History

Excerpts on the Influenza and Pneumonia Pandemic of 1918

II. DIVISION OF LABORATORIES AND INFECTIOUS DISEASES

The principal changes in the organization of this division from the year 1918 were in the separation of the section of urology and

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dermatology from the division, urology, becoming a section of the division of surgery and dermatology going to internal medicine, and the addition to the division of the Army Medical Museum and instruction laboratory at that place.

At, the beginning of the fiscal year, July 1, 1918, there were 527 medical officers of the laboratory service on duty in the United States, 184 Sanitary Corps officers, and 125 female technicians; the division had also sent overseas 315 trained laboratory workers; a total of 1,151. As the number of female technicians increased, it became necessary to secure first one and then a second female physician. Both were employed as contract surgeons to supervise the many details and large correspondence relating to the training schools, at the New York City Board of Health; the Massachusetts Institute of Technology, the Rockefeller Institute, and the stations to which the technicians were assigned. By the middle of August the personnel had increased to 1,333, distributed as follows: Overseas, 470; at schools of instruction, 250; at general hospitals, 86; at base hospitals, post hospitals, the Army Medical School and Museum, 484; at ports of embarkation, 37; at the Surgeon General`s office, 6.

The principal changes in laboratory personnel are shown in the following table:

	Aug. 1	Sept. 1	Oct. 1	Nov. 1	Dec. 1
Overseas	470	536	636	665	766
Schools of instruction	250	321	314	315	248
General hospitals, post hospitals, base hospitals, Army Medical School, and Army Medical Museum	484	345	423	466	492
Ports of Embarkation	37	50	52	54	66
Surgeon General`s Office	6	7	10	11	11
Total	1,333	1,358	1,564	1,698	1,755

The end of November found the largest personnel on duty of anytime during the war. The total of 1,755 persons was made up as follows: Medical officers, 945; Sanitary Corps officers, 405; female technicians, 398; contract surgeons, 6.

After the 1st of December the effect of demobilization became apparent, and on January 2, 1919, the total strength was 1,493; February 1,1,333; November 1, 1,279; April 1, 1,194; May 1, 1,130; June 1,908; July 1, 836.

All the schools for the special instruction of laboratory personnel, Medical and Sanitary Corps officers, enlisted men of the Medical Department, and female technicians were continued in 1918. The principal schools for officers were the Army Medical School, the Yale Army Laboratory School, the Army Auxiliary Laboratory No. 1 at the Rockefeller Institute, New York, the medical officers` training camp at Fort Oglethorpe, Ga., and, in addition, the laboratories of some of the base hospitals, particularly that at Camp Devens, Mass. Enlisted men were trained principally at the Army Medical School and the Yale Army Laboratory School, though a few were sent to the Rockefeller Institute, and many were necessarily trained at the various camps.

Providing proper faculties for these schools was a matter of great difficulty, and all of them were undermanned the greatest part of the time, entailing long hours of teaching upon the existing facul-

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ties. The department is thoroughly appreciative of the work done by this small group of enthusiastic and devoted workers and takes pleasure in acknowledging how much it owes to their patriotic devotion to duty.

During the influenza epidemic the schools were all practically closed, as it was necessary to send the students to duty in camps and civil communities because of the scarcity of physicians.

At no time during the war was there a sufficient number of trained pathologists in the service. The same condition seems to exist in civil life, for it proved impossible to find a sufficient number of trained men. The medical profession apparently realizes the significance of this lack of trained men, and doubtless some effort will be made in future to attract more men to this specialty by providing additional positions in universities, colleges, and hospitals, where the experience necessary can be gained under suitable conditions for routine work, research, and cooperation with other departments of the institutions. It is evident that something is needed to make the calling of pathologist more attractive than it has been in the past. In the Army hospitals a distinct step was made when the position of chief of the laboratory service was made coordinate in standing and authority with that of the chiefs of the medical and surgical services. Formerly the laboratory department had been a brevet of the medical service, with the result that many young men, finding promotion impossible in the laboratory, left it for clinical work in medicine and surgery. This has now been changed, so that a laboratory man may be promoted and still work in his proper special line. During the year arrangements were made for the instruction of medical officers in pathology at St. Elizabeth`s Hospital, Washington, where an average of 600 autopsies are performed yearly, and also at the Brady laboratories of the New Haven hospital. At the latter place pathological technicians were trained, in addition, and a considerable number were distributed to hospitals in this country and abroad. Some received further instruction in neuropathology at the Army Medical Museum, and were also distributed to hospitals for the treatment of nerve injuries.

Pathology, however, is a subject in which a large experience is acquired slowly, and, in spite of efforts to train additional men by the arrangement of special courses of instruction, the number of qualified pathologists could not be greatly increased during the war.

The study of respiratory diseases, particularly pneumonia, was continued throughout the year. A commission of five officers was sent to Camp Funston in July, 1918, and they were enabled to make a thorough and complete study of acute respiratory infections at that camp, including epidemiological, bacteriological, and pathological investigation, before the great wave of epidemic influenza appeared. Their conclusions included a statement that a mild form of acute epidemic influenza had been present in the camps for months before the fatal form of the disease became evident. Upon the conclusion of the survey at Funston, the group was transferred to Camp Pike, arriving about three weeks before the outbreak of the great epidemic. Both these studies are rich in results and give a picture of the respiratory disease condition both before and after, as well as during, the epidemic, made in a comparable way by the same

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group of men. Partial reports have already appeared in the current medical literature.

A series of studies on acute lobar pneumonia produced by type1 pneumococci in monkeys has been carried out at the Army Medical School and will soon be published. The studies show the changes in the respiratory organs from hour to hour after intratracheal inoculation and have given a perfectly clear explanation of the pathological picture seen in human beings. A considerable number of new points have been brought out, which add much to our knowledge of the histogenesis and bacteriology of pneumonia.

In August, 1918, the Army Medical School prepared a vaccine against pneumonia, containing pneumococci of types 1, 2, and 3, and this vaccine was used on more than a hundred thousand men without any bad results. The degree of protection given by the vaccine is still being studied and statistics are not yet ready as to the number of vaccinated men who developed pneumonia. The determination of the value of the vaccine was made unexpectedly difficult by the outbreak of influenza, which began during the following month. The vaccine, like that used by Lister in South Africa and by Austin and Cecil in this country, was designed to give protection against primary lobar pneumonia and secondary pneumonias, like those following influenza, had not been taken into consideration. The difficulty of eliminating influenza pneumonias from the tables had made the compilation quite laborious. It may be said, however, that there is apparently good clinical and laboratory evidence for believing that a considerable degree of protection can be given, however, by such a vaccine.

Studies on the etiology, pathology, and bacteriology of influenza were carried out energetically throughout the Army. Many reports have already appeared, and additional studies are still being carried on, both at camps and the Army Medical School, upon which reports may soon be expected. There is no room for doubt but that it was the same disease with which we had to deal throughout the United States, as showed by the clinical course of the disease and the pathological specimens which have been sent into the Army Medical Museum. Yet the bacteriological reports are not uniform, although in the greater number of the laboratories the influenza bacillus of Pfeiffer was regularly found at some portion of the respiratory tract, sometimes in pure culture, though more often in association with other organisms capable of growing in the lung. At a few camps quite contrary findings were reported. In addition, the influenza bacillus was found in many persons who were either not ill at all or who were suffering from some other disease. At the Walter Reed a series of lung punctures were made on influenza pneumonias with the result of finding a pure culture of bacillus influenza in most of the cases. The significance of this finding is still being investigated. There is considerable diversity of opinion as to the importance of the influenza bacillus and, as the question is by no means settled, extensive studies have been, planned and are being carried out at the Army Medical School, which at the time of reporting promise to contribute to our knowledge of the etiology and pathogenesis of the disease.

An influenza vaccine, consisting of many pure cultures of the influenza bacillus without any other organisms was prepared at the

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Army Medical School, and was used at many camps. It can not be said, however, that in the dosage used, that it was efficacious in preventing infection or in diminishing the mortality of the disease, and after a short trial during October, November, and December, its use was abandoned although in animals there seemed to be some indication of its value.

Empyema investigations continued through the year, and extensive reports have already been published in the current medical periodicals, The number of cases and the mortality was much less than during the preceding year, as will be seen by consulting the statistical tables. It is believed that a distinct advance has been made in our knowledge of the subject, and it has been shown that distinct lines of treatment are indicated by the bacteriological examination as to whether the cause is the pneumococcus or the streptococcus. The pathological physiology of the disease was reported upon quite fully by Graham and Bell, and the principles of surgical treatment have been firmly established for the first time.

The question of haemolygic streptococcus carriers and cases and, in fact, the bacteriology of streptococcus infections at the beginning of the year was in considerable confusion, and to bring order out of it a conference of experts in the field was called together at the Rockefeller Institute at Princeton, N. J., with the permission and active interest of Prof. Theobald Smith. The conferees numbered about 20 and represented the principal workers in this field. As a result of the meeting, a circular on standard methods of streptococcus investigation was prepared, printed, and distributed to all Army laboratories. Its effects were excellent and the standard methods and nomenclature permitted the collection of comparable data from the entire country.

Studies on the importance of chronic and acute carriers of these organisms are still being carried out; though reports have been published from time to time in the current medical journals, it is felt that many points still remain to be investigated.

Epidemic cerebrospinal meningitis, while prevalent, particularly after influenza, did not become alarming, and very little new was developed. Some studies already published show that there is reasonable grounds for believing that chronic carriers are immune to the disease, and also that vaccination is theoretically possible and that, if necessary, large numbers of troops could be immunized against the disease. Very little work was necessary to control the few chronic carriers; two incipient epidemics were apparently easily controlled by the recognition of the carriers, who yielded as a rule to medical or surgical treatment after a time.

In the early part of the year, the number of chronic carriers was so great that a special camp in Florida was planned for their reception and treatment, but, with the advent of better weather in the spring, the number rapidly diminished and it never became necessary to establish the carrier camp.

Triple typhoid vaccine was manufactured throughout the year at the Army Medical School in ample quantities. From August 1, 1918, to March 12, 1919, triple typhoid lip vaccines were in use, but, as they were adopted as a war measure and as some details regarding their manufacture needed further investigation, and the question of their value as protective agents was in question, their use was

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continued and the use of the saline triple typhoid vaccine was resumed.

The sharp outbreak of anthrax, due to the use of infected shaving brushes, referred to in the last annual report, continued for a time in the current year, but the good effects of the principal preventive measures quickly became apparent, and early in the year cases ceased to be reported. A full statement of the number of cases and deaths will be found in the statistical tables. The principal protective measures adopted in the Army were the adoption of a regulation preventing the purchase of shaving brushes by the Army except from factories which had been inspected and passed by the United States Public Health Service and the disinfection by hot cresol and formal in solutions of brushes already purchased. Early in July the United States Public Health Service certified eight firms of whom it was safe to purchase, and additional inspections rapidly increased the number of plants equipped with apparatus for the disinfection of the hair of which the brushes were made. It was interesting to learn that all hair used in making shaving brushes has to be boiled to straighten the hair, except that from horses, and, as the boiling kills the anthrax spores, it is horsehair alone which remains infected, and anthrax bacilli were obtained in the laboratory from horsehair alone, of all the varieties examined.

The policy of ordering all chronic typhoid bacillus carriers to the Walter Reed General Hospital for treatment was adopted, as the number found in the routine examination of all food handlers proved to be small; much smaller, in fact, than was expected (see statistical tables for numbers), and such a policy proved practical. The principal results of the surgical treatment at the Walter Reed has been published, and it is here merely necessary to state that five out of seven chronic carriers were cured by a complete cholecystectomy, giving a much higher percentage of cures than has been obtained heretofore by any method of treatment.

Enlargement of the laboratories in all the camp base hospitals was undertaken early in the year, and the floor space provided was approximately doubled to provide working room for the many activities of the laboratory personnel. For the newer hospitals an entirely new laboratory plan was prepared, which is much more satisfactory in its arrangement than the original plan used in 1917. Due to the conclusion of the war, not many of these were built, but they, particularly the one at Camp Mills, N. Y., have proved very satisfactory. For the semi permanent tuberculosis hospitals, particularly the one at Denver, Colo., a still better plan was worked out.

Plans and specifications for two new permanent department laboratory buildings, to be located at Fort McPherson, Ga., for the Southeastern Department, and at Fort Sheridan, Ill., for the Central Department, were prepared, but up to the present time no action has been taken on the recommendations.

Receiving wards for infectious diseases were never planned to meet the needs which developed, more particularly in the South, where measles prevailed extensively, and in July, 1918, a new set of plans was prepared, after consultation with the principal pediatricians and contagious-disease specialists. A few such buildings were erected and most of the older buildings were modified to give suitable receiving wards, in which cross infection could not readily take place.

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The arsphenamine manufactured in this country was fully as good as the product formerly obtained from Germany, yet, nevertheless, deaths continued to be reported from time to time following its use.

In cooperation with the Army Medical School and the Hygienic Laboratory of the Public Health Service, it was arranged to raise the permissible minimum lethal dose for small animals to about double that shown by the German salvarsan in this country at the outbreak of the war. The manufacturers willingly complied with this request, and early in the year the arsphenamine situation was more satisfactory, both as to quality and quantity of the drug, than it had ever been before.

The number ct cases of venereal disease among selective-service men became so large that in August, 1918, plans of special dispensaries in the development battalion of each camp were prepared. In order to avoid constructing new buildings and to use existing structures to the best advantage, the standard two-story barrack was modified to meet the needs of a venereal dispensary. At the same time a full set of instruments and other equipment for the treatment and diagnosis of venereal disease was furnished. For some time men had been under training in urology and venereal diseases at special schools in Boston, New York, St. Louis, and Fort Oglethorpe, and a large number were detailed for duty in these dispensaries. It was not uncommon for them to treat as many as 2,000 cases a day. It was found that subacute and chronic gonorrhea, under the conditions prevailing in our camps, was much more amenable to treatment than had been believed, and approximately 95 percent of such. cases were returned to duty cured.

The experience of the venereal disease service in the opinion of the consultants in this office justified a new issue of the "Red Book," or Manual of Treatment of Venereal Diseases, which was first published early in 1917. The second edition was published in 1918, and distributed to all the urologists in the service. The publisher (the Journal of the American Medical Association) reported the existence of a large civil demand for the book, and early in 1919 a third edition was prepared and published for civil use and for the benefit of the United States Public Health Service, which had adopted the manual for use in its own hospitals and in those which are aided or supervised by the service. it is believed that in the future as a result of the activities of the Medical Department of the Army and its sister services that there will be relatively fewer venereal infections, and that those which do occur will be diagnosed more correctly and receive better treatment than was available before the war.

The laboratory railroad cars, Metchnikoff, Reed, and Lister, were continued in service throughout the year. One was sent to Camp Wheeler to serve as an extra base laboratory for work in controlling the study of pneumonia and pneumococcus vaccinations at that camp. One was used at Camp Funston, Kans.,Camp Pike, and Little Rock, Ark., by the pneumonia commission in their study of pneumococcus, streptococcus, and influenzal pneumonias. One was used at the Army laboratory school at Fort Oglethorpe, Ga., and also at the laboratory school at Fort Leavenworth, Kans., until it Was discontinued there and transferred to Yale University, New Haven, Conn.. As a provision for providing for emergency work, they proved superior to any other mobile or transportable laboratory, and were very satis-

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factory agencies in the control of epidemics of infectious disease. In the future they should be provided with motor cycles and side cars since it is often necessary to park them in inaccessible locations in the camp, and the crew needs some form of transportation for themselves and the materials to be examined to and from the patients in the hospitals and the troops in barracks. The distances to be traveled during a single day amount to many miles.

The sterilization of surgical catgut became a matter of considerable importance early in the year, as the demand increased and new sources of supply were developed. A standard method of sterilization and of sterility tests was finally agreed upon, and the catgut situation at the end of the year was quite satisfactory.

Antitoxins against diphtheria and tetanus had been available in ample quantity from the beginning, but there was no available supply of anti gas-gangrene serum. At the instance of the chief surgeon, American Expeditionary Forces, two medical officers who had had abundant experience with these products were returned to this country to instruct and supervise the commercial manufactures in the preparation of antitoxin against the three commoner causes of gas gangrene: The bacillus perfringens (Welchi), the bacillusoedematiens, and the vibrion septique. By the 1st of November five firms had succeeded in producing a potent anti-Welch serum, which passed satisfactorily the requirements of the Public Health Service. The serum was, in fact, more potent than the majority of the samples which have reached us from France. The commercial production of antisera for oedematiens and vibrion septique was well under way, although no method of standardization of the latter sera was then available. The conclusion of the armistice stopped the work, since there is no commercial demand for anti gas-gangrene sera.

The medical war manual on the laboratory methods of the Army proved extremely useful, and a second edition, considerably enlarged and improved, was published at the end of the year and distributed to all laboratory officers and to the laboratory schools.

Infestation by lice was never a serious matter among troops in the United States; a series of surveys of limited numbers at ports of embarkation showed that only 1 out of every 500 white men were carriers of vermin.

Measles investigations were carried out on volunteers at Camp Devens, Mass., and Camp Meade, Md., but all attempts to reproduce the disease by the inoculation of volunteers with blood from measles patients were unsuccessful and the etiology of the disease remains unknown. It is hoped that opportunities for additional investigations will occur in the future, since measles is one of the most important diseases which the medical officer is called upon to control.

Studies on the prevalence of hookworm and other intestinal parasites were carried omit at most stations in the Army, but more especially in the South, particularly at Fort Sam Houston, Tex., and at the port of embarkation, Hoboken, N. J.. At the latter station, comparative studies were made which showed a much higher percentage of infection with intestinal parasites among troops returning from overseas than among men who had not been out of the country. The findings give additional support to the statements regarding the great amount of pollution of the soil and water in the regions occupied by our forces. In the battle areas, the soil was everywhere

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polluted and the findings at Hoboken confirm the opinions and reports of sanitary inspectors at the front. This finding helps to explain the incidence of all intestinal affections and gives a satisfactory explanation of the prevalence of diarrheas, dysenteries, and typhoid infection in the Valley of the Marne and at Chateau-Thierry.

Department laboratories have existed in the Southern, Central, Southeastern, and Northeastern Departments for some time. The higher grade of work for the Eastern Department has been done at the laboratory of the port of embarkation, Hoboken, N. J., and at the Army Medical School; that for the Western Department at the Letterman General Hospital. The closing in the near future of the port of embarkation at Hoboken has made it necessary to establish a laboratory under the direction of the chief surgeon of the Eastern Department. The activities of the department laboratories have been increased by the addition of a representative of the Veterinary Corps, to perform complement fixation tests for glanders and do other veterinary work in pathology and bacteriology.

The staffs of the department laboratories are being made use of to an increasing extent by department surgeons for the epidemiological investigation of local outbreaks of communicable disease in their respective departments.

Laboratory supplies originally were listed in the Manual of the Medical Department in paragraph 846; early in 1917 this paragraph was revised and enlarged and was published as a pamphlet for the use of supply and laboratory officers. The experience of the past year has shown the need for another revision and, in cooperation with the supply division, a new list of laboratory apparatus, chemicals, and reagents has been prepared for the printer, and it is hoped will soon be issued by the supply department. The preparation of detailed specifications for the various articles on the list is under way and considerable progress has been made.