[Welcome to the Public Health, Demography and American Medicine Symoposium [sic]. Lister Hill Center Auditorium. 22 May 1996.]

Dr. Philip Teigen: Testing...let's see. Maybe he's not up there yet. Good afternoon ladies and gentleman. Welcome to the symposium on Public Health, Demography and American Medicine.

A symposium organized in order to recognize Jim Cassedy's distinguished record of scholarship in the history of medicine.

My name is Phil Teigen and I'm the deputy chief of the History of Medicine Division here at the National Library of Medicine, and I'll act as moderator this afternoon.

Welcoming us this afternoon is Dr. Donald A.B. Lindberg, the director of the National Library of Medicine. Dr. Lindberg...

Dr. Donald Lindberg: Dr. Teigen, ladies and gentlemen. Welcome. It's certainly a pleasure to be with you.

I keep thinking what a wonderful honor for Jim Cassedy. He's one of the people at NLM we cherish. He's a scholar, and productive.

He's been recognized by our board and by the director of NIH. But the sweetest acknowledgement, I'm sure, is to be toasted, if you will, by your colleagues, by your professional associates.

And a symposium in one's honor, what could be sweeter. So my congratulations to you as well as those of all the others assembled here.

Jim came to the library I guess in '68, so was virtually a founding father of the division.

And one whom we greatly cherish. About the topic of the meeting...I'm sure we'll all enjoy the presentations, but strikes me as surprisingly timely.

I know that John Parascandola has seen some of the thrashing about, the debate concerning...I guess there's no debate about the past of the Public Health Service, but there sure as heck is a debate about the future thereof.

I don't think among this audience there would be much debate about the accomplishments and the present great worth of public health in the U.S. and in the world.

But as I said, I think this is a very timely meeting. Just this morning, in fact, at the Board of Regents, the debate swirled very much around the present circumstance in which the U.S. Public Health Service finds itself.

And the debate, as I said, about its future. The currency and question of validity of the agency for health care policy research and all those who try to establish a neutral ground for the truth out, if you will.

So, I'm very interested in the meeting, I look forward to it, and I salute Dr. Cassedy. Congratulations.

[Applause]

Dr. Teigen:  Also bringing welcoming remarks is Dr. Sheldon Cohen, scientific advisor in the office of the director of the National Institute for Allergy and Infectious Disease, and president of the Washington Society for the History of Medicine. Dr. Cohen.

Dr. Sheldon Cohen: Thank you, Phil. It's a delight to be able to second Dr. Lindberg's welcome. So welcome, and a second welcome.

The Washington Society for the History of Medicine, in concert with the National Library of Medicine, History of Medicine Division, and the Office of the Historian of the Public Health Service, are co-sponsoring this afternoon's event and the reception that follows.

It's difficult to draw the line of division between these three entities because there is so much overlap in the hats that are worn.

On the program this afternoon will be Dr. Alan Kraut, who is the incoming president of the society and will be working in the NIH History Division on his sabbatical.

Dr. Parascandola, who represents the office of the historian, is also the incoming president-elect, and Victoria Harden is the immediate past president.

So the lines of division fade as we overlap in our endeavors.

The...immediately after I leave the podium I leave the presidency of the society, so it's especially fortuitous and gratifying for me to be able to do this little bit of welcoming today, and to congratulate and acknowledge our debt to Jim Cassedy.

And I do say, it's a real debt. Having come lately into the history of medicine, a third or perhaps a fourth career for me...I've been able to do this because of the resources of the NLM which have been made available to me.

The vast stacks...but one of the most important resources is the staff. And within the staff one of the most important resources has been Jim Cassedy, a real pleasure, a real delight, and a real educational experience.

We thank you, Jim.

Dr. Teigen: Thank you Dr. Cohen. The first speaker this afternoon is the African historian Philip D. Curtin. Professor Curtin is the Herbert Baxter Adams Professor of History at the Johns Hopkins University where he has taught since 1982.

His research has focused on African slavery and migration and the mortality and morbidity of Africans in Africa, and the impact of tropical climates on Europeans.

In 1966, his book, The Image of Africa, won the Robert Livingston Schuler prize of the American Historical Association.

And in 1992, his book, Death by Migration, won the William H. Welch medal of the American Association of the History of Medicine.

In 1983 he was the president of the American Historical Association and during the years 1983 to 1988 he held a MacArthur Prize fellowship.

Among his most recent articles are Malarial Immunities in 19th Century West Africa and the Caribbean, Disease Exchange Across the Tropical Atlantic, and The Slavery Hypothesis for Hypertension Among African-Americans: The Historical Evidence.

Today he will speak on yellow fever as a public health problem in 19th century West Africa. Professor Curtin.

Professor Philip Curtin: Thank you very much. I would like to speak today about the yellow fever as a public health problem not in the United States, but in West Africa in the 19th century and the peculiarity of yellow fever.

It has very different forms in different places. And this is dependent on certain qualities of the virus itself and the vectors that carry it.

The virus itself's key peculiarity is that it makes people sick but you can't tell what they're sick of, much of the time.

That is, it's very hard to diagnose. It comes off as jaundice,as malaria, and as a lot of other things.

So, as a public health problem, some doctors practicing in 19th century West Africa knew about yellow fever but couldn't recognize it when it turned up.

This leads to other peculiarities, too. Second one is that the vector is very peculiar, too, aedes aegypti. It's a domestic mosquito, it's very highly anthropophilic.

It doesn't like to bite anybody but human beings if it can avoid it. Therefore it hangs around people's houses. If you don't know what you're looking for, it's hard to eradicate, but once you recognize the domesticity, that's one of the, probably the most easy, vector of serious illness to be eradicated.

Much easier than the malaria mosquitoes. Another peculiarity is once it bites the person, once it infects the person, the person s immunized for life.

So that this is the most perfect immunity and you'll hear probably later about the vaccine that carries on this tradition of [?] immunizing vaccine.

This is combined with another characteristic that, it's, in biting children or infecting children, yellow fever often has no clinical symptoms at all.

So that a whole population of children can be infected but without having doctors recognize it.

In the Sudan, for example, in the 1930s, when they first discovered a way to test for immunities, no doctor in the British Federal Service in Sudan had seen any cases of yellow fever.

But in some areas, 62 percent of the population was immune. They had had yellow fever but without ever seeing a case serious enough to be investigated.

So that these characteristics together give the epidemiology of the disease a very different pattern in different parts of the world.

We know about the pattern in North America best because it's been studied by North Americans most thoroughly.

And here is, the pattern is it's a summertime epidemic, almost entirely urban. It doesn't seem to spread to the countryside in the 19th century.

It can, in cases like the Memphis epidemic of 1878, kill up to 10 percent of the population, but that's about the most on record.

And then in first frost, it dies, because the aedes aegypti that carries the virus dies and returns again the next year.

So that it's strictly seasonal, and it has difficulty establishing itself between occurrences because in the immunizing quality of the disesae, the population quickly develops a herd immunity so that if it's a fairly small community, so many people are immunized that the virus dies out even if the mosquito is still around.

And in the tropics, though, in the Caribbean, it has another fallback position. Another species of Aedes can carry the disease among primates in the forest canopy.

So that if a sufficient population is immunized, then the mosquito or the virus can retreat to the forest canopy and it can occur again when a new generation of non-immune is born.

Now this gives the epidemiology of the Caribbean a very distinct characteristic because this forest canopy doesn't exist on islands.

So, for example, an island can be attacked and immunized as Cuba was in 1648...the epidemic yellow fever first appeared in Cuba. In 1655 it disappeared.

Now the people who look back on this assume that it had immunized so much of the population that the virus died out and there was not sufficient control or intercommunication between Cuba and other islands to reintroduce it.

So that Cuba was yellow-fever free for, up until 1761 when yellow fever was reintroduced and to a population that was almost entirely non-immune, and then you had an epidemic that is far worse than the epidemics in the American South.

It wiped out out about half of the British Army that was besieging Havana in 1762 and probably equivalent numbers in the Cuban population as well.

So that you get a different pattern here in the Caribbean. Then you get a different pattern again in West Africa because the forest canopy is more extensive and the aedes vectors, aside from aegypti, can sometimes go back and forth between the primates in the forest and human beings.

And you get a pattern there of, not of yellow fever epidemics, but of yellow fever traveling through the younger population and very rarely appearing in the adult population.

In Ghana for example, in this century, data from 1901 to 1960, there were nine years where no yellow fever was recorded at all.

Almost every other year, yellow fever was recorded, but the highest yellow fever infection rates for a population of say three million is 80 cases or a little bit more, twice.

This is not an epidemic that would kill ten percent of the population or anything like it.

So here we have a peculiar circumstance in that yellow fever in the tropics is less dangerous than yellow fever in the Caribbean and less dangerous than yellow fever in the United States because of the quality of immunizing kids.

And this has led the Europeans to, well, you can take this along with other characteristics, the difference between Europeans in the tropical world and people who lived there.

This is the data from the Sierra Leone command of the British Army in, uh, the date given is 1637. [Table of data projected on screen.]

And here you see the difference between African troops, recruited in Africa, and Europeans coming down there.

The [?] fevers, which is smallpox basically, is very high for Africans, not so high for Europeans. Other fevers with simply a fantastic death rate, 400,000 for Europeans, with negligible death rate for Africans.

Who in turn suffered much more than Europeans from diseases of the lung. Gastrointestinal infections broke about even.

These are differences not of race but of childhood immunities and this is carried on into the, especially, the dangerous circumstances for troops who were brought into West Africa.

Troops are like a small city. I forgot to mention that the Aedes aegypti has a very short range, so the epidemic would go from house to house, street by street rather than broadly through a city.

Troops are just ideal. They're usually recruited outside of the country. They're brought in, they're all non-immune, and if the mosquito can get, biting one after another, you can find a very high death rate indeed.

And this is probably, alleged that the acquisition of Louisiana by the United States is thanks to Aedes aegypti. The French sent out a large force, 59,000 men, into Haiti in the years between the slave rebellions in 1791 and 1804.

Ten thousand of them got back and they almost all died of yellow fever. So that there were, the French had no available force in the new world to defend Louisiana from the Spanish or the English and therefore they sold it to the United States.

So that we may attack the Aedes aegypti for some things but at least we did get some nice chunk of land west of the Mississippi.

And that's what having it...leads to a national point of view.

The second thing, the other thing, an African example of yellow fever epidemics among troops is really something you don't think about because it isn't constantly in the news.

In 1825-26, a yellow fever hit a number of African, sorry, European troops stationed in the Gambia, and the statistician making the survey of this had to point out that it is possible to have a death rate of 1200 men per thousand [?] in the year because in this particular...

From May 1825 to December 1826, there were 279 dead in a force that exceeded 125 only once, and very briefly, and often as many as 40 people.

So the new troops, new, non-immunes, were added to the combination and you've got this really horrifying death rate. When one is to talk about the [?] yellow fever epidemics in Senegal, leading up to the ones in...

And there, the percentage of mortality is very consistent and very high. There were very few diseases that kill as much as 70 percent of the people at risk and the only people that are seriously at risk are the European population, so that's the percentages here. [Table showing mortality data is projected on screen.]

Up to 81 percent in 1881. And this is unusually high because of the particular qualities of this part of the African coast.

The Europeans were concentrated as though they were a military establishment or a military post. They really were concentrated at the island of Saint-Louis here at the mouth of the Senegal River. [Black and white map with borders and rivers shown asnarrow black lines is projected on screen.]

It's an island about three miles long and four miles wide, and all the Europeans who lived in Senegal lived there, except for a few scattered...

But they're really concentrated within about 200 yards of the principal fort so that they were just perfectly suited for the yellow fever epidemic.

And the other island is Goree here, on the mouth of the Dakar Harbor. It's not on the river, in the river, but out at sea.

And this is about a mile, two miles from shore and about a half-mile long and a quarter-mile wide. This is the population that is even more concentrated.

So that this is set up to be a better case for yellow fever epidemic than almost anywhere else because of the concentration of the people.

In the 1878, were the really serious epidemics and they were occasioned above all...the fact that the French brought in an unusual force in that year.

They were preparing to attack and acquire the western Sudan here, above the navigable part of the Senegal River, so they're assembling the force on Goree and other forces on Saint-Louis.

The yellow fever epidemic hit in July 1878 and it forced the public health authorities and the military doctors to try to do what they could about the disease.

At this time the diease, yellow fever, in the French medical thought, went back to Nicholas Chauvin, who was...he'd written up [?] in detail. He died in 1848, but his anti-contagionist views still held very strongly in the French thought about yellow fever.

And he held that the disease could not pass from person to person but could arise from a locality as a miasma and attack the people who were there.

Not...they didn't distinguish between immunity and non-immunity, but he believed that because Africans didn't get yellow fever that Africans had a racial immunity and Europeans didn't.

So the way to treat or guard against yellow fever is that when the disease appeared, to try to disperse people away from the locality of the disesae.

And this involved a combination of...well, first a quarantine, not letting anybody in with disease just in case they're contagious.

But to disperse the military forces in particular. In 1878 for example, the forces on Goree, the military was sent across the way to what would now be suburban Dakar, within sight and they were safe for a time.

We don't know how it happened, but no doubt somebody went to the new camp with yellow fever and half the dispersed forces, more than half the dispersed forces, died as well.

And because they didn't know how the disease was carried they didn't hesitate to transfer personnel from place to place.

So that, for example, the disease began first in Goree, and then it skipped...it didn't go by sea to Saint-Louis as one might expect.

But it turned up here in Bakel, way up the river because a military doctor who had been stationed in Goree was transferred to Bakel, and the result was. [Black and white map projected on screen.]

Only a very small number of Europeans there, a total of eight in the post that he joined, but six of them died, in very short order.

This is another kind of reminder. These epidemics that began in 1878 were the worst probably in Senegal in the French period. If you've been to Goree you've noticed that the most prominent monument is to the doctors who died in 1878-79.

It also was curious, in that a number, a very large number of people began to study the disease, so that you have seven French medical theses just written by the people who were there in this buildup for the conquest of the interior.

All aspects of the disease and trying to see what they could see from what went on there.

So they studied very carefully the facts and the facts were very curious because in 1881 they dispersed the forces as they had in 1878, with three places along the Senegal River, troops from Saint-Louis.

Two of the three places they dispersed the troops had no yellow fever at all, even though half the population of Saint-Louis was killed in that year.

The other one had death rate equivalent to the city itself. There's one sort of record expedition of this time. In 1878 the French, even though yellow fever had broken out in Goree, ordered an expedition to go up the river in the summer season, that is the beginning when the water was high enough, in July, in October.

A little expedition that was to go up and attack a kingdom of [?]...just above this spot here. They went up the river by steamer. The disease had not been recognized in Senegal, I'm sorry, in Saint-Louis yet, but they went up the river by steamer with a very fast passage up the river, nine days. [Map is shown again and Dr. Curtin points to the river mentioned.]

They unboated here at Mahana, Port St. Joseph, they attacked the city, they were sent out to attack an African town, bombarded it, destroyed it, and then retreated.

At that point they had only nine deaths of any kind, and this looks like a successful attack, but in the next month and a half, they lost again about 70 percent of the force, because they had picked up yellow fever unknowingly.

Probably on passage through Saint-Louis and had carried it with them and the force was so disrupted by the end of the campaign that they settled up in various points along the river and so this is the kind of evidence they had to deal with.

And it's very bad evidence indeed from any point of view of epidemiology because you couldn't really tell what was going on. You thought you knew that the disease was either spread by miasma or contact.

You thought the disease could be controlled by dispersion, you thought that the disease could be controlled by disinfection.

And this is a curious error because it's a disease spread by a mosquito with such a low flight range and personnel were brought in to disinfect the house of a person who died of it.

Then you have a nice collection of non-immune potential victims for the mosquitos...they don't even need to go anywhere different to pass these along.

So that the disinfection caused more problems probably than it cured. But the whole pattern is such an interesting problem that some of the doctors who are investigating it carried out what I think is a most interesting piece of epidemiological research for a period, for a disease

where the vector isn't known, the virus isn't known. All you have is epidemiological evidence to go on. And a young man named Alexander [Legendre?] and he said, well you don't have cause-of-death data, but you have an epidemic which was identified by the time he wrote as yellow fever.

So he tried to separate various groups of people that would be distinct. Colored people, Africans, Africans from other places, other than those born and raised in the islands, Europeans, Europeans who had been born in the tropics, Europeans who had had yellow fever.

And a couple of other categories. And then he tried to say, in a yellow fever epidemic year, if you get data on all these people for a year before and a year after, and the epidemic year itself, the difference is a caseload for yellow fever itself.

And out of this he put together a statement about the immunities from yellow fever and he said that, in the paper that he wrote in 1882, it's not racial, because Africans from somewhere else who came here died just like Europeans.

It's not...Europeans are not immune, but Europeans who have had yellow fever or who are born and brought up in the tropical world, say in the West Indies, are not immune, and the result is that he published the final conclusion in a paragraph that I will read in translation.

Experience demonstrates two categories of people enjoying an absolute immunity and that this immunity is independent of all conditions of race or color, that it is not limited, that it is not lost under the influence of any other modification in the conditions of residence or in climate.

In those who possess it, it is irrevocable. The first category consists of people native to the country where yellow fever is endemic. The fact of being born in such a country confers an immunity which we call native.

The second consists of those who have survived a first attack of the disease and they have acquired immunity.

That is pretty well what people thought about yellow fever immunities a century later. Well, it hasn't been...but a century later. So this is very interesting because it is pure empricism with no scientific knowledge to back it up and no knowledge of the vector and no knowledge of the disease.

But careful examination of the evidence he had led him to this conclusion. Very impressive for its time and its place.

And the final point is that this was published in 1882, a year after the follow-up epidemic of 1881, and the follow-up epidemic was much more, much worse than the individual first epidemic with a death rate of 81 percent.

And the French didn't follow the [Legendre?] suggestions because they hadn't been published yet. But they did absolutely the wrong thing. They rotated the troops who been attacked in the epidemic back to France and brought in a new, fresh, non-immune force to be attacked the next two years, later.

And they rotated back to France a large number of the civilian population, so that if they had just let the people die off, and leaving immunes to withstand a new attack of the disease, they probably would have been pretty well off.

But instead they caused, in effect, by wrong public health measures, just exactly what they were trying to prevent.

Dr. Teigen: We do have time for questions, and you can address them right to Professor Curtin.

Audience member 1: Phil, I was meditating while you were taking about the parallel situation with this country. You mentioned the Memphis catastrophe. That continues for the next umpteen years in the south.

And one of the fine foci of the research in this country was also in the Army. The Army was out in the west, the Army that was helping to run around 1880 the National Board of Health.

And as Pat Gossel among others has found out, an Army man, George Sternberg, later surgeon general, was brought from the far west. from a small military post in Washington, to work for the Sanitary, for the Board of Health, and to go to Cuba with a commission to look for problems, solutions, care, and so forth of yellow fever.

They were looking along some of the same lines. I don't know if they heard about your friend's, his hypothesis, because it wasn't published at that time, but they were working also.

Professor Curtin: Another point that I should have made is that this pure empiricism of Legendre's [?] case is fragile because other people won't necessarily believe it.

So that it dropped out of tropical medicine as a body of knowledge as fast as it got in, and it's only by going back and reading these doctoral theses at this time that you can find out what they had discovered but didn't pay any attention to.

That's another lesson.

Audience member 2: You mentioned that children have subclinical infection and then are immune and I wondered if it's known now about what age do you start getting clinical disease and when you're infected subclinically, how long are you a carrier where a mosquito can pick it up from you?

Professor Curtin: We know that part. You can't be a carrier. If you've had the disease it kills fairly fast, or you're safe.

Audience member 2: But if a child gets it they don't carry the virus.

Professor Curtin: They don't carry. In fact the virus dies in the bloodstream almost instantly of any past victim.

Audience member 2: Do we know what kills them? I mean, in a child victim?

Professor Curtin: In any past victim.

Audience member 2: My other question is what is the case fatality rate today if adults get yellow fever? The last century it was I guess 50 to 70 percent were dying from the way you're describing it. With modern medicine how do we do?

Professor Curtin: I will pass to...our continuing speaker will answer that question.

Any other questions? Good, well thank you very much.

Dr. Teigen:  Our second speaker this afternoon is Alan M. Kraut. He obtained his Ph.D. at Cornell University and is now professor of history at  The American University in Washington, DC.

There he teaches and writes on United States political and immigration history. Among his recent articles are "Plagues and Prejudice: Nativism's Construction of Disease in 19th and 20th Century New York City" and "Historical Aspects of Refugee and Immigration Movements."

His 1994 book, Silent Travelers: Germs, Genes, and the Immigrant Menace, reached a wide audience or historians and non-historians, especially after being the subject of an interview with Terry Gross on National Public Radio's Fresh Air.

His presentation today is entitled When the Truth was Not Enough: Joseph Goldberger and the Pursuit of Public Health. Professor Kraut...

Dr. Kraut: Please let me know if you have difficulty hearing me. I think I've got this on right.

This is a wonderful, wonderful occasion in honor...celebrating Jim's accomplishments. I thought we might start with some music. Would you roll the tape please? Count Basie, 1940.

[Jazz music plays]

Dr. Kraut: Hello?

[Jazz music plays, with lyrics sung]

Dr. Kraut: Thank you. In case you missed the lyrics in addition to the reference to the lynching of a CIO organizer, the song made reference to "let the northerners keep Niagara, we'll stick to our southern pellagra, it's the same old south."

Pellagra of course conveniently rhymed with Nigara, but it was also a reference to an all-too-real disease that had bedeviled poor southerners, white and black, during the early 20th century.

Often referred to as the scourge of the south, pellagra was best known by its symptoms. It was called the disease of the four Ds: dermatitis, diarrhea, dementia, and death.

To southerners who heard Jimmy Rushing sing that song, and Count Basie playing it, the word pellagra in the early 1940s was anything but an obscure reference.

Pellagra had been identified in the 18th century in Spain. In 1907 the disease was first recognized in the American south, among the insane in an Alabama hospital, although there were reports of patients with symptoms as early as 1902.

By 1909, a national conference in Columbia, South Carolina discussed the malady. Firmly committed to germ theory, investigators announced that a pellagra germ could be found, perhaps one that could be spread by an insect vector.

Others blamed overexposure to the sun. Quack remedies abounded. In 1913, Dr. Joseph Goldberger, already an accomplished epidemiologist with the United States Public Health Service, was assigned to investigate pellagra.

Four years after the South Carolina conference, Goldberger found the pellagra germ still undiscovered. Goldberger's research and human experimentation yielded not only a cure, but the cause of pellagra, a dietary deficiency.

Not long after Goldberger's untimely death of hypernephroma in 1929, researchers discovered that niacin was the nutrient missing from pellagrans' diets. Goldberger's research was controversial. [Image of Dr. Joseph Goldberger is projected on screen.]

Not all physicians were prepared to relinquish the notion that pellagra was a germ disease. Goldberger's outspoken critique of southern poverty, the root cause of pellagra in his view, offended the regional pride and social conservatism of southern politicians,

even as it frustrated southern businessman seeking nothern investments. Pellagra as germ disease thus seemed pellagra's preferred construction for a lot of reasons, for a lot of southerners.

Moreover, Goldberger's experiments with human subjects, prisoners especially, designed to prove his dietary hypothesis, proved to be as hotly debated as his results, both in his own time and afterwards.

As recently as January of 1995, 80 years after Goldberger began his pellagra work, a letter to the editor of the Annals of Internal Medicine questioned the ethics of Goldberger's prisoner experiments.

The writer, a physician, objected to an Annals articled entitled "Joseph Goldberger: An Unsung Hero of American Clinical Epidemiology."

In their article, authors Joanne Elmore and Alvin Feinstein, had defended their unsung hero on the grounds that, quote, "At the time of Goldberger's work, some of our modern legal and ethical principles had not yet been developed. Conducting research on prisoners was a common procedure," end quote.

However, their unsatisfied critic, Dr. Bradley Evans, accused the article's authors of being apologists for Goldberger. Evans insisted that whether or not today's standards and procedures were available to Goldberger was beside the point.

Because quote, "ethical principals from religion and physicians, Hippocrates to Claude Bernard, were available to Goldberger, including the oldest standard, never try to harm the patient," end quote.

Unwilling to let Goldberger off the moral hook, Evans contended that whether or not experiments using human subjects were common, or standards of informed consent were broken, was irrelevant to calculating the ethical weight of Goldberger's Behaviour.

However, Evans did allow that he did not know the state of Goldberger's mind concerning his experiments. Quote, "perhaps he thought that he had consent, that the prisoners were not patients, that the harm would be small, or that there were overriding social concerns," end quote.

What was Dr. Joseph Goldberger's state of mind regarding his use of human subjects? I'm currently working on a biography of Dr. Goldberger. Preliminary investigation suggests that Goldberger, a federal civil servant as well as a physician, was aware of the need for patient consent, and approval of his superiors.

And as I shall suggest to you this afternoon, he believed that he had obtained both according to the prevailing standards of his day. He also appears to have been a compassionate physician, sensitive to humanitarian issues and determined to employ science in pursuit of a truth most valuable in its ability to alleviate human suffering.

He took seriously, very seriously, the injunction to do no harm. However, Goldberger, always a painstaking pursuer of medical science's truths, was less patient and painstaking when the truths being articulated by his adversaries, were the product of economic or cultural sensitivities, or greed, as he often thought, rather than the result of scientific research.

A little background about Joseph Goldberger. Joseph Goldberger was born on July 16, 1974 in Giralt, in the foothills of Hungary's Carpathian mountains, a sheepherder's son.

In 1881, the Goldbergers joined the growing number of central and eastern European Jews emigrating to the United States in search of economic opportunity.

For Samuel and Sarah Goldberger, and that's Joseph Goldberger's father, the main chance was a small Pitt Street grocery store on Manhattan's Lower East Side. [Image of Samuel Goldberger, Joseph's father.]

For their son, Joseph, youngest of their seven children, it was education that was the main chance. Three years at City College followed by an MD at Bellevue in 1895.

Finding private practice unsatisfying, the young physician joined the United States Marine Hospital's Commissioned Corps in 1899, renamed the US Public Health Service, of course, in 1913.

A naturalized immigrant, Goldberger began his career inspecting other newcomers for infectious, contagious diseases at the barge office at the tip of Manhattan Island while a charred Ellis Island was being rebuilt following a fire.

However, he was soon sent into the field to study epidemic diseases. Between 1902 and 1914, Goldberger hunted germs, fighting yellow fever, typhus, typhoid, dengue fever, among others.

Overcoming the objections on religious grounds of both his family and hers to the marriage, Goldberger wed Mary Humphries Farrar, the daughter of a wealthy Episcopalian New Orleans attorney, Edgar Farrar, and the grand-niece of Confederate president Jefferson Davis's wife, Varina. [Image of Mary Farrar.]

He married into Southern aristocracy. It was a happy marriage, with four children. This is Goldberger at his in-laws' summer place in Biloxi. And in his extensive correspondence with Mary throughout their courtship and marriage, Goldberger shared his absolute faith in science as the most reliable evidence of an infinite intelligence in the universe. [Image of Joseph Goldberger with three of his children facing the camera and a fourth in the lower left with her back to the photographer.]

In 1906 he wrote to her that, quote, "The truest priest of this infinite intelligence is the patient, open-minded, honest worker in science. It is the latter who is striving with infinite pains to learn something," end quote.

With science, then as his adopted faith, Goldberger immersed himself in epidemiology, for what he perceived to be the loftiest of purposes. In 1913, Goldberger was assigned a pellagra study that Congress had requested of the surgeon general.

Concern was great, especially among congressmen from the south. By 1912, South Carolina alone had reported 30,000 cases of pellagra with a mortality rate of 40 percent.

Goldberger traveled the south, observing pellagrans in mental hospitals, orphanages, cotton mill towns, where the cases were plentiful.

This is the kind of thing he saw. [Image of child with sores on his face and hands.]

He was struck by the population's poor diets, noting that while inmates of hospitals, orphanages, and other institutions often contracted pellagra, staff, who ate a different diet, rarely if ever, and usually never, got it.

On small cotton farms and in surrounding mill villages, diets were equally poor.

There were a few vegetable patches, and mill workers had neither the time nor space for gardens.

What Goldberger saw in the south squared with what he had read in state health reports. Perusing a 1909 report from the Illinois State Board of Health, Goldberger underlined the observations that staff in public institutions did not get pellagra. [Image of a pair of hands with sores and discoloration.]

Point this out. [Red laser pointer highlights section of page in image of report projected on screen.]

What he also pointed out was that Illinois health officials thought that improving the victim's diets and adding milk to them would also be helpful.

[Speaker uses red laser pointer to locate relevant passage on screen.]

Notice at the same time, none of the nurses, attendants, or other employees has as yet shown any evidence of pellagra.

Again, Goldberger's underlinings from our copies here at the National Library of Medicine: "At the present time the most rational line of treatment would seem to be improvement in diet and the treatment of any complicating disease. We believe that the use of clabbered milk will prove of value in controlling the intestinal symptoms."

So, diet, then, is what Goldberger was thinking about. According to Goldberger's surviving son, Joseph, who I interviewed in Austin, Texas a couple of summers ago, his father's earlier investigations of germ diseases caused Goldberger to know, or at least very strongly suspect, that pellagra was not a germ disease, even before he began experimentation.

In Milledgeville, Georgia, at the Georgia state sanitarium, Goldberger found the same pattern. There, too, only the patients contracted pellagra. None of the 293 employees had ever developed the disease. [Image of affected woman holding a child.]

Contagion was not known to make distinctions between patients and staff.

Then, on to Jackson, Mississippi, and the Methodist Orphan Asylum, where 168 of the 211 children had been stricken. By June 1914, Goldberger confessed that while he did not know, quote, "what in the dietary was responsible," end quote, he observed that pellagrans tended to have a largely cereal and vegetable-based diet.

He suggested instead an increase in the fresh animal food component, such as fresh meats, eggs, and milk.

Dr. Joseph Goldberger's state of mind, then, on the eve of his human experimentation, was a strong belief that only human subject testing would lead to answers, but that such testing need involve nothing more invasive than dietary modification.

As a federal physician, Goldberger could only proceed with human experiments subject to the approval of his superiors. Goldberger's letter requesting permission from Surgeon General Rupert Blue said that he felt he must offer test results, not assertion.

Quote, "While confident of the accuracy of our observations and of the justice of our inferences, there is nevertheless great doubt in my mind as to their general acceptance without some practical test with demonstration of the correctness of the corollary.

Namely, that no pellagra develops in those who consume a mixed, well-balanced diet." End quote.

Goldberger secured federal funding for two years of extra food for the Jackson Methodist Orphanage and the nearby Baptist Orphanage, where 130 boys and girls had pellagra.

What kind of permission did he have from these institutions, the childrens' legal guardians? While I have as yet been unable to find written permissions, though I suspect that they exist, in an unpublished manuscript written after 1929, after Goldberger's death, Goldberger's widow recounts her husband's aqcuisition of permission.

Quote: "Upon his return from the south, the light of battle was in his eyes. He wrote me on September 30, 1914, quote, 'it is just a daily round of grind, going over the records and verifying data. The thing works out with almost the precision of a mathematical problem.'

He then gained the consent of the heads of two orphanages in Jackson, Mississsippi to add to the diet of the children a glass of milk at each meal, and meat once a day, with the astounding result that in a few months he had no case of pellagra at the institution." End quote.

Where Mary Goldberger oversimplified and perhaps overdramatized her husband's experiment, it seems clear that he believed himself to be proceeding with the permission of those directly responsible for the children's welfare.

At a South Carolina orphanage, where Goldberger was denied immediate access to the children by a physician who was described by him as a state health officer, by a state health officer, as an earnest plodder without much intelligence, Goldberger fumed, quote: "I had once hunted up the orphanage doctor and had a talk with him.

He was not disposed to give me a clear field in the study of the orphanage, so I left it entirely to him." End quote. Goldberger might boil with anger -- and he did -- but he did not trample upon the prerogative of officials at these private institutions in the matter of human experimentation.

The experiment involved orphanage children and asylum inmates. Goldberger was puzzled by the age distribution of orphanage pellagra cases especially. Young pellagrans were almost always between the ages of six and twelve.

Among the 25 orphans under six years of age, only two cases had appeared. Of the 66 over twelve, only one had pellagra. However, in the middle group, ages six to twelve, 65 had pellagra.

Why? The answer might be diet. The youngest got milk. The two older groups got almost none. But the oldest group often got meat more frequently than the middle group.

Also, the older children supplemented their diet when hunger struck. They stole food for snacks. The middle group, too old for milk, too young for meat, was perhaps insufficiently bold for successful thievery. Their diet was not unlike that of the poorest mill workers.

Biscuits, hominy grits, corn mush, syrup, molasses, gravy, and sow belly. A fare that almost never included foods rich in animal protein as milk, eggs, butter, and lean meats.

Starting in September 1914, children at both Methodist and Baptist Orphanages under the age of twelve, got 14 ounces of milk per day. Those under six were given 21 ounces. Eggs, rarely served before now, became standard fare. Fresh meat was served four days a week.

By spring of 1915 there was no pellagra at the orphanages. If the previous rate had continued, there should have been at least 33 cases at the Methodist Orphanage and 52 among the Baptists.

Those who had contracted it before and been cured, did not get it again, and there was not a single new case.

Later in the fall, a similar program was started at the asylum at Milledgeville, Georgia. Goldberger and an assistant isolated 36 white female pellagrans in a separate ward, and 36 female African-American pellagrans in another ward, observing the southern custom of racial segregation, and perhaps also to see whether or not there was a racial differential.

Both groups' diets were altered with fresh milk, eggs, meat, and so on. As a control group, 32 other pellagrous women, 17 black and 15 white were continued on their normal diet.

Goldberger's account begins, quote: "Through the courtesy and with the very helpful cooperation of the board of trustees, superintendent, clinical director, and staff of the Georgia state sanitarium, two female wards were turned over to the writers for tests of the value of diet in the prevention of pellagra." End quote.

At the Milledgeville asylum, 15 of the control group of 32 showed recurrences. The 72 pellagrans on the new diet, 36 black, 36 white, recovered fully. According to the usual occurence rate for women, 27 of the 72 should have shown recurrences.

There was not even one. All were entirely free of pellagra. Goldberger told reporters, to cure pellagra, eat beans. To prevent pellagra, eat more beans.

Well, he was being a bit cheeky. James A. Haynes, South Carolina's health officer, often referred to Goldberger's view as no more than a bean theory, and an absurdity.

Goldberger was aware that he must demonstrate the existence of a particular susbstance, the absence of which from the body induced pellagra.

Logically, he should be able to produce in robust, vital bodies through dietary modification. After considering his need to confine and observe an experimental population, as well as the requirements of regulating diet and persuading participants to accept the risk of intentionally induced diseases, Goldberger decided to recruit volunteer prisoners for his research design.

Goldberger had noticed that the inmates of Rankin Prison Farm near Jackson, Mississippi, were free of pellagra. They grew their own food.

Goldberger wanted to alter some inmates' diets to see if he could induce pellagra. However, using American prisoners as subjects in systematic medical experimentation, the goal of which was non-therapeutic, promised to be politically controversial.

In the winter of 1914-1915, Goldberger persuaded Mississippi's progressive governor, Earl Brewer, to support a plan to induce pellagra in subjects chosen from among Rankin's inmates.

Brewer rightly feared that the death of any prisoner would be construed as thinly-veiled state-authorized murder. Goldberger's experience curing pellagra in the orphanages contributed to persuading Brewer to take the risk.

Brewer dangled the promise of pardons before the approximately 80 inmates. All they had to do was volunteer to spend the next six months eating the traditional Southern, largely cereal diet.

According to a newspaper article, quote: "They, meaning Brewer and Goldberger together, presented the matter frankly to the prisoners, telling them just what they would have to undergo. There was no effort to minimize the physical risk." End quote.

However, an article that appeared after the experiment ended, suggested  at the very least an implicit coercion. Quote: "When the pellagra squad was made up, no persuasion was used to get members four times the number needed volunteering, most of them life-termers who were willing to take a chance with the loathsome disease rather than spend the remainder of their days on the state farm. The remainder of their days." End quote.

From the many volunteers who came forward, Brewer selected twelve, half of them murderers serving life terms. All were Caucasian. Some physicians in the south believed whites to be less susceptible to pellagra than blacks.

Goldberger hoped that by inducing pellagra in white prisoners, he could demonstrate that diet, not race, was the key.

Also, Goldberger thought that a pellagra diagnosis could be more readily made with Caucasian subjects because white skin showed more starkly pellagra eruptions than did African-Americans' darker pigmentation.

There might have been a third reason. Traditionally, participation in medical experiments involving tangible rewards was a privilege reserved for those at the top, not the bottom of society's pecking order.

Perhaps neither Goldberger nor Brewer chose to increase the controversy by violating the south's social patterns.

Lawyers retained by some of the prisoners made certain that the rules of participation,and the conditions of pardon, were clear and explicit. And on February 4, 1915, the experiment began.

The subjects were isolated from the prison population in a separate building. Goldberger and Brewer, concerned about public reaction to inducing disease in prisoners, insisted upon secrecy.

In fact, few voices were raised in protest among those who learned of the experiment. Perhaps it was merely evidence of the general public's unconcern with the fate of convicted murderers.

Most protests, when they occurred, concerned in fact the pardons. The secrecy policy led to charges that participating convicts were being offered pardons for service that was frivolous, compared with the crimes for which the prisoners were being punished.

Mississippians let their governor know that they opposed putting serious felons back on the streets. W.H. Rucker, editor of the local newspaper, addressed the governor concerning one murderer named Guy James.

Quote: "If he deserves a pardon, there are none deserving punishment. I am hoping that you will not do this community a wrong by granting the pardon." End quote.

Six of the eleven prisoners who finally participated showed pellagra lesions. Expert dermatologists were invited to make the actual diagnosis so there could be no accusations that Goldberger had claimed to see something that did not exist.

The inmates were pardoned and released. None chose to accept the offer of remaining for another change of diet.  The medical and scientific communities' response to Goldberger's experiment was not unanimously laudatory.

One critic denounced Goldberger in the Journal of the American Medical Association, on behalf of those still committed to the infectious disease definition of pellagra.

They wanted a germ.

Some accused him of faking the experiment. Few scientific colleagues raised the ethical issue of medical experiments on prisoners. The issue was one rather of competing truths.

One truth was based upon the assumption that microbes were responsible for all diseases, and pellagra was an infectious disease and therefore there must be an attending microbe.

The other truth, Goldberger's truth, was based upon observations in a controlled experiment that defied the existing wisdom.

Goldberger's prison experiment had succeeded. Still, to quiet any remaining critics, Goldberger again used human subjects. He would try to transmit the illness from pellagran to healthy volunteer as though it were indeed a germ disease.

Twenty friends volunteered for what Goldberger called his [?] parties. He used 14 of them plus himself and his wife.

On April 26, 1916, Goldberger injected five cubic centimeters of a pellgran's blood into the shoulder of his associate, Dr. George Wheeler.

Wheeler then shot six cubic centimeters of the blood into Goldberger's shoulder.

Then they swabbed out the secretions from the patient's nose and throat and applied to the swabs to their own noses and throats. Even after an incubation period of several days, neither physician felt ill.

Just the thought of it makes one feel ill.

Other such experiments followed, including one involving Mary Goldberger. Goldberger withheld publication lest the subjects suffer delayed symptoms. He wanted to be careful.

The names of the volunteers were not mentioned in print, of course. They were described by Goldberger in the ubiquitious male chauvinist vocabulary of his day, as simply, "Fifteen men and a housewife." His housewife.

So what did Dr. Joseph Goldberger think of what he was doing? Come back to our question...

Did he think that his subjects had been adequately informed? Was he conducting an experiment that he thought might lead to permanent illness? Or perhaps even the death of his subjects?

Did he pursue his research in the belief that there was a higher social purpose at stake?

The orphanage and asylum experiments convinced Goldberger that he could cure pellagra with diet and that therefore the prisoners were in no mortal danger.

Nor can there be any doubt that Goldberger believed curing and preventing pellagra was a cause well worth the risk of human experimentation.

Writing to his wife Mary, the usually restrained Goldberger gushed with enthusiasm. Quote: "I do not yet realize that we have really and truly produced pellagra in great big vigorous men by just feeding them properly, or rather, improperly. However, it is a fact about which seven of us who have seen the patients agree."

Still, intentionally inducing pellagra in healthy prisoners is problematical. Initially, Joseph Goldberger did not regard the Rankin prisoners as patients because they were not ill when he encountered them.

They were laboratory volunteers who had been informed of the risks and rewards of participation. Goldberger approved granting pardons, but there is some hint that in his own mind, the pardons represented a self-interested element that distinguished these participants from his laboratory colleagues who put themselves at risk for no reward but scientific truth.

In a letter to Mary, Goldberger refers to the men as convict volunteers, volunteers in quotation marks. The use of quotation  marks around the word volunteers lends it a certain ambivalence.

Once they were under his care though, the prisoners became Goldberger's patients, and his interest in their wellbeing appears no less than in the asylum inmates he had treated earlier.

However, once the experiment was over and the pardons granted, Goldberger ridiculed the speed of their departure to Mary Goldberger as follows. Quote: "Well, the experiment is over. The men were pardoned yesterday and all went off like a lot of scared rabbits." End quote.

Very important throughout the prison trial is Goldberger's absolute confidence in his ability to cure pellagra with diet. He was thus thoroughly persuaded he was not placing his subjects in harm's way.

Likewise, Goldberger believed that whatever risks were inherent in the use of human subjects were worth taking because of the potential of his discovery, to rid humankind of pellagra, especially the poor, who were so often its victims.

Goldberger wrote Mary of his publicity plans. Quote: "I shall be in favor of bucking the publicity line hard. We will have something then that will have weight with the man on the street, or the street corner for that matter.

After all, he is the fellow we are after. Not the highbrow who is more interested in a hair-splitting discussion of the derivation of the word pellagra than in getting the true faith as to decent diet to the plain everyday worker.

I am strong for laying the true faith before the chap and Mrs. Chap who are living on bread and molasses and have pellagra than to Mr. and Mrs. Silk Stocking who have been interested in this subject to the extent of discussing it over beefsteaks." End quote.

Earlier he had written to her, quote: "The knowledge we have gained is sure to save thousands of lives of your southern people, not to mention the misery of many years of suffering and ill health of thousands of others."

Goldberger continued controlled feeding experiments at the Public Health Service's pellagra hospital in Spartanburg, South Carolina, and at the Georgia State Asylum at Milledgeville.

[?] vats in which they prepared food at Spartanburg.

Later in the early 1920s and again at the time of the Mississippi flood in 1927, numbers of pellagra cases spiked, and Goldberger waxed critical of southerner's diets and the social system that circumscribed so severely the dietary choices of the poor.

Some southerners, including South Carolina congressman Jimmy [Burns?], later secretary of state in the 1940s, sensitive to Goldberger's outspoken criticism of the south and its social system, attempted unsuccessfully to have Goldberger muzzled. [Image of worker standing over two rows of vats.]

However, Goldberger's voice would not be still.

During the flood, Goldberger and a PHS statistician, [?], traveled the Mississippi Valley collecting statistical data in the hope of isolating the dietary deficiencies that caused pellagra. [Head shot of Goldberger.]

Dr. Joseph Goldberger's work is much admired by the medical elite of his generation. After visiting Goldberger in the south and inspecting his research at the request of the Surgeon General, eminent physicians William Welch, Victor Vaughan, praised Goldberger in their reports.

Welsh wrote of Goldberger's research as, quote: "Admirably planned and conducted, most creditable to the Public Health Service." And having, quote, "Resulted in most important scientific and practical contributions to our knowledge of this important and perplexing subject. I believe that these reults will lead to the saving of thousands of human lives." End quote.

If Goldberger's human experimentation has lately played to mixed reviews, and it has, the positive verdicts of his work far outnumber the negative, both then and now.

The themes of Goldberger's career:  a selfless devotion to public health, social criticism, even the systematic collection of social data for statistical analysis, are all familiar themes for those of us who read and admire Jim Cassedy's work.

Like Charles Chapin, about whom Jim has written so eloquently, Joseph Goldberger deserves the accolades of a public health hero for his unwillingness to allow prevailing scientific wisdom to predetermine his research path.

And willingness to wed science to social critique. Like Chapin, Goldberger understod the futility of considering public health  separate from broader economic and social patterns of change. [Portrait of a middle-aged Goldberger.]

At the end of Chapin's biography, Jim Cassedy quotes Chapin's 1927 article, Science and Public Health, quote: "Science can never be a closed book. It is like a tree, ever-growing, ever reaching new heights. Occasionally the lower branches, no longer giving nourishment to the tree, slough off. We should not be ashamed to change our methods. Rather, we should be ashamed never to do so. We should try new things, but should show common sense about it."

I am quite certain that if he read that article, Joseph Goldberger would heartily agree. Thank you very much.

[Applause]

[Dr. Kraut prepares to take questions from the audience]

Audience member #1: [?] discussions of the work at the orphanage and the non-, the work other than at the prison. Because certainly these are experiments and they are clearly human experiments. Their intent is experimental, but obviously I mean on one hand, one could see them as therapeutic.

At least in the sense that the people already had the disease. But in addition to that, it strikes me as interesting that, if a charitable organization had come along and said to one of these orphanages, we'd like to improve the diet of these folks and we're gonna contribute, we think these kids oughta have milk and we're gonna contribute a quart of milk a day per kid or whatever it be, and had made this offer, and it had gotten [?] it wouldn't have presumably been seen as an experiment.

And of course its intent would not have been experimental. So the whole issue here is in the intent, and I'm just wondering, you know, what were the reactions at all to those experiments done at the orphanages as opposed to the prison ones which were clearly non-therapeutic.

Dr. Kraut: More in the sense of interference...I mean, he was coming down there and he was interfering. There was nothing wrong with the southern way of life that needed the federal government's involvement.

Now interestingly enough, the head of the orphanages often felt differently. They were only too happy to accept the food. But the community and community leaders often different considerably in their views.

This guy was a northerner, an outsider, he was intervening in their way of life. Goldberger of course, saw it as both humanitarian and as a scientific experiment. He was taking notes, keeping records, monitoring constantly...he had one assistant at one orphanage, another assistant at  the other orphanage.

For him, it was a combination of things. It was an experiment that would prove what he thought he already knew and yet at the same time, it was clearly humanitarian, he was helping children.

And so, consequently there wasn't always the distance. He was aware that this was a humanitarian gesture. I think one of the interesting aspects of your question is this interplay between what the scientist thinks and what the community perceives.

Audience member #2: Goldberger would have to have gotten clearance either from Rupert Blue or from McCoy...

Dr. Kraut: He did.

Audience member #2: for the Mississippi experiments [?] whether they viewed the problem in Mississippi as a political problem or a legal one, or...[?]

Dr. Kraut: No, he proceeded with their permission and they did not in their permission to him, in their communication with him I should say, indicate that there was for them any ethical problem whatsoever. Brewer perceived a problem, but Brewer's problem was less ethical than it was political.

Audience member #3: Alan, would you comment on the difference or contrasts [?] between Goldberger's reception in the south and that of his colleague Charles Wardell Stiles [?].

Dr. Kraut: I'm not sure I know enough about Charles Wardell Stiles' reception to really go into it in much detail. One of the things that I thought initially about Goldberger because of some early evidence that I saw was that a lot of the reaction to him was anti-Semitic in quality.

And the more I read, the more I followed him, the more I looked around, the less the initial anti-Semitic comments that I came across seemed to characterize the overall reaction to him.

Rather, the reaction to him was not so much anti-Semitic but rather somebody who was meddling in the south's affairs, and whose overall impact upon the south, still after all recovering from the Civil War and Reconstruction, could be negative.

The criticism was what was feared. The fear that his criticism of the south might turn away northern investment in the south, might slow the building of mills. Mill-building was almost a religion at this point in the south.

One minister said build the mill for goodness' sake, for God's sake, as well as for your own sake. And that's an incredible comment about the importance of investment and changing the nature of the southern economy.

And Goldberger was looked upon by some southerners as an obstacle in that larger growth and recovery.

And I think that's why the antagonism.

Audience member #4: [?] his style as a public figure. When he spoke to the community, he was very rigid, and did not come across very well. [?] Goldberger was very impatient with scientifc colleagues who didn't keep up or agree with him, but I don't know very much about his personal or community relations, patient relations. Do you have any sense of a bedside manner or whatever...

Dr. Kraut: I htink he had excellent bedside manner with the youngsters in the orphanage, he joked with the prisoners and so on. What he had little patience for was the community leadership that was critical of feeding the poor and changing the way that the south did business.

He had very little patience with that, in fact that's a whole separate paper and will be of course an important part of the book. It's not just what the south thought of Goldberger but what Goldberger thought of the south.

And it was not complimentary. He was after all a man of science. From his point of view, on balance between religion and science, Goldberger opted for science.

And consequently anyone who resisted the findings of science and humanitarianism that he thought as part of his findings, he viewed as enemy, and he did not hesitate to lambaste them.

Dr. Teigen [pointing toward audience]: Time for one more question.

Audience member #5: [?] a passing reference to Edgar Sydenstricker. The collection and tabulation of data [?] from the early experiments was his work.

Dr. Kraut: Well, here's where I could use your help in fact. If anybody knows where there is a body of Sydenstricker papers, manuscripts, I am looking for it. I've been successfu, of course, in finding all the papers published with Goldberger, and his earlier work, and so on.

But I've not been able to find a collection of manuscripts. As some of you may know, Edgar Sydenstricker's sister was Pearl S. Buck, Pearl Sydenstricker Buck. And so one would think that with a family that distinguished, there might be a body of papers. But I have tried to find that correspondence, so far unsuccessfully, but I have not given up.

So if you know of any place where there are Sydenstricker papers...

Audience member #5: The daughter Myrtle Sydenstricker was a clerical employee of the Public Health Service.

Dr. Kraut: Thank you, that might be helpful. Do we have time for any more?

Dr. Teigen: I think we should move on to the next paper. Thank you very much.

[Applause]

[Dr. Teigen returns to the podium.]

Dr. Teigen: Our next speaker this afternoon is Caroline Hannaway, an historical contractor for the National Institutes of Health. She has a Ph.D. degree in the history of medicine from Johns Hopkins University. For 11 years after completing that, she continued there as a faculty member and as editor of the Bulletin of the History of Medicine.

[Man walks up to podium and speaks to Dr. Teigen.]

Dr Teigen: She subsequently directed the Frances C. Wood Institute for the History of Medicine at the College of Physicians of Philadelphia. In her work for the NIH, she recently completed an assessment of the NIH contribution to the development of cochlear implants. Her current project for the NIH is the preparation of oral histories of the NIH's responses to AIDS.

Among her recent publications are Vicq d'Azyr, Anatomy, and a Vision of Medicine, and Caring for the Constitution: Medical Planning in Revolutionary France.

Today she will speak on the Approach to Epidemics: The Scientist's Perspective Past and Present.

[Dr. Caroline Hannaway takes the podium and adjusts her microphone.]

Dr. Hannaway: Excuse me drinking water at intervals, but I've had a throat infection for the past week and I need something to keep the vocal cords moist.

It's a great pleasure for me to speak at this symposium in honor of Jim Cassedy, whom I have known for over 25 years. I first came to know Jim in the late 60s and early 70s when I was working on my Ph.D. dissertation at Johns Hopkins.

The History of Medicine Division at the National Library of Medicine was then, as it is now, an unparalleled treasure trove of materials in the field, and I used to come over frequently from Baltimore to Bethesda to conduct research.

Jim has always encouraged other people in their research, and his bibliographic knowledge was invaluable to a student starting out. I owe him many a debt.

At the time I first met Jim, I was investigating a group of government medical scientists who were confronting epidemics. Now, research has its circular characteristics. In 1996, I once again engaged in a project, which is also concerned with a group of government scientists confronting an epidemic.

In this instance, a specific epidemic, AIDS. These two groups of scientists are 200 years apart in their endeavors, and belong to two different nations, France and America, both dear to Jim's heart.

But on reflection, I believe there is value in juxtaposing their responses to epidemics and in the process learning more about the effects such outbreaks of disease can have on medical science, and on the nature of govenrment response to scientific need.

The contrasts and comparisons may be instructive. Let me state at the outset that I do not dissent from the view that reaction to disease is contigent on the circumstances and context in which it occurs.

But in recent years the social history of epidemics has become almost too fashionable a topic. There has been much less research on the scientific challenges presented by epidemics and on how medical scientists in different historical circumstances and places responded to the challenges.

The two groups of government scientists that I want to juxtapose are the physicians belonging to the Royal Society of Medicine in late 18th century France, and scientists at the National Institutes of Health in late 20th century America.

The French physicians' group, which was the subject of my dissertation, was specifically founded in 1776 to combat epidemics. The epidemic that was the immediate instrument of its coming into being was an animal epidemic, that of rinderpest, or cattle plague as it was known at the time.

Rinderpest was not a new disease in Europe in the 18th century, but the outbreak of the 1770s was particularly devastating in the extent of its spread right across Europe and in the numbers of cattle affected.

Governments scrambled to prevent destruction of their economies in which agriculture was the prime resource of wealth. The development of the AIDS epidemic in the United States did not have the same immediate impact, for a complex of reasons, having to do with its transmission characteristics, the groups in the population that were most affected, and with the uncertainty of many medical scientists that AIDS would develop into a major disease problem.

But AIDS did lead to a restructuring of research priorities within the biomedical community, within a relatively short time. And scientists at the NIH were amongst those who responded quickly. Those working at the NIH did not coalesce into one group.

The independent attributes and interests of institutes co-existing under  this umbrella entity prevented that.

But their interaction was significant, and scientists with expertise in many areas contributed to the intramural research program.

Only this spring in fact has there been an announcement of a plan to coordinate all AIDS research at the NIH. My work on the NIH response to AIDS is part of a project of oral history interviews that will be developed into a book.

The project is being conducted by the NIH Historian's Office, directed by Dr. Victoria Harden.

One of the changes in the scientists' perspectives that epidemic bring is the relative importance of certain diseases as subjects for research and funding.

In the 1960s and 1970s in America, as well as elsewhere, infectious diseases were declining in status as subjects for medical research.

The success of antibiotics after World War II in curbing many infectious diseases, and the development of vaccines to ward off others, had enabled many people to live longer and less disease-troubled lives.

But the consequence of these therapeutic and preventive achievements was the rise in the number of persons suffering from chronic ailments that have their own [?]

Medical research began increasingly to focus on cancer and heart disease.

And funding for research was concentrated on ailments such as these. Even at the NIH, where research was conducted on almost every topic, the National Institute of Allergy and Infectious Diseases, NIAID, felt itself to be low man on the totem pole.

The advent of AIDS changed all that.

Once it was recognized as a new infectious disease, medical thinking and priorities underwent adjustment. NIAID is now one of the leading institutes at the NIH in terms of recognition and funding.

In the 18th century, there was a similar effect. Epidemic disease had not been at the forefront of medical or government attention in France since the terrifying outbreak of bubonic plague in Marseilles and the southern regions in 1720 and '21.

But rinderpest changed that, setting up a royally funded group in Paris to gather information on human and animal epidemics from all over France, generated much greater attention on the part of local provincial physicians, to such outbreaks of disease, and made them meterological observers as well.

The correlation of weather and onset of epidemics was an important quest in 18th century disease research.

A network of investigators was initiated, contributing to a disease map of France. The careers of medical scientists changed as well. I can still remember when I was a history of medicine person on the medical school council at Hopkins in the early 1980s.

And the representative for infectious diseases came running in late to a meeting, to tell us excitedly about this new syndrome that was appearing.

He predicted that it would change the face of infectious disease. He was excited by the new research challenge, but also by its implications for his department. He and his colleagues were going to become much more prominent in the scheme of things.

Certain scientists at the NIH had similar reactions. Witness the experience of Dr. Anthony S. Fauci, now one of the leading research scientists on AIDS in the United States.

In 1981, when the opportunistic infections consequent upon AIDS were recognized, he was the Chief of the Laboratory of Immunoregulation in the National Institute of Allergy and Infectious Diseases.

The laboratory focused on fundamental immunology, predominantly looking at diseases of hyperreactivity of the immune system and the hypersensitivity diseases.

Fauci, by all accounts, early recognized from the Centers for Disease Control reports, in the morbidity and mortality weekly report, that a disease that was bloodborne and sexually transmitted could be, in his words, a disaster for society.

His response was to engineer a gradually accelerating transition of his laboratory to work on AIDS. He comments on the reaction he received as follows:

"Some people were a little concerned about me. They said, he has been so successful in what he is doing with fundamental immunology and the hypersensitivity diseases. Why does he want to switch over to an area where we do not have any idea what the disease is, and in which he is not an expert?"

But the fact was nobody was an expert yet. Before AIDS Fauci envisaged that he would continue indefinitely to dissect out the immunoregulatory mechanisms of the immune system. When AIDS came it turned his world around, but not as much, he claims, as it may appear at first sight.

Now he studies AIDS from the context of what the immunoregulatory effects are. In his description of this turn of events, Fauci the research scientist states, quote:

"Although AIDS is a terrible epidemic, it is an extraordinary model for gaining insights into the immune system, the likes of which cannot be obtained from any experimental, in vitro, or animal model."

The public health crisis of an epidemic offers scientists opportunities for research, not just into the particular disease but into other areas of physiological response.

This is the viewpoint that it is difficult for the disease-sufferer to appreciate. Dr. Henry Masur, who is a clinician of the Clinical Center at the NIH, characterizes the scientist's attitude as follows, quote:

"My perception of scientists is that they are like businessmen, and that although there are some who are purists, and will do what interests them regardless of what else is happening in the world, most of them are very practical."

"If they see a new disease that will help their careers in terms of publications, of getting a more prestigious job, and if they see opportunities they will be attracted into that field."

"They are not going to be attracted by a dead issue, no matter what the president or anybody else says." End of quote.

My 18th century protagonist, the physician Felix Vicq d'Azyr, likewise found his career turned around by his excursions into epidemiology. His career goal was to be a professor of anatomy at one of the prestigious royal research and teaching instititutions in Paris.

Twice thwarted in these ambitions, he was hired as a consultant in 1775 by the Royal Administration of France on the rinderpest epidemic, and traveled to remote provinces directing efforts to contain the epidemic by procedures of slaughter and quarantine.

From this experience he conceived the idea of a group of government-funded physicians to research and provide expert advice on epidemics, not only in humans but in animals as well.

He was successful in this endeavor and obtained the key position of Perpetual Secretary of the group with a government salary. His touring experience he put to good use as well, for his anatomical research.

The practice of slaughtering infected and diseased animals allowed him to try physiological experiments on respiration, sensibility, and movement, that had only previously been conducted on medium-sized four-legged animals such as dogs.

Now he had the chance to experiment on large quadrupeds. As he described it himself, "I made every effort in the midst of this public calamity, at least to make some use of the very expensive sacrifices that the prudence of the government has judged necessary."

Later he noted, as a additional incentive to encourage research in an area that many physicians might think was beneath them, that animal epidemics offered the opportunity for bold experiments that would be regarded as cruel if tried on humans.

In their views on how medical scientists should conduct research on epidemics, the two groups show both simililarities and differences.

The precept that was supposed to govern the 18th century investigator of epidemics was that he should try not to embellish nature but only be its interpreter.

To understand disease patterns, it was necessary to bring many observations together, put them in order, in a certain sense assimilate them and let them mature.

Then consider them from every aspect possible, and finally draw out consequences from them. In other words, a [?] strategy.

The physician must give as much time as necessary to this work, not try skim through it in too quick or hasty a manner, nor take any steps that have not been reflected upon and verified as much as possible.

The NIH AIDS researchers, too, believed that a broad net must be cast in searching for information about the disease. They planned to look for every virus and bacteria that had ever been associated with immuno-suppressive illness.

It was also argued that time must be devoted to the understanding of disease mechanisms, because without this, much energy would be wasted in pursuing blind alleys in the developments of treatments and vaccines.

As Dr. Kenneth Sell, former Director of Scientific Research at NIAID noted, "One needs basic research to stimulate new ideas about immune system intereactions that may cause or influence disease processes."

"I think most scientists would agree that you make much less progress when you are disease-focused than when you try to go back and establish some basic understanding of fundamental biochemical, physiological, and cell biological reactions."

The 20th century medical scientists also have faith in serendipity in science. Dr. Kenneth Sell again, "I think that almost every investigator would agree that basic research is truly serendipitous. Many great discoveries have been made quite unknowingly in terms of the original intent of the research."

"It is good to have aims and objectives, but what comes out of research often has nothing to do with the original aim or objective of the research."

In 18th century rhetoric, by contrast, the emphasis was on building communication so that meritorious pieces of information would not be lost.

In the 18th century, it was stressed above all that the person trying to comphrehend the development of epidemic disease, must never make the mistake of taking some striking but isolated instance as an experience that was certain and capable of leading to a constant and general law.

As the Royal Society of Medicine put it, in its instructions to correspondents:

It has not been on rare and extraordinary cases that we urge those who wish to be good correspondents with us to concentrate their attention. It is necessary above all to avoid the bad habit of certain physicians whom the marvelous alone interests.

Who are happy only when they can wonder at something and for whom there is nothing striking in nature except that which goes beyond its ordinary boundaries.

Dr. Robert C. Gallo of the National Cancer Institute, a leading AIDS researcher, would agree with his 18th century counterpart that a scientist should not leap upon the exotic instance.

To the charge that scientists did not want  to conduct research on AIDS because it was gay men who had the disease, he responds that the problem was not which group had the disease, but the fact that it was, quote, "An obscure disease of a small number of people at the time." End of quote.

He, for instance, was working on leukemia and aplastic anemia, for which he had viruses in  hand.

As he comments, quote, "If somebody tells you that a disease called Kaposi's sarcoma, that you had heard about but did not know much about, a rare disease in old Jewish, Italian, and Greek men, has now been found in some gay men in San Francisco and New York, you say, okay it's interesting."

"But how many new things do we hear about every week at NIH? If I started looking at a newspaper and responding to every report about disease incidents, I would be working on a different disease every two weeks."

The processes of searching the literature and drawing inferences of disease from published reports, in understanding epidemics, are used by researchers in both time frames.

But somewhat different strategies are followed. In the 18th century, the medical scientists looked a long way further into the past than his 20th century counterpart.

In its quest to develop a coherent history of epidemics, the Royal Society of Medicine had one of its members searching the literature from the Greeks on for information.

Nor was the search limited to medical writers. Greek and Latin poets, travelers' accounts, chronicles of the Middle Ages, and the works of general historians were all regarded as potentially worthy of consultation.

This was not just an attempt by these physicians to put a graceful, humanistic gloss on their project, but one to seek detailed and thorough knowledge of all factors relating to the onset of epidemics.

The 20th century medical scientist is much more presentist. He or she believes that material more than ten years old is likely to be out of date. He or she would not look beyond the scientific literature, and any reference to Hippcrates that is made is a genuflection to the past.

What incentives are there at particular times to get scientists interested in researching epidemics? In the 20th century, the NIH has several incentive programs.

First, for intramural investigators, there is considerable freedom to divert the research in their laboratories to new areas when these appear to be of biomedical interest.

Dr. Kenneth Sell describes what NIAID did about AIDS, quote: "It was ruled that we could transfer resources to the AIDS problem and we did, almost immediately. We expanded our intramural program just as fast as we had new ideas."

"There was no limitation in terms of dollars. We could always reassign or get additional dollars. Our problem was trying to think of new things to do, and new people to do them, so that we could expand our intramural program."

Second, the grant and contract mechanisms of the NIH provide funding to institutions around the country to conduct research on particular topics.

Part of the debate on the NIH's response to AIDS, which Vickie Harden has described, is whether these mechanisms are too cumbersome to be effective in their response to new problems.

The 18th century Royal Society of Medicine also had its incentive program to encourage research on epidemics. It was the offering of monetary prizes of sizable amount on particular topics, and the publication of prize-winning reports.

The Royal Society of Medicine offered prizes on topics relating to epidemics in general, as well as prizes on particular diseases.

The search for causes of an epidemic in the 18th and 20th centuries is obviously different in many ways. But also it can show surprising similarities when an outbreak of disease begins.

In the 18th century, epidemics were defined as diseases that were widespread and more deadly than others, and that attacked a large number of individuals at the same time.

A marked identity in all the essential symptoms was the principal characteristic of this type of disease. They were not necessarily contagious.

At this time the causes of epidemics were sought both in the external world and within the body. Substances ingested were what physicians had to concentrate on.

Food of bad quality was regarded as an obvious suspect, as was vitiated water that was muddy and loaded with insects, and rotten grain. The air was always regarded as the source from which putrid and contagious diseases came.

This, to us, may seem like indeterminate research. But in the 20th century, in the absence of a specific causative agent, suggestions for possible causes of epidemics also proliferate.

The initial reports on groups of young men developing Kaposi's sarcoma and Pneumocystis carinii pneumonia led to a variety of causes being suggested for AIDS.

These ranged from aspects of the lifestyle of gay men, such as sexual practices, to use of stimulants, to fungi, to retroviruses. In fact, one of the earliest objections to retroviruses as causative agents was that retroviruses caused cancers.

As Dr. Jack Whitescarver, Office of AIDS research, NIAID, noted in his interview, quote, "There are some bizarre things that folks looked into as possible causes of AIDS, such as fungus. One investigator, bless his heart, thought for a while that maybe something from dogs caused it, because all the gay people had dogs." End of quote.

Another NIH investigator, Dr. Arthur Levine of the National Institute of Child Health and Human Development, recalls, quote: "Before April 1982, most investigators believed that the cause was something restricted to the gay population, and that it probably was a drug or a toxicant which was depressing their healthy lymphocytes."

"The likely candidates were thought to be inhalant aphrodisiacs or tanning salons. There was some thought that they ultraviolet radiation in the tanning salons might be suppressing the T-cells."

"There were actually some experiments to show that nitrate-based inhalant aphrodisiacs could indeed suppress the acceptable T-4 count, as could UV light." End of quote.

The political climate and its effect on medical science is another element in the history of the scientific investigator's reaction to epidemics. Although operating under very different political systems, one a democracy and the other royal [?], both groups show the ability and the need to negotiate their way through the system.

The medical scientist is not immune to political pressures and realities. The aim is to conduct the research one wants to do and receive funding for it from the political system.

In 20th century America, when constitutents seek action from their representatives in Congress on a disease problem, the representatives ask the government agency responsible for information on what is being done to respond.

Thus, for example, Dr. Jack Whitescarver recalls vividly that NIAID was asked by an aide to Representative Henry Waxman, chair of the House Subcommittee on Health and the Environment, to send representatives to come down to Capitol Hill and talk about AIDS and what the NIAID's effort was in it.

This was before HIV had been identified as the causative agent. The two NIAID representatives, Dr. Kenneth Sell and Dr. Richard Krause, talked about, quote...this is what Dr. Whitescarver says, "The overall NIAID effort in virology and immunology as basic research endeavors that would provide answers in dealing with the new disease."

"Such an answer did not suit the aide at all. He was very straightforward and made it quite clear that his impression was they were building a story of excuses for why they did not have a more targeted effort towartds AIDS."

"Krause's defense was that many of the great scientific breakthroughs came from a free-ranging research effort and that this was what NIAID was supporting. They were supporting the broad base of virology, with greater emphasis on sexually-transmitted disease research and immunonology."

"But it was quite clear that this was not sufficient as far as Waxman's aide was concerned." End of quote.

The Congressional viewpoint was that a more specific program directed at AIDS was definitely needed.

The Royal Society of Medicine also had to show fast footwork to keep up with political change. In its first year of operation, the royal minister who sponsored its existence was ousted, and he was followed not by one replacement, but by two.

Fortunately for this group of medical scientists, Louis XVI continued to wish to show patronage for research into matters concerning the health of his people and the livestock of the nation.

A little investigation by Society members into what disease was causing problems among the royal stags in St. Germaine forest did not go amiss either in maintaining this kingly patronage.

Finally, to finish this survey of perspectives of scientists two centuries apart on epidemic disease, let us compare the views of scientists conducting autopsies to figure out the pathology of the diseases they were confronting.

The first patient with AIDS who was admitted to the NIH Clinical Center already had numerous opportunistic infections, including Pneumocystis pneumonia, cytomegalovirus, and mycobacteria avium,and he died within several months.

By the time he received this hospital care, he was in the last stages of AIDS. He was a young gay man who had holidayed in Haiti, and two of his partners had died of terrible infections.

To Dr. Abe Macher, an NIH pathologist, he was not only a patient, quote: "He was a classic case; he remained the best teaching case available." End of quote.

In order to try and find out the source of his problems, the patient was autopsied. The pathologist soon realized that whatever was causing this immunosuppressive disease, was predisposing these patients to multiple, very serious opportunistic infections.

Dr. Macher relates that the NIH researchers began flying in bodies of others who had died, because other institutions refused to do autopsies.

Quote: "We were so interested in the true pathology that we were recruiting the cases to the NIH. Scientific curiosity was at work."

This practice, I might add, only lasted for a short time, but because the NIH investigators also were sent all the charts, x-rays, and biopsy results of these patients they autopsied, they gained insights into AIDS' evolution and epidemiology.

The 18th century epidemic physician also resorted to autopsy in his determination to find what caused the patient to die. This may come as a surprise to those who believe that the correlation of post-mortem findings with symptoms only occurred in the 19th century.

Take the account of Dr. Rene Gastellier of Montargis on the autopsy of a 17 year old boy who had died of an epidemic disease affecting the chest and lungs in 1785.

Six hours after the death, Gastellier and the surgeon proceeded to the opening of the body, which he noted was already in a state of considerable putrefaction.

They first opened the chest which they found filled on both sides with a thick, green, and very fetid liquor. The substance of the lungs seemed to be completely gangrenous, also that of the trachea.

But the putrefaction and the smell that came out of the body was such that, as Gastellier recounts, 'Although we were in the cemetery, and the open air, we were not able to continue our examination.

The surgeon was so overwhelmed by the foulness of the smell, his stomach heaved to the point that he made several efforts to vomit.'  End of quote.

It was evident that the gangrenous character of the organs was the endpoint of the disease. And as Gastellier says, that all the harm was done by the time the young man first complained, and consequently he was beyond all human help.

This case, I think, has a certain resonance with AIDS.

To conclude, the tensions between scientists and others in the community when confronted by epidemic disease are not novel to the 20th century. They occurred in the 18th century, too.

In outlook, methodology, and action, scientists may approach matters differently than patients or politicians. All have valid viewpoints and concerns.

The problems lie in lack of understanding by the public of what interests and motivates scientists, and perhaps in the scientists' lack of understanding that the discipline has a past. Thank you.

[Applause]

Dr. Hannaway: Yes, I can, I'll take some more water.

Dr. Teigen: We have time for a couple questions.

Audience member 1: I wanted to ask about a couple of what I think to be real differences in these situations and get you to comment and maybe expand on them...

one is that as I understand it, the 18th century inquiries, it was much more of a democracy of who could be in the [?]...almost any physician in France could participate and contribute to that effort.

It was clearly a much more a collaborative [?] and opportunity and resource...[?] and related to that I wonder if you can say something on the 20th century, about the relationship over time of the epidemiological work to the laboratory work.

And my contention would be that the epidemiological work would become relatively rapidly subordinated to the work on a molecular [?] in a way that does not respond...[?]

Dr. Hannaway: I'm not trying to claim that the 18th and 20th century situations are the same, as I said at the outset. But I thought it was instructive to look at this and partly...destroy some myths, but let's stay away from that.

To come to your first question. I don't think I would perceive it the way that you do, as a more democratic situation in the 18th century. There was very definitely a hierarchy, and not everyone could come to the table.

This group of provincial physicians had to produce information that was of a certain standard, as you know but others may not, the society was supposed to make weather reports three times a day, take thermometer readings, as well as going out and attending to their patients.

This was quite a lot to ask of a provincial physician. The hierarchy I would say is stronger in the 18th century, but 20th centruy historians of medicine may disagree.

Vis a vis epidemiology and its contribution to AIDS...whether you think that there's more concentration now on molecular biology or not, it's still interesting to look at the reaction to epidemics, especially one of the magnitude and type that this disease represents.

So that would be my...

Audience member 2: I'll just add that you're working on this...you still have a fair amount of research to do, but it appears to me at this point that you get a parallel process.

You've got more and more laboratory work being done, but you have the long-term epidemiological studies going on and you have to have the two feeding back and forth to one another.

Dr. Teigen: Well, thank you very much. Thank you very much, Caroline Hannaway.

[Applause]

We'll now pause for a few minutes and take a break. There are some liquid refreshments out in the front lobby, coffee, soft drinks, and please do not bring the drinks back in here. Consume them out there, and we'll come back here again in 15 minutes, at four o'clock.

Dr. Teigen: Is the microphone on, can you hear me through the microphone? Is the microphone working? Okay, oh, they can't hear... Flick the lights, just like the metro.

Our fourth speaker this afternoon is Victoria A. Harden, who is the historian of the National Institutes of Health, and director of the DeWitt Stetten Jr. Museum of Medical Research.

A student of James Harvey Young at Emory University, she was a doctoral fellow at the National Museum of American History and then a post-doctoral fellow at the Institute for the History of Medicine at Johns Hopkins.

She has written two books, Inventing the NIH: Federal Biomedical Research Policy, 1887-1937; and Rocky Mountain Spotted Fever: History of a Twentieth Century Disease. The latter book won the 1991 Henry Adams prize of the Society for History in the Federal Government.

Today she will speak on Yellow Fever: The End of the Story: Mason V. Hargett and the Development of an Aqueous-Based Vaccine During World War II.

[Dr. Harden approaches podium and affixes microphone to her jacket.]

Dr. Victoria Harden: I'm honored to participate in this symposium honoring Jim Cassedy. It's fitting, perhaps, that I first encountered someone of Jim's wide-ranging medical history interests, not as a human being, but as an authoritative footnote.

When I was conducting research for my Ph.D. dissertation on NIH history, I discovered that one James H. Cassedy had already written two papers and the definitive biographical sketch of Charles Wardell Styles, the first director of the Division of Zoology of the Hygienic Laboratory, which is the precursor of NIH.

When I finally met Jim in person, I found him to be generous with his extensive knowledge and supportive of the efforts of junior scholars.

In this paper, I want to discuss one episode in the history of public health, to which Jim has made so many contributions, and simultaneously to highlight one portion of the National Library of Medicine's strong collections on the history of tropical medicine in the western hemisphere.

A decade ago, when I was researching material for my book on Rocky Mountain Spotted Fever, I interviewed Dr. Mason V. Hargett, a career Public Health Service physician whom you see here, about his work during World War Two, making yellow fever vaccine at the Rocky Mountain Laboratory of what is now the National Institute of Allergy and Infectious Diseases.

[Image of Dr. Mason V. Hargett projected on screen at front of auditorium.]

Dr. Hargett also had a collection of notebooks and photographs documenting his work. Later I also interviewed his technician, Harry Burruss, who possessed the sole extant copy of a detailed protocol of the vaccine production process, which he prepared after World War Two and which is shown here.

[Image of leather-bound notebood projected on screen at front of auditorium.]

NLM was interested in augmnenting its collection of tropical medicine materials, especially with respect to the western hemisphere, hence Peter Hirtle, who was then Curator of Modern Manuscripts, arranged to accession these materials.

When asked to present a paper at this symposium, I decided the time had come to revisit these materials and to write up this most interesting episode in the history of yellow fever.

Many of the slides I show will come from this collection.

If one searches the medical history literature, books and papers abound on yellow fever before the 20th century. You've already heard Dr. Curtin describe yellow fever in west Africa in the 19th century.

And his comments about the difficulty in diagnosing the disease of course continue to apply. Yellow fever is a viral disease that attacks the liver and therefore produces jaundice, yellowing of the skin, yellowing of the eyes, and other symptoms of malaise and internal hemorrhaging.

This slide shows the pre-1915 distribution of yellow fever in the western hemisphere. [Image of lower North America, Central America, and upper South America, with mainly coastal areas highlighted indicating presence of yellow fever, projected on screen at front of auditorium.]

In 1900, Walter Reed's demonstration of the mosquito vector of the disease, suggested that control of the Aedes aegypti mosquito would lead to elimination of the disease.

But as Dr. Curtin said, the subsequent discovery that monkeys in tropical regions served as mammalian reservoirs, dashed the eradication hopes.

Investigators associated with the Rockefeller philanthropies launched broad-based research projects on yellow fever in Africa, South America, and the Rockefeller Institute for Medical Research in New York.

In 1934, Max Theiler, working at the Rockefeller Institution, produced an attenuated strain of yellow fever virus known as the 17-D strain, that could be used as seed virus for making a vaccine.

It apparently provided complete protection from yellow fever, with no serious side effects. This is the description of the perfect vaccine.

Shortly after Theiler's discovery, the international health division of the Rockefeller Foundation set up a vaccine production facility in Brazil, in conjunction with Brazilian authorities. [Image of Brazilian yellow fever vaccine production facility projected on screen at front of auditorium.]

And in 1937 began clinical trials of the vaccine.

This slide shows the location of yellow fever service centers throughout Brazil that were initially established, also as Dr. Curtin talked about, to gather baseline information on who was immune and who was not immune in the country. [Image of map of Brazil with cities/towns pinpointed, and in the lower left an image of a syringe and a mouse, projected on screen at front of auditorium.]

I found it interesting that it features the syringe for taking blood, and the mouse, which was used in the research programs, as images associated with the program.

To gather epidemiological evidence on the vaccine's efficacy, representatives of the service carefully followed reported cases of yellow fever, noting whether or not the victim had been vaccinated.

And obtaining a liver specimen for pathological confirmation of the diagnosis.

This image instructed technicians in the service where the liver was located.

[X-ray-like image of rib cage and liver, with arrow pointing to liver and accompanying instructions, projected on screen at front of auditorium.]

And this instrument -- it's wicked-looking -- was used to obtain the specimen. One must remember that this was obtained from corpses, not from living people. [Image of medical instrument resembling a utility knife, with an exposed blade, projected on screen at front of auditorium.]

By 1940, shortly after Europe was plunged into war, and the United States feared that it might be drawn into hostilities, the results of clinical trials of the Rockefeller's yellow fever vaccine demonstrated its efficacy, and the Rockefeller Foundation began producing lots of vaccine on demand.

In the summer of 1940, U.S. involvement in the war loomed closer as the British evacuated Dunkirk and the Battle of Britain began.

[Slide with bullet points, "Steps Toward War - 1" projected on screen at front of auditorium.]

Government preparedness for war included surveys of what diseases would likely threaten U.S. troops in the different theaters of war.

Typhus, malaria, and yellow fever were three historic diseases that had plagued armies, and in 1940 a prototype typhus vaccine was the subject of a crash research program.

There was no vaccine against malaria, and the Japanese at this time controlled the Dutch East Indies, the source of cinchona bark for making quinine.

The Rockefeller's yellow fever vaccine appeared as a bright spot among these medical concerns. During the summer, concerns about yellow fever rose when an extensive epidemic occurred in the Sudan, close to the African war zones.

If the U.S. joined the war, American servicemen would also be vulnerable to yellowjack in central and South America if they were called upon to defend the western hemisphere.

Yellow fever posed a special threat to the hostilities in the Pacific, because the disease had never been introduced into Asia.

In epidemiological terms, the large populations of Asian cities were pools of non-immunes that could be devastated if yellow fever gained a foothold along with western military forces.

Vaccination against this disease, therefore, was not only essential to protect American forces from illness, but also to prevent them from accidentally spreading the disease into a new and vulnerable area of the world.

In June 1940, the National Research Council requested the Rockefeller Foundation to stockpile 100,000 doses of its yellow fever vaccine for use by the armed forces and to submit a plan for production of the vaccine by the U.S. government.

In September, Congress enacted and President Franklin Roosevelt signed the first peacetime draft in U.S. history. This action was taken in response to the mutual assistance pact that Japan signed with Germany and Italy, which fused the European and American conflicts between fascism and democracy into global war.

[Slide with bullet points, "Steps Toward War - 2" projected on screen at front of auditorium.]

As young men were inducted into the U.S. military, they received vaccinations against many diseases.

As you can see in this slide, between January 1941 and April 1942, more than seven million doses of yellow fever vaccine was distributed gratis by the Rockefeller Foundation.

[Image of chart with columns projected on screen at front of auditorium.]

By the  middle of March, however, 1942, a sudden and widespread outbreak of jaundice occurred in Army camps.

Jaundice, as we said, could describe yellow fever. It also can describe hepatitis. Today, we distinguish among several types of hepatitis caused by different viruses.

But in 1942, the two major types of hepatitis, A and B, were only dimly distinguishable on epidemiological grounds.

Both were referred to as jaundice and there were various adjectives used in front of it. This particular epidemic began the week ending March 7, 1942 and peaked during the week ending on June 20.

Almost immediately after the epidemic began, etiologic investigations were launched by the Rockefeller Foundation and by the Army's Board of Investigation and Control of Influenza and Other Epidemic Diseases.

By mid-April it appeared that a connection existed between the jaundice and certain yellow fever vaccine lots. [Slide with bar chart projected on screen at front of auditorium.]

Especially the ones that I have identified here, lots 307, 329, 331, 334, 335, 338, 367, 368, and 369, all in the 300 series.

These nine lots were responsible for more than 88 percent of the cases of jaundice. On 15 April, 1942, the Surgeon General of the Army ordered a halt to yellow fever vaccinations.

He recalled all vaccine in lots numbered above 330. He suspended production for at least two months of yellow fever vaccine manufactured by the Rockefeller Foundation.

On April 10, however, even before this official directive was issued, the Rockefeller Foundation had voluntarily discontinued production of the vaccine.

Previous incidents of post-vaccinational jaundice in Brazil and England had led investigators to conclude that the source of the jaundice must either be the seed virus itself or the human serum used to stabilize the viral proteins during the production process.

Serum is the liquid portion of the blood remaining after the solid cells have been removed. All seven million doses of yellow fever vaccine used by the military, however, had come from the same 17D virus, while jaundice was only associated with particular lots of the vaccine.

Hence, the seed virus was ruled out as the cause. Suspicion focused instead on the serum component of the vaccine.

Published accounts of jaundice following injection of other vaccines, anti-toxins, or convalescent sera lent support to this theory.

More than 300 people who donated serum used in the vaccine were interviewed about their histories of jaundice.

One donor whose serum was associated with the most infectious lots had suffered an attack of jaundice in February 1941, before being bled in November 1941 and February 1942.

Another donor suffered an attack of jaundice in December 1941 and was bled in January 1942.

The vaccine lots in which his serum was used, however, proved only moderately infectious.

In any event, not all donors could be contacted, so it was impossible to identify a single definitive source of the contamination.

This military medical crisis ended satisfactorily, because Public Health Service officer Mason V. Hargett had developed a vaccine that excluded human serum as a component. [Image of news article titled Aqueous-Based Yellow Fever Vaccine projected on screen.]

He designated this vaccine aqueous-based because it utilized sterile water as its base and proteins from the fertile hen's eggs in which it was grown to stabilize the highly labile 17D virus

Hargett was born April 24, 1904 in Farmingville, Iowa, the son of a Methodist minister. He earned his AP degree from Asbury College and his MD degree in 1928 from Northwestern University Medical School, and interned at Kansas City General Hospital.

He briefly engaged in private practice, but like Goldberger, he felt he was not suited for it. A lot of people came to the Public Health Service this way.

He took a job with the Louisiana state department, state health department in East Carroll Parish, where he dealt immediately with an epidemic of spinal meningitis.

There he met Dr. Charles E. Aiken of the Public Health Service who was directing a program of health and welfare in the area hard hit by the 1927 Mississippi flood.

Aiken suggested that Hargett join the service...he did, and was assigned to the usual rotation of duty stations, foreign and domestic.

In 1936, Hargett began a course of study at the London School of Tropical Medicine. After his return in July 1937, he served as the chief quarantine officer in Miami, Florida.

In 1938, Surgeon General Thomas Parran sent Hargett to Brazil to learn how to make yellow fever vaccine at the Rockefeller Foundation's laboratory. This picture shows Hargett in 1939, with some of his colleagues. [Photograph of public health officers in clothing suitable for a tropical climate projected on screen.]

I guess you can tell which one is Hargett. This is he right there.

Parran's concern, and the reason he sent Hargett to learn the techniques...was, this was in the pre-war period and his concern was that a yellow fever epidemic might occur in areas of the United States with a sizable population of the mosquito vector,

and an increasingly mobile, potentially infectious population of air travelers entering the United States from endemic areas in Central and South American and in Africa.

While studying the Rockefeller vaccine techniques, Hargett discussed with the laboratory's chief vaccine-maker the possibility of eliminating the serum component from the vaccine.

The following year, Hargett's suggestion was adopted at the Rockefeller laboratory, which began testing the efficacy of the new product while continuing to produce the serum-based vaccine for distribution.

Hargett returned to the United States in 1940, shortly before the National Research Council recommended that the US government establish as soon as possible its own yellow fever vaccine production facility to take over from the Rockefeller Foundation.

Surgeon General Parran and NIH Director L.R. Thompson, viewed this recommendation as an opportunity for the service to strengthen its position with respect to national defense, and they identified the Service's Rocky Mountain Laboratory, in Hamilton, Montana,

shown here, as a likely site because production of Rocky Mountain spotted fever vaccines and typhus vaccines, which used similar cultivation methods in eggs, was already underway.

Hence, the addition of the yellow fever vaccine production unit would be more economical than at any other station in the Service.

The fact that the vector mosquito did not inhabit the cool climate in Montana was an added benefit.

Explaining the political implications of the vaccine unit, Thompson noted, quote, "To have the Service actually doing something that is a definite necessity for the Army, means additional stability for the future."

"In the last war, our status was never clearly defined, and we contributed little except in extra [?] sanitation. This time, things look different. Already the National Institutes of Health is being called upon for its possible scientific contributions. So you see, the yellow fever vaccine work falls in very well with Dr. Parran's idea to make the Service indispensable to the military."

In October 1940, Hargett moved to Hamilton and began setting up this laboratory, the floor plan for which you see here. [Architectural drawing of floor plan projected on screen.]

With the help of NIH Deputy Director Rolla E. Dyer, he arranged to hire Harry Burruss as his chief technician. Since 1928, Burruss had worked in the Rockefeller yellow fever laboratories in Africa, New York, and Brazil, so he was highly skilled in the required techniques.

The first batch of yellow fever vaccine they produced contained human serum as a stabilizer.

Quote, "We went to the University of Montana and got blood from the students there at 25 dollars a pint," end quote, Hargett noted.

Beginning with the second batch of vaccine, however, Hargett switched to his aqueous-based vaccine.

This slide shows a storage carton filled with vaccine. [Slide with image of carton with notation YF-VACC 1002 projected on screen.]

By June 1941, all production problems with the aqueous-based vaccine had been solved, and all equipment was in place and running properly.

In March 1942, when the jaundice outbreak occurred in the U.S. troops and was associated with the human serum, Hargett had 66,000 doses of his aqueous-based vaccine available.

This is a vaccine shipping container that the smaller box goes into. [Shipping box with dimensions noted projected on screen.]

In April, Rolla E. Dyer, who was named NIH Director shortly after the attack on Pearl Harbor, ordered that production of Hargett's vaccine be stepped up to 50,000 doses per week, and the following month to double that amount.

To meet these goals, it became necessary to operate a night shift and move to a seven-day work week.

This is the final shipping box to ship the vaccine out to the troops. [Slide with image of taped-up shipping carton projected on screen.]

Within a year Hargett had a reserve of 900,000 doses of vaccine and was aiming to build up his reserves so that he would at all times have on hand 400,000 doses over and above the possible emergency requirements of the Army, as nearly as they could be anticipated.

Now, having shown you the boxes in which the vaccine shipped, I would now like to examine in some detail the technological context that enable Hargett to introduce this new vaccine so swiftly and effectively.

The vaccine production techniques developed during the 1930s still today serve as the conceptual methods of producing yellow fever and influenza vaccines, so we should take note of how they developed.

As you may recall, vaccines before 1930 were produced in animals and tissue cultures. Smallpox vaccine came from the scabs on the bellies of calves with cowpox.

Rabies vaccine was produced by drying the spinal cords of rabbits.

Rocky Mountain spotted fever vaccine was produced from infected brown duck ticks.

Typhus organisms were grown for vaccines in lice and mice.

The key problem was identifying some culture medium in which the microorganisms could multiply sufficiently to make vaccine production possible on a large scale.

Tissue and organ culture substrates offered promise, but proved difficult to standardize and to replicate on demand.

A breakthrough occurred in 1931 when Alice Miles Woodruff and Ernest Goodpasture at Vanderbilt University, found that the chorioallantoic membrane of the developing chick embryo provided the ideal medium for the growth of fowlpox virus.

You can see here in this slide the major structures of the chick embryo. [Slide with drawing of chick embryo with tissues labeled.]

And soon after Woodruff and Goodpasture announced their method, other researchers identified viruses and Rickettsia that flourished on this membrane and other membranes or in the embryo itself.

In making yellow fever vaccine, the seed virus is inoculated into the allantoic cavity, as you can see, and then multiplies in the embryo.

The first requirement for yellow fever vaccine production, therefore, wasa stable supply of fresh, fertile, white leghorn eggs weighing 24 to 28 ounces per dozen.

All had to come from disease-free flocks and to bear seals such as this which certified that a state agency, a state university, and the US Department of Agriculture had approved the conditions under which they were produced. [Image of egg carton with various stamps and seals displayed.]

They were to be not more than seven days old when they arrived at the laboratory.

Each egg was stamped with its lot number and placed in a Jamesway incubator in a vertical position with the small end down.

This is a picture of the large incubator...and I will say that we have one of these incubators from the Rocky Mountain Laboratory in the collection of the Stetten Museum.

[Image of Jamesway poultry incubator.]

Here's another picture; this one shows Rickettsia being cultured, identifying different diseases, but it gives you a better close-up view -- it was made for Life magazine -- that shows how the eggs were stored,

A temperature of 99.5 to 100 degrees was maintained and the eggs were automatically turned every four hours. On the seventh day of incubation, the embryos were candled.

That is, a light source was placed behind them to determine whether the embryo was alive or not by looking for signs of movement such as the beating of the heart.

Dead embryos were discarded.

Meanwhile, stored 17-D yellow fever seed virus was prepared for use in inoculating the eggs by adding visiological [?] saline to the frozen stored virus.

Eaxctly five-hundredths cc of the diluted virus was inoculated into the allantoic cavity of each egg.

Here you can see a two-person team at work, wearing gowns and masks, but interestingly, not gloves.

The eggs were prepared by spotting the large end centrally with a tincture of methylate anda punching a small hole in the center of the large end to receive the inoculating needle.

Here's a close-up of the inoculating apparatus.

The prepared egg was slipped over the inoculating needle to a prescribed depth, with care to keep the long axis of the egg in line with the needle.

The same needle was used for the entire lot of eggs, but it was sterilized in a flame every six to eight eggs.

After inoculation the eggshells were closed with drops of paraffin and returned to the incubator. Two tubes of [?] infusion broth were inoculated with the same diluted seed virus to check for any bacterial contaminants.

If this test proved positive, all the inoculated eggs would be discarded.

The virus was allowed to grow in the eggs for four days, after which the embryos were harvested.

Dead embryos were again identified and discarded.

What you see here is an oxyacetylane torch being used to cut loose the shell at the large end of the egg.

Devised by Dr. Hargett, this torch was a technical improvement over cutting the shell with scissors.

The embryos were removed with sterile forceps and placed into aluminum homogenizer cups, with an admonition in the protocol that care was more important than speed to avoid contamination.

One cc of sterile water was added to each three grams of embryos and the mixture homogenized for ten minutes in a Wareing blender. The aluminum cup of the blender was packed in just enough dry ice to prevent inactivation of the virus from either overheating or freezing.

Here you see the technician packing dry ice around the blender.

The protocol commented, quote, "Experience soon indicates the quantity of dry ice required," unquote.

The homogenized embryos were then transferred into heavy Pyrex centrifuge tubes as shown here and centrifuged for 30 minutes.

During centrifugation, the solid material from the embryos was deposited at the end of the tubes.

The supernatant fluid, which contained live, attenuated yellow fever virus, was the yellow fever vaccine.

Here you see the vaccine being carefully drawn out of the centrifuge tubes, so as not to disturb the sediment.

A small amount of the vaccine was reserved for purity and potency tests, and the rest was transferred into storage bottles as you can see here.

Excessive heat or cold would rapidly inactivate the vaccine, so it was essential to maintain a stable temperature throughout the vaccine in each bottle.

To this end, the vaccine was frozen in a thin shell on the inside of the bottles by rotating them in an alcohol dry-ice bath...then the bottles would be held for seven days until tests verified that the lot was both pure and efficacious.

Acceptable vaccine was thawed and transferred back into a dispensing flask as you can see here.

And then, from the dispensing flask into ampoules, as shown here. The ampoules ranged in size from a half to five cc's.

This shows how the filled ampoules were again shell-frozen, just like the larger bottles, in an alcohol dry-ice bath.

Usually 567 ampoules were prepared at a time, because this was the capacity of the dessicators that removed the water from the vaccine in the next step of the process.

And here you see the dessicator with the ampoules on every outlet.

Just over two hours were required to complete dessication of the vaccine in the smaller ampoules, and four to five hours were required for the larger ampoules.

The thin stem of each ampoule was sealed in the oxyacetylane flame, and after inspection for defective containers, defective seals, and previously missed contaminants, each ampoule was labeled with the lot number and quantity of saline in which the contents should be dissolved before the vaccine was administered.

You've already seen the boxes in which the vaccine was packed and shipped.

In March 1946, six months after the war ended, Hargett was transferred out of Montana, leaving vaccine production to Burruss, who continued to make the vaccine at the Rocky Mountain Laboratory until 1952, when production was transferred to the private sector.

Today, Conant Laboratories is the sole producer of yellow fever vaccine in the United States.

It continues to use the 17-D seed virus as the basis for the vaccine and to culture it in chick embryos. When I interviewed Dr. Hargett, he echoed Dr. Curtin's statement that inoculation with yellow fever virus, one dose, produced lifetime immunity.

Currently, however, the standards require reinoculation every ten years just as a safety precaution.

It seems, therefore, with the development of first a serum-based and then an aqueous-based vaccine, we have reached the end of the story of yellow fever as a scourge of humankind.

Medical historians, however, are skeptical types, preferring the perspective of centuries before they are ready to dismiss any disease as conquered.

Aedes aegypti mosquitos, furthermore, have recently been reported as carrying dengue fever, another insect-borne virus, and transmitting it to people in the Caribbean.

And threatening the population of the southern United States. If dengue can be transmitted, might yellow fever not also make another appearance?

I will conclude with a slide of a recently published paper that may represent the successor control technique to yellow fever vaccine.

The authors report that they have genetically engineered mosquitos so that they can no longer transmit dengue. Presumably this technique can be used for other arboviruses such as yellow fever virus.

Extremely high hurdles remain before this technique becomes viable. Scientists must learn how to introduce genetic alterations into mosquito populations in the wild, and how to manipulate mosquito genomes so that the controlling genes will be transmitted to future generations of mosquitos.

Meanwhile, the yellow fever vaccine developed in the 1930s and perfected by Mason Hargett will continue to protect people venturing into endemic yellow fever areas.

Thank you very much.

[Applause.]

Audience member 1: [?] fascinating...Dr. Curtin discusses West Africa, and you're in America. The 17-D came from a young Nigerian named [?] who was picked up by the [?] Theiler/Stokes team and that's where the virus came from.

Dr. Harden: Yes.

Audience member 1: that Max Theiler almost accidentally attenuated. He was sloppy about it. The Rockefeller earlier had [?] already shown in South America that there was a hepatitis associated with the Rockefeller vaccine.

You properly identified the British pathologist who came up with the same thing.  The Rockefeller began to look at heat, UV, not understanding of course at that time about hepatitis B virus.

They were concerned when Jim Simmons, who was the chief of preventive medicine for the Army, said I want everybody to get yellow fever vaccine, for two reasons.

The public one was, I don't know where people are going to be stationed, they could be sent to Africa, they could be sent to South America.

I was told on two different occasions, once by Stanhope Bayne Jones and once by [?] that the other reason was they were afraid the Germans would use yellow fever as a B.W., biological warfare, but I've never seen that in print. If you have...

Dr. Harden: No, I haven't.

Audience member 1: But the story is [?]. The other issue that you may be able to pin down...it is said that the human volunteers that Rockefeller used to increase production [?] came from Johns Hopkins, medical students and nurses and residents [?] high standard of living people.

[Unintelligible]

Nobody has ever followed up on the people who got hepatitis, if it is hepatitis B [?]...the epidemiology...

[Unintelligible]

Audience member #1: If you think that yellow fever is coming back, [?] and we're gonna miss the first cases, absolutely gonna miss it.

Dr Harden: I've heard you say this before, yes. The governor's, the study I showed was parts 2, 3, and 4 of a two-part study, each of which was more than a hundred pages long.

It was the most exhaustive thing I've ever seen. Indeed, a lot of the donors were Hopkins medical students. But they couldn't get to all of them.

Some of them had gone home for the semester when they started looking. And then when they came back around...

So they, epidemiologically it just couldn't be rigorous and it didn't seem to match up perfectly.

Harry...

Audience member #2: You said that Hargett, when he was in Brazil, in South America, he discussed with Rockefeller workers ideas about the aqueous virus, the aqueous vaccine. It brings up the question, why didn't they develop it?

No perceived need, technical views about the efficiency of production...

Dr. Harden: Yes, that's a good question. My question to start with was, why didn't they use it to begin with? Well, the virus is very labile. When they were working with it at first, they were passing it through different animals and what have you...

They were afraid that it would be inactivated very rapidly and they knew it wouldn't be with this human serum, so that's where they started.

There were several different vaccines, approaches that were worked on, before this one worked. They did recognize...well, here is the priority issues, which I found very interesting.

The classic book on yellow fever is the Strobe book on yellow fever which is an accounting of the Rockefeller's work, basically, and they cite Mason Hargett's paper in a footnote and say, an aqueous-based vaccine was developed.

I thought, and that's the end of that. But that said a lot to me. And he had his publication and  he was quite emphatic that he had thought this up himself.

Now, you can take it as you will. But they instantly saw thw wisdom, if you could get rid of the human serum you could eliminate a whole possible contaminant.

And they did, as I said, they made it, they were making it in 1940, but they had not run clinical trials to verify it yet.

And so, they were using it what they knew, and were giving out the human serum to start with, and were beginning to convert already themselves.

But the inoculations fell into this period in between.

[Applause.]

Dr. Phil Teigen: Our final speaker this afternoon is John L. Parascandola, Public Health Service historian. Studying with Aaron Eid at the University of Wisconsin, he received his Ph.D. there and then spent a post-doctoral year at Harvard University.

Returning to Madison, he taught the history of pharmacy and the history of science until 1983.

From then until 1992, he was the Chief of the History of Medicine Division at the National Library of Medicine.

His research interests are focused on the history of modern pharmaceutical and biomedical science, including the use of animals in research.

His book, The Development of American Pharmacology: John J. Abell and The Shaping of a Discipline, was awarded the George Urdang medal in 1991. Today he will speak on Syphilis at the Cinema: The U.S. Public Health Service's V.D. Films of the 1930s and '40s.

[Dr. Parascandola approaches the podium and affixes the microphone.]

Dr. John Parascandola: Well, I, too, am delighted to be able to participate in this celebration of the work of Jim Cassedy, friend, colleague in the field of medical history, and a coworker at the History of Medicine Division during the years that Phil mentioned where I was head of the division.

And today I'm going to be talking about, also a topic in the area of public health, which again, as we've all heard, is a field in which Jim has toiled very successfully.

In 1942, Dr. James A. [Dolse?] of the United States Public Health Service wrote to a colleague and I quote,

"We feel very strongly that motion picture films are a most important medium for health education. Well-written and -produced films not only command large audiences, but as you know, actually instill more information into observers than does any other teaching aid." End quote.

Among the motion pictures that figured prominently in the health education efforts of the PHS by the 1940s were films on venereal disease.

These films formed an important part of the PHS campaign against venereal disease, which had been inaugurated by Thomas Parran, the PHS Surgeon General, who had, soon after he had come into that office in 1936, and which intensified afterthe outbreak of war in Europe. [Portrait of Dr. Parran.]

Now neither the involvement of the PHS in venereal disease nor the use of films to educate the public about syphilis and gonorrhea were new in the 1930s.

The PHS had been operating a VD program since the First World War, when concern over the number of army recruits infected with syphilis and gonorrhea led Congress to enact a law which created a veneral disease division in the Public Health Service. [Image of poster: Surgeon Sage Says--Only a poor boob pays his money, loses his watch, gets the syph, and brags that he's had a good time.]

The first film ever produced by the U.S. government, Fit to Fight, was aimed at warning American troops about the dangers of venereal disease.

Produced during World War One by the Committee on Training Camp Activities, it followed the experiences of five draftees, two of whom contract syphilis after having sex with a prostitute.

After the war, the title was changed to Fit to Win, but the film soon fell into disfavor.

Socially conservative groups objected to its message that if you cannot be moral, at least be careful, that is, use chemical prophylaxis.

And the New York State Board of Censors declared it obscene in 1919.

With the end of the war, Congress lost interest in the venereal disease problem, and funding for this purpose declined dramatically.

Thomas Parran was later to comment, quote, "Congress apparently thought the spirochetes of syphilis would demobilize with the Army. More accurately, no further thought whatever was given to syphilis, and the first national public health effort came to an untimely end." End quote.

When Parran was appointed Surgeon General of the PHS in 1936, however, he wasted no time in launching a new national campaign against venereal disease. [Portrait of Dr. Parran.]

Now, Parran had served as chief of the Public Health Service venereal disease division earlier in his career.

And that's a picture of the earlier, a young Parran. [Photograph of a younger Thomas Parran in uniform.]

And he had never lost interest in the subject.

In the early 1930s he was detailed by the PHS to New York to serve as health commissioner of that state, and he made venereal disease a priority of his administration.

In one well-known incident, Parran made headlines in 1934 when he cancelled the radio address at the last minute because he was told that he could not mention syphilis or gonorrhea by name on the air.

Parran's articles in magazines and his 1937 best-selling book, Shadow on the Land, were instrumental in breaking down the taboo in the popular press against the frank discussion of venereal disease.

He sought to focus the battle against venereal disease on scientific and medical grounds rather than emphasizing moral or ethical views concerning sex, and played a key role in the passage of the National Venereal Disease Control Act in 1938.

The act provided federal funding through the PHS to the states for venereal disease control programs as well as supporting research into the treatment and prevention of venereal disease. [Poster: Duties of the Health Department in Syphilis Control.]

As a part of its efforts to combat venereal disease, the PHS issued posters, brochures, and other publications on the subject.

Also among the weapons in the anti-VD arsenal developed by the PHS in the 1930s and 1940s were motion picture films. [Film poster of human figure with "skin" consisting of newspaper headlines and articles, pouring liquid medication from a bottle into a teaspoon.]

Within a year or so after Parran had become surgeon general, the PHS had produced two films on syphilis. One of these films was aimed at a lay audience, and the other, produced jointly with the American Medical Association, was more clinical in nature and presumably geared to physicians.

My concern today will be with educational films intended for the lay public, including military audiences, rather than with the clinical films.

The film for lay audiences, to which I have just referred, entitled Syphilis: Its Nature, Prevention, and Treatment, was produced in either 1936 or 1937.

And I have not yet been able to locate a copy of it. Later references to it by PHS staff, however, term it amateur in nature and note that it was outdated and outmoded by 1940.

It was silent and it has been described as being more of a slide lecture than a film. Presumably the PHS was still inexperienced in the art of film production at this point.

Over the next decade, however, the PHS was to become more sophisticated in the production of films, collaborating in many cases with government agencies more experienced in this field, such as the Department of Agriculture, or with Hollywood producers.

For example, in 1939, the PHS contracted with the Department of Agriculture, which had a well-regarded motion picture production section, to produce the film, Three Counties Against Syphilis.

This film depicted the work done by the PHS-supported trailer clinic in the fight against syphilis among rural blacks in three Georgia counties.

And it was apparently made to publicize the program and to stimulate similar efforts. Ironically, at the same time that the PHS was sponsoring this laudable program to help to control the disease, it was also conducting the now well-publicized, even infamous, Tuskegee Syphilis Experiment.

The PHS was already discussing possible collaborative efforts with Hollywood filmmakers by the late 1930s, although the first project to come to fruition appears to have been the film, Know for Sure, produced for the PHS by the Research Council of the Academy of Motion Picture Arts and Sciences in 1942. [Poster: Yellow background, man in suit and hat is carrying a woman wearing a dress, hat, and heels, in his arms. Title: Know for Sure. Get Blood Tests Before Marriage.]

This is not actually a poster advertising the film, but on the same theme, the idea being that you should know for sure by getting a blood test if you suspect that you may have syphilis.

I'll have more to say about this film shortly, but let me mention here another collaborative effort with Hollywood first.

When Warner Brothers produced the 1940 feature film, Dr. Ehrlich's Magic Bullet, starring Edward G. Robinson as the German scientist who discovered a cure for syphilis, the PHS saw an opportunity to make use of this popular film in its campaign against venereal disease. [Film poster for Dr. Ehrlich's Magic Bullet.]

In the summer of 1943, the PHS contracted with Warner Brothers for the studio to produce an edited version of the film Dr. Ehrlich's Magic Bullet for PHS use.

And Susan [Leider?] and I have discussed both the Hollywood film and the PHS version in a paper that we gave about a year ago.

The adapted version of the film, called Magic Bullets, was 30 minutes in length and focused on the portion of the story that dealt with Ehrlich's discovery of Salvarsan and its use against syphilis. [Image of bearded man in a suit holdinga sheaf of papers and looking over a lab table with several canisters of different sizes arrayed on it.]

Films dealing with venereal disease and intended for release through theatrical channels still remained controversial, and Warner Brothers had had to obtain an exemption from the motion picture production code's policy against films dealing with the subject when they produced Dr. Ehrlich's Magic Bullet.

The production code had forced alterations of scripts of some films to delete any reference to venereal disease.

For example, when Sidney Kingsley's 1936 play, Dead End, was made into a film, the story was changed to substitute tuberculosis for syphilis as the disease suffered by one of the characters, a prostitute.

Although government films were not subject to the restrictions of the production code, the PHS nevertheless was sensitive to public attitudes and pressures about such a controversial subject as sex.

While intent upon dealing with venereal disease as a public health problem, it could not remain oblivious to moral considerations in its educational campaign.

Given the time constraints of my talk, and especially since I want to leave time for you to sample a few clips from these films, to experience something of their flavor, I'm going to focus the rest of my remarks on this question of the tension between moral and public health issues in the PHS VD campaign.

I will use three specific films to illustrate the points that I wish to make, and we'll see, as I say, at the end clips from these films.

I also want to emphasize that this is very much a work in progress, and I still have a good deal of research to do before I'm ready to present more definitive conclusions.

The first film I want to consider is Know for Sure, which I mentioned earlier.

The film was aimed at male audiences, especially the military and war industry workers, since by this time the U.S. had entered the Second World War. [Poster: Knock out VD.]

It was designed to instruct men in how to avoid venereal disease and recognize its symptoms...and this is a scene from the film...

and to convince them of the importance of seeking proper medical attention if they suspected that they had the disease.

The film also warned against quacks who promised swift and simple cures.

Another scene from the film -- and many of you will recognize that this is obviously a play -- this quack, Dr. Welch, has a product called 6006. Ehrlich's Salvarsan was of course 606. [Man stands facing a neon sign reading Dr. Welch's 6006.]

And so this is sort of a takeoff on that, perhaps implying that this guy had done even ten times more experiments than Ehrlich to produce his product.

Because the directors, actors, and others had donated their services, the PHS was able in this case to produce a relatively high-quality film with professional actors at a cost of only about 15 thousand dollars.

Now, typically, the film warns that prostitutes and pickups are a major  source of VD and should be avoided. Not from the film, but this is a typical poster of the period. [Poster of smiling dark-haired woman. Title: She May Look Clean -- But. Pick-ups, 'Good Time' Girls, Prostitues Spread Syphilis and Gonorrhea.]

In the entire campaign, the films as we'll see examples of, the posters, the literature, a good part of the blame for the spread of syphilis is placed on prostitutes and other loose women.

One question that's never addressed, interestingly of course, is where did these women get the disease? It's almost as if it just magically appeared in all of them and somehow men didn't play any role in the process.

But the film avoids, the film suggests avoiding prostitutes etc. and easy women. In fact, one of the characters actually mentions, "Well, I went to this prostitute, but she looked clean."

And the doctor tries to emphasize that you cannot tell by looking at a woman whether she is clean or not. However, the film is not overly concerned with moralizing, even though this is mentioned.

There's really much more emphasis on what we would think of as safe sex, perhaps the use of condoms and other prophylactic measures. The film includes explicit depictions of male genitalia and a demonstration of how to use a condom.

I will not be including these sections in the clip I've selected for your viewing pleasure today.

I should note in passing that a later version of the film deleting the scenes showing the male sex organs and the use of condoms was produced for mixed-gender audiences.

The PHS's decision to emphasize prophylaxis in the version of Know for Sure for male audiences came in for criticism from several groups, a pattern that was to be repeated with other films, another example of which I'll cite shortly.

The director of the American Social Hygiene Association, which waged its own campaign against VD, complained to Raymond Vondelehr, who was the head of the PHS division of venereal disease at the time, about the depiction of prophylactic methods in the film. [Portrait of Dr. Vondelehr.]

Vondelehr replied in defense, and I quote,"Our belief was, and still is, that a certain number of men are going to find and use opportunities for extramarital sex relations no matter what happens.

As I see it, an important part of our job is to prevent infection. Teaching men how to protect themselves from venereal disease does not imply that we condone sexual promiscuity, no more than teaching soldiers how to protect themselves against poison gas proves that the Army wishes to encourage the use of such gas by the enemy." End quote.

The executive officer of the Montana State Board of Health also raised a concern about whether the film might encourage quote, "sex, immorality, and birth control." End quote. Of all things.

A PHS physician, E.R. Coffey, replied that the PHS believed that the need for enlightenment on methods of preventing VD outweighed other considerations, and that he was confident that those who saw the picture would understand that the objective was not to encourage immorality but to emphasize methods that would prevent the spread of VD.

This debate about how much to emphasize sexual morality versus prophylaxis, which I'm sure will have a familiar ring to you, since it's obviously still with us today, extended throughout the discussion of VD education programs, and placed the PHS in a difficult position.

Although wishing to cooperate with social and religious groups in the fight against VD, the PHS nonetheless felt that it had to view the subject primarily from a public health viewpoint.

Surgeon General Parran noted in a letter describing the PHS VD education campaign that the teaching of sexual morality was primarily the function of the home, the church, and the school, and that health agencies were responsible for dealing with venereal disease as a dangerous contagion. [Image of Dr. Parran seated at his desk, pen in hand.]

He added that it should be possible, using available scientific methods --  and here he was being a bit optimistic -- to eradicate these diseases in our lifetime, a timetable that quote, "May be well in advance of any major changes in the sex habits of the population as a whole." End quote.

Now this does not mean that PHS staff such as Parran and Vondelehr were not concerned about the moral issues involved in such questions as prostitution. They certainly were.

Both of these men expressed their opposition to prostitution and saw it as a major contributor to the spread of VD.

Official PHS policy supported the rigid repression of prostitution. When one PHS officer in Puerto Rico suggested a system of registration and identification of prostitutes, he was soundly rebuked by Parran, who reminded him of his obligation to follow PHS policy.

Parran noted that he realized the physician probably looked at registration as a means of controlling infection, but the practical result of such a system would be an official toleration of commercialized prostitution.

Although Vondelehr also favored repression of prostitution, he distinguished between the moral and public health aspects of the problem in response to a critic of Know for Sure, quote,

"Strictly speaking, our only interest in prostitution lies in its role as the most important carrier of infection. Morals and self-control are important in our purview simply because of their preventive value. If all men invariably protected themselves, then from a public health standpoint, prostitution unlimited would not concern us public health officers, even though we might strongly object to it on other grounds."

And this leads me to the second film, Venereal Disease Rapid Treatment Center, produced for the PHS in 1944 by the Department of Agriculture.

In 1943, as a wartime emergency measure, the PHS worked with state health departments to establish a series of Rapid Treatment Centers, so-called, for patients with VD.

By 1944, there were 47 of these facilities in operation, mostly near military training facilities or cities with important war industries.

Although some of the facilities accepted men and even children, the overwhelming majority of patients were women.

As you will see from the film clip to be shown shortly, the major focus of these centers were prostitutes and other fallen women.

The centers were designed both to cure the women in a relatively short period of time by intensive inpatient treatment, usually with arsenic and bismuth compounds, and to teach them a trade to prevent them from falling back into their promiscuous ways.

Both state and federal VD laws gave authorities ample latitude for confining persons with VD.

The PHS tried very hard, however, to portray these centers as hospitals, similar to quarantine hospitals, rather than as prisons, as you will see in the clip.

Vondelehr expressed concern that undue publicity labeling these centers as prostitute prison camps, worked against the efforts to rehabilitate the women and branded all the inmates as prostitutes.

He also complained on another occasion about a Rapid Treatment Center that was surrounded by high fences with electrically-charged barbed wire, which gave the facility, quote,  "the characteristic of a penal institution rather than a medical center with a rehabilitation program." End quote.

This film was made in part, I suspect, to justify the centers and present them in the best light.

Although these centers may not have been prisons in the same sense as the narcotic farms or hospitals operated by the PHS, clearly the patients were not necessarily there voluntarily, and the PHS was obviously not comfortable with the police aspects of its role.

While opposed to prostitution, the PHS was reluctant to become involved in policing it. In fact, in 1941, a social protection section was established within the Federal Security Agency, the organizational home of the PHS at the time, specifically for the purpose of repressing commercialized prostitution.

The statement which established this section, explicitly noted that the PHS, quote, "prefers not to carry the responsiblty for bringing pressure upon law enforcement officials who are laggard in the repression of prostitution." End quote.

The problem of moral versus public health issues in VD, and the PHS dilemma of being caught in the middle, is reflected again in the third film that I wish to discuss briefly.

To The People of the United States, which was produced in 1944, by Walter Wanger of Universal Studios, under contract with the California State Department of Health and active PHS cooperation.

The films starred Gene Herschel, a familiar face in movies at the time, and also featured actors Robert Mitchum and Noah Beery, Jr. in lesser roles. Like Know for Sure, it proclaimed that syphilis could be cured with medical treatment, stamped out by public health measures.

To The People placed special emphasis on the importance of bringing syphilis out of the shadows and into the light of day. The open attitude of Scandinavian countries towrads the disease was contrasted with our own hesitancy to discuss it in polite company.

The Public Health Service was prepared to serve as the national distributor of the film until the Legion of Decency reviewed it and protested to Surgeon General Parran about its theatrical release.

While the Legion admitted the film was dignified anad restrained in its treatment of the subject, it was concerned that it failed to stress the fact that promiscuity was the principle cause for the spread of venereal disease.

The Legion worried that it might pave the way for a flood of pictures on VD by, quote, "producers who do not hesitate to avail themselves of every opportunity for lurid and pornographic material for financial gain." End quote.

Parran quickly called a meeting of the PHS advisory commission on venereal disease education, which was made up of clergymen, health professionals, and teachers.

The committee recommended that the PHS not sponsor national theatrical release of the motion picture. Their concern was that the controversy that was sure to follow through the influence of the Legion might jeopardize the whole PHS VD campaign and other important public health activities.

And they just didn't think it was worth it.

Although opposed to having the PHS sponsor commercial release of the film, the advisory committee suggested that with minor changes, it might be made suitable for controlled distribution through state and local health departments, voluntary health agencies, and similar organizations.

And the Legion of Decency agreed to this kind of controlled, limited distribution, and the matter was resolved in this way.

The major alteration that was made in the film was to revise the brief speech by Parran at the picture's end. His new closing words, as you will see, emphasize promiscuity as a major cause of VD, and give credits to churches and social groups combating this problem.

If you look very closely, you may be able to see where the splice was made to replace the original Parran speech with the new one; it wasn't the most professional job.

These films and the documentary evidence concerning them represent another tool for us to examine the PHS VD education campaign of this period, and the interplay between social, political, and public health concerns in shaping PHS policies.

I have only been able to touch upon many of the interesting questions involved, but hope I have at least been able to provide you with some insights into the subject.

And now, onto a glimpse of the primary documents themselves. Can we roll the tape, please?

[Film begins to play on screen at front of auditorium.]

[The following are excerpts from 1940s venereal disease films proudced by or in cooperation with the U.S. Public Health Serivce.]

[Edited versions preapred by Audiovisual Program Development Branch. Lister Hill National Center for Biomedical Communications. National Library of Medicine. 1996.]

["Know for Sure" print provided by National Museum of Health and Medicine.]

[Dramatic music.]

["Know for Sure" know for sure - get a blood test for SYPHILIS]

[Produced by The Research Council of the Academy of Motion Picture Arts and Sciences]

[For the United States Public Health Service]

[White-haired doctor sits down at desk and begins to question a patient. Another man is seated there as well.]

White-haired doctor: Well young man, what seems to be your trouble? That's all right, this is Dr. Martin.

[Patient places a piece of paper on the doctor's desk.]

Patient: Well, some time ago I picked up a girl at a dance hall...and well,about three weeks later I noticed a little sore here on my mouth. Didn't pay much attention to it, I thought it was just a cold sore.

But the darn thing hung on so long I got kinda worried about it. I happen to pick up one of these Public Health Service folders and got to reading about syphilis, and I got scared.

[White-haired doctor examines brochure titled Syphilis: Its Cause, Its Spread...its cure!]

White-haired doctor: Hmmm, did the folder explain everything all right?

Patient: Yes, sir. It said in there that even though a sore might heal up just like mine did, if you got syphilis, the germs might still be in your body.

I found out all the things that could happen to you if you didn't get to it right away. I figured I better come down here and find out about it.

White-haired doctor: Good boy! Miss Jones...I want to take a blood test on this man.

Nurse Jones: Yes, doctor.

[Cut to white-haired doctor and Dr. Martin walking through a doorway into an office area.]

Dr. Martin: He's pretty lucky to have picked up this folder.

White-haired doctor: Sit down, make yourself comfortable.

Dr. Martin: Thank you.

White-haired doctor:: Yes, he was lucky to have picked up that folder. But there are hundreds of thousands of men and women in this country suffering from syphilis who won't pick up a folder.

It's a pretty sad state of affairs when we have to depend on luck to whip this syphilis problem. If they could see the truth behind newspaper articles reporting nervous breakdowns, suicides, and deaths from heart failure, they'd find a shocking percentage could be chalked up to late syphilis.

Now I was called as a consultant in this case.

[White-haired doctor hands Dr. Martin a news clipping with headline reading Stanton Brokerage Firm Crashes: Robert Stanton, President, Suffers Nervous Breakdown]

Stanton didn't have a nervous breakdown. He had [?], probably contracted syphilis fifteen to twenty years ago.

The outward symptoms disappeared and the thought he was cured.

And syphilis began to soften his brain, and his business judgment went bad, but by the time he went to pieces, it was too late to save either the public's money or Stanton.

Dr. Martin: And yet he could have been cured it he had received medical care in time.

White-haired doctor: Surely.

[Fade out]

[United States Public Health Service presents]

[A Venereal Disease Rapid Treatment Center]

[Filmed by U.S. Department of Agriculture Motion Picture Service]

Narrator: Bird's-eye view of a typical Rapid Treatment Center in a southern state located in a former CCC camp, as are many of these hospitals.

[Aerial view of a Rapid Treatment Center.]

Here, infected women are treated with the new intensive therapies for syphilis and gonorrhea.

[Five women are shown outdoors reading, writing, studying.]

The fact that these centers are not jails, based on penal restraint, but real hospitals, is reflected in these faces of these girls.

[Women clad in matching dresses walk single-file.]

Young, old, city girls, farm girls, good, bad, average girls.

But there are other places where infected women are taken. This is a jail. [Image of brick building with wooden staircase leading up to second floor.]

A small, country jail. And [?] women are detained in even more squalor and filth.

At the Rapid Treatment Center, the arrival of a group of girls is the beginning of a carefully planned schedule of several weeks duration.

[Two autos are shown passing through an entrance to the grounds of the Center.]

The girls are taken directly to the hospital's reception center.

Let's follow a typical new patient. We'll call her Mary Lou. That's Mary Lou there with the rumpled dress and package under arm.

[Females enter the reception center. A man wearing a hat stands next to an auto parked near the front door.]

Like all the others, Mary Lou is interviewed by a receptionist who tries to make her feel at home.

[Mary Lou seats herself in a chair next to a desk occupied by a woman with pen and paper.]

A patient, one of the hospital's clerical helpers, types her name and address for the record[?].

This girl not many weeks ago was a new patient like Mary Lou.

[Woman sits at desk typing.]

[Fade out.]

[To the People of the United States. Starring Jean Hersholt.]

[Airplane taking off.]

Man in military uniform standing at window: There they go, colonel. Maybe Faith could have been up there with 'em.

Second man in military uniform: I kept her out. Cruel [?].

First man: Bad luck. We're going to have to work fast to get you back into action.

[The men move about an office, one sits down.]

Second man: Action? I know I'm through flying for good. I know I'm headed out for an asylum or a seeing-eye dog. I wouldn't have minded so much getting the works from a Messerschmidt or a Zero. If I had a couple of good pokes at 'em first.

First man: Captain, I wouldn't try to tell you how to handle baby-face. Why tell me how to run my business?

Second man: What do  you mean, sir?

First man: I mean you don't know a thing about syphilis, except that you've got it. Let's get to know the enemy before we start talking bomb [?].

[The first man urges the second to examine something through a microscope.]

[?] Those little wriggling things, they're the syphilis germs, the spirochetes. They've gotten into your body tissues, but we're going to kill them before they do any harm.

First man: Before they do any harm?

Second man: That's what I said. Medical science has developed a specific cure for syphilis. Anytime we can find them early, we can cure it, and the earlier we find it the quicker the cure.

And we caught your case right at the start.

First man: But I've always heard...

Second man: From whom? The kid next door? The patent medicine salesman? Surely not from anyone who knew what he was talking about.

First man: Colonel, give me the works. I've got to get back to that big plane. When do we start treatment?

Second man: We're starting now.

Narrator: The children who follow us must inherit health and freedom and happiness.

[Children jump rope, go down a slide, and play in a park-like setting.]

The scourge of disease must be wiped from the land, and then there will be a new day ahead. A day without insidious, lurking, evil sickness.

[Men and women are shown playing various sports.]

A day without the useless, hypocritical attitude which refuses to name a germ, yet permits the horrible devastation caused by it.

[Images of a wheat field and a threshing machine at work.]

Syphilis: Say it! Syphilis. Learn about it. Have a blood test to make sure you haven't got it.

[Boy Scouts marching in a parade, women carrying flags, people at work in a field.]

Working together, we will stamp it out.

PHS Officer: Here, we have told only part of the story of venereal disease control. Untold is the fine work that churches, schools, and social agencies are doing to prevent the promiscuity which spreads infection.

It is important to remember that the only sure way for the individual to avoid infection is to avoid exposure. Learn the facts. With knowledge and intelligent action, the people of America can eradicate venereal diseases.

[Produced by Walter Wanger in Cooperation with United States Public Health Serivce and Your State Department.]

[Patriotic music plays.]

Dr. Parascandola: That's all, folks.

[Applause.]

[Question from audience member; cannot be heard clearly.]

Dr. Parascandola: Well, you heard what he said in the film, that women are arriving for a treatment of several weeks duration.

Audience member: [?]

Dr. Parascandola: That doesn't matter...but there was a treatment.

They believed it worked at the time. It's ttue, there were other treatments, too, there were fever, you know, high temperature treatments...

Audience member: [?]

Dr. Parascandola: No, they were actually using it, trying to use it...I couldn't show the whole film, unfortunately; it's a wonderful, it's my favorite of these...

And they were doing this intensive IV treatment, with arsenic and bismuth, and keeping people for several weeks, several months, calling it rapid treatment rather than say, giving a weekly shot for a year or more.

At the time, again, we have to remember it's wartime and this desperate feeling...the fact they were actually, essentially kind of rounding up and confining people, you know...

I really, I'd like to know more about these treatment centers, I don't know as much about them as I'd like yet. I have to dig more into them.

Although, supposedly...they emphasized that they were hospitals, you know, my guess is that if you a prostitute particularly, convicted and found to have VD, presumably you had a choice, go to the treatment center or go to jail.

Audience member: [?]

Dr. Parascandola: And there were both state, I think just about every state had laws that would allow you to confine somebody with VD, and the Public Health Service had authority, the Surgeon General, in dealing with people crossing state lines. So there were mechanisms by which you could confine people to these hospitals.

Audience member: I think that perhaps from the public health point of view, they were able to render them non-infectious, but unless they had further treatment, it wasn't a very, perhaps a very effective cure, so that would bring up another nice ethical question.

Dr. Parascandola: Certainly, they presumably would have, with that intent to treat, as you say, at least for the time rendered them non-infectious.

And part of the philosophy behind these, too, which again, I couldn't show the whole film...I mentioned in passing, was to provide vocational kind of training, and because this was wartime, it wasn't all, they show you scenes, and of course much of it we would think of as typical careers they would train a woman to do in in terms of cooking and so...

But because this was wartime they also trained them to be welders and riveters, etc. and Mary Lou in fact, the woman in the picture, comes out being a welder in war industries, and you know, successfully gets through the program.

Audience member: What was a post-World War II public reaction to public mention of syphilis. Was there anything comparable to [?]

Dr. Parascandola: What do you mean?

Audience member: Did they lapse, in other words, after having the message getting out to the troops.

Dr. Parascandola: Well, I haven't studied that period, but looking at, for example, [Brannen's] book, you never, once again, after the war, there was not the same interest or concern as there had been in the wartime, in terms of having more active campaigns.

And of course now people are arguing that these diseases like syphilis and gonorrhea are making a comeback.

Someone else may want to comment on that, may know more about the more recent period.

Audience member: Well, I don't know, I think there is [?] and I speak from a limited amount of experience. [?] the English had these programs continuously, so I don't know the dates. [?] But I would say until 1950- something.

Dr. Parascandola: That's a good point, I've been thinking more and more in the situation, just in the US in general, but in any areas where there are still troops.

Audience member: But you see, the point was to protect the men not the women, so...

Dr. Parascandola: Well, the women were the cause of it all [laughing]. Campaigns, I mean...

Audience member: [?] Penicillin...

Dr. Parascandola: As a matter of fact, even, this film was made in '44. The Rapid Treatment Centers started in '43. The film was made in '44. Once penicillin becomes more widely available, then you really do have rapid treatment. But admittedly...even though penicillin was around in '44, they didn't have supplies of it to use in these, for these civilians.

Audience member: Penicillin was released in good quantity in the civilian population, at least in this country, by '45, because there are pictures of posters that the Public Health Service put on mailboxes.

Dr. Parascandola: In fact, in April '45 the monthly journal of the American Pharmaceutical Association has a special issue on pharmacists and penicillin because as of March of '45 the restrictions were removed.

I'm assuming you could get the supplies and all, it was available in the corner drug store.

Audience member: Just an example of a model, 1943, I was on the dermatology service at Bellevue, which was a Rapid Treatment Center. There were two large wards, one male and one female, so the men were being treated as well as the women.

All patients identified in New York were brought into Bellevue for two weeks of intravenous arsenical therapy.

Those that had cardiac complications were given bismuth in preparation but that apparently [?] as toxic as arsenic and then in two weeks they were released, whether they could keep the follow-up or not, which was problematic.

There was one ward for central nervous system syphilis. And on the, this was fever treatment, with malaria. And interestingly enough there were always two or three patients who were in residence because that's the only way we could keep the malarial stream going.

So, in order to do a fever therapy you had to draw blood from one person...

Dr. Parascandola: Did they use artificial devices to produce fevers? Because in this film they show, actually, putting people in an incubator-type thing and raising their blood temperature, too.

But these were not people in third-stage syphilis. Sounds like I have to interview Sheldon.

Audience member: The interesting point was that it was under the direction of Evan Thomas who was the brother of Norman Thomas [?].

Both Evan, the director of the Rapid Treatment Center, and his brother Norman were ordained Presbyterian ministers who had subsequent [?].

Dr. Parascandola: OK, the last question.

Audience member: It was really a comment. I was wondering whether or not the emphasis didn't shift  from the armed forces to the schools in the postwar period, when you get a lot of commercial films as well as documentaries about juvenile delinquency.

And folded back into that is the issue of venereal disease in the schools.

Dr. Parascandola: And we all know some of those wonderful fifties films about how teenagers should behave, and dates, and all that good stuff.  [?] and I'm not sure, I don't know, how much the Public Health Service got involved in that campaign.

[Appaluse]

Dr. Teigen: Before everyone leaves I'd just like to give a few directions to those of you who are going to attend the buffet reception in the Natcher Building.

The Natcher building is one block from the Lister Hill Center. You go out the front door and walk one block and you'll see a great big, green glass and granite building facing you.

The front door is almost an extenstion of the driveway that leads to this building. So just walk that one block, go into the Natcher building, and continue to your right, there's a hallway going to your right, and then that will lead you to where the buffet is and the tables and so forth.

Let me conclude by thanking our speakers this afternoon. They provided a most wonderful afternoon of interesting and stimulating research, showing us how central public health, demography, and American medicine is, not only to the history of medicine but to social and political history as well.

And I think they have truly shown the potential of this field and with the same depth and breadth that Jim Cassedy has shown us all these years.

I'd also like to thank Karen Pitts, who helped a lot with the organization of this symposium, and Janet Joy who worked on the buffet reception and Joe Fitzgerald and Roger Gilkerson who did a lot of work on the publicity.

Finally, I'd like to thank you, the audience, for coming today and for adding such an essential dimension to the success of this symposium.

[Audience mills about, talking, leaving seats and exiting auditorium.]