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

CHAPTER XI
The Registry Movement
"The evolution of the pathology registries stands out as the most important organizational development in American pathology," declared Brig. Gen. Elbert DeCoursey, addressing the annual meeting of the American Academy of Ophthalmology and Otolaryngology in 1952. 1
When General DeCoursey, then the Director of the Armed Forces Institute of Pathology, made his comment upon the importance of the registry movement, there were 21 registries in successful operation, with many thousands of cases registered and subject to the organized and systematic study of the manifestations of disease and trauma, with provision for regular periodic followup to check on developments and responses to treatment.
In the 1920's, however, the registry movement was quite limited in scope, being confined for the first 5 years to but two examples— the original arrangement with the American Academy of Ophthalmology and Otolaryngology, set up in 1921, and a second registry in lymphatic tumors, established in cooperation with the American Association of Pathologists and Bacteriologists in 1925. Two years later a third registry, in bladder tumors, was set up under the sponsorship of the American Urological Association.
Succeeding Maj. George R. Callender as Curator of the Museum was another native of Massachusetts and graduate of Tufts Medical College, Maj. James Francis Coupal (fig. 66), who had been Assistant Curator under Callender. He was to serve from 1922 to 1924, in which year he was appointed White House physician during the administration of President Calvin Coolidge. Upon his withdrawal from the Museum, Major Callender returned to serve as Curator in the 5 years from 1924 to 1929.
Figure 66.—Maj. James F. Coupal, thirteenth Curator of the Museum, 1922-1924.
Under the new system, the anatomical names and the pathological lesions which produced disease and death were listed, with a number assigned to each of the anatomical terms used. The numbers, listed in accordance with the International List of Causes of Death, were used as a code. The code was cross-filed, so that it was possible to locate specimens by their anatomical names, by ​ their pathological classifications, and by the names of their contributors. By 1924, the new system had been applied to 5,000 protocols, 4,000 gross pathological specimens, and 4,500 miscellaneous items. 2
By the end of Major Calender's second tour of duty as Curator of the Museum, in 1929, the original ophthalmic registry had accumulated 2,000 registered cases, while the two tumor registries had about 200 each. The registries, in Major Callender's opinion, were well established and had "reached that stage of development and activity which makes necessary more professional, technical and clerical work that can be given by the Army Medical Museum."
To find adequate support and to insure that there should be continuity of policy in the registry movement, Major Callender took up with Dr. Ludwig Hektoen, Chairman, Division of Medical Sciences of the National Research Council, the matter of recognition of the registries as a joint activity of the Council, the Museum, and the sponsoring professional societies. As a result, and with the approval of the Council, the American Registry of Pathology was formed, in 1930, by a committee headed by Dr. Howard T. Karsner (fig. 67) of Cleveland as chairman and Major Callender as secretary. Other members of the committee included : Dr. James Ewing of New York, Dr. Stanley P. Reimann of Philadelphia, and Doctors Bowman C. Crowell, Harry S. Gradle, and Herman L. Kretschmer of Chicago, all of whom had been active in promoting the existing registries or were interested members of professional societies, such as the associations combating cancer, who were naturally interested in the project.
Objective of the Registry
Figure 67.—Dr. Howard T. Karsner, pre-eminent pathologist who throughout the years, has been a discerning critic, a firm friend, and a staunch supporter of the Medical Museum and its offspring, the Armed Forces Institute of Pathology.
Diagnosis in the early stages of disease "offers the best chance of cure," Major Callender said, but early and accurate diagnosis is not possible in the absence of opportunity to observe enough cases to form a basis for reasonable ​ judgments. Except at large medical centers, there were too few cases of any one kind to afford such opportunity for study. By combining cases from the country as a whole, Major Callender observed, "It will be possible to obtain considerable numbers of cases and specimens in a much shorter time."
The Registry was not intended to replace the local pathologist and would "never serve as a diagnostic laboratory." Rather, it was to be "a clearing house in pathology to which will be sent cases already diagnosed and the obscure cases about which more can be learned by obtaining the opinions of several pathologists. In addition, by sending 'follow-up' letters to the physician registering cases, the Registry will be a means of helpful stimulation."
The success attained by the three registries already in operation when the American Registry was formed, had "been obtained in spite of a minimum of publicity effort because there has been insufficient personnel at the Army Medical Museum to conduct larger collections. As the registries have become better known, the 'follow-up' work alone is more than can be handled adequately in the time of the Museum personnel available for it."
"The expense of these registries has thus far been borne entirely by the Museum, whose entire budget, inclusive of all personnel and upkeep of plant, is about $30,000. The expense for materials and equipment for the proposed registry can be handled by the Museum," he added, "but it is necessary to have additional help in the form of professional, clerical and technical personnel."
Other activities of the Museum personnel included the handling of the tissues and histories of all cases of tumor or suspected tumor in the Army, and the review of the protocols of all Army necropsies, numbering about 800 a year. 4 With a staff of but one medical officer, two medical technicians, one stenographer, and one typist, it was obvious that additional help must be had if the registries were to realize their full potential. Another obstacle to securing continuity of policy was the fact that the officer personnel on duty at the Museum was shifted every 4 years, usually, and in many cases after even shorter periods.
In his outline of the operations and potentialities of the American Registry of Pathology, Major Callender paid particular attention to the possibilities offered by the registry in the earlier diagnosis of malignant growths. "It is generally acknowledged by pathologists," he said in his 1930 outline," that many neoPlasms are difficult to diagnose. * * * The earliest changes which signify malignancy are not sharply defined. In fact, there is serious doubt if we know by sight the earliest malignant changes in any tissue. Unless cases are followed up we cannot ​ learn these changes. Even if a definite cause for cancer should be found, it will still be necessary to recognize the earliest change indicating its presence."
In his outline of the American Registry of Pathology, he referred to the project for a new building for the Museum and the Library at the Army Medical Center, adjacent to the Walter Reed General Hospital as "being before the Bureau of the Budget. In the new building, as contemplated, there will be rooms available for research by scientists not on the Museum staff. Laboratory facilities will be available and all collections of the Museum will be more accessible for research."
The dream of the new building was not to come to fruition for yet another quarter of a century after the American Registry of Pathology was set up by the National Research Council, an agency of the National Academy of Sciences, which was authorized to receive and administer any funds contributed to the Registry. Through the channel thus opened, the medical specialty societies could conveniently make financial contributions to the work of the Museum in pathology.
Organized Civilian Cooperation
These contributions have continued over the years, but the greater contribution by far has been the active cooperation of the specialists in the registry work in what has been aptly called an "effective synergism." 5 The way in which the Museum and the civilian specialists worked together was well described in the 1927 report of Maj. Gen. Merritte W. Ireland, The Surgeon General of the Army, as follows:
In the operation of a registry, case reports accompanied by specimens are sent in to the registrar. Slides of the specimen are prepared, and when the diagnosis is in doubt the entire case is circulated to a group of pathologists. The diagnoses furnished are studied and the case is classified by the registrar in cooperation with a committee appointed by the society conducting the registry. In so far as possible, only cases living at the time of registration are accepted and every case is followed to its conclusion. In this way large numbers of cases are brought together, followed by subsequent reports to their decease, and classified and studied to determine the character of the disease process, the course of the disease, and to evaluate the methods of treatment.
Figure 68.—Title page and an illustration from volume XII of "The Medical Department of the United States Army in the World War." The illustration shows the lung in a case of pneumonia following influenza.
General, "are the source of the most valuable material now being received, and the museum is fortunate in being chosen to conduct them." Since the registries had been "accepted as offering the greatest aid in determining the best method of reducing the mortality from malignant disease," it was confidently predicted that "registries in other lines will follow as the years go by."
Six years were to go by, however, before another registry was established—years in which Major Callender was to complete his second tour of duty at the Museum, in 1929, to be succeeded by Maj. James Earle Ash, whose first tour of duty covered the years to 1931 and who, in turn, was to be succeeded by Maj. Paul Edgar McNabb, who served until 1933 when Maj. Virgil Heath Cornell became Curator.
The year 1929 was marked by the publication of volume XII of "The Medical Department of the United States Army in the World War" (fig. 68), which dealt with the two subjects chosen as the most important conditions of the war from the standpoint of pathology. The first section of the work, "Pathology of ​ the Acute Respiratory Diseases" was written by Major Callender; the second section, "Pathology of Gas Gangrene Following War Wounds," by Maj. James F. Coupal, former Curator of the Museum. The richly illustrated volume, with 24 plates in lifelike color and 312 black-and-white pictures, was based to a large extent on material in the Medical Museum, and made use of the photography and artwork produced by the Museum staff, including Maj. Theodore Bitterman, S.C., Capt. R. W. French, Inf., and Messrs. Roy M. Reeve, F. E. Prior, Garnet Jex, L. W. Ambrogi, Walter Parker, and Edward V. McCarten, to whom grateful acknowledgement was made.7
Major Callender's successor, Major Ash (fig. 69), was a native of Philadelphia and a medical graduate of the University of Pennsylvania. His 6 years of postgraduate experience in various hospitals had been supplemented by study in Vienna, where the young doctor and his slightly older colleague, Howard T. Karsner, both men destined to distinction, worked at the State Therapeutic Institute. Upon his return to the United States, Dr. Ash served 3 years on the staff of the Harvard University Medical School. There he became interested in tropical diseases — an interest which turned him to the Medical Department of the U.S. Army, which was outstanding in that field. He was commissioned in the Medical Corps in 1916.
On his second tour of duty at the Museum, from 1937 to 1947, he was to become known as the principal protagonist of the spreading registry movement, but during his first tour, 1929 to 1931, there was no further increase in the roster of registries. This may be partially accounted for by the "greatly increased" work of the Museum staff in the fields of diagnosis and consultation, following the issuance of The Surgeon General's Circular Letter No. 2, on 12 February 1929.
Histopathology and the Museum
Figure 69.—Col. James E. Ash, fifteenth Curator, 1929-1931; twentieth Curator, 1937-1946; and first Director, Army Institute of Pathology, 1946-1947.
The availability of this diagnostic service at the Museum "apparently is not fully appreciated by the surgeons of all military hospitals," the letter said, in announcing that certain hospitals had been designated as centers to which selected portions of tissue might be sent for emergency diagnosis "when the best interests of ​ the patient necessitate a microscopical diagnosis at the earliest possible moment and local facilities for such diagnostic work are not available."
The hospitals so designated were Letterman General Hospital, for the IX Corps area; William Beaumont General Hospital and the Station Hospital at Fort Sam Houston, for the VIII Corps area; Fitzsimons General Hospital, for the VII Corps area; and the Army Medical Museum itself for the I through the VI Corps areas. The officer making the diagnosis was instructed to report by telegraph or radio when, in his judgment, such a course was required. In all cases, specimens were to be furnished to the Museum, together with a copy of the report. Explicit instructions were given for the preparation and shipment of specimens and the writing of autopsy protocols, all of which were to enter the collections of the Medical Museum for final study, review, and preservation.
Inescapable Housekeeping
"There is an enormous amount of work that should be done in rearranging exhibits and developing the material already on hand," said the annual report of the Surgeon General for 1929, "but it must be put aside for the more urgent current demands" of the consultation and diagnostic service which, as the Museum's most important function, "has precedence over all other activities." 8
Although the diagnostic and consultation functions of the Museum had first precedence, there were always inescapable housekeeping chores to be attended to. The Museum's material, stored in the basement, was surveyed, and the portions which had deteriorated and become useless were disposed of. The cleanup was hampered by the chronic shortage of personnel. The task of sorting material, and especially the "enormous amount of facio-maxillary material which had accumulated during the few years after the war" was perhaps made simpler by the adoption, in 1930, of straight alphabetical indexing, which was described as "much simpler and more efficient" than the numerical system of coding adopted in the years just after World War I. Even though there were no new registries set up, "active interest" in the three existing ones was continued. In fact, nearly one-third of all accessions in 1930 were contributed through the route of the registries. 9
Figure 70.— Maj. Paul E. McNabb, sixteenth Curator of the Museum, 1931-1933.
included tours of duty in the Canal Zone and the Philippines, where he had been president of the Army Medical Research Board.
During Major McNabb's administration, the photographic section of the Museum was particularly active in color photography of both gross and microscopic specimens for museum display and also for lantern-slide demonstration. ​ There had been earlier efforts at the Museum to produce true color reproductions of pathological specimens, as reported by Major Callender, Major Coupal, and Mr. F. E. Prior, in an article published in Bulletin No. X of the International Association of Medical Museums. Effective results were produced by a method which involved accurate photographic prints which were colored by hand, with the resulting picture reproduced by lithography. The 1932 experiment, carried on by Roy M. Reeve, photographer for the Museum, and Joseph Carter of the U.S. Department of Agriculture, sought to secure correct coloring by making three color separation negatives, from which prints were made in blue, red, and yellow. The prints were superimposed upon one another, checked for accurate registration, and true color values, corrected by differential printing of the three images, and then mounted — yellow image first, red second, and blue third, to complete the picture. The Reeve-Carter process produced effective color prints, even though it required much patience and a high degree of manipulative skills, and was a distinct advance in the development of today's simpler and more rapid systems of producing photographs in color. 10
The Museum at Threescore Years and Ten
In 1932, the 70th year of the existence of the Army Medical Museum, its exhibits were viewed by 67,689 visitors. Because of a lack of space, only about half its collections could be placed on exhibition. The collections "combined exhibits of historical value and interest to the Medical Corps of the Army, to the medical profession at large, and to the general public." There was, however, a "great volume of material of a purely pathological character"— for it could never be forgotten that the Museum was, above all else, "the active central unit of pathology in the Army." As such, it received, in its 70th year, protocols and specimens from nearly 1,000 autopsies performed at Army hospitals, representing more than 56 percent of all deaths in these hospitals. 11
Major McNabb was succeeded as Curator by Maj. Virgil H. Cornell in IQ 33 (fig- 7 1 )- The new Curator was a native of Brooklyn and received his medical degree at the Long Island College of Medicine in 1913. Thirty years
Figure 71.—Maj. Virgil H. Cornell, seventeenth Curator of the Museum, 1933-1935.
Army posts, including service in both World Wars, Major Cornell received from Harvard University the degree of doctor of public health. His Army service is further memorialized in the name of the Cornell Laboratory, the special section of the Medical Museum set aside for the use of medical research workers.
The Dental and Oral Registry
Major Cornell's administration as Curator was signalized by the establishment, in 1933, of the fourth of the registries and the first to be set up as a part of the American Registry of Pathology. The Dental and Oral Pathology Registry added in 1933 was, in a sense, a reactivation of the arrangement of 1895 under which the American Dental Association designated the Museum as the national depository for its dental and oral specimens and materials. Since this designation, there had been periods of activity, and also of inactivity, in carrying out the plan for the deposit of material in the museum. The action taken in 1933 contemplated a different and more active participation of the dental profession in the development of a full-fledged registry, with the working support of a committee of the American Dental Association, headed by Dr. Henry A. Swanson of Washington.
By the end of 1936, the Dental and Oral Pathology Registry had a total of 483 accessions, many of which had been transferred to it from the materials already collected in connection with the earlier registries. The dental registry, however, was not yet "actually functioning" to the same degree of activity as the other registries, even though there had been an official relationship between the Museum and the organized dental profession for 40 years.
In a mimeographed statement, undated but apparently issued in 1939, when there were 808 cases in the Registry, the purposes and intentions of the committee of the Dental Association cooperating with the Museum were outlined along general lines. It was intended to "collect material from, and com- pile data appertaining to, the pathological disturbances of the hard and soft tissues of the oral cavity * * *. All cases of definite or suspected malignancy * * * will be followed by annual inquiry addressed to the contributor for a period of five years." The purpose of the Registry was to furnish consultation service in such cases as could not be diagnosed locally, and to prepare loan collections consisting of microscopic preparations, photographs, lantern slides, and other material of illustrative cases for use in dental schools, societies, and study clubs. It was the expressed desire of the committee to enlarge and modernize the dental exhibit of the Museum "so that it will be of interest, educational value and historic record second to none." 12 ​
More Registries Formed
Whether because of this appeal for more active cooperation on the part of the profession, or because of the general pickup in military activity following the near collapse of Allied defenses in Europe, the number of new cases received in the Dental and Oral Pathology Registry went up from 95, which it was in 1938, 13 to 226 in 1939, and to 692 in 1940 — a sevenfold increase in 2 years.
While the dental and oral section of the American Registry was overcoming the degree of indifference which it met at the outset, two other registries were being successfully launched. In 1935, the ear, nose, and throat cases in the original combined ophthalmic and laryngic registry were separated to become the Registry of Otolaryngic Pathology, under the sponsorship of the Academy which had started the registry system at the Museum.
The addition of two more registries was reported in 1937— a Tumor Registry sponsored by the American Society of Clinical Pathologists, and one in Dermal Pathology sponsored by the American Dermatological Association and now under the sponsorship of the American Academy of Dermatology and Syphilology. With these additions to the list, it appeared to Surgeon General Charles R. Reynolds that "practically all the special fields are covered except neuropathology, and it is possible that this will be taken care of in the near future." 14
The Surgeon General underestimated the extent to which subdivision of specialties would be carried in the next two decades, as well as the range of additional fields in which pathology would be found basically useful. Neuro- pathology was indeed "taken care of" in the formation of a registry in 1942, jointly sponsored by the American Association of Neuropathologists and the American Psychiartic Association.
The registries in tumors, originally limited to the lymphatic tumors and those of the bladder, evolved into a total of six tumor registries through the addition of those on Kidney Tumors (1938), Prostatic Tumors (1943), and Testicular Tumors (1959), all sponsored by the American Urological Association; and that on Chest Tumors (1940), sponsored by the American Association for Thoracic Surgery.
In the field of pathology of particular organs, areas, and systems there are, in addition to the registries already mentioned, registries covering Orthopedic Pathology (1943), the Female Reproductive System (1952 )> and the Gastrro​ intestinal Tract (1952), all sponsored by the American Society of Clinical Pathologists; Genitourinary Pathology (1947), sponsored by the American Urological Association; Cardiovascular Pathology (1948), with the American Heart Association as sponsor; Hepatic Pathology (1949), under the sponsorship of the American Gastroenterological Society; Pediatric Pathology (1956), with the American Academy of Pediatrics as sponsor; and one of Endocrine Pathology, organized in 1948 and currently unsponsored.
In the broader fields of function and treatments, registries are found in Gerontology (1945), sponsored by the Gerontological Society; Radiologic Pathology (1947), jointly sponsored by the American College of Radiology, the American Roentgen Ray Society, and the Radiological Society of North America; and Nutritional Pathology (1951), sponsored by the American Institute of Nutrition.
The field of veterinary pathology is covered by a registry organized in 1944, with the American Veterinary Medical Association as sponsor (fig. 72). The specific disease of leprosy is the field of a registry, formed in 1950, under the sponsorship of the Leonard Wood Memorial. Most recent in the roster of registries are the ones on Forensic Pathology, formed in 1958, with the College of American Pathologists as sponsor and two formed in the centennial year of 1962 — one on Radiation Pathology, under the sponsorship of the U.S. Public Health Service, and another on Geographic Pathology, sponsored by the International Academy of Pathology. Both new registries were formed to meet the increasing need for accurate information as to radiation, in the one case, and as to diseases which may be encountered in lands other than the United States, particularly those in the Tropics.
The registries are a living link between the practitioners of the various medical specialties and the staff of the Museum and its successor organizations — first the Army, and then the Armed Forces Institute of Pathology, in the consultation, education, and research which are their common objectives.
Publications of the Registries
Figure 72.—Maj. T. C. Jones, VC, Registrar, Registry of Veterinary Pathology, Army Institute of Pathology.
worked both ways, with the Museum staff providing study materials for loan to responsible individuals and sets of lantern slides for group teaching. A combination of group and individual instruction were the seminars conducted for several years by the American Society of Clinical Pathologists for which the Institute of Pathology furnished, upon occasion, as many as 37,000 microscopic slides in sets of 25 slides to each of about 1,500 participants in the program.
From these loan sets of slides, the Museum evolved the atlases which were to become one of the strongest ties between the pathologists of the armed services and the medical profession. In addition to the "Atlas of Tumor Pathology," the Registry has published an "Atlas of Angiocardiography" dealing with observation of the heart and great vessels after intravenous injection of an opaque liquid, and an "Atlas of X-Ray Myelography" dealing with X-ray examination ​ of the spinal cord. Other publications of the Registry include syllabuses on various disease conditions, issued in connection with courses of instruction.
Most of the publications have gone through more than one edition, with revisions and reprinting. "Our original atlases were rather primitive," said Colonel Ash in the course of reminiscent remarks at the 1952 session of the American Academy of Ophthalmology and Otolaryngology. The pages of the first editions were mimeographed and had as illustrations actual photographs instead of printed reproductions. This limited the editions to about 100 copies of each. "I remember so well the job it was to collate the pages," said Colonel Ash. "We had the pages in a series of pigeonholes on the balcony of the old Museum and it was the habit of the few of us who were then at the Museum to stop and collate a book or two on our way back from the rest rooms on the first floor."
Continuing, Colonel Ash said that "after this initial effort of using photographs, we did manage to acquire a little offset reproducing machine with which the second edition was run off * * *. All the time, however, we had in mind atlases that were more comprehensive professionally and technically less amateurish."
Advantages of the Registry System
Speaking from his long experience with the Registry system, Colonel Ash expressed the conviction that "registries, properly sponsored and properly administered, can be very potent factors in education, in research, and in the advancement of the various clinical specialties."
Speaking as a general pathologist, the colonel declared that "much of the pathology of several of the specialties has been developed by clinical specialists frequently not too well grounded in general pathology. On the other hand, general pathologists have very little notion of the eye pathology and not too much of skin, bone, teeth, and so on. Well, it is our idea that with these very specialized activities at the Institute we have helped the specialist in the pathology of his field, but at the same time have importantly stimulated the general pathologist to an interest in these special fields."
Colonel Ash was speaking 30 years after the organization, by General Callender, of the first of the Museum's registries. In those years, 22 registries had been formed. Others were to be added in the decade which followed, bringing the total to 27 at the close of the first century of the life of the Museum and its successor, the Institute. The value of the Registry as an essential part of the activities of the Institute has been abundantly proved by the better ​understanding it has fostered between pathologist and clinical specialist and between civilian and military medicine. "Medicine," as Colonel Ash concluded, "owes a great debt to this Academy for being the pioneer in this activity. We should honor Dr. Gradle and General Callender for fostering the idea in its early stages. It has been a great privilege of the Institute and of the Army to have participated in it." 17
* ↑ 1 DeCoursey, Elbert: The Atlases of Pathology. A symposium, presented at the Joint Session of the 57th Annual Session of the American Academy of Ophthalmology and Otolaryngology in Chicago, 12-17 October 1952, and reported in: Transactions of the American Academy of Ophthalmology and Otolaryngology 57: 15, 16, January-February 1953.
* ↑ 2 Coupal, James F.: Modification of the Wyatt-Johnson Museum Classification in Use at the Army Medical Museum, Washington, D.C. International Association of Medical Museums Bulletin X, April 1924, pp. 47-73.
* ↑ 3 Callender, George R.: Report of Committee on Ophthalmic and Oto-Laryngic Pathology, 35th Annual Meeting of the American Academy of Ophthalmology and Otolaryngology. Transactions of the American Academy of Ophthalmology and Otolaryngology, 1930. PP- 530-535.
* ↑ 4 Army Regulations No. 40-410, 18 January 1922. paragraphs 19. 20.
* ↑ 5 Dart, Raymond O.: The Army Medical Museum. International Association of Medical Museums Bulletin 27: 13, 1947.
* ↑ Annual Report of the Surgeon General, U.S. Army, 1927. PP. 221, 222.
* ↑ 7 The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1929, volume XII, pp. v, vi.
* ↑ 8 Annual Report of the Surgeon General, U.S. Army, 1929, p. 267.
* ↑ 9 Annual Report of the Surgeon General, U.S. Army, 1930, pp. 271-273.
* ↑ 10 (1) Callender, G. R., Coupal, J. F., and Prior, F. E.: True Color Reproduction of Pathological Specimens. International Association of Medical Museums Bulletin X, April 1924, pp. 38-41. (2) Reeve Roy M.: Color Photography in the Medical Museum. Journal of Technical Methods and Bulletin of the International Association of Medical Museums 19: 12-19 October 1939. (3) Reeve, Roy M.: Color Prints by the Carter-Reeve Color Process. The Journal of the Biological Photographic Association 4: 132-136 1936.
* ↑ 11 Memorandum, Maj. P. E. McNabb, for The Surgeon General, U.S. Army, 1932. On file in historical records of AFIP.
* ↑ 12 Ash, James E.: Data for the Preparation of Statement Requested by Dr. E. H. Bruening, undated. On file in historical records of AFIP.
* ↑ 13 Annual Report or the Surgeon General, U.S. Army, 1938. P. 182.
* ↑ 14 (1) Idem. (2) Annual Report of the Surgeon General, U.S. Army, 1937. P. 171.
* ↑ 15 Callender, George R., Transactions of the American Academy of Ophthalmology and Otolaryngology, 57 (1953). P. 15.
* ↑ DeCoursey, Elbert, Transactions of the American Academy of Ophthalmology and Otolaryngology, 57 (1953). p. 16.
* ↑ 17 Ash, James E., Transactions 0} the American Academy of Ophthalmology and Otolaryngology, 57 (1953). PP. 18. 19.