CHAPTER XII
THE DIVISION OF LABORATORIES AND INFECTIOUS DISEASES
(Continued)
SECTION OF INFECTIOUS DISEASES; SECTION OF WOUND BACTERIOLOGY
SECTION OF INFECTIOUS DISEASES
In November, 1917, the director of laboratories planned the organization of a subdivision to be called the "subdivision of infectious diseases." It was proposed that this work be placed under the direction of an assistant director of laboratories, who should act as general advisor to the chief surgeon, A. E. F., in all matters pertaining to communicable disease.1 The officer assigned to this position on December 1, 1917,2 had begun the organization and formulation of plans of procedure when, in the following month, he was assigned to the trench fever commission. Thereafter, until midsummer of 1918, he was unable to take an active part in the subdivision of infectious diseases, but being frequently consulted by letter and by personal interview, offered many helpful suggestions.1 In February, 1918, another officer was appointed assistant director in charge of the section of infectious diseases, and with the cooperation of the first incumbent, perfected the organization of the section.1
FUNCTIONS
The functions of this section were outlined as follows:3
The function of the subdivision of infectious diseasesis to provide an instrument for the prompt epidemiological and bacteriological investigation of transmissible diseasesamong troops of the American Expeditionary Forces. It constitutes, therefore, direct liaison between the division of sanitationand inspection and the laboratories, and is grouped with the latter only because its activities require the occasional mobilizationof laboratory facilities and because its personnel should be capable of directing on the spot any laboratory workwhich the thorough study of any given situation may require. While operating from the laboratories as bases, therefore,this subdivision constitutes actually a part of the machinery of sanitation.
The duties of the subdivision of infectious diseases consistin:
1. Epidemiological and laboratory studies of outbreaksof transmissible diseases in the American Expeditionary Forces, having as primary purposes the discovery of source of outbreak,its mode of dissemination, and its control.
2. The study and organization of new prophylactic measures.
3. The investigation of special problems which may arisein connection with the control of epidemics.
4. The inspection of laboratories in so far as their diagnosticwork, carrier examination, and epidemiological work are concerned.
5. The organization of mobile laboratories for epidemiologicalwork in base sections.
6. The preparation of circulars and literature concerninginfectious disease for submission to the chief of the division of sanitation and inspection, laboratory, and infectiousdiseases.
7. Advisory cooperation with the various sanitary andmedical authorities in the hospitalization and isolation of infectious diseases.
Organization.-There will be a central office ofthis subdivision at the central Medical Department laboratories, A. P.O. No. 721, American Expeditionary Forces, which will be in charge of officersdelegated to this work by the director of laboratories.
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The activities of this office will include:
(a) The selection of personnel to carry on thework of the subdivision.
(b) The supervision of the work of this personnelwhenever necessary in a given outbreak.
(c) Periodical inspection of the laboratories ofthe front area in regard to their work on infectious diseases, and similarinspection of other laboratories of the American ExpeditionaryForces when so instructed by the director of laboratories.
(d) The maintenance at the central medical laboratoriesof records of the activities of this subdivision.
(e) The study of special problems that may arisein connection with transmissible disease.
(f) In the advance section and zone of the advance,the officers assigned to the work will keep in constant touch with the incidence of infectious disease and personally investigateany focus which seems to them or to local authorities to call for investigation. They will personally undertake similarinvestigations in the base sections when instructed to do so.
There will be assigned to the base laboratory in eachbase area and to each army laboratory an officer who is ready to carry out similar work in his respective area at the directionof the division of sanitation, inspection, laboratories, and infectious diseases. He will be ready to proceed to any point inthe base section when notified by the chief surgeon of the section to do so. His orders will come through the commanding officerof the base laboratory to whom he will be responsible for the proper performance of the laboratory work and the return ofthe property he may take with him. He will take with him from the base laboratory a mobile laboratory car or any material andpersonnel he may require for the particular work to be done. If, in the opinion of the authorities concerned, any situation becomessufficiently grave to require advisory cooperation of the officers in charge of infectious diseases at the central medicallaboratories, a telegraphic request will be made on the central medical laboratory and the director of laboratories will sendone of the officers in charge of the subdivision of infectious diseasesto the point where advice is needed.
In the advance section and zone of the advance similarpersonnel will be assigned for similar purposes to the Army laboratories. But in addition to this, these areas beingdirectly accessible to the central medical laboratories, the officers assigned as assistant directors for infectious diseaseswill keep in constant touch with infectious disease occurring in these areas and proceed without further orders to any pointwhere infectious disease is reported, in order to investigate whether further study, segregation, etc., is needed.
Suggested mode of procedure.-When the occurrenceof cases seems to call for the detailed study of local conditions, orders will be issued to the officer stationedat the respective base laboratory who will proceed to the station indicated. On arrival, he will report to the local chiefsurgeon and will familiarize himself with local laboratory facilities andarrange cooperation with local laboratory personnel.He will consult local sanitary officers and obtain a careful history ofthe outbreak from its beginning, will visit commands andquarters from which cases have been taken, make spot maps of occurrence, trace contacts, and investigate relationsof case to case. He will study relations of outbreak to water and food supply and will proceed to organize and carry out anylaboratory work or serum tests necessary to elucidate the situation and control the disease.
In consultation with local medical authorities he willinaugurate sanitary measures aimed at control of the disease and on completion of the work will submit a report, incorporatingspecific recommendations. A duplicate copy of this will be sent to the chief of the division of sanitation and inspection,laboratories, and infectious diseases. One copy will be left with localchief surgeon, and one will be retained as a record of thesubdivision of infectious diseases.
In the advance section and zone of the advance, the officersin charge of the subdivision of infectious diseases will supplement this system by visiting as promptly as possible all locationswhere infectious disease is occurring, and determine by personal investigation whether the situation requires specialstudy.
The duties of this section as finally prescribed were published in CircularNo. 40, chief surgeon's office, July 20, 1918. (SeeAppendix, p. 958.)
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It was not proposed that this section would engage in research, exceptin so far as the study and suppression of outbreaks of disease necessitated. Its primary purpose was the early discovery offoci of infection, the prompt tracing of cases to the point of their infection, and the suppression of diseases traced in thismanner before they could reach epidemic proportions.1
Though the foregoing plans had been formulated for the development ofthis section of the director's office, no personnel was at first available to carry these into effect.4 Such outbreaksof epidemic diseases as did occur were investigated by field parties sent out from Army laboratory No. 1 at Neufchateau.4Only four divisions were in France at the end of December, 1917, and the only epidemic diseases requiring investigation by thissection were small outbreaks of meningitis, diphtheria, scarlet fever, influenza, and pneumonia.4 Water supply surveyswere carried out in very considerable portion of the then existing divisional training areas by field parties from Army laboratoryNo.1, and it became evident, from these early surveys, that approximately 85 per cent of the water for drinking purposes wascontaminated. This initial estimate of the water-supply situation in France was confirmed by surveys at a later date.4
All matters relating to transmissible disease were referred to the sectionof infectious diseases, for it was concerned mainly in the investigation of epidemics, development of the organization fortheir control and prevention throughout the American Expeditionary Forces, the preparation of bulletins relating to preventionand control of transmissible diseases, the standardization of methods for combating them, and standardizationof the use of therapeutic sera which were of value in this work.4 Reserve personnel for the investigation of epidemicswas attached to the central Medical Department laboratory at Dijon, and most of the investigations of epidemics conducted underthe control of the director of laboratories and infectious diseases were prosecuted in cooperation with and under the direct supervisionof the commanding officer, central Medical Department laboratory.4 The duties assigned to the divisionof laboratories and infectious diseases by Circular No. 40, chief surgeon's office, and the memorandum quoted above, indicate how closelythe central laboratory and the section of infectious diseases were associated.4In April, 1918, preliminary steps were taken to coordinate the centraloffice of the section of infectious diseases with those engaged in similarservice in the several administrative sections of the Services of Supply.4
Because of rapidity with which American troops arrived and of the largeterritory over which they were distributed, decentralization of the epidemiological service became necessary forproper supervision and prompt action.1 In the original plan it had been contemplated that a standard uniform method of controlthroughout the American Expeditionary Forces would be adopted and that a selected and trained officer qualifiedto make epidemiologic and bacteriologic studies of outbreaks of infectious diseases would be stationed in every sectionof the Services of Supply. Each section epidemiologist was to have available a main laboratory adequately equipped for theperformance of any diagnostic or other laboratory work. It was expectedthat this officer ordinarily would handle problems arising in his sectionbut that in emergencies he would obtain extra personnel and equipment fromthe director of laboratories
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and infectious diseases.1 Later, after conferences with medicalrepresentatives from the various administrative sections of the Services of Supply, and after receipt of their replies to a circularletter sent them concerning the adoption of methods for control of infectious diseases, a somewhat different plan for the organizationof epidemiologic service in these sections was formulated.1 This plan, which was generally adopted, withsome variations to meet particular local problems, provided that the severalsections of the Services of Supply would solve their respective problems.1However, in each section an epidemiological service with laboratory facilities was established,and though each such epidemiological service operated more or less independentlyof the central administration of the division of laboratories and infectiousdiseases, it called upon the central laboratory for advice, personnel,and material, whenever needed, and was in constant communication with it.1
Also it had been planned that in the advance section and zone of thearmies the epidemiologic work would be centralized at the office of the director of laboratories and infectious diseases,that through the office of the respective chief surgeon, the director would be kept constantly informed concerning the incidenceand location of infectious diseases, and that he would have sufficient personnel and mobile laboratory equipment immediatelyto give assistance where necessary.5 In point of fact the controlof infectious diseases among troops in the army zone remained under thedirect supervision of the director of laboratories until the later summer months of 1918.1
Arrangements for the prevention and control of epidemics among the troopsin the zone of the armies utilized and expanded resources and methods already provided by Tables of Organization.5The division sanitary inspector, as assistant to the division surgeon was, as theretofore, primarily responsible for thehealth of the division. He attended to all ordinary matters affecting sanitation in which duty he was assisted by two officerspreviously not provided in our service, viz, the laboratory and water supply officers.5 The divisional laboratory officerwas in charge of a small laboratory equipped for clinical pathology butinadequate for extensive cultural work; the divisional sanitary inspectorof water, who had had some training in general bacteriology, performedexamination of water supplies.5 As soon as resources of personnelpermitted, these officers, intended for these positions, were given anintensive course of training at the central laboratory at Dijon, beforethey were assigned to divisions.5
Some divisions came to France without laboratory officers, but theywere furnished them after arrival from personnel assembled and equipped by the section of infectious diseases.1
It was intended that the divisional laboratory officer should act notonly as a technical laboratory worker for the division but should assist the sanitary inspector in making epidemiologic surveysand sanitary inspections.1 It may be said, in passing, that in many cases this could not be effected because of the lack of transportation.1Thisdivisional organization was quite adequate under ordinary circumstancesto deal with conditions that threatened the health of the troops, but becauseof insufficient laboratory equipment and shortage of personnel, it wasnecessary in any considerable outbreak of communicable disease to sendreenforcements.1
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The duties of the division sanitary inspector of water were reducedto their simplest forms. He supervised the chlorination of drinking water in the division, gave appropriate instructions, keptin touch with any water problems that arose, and constantly reported concerning the purification apparatus available.1Laboratories adequately equipped for the examination of all water supplies were not available for issue to the divisions.1
Because of insufficient personnel and laboratory equipment in a divisionwherewith to combat epidemics, Bulletin No. 32, G. H. Q., A. E. F., May 27, 1918, was issued, which provided that suchresources could promptly be augmented whether troops were in the lines or in training areas. This bulletin authorizedan army or division surgeon to communicate in emergencies directly with the director of laboratories and to requestassistance; the director of laboratories was authorized to send such personnel and equipment as might be necessary, and to cooperateto the extent of his resources.
The section of infectious diseases was active throughout the advancesection and assisted in the control of outbreaks of diphtheria, scarlet fever, measles, meningitis, influenza, and diarrhea,employing in this service additional laboratory personnel and equipment; e. g. mobile laboratory cars, constructed and completelyequipped according to the English plan (with some modifications) for the investigation of such epidemics as might arise.1Usuallythey were manned by one commissioned officer, a driver and a technician,dispatched on telegraphic requests either from the central Medical Departmentlaboratory at Dijon or from Army laboratory No. 1, at Neufchateau (whereone of these cars was stationed), according to the area from which therequest was received.1 Sometimes the local laboratories of baseor evacuation hospitals were utilized, and additional resources were dispatchedin response to telegrams to the director of laboratories at Dijon.1
To further meet the requirements of field investigations of outbreaksof epidemic disease the laboratory service began, about April, 1918, to assign to duty at the central Medical Department laboratoryspecial, well-trained medical officers whose primary duty was the direction of field parties engaged in the investigationof epidemics.4 Usually there were from two to four such officers engaged in activities of this character. There were alsomobilized at the central laboratory for use by these parties several speciallaboratory units consisting of equipment packed in chests and two of themotor laboratories mentioned above.4
Laboratory methods securing early diagnosis, detection of carriers,and practical measures of control of infectious diseases were standardized and put into general operation.5
In July, 1918, American troops actively engaged in the Chateau-Thierrysector suffered very extensively from diarrheas and dysenteries.5 During the period from July to November, 1918,the activities of this section were greatly decentralized so that by November its functions were mainly those of adviser to the chiefsurgeon's office in general policies relating to the prevention and control of transmissible diseases.4
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Meanwhile decentralization had continued so that the several administrativesections of the Services of Supply were relatively independent of central supervision and in each a special base laboratoryhad been established.1
As American troops concentrated in the advance section and in the zoneof the Army, and more and more divisions began to participate actively in combat, other daughter organizations were splitoff from the central office of the section of infectious diseases, to serve the several corps or armies.1 It wasdecided, as the result of experiment, that these organizations should belong to armies rather than to corps.1 Therefore a sanitaryinspector was assigned to the Second Army and a system similar to that in the administrative sections of the Services of Supply wasput in operation but modified to suit moving troops. In consequence, the sanitary organization of an army also became largelyindependent, (except for personnel and laboratory supplies) of the central office.1 When the Third Army wasorganized, for the occupation of the American sector on the Rhine, a sanitarydivision was created, as part of the office of the army surgeon.1Theduties of the section of infectious diseases in so far as the Third Armywas concerned, pertained especially to coordination, supervision, inspection,advice, and provision of personnel and equipment.1
As a result of this sectional organization, with trained men in definiteareas or assigned to service of bodies of troops, and the aid of mobile laboratories, it was possible to render prompt assistance,make surveys for carriers, correct sanitary defects, and materially aid in the prevention and suppression of epidemics.5Numerous investigations were made of outbreaks of measles, meningitis, influenza, pneumonia, diarrhea and dysentery,typhoid and paratyphoid fevers, scarlet fever, diphtheria, and similar diseases. The sources were sought out and recommendationsfor their control made.
Concurrent with the development of its field service the section ofinfectious diseases prepared circulars pertaining to control of infectious disease, and conducted instructional work.1This latter activity which at first was limited to consultations with laboratory officers intended for assignment to divisions, developedinto a course of instruction in carrier investigation and other techniqueneeded in field work concerning communicable diseases and the supervisionof drinking water.1
When the armies had been organized with epidemiological facilities thisservice, for all the larger units of the American Expeditionary Forces, had become decentralized.1 Thereafterthe duties of the section of infectious diseases were more of a supervisory and advisory character than those of actual participationin the solution of problems, as they had been formerly.1
The section of infectious diseases continued to act as adviser of thechief surgeon, A. E. F., in the formulation of broad policies of sanitation,and in the circularization of information relative thereto, until it wasabolished.1 Its activities were absorbed into the chief surgeon'soffice after headquarters of the division of laboratories moved to Toursin June of 1919.1
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SECTION OF WOUND BACTERIOLOGY
After a study of bacteriologic investigation of war wounds as conductedby our allies, and a survey of the organization employed for this purpose, at La Panne, Bouleuse, Epernay, and Chalons,a section charged with the supervision and correlation of such work in the American Expeditionary Forces was establishedin the division of laboratories in March, 1918.6 Its purpose was to be the dissemination of informationon this subject and the determination of the circumstances under which a delayed primary or secondary suture of a wound mightbest be performed. Secondary and delayed primary closure were being practiced among our allies only after laboratoryfindings indicated the advisability of such practice and the provision of personnel and equipment for obtaining similar findingsin the American Expeditionary Forces was deemed advisable.6
The scientific value of the examination of war wounds was subordinatedto practical needs in the organization of this section, for few statistical data apparently were being collected by the laboratoriesof our allies where research work was being conducted. The prime services rendered by this section were assistanceto surgeons who had not had much experience in treatment of war wounds, the provision of a control which would complementprofessional acumen of the more experienced surgeons, and, in time of stress, would relieve them of making closestudies which otherwise would have been necessitated clinically.6
It was planned that a trained wound bacteriologist and an assistantwould be assigned to each mobile, evacuation, and base hospital, and that this personnel would be increased as resources ingeneral laboratory personnel permitted. This additional personnel was to be organized in teams which were to be transferredas required. The entire service of wound bacteriology was to be under the control of an assistant to the director of laboratories,who was to provide, train, and distribute these specialists, supervise their activities and conduct appropriate research.6Itwas planned that a statistical bureau would collect data concerning the bacteriology of war wounds from all hospitals inthe American Expeditionary Forces and that an agency which would distribute literature on this subject would also be established.Studies at the central laboratory were to supplement those in the several hospitals and the central laboratorywas to prepare and distribute media and reagents both in order to lessen the work of the laboratories at the front and in orderto standardize materials. Such research as was to be
conducted was to be of immediate practical value.6
But these plans did not fully materialize: The paucity of officers didnot permit the formation of teams as planned; lack of transportation prevented the central laboratory renewing prepared media,ingredients for media being substituted therefore.
Officers who, in their replies to a questionnaire, were found to havethe necessary training in general bacteriology were ordered to the central laboratory at Dijon where they were given anintensive course in wound bacteriology. This comprised laboratory instruction, autopsy demonstrations, and a certain amountof training at the bedside. Classes consisted of about 20 officers, whosecourse of training lasted two weeks. The number instructed at the centralMedical Department laboratory totaled 134.6
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A few officers were trained at other points, viz, 7 at Epernay, 6 atAutochir No. 21, 7 at Evacuation Hospital No. 1, and 4 in hospitals belongingto the Allies. When the armistice was signed, officers trained in woundbacteriology were assigned to all evacuation, mobile and base hospitalsexcept the most recent arrivals and a few of the hospitals serving at hospitalcenters. The number of wound bacteriologists thus assigned were as follows:6 Evacuation hospitals, 16; mobile hospitals, 13; Red Cross military hospitals,10; base hospitals operating separately, 18; base hospitals in hospitalcenters, 66.
Though there was inadequate time to work it out, the plan was to provideone officer trained in wound bacteriology for each 500 surgical beds and recall from time to time officers already instructedto receive further instruction in newer methods and to discuss their severalproblems, administrative and professional.6
The most difficult problem experienced by this section was the preparationof records and the collection of statistical and other data. Two blankforms were devised, one relatively very brief for use in periods of stress,the other more thorough, to be used in periods of relative quiet, but onlya relatively small number of organizations found it possible to collectfairly complete records.6
A monthly statistical report form was also called for but this was utilizedby only a small number of organizations. These units, however, went far toward collecting the information desired.6
Special investigations concerning gas gangrene, the use of antigas gangreneand antitetanic sera, and the possible infection of wounds by attendants were undertaken. Research seeking the recoveryand identification of organisms concerned in wound infection and the value of certain smears and indicators was also undertakenat the central laboratory.6
On October 29, 1918, the head of this service reported as follows tothe director of laboratories:6
At present the central organization of the section ofwound bacteriology is still undermanned. While an adequate number (consideringthe number of laboratory officers in the American Expeditionary Forcesand the needs of other sections of this division) of wound bacteriologistsfor service in the field is now available, the administrative force inthe central office is inadequate properly to control the work of the officersin the field, to analyze and arrange the statistical evidence which israpidly accumulating, and finally to verify the identification of bacterialspecies recovered from important cases.
The most important single need of this section is an officerwith considerable laboratory experience whose duty it will be to make frequentinspections of all the laboratory units engaged in the bacteriologic studyof war wounds with a view of determining the efficiency of the workersin this field, of raising the standards of the work done by correctingobvious defects and stimulating enthusiasms for this particular work, bothamong the laboratory officers and among those engaged in the surgical careof the wounded, and finally of collecting data which might serve as a basisfor the improvement of the service. The rapid increase in the number ofhospital organizations in the American Expeditionary Forces and the extentof the area which they occupy makes such additional assistance necessary.
Two additional officers to conduct research concerning the bacteriafound in wounds, an officer to analyze reports received, and two file and record clerks for headquarters were also required.These needs were obviated by the declaration of the armistice on November 11 and the section as such submitted its finalcomprehensive report on December 4, 1918.6
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REFERENCES
(1) Report on general plan, organization, and developmentof the section of communicable diseases, A. E. F. (undated), by Lieut.Col. Hans Zinsser, M. C. On file, Historical Division, S. G. O.
(2) Letter from The Adjutant General of the Army to Lieut.Col. Richard P. Strong, M. C., December 1, 1917. Subject: Appointment asassistant director of laboratories. On file, A. G. O., World War Division,chief surgeon's files, 201 (Strong, Richard P.).
(3) Report on division of laboratories and infectiousdiseases, subdivision of infectious diseases, A. E. F. (undated), by Lieut.Col. Hans Zinsser, M. C. On file, Historical Division, S. G. O.
(4) Report from Col. J. F. Siler, director of the divisionof laboratories and infectious diseases, to the chief surgeon, A. E. F.(undated). Subject: Activities of the division of laboratories and infectiousdiseases, from August, 1917, to July, 1919. On file, Historical Division,S. G. O.
(5) Report from the chief surgeon, A. E. F., to The SurgeonGeneral, U. S. Army, May 1, 1919. Subject: Activities of the chief surgeon'soffice, A. E. F., to May 1, 1919. On file, Historical Division, S. G. O.
(6) Report on the section of wound bacteriology, A. E.F., December 4, 1918, by Lieut. Col. William J. Elser, M. C. On file, HistoricalDivision, S. G. O.
