CHAPTER XI
THE DIVISION OF LABORATORIES AND INFECTIOUS DISEASES
(Continued)
THE SECTION OF LABORATORIES;a TECHNICALWORK OF LABORATORIES
THE SECTION OF LABORATORIES
The laboratory section of the division of laboratories was distinct from the central laboratory, but closely connected with it.1 Its headquarters at Dijon exercised technical supervision over the Medical Department laboratories throughout the American Expeditionary Forces, and was charged with their inspection and supply, the pathological service of the American Expeditionary Forces, special research, the collection of museum specimens, photographs, and other art records of medical department activities, cooperation with the water supply and gas defense services, and the destruction of rodents.1
From the viewpoint of the nature of their activities, the laboratoriesof the American Expeditionary Forces were divisible into two general typeswhich were comparable, respectively, to the laboratories which served boardsof health in civil communities, and those which served hospitals.1
The base laboratories located in the sections of the Services of Supply,and the mobile units attached to armies and the divisional units were concernedmainly in the control and prevention of transmissible diseases, while theprincipal activities of all other units were similar to those carried onin laboratories pertaining to the larger and better hospitals in civilcommunities in the United States.1
Also, from the viewpoint of equipment, the laboratories of the AmericanExpeditionary Forces could be classified into two general categories: Stationaryor mobile.1 The equipment furnished the stationary units wasquite similar to that used in hospitals in civil communities in the UnitedStates though in some respects it was not so elaborate. For example, provisionof apparatus for blood chemistry was considered but was excluded becauseof its very questionable practical importance under war conditions.1On the other hand, the equipment furnished laboratory units attached tothe headquarters of the armies, to evacuation and mobile hospitals, andto divisions was packed in special chests to facilitate transport. Theseunits were constantly moving from place to place as the zone of battleactivity shifted from one section to another.1
The general laboratory system for the American Expeditionary Forcesis shown diagrammatically in Figure 8.
As shown by Table 4, 278 laboratories conforming to the different typesoutlined above were in the service of the American Expeditionary Forceson November 11, 1918, the date the armistice was signed. 1
aThe Medical Department laboratories which did not pertain to the division of laboratories of the chief surgeon's office are discussed in other chapters of this volume. Thus the dental laboratory is discussed under the chapter pertaining to dental division of the chief surgeon's office.
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TABLE 4.-Typesand numbers of laboratories in operation in the American ExpeditionaryForces, May, 1917, to April, 19191
1917 | 1918 | 1919 | ||||||||||||||||||||||
| May | June | July | Aug | Sept | Oct | Nov | Dec | Jan | Feb | Mar | Apr | May | June | July | Aug | Sept | Oct | Nov | Dec | Jan | Feb | Mar | Apr |
Central Medical Department laboratory | --- | --- | --- | --- | --- | --- | --- | --- | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
Base laboratories, sections of Services of Supplya | --- | --- | 1 | 1 | 1 | 1 | 1 | 1 | 3 | 3 | 5 | 5 | 7 | 7 | 7 | 7 | 10 | 10 | 10 | 10 | 9 | 9 | 8 | 8 |
Base laboratories, in hospital centers (included in next line) | --- | --- | --- | --- | --- | --- | --- | --- | 1 | 1 | 1 | 2 | 2 | 5 | 7 | 11 | 14 | 16 | 17 | 17 | 11 | 9 | 9 | 8 |
Base hospital laboratories | --- | 1 | 5 | 7 | 7 | 8 | 9 | 13 | 14 | 15 | 19 | 20 | 25 | 33 | 47 | 57 | 84 | 87 | 112 | 112 | 82 | 66 | 47 | 45 |
Camp hospital laboratories | --- | --- | --- | --- | --- | 1 | 2 | 3 | 3 | 4 | 24 | 24 | 25 | 25 | 33 | 33 | 42 | 45 | 51 | 56 | 63 | 58 | 61 | 59 |
Evacuation hospital laboratories | --- | --- | --- | --- | --- | --- | --- | --- | 3 | 3 | 3 | 4 | 8 | 8 | 8 | 12 | 23 | 25 | 37 | 37 | 24 | 20 | 9 | 18 |
Mobile hospital laboratories | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | 1 | 2 | 3 | 5 | 7 | 10 | 12 | 13 | 3 | 5 | 4 | 1 |
American Red Cross hospital laboratories | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 4 | 4 | 4 | 8 | 15 | 18 | 18 | 19 | 19 | 19 | 14 | 12 | 9 | 8 |
Division laboratories | --- | --- | --- | --- | --- | --- | --- | --- | 3 | 3 | 4 | 5 | 6 | 8 | 14 | 21 | 33 | 35 | 36 | 36 | 28 | 21 | 16 | 13 |
| Total | 3 | 4 | 9 | 11 | 11 | 13 | 15 | 20 | 30 | 32 | 60 | 63 | 77 | 92 | 128 | 154 | 218 | 232 | 278 | 284 | 224 | 192 | 155 | 153 |
Base hospitals with British | 3 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 3 | 1 | 1 | 1 |
aIn this table ArmyLaboratory No. 1 is listed as a base section laboratory.
FIG.8.-Diagram showing types of laboratories in the American ExpeditionaryForces
INSPECTION OF LABORATORIES
In January, 1918, certain officers of the laboratory service made ahurried visit of inspection to the then existing centers of activity ofthe American Expeditionary Forces, in order to acquire first-hand knowledgeof the laboratory personnel and equipment then available, to inspect availablesites for the
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establishment of base laboratories in the sections of the Services ofSupply and to expedite the organization and development of those units.1This was the beginning of a system of general inspection which later wasactively developed.1 This inspection service was under the chargeof the officer commanding the central laboratory, but it was quite impossiblefor him to cover more than a small part of this phase of the work aloneand at the same time perform his other duties. When new areas were to beoccupied by the American Expeditionary Forces or new projects were contemplated,that officer visited the area concerned and after consultation with itssenior medical officer, made a survey of the general situation from theviewpoint of laboratory requirements, conferred concerning the latter'srecommendation, and submitted a report to the director of laboratoriescovering the situation, with recommendations to meet it.1 Whenthe director, or other officer, returned from a trip of inspection a conferencewas held and verbal reports were made, followed by a written report thatwas circulated in the office of the director of the division.1
This inspection service gave the director and his assistants an infinitelybetter conception of existing conditions than could have been obtainedotherwise, resulted in a much higher degree of coordination in the laboratoryservice at large, and enabled the director on many occasions to make decisionsof much greater value to the service than would have been possible hadthis system of inspection not been in force.1
STATIONARY LABORATORIES
BASE LABORATORIESASSIGNEDTO SECTIONS OF THE SERVICESOF SUPPLY
In accordance with the original plan of organization one base laboratorywas established for each section or other subdivision of the Services ofSupply.1 These units were under the direct control of the sectionsurgeon and were located at the headquarters of each section, except thatthe laboratory for the intermediate section was at Tours, that for theadvance section at Neufchateau, and that for base section No. 3, at Winchester,England. These base laboratories occupied permanent buildings and werecompletely equipped for general laboratory work, affording general andspecial laboratory facilities for troops in the section who were not servedby other laboratories.1
Their activities consisted of clinical examinations, general and specialbacteriology, general and special serological work, the distribution ofculture media, laboratory examinations of water supplies, the investigationof outbreaks of epidemic diseases and such other activities as the sectionsurgeon deemed advisable.1 They were established as rapidlyas the necessity for them arose and personnel and equipment became available.1Thefirst unit of this type, Army laboratory No. 1, was established as mentionedabove, at Neufchateau, in September, 1917, and the last at Le Havre, inSeptember, 1918, where it served Base Section No. 4. By that time a laboratoryof this type was operating in each section or other subdivision of theServices of Supply.1
In the original plan of organization for these units provision was madefor the transportation necessary to carry out field surveys of water supplies,to investigate outbreaks of epidemic diseases and to forward therapeuticsera
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emergencies, but the transportation problem in the American ExpeditionaryForces was of such a nature that vehicles were not always available forthe effective prosecution of these duties throughout the areas they soughtto serve.1
The following brief history of the base laboratory for Base SectionNo. 5 is illustrative, to a degree, of those of other sections of the Servicesof Supply.
BASE LABORATORY,BASE SECTIONNO.5
This laboratory was organized in February, 1918, under the title ofstationary laboratory No. 2.2 This occurred in Washington, D.C., where the various officers and men connected with it assembled andremained on duty until their departure for France, May 1, 1918. On arrivalin France there were no available supplies for the laboratory, those originallyshipped having failed to arrive, and substitutes were extremely difficultto procure. These defects, however, were gradually overcome.2 Shortlyafter its arrival in this section the name of the laboratory was changedto base laboratory, base section No. 5, under which title it continuedto operate.2 It gradually developed into a concrete organizationso staffed and equipped that practically any type of laboratory diagnosisor research could be performed.2 Its greatest activities werethe study and control of infectious diseases in base section No. 5.
About June 12, 1918, the base laboratory absorbed that of Camp HospitalNo. 33, whose premises it occupied and enlarged to four rooms. Permanentfixtures were installed, but six weeks later, when other quarters becameavailable, the base laboratory left this location, which was reoccupiedby the laboratory of Camp Hospital No. 33.3 In August, 1918,the base laboratory was installed completely equipped in a house in Brest,formerly a private residence, but which lent itself well for the purposes.2
In the organization of this unit various departments were created, eachin charge of the officer best qualified for that particular work. As faras possible these departments were kept strictly separated that their workmight be unhampered by the necessity of their respective personnel undertakingother work for which they were less qualified.2 The departmentsconsisted of office and records, property, bacteriology, pathology andserology, chemistry, and water control. In the investigation of infectiousdiseases in this base section the laboratory was entirely dependent uponthe activities of its own personnel to secure specimens for examination.2Therespiratory infections which swept through base section No. 5 in the falland winter of 1918 were studied by the bacteriological and pathologicaldepartments. Cultures were made from the sputum and the various organsat autopsy. All organisms secured were carefully typed and, when possible,preserved for future study. The bacteriological and pathological work donein common with these diseases was of an advanced and extremely thoroughcharacter. All this work was done under the direct supervision and at thedirection of the base surgeon base section No. 5.
Complete liaison, both official and unofficial, existed between thisorganization, the local hospitals, and the Engineer Corps.2 Mostof the laboratory activities pertained to the service of these agencies.The chief association with the engineers related to the water supply ofBrest, and that with hospitals to the control of infectious diseases.2
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In addition to the duty indicated above this organization exerciseda general control and supervision over the smaller laboratories attachedto hospitals in and about Brest, and in a way served as a supply depotnot only for laboratory material but also for therapeutic and diagnosticsera.2 The therapeutic sera were secured by requisition, aswere some of the diagnostic sera, but most of the former were preparedby the department of bacteriology connected with the base laboratory.2Hospitals in the vicinity were supplied sera on requisition by means ofthe light truck above mentioned. All trans-Atlantic transports requiringsera were supplied in like manner on telephonic request that was laterconfirmed in writing. Because of the fact that they were frequently demandedin emergencies, these supplies were sent out day or night, for the laboratoryoperated throughout the 24 hours of the day.2
A great handicap, which this laboratory experienced and which causedmarked detriment to complete efficiency, was inadequate transportation.
After great difficulties this laboratory secured a light truck, whichalone made it possible for its personnel to cover much ground and securethe specimens requested in connection with the control of infectious diseases.2The one vehicle permanently supplied was not sufficient to meet the demands,and the procurement of other transportation from the Motor TransportationCorps was very uncertain and inadequate. This feature caused much lossof valuable material and time. Another handicap was the fact that supplieswere limited, for it was always difficult and sometimes impossible to obtainthem.2
BASE LABORATORIESFOR HOSPITALCENTERS, AND HOSPITALLABORATORIESSERVING IN CENTERS
Plans for the organization of the laboratory service had consideredthe conservation of personnel, equipment, supplies, and construction, inorder to release tonnage and to utilize resources to the best advantage.1Inthe laboratory service of the large hospital centers which were made upof several base hospital units great economies were thus effected. Eachbase hospital included in its personnel two or more commissioned laboratoryofficers, a varying number of enlisted technicians, and a complete laboratoryequipment. By centralization of the laboratory service the efficiency wasincreased, personnel released, equipment conserved, and construction diminished.1Therefore, in each hospital center one base laboratory for the entire serviceof the center was organized and one small clinical laboratory establishedfor each base hospital unit. The laboratory for the center was part ofthe headquarters organization, and its commanding officer the representativeof the commanding officer of the center in all matters relating to thelaboratory service. Its personnel consisted of selected officers and enlistedtechnicians drawn from the hospital units comprising the center; its equipmentwas drawn from the same sources.1
Standard plans for the laboratory buildings for the centers and forsmaller clinical laboratory buildings for each unit were prepared in theoffice of the director of laboratories, A. E. F., and turned over to thehospitalization division of the chief surgeon's office for inclusion inthe general plans of construction.1The original plans providedfor two standard barracks for the base laboratory and one small buildingfor each hospital unit functioning in the center, but the
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accommodations for the base laboratory were later reduced to one buildingbecause of scarcity of materials.1
The base laboratory for the center in general performed such routineclinical and pathological work as might be necessary, all highly technicalbacteriological and serological work for the center, and prepared culturemedia and special reagents, which it issued to the subsidiary clinicallaboratories.1 Those organizations operating in the severalbase hospital units composing the center carried on the clinico-pathologicwork for their respective units. 1
The general method outlined above was that followed in the large hospitalcenters of temporary construction.4 In the large centers whichutilized permanent buildings that were a considerable distance apart itwas not always possible to centralize the work so definitely.4However, by November, 1918, a laboratory service which conformed in generalto the method outlined above had been established in all hospital centersoperating in the American Expeditionary Forces.4
In those hospital centers where permanent buildings were utilized thelaboratory services were housed in such rooms or buildings as were foundmost suitable for their purposes without extensive alterations.5The laboratories, therefore, at these centers varied considerably in sizeand character, ranging in size, for example, from a temporary wooden buildingerected for laboratory work at the hospital center at Limoges to an entirehotel quipped for laboratory purposes at the hospital center at Vichy.5
At all the hospital centers except that at Vichy the laboratory workwas organized in conformity with Memorandum No. 8, July 23, 1918, divisionof laboratories and infectious diseases.5 As this memorandumis reproduced in the appendix it is sufficient here to state that it providedfor a laboratory officer who, as a member of the staff of the commandingofficer of the center, would exercise control over its entire service,in so far as his specialty was concerned, and for the establishment ofa center laboratory and unit laboratories.5 Each of the hospitalscomposing the center was to be served by a unit laboratory. The centerlaboratory was to perform such examinations as required greater time andmore technical skill, while the unit laboratories were to perform ordinaryroutine clinical pathological examinations.5
In order to illustrate the laboratory activities at these centers therefollows the history of that service at Mesves and at Vichy. The organizationand activities of the laboratory service at Mesves, which grew to be thelargest center in France, were typical of those in other centers,5except Vichy. This service at Vichy is, therefore, described also becauseof its unique character.
TYPICAL LABORATORYORGANIZATIONOF A HOSPITALCENTER (MESVES)
The first base hospital assigned to Mesves, arrived August 1, and onAugust 3, a laboratory officer for the center was assigned.6Efforts were inaugurated and continued to provide accommodations, equipmentand organization for the laboratories of base hospitals as they successivelyarrived. Construction was expedited, by loaning to these units a MedicalDepartment tool chest, by which construction of much apparatus, shelving,furniture and other articles was expedited-apparently a minor matter, butone which proved of very
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great importance. Supplies were procured on requisition from intermediatemedical supply depot No. 3.6
In conformity with Memorandum No. 8, division of laboratories and infectiousdiseases, July 23, 1918, the laboratory organization for this center comprised(1) a central laboratory whose commanding officer was a member of the staffof the commanding officer of the center, and supervised all its laboratoryactivities; and (2) unit laboratories, viz, one for each of the hospitalscomposing the center and the convalescent camp. The work of these departmentswas divided as follows:6
Center laboratory: (a) Special pathology (gross and miscroscopic);(b) special bacteriology (pneumococcus type, typhoid, and dysentery);(c) Serology (agglutination and complement fixation reactions);(d) general board of health for center (water analysis, carrierwork); (e) preparation of media, purchase and requisition of supplies).
Unit laboratories: (a) Gross pathology (autopsies on all patientsdying in hospital); (b) bacteriology (general culture work, blood,throat, wound, etc.); (c) general clinical pathology (urine, sputum,blood, feces, etc.); (d) preparation of Dakin's solution, care ofunit water supply, etc.
This partition of duties was inaugurated August 15, 1918, and continuedunchanged, though in September it was apprehended that laboratory suppliesavailable for incoming units might not be adequate for the performanceof all the duties allotted them. Laboratory work, however, was simplifiedby the practice of distributing patients, according to their ailments,among the hospitals best equipped and otherwise qualified to care for them.6The distribution of duties proved highly satisfactory, but a convictiongrew that centralization of post-mortem service and burials might havebeen advantageous, although this would have deprived clinicians of opportunitiesto attend autopsies in which they were interested.6
The center laboratory, until September 17, occupied quarters in commonwith those of Base Hospital No. 67, when it moved to a special buildingprovided for it. This was 100 by 20 feet in dimensions and was later supplementedby a cool room 6 feet by 6 feet 6 inches, and an animal house 13 by 26feet. These buildings were occupied several weeks before they were equippedwith light, water, or sewer connections.6
Each unit laboratory centrally located in the hospital which it servedoccupied a building 20 by 40 feet, divided originally into an autopsy room,a morgue, and a clinical laboratory, but several changes were made in theinterior plan of these structures. Each laboratory built most of its interiorfittings.6
All laboratory supplies reaching the center were invoiced to the centerlaboratory officer and by him issued on memorandum receipt to the unitlaboratories. In connection with such supplies, many economies and improvisationsproved necessary. The supplies most difficult to obtain were those commonlyused articles not listed in Memorandum No. 21 from the division of laboratoriesand infectious diseases, e. g., stoves, books, basins, pens, wire, etc.Animals, except mice, were procured without difficulty.6
Records were kept in the following manner: Request slips were made outin the wards and on these slips laboratory findings were entered, the slipsthen
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being returned to the wards. Retained laboratory records consisted of(1) a journal or daybook in which all specimens or requests were listed;(2) a file of index or ledger cards on which the reports mentioned abovewere transcribed. All the work done on a given case was entered on oneor more of these cards. This system simplified clerical work and facilitatedcooperation with the clinical services.6
General reports of infectious diseases were carried on spot maps andon separate card indices for the more important diseases-pneumonia, diphtheria,typhoid, dysentery, meningitis, and scarlet fever. These records were obtainedfrom (1) the morning report of infectious diseases, (2) from individualreports of cases which were required by a special memorandum of the commandingofficer of the center, and (3) from the medical consultant. Each case ofdiphtheria, meningitis, and typhoid fever was personally investigated byan officer from the center laboratory. Routine reports of water analyseswere made to the center sanitary inspector and to each hospital. The locationsof all Lyster bags were posted on spot maps, to facilitate checking theroutine bacteriological examinations. 6
The laboratory staffs of the entire center consisted of 29 officers,7 nurses or civilians, who had had previous laboratory experience, and63 enlisted men. Of this number 5 officers, 1 technician, and 15 enlistedmen served at the center laboratory, while the others were distributedamong 8 base hospitals, 2 provisional base hospitals, 2 evacuation hospitals,and the convalescent camp.6
The idea of developing the laboratory service from a central laboratorywith subsidiary laboratories in each hospital organization proved practicaland efficient. As each hospital occupied somewhat the same position inthe center that the regiment held in a division, this organization, morethan any other factor, simplified the development and operation of thelaboratory service. The old and established functions of the laboratoryproved of most value, but the preparation of Dakin's solution and the supervisionof the water supply in each hospital by its laboratory, in addition tothe regular bacteriological examinations of the camp water supply, wereother valuable services. Wound bacteriology and pneumococcus typing provedof little practical importance.
With the exception of influenza and influenza pneumonia, there wereno epidemics in this center. Diphtheria was the most prevalent of the carrier-bornediseases (151 cases), and the number of diphtheria carriers detected wascorrespondingly high (112 cases). The presence of diphtheria and of virulentdiphtheria-like organisms in wounds was frequently noted. Twenty-six casesof cerebrospinal meningitis were treated, of which 12 died. Twenty-fiveof these cases developed in this center. Seventy-three cases of typhoidfever, one case of paratyphoid A, and two cases of paratyphoid B were treated,of which total, 21 were believed to have originated here. Thirty-eightof these cases were verified bacteriologically.6
THE LABORATORYSERVICE, HOSPITAL CENTER,VICHY
The organization of the laboratory service at the hospital center atVichy differed from that in other centers because of the fact that it appearedadvisable to centralize all laboratory personnel and equipment. This decisionarose
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from the fact that the hospitals comprising the center operated in some80 hotels which varied in their capacity from 50 to 1,200 beds. Becauseof the consequent unevenness in the distribution of buildings and bed capacity,operation of unit laboratories would have been difficult. In one hotel,accommodating 1,200 beds, one small subsidiary laboratory was establishedbut this was the only departure from this plan for centralization.5
The laboratory equipment of the five base hospitals at this center was,therefore, assembled at the center laboratory to which all Medical andSanitary Corps officers belonging to the laboratory staffs of the variousbase hospitals were assigned. Enlisted men who had had previous experienceas laboratory technicians, photographers, and artists from all organizationswere similarly assigned.5
The laboratory and its enlisted personnel occupied an entire hotel withthe exception of three small rooms which were assigned to the AmericanRed Cross for office purposes.5
In this, as in other centers, an experienced laboratory officer whowas assigned to the staff of the commanding officer of the center, organizedand controlled its laboratory service, and was responsible for its activities.5
The laboratory staff here consisted of the following personnel:5 Medical officers, 9; Sanitary Corps officers, 2; civilian employees,4; enlisted men, 35; French employees, 7; total, 57. This personnel wasdistributed among the following departments: Administrative, pathological(including clinical and neuropathological), bacteriological, serological,art, photographic, and preparation of media.5
The administrative department had charge of the laboratory building,its proper policing, discipline of the enlisted personnel, the cleaningof glassware, operation of stock rooms, collection of specimens, and theissue of laboratory reports.5
The assistant director of the laboratory took complete charge of anylarge bacteriological problems that arose, such as extensive investigationsfor diphtheria, meningitis, or typhoid carriers, and was authorized todetail as his assistants any subordinate member of the laboratory staff.5
So far as possible the laboratory staff of each of the five base hospitalscomposing this center performed the routine laboratory work of their respectivehospitals; e. g., clinical pathology, wound bacteriology, etc. Therefore,the service for each base hospital was left in charge of its own pathologistwho was responsible to the laboratory officer of the center through theassistant director of the laboratory.5
The pathological department had entire control of the autopsy serviceand of surgical pathology. The laboratory officer of each unit performedpractically all the autopsies pertaining to it, but the brains and spinalcords were removed by the neuropathologists and their technicians. Allpatients dying at this center were autopsied, a stenographer taking thedictated protocol at the post-mortem table. Almost every autopsy includedan examination of the brain, spinal cord, and accessory sinuses of thehead.5 This department was able to prepare microscopic sectionsof the important viscera from most
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of the autopsies, to study them, prepare microphotographs and, withthe aid of the art and photographic departments, to make drawings of grossand microscopic lesions. Clinical pathological meetings which the entiremedical staff of the center were requested to attend were held three timesa week in the lecture room of the laboratory. At these sessions clinicalhistories of all cases coming to autopsy were read and discussed, the grossanatomic material was demonstrated, and microscopic sections, drawings,charts, etc., were exhibited.5
FIG.9.-Pathological room in the laboratory, Vichy hospital center
Wassermann tests, the typing of pneumococci, weekly water analyses andsuch other procedures as required more or less routine work, were assignedto a few officers and men and the individual base hospitals' laboratorystaff was thus relieved of these duties.5
Though serology was done by the department of that name there was alwaysopportunity for the laboratory staff of each base hospital to perform anyof this work, if they so desired and had the time.5
The art and photographic departments had charge of all the medical artwork of the center. Reenforced by a special group sent from the UnitedStates, this department was engaged in taking photographs of clinical cases,making black and white drawings, and colored drawings of gunshot wounds,
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mustard gas burns and peripheral nerve injuries. It also took photographsor made drawings of surgical specimens, autopsy lesions and constructedplaster or wax models of facial injuries and other lesions. When the armisticewas signed, this department was prepared to furnish on request, medicalphotographs and artists to other hospitals. It was planned and to a largedegree accomplished that this center be made a collecting point for medicalart work in the American Expeditionary Forces.5
The basement of the hotel utilized for laboratory purposes, containedthe morgue for the entire center with a central autopsy room. Another roomon this floor used for the preparation of bacteriological media was equippedwith hot and cold water, gas and electricity. In a third room were storedthe coffins which were made by the Quartermaster Department while a fourthroom was shelved and used for the storage of antitoxins, sera, vaccines,etc.5 Offices of the laboratory officer and his assistant anda small medical library were on the ground floor. Another room accommodateda large clinical and bacteriological laboratory which provided a desk benchfor the pathologists and laboratory personnel of all the hospitals in thecenter. Most of the routine work was done in these rooms. On the same floorwere a lecture room seating about 100 persons (also used for a museum andfor the display of the work of the art and photographic departments) anda media and chemical supply room which served the entire laboratory.5
On the first floor were located the pathological, art, and photographicdepartments. These afforded facilities for officers engaged in histologyand the preparation of gross pathological specimens for museum purposes,for artists engaged in medical art work, for a modeler of plaster and waxpreparations for face masks, etc. Here were provided storage of pathologicalspecimens for shipment to the Army Medical Museum, a portrait studio, andfacilities for developing and mounting photographs. The brains removedfrom all cadavers were hardened, studied, and stored for shipment to theArmy Medical Museum.5
The second and third floors of the hotel were used for living roomsfor the laboratory personnel, about 40 being quartered there. All the roomsin this building were well equipped with water (hot and cold), gas, andelectricity.5
The laboratory equipment and apparatus were excellent. Much of the equipmentwas brought to France by the several base hospitals, but additional articleswere obtained from the medical supply depot and the central Medical Departmentlaboratory. The equipment compared very favorably with that seen in mostlarge civil institutions. An elaborate equipment for neuropathologicalwork, consisting of large brain microtomes, etc., costing about $18,000,was shipped to the center from the United States but was never received.5
The methods of procedure employed by the laboratory in the service ofthe scattered hospital establishments were comparable to those used bydepartments of health in a civil community supporting a diagnostic bacteriologicallaboratory.5
As glassware containers for the collection of specimens were quite limited,small stations supplying this material were established in the largestof the
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hotels occupied by the several hospitals. These culture stations, asthey were called, were usually located in the pharmacy of the building.At one time 22 of these stations were in operation, and at each the laboratorymaintained an adequate supply of the containers for urine, feces, or sputum;diphtheria culture tubes, wound culture tubes, and "venereal outfits,"the last mentioned consisting of glass slides and swabs for taking smears.5From each station containers for the collection of specimens were distributedas required to smaller buildings and conversely here were collected specimensand requests for laboratory service.
Pasted on each container was a mimeographed blank for the entry thereonof appropriate data. Similar detached blanks were kept at the culture stationsfor use as requests upon the laboratory for special services.
FIG.10.-Bacteriological laboratory, Vichy hospital center
In an emergency, e. g., a blood transfusion, or a leucocyte count inan appendicitis case, there quest was sent direct to the laboratory byan orderly, and delivered to the pathologist of the hospital in which thesoldier was a patient. This officer was responsible for an immediate laboratoryexamination. None of the Army forms or blanks were employed in the laboratoryservice here.5
Three enlisted men, who acted as culture collectors, visited each ofthe culture stations three times daily, employing a motor cycle and sidecar.5
All specimens brought to the laboratory by the culture collectors orsent direct by a hospital were noted in numerical sequence on an entrybook at the
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receiving office. The specimens were then distributed for examinationand the results of these examinations were noted upon report blanks, thelaboratory retaining a carbon copy for its file, the original copy beingsent to the hospital and ward from which the specimen came or for whichthe examination was made.5
Though the laboratory at Vichy existed for a year, it operated activelyonly for five months. During this time, 44,767 laboratory examinationswere made, including practically all the common tests, reactions, and proceduresrequired by modern clinical medicine in bacteriology, serology, clinicalpathology and pathological anatomy.5
BASE HOSPITALLABORATORIESFOR BASEHOSPITALSNOTOPERATING IN CENTERS
The laboratories of detached base hospitals performed all routine clinicaland pathological work for the organization they served. Their installationwas a matter of local administration and their operation presented no difficulties.7
Many of the following details, taken from the history of the laboratoryactivities of Base Hospital No. 27, are illustrative of the activitiesof those establishments in detached base hospitals generally. This unitwas selected for discussion here because of the completeness of its history.7
The staff of the laboratory originally consisted of 3 medical officers,1 trained nurse, and 3 enlisted men. One officer was engaged in pathology,another in bacteriology, and the third (who gave part of his time to wardwork) in clinical microscopy, parasitology, and chemistry. Late in November,1918, a Sanitary Corps officer joined the staff, but at intervals one ormore officers were detached for periods of three months or less. The servicesof civilian photographer and artist were made available to this unit andthus some valuable material in this field of endeavor was procured.7
The laboratory of Base Hospital No. 27, which was located at Angers,first occupied two rooms in a permanent building. Since these rooms wereovercrowded, a temporary structure was obtained into which the laboratorymoved as soon as the new building was completed. This building was centrallylocated and was of the wooden barrack type, with cement floor and plasterwalls. The floor plan included two workrooms, measuring 6 by 12 meters,with an incubator room 2.5 by 2 meters and a storeroom 2 by 2 meters betweenthem, one on either side of a short passage connecting the two large rooms.7The workrooms contained benches, along both sides, and center tables. Largesinks, supplied with hot water and adapted to cleaning glassware, etc.,were provided for each room, and a sufficient number of small sinks forthe side or center tables. Both rooms were wired for electricity, withnumerous ceiling and side lights and a number of floor plugs at the sidesof the room. Ample shelf space was provided, the storeroom being shelvedto the ceiling. Gas connections were installed along all the side tables.A hot-air sterilizer, a paraffin oven, and a large centrifuge were operatedin the incubator room, and the Arnold sterilizer and the autoclave in thebacteriological room. As far as possible, the reserve supply of laboratorymaterials was kept in the storeroom.7
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When the temporary structure was occupied, the rooms whence the laboratorymoved were thoroughly equipped as a morgue and as a fixation room for specimens.7
The equipment originally brought to France was that estimated on thebasis of the needs of a 500-bed hospital for one year, but when the bedcapacity was doubled (or counting emergency beds, quadrupled), a requisitionwas submitted for corresponding additions to equipment. Availability ofgas and electricity secured the issue of apparatus not considered in theoriginal list of equipment.7
Arrangements for the delivery of specimens to the laboratory were leftto the respective ward surgeons, but phenolphthalein tests, diagnosticlumbar punctures, procurement of specimens for Wassermann tests, bloodcultures, and blood counts were all attended to on request to the laboratorystaff.7 Each specimen was accompanied by a requisition slipupon which the reports desired were entered and was returned to the properward by the laboratory personnel. Laboratory records were kept for themost part in separate ledgers, one for each class of work, e. g., bloodcounts, urine analysis, etc., but general bacteriological findings wererecorded in one book and wound bacteriology findings in another, each innumerical sequence. Record of examinations of surgical pathological tissueswere entered on the original requests for examination. These were retainedat the laboratory and duplicates of the findings noted were sent to thewards. Autopsy records were made on appropriate forms with histologicalnotes appended when necessary to make the diagnosis complete. Wassermanntests were recorded on cards, each day's list being entered on a separatecard.7
The chief activities of the laboratory were clinical pathology, anatomicpathology and clinical bacteriology. A considerable part of the bacteriologicalwork was incidental to the epidemiological study of cultures from thisand other hospitals in the vicinity of Angers.7 The laboratoryalso made the water analysis for this region.
The somewhat limited official personnel and lack of trained techniciansnecessitated such close cooperation and application to the routine workin hand that research work was precluded.7
CAMP HOSPITALLABORATORIES
Effort was made to furnish each camp hospital with laboratory service in accordance with its requirements.4 This was not entirely uniform, for these hospitals varied greatly in size and in the nature of their service. Some functioned as base hospitals; others were little more than evacuating infirmaries, or varied between these two extremes. In November, 1918, 58 camp hospitals were operating with the American Expeditionary Forces and there is record of laboratory service in 51 of these.
The following notes from the history of the laboratory of Camp HospitalNo. 15, exemplified to a degree the activities of these units.8This hospital was organized in France from casual personnel. Its capacitywas 700 beds, expansible to 1,000 beds in emergency. Located at Camp Coetquidan,which accommodated 20,000 troops, the hospital began to admit patientsNovember 1, l9l7.8
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The laboratory staff consisted of one officer and four enlisted men.At first equipment was very limited but was augmented from time to timeas resources permitted by American and French apparatus. The laboratoryoccupied two rooms, with floor areas of 50 and 25 square meters respectively,in a centrally located permanent building and utilized rooms in a neighboringstructure as a morgue and an animal house.8
Requests for examinations as well as specimens were sent to the laboratoryby ward surgeons. Findings were recorded in note books and reports thenrendered the ward officers. Requests from officers outside the hospitalwere sent through the receiving ward, and reports returned through thesame channel.8
An important part of the laboratory service was the periodic examinationof water supplies in villages where troops were located throughout thesurrounding territory, and sanitary surveys, with studies pertaining toepidemiology among the troops occupying the area. As meningococci werediscovered in the course of the influenza epidemic at Camp Coetquidan,approximately 8,000 cultures for these organisms were examined, of which662 were positive. Because of limited equipment, chemical examinationswere few.8
MOBILE LABORATORIES
ARMY LABORATORIES
In the original plan of organization, a laboratory unit for each armywas provided, but it was thought best to await developments before theproject was further defined.1 Until July, 1918, all laboratoryinvestigations of outbreaks of epidemic diseases in the advance sectionand zone of the armies were performed by personnel and motorized laboratories-i.e., "field laboratory cars"-sent out by the central Medical Departmentlaboratory or Army laboratory No. 1.1 During the Chateau-Thierryoperation, a field laboratory car was attached to the First Corps for theinvestigation of epidemic diseases and it was understood by the chief surgeonof the Paris group, of which that corps then formed a part, that this carwas available for the service of the entire group. The work of this unitin the Chateau Thierry sector proved to be of great value, for it demonstratedthat much of the so-called diarrhea and dysentery occurring there was truebacillary dysentery, typhoid or paratyphoid.1
In August, 1918, it became evident that there should be attached toeach army a laboratory unit equipped to do general bacteriology, serologyand examination of water supplies.1 A transportable laboratoryequipment for service of the first army was assembled and shipped to Touljust prior to the St. Mihiel operation (September 12, 1918). As specialpersonnel was not immediately available, the equipment was installed atthe Toul hospital center where the laboratory served the center and alsomet the emergency requirements of the First Army.1
During the early phases of the Meuse-Argonne operation, a field laboratorycar was attached to the First Corps of the First Army.1
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When the Second Army was formed, a field laboratory car was attachedto the office of the surgeon of that army. It operated under the sanitaryinspector, Second Army, in the investigation of epidemic diseases.
When the Third Army was organized to constitute the Army of Occupationin Germany, a survey of the laboratory requirements was made and the personneland equipment necessary for its service were supplied.9 Armylaboratories were established at Coblenz and at Trier, that at Coblenzbeing supplemented by a mobile laboratory.9
The laboratory service of the Third Army illustrates the full developmentof this specialty in this field. On March 16, 1919, it included 2 armylaboratories, 10 hospital laboratories with 2 annexes, and 8 divisionallaboratories; i. e., 1 for each division.9
The army laboratories were staffed and equipped to perform all the ordinaryduties of laboratories serving large cities or even States. The personnelof the unit located at Coblenz consisted of 10 officers and 24 enlistedmen, excluding those assigned to the field laboratory car which also servedthis army and which was attached to this unit.9 It includeda commanding officer, executive and supply officers (one officer sometimesdischarging the duties of both assignments) a pathologist and histologist,bacteriologist, water analyst, serologist, chemist (with exceptionallybroad attainments, especially in the field of toxicology), three clinicallaboratory experts, and a skilled technician.9At the army laboratoriesautopsies were performed, histologic diagnoses and Wassermann tests made,bacteriologic differentiations conducted, water samples tested and chemicalanalyses made of food, beverages, medicines and supplies, e. g., chlorinatingmaterials for water purification.9 Each of these units alsoconducted a clinical laboratory service for the hospital wherein it waslocated and issued supplies to other laboratories in their respective areas.The laboratory at Coblenz performed the usual laboratory service for EvacuationHospital No. 27 (formerly No. 6) and sent out officers to conduct autopsiesat other hospitals. 9
Attached to the Third Army laboratory at Coblenz was a field laboratorycar which was staffed by one officer and three enlisted men. This unitwas of especial value during the initial emergency and in the prosecutionof surveys of meningococcus
carriers.9
The army laboratory at Trier occupied space in Evacuation Hospital No.12, for which it performed all the clinical laboratory service in additionto its other duties, which were similar to those outlined above for thelaboratory at Coblenz.9
Ten laboratories each adequately equipped with material packed in eightchests, served the 10 evacuation hospitals, which in the Third Army servedas base hospitals.9 These hospitals varied in capacity from400 to 1,800 beds and in the character of the cases treated. In some unitsthe cases were almost entirely medical, in others many cases were surgical;a few units were largely devoted to the specialties. The laboratory servicein each of these hospitals naturally conformed to the character of thepatients treated therein. In very general terms this service included examinationof urine, sputum, blood, cerebrospinal fluid, feces, and the bacteriologyof wounds, epidemics, venereal, cutaneous, and ocular diseases, i. e.,the usual lines of investigation connected with hospitals.
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The staffs of some laboratories also performed autopsies for the hospitalswhich were not thus served by the army laboratories.9
No laboratories, other than the eight assigned to divisions, were providedfor the field hospitals, of which 35 were in operation. These divisionallaboratories, each provided with 8-chest equipment, were utilized to makewater analyses,epidemiological studies and urgent clinical laboratory examinations.9
FIELD LABORATORYCARS
Each of the field laboratory cars, which on occasion reenforced thelaboratory service of armies, was essentially a completely equipped unit,relying on its own motor power, but was supplemented by additional transportationconsisting of a Ford car and a motor cycle with side car.10The unit could be shifted and moved rapidly to meet varying conditionsin the field as well as to cover a large territory and was independentof field, evacuation, and base hospitals. The additional transportationpermitted sanitary surveys covering a large area and facilitated the collectionof specimens for examinations.10 Three of the cars were thePeerless type and one a De Dion Bouton. They were specially designed andequipped to meet field conditions, for oftentimes the laboratory wouldwork in a division removed from hospitals and other laboratories.10
The equipment was compact and provided with a work bench and compartmentsfor the apparatus and supplies. The arrangement made work in the car possibleand prevented breakage while the car was being moved. The provisions madefor actually doing work in the car constituted one of its greatest
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advantages, but usually a room in some building was utilized for makingmedia, washing glassware, and for a storeroom. Occasionally one was fortunateenough to be located where the apparatus could be set up in a separateroom.10
The equipment consisted of incubators, autoclave, hot air sterilizer,distilling apparatus, ice chest, water bath, Wassermann outfit, centrifuge,microscope, hemocytometer, water testing outfit, material for spinal punctures,blood cultures and the usual laboratory accessories. A storage batteryand generator, connected with the motor, provided electric lights. Thiswas of great help, for often it was necessary that work be done in thecar at night. This apparatus also gave excellent illumination for microscopicalexaminations.10 A gravity water system was provided, consistingof a water tank fastened on the roof of the car and connected with a faucet.A sink drain was also provided. Supplies were carried in the car to makethe necessary media, a complete supply of diagnostic as well as therapeuticsera, and reagents for the Wassermann test. The equipment made possiblethe performance of the following laboratory tests:10 Routineclinical examinations, such as those of urine, blood, sputum, smears andbody fluids; examinations for typhoid, dysentery, and enteric ailmentsgenerally; examination to determine positive diagnosis of meningitis andexamination for carriers; examinations for diphtheria cases and carriers,and performance of Schick tests; investigation of respiratory epidemics,especially pneumonia and influenza; water analyses, bacteriological; Wassermannfixation test. These laboratories were not called upon however, for thiswork.
FIG.12.-Frontof interior of field laboratory car
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FIG.13.-Rear of interior of field laboratory car
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FIG.14.-Interior of field laboratory car showing water still, autoclave, andsterilizers
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The field laboratory car aided the sanitary inspector of an army tocope with epidemiological problems and it was in this capacity that itwas of greatest use, though it was often called upon to assist in establishingclinical diagnoses.10 Being attached to army headquarters underthe immediate supervision of the sanitary inspector, reports of its findingswere made to him direct. The peculiar value of the laboratory cars rosefrom the fact that the divisional laboratories usually were unable to handlethe larger epidemics and sanitary surveys, while performing their normalduties. The stationary laboratories were not provided with transportationfor extensive field work though the collection of samples was of the greatestimportance, while the excellent transportation facilities of the laboratorycars enabled them to reach sites where their services were needed and tocarry supplies adequate for several months. These supplies usually werereplenished from evacuation and base hospitals.10
The personnel consisted of 1 or 2 officers, 2 technicians (preferablysergeants or sergeants, first class), and 2 chauffeurs.10
These laboratories aided greatly in the investigation and control oftyphoid fever in the 77th and 79th Divisions; meningitis in the 7th and90th Divisions; diphtheria in the 32d and 35th Divisions; pneumonia andinfluenza in the 26th Division and in the labor battalion at Jonchery.10
The most important advantages which these laboratory cars presentedwere the following:10 The unit could function anywhere in thefield, requiring no special housing or additional equipment and could,therefore, operate in any area occupied by the troops. It was suppliedwith its own light and water systems. Being supplied with its own motorpower it was ready for immediate service and the transportation could notbe diverted for other use, thus ensuring a mobile organization. The unitwas able to handle large epidemics and to cooperate with the army sanitaryofficer in solving special problems and making surveys. It thus permittedother laboratories and those with divisions to continue their normal dutieswithout interruption. On the other hand, the chief disadvantages of a fieldlaboratory car were, the initial cost of the car and its special equipment,which was about $7,500; the car being of special design, could be manufacturedonly in limited numbers, and in case of motor trouble the whole organizationwas unable to function.10
EVACUATION AND MOBILE HOSPITAL LABORATORIES
The laboratory equipment for each evacuation and mobile hospital wasassembled in eight chests which could be packed and unpacked quickly andcould be easily transported.4 It was adequate for all typesof clinical and general bacteriological work, for the performance of autopsies,and the collection and preservation of museum specimens. As a rule, onlyone laboratory officer and two technicians were assigned to the laboratoryunits which served hospitals under consideration though a larger personneloriginally had been contemplated.4 The personnel prior to assignmentwas given a special course of instruction in wound bacteriology. It wasplanned that these units would perform clinical pathology and autopsiesas well as general and wound bacteriology and collect and preserve museumspecimens, and work of this general character was per-
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formed at those evacuation and mobile hospitals which were partiallyimmobilized and operating in quiet sectors, but after July, 1918, whena war of movement began, the activities of many of these units necessarilychanged.4
During 1918, the number of evacuation hospitals, each of which was equippedwith a laboratory, increased as follows, until the time of the armistice:March, 1; April, 2; May, 2; June, 4; July, 8; August, 8; September, 13;October, 18; November, 18.11
The first evacuation hospital (No. 1) was established near Toul in March,1918, where it operated throughout the remainder of the war.11Except during periods of active military operations its services were toa degree comparable to those of a base hospital, but during active engagementsthey were of the character which its name indicated. As at all times itwas almost exclusively a surgical hospital, its chief laboratory activitieswere wound bacteriology and post-mortem pathology. Similarly, EvacuationHospital No. 2, established in April, at Baccarat, was engaged chieflyin the treatment of battle casualties and its laboratory during that periodwas occupied in corresponding service.11
FIG. 15.-Transportablelaboratory, in eight chests
Wound bacteriology occupied intensively the laboratories of evacuationhospitals during the period from July, 1918, to the armistice; but duringperiods of greatest battle activity, laboratory officers often were detailedto assist in the treatment of patients.11 After the onset ofthe influenza epidemic in October, 1918, the laboratories were engagedalso in the study of infectious diseases and frequently made the diagnosesfor the ward surgeons. Post-
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mortem examinations which they conducted on all bodies acted as a checkagainst gross errors and furnished clinicians with invaluable information.Autopsies and histological and bacteriological examinations of specimenswere made the occasion of clinico-pathological conferences.
During the Meuse-Argonne operation some of the evacuation hospitalswere specialized to a degree, a number of them receiving medical casesand a number of others surgical.11 Their laboratories suppliedinformation required for diagnosis and treatment and for the preventionof the wider spread of infectious diseases. In general terms the equipmentof these laboratories was very satisfactory.11
FIG.16.-Chests of transportable laboratory opened to show contents
When American troops took over their sector in occupied Germany thiswas divided into two districts, that of Coblenz and that of Trier. Sevenevacuation hospitals served the six divisions in the Coblenz or Bridgeheaddistrict, and two, the two divisions in the district of Trier. Since theseunits operated as advanced base hospitals and some of them specializedon certain types of cases, the activities of their respective laboratorieswere modified accordingly. The laboratories in each district were supplementedby an army laboratory which conducted the more highly technical examinationsin bacteriology, chemistry, pathology and serology.11 The personnelof the army laboratories also performed the duties of consultants in specialproblems, especially surgical pathology, conducted depots of laboratorysupplies and apparatus and performed autopsies for the hospitals in theirvicinity.
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With a few isolated exceptions the work of the laboratories in the evacuationhospitals would have compared favorably with that in the average civiliangeneral hospital, for in spite of the deterrent influences of campaignthey proved their utility-in fact their indispensability.11The laboratories proved to be of immediate clinical value in both medicineand surgery and collected a number of specimens for the Army Medical Museum.11
The laboratories of mobile hospitals were especially engaged in woundbacteriology, for these units were organized to receive the nontransportablewounded.12 They made, however, a number of examinations in otherfields, as blood and throat cultures, differential blood counts, examinationsof joint, spinal, and chest fluids, of blood, sputum, urine, urethral smears,and feces.13 Serum for Wassermann tests was collected and sentto designated laboratories. Autopsies were performed and museum specimenscollected.13
Some of these laboratories moved quite frequently, that with MobileHospital No. 1, for example, changed station nine times in five months.12Some used tentage but when possible a room in a permanent or temporarybuilding was employed. The equipment issued was found to be ample. Manytechnical expedients were employed in the effort to expedite reports tothe attending surgeon.12
DIVISIONAL LABORATORIES
A laboratory attached to each division was staffed by two officers andfour technicians,4 who constituted a part of the staff of thedivision surgeon.
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In close cooperation with the division sanitary inspector, these unitswere engaged chiefly in control of epidemic diseases, in the inspectionof water supplies, and supervision and control of water purification.4In effect they were under the control of the sanitary inspector. The equipmentissued these units was packed in three chests and was not adequate forgeneral bacteriology, for it was planned that work pertaining to that specialtywould be performed in the laboratories of evacuation and mobile hospitals.4Such material as was furnished for work of that character was adequateonly for the performance of routine clinical examinations.4
After the armistice began, when divisions went into training areas,many of these laboratories requisitioned and procured additional cheststo complete equipment adequate for general laboratory work, including generalbacteriology.1 All the divisional laboratory units with theThird Army were supplied with complete transportable laboratory equipments,in eight chests each, thus permitting general bacteriological and clinico-pathologicalwork.1
On July 7, 1918, in Memorandum No. 5, division of laboratories and infectiousdiseases, the personnel, transportation, and duties of the divisional laboratoryunit were prescribed in some detail.1The provisions of thiscircular were later republished and somewhat amplified, in Memoranda Nos.5 and 7 from the same office 1 (see Appendix).
These units usually were located at division headquarters, especiallywhen the division was in a rest or training area or at headquarters ofthe sanitary train. In trench warfare or in training or rest areas thedivisional laboratories
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usually occupied two rooms in some building, preferably where heat,light, and water were available. During battle, as a rule, they were fromfive to seven miles behind the front, often in open fields, by the roadside,in tents, dugouts or unused buildings.14 Under combat conditionsit was found expedient to divide the laboratory, the bacteriologist andsufficient personnel being located with the bulk of the laboratory equipmentat one of the field hospitals, preferably the surgical hospital or oneused for evacuation purposes.14This part of the laboratorysupervised the preparation of Dakin's solution and dichloramin-T and performedgeneral bacteriological and pathological services. The other part, withthe water supply officer and two enlisted men with the necessary equipment,tested for poisons the water supplies in advanced positions, selected waterpoints, and examined treated water for free chlorine.14Factslearned by this party were promptly reported to the water-supply engineers,who then supplied the personnel and equipment necessary to produce a satisfactorydrinking water. The water supply officer was charged with purificationof this water if necessary and with successive checks upon it. Chemicalanalyses that required the use of standard solutions presented difficultiesthat could hardly be overcome in the field, but it was found expedientto test all water sources for poison during advances. This was readilyfeasible.14
Also in training or rest areas the laboratory cooperated in the locationof water sources, determined the quality of their outflow, and performedthe chemical and bacteriological tests incident to the control of waterservice.14
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No hard and fast rule could be laid down for methods of procedure inrest areas, trench or open warfare. Methods in one field were not applicablein another, but when the division was engaged in trench warfare they weresimilar to those followed when in a rest or training area. Under the lattercircumstances as much work as possible was placed on a routine basis.14
Whether at the front or in training or rest area the value of theseunits was clearly demonstrated, for they very materially strengthened theservice of the sanitary inspector. A case of suspected epidemic diseasearising in a regiment was immediately reported to the division surgeonand was sent to a field hospital where cultures were taken and forwardedby courier to the laboratory.14 If a diphtheria culture wasfound positive, contacts also were examined within two hours. The usualroutine work arising in field hospitals was handled very readily by a courierservice.14
The success of laboratory activities was commensurate with the abilityof the unit to maintain close contact with the division surgeon and sanitaryinspector, to adapt itself to field conditions, and to make the most ofthe limited facilities at hand.14
While some of these units did admirable work and were considered indispensableby some division surgeons, a large percentage were unable to function properlyunder combat conditions. The principal reason for this failure was lackof transportation. These laboratories had been included in the tentativetables of organization formulated for the American Expeditionary Forces,and adopted in August, 1917, but no transportation had been provided forthem at that time.1 For some reason, unknown to the divisionof laboratories, they were incorporated in the priority shipment scheduleas "mobile laboratories" and as Services of Supply units.1 Severalefforts were made to secure transportation for these formations, and theinclusion of the personnel and their transportation as divisional unitswas recommended by the director of laboratories in the proposed revisionof the Tables of Organization, when these were under consideration duringthe summer of 1918. This proposed revision had not been approved on thedate of the declaration of the armistice.1 Had even a motorcycle been available for each of these laboratories there is but littledoubt that water discipline would have been better throughout the division,with a consequent decrease in the prevalence of typhoid and paratyphoidfevers and dysentery.1Lack of transportation in a number ofcases caused the elimination of these laboratories as divisional units.14
In January, 1919, on special request of the division of laboratories,G-4, general headquarters, directed that one motor cycle with side carbe issued to the divisional laboratory of each division still in France.This transportation permitted much closer and more satisfactory supervisionof chlorination of water supplies in divisional areas.1
TECHNICAL WORK OF LABORATORIES
Many types of technical laboratory work (e. g., gastric analyses, tumordiagnoses, etc.) of peace time had little place in the laboratory serviceof the American Expeditionary Forces. Instead of these, large numbers ofexaminations of relatively few ordinary types prevailed, with occasionallya highly specialized study to meet an emergency.4
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The officer in charge of a laboratory assisted the attending medicalofficer and the surgeon by making urinalyses, blood-cell examinations,etc., and by determining the types of bacteria in wounds.4Hiswork was final in the diagnosis of many infectious diseases, and for thespecific prevention and treatment of these he cooperated in the administrationof vaccines, therapeutic sera, salvarsan, etc. He was consultant to theepidemiologist concerning the essential cause of a prevailing disease,the identification of immune carriers, and the character and extent ofwater pollutions.4 He inspected in large part the chlorinationwork of the water-supply service and in some measure the professional workof attending medical officers by determining at autopsy any error in diagnosisor treatment.4
The technical work of the laboratory section of the division of laboratorieswas so modified by the stages of development in its organization, by theincidence of epidemics and by active military operations that its history,for present purposes, is divided roughly into four periods: (a)From the first landing of troops, June 10, 1917, to November 30, 1917.Toward the latter part of this period a large number of cases of pneumoniadeveloped. (b) From December 1, 1917, to May 31, 1918. It was duringthis period that activities of the hospitals of the American ExpeditionaryForces began to be actively concerned with battle casualties. (c)From June 1, 1918, to November 30, 1918, the period of serious epidemicsand of greatest battle activity, during which time the laboratories generallywere concerned largely with enteric disease, influenza, and wounds. (d)The period of demobilization after December 1, l9l8.15
The first period, that from June 10, 1917, to November 30, 1917, wasone of tentative organization when the laboratories were engaged chieflywith the clinical pathology and bacteriology incident to ordinary illnessand to accidents in a small body of troops in the services of supply orin training.15
On August 28, 1917, the director of laboratories submitted to the chiefsurgeon, A. E. F., certain suggestions concerning autopsies, the renditionof autopsy protocols, and the scope of the latter, and recommended thata bulletin concerning these matters be issued from the chief surgeon'soffice.16 The Wassermann service was begun in September, 1917.15In the few laboratories then operating (4 camp hospital laboratories, 8base hospital laboratories, and 2 section laboratories) a small but importantautopsy service was begun.15 Very meager data concerning thetechnical laboratory work of this period are available, since no monthlyreports were made.15
In the second period, from December 1, 1917, to May 31, 1918, additionallaboratories in 12 camp hospitals, 3 evacuation hospitals, and 10 basehospitals, as well as the central Medical Department laboratory began tofunction, and the organization of the division of laboratories and infectiousdiseases was completed, thus greatly increasing the facilities for alltypes of technical work.15 Early in this period epidemics ofpneumonia, diphtheria, scarlet fever, and meningitis among our troops taxedthese facilities to their full capacity for routine clinical and bacteriologicalexaminations.15 At the end of this period the system of monthlylaboratory reports was begun, but the available information for most ofthe period was quite incomplete.15
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When the German offensive of May 28, 1918, in the Marne area broughtrelatively great numbers of American wounded into our hospitals, the MedicalDepartment was still very greatly undermanned in its laboratory as wellas in its other services.15 So great was the need for medicalattention that in many organizations all laboratory officers were divertedfrom laboratory work to the more direct care of the wounded. From thistime until the signing of the armistice, laboratory officers were neveravailable in half the number necessary to make the routine technical examinations,while research was, in general, wholly out of the question.15However, laboratory officers succeeded in organizing and developing theirlaboratories, in doing most of the absolutely essential clinico-pathologicwork, and in meeting emergencies, such as the performance of large numbersof bacteriological examinations and of autopsies incident either to battlecasualties or to epidemics of enteric diseases, influenza, diphtheria,meningitis, etc.15 Until the 8-chest transportable laboratoryunits became available, the laboratory work was accomplished with equipmentrelatively so inadequate that the results obtained would have been consideredpractically impossible by laboratory personnel prior to the war.15By November 1 the total number of laboratories in operation had greatlyincreased, as shown by Table 4, the personnel was advantageously distributed,and officers had learned to virtually "make bricks without straw." Thisthird period of the laboratory activities of the American ExpeditionaryForces-i. e., from June 1, 1918, to November 30, 1918-stands out preeminentlyas an index of how much may be done under most difficult conditions.15
The available information concerning the technical work for this periodis fairly good. In May, 1918, a standard form (No. 5) for laboratory reportsto the director of the division of laboratories had been devised and afterJune, 1918, this report was received monthly from most of the laboratoriesin operation in the American Expeditionary Forces. In October, 1918, thisform was revised and improved.15 This monthly report, whichwas intended primarily to supplement the direct supervision from the officeof the director of the division of laboratories, presented sufficient clinicalinformation, concerning the activities of the hospital under "data forcomparison," to enable the reviewer to determine something of the characterand amount of work which should have been done by the laboratory and thepersonnel available for its accomplishment.15 Activities weredivided into six groups among the personnel of the laboratory. All attemptsto determine the clinical incidence, as of infectious diseases, were purposelyomitted since it was believed that these more properly belonged to specialreports of the section of infectious diseases and other agencies. The numberof "positive" examinations in certain diseases was given merely to aidthe reviewer in determining whether the clinician was underusing or overusingthe laboratory.15 For example, a very high percentage of "positives"usually indicated underuse and a very low percentage suggested overuse.The careful review of each report immediately upon its receipt, and, ifnecessary, its return with a critical indorsement thereon, did much toimprove the weak points in the service of some laboratories.15
The signing of the armistice marked the beginning of the fourth periodof activity of the laboratory service. Many of its officers who had enteredfrom
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civil life requested orders for their return to the United States.15Theserequests could not well be refused, though the quota of laboratory personnelwas still far below that of any other branch of the medical service.15The situation was aggravated by the fact that at this very time the appearanceof typhoid fever in a number of organizations rendered necessary extensivebacteriologic examinations; thorough examinations for venereal diseasewere being conducted among troops in training areas, and potential dangerpoints, which demanded increases of local laboratory service, were createdby the concentration of troops in embarkation camps and at base ports.15Because of decreased personnel and of the increased service demanded, muchof the technical service of the laboratory division even in this finalperiod was performed under stress. Fortunately, however, early in thisperiod the receipt and distribution of laboratory supplies had been greatlyexpedited and this fact, coupled with the transfer of material from organizationsbeing demobilized, greatly improved the physical conditions under whichthe service was rendered.15
As was inevitable, not all hospitals in the American Expeditionary Forceswere staffed by attending medical or surgical officers well trained inthe selection of cases in which clinico-pathologic examinations might beof assistance; nor were they all sufficiently trained in interpreting theresults of these examinations. In some instances serious diagnostic errorswere made which might have been prevented by even a urinalysis; in othersthe laboratory was called upon to make large numbers of difficult examinationsin a search for the specific cause of a disease which was scarcely evensuggested by the symptoms.15 Personal supervision by medicaland surgical consultants did much to improve the clinical services in thisrespect but this was obviously inadequate to cover with sufficient detailthe activities of several hundred hospitals. In hospital centers the assignmentof the laboratory officer of the center to the headquarters staff greatlyincreased the efficiency of the laboratory service of the center and promotedits coordination with the other professional services.15
THE CLINICO-PATHOLOGIC SERVICE
The clinico-pathologic service up to November 30, 1917, constitutedthe bulk of the laboratory work, though it was far from large. During thisperiod, there were few patients in hospital and, as the troops were mostlyin the Services of Supply or in training areas, clinicians were able bothto study their cases carefully and to utilize the laboratory facilitiesto good advantage.15 Many of the cases in hospital during thisperiod were suffering from acute infectious diseases of respiratory types,though true pneumonias did not reach a high rate until December. A relativelyhigh venereal rate which occurred in November, 1917, made necessary manyroutine laboratory examinations. The laboratory records for this period,however, are very meager, since regular monthly reports were not then made.15
The clinico-pathologic work for the second period, from December 1,1917, to May 31, 1918, was similar to that of the first. The epidemic ofpneumonia, beginning in the fall of 1917, gradually subsided, but a relativelylarge number of patients with other diseases, particularly meningitis,scarlet fever, diphtheria, and measles, were in hospital, and on thesepatients a large amount of clinico-
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pathologic work of a routine character was necessary.15 Therelatively high venereal rate in December, 1917, dropped materially towardthe end of this period.15
The total amount of clinico-pathologic work done during the first andsecond periods was low in relation to the number of cases in hospital andto the number of both commissioned and enlisted personnel.15 Thiswas due to difficulties in providing accommodations for laboratories, tolack of equipment, to untrained enlisted personnel, and in some instancesto "overtrained" commissioned personnel. Many of the base hospitals inthe American Expeditionary Forces which first arrived in France were mannedon the laboratory side, as well as in the other professional departmentsby highly trained specialists.15 A number of these had beenconcerned in their recent civil experience only with teaching or researchand a considerable period elapsed before some of them could readjust theirideals so as to properly evaluate simple routine clinico-pathologic examinations,such as those of urine and blood.15
For the third period-i. e., from June 1, 1918, to November 30, 1918-therecords were fairly complete, though during this period the laboratoryservice being to the extent of only about 40 per cent of its normal strength,was so greatly overworked that preparation of detailed reports was verydifficult.15
During the fourth period following December 1, 1918, a marked decreasein trained laboratory personnel developed though the continuance of influenza,the outbreak of numerous small epidemics of typhoid fever, and the morecareful venereal survey of all troops, necessitated a large amount of laboratorywork.15
It is not the purpose to give here numerical summaries of laboratorywork, however, certain points of interest relative thereto should be mentioned.
Leucocyte counts showed a gradual monthly increase which was not commensuratewith the greatly increased number of patients in hospital, and did notreach even an approximately proper proportion till February, 1919. Thiswas most noticeable in the relatively small number of differential countsmade and was probably due to failure of clinical officers to appreciatethe importance of this diagnostic procedure or their failure to insistupon the necessity for such counts.15
Malaria examinations, which reached their highest number in August,1918, were notable for their rarity though they probably covered the necessaryfield more completely than any other laboratory procedure. 15
Examinations of feces for parasites and ova and for entameba were altogethertoo few. There was little time for these during periods of great stressbut during the fourth period they might have been more numerous. It isunfortunately true, however, that laboratory personnel properly trainedin the technique of these examinations was seriously lacking.15There was a sudden increase in the number of examinations for intestinalparasites in August, 1918, which continued until November of that year.15
Urine examinations were fairly numerous, but their distribution andquality were very irregular. In many hospitals the specimens were intelligentlyselected, properly collected, and carefully examined. In some, this wasnot the case. In others very few such examinations were made.15
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In examinations of sputum for tubercle bacilli, as well as in thoseof urine, relaxation in thoroughness was prone to occur. Specimens whichthe laboratory officer knew were not intelligently selected or collectedwere apt to be superficially examined, thus rendering negative reportsof little value.15 In some hospitals as many as four or fivehundred specimens were examined with only four or five "positives" reported.It is true that these were intended as controls in cases of recovery frominfluenza and pneumonia, but it was suspected that in many instances thelack of care in the collection of sputum and the hasty search for bacillimade the negative findings of relatively little value.15 Thenumber of examinations of sputum for tubercle bacilli gradually increasedreaching their highest point in January, 1919.15
The number of examinations for gastric contents was relatively smallin comparison with such as would have been necessary for an equal numberof patients in civil hospitals. Most of the military patients being young,robust, and subject only to wounds and acute diseases, there was littlenecessity for the examination of gastric contents with a view of reachinga diagnosis of gastric ulcer or cancer.15
In addition to the chemical laboratory tests which were made in mostsuspected cases of this character, great reliance was placed upon roentgenology.15
The occurrence of sporadic cases of true epidemic meningitis at widelyseparated points in the American Expeditionary Forces, kept the whole MedicalDepartment on the alert. While it can not be demonstrated beyond peradventurethat had no measures been taken, serious epidemics of meningitis wouldhave developed, yet it is probable that the early accurate diagnosis andthe vigorous methods instituted in most instances immediately on the developmentof a single case, served in large measure to prevent epidemics.15In this service the laboratory officer rendered inestimable assistanceto the attending medical officer.15
Smears for gonococci showed a gradual monthly increase though not reachinga considerable proportion until February, 1919.15
Dark field examinations for Treponema pallida were considerablythough not sufficiently increased after the armistice began.15 Itwas difficult to find enough officers to make the large number of necessarydark field examinations in a competent manner.15
Except in the few instances noted above, the general quality of theclinicopathologic examinations was good. A large number of clinicians hadbeen trained in civil practice to expect and more or less intelligentlyto interpret these examinations. This counteracted the tendency on thepart of some laboratory officers to relegate this work to untrained personnel.15
Up to November 30, 1917, very few post-mortems were made in the AmericanExpeditionary Forces. The clinical service before that date was very light,the attending medical officers and surgeons had time to study their caseswith great care, and thus the necessity for a post-mortem examination ofthe few cases that died was not very apparent.15 Of the post-mortemsthat were made, the records either were incomplete or in some instanceslost, so that but 14 protocols for this period-representing about one-fourthof the deaths-were received in the offices of the director of the divisionof lab-
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oratories. Most of these autopsies were made at Army laboratory No.1, Naval Base Hospital No. 1, and Camp Hospital No. 33.15
During the period from December 1, 1917, to May 31, 1918, the numberof autopsies increased in May to 57 per cent of the total number of deathsin hospital. This was due in part to the fact that on April 2 CircularNo. 17, (q. v. in the Appendix) was issued from the chief surgeon's office.15
By the end of May, 1918, there were in the American Expeditionary Forceslaboratories serving 25 base hospitals, 8 evacuation hospitals, 32 camphospitals, 4 Red Cross hospitals, and 1 mobile hospital, besides Army laboratoryNo. 1, the central Medical Department laboratory, and the base laboratoryof the intermediate section, or a total of 70 hospitals and 72 laboratories,in addition to those pertaining to divisions.15
Less than 15 pathologists in the American Expeditionary Forces werethen capable of making post mortems and intelligently interpreting theresults. This condition was due in part to the long neglect of the autopsyservice in many civil institutions in the United States with inevitablereduction in the number of pathologists, and in part to the overshadowingstatus of bacteriology in military laboratories.15 The autopsyservice had not been established as a routine procedure in the Army buton the contrary, autopsies were made only on the written authority of thecommanding officer of a hospital. However, in the American ExpeditionaryForces the need of a routine autopsy service amounting in fact to a professionalinspection of the diagnostic and therapeutic measures of officers engagedin clinical service, rapidly became apparent during the summer of 1918.Surgeons were called upon with little time for study or reflection to diagnoseand treat enormous numbers of gunshot wounds with which they had had littleor no previous experience. Even those who were well grounded in the generalprinciples of surgery were forced to make decisions and institute treatmentthereon without sufficient opportunity for study.15 As a result,there were many errors in diagnosis and corresponding errors in treatment.15The worst of these could be determined only by the pathologist. Likewise,medical officers attending cases of gas poisoning, influenza, and pneumoniawere confronted by conditions with which they were totally unfamiliar,and frequently were forced to make diagnoses and to institute treatmentwith a very meager knowledge of the facts. Here autopsies proved of tremendousimportance for they afforded knowledge of pathologic lesions which thephysicians treating the case could use in their subsequent diagnoses andtreatment.15 When, in the fall of 1918, and in the followingwinter, numerous isolated epidemics of typhoid fever began to appear, thesymptoms and physical signs, in any instances, were so obscure that theclinicians failed to make proper diagnoses and the pathologist was thefirst to recognize the true nature of the disease on the autopsy table.15
The director of the division of laboratories, in June, 1918, requestedthat 10 competent pathologists be cabled for from the United States, inaddition to those coming over with hospital organizations.15These10 pathologists arrived in due time and assisted materially in improvingthis service. The activities in forward areas were now covered to betteradvantage by dividing the territory into sectors and placing at Baccarat,Toul, Souilly, and Paris,
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respectively, competent pathologists attached to an evacuation or basehospital, with orders to act as consultants in their specialty for thesurrounding areas.15 In addition to these measures, the importanceof autopsies was brought to the attention of laboratory officers and commandingofficers of hospital organizations by inspectors from the division of laboratories,by letters, and by indorsements on monthly reports.15 As a result,the autopsy service rapidly improved, though there were never sufficientcompetent pathologists in the American Expeditionary Forces to cover theneeds at all points. There were not more than 50 or 60 pathologists amongthe 685 medical officers in the laboratory service when the armistice wassigned, but the service had so increased during the summer and early fallof 1918, that autopsies were performed on 95 per cent of all deaths inhospital. In October the total number of autopsies reached 3,896.15This was but 85 per cent of the deaths then occurring in hospitals forthe autopsy service like every other was overwhelmed by the enormous numberof deaths from influenza and by the battle casualties of the Meuse-Argonneoperation.
The greatest number of deaths occurred in the base hospitals. AfterJuly, 1918, many more autopsies were done in camp hospitals than in evacuationand mobile hospitals for they not only were more numerous but many of themactually functioned as base hospitals.15 An attempt was madeto study battle casualties, particularly gas poisoning, by centrally locatedlaboratory officers who could be concentrated by the use of motor transportationat any point where casualties occurred. This plan, which was then employedin the French service, usually failed because of lack of transportation.15
Early in July the recording and cross indexing of autopsy protocolswas begun in the office of the director of division of laboratories, butinadequate assistance rendered progress in this direction very slow.15
After the signing of the armistice, the release from duty elsewhereof a few competent pathologists made it possible to place the analysisof the autopsy protocols concerning a few diseases, on a better basis.In order to facilitate this work in the central laboratory and to obtainthe benefit of the review by the competent pathologists scattered throughoutthe American Expeditionary Forces, three office letters concerning, respectively,influenza and pneumonia, gunshot injuries, and war-gas poisoning were sentout to laboratory officers selected because of their ability and experience.15These office letters gave forms for the analysis by the laboratory officerof all cases coming to autopsy under his individual observation. On thereceipt of these analyses in the office of the director of laboratoriesthey were compiled and coordinated with one another and with scatteredprotocols from other laboratories. Two other compilations were undertaken,one on typhoid fever and another on tuberculosis. In addition to these, however, the other autopsy protocolscontained a wealth of data for further study on a number of subjects; e.g., meningitis, dysenteries, and cardiovascular lesions. 15
One field of post-mortem examinations which might have yielded invaluableresults from the purely military standpoint was entered by but one pathologistin the American Expeditionary Forces. This was the examinations of thebodies of soldiers killed in battle.15 This service did notnecessitate the making
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of autopsies, but was limited to a study of the site and character ofimmediately fatal injuries by a medical officer who had a good knowledgeof anatomy and some appreciation of the character and effects of missiles.15
REFERENCES
(1) Report from Col. J. F. Siler, M. C., director of laboratoriesand infectious diseases, A. E. F., to chief surgeon, A. E. F. (undated),on the activities of division of laboratories and infectious diseases,from August, 1917, to July, 1919. On file, Historical Division, S. G. O.
(2) Report on the Medical Department activities of basesection No. 5, A. E. F., undated, made by the surgeon, base section No.5. On file, Historical Division, S. G. O.
(3) Report on the Medical Department activities of CampHospital No. 33, by First Lieut. George R. Cowgill, S. C. On file, HistoricalDivision, S. G. O.
(4) 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, HistoricalDivision, S. G. O.
(5) Report on the laboratory service of hospital centersin converted permanent buildings, undated, by Maj. Harrison S. Maitland,M. C. On file, Historical Division, S. G. O.
(6) Report of hospital center at Mesves, undated, preparedunder the supervision of the commanding officer of the center (not datedor signed). On file, Historical Division, S. G. O.
(7) Report on the activities of the laboratory, Base HospitalNo. 27, A. E. F., January 20, 1919, by the officer in charge of the laboratory.On file, Historical Division, S. G. O.
(8) Report of laboratory of Camp Hospital No. 15, A. E.F., April 1, 1919, by Capt. M. L. Holm, M. C. On file, Historical Division,S. G. O.
(9) Report on the laboratory situation in Third Army,by Lieut. Col. W. M. L. Coplin, M. C., March 18, 1919. On file, HistoricalDivision, S. G. O.
(10) Report on mobile laboratories, A. E. F., undated,by Capt. C. O. Rinder, M. C. On file, Historical Division, S. G. O.
(11) Report on the laboratory service of the evacuationhospital, January 3, 1920, by Maj. Arthur U. Desjardine, M. C. On file,Historical Division, S. G. O.
(12) Report on the laboratory work of Mobile HospitalNo. 1, A. E. F., by Capt. A. A. Johnson, M. C., officer in charge of laboratory,January 1, 1919. On file, Historical Division, S. G. O.
(13) Report on the laboratory work of Mobile HospitalNo. 39, January 2, 1919, by First Lieut. William S. Keister, M. C. On file,Historical Division, S. G. O.
(14) Report on the laboratory service of divisional laboratories,A. E. F., undated, by Capt. Lucius A. Fritze, M. C. On file, HistoricalDivision, S. G. O.
(15) Report on the pathological service, division of sanitationand inspection, American Expeditionary Forces, undated, by Colonel LouisB. Wilson, M. C. On file, Historical Division, S. G. O.
(16) Letter from director of U. S. Army Laboratory No.1, to the chief surgeon, A. E. F., August 28, 1917. Subject: Post-mortemexaminations. On file, A. G. O., World War Division, chief surgeon's files(321.630).
