THE MORE IMPORTANT MEMORANDA PROMULGATED BY THE DIVISION OF LABORATORIES
AND INFECTIOUS DISEASES, A. E. F.
From: The director of laboratories, A. E. F.
To: The division surgeon, --- division.
Subject: Divisional laboratory unit.
1. The accompanying letter of information is intendedto define the organization, equipment, and scope of work of the divisionallaboratory.
2. The section of infectious diseases of this office hasbeen organized for the instruction of divisional laboratory personnel andthe advisory reinforcement of divisional facilities in the control andsuppression of communicable disease. Paragraph 4 of the accompanying memorandastates the mechanism by which this reenforcement can be obtained when desiredby division surgeons.
3. As the divisional laboratory personnel (mobile laboratories),in many instances, is not coming to France as an integral part of divisions,but arriving as casual units, division surgeons are experiencing some difficultyin locating this personnel.
In order to overcome this difficulty, the chief surgeon,A. E. F., has been requested to automatically order all these units tothe central Medical Department laboratory for special instruction, to obtainequipment, and for assignment to divisions.
4. If your divisional laboratory personnel (1 medicalofficer, 1 Sanitary Corps officer, and 4 enlisted men) did not arrive asan integral part of your division, the personnel and equipment will besupplied by this office, as soon as available, on written or telegraphicrequest from you.
5. If your divisional laboratory personnel arrived withyour division and has not received special instruction and equipment fromthe central Medical Department laboratory, it is requested that the namesof the commissioned officers, two in number, be submitted to this officein order that we may request orders for them to proceed to the centralMedical Department laboratory for temporary duty.
(Office letter 5-a (revised), divisionof laboratories and infectious diseases, July 7, 1918.)
OUTLINE OF ORGANIZATION AND ADMINISTRATION OF LABORATORYACTIVITIES IN HOSPITAL CENTERS
1. In order that building space, equipment, and personnelmay be conserved and at the same time that units comprising hospital centersmay be given high-grade laboratory service, it has become necessary topool the laboratory facilities of such units and to establish a base laboratorywhich shall serve equally all units comprising the center together withsmall subsidiary laboratories attached to each unit.
2. The plans of organization contemplate that all highlytechnical bacteriological, serological, pathological, and medical chemicalwork shall be done at the base laboratory of the center and that the smallsubsidiary laboratories shall be equipped for clinical pathological examinationsonly.
PERSONNEL
3. The allowance of personnel estimated for in the proposedrevision of the Tables of Organization is 6 officers and 18 enlisted men.This is only an estimate, however, and the personnel may be increased,decreased, or distributed to meet local conditions.
4. Laboratory personnel, as outlined above, should bedetailed by the commanding officer of the hospital center from the personnelof the units comprising that center. French women should be utilized aslaboratory technicians wherever possible, thus releasing enlisted men forother duties. Requests for the employment of such women will be made tothe chief surgeon, A. E. F., through the commanding officer of the hospitalcenter and paragraph 3, General Order 13, headquarters A. E. F., July 13,1917, compiled with.
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5. The laboratory officer of a hospital center will bedetached from his unit and attached to the staff of the commanding officerof the hospital center. All other laboratory personnel, commissioned andenlisted, will be attached to the laboratory service for professional dutiesonly and be carried administratively on their unit returns.
DUTIES OF THE LABORATORY OFFICER, HOSPITAL CENTERS
(a) In charge of base laboratory.
(b) Responsible to the commanding officer of thehospital center in all matters relating to laboratory activities.
(c) General supervision of the subsidiary laboratories.
(d) Direct supervision and control of all laboratorypersonnel under the commanding officer of the hospital center.
(e) Correlation of the activities of the laboratoryservice, both central and subsidiary, with those of the clinical serviceserved.
(f) Advisor to the medical supply officer of thecenter as to issue, distribution, and requisitioning of laboratory suppliesfor his center.
The name of one medical officer, well grounded in generalbacteriology, will be submitted to the director of laboratories and infectiousdiseases, chief surgeon's office, A. P. O. 721, who will request ordersfor his transfer to the central Medical Department laboratory for a
two-weeks' course of instruction in wound bacteriology.
SUPPLIES
6. All laboratory equipment now on hand at units comprisinghospital centers will be pooled and turned over to the medical supply officerof the center and will be redistributed by him on memorandum receipt, afterconsultation with the laboratory officer, as the latter indicates. Inventorieswill be prepared showing all items that are not suited for use in the center(such as electric equipment not suited to the current available), togetherwith items that are in excess of the actual needs, and forwarded directlyto the office of the director of the division of laboratories and infectiousdiseases, office of the chief surgeon, A. P. O. 721, who will indicatethe disposition to be made of such items.
7. All requisitions for supplies for the laboratory servicewill be prepared and forwarded by the medical supply officer of the center.Requisitions will be made in quadruplicate, one copy being retained andthree copies forwarded. Requisitions for laboratory supplies only shouldbe sent to the director of the division of laboratories and infectiousdiseases, office of the chief surgeon, A. P. O. 721, and it is desiredthat as far as possible requisitions be so timed as to permit shipmentthereupon to be included in larger shipments made from supply depots onordinary requisitions. These special requisitions should therefore be sentapproximately ten days prior to larger requisitions contemplated and shouldbear notation that shipment should be held pending the receipt of requisitionfor general supplies.
8. Laboratory animals (sheep, rabbits, guinea pigs, andmice) will be purchased locally if possible, and if not, required for fromthe nearest army or base laboratory. In view of the great demand for laboratoryanimals in France by the Chemical Warfare Service, requisitions for suchanimals, especially mice, will be reduced to a minimum. Requisitions forwhite mice will be honored only in cases of great emergency and in smallquantities. The Avery method or some other suitable technique as a substitutefor the mouse method of pneumococcus type determination should be used.
9. Estimates have been prepared and orders are now beingplaced for standard items of laboratory equipment, and it is hoped thatthe laboratory equipment for hospital centers may be standardized in thenear future. Until then, medical officers should be guided by the realizationthat technical apparatus of all sorts is obtained with great difficultyunder present conditions and, that in view of the difficulties of transportation,all ordinary demands should be anticipated two or three months in advance.
10. An allotment of $100 per month will, on request, bemade by the chief surgeon's office to the medical supply officer of eachhospital center to cover purchases of laboratory animals, milk, eggs, meat,and other ingredients of culture media and such other items as are necessaryfor the proper functioning of the base laboratory, and properly chargeableagainst Medical Department appropriations.
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TRANSPORTATION
11. Transportation for central laboratories at base hospitalcenters has not been authorized as yet but this office has recommendedthat these laboratories be allowed one motor cycle with side car and onebicycle in the proposed revision of the tables of organization.
(Memorandum No. 8, division of laboratories and infectiousdiseases, July 23, 1918.)
DIVISIONAL LABORATORYUNIT
1. In the organization of the laboratory service for theAmerican Expeditionary Forces provision was made for a divisional laboratoryunit to serve with each division.
The personnel, equipment, and proposed transportationfor each unit is as follows:
Personnel:
1 Captain or First Lieutenant, Medical Corps or Medical Reserve Corps,Medical Department.
1 Captain or First Lieutenant Sanitary Corps, Medical Department.
4 enlisted men, Medical Department.
Equipment:
Chest 1. Standard equipment for clinical pathology.
Chest 2. Standard equipment for clinical pathology.
Chest 3. Standard equipment for bacteriological incubator.
Transportation:
1 light truck (¾-ton Ford or other standard).
1 motor cycle with side car.
2. It is contemplated that these laboratory units shallconstitute a part of the sanitary staff of the division surgeon and thatthey will be used by the divisional sanitary inspector in the investigationand control of communicable diseases and in the inspection, supervision,and control of sterilization of water supplies. While the question of immediatecontrol of these units is a matter of internal administration, it is deemedadvisable to place the medical officer in charge of the divisional laboratoriesbecause of the relative importance of the fields covered by the membersof these units.
Some division surgeons have found it most practicableto attach the laboratory unit to the divisional sanitary train. When indivisional training or rest areas, it is contemplated that the laboratoryunit will be attached to the camp hospital functioning for the division.At the front it is attached to an immobilized field hospital, preferablythe one through which infectious diseases and medical cases are evacuated.
3. To properly perform its functions, it is contemplatedthat the medical officer and officer of the Sanitary Corps attached tothis unit shall, on arrival in France, be sent to the central Medical Departmentlaboratory for temporary duty for a brief course of instruction in theepidemiology of communicable diseases and supervision of water suppliesrespectively and to obtain their laboratory equipment. Further practicalinstruction will be given these officers by specially trained officersof the infectious diseases and water supply sections of this office, whowill visit them from time to time for the purpose of giving aid in thesolution of local problems.
4. When an epidemic disease prevails in a division insuch proportions as to make it seem desirable to temporarily reinforcethe divisional personnel and to have special epidemiological and laboratorystudies made for the control of the disease, the division surgeon is authorizedby Bulletin No. 32, general headquarters, A. E. F., to communicate directlywith the director of laboratories and infectious diseases, who will dispatchspecial personnel and mobile equipment to reinforce the divisional authoritiesin controlling the epidemic. In the zone of the advance these units areusually located in close proximity to evacuation and mobile hospitals.These organizations are provided with a complete laboratory equipment,which is available for use by the members of the divisional laboratoryunits when highly technical laboratory examinations are required.
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Many of the evacuation and mobile hospital laboratoriesare prepared to do Wassermann tests, and the officer in charge of the divisionallaboratories should consult with the laboratory staff of the organizationto determine whether demands for such examinations can be met.
5. The equipment to be supplied the divisional laboratoryunit has been standardized and arranged in chests in order that it maybe packed and moved at a moment's notice. Chest 1 (weight 230 pounds, dimensions24 by 24 by 36 inches), chest 2 (weight 140 pounds, dimensions 21 by 24by 30 inches), chest 3 (weight 180 pounds, dimensions 39 by 22 by 28 inches)constitute the divisional Laboratory equipment. Chests 1 and 2 containthe equipment and supplies for routine clinical pathology, while chest3 contains a bacteriological incubator complete, arranged for heating withcoal oil. The coal oil is to be secured from the divisional supply officer.
6. With the equipment mentioned above, the following classesof work can be done:
Sputum.-Microscopic examinations of smears forthe tubercle, pneumococcus, influenza, and animal parasites.
Urine.-Appearances, color, odor, reaction, specificgravity, and qualitative tests for albumin, sugar, acetone, and diaceticacid. Microscopic examinations of urinary sediments. In suspected casesof typhoid fever about 10 c. c. of the urine should be sent to the centralMedical Department laboratory or the nearest base or army laboratory ina bottle of bile medium, for isolation of the suspected microorganism.
Venereal lesions.-Miscroscopical examinations ofsmears for gonococci and Fontana stained preparations from venereal soresfor spirochetes.
Blood.-Hemoglobin estimations (Tallquist), leucocytecounts, red-cell counts, and differential leucocyte counts. Microscopicalexaminations of stained preparations for pathological changes, plasmedia,etc. In every case of undetermined fever of over 48 hours' duration, 2to 5 c. c. of blood should be collected in a bottle of bile medium andthe culture sent to the general Medical Department laboratory or the nearestbase or army laboratory for further study. Sera for agglutination tests,the Wassermann test, etc., should be collected in the serum capsules furnishedwith this equipment and sent to the nearest of the laboratories mentionedabove.
Feces.-Microscopical examinations of fresh specimensfor parasites, ova, blood, mucus, and pus cells.
In suspected cases of typhoid fever, paratyphoid fever,or dysentery, about a gram of the feces should be sent to the central MedicalDepartment laboratory, or the nearest base or army laboratory, in a bottleof bile medium, for isolation of the specific microorganism.
Transudates and exudates.-Microscopical examinationsof stained specimens for tubercle bacilli, gonococci, spirochetes, etc.,and cytological changes.
Spinal fluid.-Microscopical examinations (cytologicand bacteriologic).
7. It is not intended that highly technical bacteriologicaland serological work shall be done by these units. In epidemics requiringepidemiological study and laboratory control, it is contemplated, as notedin paragraph 3 above, that special personnel and mobile equipment willbe sent to reenforce the local authorities on request from the divisionsurgeon.
8. It is not contemplated that the Sanitary Corps officerattached to this unit for supervision of water supplies shall do any extensivechemical or bacteriological laboratory work. In so far as his water workis concerned, it will usually be confined to sanitary surveys of sourcesof supply, recommendations concerning quality of water, and supervisionand instruction of sanitary detachments in the detail of the sterilizationof water by chlorination or otherwise. His work will be done under thesupervision of the divisional sanitary inspector. Where bacteriologicalor chemical analyses are deemed advisable, the specimens will be collectedby the water supply officer of the laboratory unit and forwarded to thenearest army or base laboratory or mobile water laboratory. A chlorinetesting outfit for use in controlling the chlorination of water supplieswill be issued to divisional laboratory units. Where extensive surveysrequiring laboratory control are necessary, the Medical Department representativeon the staff of the water supply officer for the army will be called onfor assistance. He has under his control mobile water analysis laboratoriesdesigned to carry out such investigations.
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9. Instructions for Sanitary Corps officer attached todivisional laboratory and for other officers concerned in the chlorinationof drinking water.
(a) The official method of sterilizing water isby means of calcium hypochlorite. The powder is issued in 1-gram tubes.One tube is usually sufficient to sterilize one Lyster bag full of water.Break a tube of calcium hypochlorite into a clean ordnance cup, moistenthe powder with a few drops of water, and mix into a smooth paste. Nowfill the cup with water to within 1 inch of the top and mix thoroughlyby stirring with clean spoon. Add this solution to a Lyster bag filledwith clear water, stir thoroughly and allow to stand 30 minutes beforeusing. After 30 minutes, test a cupful by adding 10 drops of a solutioncontaining 10 per cent potassium iodide and 1 per cent soluble starch (suppliedin laboratory equipment). The appearance of a blue color is indicationthat sufficient chlorine has been added to the water. If no color appears,the water is highly polluted and should be reported immediately to themedical officer having water supplies under his supervision.
(b) In emergency, when a Lyster bag is not available,the hypochlorite method can be applied to smaller containers of known volume,by calculations based on the knowledge that a Lyster bag contains about36 gallons of water. Thus if a 10-gallon container is available one-quarterof the concentrated solution prepared in the ordnance cup as above canbe added, etc. When smaller containers, such as 2-gallon tins, are usedthe original concentrated solution in the ordnance cup can be diluted byone-half, this dilution again diluted by
one-half in another ordnance cup, and one-quarter ofthis second dilution added to the tin. By using a little ingenuity, thehypochlorite method can thus be applied to any container of known capacity.
(c) When tubes of calcium hypochlorite are notavailable and the powder is available in bulk, the following procedureshould
be adopted:
(1) An empty shell used in the Colt's 45 automatic pistolwill hold 1-gram of powdered calcium hypochlorite when filled level withthe top. Always use this empty shell as a measure. Add one shell full ofpowdered calcium hypochlorite to an ordnance cup and make a solution asdescribed in paragraph (a), filling the cup with water to 1 inchfrom the top. Part of this solution is used in titrating the water to besterilized, and the remainder is used for sterilizing the water.
(2) Rinse four ordnance cups with the water to be testedand fill all four cups to 1 inch from the top (500 c. c.) with the waterto be tested. From a medicine dropper (to be obtained from regimental medicalsupplies) or pipette, add 4 drops of the calcium hypochlorite solutionto the first cup, 8 drops to the second cup, 12 drops to the third cup,and 16 drops to the fourth cup. Mix the solutions in each cup thoroughlyand allow the cups to stand 30 minutes.
NOTE.-Twentydrops delivered from a medicine dropper or a glass tube of 2 or 3 mm. boreis equal to 1 c. c.
(3) After 30 minutes, add 10 drops of potassium iodide-starchsolution from a clean medicine dropper or pipette to each of the four cupsand mix thoroughly. Some of the cups will show no color, some will showa blue color. The cup that contains the smallest amount of a hypochloritesolution capable of giving a blue color with the potassium iodide-starchsolution contains the proportion of chlorine necessary to sterilize thewater being tested. Thus, suppose the cup of water to which 8 drops (0.4c. c.) of this hypochlorite solution was added gives a color with potassiumiodide-starch solution, and the sample to which 4 drops (0.2 c. c.) ofthe solution was added gives no color. The cup to which 8 drops (0.4 c.c.) of the hypochlorite solution was added contains the right amount ofchlorine to sterilize the water being tested.
(4) There are 36 gallons, or 288 pints, in the water bagwhen filled to the white mark on the inside. Since eight drops (0.4 c.c.) of the hypochlorite solution were sufficient to sterilize 1 pint, 115c. c. of the same solution will be sufficient to sterilize the 288 pintsin the Lyster bag. In practice, it is believed to be safer to use twicethe amount indicated by the titration, so that in the example quoted 230c. c. of the hypochlorite solution would actually be added to the waterto be treated, or one-half of the concentrated solution, in the cup towhich the 1 gram of calcium hypochlorite has been added, could be addedto the water in one bag, and the solution prepared from the measure ofhypochlorite would be sufficient to sterilize two bags of water.
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(5) The following table shows the amounts of hypochloritesolution to add to a bag of water corresponding to the number of dropsused in the titration:
Number of drops | ||||||||
4 | 8 | 12 | 16 | 20 | 24 | 28 | 32 | |
Amount of hypochlorite solution (cup measure) | ¼ | ½ | ¾ | 1 | 1¼ | 1½ | 1¾ | 2 |
NOTE.-In the titration, if the first series of drops donot show a blue color the water requires more than one measure of hypochlorite.The second series of drops will indicate the amount of a second measureof hypochlorite dissolved in a cup of water to be added to the bag in additionto the first cup.
10. In order that troops may be protected from the possibilityof contaminated water, it has been ruled that all water not specificallydesignated as safe by the water-supply division of the Engineering Departmentshall be regarded as probably polluted and subjected to chlorination inLyster bags. The ideal to be attained is that eventually no soldier withhis unit shall drink untested or unchlorinated water. There are two obstaclesnot easily overcome, which render the attainment of this purpose difficult.These are chiefly the prevention of drinking at unapproved promiscuoussources, and the proper supervision of chlorination. The former difficultyis a matter of discipline in individual units. The latter can be accomplishedonly by the utilization of the proper personnel. In each division it isthe duty of the Sanitary Corps laboratory officer to supervise the properhandling of Lyster bags and the chlorination of the water. Alone, however,he can not carry out this duty. No special personnel being available forthis work, it is suggested that men be selected from the regimental sanitarydetachments who can assist the sanitary laboratory officer in these duties.If, in each regimental sanitary detachment, one noncommissioned officer and two men could be assigned to the water service,these men could be instructed in the dosing and perhaps the testing ofchlorinated water, under the guidance and supervision of the laboratoryofficer.
11. Expendable items of the laboratory equipment willbe replenished from the central Medical Department laboratory, and spareparts of the nonexpendable equipment are carried in stock at the centralMedical Department laboratory and will be supplied on requisition. Allreplenishment items should be requisitioned for by number as well as byname.
12. At the present time no transportation is providedfor these units in Tables of Organization, and request has been made thatone motor cycle with side car and one light truck (¾-ton Ford orother standard) be included in the revised tables of organization for thisunit. The request has not as yet been approved.
(Memoranda 5 and 7, division of laboratories and infectiousdiseases, August 14, 1918.)
TECHNIQUE FOR THE "WASSERMANN TEST"
In order that the results of Wassermann tests made on members of the American Expeditionary Forces may be as nearly comparable as possible when different workers in different laboratories are performing the tests, and in consideration of the fact that tests on the serum of the same individual may not always be made in the same laboratory, it is necessary to adopt a uniformity of reagents and a standard method. Moreover, there are not many instances of any two men who use exactly the same methods for performing the test, unless their training in Wassermann work was obtained in the same laboratory. The principal differences have to do with the hemolytic system, the "antigen," the preliminary amboceptor or complement titration, and the total volume of the test. While every laboratory worker naturally feels that his method is either as good or perhaps better than some other, it is advisable that the various workers adapt themselves to the method herein prescribed. However, if there be any suggestions for improvement which will materially benefit the purpose, the director of laboratories will be pleased to receive them in written form and they will be given full consideration.
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REAGENTS
"Antigen"; alcoholic extract of beef heart or calf heart,half saturated with cholestrin.
Hemolytic system: Anti-sheep (amboceptor, or sensitizer).
Complement, or alexin: Guinea-pig serum.
"Antigen" and amboceptor will be prepared and standardizedat the central Medical Department laboratory and furnished to laboratorieswhere Wassermann tests are made. Monthly supplies will be forwarded withoutrequisition, and additional supplies will be forwarded on special requestby telephone, telegraph, or letter.
Arrangements have been made for each laboratory to befurnished with guinea-pigs and sheep.
STANDARD METHOD
The total volume of each test is 1.25 c. c., one-fourththat of the original Wassermann.
1. Amboceptor, or sensitizer.-The test is basedon the "quarter-unit" amount; i. e., the amboceptor unit is that amountgiving complete hemolysis of 0.25 c. c. of 5 per cent sheep cell suspension,in the presence of excess complement, after incubation in water bath at37.5° C. for one hour. The amboceptor is furnished in glass ampulescontaining 0.1 c. c. inactivated anti-sheep serum. The dilution statedfor any particular lot of serum represents the dilution in the titrationcontaining the amount of serum determined as one unit. For example: Itmay be stated that a dilution of 1:3,000 is one unit, meaning that thisdilution contains the amount of serum which is one unit. Two units areused in the test, so in preparing the reagent a dilution of 1:1,500 willbe made; i. e., 0.1 c. c. of serum diluted with 149.9 c. c. of physiologicalsaline will give a reagent each 0.25 c. c. of which represents two unitsof amboceptor.
2. Complement, or alexin.-Without entering intoa controversy about the advisability of whether a preliminary complementor amboceptor titration be made, we feel that the variation in amboceptoris less than that of complement and that it is better to adjust the complementto a given unit of amboceptor.
Two or three guinea pigs should be bled the night beforethe day the test is done. The blood should be taken from the heart by meansof dry sterile needle with syringe or suction apparatus and placed in adry, sterile, conical centrifuge tube. After clotting has taken place,a stiff sterile wire should be run around the rim of the clot and the tubeplaced in an ice box until the following morning. The following morningthe tube should be centrifuged and the clear serum drawn off. The serumis diluted 1 to 10 with physiological saline for use as complement. Eachserum should be tested for hemolytic and complementary properties. Forhemolytic properties, 0.5 c. c. of the dilution and 0.25 c. c. of 5 percent suspension of cells should be incubated in the water bath at 37.5°C. for one hour. Providing each serum has good complementary propertiesand no hemolytic property, the sera should be cooled and diluted. In titratingfor complementary properties the following protocol should be followed:
Protocol for complement titration?
Tube | Guinea pig serum 1-10 | Physiological saline | 2 units amboceptor | 5 per cent sheep cell suspension |
C. c. | C. c. | C. c. | C. c. | |
1 | 0.15 | 0.60 | 0.25 | 0.25 |
2 | .14 | .61 | .25 | .25 |
3 | .13 | .62 | .25 | .25 |
4 | .12 | .63 | .25 | .25 |
5 | .11 | .64 | .25 | .25 |
6 | .10 | .65 | .25 | .25 |
7 | .09 | .66 | .25 | .25 |
8 | .25 | .75 | .00 | a.25 |
9 | .00 | 1.00 | .00 | b.25 |
10 | .00 | .75 | .25 | c.25 |
aComplement control.
bSaline control.
cAmboceptor control.
The dose for the test is twice the amount in the tube,showing complete hemolysis after incubation in the water bath at 37.5°C. for one hour. With a good serum 0.1 c. c. will usually be this amountand 0.2 c. c. will be the dose for the test.
3. "Antigen."-"Antigen" is adjusted so that 0.1c. c. of an emulsion in physiological saline will be the dose for the test,the proper dilution will be stated with each lot. It is
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very important that the "antigen" emulsion be preparedas follows: Place the amount of alcoholic extract to be emulsified in aflask, add physiological saline drop by drop, shaking the flask vigorouslybetween drops, until at least 5 c. c. volume is obtained. The balance ofthe saline may be added in large amounts, the flask shaken well betweeneach addition.
4. The test.-The amount of patient's serum (inactivated)used in each test is 0.05 c. c. In many instances there is sufficient naturaland sheep hemolysia in human serum to produce hemolysis of one unit ofcells with the amount of alexin or complement used in the test. On accountof this, a unit of cell suspension, 0.25 c. c., is added to the test andallowed to incubate 15 minutes. At the end of this time complete or nearlycomplete hemolysis will have taken place in the control tube (back tube).It will not be necessary to add amboceptor to these tests. To all othertests, 0.25 c.c., representing two units of amboceptor are added to eachtube.
First incubation period (for complement fixation), 1 hour.
Second incubation period (for natural hemolytic activity),15 minutes.
Third incubation period (for hemolysis), 1 hour.
Too much emphasis can not be laid upon the necessity ofcontrols for every reagent, and for their behavior with known negativeand positive sera, before the actual test is set up.
The following protocol serves to illustrate the tests:
[Sera for controls: One serum; one serum; one serum; one(-) serum]
Inactivated patient's serum | Antigen emulsion | Complement | Physiological saline | 5 per cent sheep cell suspension | Amboceptor, 2 units, if necessary | |
C. c. | C. c. | C. c. | C. c. | C. c. | C. c. | |
Back tube | 0.05 | 0.0 | 0.2 | 0.50 | 0.25 | 0.25 |
Front tube | .05 | .1 | .2 | .40 | .25 | .25 |
Antigen controls
I | II | ||
C. c. |
| C. c. | |
Known negative serum | 0.25 | "Antigen" emulsion | 0.3 |
"Antigen" emulsion | .2 | Complement | .2 |
Complement | .2 | Saline | .25 |
Saline | .25 | ||
Incubate in water bath at 37.5° C. for 1 hour. | Incubate in water bath at 37.5° C. for 1 hour. | ||
5 per cent suspension sheep cells | .25 | 5 per cent suspension sheep cells | .25 |
Incubate in water bath 15 minutes. | Ambocepter, 2 units | .25 | |
Incubate in water bath, etc., for 1 hour. | |||
Protocol for spinal fluid
Tube | 1 | 2 | 3 | 4 | 5 |
C. c. | C. c. | C. c. | C. c. | C. c. | |
Spinal fluid | 1.0 | 1.0 | 0.5 | 0.25 | 0.12 |
"Antigen" | .0 | .1 | .1 | .1 | .1 |
Complement | .2 | .2 | .2 | .2 | .2 |
Saline | .0 | .0 | .0 | .2 | .25 |
Incubate in water bath at 37.5° C. for 1 hour. | |||||
Amboceptor, 2 units | .25 | .25 | .25 | .25 | .25 |
5 per cent sheep cells | .25 | .25 | .25 | .25 | .25 |
Incubate in water bath at 37.5° C. for 1 hour. | |||||
Another important control which should be run in the regulartest is one for serum specimens showing marked hemolysis when received.
| C. c. |
Inactivated patient's serum | 0.05 |
5 per cent suspension sheep cells | .25 |
Saline | .95 |
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The tinge of red imparted to the supernatant fluid willserve as a comparison for reading the result on that particular serum.
INTERPRETATION OF RESULTS
Four symbols will be used to designate results:
+ + (complete fixation).
+ (almost complete fixation).
+ - (partial fixation).
- (complete hemolysis).
Attention is directed to the necessity of having thoroughlyclean glassware for serological work.
Reports should be made on Form 55q M. D.
(Memorandum No. 3 (revised), division of laboratoriesand infectious diseases, August 15, 1918.)
DIRECTIONS FORUSE OF APPARATUSFOR INTRAVENOUSINFUSION OF GUM-SALTSOLUTION
An outfit for the intravenous infusion of standard gum-saltsolution is now available for issue and may be obtained for use in allplaces where gum-salt solution is used. It is the object in putting thesesets out to enable the surgeon to use the solution directly from the originalbottle and thus avoid an unnecessary transfer from one container to another.The articles composing this outfit are:
1 glass tube with curved end (long).
1 glass tube (short).
2 pieces rubber tubing.
1 rubber stopper (double-hole).
2 needles.
These outfits are furnished to facilitate the use of thegum-salt solution, and are to be considered as permanent property, whichmay be replaced only under the same conditions that other property is soreplaced. The same care must be taken of these parts as of those of thetransfusion sets. Great care must be exercised in the care of the needles,as they are scarce and hard to obtain. The use of the paraffin oil furnishedwith the transfusion sets is recommended for their care.
DIRECTIONS FOR USE
The tubing, stopper, and needle are to be sterilized inthe usual manner. If a fine sediment exists at the bottom of the bottlecontaining the gum-salt solution, introduce the long glass tube carefully,so as not to disturb the sediment (assuring yourself that the opening inthe curved end is above any sediment present). Then allow the solutionto run out through the long tube to the needle by siphonage, or force thesolution out by pressure from the bulb of a blood-pressure apparatus attachedto the short tube. In case the solution has no sediment, the long rubbertubing with the needle attached can be connected with the short glass tubeand the bottle inverted, so that the fluid flows into the vein by gravity.
The same precautions against introduction of air intothe vein must be taken as in the case of blood transfusion.
A supply of these intravenous infusion outfits are availablefor issue to field, evacuation, mobile, and advanced base hospitals attachedto the first Army, at army medical dumps Nos. 1 and 2. Requisitions fromother units should be addressed to the commanding officer, central MedicalDepartment laboratory, A. P. O. No. 721. The allotment for each hospitalis 6 complete sets and requisitions must be limited to this number.
(Memorandum No. 18, division of laboratories and infectiousdiseases, September 9, 1918.)
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FOOD AND NUTRITION SECTION INSPECTION DATA
1. The following information compiled from Appendix No.4 of the Quartermaster's Manual, from the new Quartermaster's InspectionManual, and from other sources, will be of value in connection with theexamination of food supplies. Officers of the food and nutrition sectionshould familiarize themselves with Appendix No. 4, Quartermaster's Manual,as well as with the information below. Quotation from new inspection manual:
It should be clearly understood that responsibility offinal inspections, upon which depend acceptance or rejection of shipments,rests as heretofore entirely upon the officer in charge at the depot orcamp where delivery is made.
2. Sizes of cans now in use in United States supplies.-
No. of can | Diameter | Height | Capacity | No. of can | Diameter | Height | Capacity |
Inches | Inches | Fluid ounces | Inches | Inches | Fluid ounces | ||
1 | 211/16 | 4 | 11.6 | 3 | 4¼ | 47/8 | 35 |
1 tall | 211/16 | 4¼ | 12.3 | 3 | 4¼ | 5 | 35.5 |
2 | 23/8 | 49/16 | 21.3 | 3 | 4¼ | 5½ | 39 |
2½ | 4 | 411/16 | 31.2 | 10 | 63/16 | 7 | 107 |
3. Inspection of spoiled protein foods.-In recentyears there has been an increasing tendency to discount the idea of ptomainepoisoning from spoiled protein material. It is now the opinion of sanitaryexperts that the intestinal disorders that result from eating such spoiledmaterial are usually due to infection from organisms swallowed with thematerial and not from organic poisons of the ptomaine character. As Rosenauputs it:
Meat poisoning is not a poisoning as that term is ordinarilyunderstood, but almost always an infection; rarely an intoxication * ** many other foods, as milk, custards, vegetables, and even water may conveythe responsible bacteria, which in the great majority of instances belongto the paratyphoid group.
Aside from the paratyphoid group, there is another typeof meat poisoning comprised under the name botulism. The bacillus (Bacillus botulinus) generates a toxin as it growsin the meat or other protein media outside the body. Sausages readily becomeinfected by this organism and are responsible for its name. When food infectedby this organism is swallowed it is the toxin which produces the evil effects.Fortunately this toxin is killed by heat, if the heat is sufficient andpenetrates through the mass.
In view of these facts and in the interest of protectionof the health of the troops, the duty in regard to spoilage may be summarizedunder the following three heads:
(a) "Swells" among canned goods should be rejected;"springers" are also as a rule decomposed, but should be carefully inspected before condemnation. Meats that have a badodor, after all possible trimming has been done, should be rejected asunfit for human food.
(b) Secure thorough cooking of all protein foodto kill the micro-organisms and toxins of the botulism.
(c) Give especial attention to preventing the contaminationof food after it is cooked, by flies, dirty hands, or any other agent whichcould plant in the material the disease-producing organisms.
4. Quartermaster specifications which form the basisof food acceptance for the United States Army.-(1) Canned goodsin general.-In sampling take at least three samples from each case.Examine cans for rust; and if found, test spots thoroughly to make surethere are no perforations. Test bent places in the same way. To detect"springers," "knock" the can on a hard surface by striking the end forcibly.If the end springs out the can is improperly processed. This does not necessarilymean spoilage, but in the field such cans should be rejected as much as"swells," as there is neither time nor facility there for analysis. Inreporting a faulty brand, give the percentage of spoilage. Also look fornail holes in the cans, which will cause spoilage without swelling.
(2) Canned tomatoes, corn, and peas.-To be soundand ripe, free from artificial coloring matter, packed without additionof water, tomato pulp, or juice. Goods guaranteed against
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"spoils" and "swells" until July 1 following date of shipment."Spoils" and "swells" to be held subject to seller's orders.
Net weight of No. 3 cans, not lessthan 2 pounds 1 ounce.
Net weight of No. 10 cans, not lessthan 6 pounds 7 ounces.
Net weight of No. 2½ cans,not less than 1 pound 12 ounces.
(3) Canned fruits.-Prime ripe fruit packed in either20 or 30 per cent sirup. Orchard run after removal of culls. May have someblemishes. Canned fruits containing pits such as cherries, may swell andstill be fit for food. Contents however, should be examined.
(4) Canned vegetables.-Field run of good stock.May be slight discoloration or breaking due to processing. Canned hominymay spoil without swelling the cans; if spoiled, is usually discoloredand has a putrid odor.
(5) Canned salmon.-Pink, red, or medium-red salmon.Smell is the best test of unsound salmon. Meat should be firm, with noundue proportion of tips and tails. Packed in 1-pound or ½-poundcans. Bones cooked soft is indication of correct processing.
(6) Canned sardines.-Fish of uniform size and evenlypacked. Not all sardines are eviscerated. Army now accepts regular Mainepack. Look out for indications of bellies burst by gas and the presenceof red food. Oil must be free of rancid flavor, decay or odor. Very littleor no added oil is a cause for rejection. Lack of or leakageof oil can always be determined by shaking the can. Contents will shakeabout in a solid mass. Net weights: Quarter cans run 3.6 to 3.8 ounces;key cans run 3.5 to 3.7 ounces.
(7) Canned bacon.-Examine condition of the baconitself for sourness or rancidity. External examination of the containersis all that is necessary, as bacon is not processed. Vacuum drawn simplyto facilitate packing. If container is defective, examine the bacon.
(8) Canned lard.-Steam rendered lard for issue.Examine labels. Beef or mutton tallow or vegetable oils, when present,are adulterants. Color should be white, surface smooth and not grainy.Flavor not scorched or burned.
(9) Lard substitutes.-Two sorts allowed: (1) Entirelyof vegetable oils (refined cottonseed oil plus 10 to 15 per cent of vegetablestearine or by hydrogenating cottonseed oil); (2) cottonseed oil plus oleostearine. Both must be firm, white in color, free from water and foreignmaterial.
(10) Meats (beef).-At the front or in the fieldin general the principal meat problem concerns care of frozen beef. Specificationsdo not concern us, because all of this beef is United States inspectedbefore shipping. The minimum weight of the carcass is 450 pounds, fromwhich should be deducted 3½ pounds from each hind quarter to compensatefor the shank bone, left on for hanging. The difference in weight betweena fore and a hind should not exceed 25 pounds the carcass. * * * Beef shouldalways be inspected for the following qualities: (a) Its soundness;(b) its quality; (c) whether it has been properly trimmed;(d) whether it satisfies requirements with regard to weight; (e)whether the limitations as to sex (steers and spayed heifers only allowed)have been satisfied; (f) whether an equal number of fores and hindsis supplied; (g) whether it has been handled in a cleanly manner.
(11) Hash, corned-beef.-Consist of 50 per centvegetables (potatoes and onions) and 50 per cent corned beef, seasonedwith salt and pepper. If the cans when shaken seem to contain much liquidthey should be considered as of suspicious quality and opened for furtherinspection.
(12) Bacon.-Inspect for soundness (10 per centinspection considered sufficient). Surfaces free of mold, insects, skippers,rancidity, or sourness.
(13) Flour.-Made from sound wheat, free from smut,good color, best quality. When in doubt on this material send sample tooffice. Weevily condition can be determined by examination of the earsand seams of the bags. Worms also can be found on outside of bag if itis exposed to sunlight for awhile, but generally they are found in theflour; can be sifted out if not excessive.
(14) Hard bread.-Square crackers, flour and wateronly, thoroughly baked. Other forms which are made in France are also nowsupplied.
(15) Baking powder.-To be a tartrate phosphate,or alum powder from pure and dry ingredients. Yield not less than 12 percent CO2 gas.
(16) Beans.-Good beans are plump and firm underpressure. They should not dent when pressed with the thumb-nail. Shouldnot exceed 20 per cent moisture. Should be
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clean, of uniform size, and free from disease, especiallyanthracnose. Beans may be weevily or worm eaten. In either case they canbe separated from sound beans by placing in water; unsound beans floatreadily and can be thus skimmed off, before cooking.
(17) Rice.-Good, clear, fresh milled, head rice.Should be semitransparent, free from grit, dust, or hulls, and presenceof broken or dead white grains. Uniform-sized grains. Should also be freefrom seeds. Rice packed in sacks may get wet, and then cake and mold. Ifthe sack is allowed to dry undisturbed, the moldy part can then be cutthrough and easily removed without contamination of the balance of therice.
(18) Potatoes.-Texture firm when pressed by thehand, crisp when cut, and the cut halves when rubbed together briskly andthen pressed together firmly should hold together. U. S. Grade No. 1, soundpotatoes, practically free from dirt, foreign matter, frost injury, sunburn,second growth, cuts, scab, blight, dry rot, and damage caused by disease,insects, or mechanical means.
(19) Onions.-
Grade | Minimum diameter | Maximum diameter | Tolerance for defects | Additional tolerance for pink-yellow onions | Maturity | Brightness | Dirt or foreign matter | Shape | Variety | |
Total | Decay | |||||||||
Inches | Inches | Per cent | Per cent | Per cent | ||||||
U. S. No. 1 | 2 | None | 6 | 1 | 5 | Must be | Must be | Free from | Well | One |
U. S. Boiler | 1 | 2 | 6 | 1 | 5 | .do. | .do. | .do. | .do. | Do |
U. S. No. 2 | 2 | None | 10 | 2 | (a) | Need not be | Need not be | Need not be clean | Any | Do |
U. S. No. 3 | 1 | None | 10 | 5 | (a) | .do. | .do. | .do. | .do. | May be mixed |
aNo limitation.
Onions of all grades, except for tolerance, must be sound,free from "doubles," "splits," "bottle necks," and seed stems and practicallyfree from damage caused by moisture, sunburn, cuts, disease, and mechanicalmeans. Sacks, ventilated barrels or crates called for.
(20) Corn goods (hominy, hominy grits, corn meal).-Thelowest grade of corn that can be used is No. 4. This grade shall be whitecorn, shall be sweet, shall contain not more than 19.5 per cent moisture,not more than 5 per cent foreign material and cracked corn, and not morethan 8 per cent damaged corn, which may include not more than 0.5 per centheat-damaged and mahogany kernels. Yellow No. 4 is same specification.Table hominy shall be degerminated hulled corn, thoroughly screened anddusted and shall contain not to exceed 1 per cent fat by ether extractionand not to exceed 14 per cent moisture. Grits shall be made from hominyscreened and dusted clean, not over 14 per cent moisture or 1 per centfat.
(21) Standard meal.-From entire grain, with 10per cent food removed and 45 per cent feed meal extracted. Not over 11per cent for export.
(22) Dried fruits.-Should be in good conditionand free of insects and decay. Prunes, 50 to 60 per cent; peaches unpeeled.Dried fruits are attacked by weevils and molds. Figs are quite apt to beweevily in the center of the fruit, and while the worm is not often foundthe web is easily seen. They also mold, and at times both conditionsare found. Dates will sour along the edges of the box, and unless promptlylooked after sourness will penetrate the entire mass. Apples and peachesmay be found moldy or weevily, or both. Prunes may sour and get wormy ormoldy, but the moldlike white, sugary formation found on prunes at timesis not ground for condemnation and can be readily removed by washing.
(23) Coffee.-Roasted and ground. Porto Rican, Hawaiian,or Central American preferred.
(24) Milk.-Unsweetened, evaporated, in 1-poundcans.
(25) Vinegar.-Cider, 4½ to 5 per cent aceticacid, in half barrels.
(26) Pickles.-Plain, uniform in size, about 40to the gallon, thoroughly cured, free from nubs and soft stock, in halfbarrels. All soft pickles, in or out of vinegar, should be rejected.
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(27) Oleo.-Must be uncolored, not less than 10per cent butterfat and 2½ to 4 per cent salt. The coloration mustbe uniform, not streaked or blotchy. Odor and taste pleasant and resemblingbutter. Not rancid or sticky or grainy in the mouth. Oleo showing discolorationor dark patches on the sides or ends of the package should be cut into.Mold will usually penetrate the entire mass.
(28) Sirup.-Sugar cane, sorghum, or sugar sirupor blend, of same.
(29) Flavoring extracts.-Lemon, 5 per cent by volumeof oil of lemon. Vanilla, 40 per cent by volume absolute ethyl alcoholand at least 2.5 percent true vanilla solids.
* * * * * * *
5. The proper care of subsistence supplies.-Ininspection of storage of supplies attention is called to a few importantfacts to have in mind. In this connection, officers of this section shouldbe familiar with sections 2729 to 2746 of Volume I of the Quartermaster'sManual; also with 2309 to 2313 of the same manual.
(1) Care of beef.-The care of frozen beef in campsis largely a question of treatment and ventilation. The following extractfrom Weekly Bulletin of Disease, No. 16, issued by the chief surgeon'soffice, covers the practical points involved:
Whenever a quarter of beef is suspected of taint, firstthoroughly wash the quarter with brine, examine the exposed surface, andif these are tainted cut off such portions as are affected. If the coveredsurfaces seem to be affected, have the butcher remove the covering tissue,taking care not to cut into the flesh. Do not condemn any part of the beefuntil these preliminary steps have been taken.
To determine whether decay has started within the beef,introduce a probe at the shoulder and hip joints; by the smell at the endof the probe you can determine whether the joints are affected or not.If they are affected, dissect out the bone and trim away the adjacent meatuntil a sound layer is reached. In no instance is it desirable or necessaryto slash the quarter, the object being removal of affected parts with aslittle waste as possible.
To prevent flyblow, make sure that fly eggs are immediatelywashed off when the beef arrives. These are usually found on the shank.
The following methods are recommended for the best careof frozen beef:
It is better to hang beef in an airy, well-ventilatedplace, out of the direct rays of the sun, rather than to store it in damp,dugout refrigerators. Meat safes, covered with cheesecloth to exclude fliesand with free access of air, will protect the beef for several days ifit is wiped as frequently as moisture accumulates on the surface.
If it is necessary to retain cut-up beef for more than24 hours, it may be placed in a container and covered with brine, but incutting up beef require the butcher to first remove any tainted outer skinbefore he cuts into the meat; this avoids the carrying of the decayed portioninto the sound meat.
In some places such safes can be constructed in the sidesof the Adrian barracks; in others they have been erected in sheltered placesout of the sun and near the kitchen. The cheesecloth that comes aroundthe beef can be used to exclude flies. The main object is to keep the beefsurface dry and with a free current of air passing over it.
(2) Bacon.-Excess of supply should not be allowedto accumulate. Note dates on packs and issue oldest bacon first. Keep dryand well ventilated, also cool. If in crates, should not as a rule be removedfrom them until used.
(3) Canned meats.-Should keep, if properly processedand stored, for many months. Should be kept dry to prevent rusting of containers.While freezing does not injure the contents, it is apt to spring seamsthrough the swelling of the liquids.
(4) Canned goods in general.-All canned goods shouldbe stored in a cool, dry place. Cold has no ill effect unless below freezingpoint, but freezing tends to bring about a separation of the contents anddeterioration of quality. In camps, this sort of goods should be kept asfar as possible from the range. Dampness causes rust, whichin turn causes perforation. On this account see that they are not leftin wet or damp boxes. Acid products should not be kept too long.
(5) Beans, rice, etc.-The greatest danger to thesearticles are weevils and moisture. Dry storage and good ventilation areessential, and they should never be placed directly on the ground. Alsosee to it that the old stock does not accumulate at the bottom of the bins.The same recommendations apply to flour, corn meal, hominy, etc.
(6) Vegetables.-Whenever possible these shouldbe in slatted, well-ventilated bins. If it is necessary to keep in sacks,the materials should be often emptied out and sorted to remove
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decayed or sprouted material. Potatoes should not be exposedto light any more than is necessary. They may be well stored in dugoutsor pits, but not piled high. Onions should not be left in sacks or crates,but emptied out and spread as thinly as possible. They should not be putin pits, as they require air. Carrots and parsnips may be stored in pitsand are not injured by slight freezing. The same is true of turnips.
(7) Dried fruits.-The best temperature is 34°to 36° F. It is important that they be protected from insect infection;also from moisture and other conditions that will produce rotting or moldiness.
(8) Coffee.-Requires dry, well-ventilated storage.Should not be kept near pepper, tobacco, or other things from which itcan absorb odors, and containers should be kept tightly covered at alltimes.
(9) Lard and butter.-Keep cool. Melting and rehardeningfavors rancidity.
(10) Protection from rats.-All goods like floursand meals are often protected from rats if old newspapers are placed betweenthe sacks. The rats use these to make nests of and spare the other materials.
(11) It seems to be an established fact that practicallyall bread mold can be traced to delayed shipment or unsuitable storage.The bread is a culture medium for mold, requiring merely favorable conditionsfor its development. Any treatment that makes conditions unfavorable tomold growth represents an optimum treatment for bread. Obviously this meansgood ventilation, freedom from moisture, the prevention of accumulationof old material, daily cleaning of bread boxes, and the like.
(12) Section 2745, Quartermaster's Manual, gives the insectsthat are injurious to subsistence supplies and their habits. The lowestand highest temperatures to which certain perishable goods may be subjectwithout injury under the conditions stated are given in the following table:
Perishable goods | Lowest outside temperature, unprotected | Temperature above which injury occurs |
° F. | ° F. | |
Cabbage | 25 | 75 |
Cheese | 30 | 75 |
Extracts, flavoring | 20 | --- |
Fish, canned | 18 | --- |
Grapes | 34 | --- |
Onions | 20 | --- |
Pickles | 22 | --- |
Potatoes | 33 | 80 |
Rice | 20 | 90 |
Tomatoes, canned | 26 | --- |
Vinegar | 22 | --- |
6. Members of this section have been familiar for sometime with the value of the garbage pail as a basis for diagnosis of messtroubles. With the garrison ration, a secondary and almost equally importantplace for this purpose is the storeroom. Learn to know the bearing of eacharticle there on the daily menu. If you find excess sugar it means no dessertsare being made. Excess flour, the same thing. Lack of fruits or bakingpowder means a definite reduction in menu possibilities, etc. This correlationbetween storage and menu possibilities should be a special study of everyinspecting officer.
7. A few waste statistics.-(a) Potato peeling:Refuse and waste as ordinarily peeled, 25 per cent; as carefully peeled,13 per cent; by machine and eyes removed by hand, 12 per cent; peeled bymachine, 4.5 per cent; unnecessary waste as ordinarily peeled, 12 per cent.
Ration (80 per cent of 20 ounces) is 16 ounces x 1,750,000men = 1,750,000 pounds; 12 per cent waste = 210,000 pounds of food forthat number of men for 1 day.
Potatoes also supply 55 per cent of all the basic ashin the ration; 12 per cent waste reduces this markedly and increases theacidity of the ration.
(b) Value of beef ration per day for 1,500,000men is $294,999 in the market at home, without adding the cost of transportation.In one shipment of 25,000 pounds of beef nearly 75 per cent was salvagedby trimming at the station, though the whole had been condemned in thefield.
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8. Methods of survey and condemnation.-Paragraph2311, Quartermaster's Manual:
Before shipping subsistence supplies to other points,quartermasters will carefully examine the supplies, opening original packageswhen there is a doubt as to the sound and serviceable condition of theircontents. Damaged or unserviceable articles, or those liable soon to becomeso, will not be shipped.
This article supplies sufficient authority to preventdepot quartermasters from sending out goods which you find defective, andcan be used by you for this purpose.
Paragraph 2787:
If the stores have not deteriorated so as to render themunfit for human consumption, and are not required in the military service,they will be sold at auction.
If the stores have deteriorated to the extent of renderingthem unfit for human consumption but are of value for other purposes, theywill be sold at auction, and prior to the sale the accountable officerwill cause each can, box, bottle, or other container to be stamped or indeliblymarked as follows: "Deteriorated military supplies condemned and sold undersection 1241, Revised Statutes."
If the stores have deteriorated to such an extent thatthey are without value for any purpose whatever, they will be destroyed.(Cir. 89, M. D. 1908.) Such stores must be acted on by an inspector orsurvey officer before being disposed of.
The last sentence of this article calls attention to thenecessity of a board survey. In practice, the following methods are used:(a) When meats are to be condemned: As soon as possible after theirreceipt the commanding officer summons a board of medical inspectors. They may call on a quartermaster meat inspector to aidthem, especially to save any part of the carcass fit for consumption. Whateverthey condemn, in whole or in part, the quartermaster credits the companyfor the amount destroyed. In such a case a field officer with his butchershould first ask for the cooperation of a sanitary inspector and take actionwith a view to saving as much as possible.
(b) Subsistence stores: Canned goods or spoiledgoods generally are usually returned to the commissaries by the mess orsupply sergeants for exchange or credit. If the quartermaster refuses toaccept these articles, the sergeant should report the matter to the messofficer and through him to the commanding officer, who may call a medicalboard to pass upon the food. It must be remembered (par. 2322): "Afterrations leave the quartermaster they are in the keeping of the troops,and any loss sustained by subsequent deterioration or avoidable circumstancesis theirs." In other words, the quartermaster is justified in refusingto receive back goods accepted by the sergeants, unless they are actedupon by a surveying officer. He may, however, accept prima facie evidence.If he refuses to accept it, the survey board is the only resource of thecompany.
There are several articles of the Quartermaster's Manualwhich should be familiar to all our officers. See paragraphs 2309-2313,also 2769-2853. The methods of appointing a surveying officer and his responsibilityand method of procedure are covered by paragraphs 710-726 of the Army Regulations,1913, corrected to April, 1917. Of these articles, 711 covers appointment;712, his duties; 715, scope of action; 716, his report; and 717 (2), thecharacter of supplies that may be destroyed and the amounts.
In the American Expeditionary Forces there is usuallyto be found associated with large camps some officer of the salvage servicewith whom you should get in touch. If none such exists, locate the nearestone and determine what is his relation to your unit. Secure his cooperationin the matter of disposal of condemned goods.
Please report to this office the names of manufacturersand brands of goods which are found to be markedly defective, in orderthat we may report the same to the chief quartermaster.
The following circular indicates the attitude of the QuartermasterGeneral in regard to disposal of canned foods. It will be noted that thisis addressed to the depot quartermaster at New York and applies strictlyto conditions in the States. It may be useful, however, for quotation introublesome cases.
Acting Quartermaster General, May 24, 1918, to depot quartermaster,New York, N. Y.-Disposal of canned foods when containers are of questionableappearance:
1. Some of the containers of canned vegetables, fruits,meat and meat-food products, and other canned goods, delivered to the Army,do not show proper vacuum. The food in such containers may or may not besound.
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2. The contents of these cans, known as "swells" and "leakers,"are unsound because of fermentation or putrefaction. The contents of othercans, commonly known as "springers" and "flippers" (those showing loosetin or insufficient vacuum), and overfilled cans usually are found to besound.
3. To distinguish between these two classes of cannedfoods, the containers of which have a questionable appearance, requiresexpert knowledge. It is impracticable to provide special inspectors havingexpert knowledge of canned foods for the examination of those productsat all camps, especially at those where only a few troops are stationed.For this reason canned foods should not be issued to troops unless thecontainers are in perfect condition and show a good vacuum. Inexperiencedpersons should not attempt to differentiate between questionable cans,the contents of which may be sound or unsound, but should reject all thosepackages which are not in perfect condition.
4. The term "good vacuum" means the ends of round cans,large sides of flat cans, and the sides and ends of high four-sided cansshould be tightly drawn and should neither show tin nor distention.
5. All canned foods, the containers of which are not inperfect condition, should be held for reclamation. "Swells," "springers,""flippers," "overdefects," should all be included in this class. Immediatelyafter the discovery of canned foods showing any one of these conditions,the facts should be reported to the depot or purchasing quartermaster,in order that arrangements may be made with the contractor to replace therejected products. (See pars. 809 and 2310, Manual for the QuartermasterCorps.)
By authority of the Acting Quartermaster General:
J. W. MCINTOSH,
Lieutenant Colonel, Quartermaster Corps, N. A.,
Subsistence Division.
9. Requests.-We are anxious to secure a seriesof recipes based on practical handling of dried vegetables. Please collectsuch data and mail as fast as accumulated to this office, that we may publishthem for the benefit of all officers.
Also continue to send in recipes which have been foundof value and which utilize the components of the garrison ration.
In case your division has special experiences such astroop movement or combat experience, send us all the information you cangather as to the efficiency of the ration under these conditions.
(Memorandum No. 22, division of laboratories and infectiousdiseases, September 10, 1918.)
PROPHYLACTIC SERUM TREATMENT AGAINST GAS GANGRENE
A test of the prophylactic value of anti-gas-gangrenesera in the human subject is about to be made.
The first serum to be used will be one which protectsin the animal experiment against the toxins of both the tetanus bacillusand the Bacillus perfringens (B. Welchii). While the experienceof French and British investigators indicates that gas gangrene may becaused by a variety of anaerobic organisms acting alone or conjointly,the high percentage incidence of perfringens infections justifies the thoroughtrial of the univalent anti-gas-gangrene serum now available in amountssufficient to conduct such experiments on a large scale.
Polyvalent sera capable of neutralizing the toxins ofother anaerobic bacteria concerned in the causation of this condition arenow in the process of preparation and will be made the subject of a similartrial where available in adequate amounts. It is proposed to use in everyinstance sera which protect against the toxin of the tetanus bacillus aswell as the toxin of one or more anaerobic bacteria to avoid the necessityof giving several injections, in some instances sera derived from horsesimmunized against the toxins of two or more pathogenic anaerobes will be employed. In others, thepooled sera derived from several horses each immunized against the toxinsof a single anaerobic bacillus will be used. For the present it is ourintention to confine the trial to antitoxic sera. Bacteriolytic and combinedbacteriolytic and antitoxic sera have been prepared byseveral French authorities and are now being put to a practical test. Theresults of these experiments will determine whether similar tests willbe undertaken by the medical staff of the American Expeditionary Forces.
To secure reliable results the complete cooperation ofall medical officers concerned with the care of the wounded and all laboratoryofficers taking part in the examination of
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these cases is absolutely essential. The development ofgas gangrene in patients who have received the prophylactic injectionsof anti-gas-gangrene serum can not be accepted as evidence against itsvalue unless it is established that the only pathogenic anaerobe present in the case is the microorganism against which the particularantiserum is supposed to protect. In view of the fact, as indicated above,that several anaerobes may be responsible for the condition under consideration,and in view of the further fact that the detection and the recovery ofsome of the less common pathogenic anaerobes presents many difficulties,it is only by the exercise of the greatest care on the part of the examiningbacteriologist that false interpretations can be avoided. Apart from thestudy of the anaerobes found, special attention should be paid to the Streptococcushemolyticus owing to the important part which this organism appearsto play in favoring the development of the gas gangrene.
To avoid errors, it is proposed to adopt the followingprecautions:
1. Every case in which the records show that anti-gas-gangreneserum has been administered as a prophylactic measure should be reportedto the bacteriologist the moment symptoms of gas gangrene develop, andall cases in which from the nature of the injury or the condition of the wounds such an occurrence might be expected shouldalso be reported so that they may be made the subject of a detailed clinicaland bacteriological study even before the symptoms of this disease havedeveloped.
2. In all such cases the bacteriologist should make everyeffort to isolate in pure cultures all of the anaerobic bacteria present.Such strains should be sent under proper conditions (preferably by courier)to the central Medical Department laboratory for verification of the diagnosis.
3. In addition the original cultivations in cases of gasgangrene should be made in duplicate. One set should be sealed and sentto the central Medical Department laboratory by courier after 24 hoursincubation, and the name, number, rank, and organization of the patientand the diagnosis of the case. In view of the good results secured in thislaboratory by the use of liver peptone water medium it is recommended thatthis medium be employed in place of the standard veal or beef broth. Theliver peptone water is prepared as follows: Peptone, 10 gr.; sodium chloride,5 gr.; water, 1,000 c. c.
Boil 30 minutes; neutralize to phenolphthalein, then add20 c. c. of normal sodium hydrate solution; autoclave for 15 minutes at115° C.; filter; tube (10 c. c. in each tube) and add approximately1 gr. of rabbit, beef, or human liver. Autoclave for 15 minutes at 115°C.; incubate for 3 days to insure sterility (if sterile, fluid will remainclear; it may assume a faint yellow color).
Owing to the importance of determining the exact natureof the infection in cases receiving prophylactic injections of the anti-gas-gangreneserum these double checks seem necessary. A report of the findings willbe transmitted to the bacteriologist submitting the specimens to the laboratory.
4. In all cases of death of individuals who have receivedprophylactic injections of anti-gas-gangrene serum, excepting when thecause of death is obviously due soley to the injury and the fatal issueoccurs very soon after the injury, a complete autopsy should be performedand detailed bacteriological examination of the blood and internal organsbe undertaken to exclude the possibility of death from causes other thana gas bacillus infection.
Method of injecting the serum.-Intramuscular injectionsshould be made in every instance. Concerning the most favorable site forthese injections opinions differ. Some French investigators claim thatthe injection should be given in the neighborhood of the wound. Since thismethod may have some advantages over the injection of the serum in distantparts, it is recommended that when possible the serum be introduced intothe extremity in cases where the most serious wound involves one of thelimbs. These injections should be administered on the proximal side ofthe wound. In all other instances, and where the pressure of work precludesthe selection of a particular site, the injection should be given in theregion recommended for the administration of tetanus antitoxin. The injectionsof tetanus antitoxins in the cases that are to serve as controls shouldalso be administered intramuscularly.
Cases that are to receive prophylactic injections.-Theoriginal trials will be confined to the wounded of a single division. Tosecure results of value the recipients will be selected at random. Approximatelyone-half of the wounded arriving on a given day will receive
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injections of a combined tetanus and anti-gas-gangreneserum, while the remainder will receive usual injections of tetanus antitoxinand will serve as controls. Both the treated and the untreated cases shouldreceive the anti-gas-gangrene card referred to below.
It seems necessary to select the controls from the samedivision and from the same group of wounded, in view of the fact that theincidence of this complication (gas gangrene) is determined by a numberof factors which may vary from day to day. Weather conditions the characterof the soil over which the fighting occurs, and the character of the misselsemployed all may have a determining influence on the incidence of gas gangreneamong the wounded.
Records.-For this experiment special antigas-gangrenerecord cards will be provided. The front face of this card concerns solelythe officer administering the anti-gas-gangrene serum and the officer whohas charge of the controls. These officers should fill in all of the datescalled for on the front face of this card. The back of the card concernsonly the medical officers in the evacuation, mobile, and base hospitals.The officers belonging to these organizations should fill in the data calledfor on the back of this card. All cases showing evidence of gas gangreneat the time the operation is performed or in which the nature of the injuryor the condition of the wound suggest the probability of such an occurrence should be reported as already indicated to the laboratory officer, whowill begin his bacteriological investigations immediately, if such areindicated, and also begin the collection of all clinical data called foron the standard bacteriological report card, Form No. 3, and all otherdata which in his opinion may be of interest in the particular case underconsideration. When the patient is to be evacuated immediately and thetime for bacteriological investigations is not available, it is importantthat the clinical data be gathered and transmitted with the patient tothe hospital organization to which he is sent.
The control cases should also be made the subject of aspecial study, but only if time and the personnel available permit. Apartfrom establishing beyond a doubt the occurrence of a gas-gangrene infectionin these cases, the results secured in connection with these controls haveno bearing on the interpretation of the results of the present experiment.
The gas-gangrene card and a copy of all other laboratoryrecords should accompany the patient. This applies to the recipients ofthe prophylactic injections as well as to the controls. After death, oras soon as the danger of the development of gas gangrene in convalescentshas subsided, these cards and all other laboratory records should be sentto the director of laboratories, American Expeditionary Forces, A. P. O.No. 721.
(Memorandum No. 24, division of laboratories and infectiousdiseases, October 16, 1918.)
ORGANIZATION OF LABORATORYSERVICEIN HOSPITALCENTERS
1. The following outline of the organization of the laboratory service in a hospital center has been worked out tentatively in the hospital center at Nantes and is submitted for your information.
2. It is requested that the chief laboratory officer submitto this office a similar statement concerning the arrangement of the laboratoryservice in his particular center.
OUTLINE OF LABORATORY ACTIVITIES IN HOSPITAL CENTER, NANTES
Clinical microscopy.-All routine work, as urinary analysis, blood counts, sputum for tuberculosis examination of warm stools for amoba, and blood cultures, is to be carried on in the subsidiary laboratories.
Wound bacteriology.-(a) Aerobes: A portionof the material to be examined is first smeared on a slide made sterileby heat, a Gram stain made, and the morphology of the organism and bacterialcount noted on the bacteriologic record card. If streptococcus is present,inoculate a portion of the material on agar slant and agariplate. In inoculating plates, a portion of the material is placed in onecorner and streaked out on plate with a platinum spatula.
To reduce as far as possible the duplication of work inthe subsidiary and central laboratories, the isolated colonies on platesare to be picked, using the original Gram stain as a guide for the differentorganisms to be sought for, subcultured on plain broth if it is a bacillus,and sent to the central laboratory with the bacteriologic record card foridentification. On the other hand, if a staphylococcus is present,
the organism is not isolated and sent to the centrallaboratory, but held for type determination in the subsidiary laboratory,and recorded on the bacteriologic record card.
iBlood.
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Should the isolation be unsuccessful from the first inoculation,and the time is pressing the original agar slant, and if advisable theoriginal agar plate, are to be sent without delay to the central laboratory.In each case note carefully the results of all previous work done.
(b) Anaerobes: For anaerobic cultures, the officerin charge of the subsidiary laboratory is to take the material from thewound to be examined with a Pasteur pipette. After sufficient materialis secured, the contents are expelled into a sterile test tube. The pipetteis secured in the test tube with a cotton stopper and sent to the centrallaboratory, wrapped in a bacteriologic record card, or Form 55u.
The subsidiary laboratory is to retain at all times theForm 55u so that preliminary reports can be recorded. On completion ofidentification, the bacteriologic record card will be sent back to thesubsidiary laboratory, where two extra copies will be made; one is to besent at the end of the month to the central laboratory, the other is tobe attached to the clinical brief, while the original copy is to be filedin the subsidiary laboratory for reference.
The same procedure holds true for aerobic identification.
Every effort should be made to secure anaerobic specimensin the forenoon as it will facilitate the distribution of the day's workin the central laboratory.
Miscellaneous examinations.-All specimens are tobe sent through the subsidiary laboratories to the central laboratory.
(a) Stool cultures: This work is to be done inthe central laboratory. Special specimen bottles are to be used.
(b) Sputum for pneumococcus typing: Sputum fromthe deep air passages is collected in a sterile Petri dish and sent immediatelyto the central laboratory.
(c) Throats cultured for diphtheria: Where oneor more wards are to be cultured the swabs are taken and sent to the centrallaboratory for diagnosis. However, if there are only a few cultures tobe made, the diagnosis can be made in the subsidiary laboratory.
(d) Urethral smears: These are to be reported onin the subsidiary laboratories.
(e) Chancre and chancroids: These examinationsare to be made in the subsidiary laboratories.
(f) Water analysis: This is to be carried out inthe central laboratory.
(g) Wassermanns: These are to be done in the centrallaboratory. The blood is to be sent to the central laboratory before 5p. m. on Monday and Thursday, with Forms 55u (in duplicate) and 97.
(h) Pleural and spinal fluids: These are to beexamined in the subsidiary laboratories.
(i) Carriers for meningococcus: Blood plates areto be inoculated and incubated overnight in the subsidiary laboratory.The plates are then sent to the central laboratory, with Form 55u.
(j) Surgical pathology: Pathological tissue removedat operation is to be wrapped in gauze moistened with saline and sent immediatelyto the central laboratory, with complete clinical data.
(k) Autopsies: The central laboratory is to benotified by the registrar of a death occurring in a base hospital. Theclinical brief is to be brought with the body to the morgue. The centrallaboratory will notify the adjutant of the time the autopsy is to be held.
It is desirous that the force in the central laboratorywill be at all times as busy with laboratory activities as those of thesubsidiary laboratories. For that reason the above outline of laboratoryactivities is to be looked upon as a tentative working arrangement.
If the officer of a subsidiary laboratory is at any timedesirous of doing central laboratory work in his laboratory, the necessarymaterial will be gladly furnished by the central laboratory.
(Memorandum No. 28, division of laboratories and infectiousdiseases, November 23, 1918.)
BACTERIOLOGICAL TECHNIQUEFOR INVESTIGATION OF PNEUMONIA
This technique and blank for tabulating findings (FormNo. 11) have been formulated with the idea of obtaining sufficient uniformityin the results of different workers for them to be readily comparable.
It has been attempted to make the methods of examinationas simple as possible so that very little extra work should be added tothe usual routine bacteriological examination of autopsy material.
If it becomes the consensus of opinion that more detailedstudies can be undertaken, the program may be enlarged accordingly.
There will no doubt be differences of opinion concerningthe best culture media, proper technical methods, etc., to be used, andyou are invited to make criticisms and offer any suggestion you may deemadvisable.
In the meantime, however, you are requested to followas closely as possible the program as outlined. Alterations which meetwith general approval may be made subsequently.
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It is the intention to send out to each laboratory takingpart in the investigation a monthly compilation of the reports receivedfrom all other participants. In this way, all may keep generally informedas to the progress and development of the undertaking.
A. AT AUTOPSY TABLE
1. Material necessary:
(a) Alcohol or gas lamp.
(b) Potato knife or similarinstrument for searing surfaces.
(c) Sterile swabs in individualtest tubes.
(d) Test tubes containing about3 c. c. of nutrient broth.
(e) Sterile pipettes.
(f) Sterile slides.
2. Material from the following places will be examined:
(a) Heart (blood).
(b) Large bronchus, right andleft lung.
(c) Small bronchi, right andleft lung.
(d) Lung tissue, right andleft side.
(e) Accessory head sinusesand meninges which may show pathological process.
(f) Pericardial and pleuralcavities in case of involvement.
3. The heart's blood will be obtained as soon as the heartis exposed and before it has been opened. The surface will be seared anda sterile pipette plunged through the seared area into the heart cavity,at least 1 c. c. of blood withdrawn and transferred to a test tube.
4. The remainder of the material will be collected bymeans of tightly rolled cotton swabs. That from the lung tissues will betaken by first searing the cut lung surface and then forcing the swab throughthe seared area. Two smears from each swab will be made separately upon different slides. The slides will have been previouslysterilized in the laboratory. This may be conveniently accomplished bywrapping them in paper and sterilizing in a hot-air oven. The swabs willthen be put in the tubes containing the nutrient broth and taken to the
laboratory for culture.
B. IN LABORATORY
1. Microscopical examination of direct smears.-Oneset of the smears will be stained with a weak aqueous fuchsin (one-fourthper cent saturated alcoholic solution of fuchsin in distilled water) andthe other by Gram's method.
The weak fuchsin stain is selected because it is particularlysatisfactory in demonstrating influenza bacilli.
The various morphological types of organisms will be notedand the relative proportion of each estimated.
It is of course obvious that the true nature of the organismsin many instances will be in doubt until cultural studies are completed,but by a comparison of the microscopic and cultural findings it shouldbe possible to link them together and obtain an accurate idea of not onlythe identity of the organisms but also the approximate percentage of each.
The direct smears will be particularly important in determiningthe percentage and the cultures in working out the identification.
Cultures.-(a) Heart's blood: One loop fullof the heart's blood will be spread on the surface of a blood agar plateand 1 c. c. inoculated into a tube containing at least 10 c. c. of calciumdextrose broth. (The blood agar will consist of a meat infusion agar havinga reaction of plus 0.5 to phenolphthalein, to which is added 3 per centof citrated or defibrinated blood. Human blood will probably be the mostconvenient to obtain. The broth will be a meat infusion broth, plus 0.5to phenolphthalein and containing 1 per cent dextrose and 1 per cent calciumcarbonate. It must be frequently agitated while tubing so that an equaldistribution of the calcium carbonate is obtained.)
(b) The swabs will be stirred about in the broth,rolled over the sides of the tube to squeeze out the excess of fluid, andinoculated over a small area of a blood agar plate. Further spreading isaccomplished by a bent wire or glass rod spreader. The importance of auniform and well-distributed seeding over the plate in identifyingB.influenzæ and slow-growing streptococci can not be overestimated.
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3. Examination of primary cultures.-(a)After incubation at 37° C. for 18 to 24 hours the plates will be readyfor examination.
The different types of colonies on each plate will bestudied and their relative numbers noted.
From all different types smears will be prepared and stainedby Gram's method.
Subcultures will then be made as indicated.
(b) If no growth is obtained from the heart's bloodinoculated upon the plate, a smear will be made from the broth cultureand a loopful streaked upon a blood agar plate and further incubated.
4. Methods of study and identification of organismsmost likely to be encountered.-(a) B. influenzæ (Pfeiffer'sbacillus) appears upon whole blood agar as minute pin-point, dewdrop-likecolonies which are very likely to be overlooked unless searched for witha hand glass. They are more easily seen in reflected light.
If such colonies prove to be small Gram-negative bacilli,a diagnosis or B. influenzæ is probably justified, but asfurther proof transplants may be made to plain and blood agar slants. Failureto grow on plain agar along with the other characteristics, is a distinguisingfeature of the organism. In some instances, especially if there is an overgrowthof other organisms, the influenza bacillus may fail to develop, in whichevent opinion as to its presence will have to be based upon the microscopicexamination of the direct smears.
Special media have been devised for its growth, but arenot so satisfactory as whole-blood agar in distinguishing other organisms,and it has seemed advisable to attempt to select a single primary mediumwhich would be generally adapted to the growth and differentiation of all organisms likely to be met with.
(b) Streptococcus and pneumococcus group.-Atleast one colony from all of the different appearing types of streptococcior pneumococci developing upon the blood agar plate will be transplantedto calcium dextrose broth (preparation previously described). After 18to 24 hours' incubation the cultures will be examined microscopicallyand the following points noted: Size, shape, regularity, and chain formation.It is advisable to always save the plate until the following day so thatif growth fails to occur in any of the transplants refishings may be made.Bile solubility test will then be performed by transferring with a sterilepipette 1 c. c. of the culture to an agglutination tube and adding 0.2 c. c. of clear ox bile. After incubating 20 to 30 minutesin water bath or 30 to 45 in incubator the results are read.
From those that are not bile soluble a subculture willbe made into plain infusion broth, containing 5 per cent citrated or defibrinatedblood, and after 16 to 18 hours' incubation the hemolytic effect will benoted. It is well to shake the culture after about 4 hours' incubation.It is very important that fresh blood be employed, and in all instancesa control tube which has not been inoculated should be subjected to thesame incubation.
Streptococci will be classified as hemolytic, nonhemolytic,streptococcus mucosus, and streptococcus viridans.
Hemolytic and nonhemolytic streptococci grow on bloodagar as small white to grayish colonies. If hemolytic, the degree of hemolyticactivity should be recorded as indicated on attached form.
Streptococcus mucosus (or pneumococcus) grow as ratherlarge greenish colonies and may be hemolytic.
Streptococcus viridans appear as small green nonhemolyticcolonies.
All bile-soluble cultures will be tested against pneumococcustypes sera I, II, and III.
There will usually be sufficiently heavy growth to usethe broth culture direct. Utmost care should be used in withdrawing a portionof the culture to prevent agitation of the calcium carbonate, which willhave settled to the bottom of the tube.
Strains of pneumococci which are not agglutinated by TypeI, II, or III sera will be subcultured to calcium dextrose broth to whichapproximately 5 per cent of defibrinated blood has been added, and after10 to 12 hours' incubation will be sealed, properly labeled with name of case and location from which culture was taken,and mailed to the central Medical Department laboratory.
Agglutination tubes containing about 2 c. c. of brothand 2 drops of blood will be found convenient for this purpose. To avoidthe loss of strains a subculture of each organism
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mailed will be retained until the notification of receiptat this laboratory has been received. Cultures in blood broth should remainviable for several weeks at room temperature after a short primary incubation.
(c) Staphylococci.-The hemolytic effect of thestaphylococci should be noted upon the plates, and if any doubt existsit should be further tested in blood broth. The presence or absence ofpigment will also be observed and classification made accordingly. It shouldbe borne in mind that pigment frequently does not developuntil 48 hours or more.
(d) Gram-negative cocci.-Transplants from coloniesof Gram-negative cocci will be made upon Loeffler's blood serum mediumor blood ether agar. From the transplants emulsions will be made in saltsolution and set up against Rockefeller polyvalent serum 1 to 200 and normalrabbit or horse serum 1 to 100.
Subcultures upon brain medium of all strains agglutinatedby the Rockefeller serum will be sent to the central Medical Departmentlaboratory for typing.
The brain medium is prepared as follows: Brain (calf)run through meat grinder, 3 pints; distilled water, 1 pint; tube and autoclave(see office letter No. 30).
5. The necessary diagnostic sera will be obtained fromthe central Medical Department laboratory.
(Memorandum No. 37, division of laboratories and infectiousdiseases, February 9, 1919.)
Consolidated report of laboratory work accomplishedin the American Expeditionary Forces during the month of January, 1919;
[Comprising 11 base-section laboratories, 16 hospital-center laboratories, 70 base-hospital laboratories, 26 camp-hospital laboratories, 22 evacuation-hospital laboratories, 2 mobile-hospital laboratories, 19 divisional laboratories, 3 water-analysis laboratories; total, 169. Number of deaths in hospitals, 948]
EXAMINATIONS MADE
I. Clinical pathology: | |
| Blood- | |
| Erythrocyte counts | 1,347 |
| Leucocyte counts | 7,361 |
| Differential leucocyte counts | 4,933 |
| Hemoglobin estimations | 1,384 |
| Malaria examinations | 492 |
| Positive examinations | 34 |
| Urine- | |
| Urinalyses- | |
| Ordinary chemical | 29,976 |
| Ordinary microscopic | 20,354 |
| Feces- | |
| For parasites and ova, examinations | 745 |
| Positive examinations | 96 |
| For Entamebæ examinations | 395 |
| Positive examinations | 42 |
| Sputum- | |
| For tubercle bacilli, specimens | 15,165 |
| Positive specimens | 750 |
| For other organisms | 881 |
| Positive specimens | 508 |
| Gastric contents, examinations of | 165 |
| Spinal fluid- | |
| Smears for meningococci | 831 |
| Positive | 286 |
| Smears for other organisms | 73 |
| Cell counts | 290 |
| Globulin tests | 228 |
| Colloidal gold reactions | 1 |
| Venereal specimens- | |
| Smears for gonococci | 6,531 |
| Positive | 2,548 |
| Examinations for T. pallidum- | |
| Dark field examinations | 1,631 |
| Positive | 164 |
| Stained specimens | 453 |
| Positive | 70 |
| Clinico-pathologic examinations not otherwise listed | 1,986 |
| Total | 95,222 |
II. Anatomic pathology: | |
| Operation specimens, macroscopic examinations | 257 |
| Autopsies performed | 846 |
| Histopathologic examinations | 552 |
| Museum specimens prepared | 50 |
| Photographs of wounds, specimens, etc. | 506 |
| Drawings of wounds, specimens, etc. | 77 |
| Anatomo-pathologic examinations not otherwise listed | 286 |
| Total | 2,574 |
III. Bacteriology (specimens examined culturally): | |
| Blood, specimens of | 1,546 |
| Urine, specimens of | 607 |
| Feces, specimens of- | |
| For dysentery | 2,048 |
| Positive | 29 |
| For typhoid or paratyhoid | 2,983 |
| Positive | 263 |
| Sputum, specimens of- | |
| For pneumococci | 1,383 |
| Positive | 653 |
| Typed by Avery's method | 702 |
| Typed by mouse method | 52 |
| For other organisms | 521 |
| Positive | 316 |
| Nasopharynx, specimens from, for B. diphteriæ | 21,542 |
| Positive examinations | 1,972 |
| For meningococci | 5,575 |
| Positive examinations | 508 |
| Spinal fluid, specimens of | 627 |
| Positive examinations | 174 |
| Pus, exudates, etc. (exclusive of wounds)- | |
| Aerobic cultivations | 816 |
| Complete identifications (number of stains) | 456 |
| Anaerobic cultivations | 228 |
| Complete identifications (number of stains) | 43 |
| Wounds- | |
| Aerobic cultivations | 1,944 |
| Complete identifications (number of stains) | 498 |
| Anaerobic cultivations | 237 |
| Complete identifications (number of stains) | 34 |
| Autopsies, Total original cultures from | 983 |
| Milk, total number of specimens of | 86 |
| Water, total number of specimens of | 3,595 |
| Bacteriologic examinations not otherwise listed | 2,322 |
| Total | 48,744 |
IV. Serology: | |
| Agglutination tests (with bacteria) | 2,063 |
| Bloods grouped (for transfusions) | 212 |
| Wassermann tests- | |
| Blood | 9,265 |
| Double plus, or plus | 834 |
| Spinal fluid | 127 |
| Double plus, or plus | 25 |
| Serologic examinations not otherwise listed | 1,453 |
| Total | 13,120 |
V. Chemistry (specimens analyzed): | |
| Blood | 174 |
| Urine, special examinations | 1,568 |
| Water | 1,280 |
| Milk | 3 |
| Drugs, foods, beverages, etc. | 32 |
| Chemical examinations not otherwise listed | 64 |
| Total | 3,121 |
VI. Operative procedures (by laboratory staff): | |
| Treatments with salvarsan | 753 |
| Treatments with therapeutic sera | 839 |
| Treatments with bacterial vaccines | 1,172 |
| Schick tests | 6,260 |
| Leutin tests | 3 |
| Animal inoculations | 172 |
| Operative procedures not otherwise listed | 1,925 |
| Total | 11,124 |
Total laboratory examinations not included above | 927 |
| Grand total | 174,832 |
(Memorandum No. 38, division of laboratories and infectiousdiseases, February, 1919.)
