CHAPTER X
THE DIVISION OF LABORATORIES AND INFECTIOUS DISEASES
(Continued)
THE CENTRAL MEDICAL DEPARTMENT LABORATORY
HOUSING FACILITIES
A building, loaned for the purpose by the University of Dijon, was utilizedby the central laboratory, established at Dijon on January 1, 1918. When taken over the building was not equipped butearly in February it was reconstructed as a modern laboratory and completely equipped with material brought from the UnitedStates for work of general and special character.1
FIG. 7.-CentralMedical Department laboratory, Dijon. The main building is in the centerof the background
By March, 1918, the buildings consisted of the initial large laboratorystructure, four barracks donated by the American Red Cross which housed the office of the director of laboratories, a largelaboratory for instruction of student officers, five well-equipped research laboratories, an operating room for experimentalsurgical research on animals, a complete X-ray installation with photographic dark room, space for the art and museumsection, and messing facilities and quarters for the enlisted personnel.1 Fixtures for gas, water, and electricity,a very complete plumbing and sewerage system, and equipment
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for general and special laboratory activities were installed in thebuildings used for laboratory purposes. Later, four small Abincourt barracks were added to provide animal houses and a carpentershop, and four additional barracks were erected for accommodation of enlisted personnel and storage of supplies.1The laboratory also secured two buildings for garage space and operateda breeding farm for laboratory animals, on funds privately donated forspecial research. The entire plant eventually occupied 18 large and small buildings.1
PERSONNEL
When established at Dijon, the central laboratory was staffed by officersfrom Army Laboratory No. 1, at Neufchateau. By March, 1918, the staff consisted of 16 officers, 35 enlisted men, and12 civilian employees.1 The average personnel on duty at thecentral laboratory between June and November, 1918, was 24 officers, 93enlisted men, and 23 civilian employees. From November, 1918, to May, 1919, the average personnel remained approximatelythe same.1
LABORATORY EQUIPMENT AND SUPPLIES
One of the greatest difficulties that confronted the laboratory servicein the early months of the war was a shortage of equipment and supplies.1 Before the war many essential technicalitems, notably of apparatus, glassware, dyes, and chemicals, had been importedfrom Germany. American industries that had begun to manufacture these articleswere still lacking in quantity production in many essentials.1Furthermore, the normal peace-time stocks of dealers in scientific apparatusand supplies were just sufficient to meet the comparatively meger demandsfor the upkeep of established institutions and the initial equipment ofan occasional new one.1 Demands such as were made by the Armyin the earlier months of the war were unheard of and they could not bemet until American scientific industries became organized for quantityproduction. The situation was further complicated by priority scheduleson raw materials, many chemicals, and skilled labor, which diverted theseto other war industries; and a priority on shipping and tonnage that madethe floating of supplies secondary to the transportation of troops. Thecongestion at base ports, American Expeditionary Forces, and shortage oftransportation in France militated against prompt handling of suppliesafter their arrival in France.1
With the exception of the initial equipment of three of the larger laboratoriesand the laboratory equipment of a few base hospitals, laboratory supplies from the United States were not availablefor issue in appreciable quantities until about a month before the armistice. Furthermore, laboratory supplies in large quantitieswere never available by purchase by us in France.1 When it became apparent that months would elapse before the automaticsupply of apparatus from the United States would become available, an attempt was made to reduce equipment and suppliesto the absolute minimum consistent with efficiency, and to standardizethe equipment of laboratory field units.2 On August 19, 1917, an order for two motor bacteriological laboratories,each to consist of a small but well-equipped outfit mounted on a 3-ton chassis, was placed with a British manufacturingfirm. This order contemplated the first use of such a unit in our service and was frankly experimental.3
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The supply division of the chief surgeon's office, A. E. F., had madeprovision for the shipment from the United States of such laboratory suppliesas appeared on the supply table of the Manual for the Medical Department,1916, but this list included only 84 items, which were quite inadequateto meet even the simplest requirements.2 To meet the existingemergency, such supplies as were available were purchased in France andcontracts made by the supply division for the continuous supply by Frenchmanufacturers of certain bulky items requiring a very considerable amountof cargo space.2 In coordination with the supply division ofthe chief surgeon's office, requisitions were prepared covering estimatedfuture requirements with a view to their inclusion among supplies shippedautomatically from the United States.2 The shipment of laboratoryequipment according to this revised list did not begin until April, 1918,and did not become available for issue in France in quantity until October,1918.2
On January 12, 1918, the director was authorized to place direct withthe purchasing agent for the Medical Department in Paris, orders for the purchase of standard laboratory equipment andsupplies, except in the case of special supplies desired in large quantity, or when the expense involved was large.4Requisitions were also placed in England and some supplies obtained from the American Red Cross.2
In the detailed plan for the organization of the division of laboratoriessubmitted to the chief surgeon, A. E. F., on January 11, 1918, the director of that division recommended that special motorizedand transportable units be provided.5 The motorized units were to be installed in their own cars while the transportableunits, packed in chests, were to be moved by any transportation available.5 This plan, which was approved,provided for motorized laboratories of two classes: Bacteriological cars and meningitis cars.5
On the same date the director of laboratories wrote that several completelyequipped motorized laboratories were urgently needed.6 The next day the chief surgeon, A. E. F., authorizedthe purchase of a "cerebrospinal" bacteriological car to cost £1,892, exclusive of the chassis,4 and on January14he authorized the purchase from the French Medical Department of one motorizedbacteriological laboratory to cost approximately $8,000.7
In order both to conserve and standardize the equipment of field units,the commanding officer of the central Medical Department laboratory undertook to design a transportable laboratoryin which the necessary equipment and supplies would be reduced to approximately 150 items.2 These items wereto be packed in eight chests so designed as to be capable of expansion in numerous ways if necessary, to meet the essential needsof any type of laboratory. The selection of equipment for a set of these chests which would constitute a division laboratory,also was undertaken.2 In reply to a query from chief of staff, G. H. Q., A. E. F., concerningtransportation which the division of laboratories would
require, the chief surgeon replied, on February 4, 1918, in part, asfollows:8 "The increase of the forces and the prevalence of epidemics would require that the laboratory service be furnishedamong other vehicles with 6 motor trucks and 10 special bacteriological cars." On February 11, the chief surgeon initiateda cable-
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gram to the War Department asking that personnel requested for divisionallaboratories be sent in accordance with the priority schedule, but thatportable field laboratories be substituted for laboratory cars.9On March 1, 1918, the director, division of laboratories, reported thattwo motorized laboratories each mounted on a 3-ton chassis were en routefrom England, but that it was anticipated that eight more of these outfitswould eventually be required.10 While most movable laboratorieswere to be of the type which utilized chests, it was planned that a relativelysmall number of motorized laboratories would also be employed. Under thisplan the equipment for a divisional laboratory would be contained in aset of three chests and a ¾-ton truck would be required for itsmovement. The laboratory for an evacuation or mobile hospital would consistof a complete set of eight chests transportable on a 1½-ton truck.2,1, 11
Toward the end of March, 1918, the commanding officer of the centrallaboratory visited England with a view of determining the possibility of purchasing laboratory material to equip the seriesof chests which he had devised, and other assemblages of material.2
On April 29, he telegraphed the chief surgeon, requesting him to authorizethe purchasing officer of the American Expeditionary Forces in London to purchase 100 transportable laboratoryunits at approximately $1,000 each. The average cost of the truck on which one complete set could be transported, headded, would be $3,400.12 The chief surgeon complied with thisrequest.2 Deliveries of the units which began on May 8, werecompleted October 24, 1918, so each division and each mobile or evacuationhospital which arrived in France after the former date, was given its equipmentbefore it entered the advance zone.2 Such transportable laboratoryunits, attached to mobile and evacuation hospitals, were equipped adequatelyfor the performance of all types of clinical and bacteriological work.Those attached to divisions were equipped for the chemical and bacteriologicalexamination of water supplies, the performance of routine clinical examinationsand the bacteriological examinations necessary for the control of epidemics.2This transportable equipment was also utilized with very satisfactory resultsin many camp and base hospitals, and in some hospital centers and baselaboratories, pending the arrival of the equipment for stationary units.2
As noted in the preceding chapter, on May 2, 1918, the director of laboratoriessubmitted a complete schedule of the transportation which would be required by the division of laboratoriesand requested that this be furnished. He also asked that motor cycles withside cars be issued to the laboratories assigned to divisions, for thesevehicles already had facilitated collection of water samples and the prosecution of investigations inoutbreaks of infectious diseases.13 This transportation schedule in so far as it pertained to movable laboratories was approvedby the chief surgeon and was forwarded by him for approval to the general staff, general headquarters,14 butdespite repeated subsequent requests, approved by the chief surgeon, transportation for the laboratory units in question was procuredwith the greatest difficulty and only to a partial degree with the resultsnoted below in the consideration of divisional laboratories.2
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On July 8, the director of laboratories reported to the chief surgeon,A. E. F., that the earlier divisions arriving overseas had brought with them their laboratory personnel and equipment, that sincethat time it had been learned that equipment could be simplified and that tonnagerequirements could be reduced by the purchaseof all the materials required in England, but that field transportation was essential if these units were to be of value.15Similarly, on the 16th of the same month, he reported that the laboratorieswith mobile and evacuation hospitals had already rendered invaluable service,but that neither the laboratories of the hospitals mentioned nor thoseof divisions could function properly without transportation, and he urgedits provision. Other pleas and arguments for transportation were forwarded,but because of the general shortage of transportation throughout the AmericanExpeditionary Forces, they were only partially successful.16
Because of the considerations mentioned in the letter of May 22, 1918,quoted in the preceding chapter,17 and the further fact thatthe laboratory cars being of special design and equipment, could be manufacturedin limited numbers, none other than the four above mentioned were procured.18
On November 4, the chief surgeon wrote the director of the Motor TransportCorps that the time consumed in the manufacture of specially constructed laboratory trucks and bacteriologicalcars had been so protracted, and the difficulty of their transport to France so great, that ordinary cargo trucks hadbeen substituted for them and that the specially constructed laboratory trucks were not needed.19
When the Armistice was signed two of these motorized laboratory unitswere attached to the general laboratory, one was with Army laboratory No.1 at Neufchateau, and one with the Second Army.2 Motorized laboratories,or field laboratory cars, as they were officially designated, are furtherdiscussed under Army laboratories below.
Circular No. 40 of the chief surgeon's office published July 20, 1918,provided that the laboratories of the American Expeditionary Forces would be of two general types, stationary andtransportable. The latter were to serve evacuation and mobile hospitals and divisions, and their equipment was to consistof standardized, expendable units in chests.
In the period from July to November, 1918, a large number of hospitalcenters were established and the equipment and organization of these were expedited.
In September, 1918, a bulletin was prepared by the commanding officerof the central laboratory, which covered in detail all matters relating to the procurement of laboratory supplies by MedicalDepartment units, A. E. F.2 This bulletin which provided for a standardization of equipment was distributed to allunits. It is reproduced in the appendix.
On September 19, 1918, the Surgeon General wrote that he desired thatthe field laboratories be numbered, and he allotted to the chief surgeon numbers from 1 to 45, inclusive, for such of theseformations as already were overseas or en route. Records of the Surgeon General's office at that time showed that laboratorieshad been sent to France with 31 divisions, but had not accompanied 6 others.20 In reference to this recordthe director of laboratories stated that
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in point of fact many of these units had not actually accompanied theirdivisions from the United States; that some had come after them, and that in all instances it had been necessary for thedirector of laboratories to find personnel in the American Expeditionary Forces who could be trained and assigned to this service.21Inview of the signing of the armistice the proposed enumeration of laboratoriesengaged in field service never became effective.22
ACTIVITIES
As soon as the central laboratory was thoroughly organized the developmentwas begun of those phases of its activities which related more particularlyto the general activities of the laboratory service throughout France.2
The central laboratory came into more intimate contact with the AmericanExpeditionary Forces in general than did any other section of the division of laboratories.2 It was plannedthat the officer commanding this institution would, with those at the headof other sections of the division, have his main office in that of thedirector of laboratories where he would be engaged only in larger problemsaffecting the service of the laboratory to the entire American ExpeditionaryForces and that his adjutant would care for the administrative detailsintrinsic to the central laboratory itself.2 But because ofshortage of personnel, this plan was not practicable and the commandingofficer of the central laboratory, in addition to supervising its professionalwork, and conforming its general activities to the plans of the directorof the division, discharged in great detail many administrative dutiesconnected with its organization, equipment, and operation.2
The central laboratory at Dijon and the other laboratories in the divisionof laboratories were highly coordinated, and except as specified below, their activities were developed concurrently.2These common interests included technical advice on general bacteriology,immunology, serology and other laboratory procedures, control of epidemics,bacteriology of war wounds, special instruction, personnel, laboratoryequipment and supplies, gross and histopathology, museum and art service,photographic history of Medical Department activities, inspections, medicaland surgical research, and liaison with other services.2
The activities of the central Medical Department laboratory which wasin reality the headquarters laboratory for the American Expeditionary Forcesconformed to those itemized on the project submitted January 11, 1918,which is quoted in the preceding chapter. These activities may be summarizedas follows:1
Bacteriology.-The work consisted in the standardization of technicalbacteriologic methods; the investigation of new technical methods; the preparation of all culture media for stockingtransportable laboratory units and mobile laboratories in the zone of the advance; laboratory studies on the incidence of communicablediseases, notably influenza, pneumonia, diphtheria, meningitis, and intestinal diseases; the isolation, intensivestudy, and classification of the aerobic and anaerobic bacteria concerned in wound infections and gas gangrene; experimentaland practical tests of the efficacy of antitoxic sera in the prophylaxis and therapy of gas gangrene; the identification ofcul-
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tures of microorganisms received from other laboratories; the preparationof bacterial antigens and vaccines; the propagation and study of lice concerned with the transmission of trench fever.These activities were carried on in addition to the ordinary routine bacteriologic examinations.1
Serology.-This included standardization of the Wassermann testand manufacture and supply of amboceptor and antigen to all laboratories performing the test. The diagnostic serafurnished the laboratories of the American Expeditionary Forces for the identification of pathogenic microorganisms, as wellas human sera for typing donors and recipients for blood transfusion, were prepared in this division. A considerable volumeof routine serologic work, notably Wassermann tests, was also accomplished.1
Pathology.-Pathology was concerned with the performance of allautopsies at Base Hospital No. 17, at Dijon, the gross examination and histologic study of operative and autopsy tissues;the collection and preparation of specimens for the Army Medical Museum, and the review of the protocols of all autopsiesperformed in the American Expeditionary Forces. The latter activity was of value in checking errors in diagnosis. Acollection of photographs, moving-picture films, paintings, charts, etc., was prepared for the Army Medical Museum.1The administration of the pathological service is considered at greater length elsewhere in this volume.
Chemistry.-The activities of the chemical laboratory coveredroutine medical chemistry, the examination of foods for the Food and Nutrition Section and the Quartermaster Department, toxicologicalexaminations, investigations of the medical properties of mustard gas, examination of drugs and other suppliesfurnished the Medical Department, and sanitary and industrial water analyses.1 During battle activities thisdivision manufactured many thousand liters of gum-salt solution for intravenous use in the resuscitation of the seriously wounded.1The laboratory also prepared standard solutions and reagents for transportable laboratories and such other laboratories as werenot equipped to prepare their own.1 So much of the chemical service as pertained to the water supply or food and nutritionsections is discussed with those subjects elsewhere in
this volume.
Surgical research.-In the laboratory of surgical research experimentalstudies on animals were fruitful in their bearing on the prevention of wastage from battle casualties. The cause, prevention,and treatment of surgical shock were studied experimentally here and the results applied practically at the frontduring the Chateau Thierry and subsequent military operations. Experimental attempts to place wounds of the chest in thecategory of those amenable to treatment by "débridement," and studies of the relation of various anestheticsand methods of anesthesia to the production of shock were also made.1
Epidemiological investigation.-Perhaps the most important workof the laboratory from the practical point of view was that concerned with the laboratory and epidemiologic investigationand control of communicable diseases.1 Specially trained commissioned and enlisted personnel with mobile equipment wereheld in reserve at this laboratory for the prompt investigation of epidemics or threatened epidemics anywhere in theAmerican Expeditionary Forces. By bacteriologic detection of early cases of communicable diseases, mild cases
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missed clinically, and carriers, this laboratory did much to preventthe spread of influenza, pneumonia, diphtheria, meningitis, and enteric infections, and thus decreased the wastage concomitantwith outbreaks of these diseases when not detected early and effectually controlled.1
Supplies.-The supply division of this laboratory was chargedwith assembling, equipping, and issuing transportable laboratory equipment to mobile units; replenishing expendable itemsand replacing those that had become unserviceable; issuing to mobile laboratory units and to camp hospitals various culturemedia and reagents required for bacteriologic work in the field; and issuing to all Medical Department units in the geographicregion served by the central Medical Department laboratory, the various biologic products used in the diagnosis, prevention,and treatment of infectious diseases.1 During the period of active participation of our troops at the front, the greaterportion of these supplies was delivered by courier service, necessitating the constant operation of numerous motor trucks and motorcycles.1
Courses of instruction.-From its inception this laboratory conductedcourses of instruction in professional subjects.1 One hundred and fifty-eight student officers were given two-week coursesof instruction in the bacteriology of war wounds; while in the laboratory of surgical research a six-day course, repeatedweekly, was given to prospective members of shock teams. This course covered the experimental evidence that had beengathered concerning the cause, prevention, and treatment of surgical shock,and its practical application to the resuscitation of the seriously wounded.Selected student officers in lesser numbers were also given special coursesin epidemiologic laboratory methods, in serologic work, and other laboratoryprocedures.1
Cooperation with Chemical Warfare Service.-In August, 1918, closecontact was established with the consulting pathologist of the Chemical Warfare Service, A. E. F., and arrangementswere completed for study of the effects produced on human beings by knownand unknown types of gases.23
REFERENCES
(1) Report from the chief surgeon, A. E. F., to the SurgeonGeneral, U. S. Army, May 1, 1919. Subject: Activities of the chief surgeon'soffice, A. E. F., to May 1, 1919. On file, Historical Division,S. G. O.
(2) Report from Col. J. F. Siler, M. C., director of laboratoriesand infectious diseases, A. E. F., to chief surgeon, A. E. F. (not dated).Subject: Activities of division of laboratories and infectious diseases,from August, 1917, to July, 1919. On file, Historical Division, S. G. O.
(3) Letter from the general purchasing officer, A. E.F., to Daird and Tatlock (Ltd.) London, August 19, 1917. Subject: Motorbacteriological laboratories. On file A. G. O., World War Division, chiefsurgeon's files (322.3271).
(4) First indorsement, Hdqrs., A. E. F., chief surgeon'soffice, to director of laboratories, A. E. F., January 12, 1918, on letterfrom director of laboratories, A. E. F., to the chief surgeon, A. E. F.,January 7, 1918. Subject: Purchase of laboratory equipment. On file, A.G. O., World War Division, chief surgeon's files (322.3271).
(5) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., January 11, 1918. Subject: Organizationof the division of laboratories and infectious diseases. On file, A. G.O., World War Division, chief surgeon's files (321.630).
(6) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., January 11, 1918. Subject: Mobile motorbacteriological laboratory. On file, A. G. O., World War Division, chiefsurgeon's files (322.3271).
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(7) First indorsement from the chief surgeon, A. E. F.,to the director of laboratories, A. E. F., January 14, 1918, on letterfrom the director of laboratories, A. E. F., to the chief surgeon, A. E.F., January 11, 1918. Subject: Mobile motor bacteriological laboratory.On file, A. G. O., World War Division, chief surgeon's files (322.3271).
(8) Memorandum from the chief surgeon, A. E. F., to thechief of staff, A. E. F., February 4, 1918. Subject: Expansion of transportationfor laboratories. On file, A. G. O., World War Division, chief surgeon'sfiles (321.630).
(9) Cablegram from General Pershing, A. E. F., to TheAdjutant General and to the Surgeon General, U. S. Army, February 11, 1918.Copy on file, A. G. O., World War Division, chief surgeon's files (322.3271).
(10) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., March 1, 1918. Subject: Motor laboratories.On file, A. G. O., World War Division, chief surgeon's files (322.3271).
(11) Report of the chief surgeon, A. E. F., to the commandinggeneral, S. O. S., A. E. F., April 17, 1919. Subject: The Medical Department,A. E. F., to November 11, 1918. On file, Historical Division, S. G. O.
(12) Telegram from Maj. George B. Foster, M. C., to thechief surgeon, A. E. F., April 29, 1918. On file, A. G. O., World War Division,chief surgeon's files (322.3271).
(13) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., May 2, 1918. Subject: Schedule of transportation.On file, A. G. O., World War Division, chief surgeon's files (451).
(14) First indorsement from the chief surgeon, A. E. F.,to the director of laboratories, A. E. F., May 6, 1918, on letter fromthe director of laboratories, A. E. F., to the chief surgeon, A. E. F.,May 2, 1918. On file, A. G. O., World War Division, chief surgeon's files(451).
(15) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., July 8, 1918. Subject: Transportation.On file, A. G. O., World War Division, chief surgeon's files (322.3271).
(16) Letter from the director of laboratories, A. E. F.,to the chief surgeon, A. E. F., July 16, 1918. Subject: Transportation.On file, A. G. O., World War Division, chief surgeon's files (322.3271).
(17) Letter from Lieut. Col. J. F. Siler, M. C., directorof laboratories, A. E. F., to the chief surgeon, A. E. F., May 22, 1918.Subject: Table of organization for laboratory units. On file, A. G. O.,World War Division, chief surgeon's files (321.6).
(18) Report on mobile laboratories by Capt. C. O. Rinder,M. C., (not dated). On file, Historical Division, S. G. O.
(19) Letter from the chief surgeon, A. E. F., to the directorof laboratories, A. E. F., November 4, 1918. Subject: Bacteriological cars.On file,
A. G. O., World War Division, chief surgeon's files (322.3271).
(20) Letter from the Surgeon General, U. S. Army, to thechief surgeon, A. E. F., September 19, 1918. Subject: Mobile laboratories.On file,
A. G. O., World War Division, chief surgeon's files (322.3271).
(21) Second indorsement from the director of laboratories,A. E. F., to the chief surgeon, A. E. F., October 24, 1918, on letter fromthe Surgeon General, U. S. Army, to the chief surgeon, A. E. F., September19, 1918. Subject: Mobile laboratories. On file, A. G. O., World War Division,chief surgeon's files (322.3271).
(22) Sixth indorsement from the director of laboratories,A. E. F., to the chief surgeon, A. E. F., November 21, 1918, on letterfrom the Surgeon General, U. S. Army, to the chief surgeon, A. E. F., September19, 1918. Subject: Mobile laboratories. On file, A. G. O., World War Division,chief surgeon's files (322.3271).
(23) Letter from pathologist of Chemical Warfare Serviceto Maj. William Elser, M. O. R. C., through director of laboratories, A.E. F., August 5, 1918. Subject: Instruction to pathologists, cooperatingwith Chemical Warfare Service. On file, Historical Division, S. G. O.
