Case studies in pathology from the National Museum of Health and Medicine, Armed Forces Institute of Pathology

FROM THE FILES OF THE AFIP

Case Studies in Pathology From the National Health and Medicine, Armed Forces Institute

Museum of of Pathology

Lenore T. Barbian, PhD, Paul S. Sledzik, MS, and Ann M. Nelson, MD The National Museum of Health and Medicine was founded as the Army Medical Museum during the American Civil War to document the effects of war wounds and disease on the human body. Since then, the Museum has created a collection of documented pathologic specimens that can be used to study the gross and microscopic appearance of disease conditions. The Museum’s collections are a vital link to the past and the future of medical research and form a unique national medical repository that is used continuously for research, education, and exhibit purposes. Today, the Museum in association with its parent institution, the Armed Forces Institute of Pathology, provides access to over 130 years of documented medical specimens. These specimens allow the unique opportunity to re-examine historical classification systems and disease diagnoses. The case of subacute chronic osteomyelitis with cortical sequestration of Private J. Potter from the Civil War is presented here.

Ann Diagn Pathol4: Index

Words:

170-173,ZOOO. Copyright

Osteomyelitis,

Civil

War

ARS often bring focus to medical research. Trauma care and the diagnosis and treatment of disease are the main responses of milita? medicine. During the American Civil War, the opportunity to learn from the “natural laborato?” of Icar \vas taken up by forwarding-thinking medical researchers. In the Union Army, Surgeon General William Hammond saw the war’s potential for aiding medical research. He established the Army A4edical Museum as a specimen repository for the study of wounds and disease. In Circular #2 issued in May of 1862, Hammond called for “specimens of morbid anatomy, medical and surgical, and projectiles and foreign bodies removed from wounds” to be forwarded to the Office of the Surgeon General along with case descriptions and the personal histories of the soldiers.’ During the Civil War, museum doctors visited

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battlefields and hospitals encouraging surgeons to submit specimens and procuring missing documentation. These specimens were organized into two sections: surgical (bone specimens documenting the erects of \var wounds) and medical (fluid-presenied specimens demonstrating the effects of disease to human organs). By the close of the \var, more than 3,500 surgical and 500 medical specimens and their associated documentation had been assembled.” In the \vords of the Museum’s first curator, John Hill Brinton, the purpose of this collecting initiative was “not for the collection ofcuriosities, but for the accumulation of objects and data of lasting scientific interest, Mhich might in the future serve to instruct generations of students, and thus in time be productive of real use.“‘% After the war, Brinton compiled the information gained from the surgical specimens while Assistant Surgeon George Otis analyzed the medical specimens. Their efforts culminated in the publication of the Medical and Surgical Histoy of the War a/the Rebellion, a six-volume compilation of more than 400,000 cases of disease and injur) from the Civil War. Reprinted in 199 1 as the 12-volume Medical and Surgiral Histon, of the c’izlil War, it still represents a major contribution to the stud) of militav medicine. During the late 19th and early 20th centuries, the Army Medical Museum staff conducted histopathologic examinations, developed methods in photomicrography,

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and carried out research on infectious diseases.” Walter Reed, John Shaw Billings, James Carroll, George Sternberg, and Frederick Russell were appointed curators. Three missions emerged for the museum: the collection of pathologic specimens, medical research into military concerns, and medical education. Highlighting these missions, the Army Institute of Pathology was created as a division of the Museum in 1944. Five years later, Congress formalized this distinction by creating the Armed Forces Institute of Pathology (AFIP). Today, the National Museum of Health and Medicine is a division of the AFIP dedicated to preserving and documenting military medicine and medical research. Within the National Museum of Health and Medicine, the anatomical collections house the Civil War specimens and thousands of others obtained since that time. The Civil War collection is composed of nearly 2,000 skeletal specimens and a number of colon sections and wet preparations of bone trauma. Skeletal specimens obtained from primav amputations or excisions document bone fractured by conoidal and round balls. Specimens procured after secondar) resections and amputations provide a record of the body’s response to infection and the resulting osteomyelitis, in some cases lasting months to several years. The Museum continues to collect 19th and 20th century specimens showing normal anatom)‘, normal and abnormal development, disease, and trauma. Recent acquisitions include several collections that could have been divided or destroyed. In 1989, the Museum obtained 1,800 specimens from the Oflice of the Chief Medical Examiner in New York City. The collection documents the variety of cases seen in that offlice from the early to mid-20th centuq. Ballistic trauma, accidental injuT, and viral or bacterial infectious diseases such as syphilis and tuberculosis are represented. Another recentI>. acquired research series, donated by James L. Shupe, consists ofskeletal specimens, documents, photographs, tissues, and microscope slides pertaining to veterinary fluorosis and hereditary multiple exostoses.

Examination

of Case Studies

The evolution of pathologic diagnosis is closely tied to aspects of nomenclature and classification. Today, the foresight of Hammond and Brinton allo\vs access to biological specimens from the Civil War. Amid the thousands of cases from the Civil War are many that are distinctive for their extensive documentation, including surgeon’s reports, gross anatomic specimens, photomicrographs, and extant histologic sections. These materials allow the re-examination of old classification systems

and

Medicine

Case

171

and the diagnosis (or rediagnosis) of historical diseases using current classification and technology. In upcoming issues ofAnnals of Diagnostic Pathology, several such cases will be presented.

Case Study: Case of Private J. Potter The Civil War skeletal collection contains hundreds of examples of ballistic trauma and related infection, including several cases of osteomyelitis resulting from a soft tissue gunshot wound. The case of Private J. Potter, currently on display in the museum’s exhibit “To Bind Up the Nation’s Wounds: Medicine During the Civil War” is an excellent example of this type of case. In addition to its exhibition use, the AFIP Department of Orthopedic Pathology presents this case as a “type specimen” of subacute chronic osteomyelitis with cortical sequestration in training courses. Photographs and descriptions of this case have been published in recent texts on orthopedic pathology and paleopathologyj6 (Figs 1 and 2). The following case information is from the Medical and Surgical Hirtoy of !he War of the Civil War7: Pri\,ate J. Potter, Co. H, 12th Illinois Cavalry, aged 45, was wounded at Cane River Ilouisiana], April 27th, 1864, and was treated in Barrack Hospital, Sew Orleans, from that date until January 31, 1865, when he \vas transferred to New York and entered De Camp Hospital. Assistant Surgeon Warren Webster, US Army, furnished the following in a special report: “The patient \vas wounded while charging the enemy with his compan)‘. The projectile, a qlindro-conoidal ball, penetrated the posterior and inner surface of the arm at about the middle of the humerus, was flattened upon the bone, and passing downward and outward lodged in the soft parts near the elbo\vjoint. He states that he did not dismount in consequence of the wound, nor throw awa). his carbine, but rode to Alexandria, a distance of ten miles, carrying the weapon on his wounded arm. . . The wound of entrance . . was of such small size and regular appearance as to render it probable that the ball \vas of its original shape when it entered the arm. After the extraction of the missile, the limb rapidl) inflamed, became greatly swollen between the elbow and the shoulder, and was affected with deep-seated and almost unsupportable pain. The constitutional disturbance appears also to have been corresponding11 great. Local anodyne applications were employed, and morphine internally administered for several weeks. Six abscesses had appeared previously to November 1864, some of which were opened by the knife and other allotted to break spontaneously. In that month Private Potter states that a deep incision, about three and a half inches long, was made longitudinally on the anterior

Barbian,

172

Sledzik,

and Nelson

Figure 2. A radiograph

Figure 1. A photograph the involucrum,

sequestrum,

of the humerus of Private Potter. and numerous cloacae.

Note

of the humerus

of Private

Potter.

aspect of the arm, app~entl>. for the purpose of extracting necrosecl lxxx, but the attempt wis alxuicloned. Whcne\~c:r the listulous opening in the parts were allo\Vetl to close thcrc \\‘;Is 31, XCCSS ol‘clccp-sc3tcd pain. The patient \\‘as ttxnsferrctl to De Ckm~p Hospital

National

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Medicine

Case

and research rcscarchcrs

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USC.”They provide in forensic

a rich source of data for

medicine,

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pathol-

o,q, paleopatholoo, and military medicine. Since the C:i\il War, the collections have formed the basis of hundreds of studies by museum staff, AFIP staff, and other researchers. In future issues, lvc \\ill examine additional cases from the museum archives, including tumors, infections, and other diseases that have undergone changes in cliagnostic classification. The re-evaluation of these spccimcns using modern techniques should demonstratc the e\.olution of our concepts of disease and diagnosis o\w the past ccntu?. References I. C~irrulx

Sumbet-

2: %I-geon

Grnrml’s

OIlice.

Washington

City.

AIn! 2 I, 1862. On lilr, National Archives, Accession no. -12 I, C:ircular/ S
19, 1862 in Museum.” of Health

.md .\Irdic-iw. Armrd Forrrs Institute of Pntholog! 4. 1ivn1~ It‘+ ‘l‘hr hrmrd Forces Institure of Patholoo: Its First C:rntut?- 1862-196’. \Vashington. DC. Governmrnt Printing CXXcr. I WI 5, \‘inh TN, Swrt DE: Bow and joint C:handlcr FL\’ (rds). P;L~holo,q or Infrrtious Prrnrirr Hnll. IWi, 1)~ IfiOl-I631

infcwions, Diseases.

in C:onnor DH, New York. W,

6. Adclrrhridr AC:, Rodrigurz .\lartin Cl: The Cambridge EnqcloIX& 01‘ IHuman Palwpxhology. Sew York. A”‘?‘. C:ambridge University Prrcs 7. Otis (;.A. .\leclical and Surgical Hislo? of the M’nr of the Rvbrllion 1111.C:i\il pm!,

( 1876). Rrlxinrrd as Thr LVu, \‘~rl S. \tilmington,

III!1 I. 1) 646

Xlrclicul ;md Surgical Histo? of SC:. Broadfoot Publishing Com-