Russell, MC. USA (Ret.). (2) Memorandum of conversation with General Russell at Louisville, Kv.. 28 April 1960. (3) Letter, General Russell to Dr. Edward B. Vedder, George Washington University Medical School, 25 October 1935.
  23. ↑ 23 Original letter, W. B. Leishman to F. F. Russell, 29 February 1908. On file in historical records of AFIP.
  24. ↑ 24 Annual Report of the Surgeon General, U.S. Army, 1909, p. 44.
  25. ↑ 25 Russell, F. F.: The Experience of the German Colonial Army with Anti-Typhoid Vaccination. The Military Surgeon 24: 53-56, 1909.
  26. ↑ 26 Journal of the Royal Army Medical Corps 12: 166, cited in: Russell, F. F.: The Prevention of Typhoid Fever by Vaccination and by Early Diagnosis and Isolation. The Military Surgeon 24: 484, June 1909.
  27. ↑ 27 Annual Report of the Surgeon General, U.S. Army, 1909, pp. 45, 46.
  28. ↑ 28 Ibid., pp. 46—50.
  29. ↑ President Taft and the Medical Profession. Journal of the American Medical Association 56: 1399-1404, 13 May 1911.
  30. ↑ (1) Siler, J. F., and others: Immunization to Typhoid Fever: Results obtained in the Prevention of Typhoid Fever in the United States Army, United States Navy, and Civilian Conservation Corps, by the Use of Vaccines. The American Journal of Hygiene, Monographic Series, No. 17, Baltimore: Johns Hopkins Press, September 1941, pp. 12, 13. (2) Annual Report of the Surgeon General, U.S. Army, 1910, p. 48. (3) Annual Report of the Surgeon General, U.S. Army, 1911, p. 51.
  31. ↑ Afterward, the Army Medical School took over the preparation of antityphoid vaccine for the Army, the Navy, and the Public Health Service. An interesting account of the process and the components of the vaccine used against typhoid and the two types of paratyphoid was published in: Callender, G. R., and Luippold, G. F.: The Effectiveness of Typhoid Vaccine Prepared by the United States Army. Journal of the American Medical Association 123: 319-321, 9 October 1943.
  32. ↑ Russell, The Military Surgeon, 24 (1909), pp. 479-518.
  33. ↑ 33 Correspondence with John I. Armstrong, Kirkwood, Atlanta, Ga. On file in historical records of AFIP.
  34. ↑ 34 Siler et al., op. cit., pp. 17, 18.
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