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SECTION II
CHAPTER IX.
DIVISION OF INFECTIOUS DISEASES AND LABORATORIES.
ORGANIZATION.
In June, 1917, the Surgeon General directed that a division be organized in his office to include laboratories and that, in addition, the activities of the Medical Department indermatology, urology, and the prevention of venereal diseases be combined therewith. 1 The thought behind the organization of this division was that the control of infectious diseases, at least those of known etiology, was largely a laboratory problem. It was equally apparent that the laboratories were to be but the working arm of the division and that scientific investigation and the inauguration and supervision of methods for the control of infectious diseases constituted its real problem. The division was therefore known as the Division of Infectious Diseases and Laboratories.
The division, at the start, was divided into three sections: Laboratories, Dermatology and Urology, and Combating Venereal Diseases. A reorganization was effected on November 30, 1918, whereby the Section of Dermatology and Urology was transferred to the Division of Surgery, 2 the Section of Epidemiology of the Division of Sanitation was transferred to this division, 2 and the Army Medical Museum with the Instruction Laboratory, Medical Depart- ment, was placed in this division. 2
The Section of Epidemiology was a most valuable addition, but its possibilities in this connection were not fully realized until very late in the war. That they were realized ultimately, and that, in consequence, the Section of Epidemiology of the Division of Sanitation was made a part of the Division of Infectious Diseases and Laboratories, is of great interest from the practical standpoint as indicating that, as the result of experience, this organization would probably obtain in future wars rather than having the section in question a part of the Division of Sanitation, as was the case in the World War. What has just been said regarding the Section of Epidemiology applies equally to the Army Medical Museum with the Instruction Laboratory. Both of these sections functioned in another division during the World War, however, so their story must be told there and not here. (See Chap. XXIII.)
The Section on Dermatology and Urology, on the other hand, was probably wrongly placed in the Division of Infectious Diseases and Laboratories, yet as it actually functioned here its administrative history finds its proper place in this chapter.
The administrative history of this division may seem to be more or less confused with that of the Division of Sanitation. Indeed, since the purposes of the two divisions were identical, in that each had for its principal object the prevention of disease in troops, it was difficult to draw a hard and fast line between them in the delegation of war-time function. Nor, as a matter of fact, did a fixed
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line of demarcation exist. Overlapping of effort was inevitable, and confusion was prevented only by frequent conferences between the divisions or sections thereof and by the exercise of a spirit of cooperation. It is not impossible, however, to show where the line was drawn between the two divisions in theory and in the main in practice. The Division of Sanitation was the executive division so far as measures taken by the Medical Department for the prevention of dis-ease in troops were concerned, while the Division of Infectious Diseases and Laboratories concerned itself with scientific study of disease in troops in the United States, and, based on this, made recommendations for its control. After all, the relation between the two divisions was not so different from that which exists between a city board of health and its laboratory, the Division of Sanitation representing the board of health and the Division of Infectious Diseases and Laboratories, the municipal laboratory, though the latter division, in its investigations of disease, by o means confined itself to laboratory procedures, as would be the case with the city laboratory. The Division of Infectious Diseases and Laboratories, like the Division of Sanitation, had certain sections which seemed to be remotely, if at all, concerned with their main object. This is true, and the fact must be accepted. The causes are actually not very hard to find. The expansion of the Surgeon General`s Office was enormous and rapid and, in consequence, some sections were placed where it was most convenient to administer them rather than where they logically belonged. The various functions are shown in Charts IX and X. Time would have corrected this condition and, as a matter of fact, had already done so in part, notably by the office reorganization of November, 1918. (See Chart XXIV.)
LABORATORY SECTION.
Progress in medicine in the decade preceding the World War is conceded to have been the greatest in the lines covered by technical laboratories, exceeding even the advances made in the surgical treatment of disease. Problems of diagnosis and treatment had been studied intensively by experienced laboratory investigators, both in this country and abroad, with encouraging advances in methods of diagnosis and treatment.
Prophylaxis against typhoid fever was made compulsory in our Army in 1911. 3 Ability to control this disease was well established during the mobilization on the Mexican border in 1911. The Medical Department felt confident that this disease would be a negligible quantity during the war. Some fear was felt that the dysenteries, particularly the bacillary types, would give some trouble. Their prevention by specific treatment had not been accomplished, but since their epidemiology was known it was believed that better sanitary appliances, plus personal hygiene, together with approximately accurate methods of laboratory diagnosis, would make possible the control of this group of diseases. In the history of all wars of which we have medical records of diseases affecting troops, two groups of disease are found of serious moment. These are first, intestinal diseases, and second, the sputum-borne infections; i. e., diseases at present conceded to be transmitted by means of discharges from the respiratory tract. With the intestinal group under control, as has already been indicated to have been the case, it appeared that our chief problem
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Chart IX.--Division of Infectious Diseases and Laboreatories, Surgeon General`s Office, June, 1918.
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Chart X.--Section of Combating Venereal Diseases, Surgeon General`s Office, June, 1918.
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during the war would be the sputum-borne group, including such diseases of both known and unknown etiology.
It was an encouraging fact that in the years just previous to 1917 considerable advances had been made in the study of the sputum-borne group, more particularly by the laboratories of the Rockefeller Institute Hospital in New York City. The diseases of this class of particular importance to the Army, in which extensive work had been done by the institute, were meningitis and lobar pneumonia. Yet the procedures required to make a diagnosis of these diseases were much more elaborate than had been contemplated previously or field laboratories, and required (particularly because of their recent discovery) special training in their technique of nearly all laboratory men available to the Army. In the past it had been possible for one laboratory officer, with a small force of enlisted assistants, more or less trained, to handle the laboratory work, including complement fixation reactions, for an entire Army department, which might contain from 10,000 to 50,000 troops. It was safe to conclude that the new procedures for the sputum-borne or respiratory group of diseases would necessitate at least a trebling of the personnel formerly required, and that they would have to be done at the various places where troops were stationed and could no longer be handled from central points.
The problems confronting the Laboratory Section, therefore, were those of providing adequately trained personnel in considerable numbers; of securing, in the construction plans for hospitals, cantonments, etc., adequate space for laboratory work; and of seeing that an adequate supply of technical apparatus and materials for this work was made available for the use of these laboratories.
PERSONNEL.
At the beginning of the war activities the laboratories of the Army capable of doing extensive work were six in number, viz: The laboratories of the Central, Southern, Philippine, and Hawaiian Departments; that at the Letterman General Hospital, Presidio, San Francisco; and the Army Medical School, Washington, D. C. Their combined officer personnel was about 12.4
With the entire medical profession of the country to draw upon, it seemed at first sight an easy matter to obtain sufficient men, adequately trained, to man the numerous laboratories which must be established. However, the procedures made necessary by the recent advances in scientific medicine were as new to the majority of physicians in civil life as to the officers of the Army. As a mat-ter of fact, the percentage of officers from civil life trained in the recent laboratory methods was probably even less than was the case in the Regular Army, as the eight months` period of instruction required at the Army Medical School before the war had familiarized all newly appointed regular officers with this work. In order to choose officers to man the laboratories of the Army, with the aid of the Medical Division of the National Research Council, a list was prepared which contained the names of physicians whose records showed that they had had considerable experience in laboratory work. These doctors were corresponded with, and as rapidly as possible were placed on active duty in the various laboratories. It soon became apparent, however, that it would be necessary to augment this list by going over the application papers of all physicians applying for commissions in order to select from them all who had had any
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experience in laboratory work, as shown by their questionnaires. But even if all of these men had been released for laboratory duty the number would still have been very insufficient to carry on the work. It became necessary, therefore, to establish laboratory training schools for officers and enlisted men, for alike necessity existed respecting the latter.
The Army Medical School, in addition to concentrating its regular course into a shorter period, increased its capacity for training students by adding to its curriculum special courses for laboratory men, both commissioned and enlisted. A special laboratory school was established at the laboratory of the Central Medical Department, Fort Leavenworth, Kans.5 This school, which soon became the most important one, was transferred on August 1, 1918, to buildings at New Haven, Conn., offered by Yale University. 6 The university erected for this school a temporary laboratory building at a cost of $40,000, in addition to opening most of the dormitories for barracks. A training school and auxiliary laboratory was also established at the Rockefeller Institute, and such members of the personnel of that institute as were necessary to do the Army work were commissioned or enlisted in the Army. 7
Until the transfer of the Leavenworth school to New Haven, Conn., laboratory units for overseas service were formed at the Army Medical School, at the Rockfeller Institute, and at the laboratory at Fort Leavenworth. There-after all laboratory units were organized at the New Haven school and held there until orders were received for overseas transportation. This change was of value and greatly facilitated the handling of personnel. The officer in command of that institution, having during his entire service specialized in scientific work and having for several years been a member of the faculty of the Army Medical School, understood the requirements of the laboratory service and relieved the division of the selection of personnel-always so hard to accomplish with only data and names available. Furthermore, a training school in laboratory work was established at the Medical Officers` Training School, Camp Greenleaf, Fort Oglethrope, Ga., and training courses were carried on in the laboratories at most of the camps, that at Camp Devens, Mass., being one of the most active in this direction. 8
The organization of the Sanitary Corps 9 offered an additional opportunity to obtain men already trained in laboratory procedures. While such men did not hold the degree of doctor of medicine, many of them were highly skilled in both chemistry and bacteriology. Some of them were commissioned directly in the Sanitary Corps, while others were inducted as enlisted men, subsequently trained in the schools, and then, if found suitable, commissioned on graduation or sent out as laboratory technicians in enlisted grades.
In the early fall of 1917 the outbreak of large numbers of cases of measles, many with subsequent pneumonias, and the occurrence of rather numerous cases of meningitis, made it evident that all the measures which had been taken would be in adequate to furnish the laboratories with sufficient trained personnel. Therefore, with the aid of the Medical Division of the National Research Council, 10 schools were established and courses were standardized for training nonmedical women as laboratory technicians. 10 The principal schools so concerned were the Rockefeller Institute, where training courses
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in chemistry and bacteriology had already been established for officers and enlisted men; the New York City Board of Health; and the Massachusetts Institute of Technology.
The following table indicates the movement of laboratory personnel during the last five months of 1918, previous to which time no accurate records are available. 11
At the end of November, 1918, the following personnel were on duty in the laboratory service; Medical officers, 945; Sanitary Corps officers, 405; female technicians, 398; contract surgeons, 6.11 Of the trained personnel numbering 1,335, 766, or 57.4 per cent, had been sent overseas. Many more were designated for overseas service and had been separated from home units but did not proceed because of the signing of the armistice. The number of trained personnel sent overseas was augmented there by the Laboratory Division of the expeditionary forces through the addition of officers, already in Europe, who had had laboratory training, and through additional training to officers not so qualified.
The need for so large a personnel may be appreciated by studying the following detailed tabulations of the work of the laboratories during the busiest period, from the laboratory standpoint, of our participation in the war. 12
Certain base hospital laboratory examinations during the months February to June, inclusive, 1918.
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Tabulation of laboratory examinations for month of March, 1918 (57 laboratories). 13
After the 1st of December, 1918, the effect of demobilization became apparent and on January 2,1919, the total laboratory personnel was 1,493; February 1, 1,333; November 1, 1,279; April 1, 1,194; May 1, 1,130; June 1, 908; July 1, 836.13
During 1918 the laboratories of the camp base hospitals were urged to co- operate in the training of both officers and enlisted men for overseas duty, while the classes at the Army Medical School and Yale Laboratory School at New Haven, Conn., had over 600 enlisted men in training as technicians, some of whom would have been qualified later for commissions in the Sanitary Corps. The arrival of a liaison officer from the Central Medical Department Laboratory, American Expeditionary Forces, in September, 1918, materially aided in the standardization of the courses, so that officers and men might be better trained for the duties they would have to perform in France, and also aided in the standardization of equipment for mobile or transportable laboratories to be sent over for field work.
During the influenza epidemic in 1918 the laboratory schools were practically closed, as it was necessary to send the students to duty in camps and civil communities because of the scarcity of physicians.
In the Army hospitals a step forward was made when the office of chief of the laboratory service was made coordinate in standing and authority with those of the chiefs of the medical and surgical services. Prior to this many young men, finding promotion impossible in the laboratory, had left it for clinical work in medicine and surgery. This was now changed so that a laboratory man might still work in his special line and yet be promoted.
During the year 1918 arrangements were made for the instruction of medical officers in pathology at St. Elizabeths Hospital, Washington, where an average of 600 autopsies are performed yearly, and also at the Brady laboratories of the New Haven Hospital. 11 At the latter pathological technicians were also trained and a considerable number were distributed to hospitals in this country and abroad. Some received further instruction in neuropathology at the Army Medical Museum and were then sent to hospitals for the treatment of nerve injuries.
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At no time during the war was there a sufficient number of trained pathologists in the service. In spite of efforts to train additional men by the arrangement of special courses of instruction, the number of qualified patlhologists could not be greatly increased during the war. The same condition seemed to exist in civil life, for it proved impossible to find a sufficient number of trained men. It was evident that something was needed to make the calling of pathol-ogists more attractive than it had been in the past
CONSTRUCTION.
At the outbreak of the war, through cooperation between this division and the Construction Branch of the Hospital Division, plans were drawn for the laboratories of the various hospitals to be constructed throughout the country, while additions were planned to the laboratories already available in permanent Army hospitals. These camp laboratories, planned for camps of 10,000 men, with a hospital bed capacity of 500, sufficed during the summer of 1917, when the ingress of troops was not particularly rapid and the season was that of least prevalence of the respiratory group of diseases. When fall came drafted troops began arriving in camp in large numbers, and as the rate for respiratory infections increased coincidently, it soon became evident that the camp hospital laboratory facilities would have to be increased. Additional space was obtained by taking over the entire wing of a building which had been shared previously with the eye, ear, nose, and throat department by nearly doubling its length and by building independent animal houses. The laboratory space thus provided was found to be adequate except in some of the largest camps, where the total strength ran over 50,000 troops. For these camps, which did not reach their maximum capacity until the latter part of the war, plans were developed for the construction of independent laboratory buildings. Because of the cessation of hostilities only a few of these were constructed. That at Camp Mills was found to be adequate for its purpose.
SUPPLIES.
Prior to 1914 a very large percentage of the supplies for technical and laboratory work had been obtained by the United States from the German and Austrian manufacturers. This source of supply was to a large extent cut off in 1914, but reserve stocks in bonded warehouses in this country served for most ordinary purposes up to the time of our entry into the war, when this reserve had become practically exhausted. American manufacturers, by this time, had taken up, to a certain extent, the manufacture of chemicals hitherto obtained abroad, and authority to manufacture certain articles under German patents was held by American branches of German concerns; but the manufacturers of such materials in this country were in no way prepared to meet the tremendous demand for supplies of technical apparatus made necessary by our entry into the war. Furthermore, these had increased in number and variety through recent advances in technical procedures. At the outset of the war the Council of National Defense, working in conjunction with the War Industries Board, prepared lists of supplies for the purpose of standardizatizon of technical equipment and material for the Army. 15 The approved articles were placed on the manufacturers` priority lists for materials by the
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War Industries Board, and their manufacture was begun. It soon became apparent, however, that for the more technical procedures of absolutely necessary laboratory work, entirely new types of products, in quantities hitherto unthought of, must be supplied. A revised list of laboratory supplies, therefore, was prepared by this division in conjunction with the officer in charge of the field medical supply depot in Washington, and this was distributed to the manufacturers and to the service. 16 Adequate supplies of such material were not available for issue until the middle of 1918.
It had been the Army practice in the past to carry stocks of all ordinary supplies, including laboratory material, in the various medical supply depots and to supply the posts from the nearest supply depot. 17 Certain supplies were habitually purchased by officers in charge of the supply depots nearest the source of supply. This method continued during the early part of the war, but it soon became apparent that any officer whose duty it was to handle laboratory supplies must also have such special knowledge of laboratory material as was obtainable only by having worked with the material in question. Only one such officer was in charge of a supply depot. This depot was in Washington. This officer, at the beginning of the war, was on the faculty of the Army Medical School in the Laboratory Division, and was thoroughly familiar with all types of laboratory apparatus. On duty with him were men who, in the early months of the war, had been trained under his direction in the handling of laboratory material. It was decided, therefore, to concentrate laboratory supplies at the Washington depot.18 This action was the more essential from the necessity of furnishing the American Expeditionary Forces a standard transportable laboratory equipment in chests, which, replacing the inadequate field laboratories of the period before the war, would be adequate for all ordinary laboratory procedures.
Three laboratory cars, Metchnikoff, Reed, and Lister, were purchased through the Red Cross and were utilized throughout the war. They were found to be extremely valuable for emergency work, proving superior in this respect to any other mobile or transportable laboratory then available, and were thus very satisfactory agencies in the control of epidemics of infectious diseases in situations where no well-equipped laboratory was on the ground.
STANDARDIZATION OF TECHNIQUE.
At the very beginning of the work of the division, it seemed advisable to institute measures which would result in standardizing the technique used throughout the laboratories of the Army to such a degree as would make results from different parts of the country comparable, but at the same time to allow individual officers to use their own ingenuity and any particular ability they might possess to simplify accepted procedures, and to elaborate new methods which might be found of value in diagnosis and treatment. By way of standardization, the officers of the Rockefeller Institute published Monograph No. 7 of that institution on the subject of "Acute Lobar Pneumonia, Prevention and Serum Treatment." This monograph which, at that time, was the last word on the diagnosis and treatment of pneumonia, contained detailed descriptions of the necessary laboratory technique. Early in 1917, a monograph, entitled "Mode of Infection, Means of Prevention, and Specific Treatment of
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Epidemic Meningitis," was published by the same agency on request of the Surgeon General. At a somewhat later date, following a conference with the Surgeon General, a standard technique for the isolation of the meningococcus was adopted and pamphlets describing this procedure were distributed. 19 Following another conference a similar circular was distributed describing the technique for isolating the types of streptococci. 19 These standard methods were adopted by the Army, the Navy, and the United States Public Health Service and by the majority of civil laboratories.
During the same period, and continuing throughout the year 1917, data were gathered together for a laboratory manual to be distributed throughout the service and to cover, in a sufficiently comprehensive way, the technique of the more important procedures to be used in laboratory diagnoses. 20 That this volume might contain the generally accepted methods of procedure in laboratory diagnosis, men who had specialized in each branch of laboratory work were requested to submit what they considered the proper technique for the procedures with which they were most familiar. Its value was apparent, and the rapid changes which had occurred between the time the manuscript was sent to the printer and the publication of the completed work made it advisable to prepare at once a second edition. From time to time, as new methods of laboratory procedure were developed and their value demonstrated reprints of articles describing them were distributed throughout the laboratories of the service, while circulars describing recent advances and suggesting methods of procedure were occasionally sent out from the Surgeon General`s Office.
SECTION OF INFECTIOUS DISEASES.
SPECIAL DISEASES.
Pneumonia.-Until the first increments under the draft act began to come into the Army, infectious diseases played only that minor role which might be expected from a relatively slow and constant increase in the regular forces. While voluntary enlistments came from all sections of the country, the larger number of these were necessarily from the centers of population where the average inhabitant had already been exposed to the ordinary infectious diseases of childhood. In the fall of 1917, at the beginning of the entrance of drafted troops, infectious diseases, particularly measles and mumps, appeared in epidemic form almost simultaneously at all camps, while at the same time the capacity of the individual camps, because of the contemplated changes in organization, was trebled. Pneumonia, following measles and occurring in dependently, became at once the chief cause of concern and of increased incidence and death rates. It became apparent at this time that an enlargement of the laboratory facilities, both as to size, material, and personnel, was necessary. Reports from the various laboratories indicated that streptococci of hemolytic type were playing a prominent r le in the pulmonary infections. In order that the laboratories might be better prepared to combat these diseases and that their nature might be more fully determined, in February, 1918, the Surgeon General sent a commission to Texas to study pneumonia from the clinical, bacteriological, and pathological aspects.21 Among other work done, the clinical and pathological characteristics of the pneumonia associated with the streptococcus hemolyticus were analyzed.
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The pathology of this form of pneumonia, for which the name "interstitial bronchopneumonia" was chosen, was described and the association of the hemolytic streptococcus, with the pathological conditions which obtained, was demonstrated. A technique was then elaborated for the isolation and identification of this organism from the sputum, nasopharynx, or other sources. The pathology found in these cases was described and published in Monograph No. 10 of the Rockefeller Institute (1919).
On May 20, 1918, a board of medical officers was appointed, by order of the Secretary of War, for the purpose of making investigations as to the nature, causes, prevention, and treatment of pneumonia and its complications in the various camps within the limit of the United States, this board to report from time to time to the Surgeon General of the Army. 22 Many conferences were held by the board, one of the more important being with a group of pediatrists, at which the management of measles and its sequelae was considered. It also reviewed data, obtained from various divisions of the Surgeon General`s Office, on the subject of pneumonia and its sequelae. Methods were considered for the earlier diagnosis and isolation of pneumonia. As a result, groups for the special study of pneumonia were sent to camps where the disease appeared to be especially prevalent, so that it might be studied more intensively and that further trials of the prophylactic vaccination against it might be made.
An experiment on prophylaxis was made at Camp Upton, where about half of the 77th Division was inoculated with a saline pneumococcus vaccine, containing Types I, II, and III.23 During the 10 weeks that elapsed between the completion of this vaccination and the departure of the troops, not a single case of pneumonia of these three types occurred among the vaccinated men, while its incidence among the unvaccinated was higher than during the corresponding period preceding the vaccination. 23 This was deemed a sufficiently strong confirmation of Lister`s findings in South Africa 24 to warrant an extension of the use of this prophylactic measure.
A group of officers practiced the use of prophylactic vaccination on incoming troops at Camp Wheeler, Ga., during September, 1918. However, the appearance of influenza in epidemic form interfered materially with obtaining results from which accurate conclusions might be drawn. During the winter of 1918 and 1919, this group of officers continued their investigations on pneumonia from the experimental standpoint at the laboratories of the Army Medical School. The results of their investigations have materially advanced our knowledge on the pneumonias. 25
Empyema.-During the latter part of February, 1918, reports began to come to the Division of Laboratories and Infectious Diseases on numerous cases of empyema following the pneumonias which had occurred during the preceding months. In March a medical officer was sent to Camp Lee, Va., where he, with officers from the Divisions of Medicine and Surgery, made an intensive study of these cases. Results of their investigations furnished valuable information regarding the treatment of empyema, particularly in respect to the necessity for maintaining a diet of high calorie value. An empyema commission 26 was created, whose studies continued throughout the remainder of the war and for sometime after the armistice. 26
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Sputum-borne disease in general.-In July, 1918, a board of officers was ordered to Camp Funston, Kans., to study respiratory diseases at that place. 27 The investigations indicated the constant presence of influenza bacillus carriers there, and also that there had been an epidemic of this disease at Camp Funston in the spring of 1918. On September 1 this group of officers was ordered to Camp Pike, Ark., 28 and a laboratory car was then sent there as additional equipment. Arriving, as they did, before the outbreak of the influenza epidemic, they were able to study the respiratory infections at Camp Pike as they had at Camp Funston; they were present at Camp Pike during the entire influenza epidemic. The enormous amount of work thrown on the laboratory force during the influenza epidemic made intensive study of this disease, except by the special groups above mentioned, practically impossible. Large numbers of specimens, however, were collected and sent to the Army Medical Museum`, where the study of the pathology of the disease was continued.
Meningitis.-In the fall of 1917 cases of meningitis began to appear. The examination of contacts and other personnel for carriers showed the percentages of carriers to vary in the different camps. This variation appeared to depend on the laboratory technique employed as well as on the location of the camp concerned. Standardization of laboratory procedures at this time proved of extreme value in determining the true carrier percentage throughout the Army. It was soon discovered that the carrier incidence was higher in camps where the civilian incidence in the localities from which the troops came was the highest. 29 This was particularly true for Camp Jackson, S. C. The fear which naturally prevailed when the high carrier percentages were revealed at certain camps sometimes led to the making of carrier surveys of the total personnel of some camps. This resulted in throwing an enormous amount of difficult technical work on the laboratories at those places. Immediately it was necessary to augment markedly the personnel of camp laboratories, to simplify the laboratory procedures, if possible, and to conduct investigations to determine whether such enormous numbers of meningitis examinations were necessary. The work of the chief of the laboratory at Camp Jackson, who used a special technique, seemed to indicate that the percentage of carriers was even higher than any previously reported figures had indicated, in some cases running as high as 60 per cent of an organization. 29 More detailed studies of the organisms found in carriers were then made. These indicated that a large percentage of these carriers were in all probability harmless, and investigations carried out, both in the absence and presence of epidemics, indicated that only occasionally were they responsible for the transmission of the disease. 29
During the latter months of the war experience seemed to indicate that on the occurrence of a case of meningitis the rational procedure was to culture immediately close contacts and to extend the culturing t. others only when it seemed, either from lack of evidence convicting a contact or from the occurrence of other cases of the disease caused by the same type of meningococus, that the focus of infection was outside of the first immediate contact group. It can not be said, however, that this was the universally accepted opinion of all laboratory workers; many still believed that the only safe way to control
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meningitis was to culture the entire camp personnel and to isolate all carriers, treating the latter for the eradication of the carrier condition irrespective of the type of meningococcus found.
Anthrax.-In March, 1918, a soldier developed anthrax while on a transport en route to Europe. 30 The lesion was in the shaving area on the neck. Examination of 15 shaving brushes used by the troops on this transport resulted in the finding of anthrax spores in all the six brushes first examined. Later, from overseas, 14 men were reported with anthrax in the shaving area on the face or neck. All but three had developed the condition while on the same transport. Of the 14 patients, five died. 30 Shaving brushes from the organizations of three of these men on bacteriological examination showed the presence of anthrax spores. In this country the first case in troops occurred at Camp Taylor, Ky. This was in April, and up to June 30, 1918, 20 individuals in the Army in the United States developed anthrax, the lesion in every case being on the face or neck. Among these 20 patients there was one fatality.30
Methods for the disinfection of shaving brushes were tested, that finally adopted being a four-hour immersion in a formalin bath at a temperature of 110º F. 30 A circular calling attention to the necessity for the disinfection of shaving brushes and outlining the proper methods was distributed to all commands. 31 Subsequently, the manufacture of shaving brushes throughout the country was investigated at the instance of the Surgeon General. This investigation was made by the United States Public Health Service, and a list of manufacturers prepared who provided for adequate sterilization of their product. 30 This list was distributed to all commands in order that unnecessary disinfection of brushes might be avoided. The Public Health Service also added an amendment (No. 6) to the interstate quarantine regulations of 1916,to prohibit the interstate transportation of shaving or lather brushes manufactured under insanitary conditions, likewise including anthrax among diseases regarded as contagious and infectious, for the purpose of interstate quarantine. 30 Subsequent to the adoption of the measures mentioned above, no further cases of anthrax were traceable to shaving brushes, nor was the number of cases of this disease reported sufficient to bring the matter up for further action.
Gas gangrene.-In June, 1917, the discovery was announced by the Rockefeller Institute of a true toxin for B. welchii (perfringens). 32 This toxin, upon injection into laboratory animals and horses, had been found to result in the production of a potent antitoxin. Several horses were placed under immunization at once, and in December, 1917, the application of this serum to the treatment of gas gangrene was commenced in France. Before this method was employed by the British at the front the toxin, the antitoxin, and the protective power of the antitoxin were demonstrated in London to the British Royal Army Medical Corps, and, as a result, a large scale production of antitoxin was at once begun in England. 32
Subsequently, it was decided by the central laboratory of the American Expeditionary Forces that the gas gangrene serum might better be used prophylactically and in conjunction with tetanus antitoxin. Furthermore, the work of French investigators had shown that gas gangrene was not caused exclusively by B. wehchii, but that the Vibrion septique (B. edematis maligni)
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was a frequent complicating factor. This organism also produced a true toxin. It was therefore considered necessary to produce as rapidly as possible a double serum, and ultimately a triple serum, tetanus-Welch-septique, these combinations to replace at the earliest possible time the tetanus prophylactic injections which were then given to wounded. Facilities for this being lacking in France, the immunization of tetanus-immune horses with the toxins of B. Welchii and Vibrion septique was initiated in the United States. 33
Quantity yields of the double serum were beginning to be secured in September, 1918, and considerable quantities were shipped to France. 33 This serum was beginning to be used in the period just preceding the armistice, but because of the brief period of time during which it was actually used, its value as a prophylactic measure could not be determined. The conclusion of the armistice stopped this work.
Miscellaneous activities.-The proper sterilization of surgical catgut became a matter of considerable importance early in 1918, as the demand increased and new sources of supply were developed. A standard method of sterilization and of sterility tests were finally agreed upon, and the catgut situation at the end of the year was satisfactory.
Measles investigations were carried out on volunteers at Camp Devens,Mass., and Camp Meade, Md., but all attempts to reproduce the disease by the inoculation of volunteers with blood from measles patients were unsuccessful. 34 It was hoped that opportunities for additional investigations in this line would occur, since during the war measles was one of the most important diseases which the medical officer was called upon to control, but this did not prove to be the case.
Studies on the prevalence of hookworm and other intestinal parasites were carried out at most stations in the Army, but more especially in the South, particularly at Fort Sam Houston, Tex., and at the port of embarkation, Hoboken, N. J. 35 At the latter, comparative studies were made which showed a much higher percentage of infection with intestinal parasites among troops returning from overseas than among men who had not been out of this country.
SECTION OF UROLOGY AND DERMATOLOGY.
With the idea of using all preventive aids and of applying modern scientific methods to the cure of venereal diseases, the Surgeon General appointed a committee of specialists versed in genitourinary diseases and syphilis to act as advisers to the chief of the division. 36 One member of the committee remained on duty in the Surgeon General`s Office continuously and the entire committee met for a discussion of new phases of the work as they presented themselves. The first task of the committee, on its organization, was to prepare a program of attack against venereal diseases, one member being placed in charge of the department of prevention, the department of treatment being undertaken by the committee as a whole. With a view to standardizing treatment, the committee prepared a manual for the use of all medical officers, giving a brief summary of existing knowledge on the subject.37
The next task of the committee was to select personnel to take charge of the venereal work in the camps. The applications of doctors seeking commissions in the medical service were looked over and their qualifications reviewed,
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then they were classified and graded according to experience and professional standing. In assigning such officers to duty, the rule was to send one experienced genitourinary specialist and one or more younger men as assistants to every base hospital and to every large camp. In the base hospitals, urological surgery, venereal diseases, dermatology, and syphilis were combined in one department under one chief. As the number of men with adequate training was found to be insufficient for filling all the positions, it was judged expedient to create an opportunity for the postgraduate instruction of younger men who might elect to work in the genitourinary section, in urology and venereal diseases, syphilis, and dermatology. To this end postgraduate schools for medical officers were established at the postgraduate school at Columbia University, New York, in connection with the Harvard Medical School, and in St. Louis. 38 Later on, these schools were discontinued and all postgraduate courses in urology and venereal diseases were concentrated in the Medical Officers` Training Camp at Camp Greenleaf, Fort Oglethorpe, Ga., so that men entering the service could receive military training and instruction in specialties at the same time. 39
While gonorrhea and syphilis of the ordinary types constituted by far the majority of the cases in the camps, there was always a fair number of other cases requiring experts in urology or dermatology, and an important part of the duty of the committee consisted in supplying such experts as the Army increased in size.
The committee sent out at various times different circulars to medical officers in camps and posts giving advice, suggestions, and instruction. Special inspection trips were made by members of the committee from time to time as emergencies arose. In the early summer of 1918, every camp in the country was inspected by a member of the committee in order that he might ascertain personally the actual conditions which obtained in regard to genitourinary and venereal diseases.
Facilities were provided for the prompt application of venereal prophylaxis, and punishment by court-martial was insisted upon for delinquents. The results were apparently satisfactory.
In order to combine the treatment of venereal diseases by medical officers with the military training of recruits by line officers, development battalions were formed in which venereal patients were grouped and treated in venereal infirmaries. 40 The number of cases of venereal disease among selective-service men finally became so large that in August, 1918, plans for special dispensary in the development battalion of each camp were prepared. 40 In order to avoid constructing new buildings and to use existing structures to the best advantage, these plans contemplated modifications of the standard two-story barracks to meet the needs of a venereal dispensary. At the same time, a full set of instruments and other equipment for the treatment and diagnosis of venereal diseases were furnished. For some time prior to this, officers had been under training in urology and venereal diseases at the special schools in Boston, New York, St. Louis, and at Fort Oglethorpe, and a large number of these officers were now detailed for duty in these dispensaries. It was not uncommon for as many as 2,000 cases a day to be treated in one dispensary.
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In 1918, in the opinion of the consultants in this office, the experience of the venereal disease service justified a new issue of the "Red Book," or Manual of Treatment of Venereal Diseases, first published early in 1917. The second edition was published in 1918, and distributed to all urologists in the service. The publishers (American Medical Association) reported a large demand for the book among the civilian profession, and early in 1919 a third edition was prepared and published for civil use and for the benefit of the United States Public Health Service, which adopted the manual for use in its own hospitals and in those aided or supervised by it. 37
While the arsphenamine manufactured in this country soon became fully as good as the product formerly obtained from Germany, nevertheless deaths were reported from time to time following its use. In cooperation with the Army Medical School and the hygienic laboratory of the Public Health Service, it was arranged to raise the permissible minimum lethal dose for small animals to about double that shown by the German salvarsan in this country at the outbreak of the war. The manufacturers willingly com-plied with this request, and early in 1918 the arsphenamine situation was more satisfactory, both as to quality and quantity of the drug, than it had ever been before.
SECTION OF VENEREAL DISEASE CONTROL.
The campaign against venereal diseases which was initiated in 1909, and which was vigorously carried on in succeeding years by the military authorities, was continued (luring the war under the direction of the Section of Venereal Disease Control, which was closely correlated with the section for the treatment of genitourinary and dermatological cases. 41
A special committee, which consisted of the administrative personnel of these two sections, was appointed to advise the officer in charge of the division on the subject. This committee prepared and distributed widely throughout the United States a program of attack on venereal diseases. The methods advised were summarized under four headings:" (1) Social measures to diminish sexual temptations; (2) education of soldiers and civilians in regard to venereal diseases and the moral hazards related thereto; (3) early treatment (or prophylactic measures) against venereal diseases; (4) medical care of the infected.
It was proposed to correlate these four major lines of attack with the Laboratory. Sanitary Inspection, Hospital, and Reconstruction Divisions of the Surgeon General`s Office, one one hand, and on the other with the War Department Commission on Training Camp Activities and the welfare organizations authorized by the War Department (see p. 541 et. seq.) and with the United States Public Health Service.
The section regarded the solution of the problem of safeguarding the morals and health of soldiers required two groups of measures: 41 (1) For the protection of the drafted mali while the is still at home, before being called to the colors. and while lie is en route to his military station; (2) for the protection of the soldier at all times while in the military service until final “ muster out."
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The work of the section was devoted largely to planning and carrying out, directly or in cooperation with other departments or civilian agencies, measures applicable to each of these phases.
Its program w as broad and, in order to make it effective, personnel and equipment were necessary. At the time, no one branch of the Army was financed, organized, or prepared to carry out this complex program, so different agencies were charged with the execution of different phases of the work. When completely organized, the special committee on the subject functioned through the following agencies, some of which were subdivided into several sections for administrative purposes: 42 (1) Social hygiene division;(2) law-enforcement division; (3) division of athletics; (4) music; (5) dramatics; (6) post exchange committee; (7) theater division.
Through the organizations affiliated with the War Department and through funds made available by still another organization (The American Social Hygiene Association), funds for personnel, equipment, supplies, and other expenses incidental to the program were forthcoming and were used to supplement and enlarge the work provided for by government appropriation. The details of this work will appear in full in the volume dealing with the scientific aspects of venereal disease control.
On December 9, 1918, the total personnel assigned to the section combating venereal disease was as follows: 43
This represents the maximum number of officers and men assigned to duty with the section, though a larger personnel was authorized shortly before the signing of the armistice. The following equipment was purchased by requisition on War Department funds appropriated for the Commission on Training Camp Activities: 43
Ten stereomotorgraphs (appropriated for the Commission on Training Camp Activities).
Five stereopticons.
Eleven copies of the film entitled “The End of the Road."
Five copies of film entitled ` Fit to Win" (about 20 copies of "Fit to Win" were purchased from supplemental funds or acquired otherwise).
In addition, the American Social Hygiene Association loaned, for the period of the war, about 40 stereomotorgraphs, 20 stereopticons, and several thousand lantern slides, as well as other material developed by this association for educational purposes.
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Statistical summary of the educational activities, section of venereal disease control, for the year ending June 30, 1919.
|
Attendance at lectures |
2,196,700 |
|
Attendance at showings of film "Fit to Win" |
900, 000 |
|
Attendance at showing of film "End of the Road" |
256, 400 |
|
Number of pamphlets distributed |
8,693,600 |
|
Number poster sets (Nos. 4, 8, 9) distributed |
3, 030 |
|
Number of posters distributed (Nos. 10, 11, 12, 13) |
1, 806 |
PERSONNEL. a
(April, 1917, to December, 1919.)
Russel, F. F., Col., M. C., chief.
Siler, J. F., Col., M. C., chief.
Callender, George R., Lieut. Col., M. C., chief.
Ashburn, Percy M., Col., M. C.
Vaughan, Victor C., Col., M. C.
Zinsser, Hans, Col., M. C.
Clark, H. C., Lieut. Col., M. C.
Draper, George, Lieut. Col., M. C.
Duenner, R. H., Lieut. Col., M. C.
Garcia, Leon C., Lieut. Col., M. C.
Haskell, Clayton K., Lieut. Col., M. C.
Lanpher, Howard A., Lieut. Col., M. C.
Nichols, Henry J., Lieut. Col., M. C.
Snow, William F., Lieut. Col., M. C.
Bitterman, Theodore, Maj., S. C.
Cecil, Russell L., Maj., M. C.
Dunham, Edward K., Maj., M. C.
Hussey, Raymond G., Maj., M. C.
Johnson, Bascom, Maj., S. C.
Meads, A. M., Maj., M. C.
Murphy, James B., Maj., M. C.
Pearce, Richard M., Maj., M. C.
Sawyer, Wilbur A., Maj., M. C.
Shipley, A. E., Maj., M. C.
Soper, George A., Maj., S. C.
Thomson, A. M., Maj., M. C.
Walker, Warren, Maj., M. C.
Young, C. C., Maj., S. C.
Clarke, Walter, Capt., S. C.
Davies, Stanley P., Capt., M. C.
Eliot, Thomas D., Capt., S. C.
Foster, J. H., Capt., S. C.
a In this list have been included the names of those who at one time or another were assigned to the division during the period, April 6,1917, to December 31, 1919.
There are two primary groups--the chiefs of the division and the assistants. In each group names have been arranged alphabetically, by grades, irrespective of chronological sequence of service.
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Funk, Forrest J., Capt., S. C.
Gans, S. L., Capt., M. C.
Long, R. R., Capt., S. C.
Mankin, Harry A., Capt., M. C.
Palmer, George T., Capt., S. C.
Phillips, W. G., Capt., M. C.
Rice, F. W., Capt., M. C.
Russell, R. L., Capt., M. C.
Sawyer, Harold P., Capt., M. C.
Spingarn, A. B., Capt., S. C.
Sutton, Alan C., Capt., AL. C.
Veeder, W. II., Capt., M. C.
Christensen, Frank, First Lieut., S. C.
Gehrke, August E., First Lieut., M. C.
Griffith, E. H., First Lieut., S. C.
Harkness, R. R., First Lieut., S. C.
Morgan, Sidney F., First Lieut., S. C.
Walker, R. M., First Lieut., S. C.
Wiseman, Mark, First Lieut., S. C.
Blosse, Nelson N., Second Lieut., S. C.
French, W. H., Second Lieut., S. C.
Morrison, Benjamin Y., Second Lieut., S. C.
McCann, Gertrude F., contract surgeon.
Taylor, Alonzo E., contract surgeon.
Young, Anna R., contract surgeon.
CONSULTANT.
Welch, William H., Col., M. C.
ROTATING ADVISORY COMMITTEE.
Politzer, Sigmund, Maj., M. C.
Pusey, William A., Maj., M. C.
Cunningham, John H., contract surgeon.
Hagner, Francis R., contract surgeon.
Morton, H. H., contract surgeon.
Wende, Grover W., contract surgeon.
REFERENCES.
(1) Annual Report of the Surgeon General, United States Army, 1918, 327.
(2) Office order, No. 97, S. G. O., November 30, 1918.
(3) G. O., No. 76, W. D., June 9, 1911; G. O. No. 134, W. D., September 30, 1911.
(4) Annual Report of the Surgeon General, United States Army, 1918, 328.
(5) Letter from Surgeon General to surgeon at Fort Leavenworth, Kans., August 2, 1917. Subject: Class at Department Laboratory. On file, Record Room, S. G. O., 129545 (Old Files).
(6) Correspondence. Subject: Medical Department of University for War Purposes. On file, Record Room, S. G. O., 324.3 (Tender of Services); 220.3 (New Haven, (Conn.) (F); 353. (New Haven, Conn.) (F); 353 (Laboratory Instruction); and 700.7 (Yale Army Laboratory School).
306
(7) Letter from the Surgeon General of the Army to Dr. Simon Flexner, Rockefeller Institute, New York City, January 7, 1917. On file, Record Room, S. G. O., 151418 (Old Files).
(8) Correspondence. On file, Record Room, S. G. O., 353 (Laboratory, Camp Greenleaf) (C); 354.1 (Instruction Laboratory Specialists); 354.6 (M. O. T. C., Fort Oglethorpe, Camp Greenleaf.) (Similar numbers under Camp Devens, Mass.)
(9) G. O., No. 80, W. D., June 30, 1917.
(10) Correspondence on file Record Room, S. G. O., 231 (Laboratory Technicians).
(11) Compiled from weekly reports concerning personnel of laboratory Division. On file, Record Room, S. G. O., Weekly Report Files.
(12) Annual Report of the Surgeon General, United States Army, 1918, 329.
(13) Annual Report of the Surgeon General, United States Army, 1919, Vol. 11, 1042.
(14) Ibid., 1043.
(15) List of Staple Medical and Surgical Supplies Selected to Meet War Conditions, by the Committee on Standardization appointed by the Council of National Defense. Part III, Laboratory Supplies, Council of National Defense, Washington, D. C., June, 1917 (Government Printing Office, 1918). On file, Finance and Supply Division, S. G. O.
(16) Laboratory Apparatus and Reagents, Proposed Revision, par. 846, Manual for the Medical Department, United States Army, 1916, Revised, February 15, 1918.
(17) G. O., No. 11, W. D., April 12, 1912, Par. V. Correspondence. Subject: Supply Depots of Territorial Departments. On file, Finance and Supply Division, S. G. O.
(18) List of laboratory supplies required for 1,000,000 to be purchased by Washington, December 31, 1917; letter from Surgeon General, United States Army, to the officer in charge, medical supply depot, New York, January 10, 1918. Subject: Purchase of Post Supplies. On file, Finance and Supply Division, S. G. O.
(19) Circular letter from the Surgeon General of the Army to the officer in charge of laboratory, December, 1917. Subject: Technique for Detecting Meningococcus Carriers. Recommendation of the committee on a standard routine method for the detection and isolation of hemolytic streptococci from throats, sputa, and pathologic exudates. Both on file Laboratory Section of Sanitation Division, 730 (Laboratory Technology).
(20) Medical War Manual No. 6, Laboratory Methods, United States Army. Compiled by Division of Laboratories and Infectious Diseases, first edition, 1918; second edition, 1919. On file. Finance and Supply Division, S. G. O.
(21) S. O., No. 21, W. D., par. 236, January 25, 1918.
(22) S. O., No. III, W. D., May 20, 1918, par. 161.
(23) Report of hospital for the year 1918. From the commanding officer, base hospital, Camp Upton, N. Y., to the Surgeon General, United States Army, March 24, 1919. On file, Record Room, S. G. O., 319.1 (Base Hospital, Camp Upton) (D).
(24) Prophylactic Inoculations of Man Against Pneumococcus Infections, and More Particularly Against Lobar Pneumonia, by Lieut. Col. F. S. Lister, R. A. M. C. Memoir No. 10, South Africa Institute of Research, November, 1917, W. E. Horton & Co., Johannesburg, South Africa. Copy on file, Library of the Surgeon General, Washington, D. C.
(25) Results of Prophylactic Vaccination Against Pneumonia at Camp Wheeler, by Russell, Cecil, and Vaughan. On file, Board of Publications, S. G. O. Published in Journal of Experimental Medicine, 1919, xxix, No. 5, 457.
(26) Cases of empyema at Camp Lee, Va. Preliminary report by Empyema Commission. Reprinted from Journal American Medical Association, Chicago, Ill., August 3, 1918, lxxi, 366, and August 10, 1918, xxi,443. Papers on Empyema, Surgery, Gynecology, and Obstetrics, 1918, xxviii, 337, 348, 362, 371, 375, and 379.
(27) S. O., No. 165, W. D., July 16, 1918, par. 252. Reports respiratory board. On file, Record Room, S. G. O., 710 (Camp Funston) (C). Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1033 and 1043.
(28) S. O., No. 203, W. D., August 29, 1918, par. 396. Preliminary report to the Surgeon General. Subject: Pneumonia Following Influenza at Camp Pike, Ark., by Maj. A. W. Freeman, Capt. F. G. Blake, Lieut. J. C. Small, Lieut. T. M. Rivers, and Lieut. Col. E. L. Opie. On file, Board of Publications, S. G. O.
(29) Correspondence and reports. On file, Record Room, S. G. O., 710 (Meningitis, Camp Jackson) (D)); 721 (Camp Jackson) (D); 721.6 (Health Reports).
307
(30) Annual report of the Surgeon General, United States Army, 1918, 333; 1919, Vol. IT, 1046. Correspondence. On file, Record Room, S. G. O., 710 (Anthrax).
(31) Circular letter from the Surgeon General, United States Army, to all camp and division surgeons of independent posts, July 2, 1918. On file, Historical Division. S. G. O.
(32) Annual Report of the Surgeon General, United States Army, 3918, 333: 1919, Vol. IT, 1918, 1945. Report on production of anti-gas gangrene serum, Rockefeller Institute. On file, Record Room, S. G. O.. 444.2-1 (Serums). Correspondence. On file, Record Room, S. G. O., 710 (Gas Gangrene). and 720.3 (Information Concerning Gas Gangrene). Toxin and Antitoxin of and Protective Inoculation Against Bacillus welchii. By Carroll G. Bull, and Ida W. Pritchett, Journal Experimental Medicine, July, 1917, xxvi, No. 1, 119, Baltimore, Md. Abstract on Gas Gangrene with Bibliography. Review of War Surgery and Medicine, March, 1918, Vol. I, No. 1, 17. (Prepared in the Office of the Surgeon General, United States Army, Washington, D. C.).
(33) Correspondence. On file, Record Room, S. G. O., 444.2 (A. E. F., France) (Y).
(34) Annual Report of the Surgeon General, United States Army, 1918, 53, 59, 164, 168, 285, 297, 332; 1919, Vol. II, 1312. Correspondence on file, Record Room, S. G. O., 720.3 (Inoculation, Camp Devens, Mass., Camp Meade, Md.) (D); 710 (Measles, Camp Devens, Mas., and Camp Meade, Md.) (D).
(35) Report on hookworm. On file, Record Room, S. G. O., 106177 (Old Files).
(36) Annual Report of the Surgeon General, United States Army, 1918, 334, 338. Correspondence. On file, Record Room, S. G. O., 156772 (Old Files) and 188331 (Old Files).
(37) Manual of Treatment of the Venereal Diseases, prepared under the direction of the Surgeon General of the Army. First edition, 1917; second edition, September 1, 1918: third edition, 1919 (Chicago, American Medical Association).
(38) Annual Report of the Surgeon General, United States Army, 1918, 335.
(39) Correspondence. On file Record Room, S. G. O., 352.4 (School of Urology, Camp Greenleaf (C); and 353 (Camp Greenleaf) (C).
(40) Weekly report of section of venereal disease control, August 30, 1918. On file, Record Room, S. G. O., Weekly Report File.
(41) Annual Report of the Surgeon General, United States Army, 1918, 335, et seq.
(42) Ibid., 1919, Vol. II, 1059.
(43) Ibid., 1919, Vol. II, 1061 and 1062.
