SECTION II
IN THE AMERICAN EXPEDITIONARY FORCES
CHAPTER IX
TRAINING PROJECT
Medical Department training, as well as the training of all other branches of the American Expeditionary Forces, was under the supervision and control of the training section of the general staff, general headquarters, A. E. F.1 Therefore the scheme for training Medical Department troops conformed, at least at first, to the general program, which was based upon the organization of the American Expeditionary Forces. In this organization, a six-division corps was adopted.2 Each corps was to have four combat divisions and two replacement divisions. One of these replacement divisions was to be established in some convenient training area behind the general position of the combat divisions.3 Its function was to hold and train replacements in officers and men of all grades for the first-line divisions. The sixth division, forming the second of the two replacement divisions, was to be called the depot division and to be stationed near the ports. This depot division was to receive drafts from the United States and give them little more than individual training. It was then to send these partially trained men to the replacement division for the completion of their training.
It proved impossible to carry out this replacement scheme; however, upon it was necessarily and conveniently hung the entire school system of the American Expeditionary Forces.3
The program referred to above was outlined by the chief of the training section, general staff, A. E. F., in the following memorandum:
HEADQUARTERS AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF OF STAFF, TRAINING SECTION,
Paris, August 27, 1917.
Memorandum for the Chief of Staff.
Subject: School project for American Expeditionary Forces.
1. A study of the French and British systems of training of troops in France indicates that the following school project will best meet the needs of the American Army:
(a) In each division a system of troop training under the direct supervision of the division commander involving such incidental school instructions as may be desirable in the training of the division and for the purpose of producing instructors in corps schools.
(b)A center of instruction for each corps for the purpose of training the replacements of all grades and the commanders of all units. This naturally places the center of instruction at the location selected for the first replacement division of each corps and contemplates that each group of corps schools shall instruct commanders of proper grades for four combat divisions, assuming that the organization of corps recommended at these headquarters will be approved in full. Until the system is in complete operation it will also be necessary to train at corps schools a number of officers who will ultimately become instructors in Army schools.
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(c)A center of instruction for the entire army in France, to be known as the army schools. This group should include a general staff college and such other schools as may be necessary to train instructors for all corps schools. The army schools should be under the direct control of these headquarters in order that the doctrine which should actuate the entire system of instruction and control our ideas of combat may be transmitted from the general staff through these schools to all units of the army.
As these schools will train a great number of men comparatively unfamiliar with actual operations, the group should be placed in contact with large bodies of troops. The necessity of economy of administration and uniformity of instruction require that the schools be grouped together so far as practicable. They should, however, be on or near the main lines of communication, close to the zone of the army, but far enough away from the front to be comparatively safe from hostile aircraft. They should be so located as to insure permanency, but not in such locality as to influence future action in regard to the front to be occupied. All of these conditions may be satisfied if the 2d Replacement Division of the First Corps, which would ordinarily be placed near one of the bases, on the west coast of France, were moved forward instead into a suitable division cantonment, in the area bounded by Orleans--Montargis--Troyes--Chaumont--Langres--Gray--Dijon--Chalon--Nevers--Bourges--Issoudun--Blois. The various army schools should be so grouped with respect to the division as to permit the members of any or all of the schools to attend any or all of the demonstrations conducted by troops without in any way detaching troops for this purpose from divisions at the front, or in any way impairing the efficiency of troop training in the replacement division itself.
2. It will be impossible to put this system into complete operation until the entire First Corps has reached France. Under the present schedule of troops arrivals, this will occur about November 15 next. In the meantime it is necessary to meet the needs of army training as they arise and to utilize existing facilities to the best possible advantage. Thus the schools at Saumur and other points may be used for the training of the 2,200 reserve officers to reach France not later than September 15; Mailly may be used for our heavy artillery school; Arnouville-les-Gonesse may be used for the training of our antiaircraft guns, but these widely scattered schools should be regarded as expedients only and every effort should be made to bring all of our institutions for army training into close proximity, if possible, in the area above referred to, where the 2d Replacement Division of the First Corps should be located as already outlined.
It may be necessary to depart from this plan in some cases, but departure from the plan should he accepted only if compelled to by circumstances beyond our control.
3. Should it be found impracticable to concentrate the army schools and the 2d Replacement Division in the area named, then it is thought that both the division and the schools should be placed near one of the bases on the west coast of France. Should this be found impracticable, which is highly improbable, then it will be found necessary to locate the schools at a number of widely separated points. In order that the best possible solution may be secured, it is thought necessary to designate at once the prospective commandants of these schools, acquaint them with the situation and direct them to make the necessary study of the corresponding British and French schools and submit recommendation in regard to the organization, equipment, personnel, and curriculum best suited to our needs. While this work is in progress, the operations and training sections, working in cooperation and with the French General Staff should locate the exact area best suited for this work and take the necessary steps to place the schools and the division in the area selected.
* * * * * *
(b) That the French Government be advised of the decision of these headquarters to place the 2d Replacement Division and the schools named in the area referred to and that the training section, in cooperation with the operations section, be authorized to take the necessary steps to accomplish the results desired.
* * * * * *
(Signed)
PAUL B. MALONE,
Lieutenant Colonel Infantry, D. 0. L.,
Chief of Training Section.
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SCHOOL PROJECT FOR AMERICAN EXPEDITIONARY FORCES
Per combat division: No schools--troop training.
Per army corps: Army corps center of instruction (located at 1st Replacement Division of each army corps and under supervision of division commander).
Object: (1) Training replacements; (2) training various commanders of all units, etc.
(A) TRAINING
1. Drafts of all arms received from base replacement division.
2. Training of men to be noncommissioned officers of all arms.
(B) ARMY CORPS SCHOOLS
1. The corps infantry school: Section A, platoon and section commanders; Section B, rifle company commanders; Section C, machine gun platoon and company commanders; Section D, trench mortar (3 inch Stokes and 37 mm.); Section E, lines of information.
2. The corps artillery school: Section A, Lieutenants and battery commanders (3 inch and 6 inch howitzers); Section B, instrument sergeants and range finders; Section C, lines of information (radio, telephone, and signal); Section D, artillery information, firing charts, sound ranging, flash ranging.
3. The corps engineer school: Section A, company and platoon commanders; Section B, sapper’s school; Section C, pioneers’ school (Engineers, Infantry, Cavalry, and Field Artillery).
4. The corps cavalry school: Section A, mounted service school. N0TE. - Captains and lieutenants attend Infantry and Engineer schools.
5. The corps gas school: For all arms of the service.
6. The corps signal school: Section A, company and platoon commanders; Section B, special noncommissioned officers.
7. The corps sanitary school: Ambulance and field hospital company officers.
8. The corps aeronautical school: Section A, combat aviation school; Section B, combat balloon school.
9. The corps field officers’ school: All lieutenant colonels and majors (includes school course and visits to all schools).
ARMY SCHOOLS
Army schools (located at 2d Replacement Division of First Army Corps and under direct supervision of general headquarters).
Object: (1) Training instructors for corps schools; (2) Training special officers.
1. The general staff college, A. E. F.: Special officers selected for general staff work.
2. The army line schools, A. E. F.: Section A, Infantry lieutenants; Section B, Artillery lieutenants; Section C, Engineer lieutenants; Section D, Signal lieutenants (trained to include company and battery commanders duties). Section E, captains, majors, and lieutenant colonels of all arms: Section F. line of information (liaison of all arms); Section G, sanitary service.
3. The army candidates’ school, A. E. F.: Training soldiers to be officers (if necessary to be divided into sections for each arm).
4. The army anticraft school, A. E. F.: Section A, Artillery; Section B, machine guns.
5. The army artillery school, A. E. F.: Section A, heavy artillery; Section B, trench artillery; Section C, railroad artillery.
6. The army signal school, A. E. F.: Section A, telegraph; Section B, telephone; Section C, radio; Section D, visual methods; Section E, system operations; Section F, carrier pigeons.
7. The army aeronautical schools, A. E. F.: Section A, aviation school; Section B. balloon school; Section C, Infantry and Artillery observers, organization and training.
8. The army sanitary school, A. E. F.: Complete outline to be announced later.
9. The army engineer school, A. E. F.: Section A, sapper’s school; Section B, pioneer school for Engineers, Infantry, Cavalry, and Field Artillery; Section C, bridging; Section D, mining; Section E, searchlights; Section F, ranging; Section G, topography; Section H, camouflage.
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10. The army Infantry specialists’ center, A. E. F.: Section A, automatic weapon; Section B, musketry, bayonet, and sniping; Section C, grenade, trench mortar, 3-inch Stokes, and 37 mm.
11. The army center of information, A. E. F.: Conferences and demonstrations for all generals and colonels of all arms.
12. The army tank school, A. E. F.
13. The army gas school, A. E. F.
BASE TRAINING CENTERS
Army corps base training center (located at 2d Replacement Division of each army corps and under supervision of division commander).
Objects: (1) Training new drafts; (2) special classes of soldiers.
(a)Training: Training new drafts individually of all arms and services.
(b)Base training schools: Section A, cooks and bakers; Section B, clerks; Section C, mechanics; Section D, saddlers, horseshoers, and stable sergeants; Section E, drivers and packers; Section F, chauffeurs; Section G, telephone operators; Section H, telegraph and radio operators.
Thus training in its broader sense was to include the field training of troops, and schools to train officers as instructors, for command, and for special service.
FIELD TRAINING
Training in the American Expeditionary Forces was intended to complete the preliminary training given in the United States, and was planned to be given as follows: (1) One month’s training in technique of the special service as required for the American Expeditionary Forces, conditions including terrain exercises and maneuvers in the open and trench operations in the training area for division, corps, and army troops; (2) one month’s training in actual occupation of a quiet sector to inure troops to field and fire conditions and to test organizations and teamwork under stress; (3) one month’s training in maneuvers and terrain exercises of open operations in training areas. In passing, it might be said that because of the pressing demand for troops for combat early in 1918, few divisions received the full period of three months’ training in France.3
To economize in time of training after arrival in France, War Department was requested, in the fall of 1917, to send ahead of each division a staff officer familiar with training in the United States to report with previous schedules to G-5 headquarters, A. E. F. The training program for the first phase in France was to supplement and complete what had been done in the United States.3
Arrangements were also made with War Department by which each division should cause approximately one-third of its officers and noncommissioned officers to precede it to France long enough to go through one of the corps schools before the arrival of the division.3 These officers then were able to meet their divisions and give them the last thing in the development of methods and practice in France.
The following outline shows the amount of training it was contemplated that sanitary troops would receive during the three months’ period referred to above:4
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SCHEME OF TRAINING FOR SANITARY TROOPS
FIRST MONTH
First week:
For all sanitary troops of the division— Hours
School of the soldier and squad......................................5
Personal hygiene; footgear, their fitting; trench feet.......................................5
Duties of the soldier; Army and camp regulations................................1
Military courtesy...................................1
Equipment of the soldier--responsibility and care.......................................1
Organization of the Army.......................................1
Materia medica and pharmacy...................................5
Anatomy and physiology.................................5
Organization and duties of the Medical Department.................................1
Care and use of animals and equipment; care of transportation; individuals or units
assigned mechanical transport will be instructed in the care of animals, equipment, and
transportation until motors are issued, when this time will be used for instruction in care,
operation, and driving....................................5
Total..................30
For medical and dental officers (in addition to the time allotted above) -
Customs of the service.......................1
Official correspondence................1
Daily reports and returns.......................1
Total ..............................3
For noncommissioned officers -
Official correspondence.....................1
Daily reports and returns............................2
Total ........................................................3
Second week:
For all sanitary troops -
School of the squad and detachment or company......................5
Diseases--classification and causes.............................1
Diseases acquired by contact--prevention--venereal prophylaxis............1
Food and fly-borne diseases--prevention................................1
Mosquito-borne diseases--prevention................................1
Louse-born diseases--prevention--laundries--delousing..........1
The Articles of War and courts-martial......................................2
Sanitary troops of the battalion, regiment, division, corps, army...............1
Materia medica and pharmacy.......................................5
Anatomy and physiology........................................................................5
The Medical Department equipment of the battalion and regiment; camp infirmary..........2
Care and use of animals and equipment--care of transportation as in first week................ 5
Total ..........................30
For medical and dental officers (in addition to the time allotted above) -
Monthly reports and returns.......................2
Property accountability and responsibility..........................1
Total..................3
For noncommissioned officers -
Same as above .............................3
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Third week:
For all sanitary troops - Hours
School of the squad, detachment, or company; manual of the litter.............5
Flea, bug, and tick borne diseases-prevention.......................1
Diseases due to exposure, trauma poisons--prevention.......................1
Excess and deficiency diseases..................................1
Sanitary service of the camp and billet....................................2
Materia medica and pharmacy..................................5
Anatomy and physiology................................5
The ambulance company--equipment and functions.................................2
The field hospital company, the mobile surgical unit, the mobile hospital, the
mobile laboratory, the medical supply unit--equipment--care of transportation
as in first week..................5
Total..............................30
For medical and dental officers (in addition to the time allotted above) -
Bimonthly, quarterly, and annual reports and returns.......................3
For noncommissioned officers -
Same as above for officers................................3
Fourth week:
For all sanitary troops -
School of the detachment and company; the loaded litter.........................5
Sanitary service of the march in campaign..................2
Sanitary service in combat...............................2
Shelter and evacuation of casualties...........................1
Pitching shelter tents, hospital ward, and pyramidal tents......................5
Materia medica and pharmacy...................5
Anatomy and physiology.................5
Care and use of animals and equipment; care of transportation (as in first week) .............5
Total............................30
For medical and dental officers (in addition to the time allotted above) -
Occasional reports and returns.....................3
For noncommissioned officers -
Same as above for officers..................3
SECOND MONTH
First week:
For all sanitary troops -
School of the detachment and company; removing wounded without litters ...............3
First aid........................3
Gas defense....................2
Effects of artillery and infantry fire.......................1
A march of 2½ miles with halt and establishment of hatta~lion and regimental
aid station or dressing station under an assumed situation, individual cooking,
and return to camp..................................6
Nursing.................4
Riding, driving, or ambulance drill for ambulance companies...........................5
A march of 7 ½ miles under an assumed situation appropriate for the sanitary
unit or detachment........................6
Total....................................30
For medical and dental officers (in addition to the time allotted above) -
Occasional reports and returns...........................3
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First week—Continued.
For noncommissioned officers - Hours
Same as above for officers...........................3
Terrain exercises: Regimental and battalion surgeons will participate in all regimental
and brigade rerrain exercises. The division surgeons, commanding officer sanitary
train, director ambulance section, and director field hospital section, will participate in
all division terrain exercises.
Second week:
For all sanitary troops -
School of the detachment or company; the ambulance..................................3
First aid...................................3
Construction of fire shelter.......................1
Gas defense...............................2
A march of 3 miles as required in first week, second month.........................6
Nursing......................................4
Riding, driving; ambulance drill for ambulance companies..........................5
A march of 7½ miles under an assumed situation appropriate for the unit or
detachment........................6
Total................................30
For medical officers only -
Terrain exercises (see note first week, second month).
Third and fourth weeks:
For all sanitary troops -
School of the detachment and company; the loaded litter; gas mask worn 15
minutes in each drill.....................................................................3
Field training: The solution of problems of the sanitary service, either independently or
in participation with organizations to which attached, under assumed situations
appropriate to the unit. Solution to cover recommendations as to sanitary procedures,
management of thesanitary service, selection of sites for unit stations, selection of
routes of approach and sanitary evacuation and preparation of casualty lists, with
patients represented by tagged individuals (problems for divisional units to be prepared
by division surgeon - 3 problems, 1 of which shall include a 10-mile march).......................18
Nursing...................................5
Map reading and sketching; location by coordinates................................4
Total........................................30
For officers only (in addition to time alloted for other instructions) -
Terrain exercises (see note first week, second month).
THIRD MONTH
First week:
For all sanitary troops -
School of the detachment or company; methods of removing patients without
without litter; masks worn 15 minutes at each drill..............................2
Field training (same as in program third and fourth weeks, second month) ......................18
Construction of splinter proofs and bombproofs.............................6
Application of the Thomas splint.....................................4
Total......................................30
For medical officers only -
Terrain exercises (see note first week, second month).
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Second and remaining weeks:
For all sanitary troops - Hours
School of the detachment or company...........................................2
Field training (same as in program third and fourth weeks, second month; one march,
halt overnight, 12 hours; problem 6 hours)..................18
Construction of splinter proofs and bombproofs.........................6
Application of the Thomas splint.................................................4
Total.......................................................................................30
For officers only -
Terrain exercises (see note first week, second month).
FOURTH MONTH
First and second weeks:
For all sanitary troops -
School of the detachment or company...........................................................................2
Field training (same as in program third and fourth weeks, second month).......................24
Application of the Thomas splint....................................................................................2
Demonstration of sanitary devices for use in the European theater of war........................2
Total...................................................................................30
For medical and dental officers only (in addition to time allotted above)—
Terrain exercises (see note first week, second month).
Instruction in reports, returns, and records and regulations of the American
Expeditionary Forces.......................................................3
For noncommissioned officers only -
Instruction in reports, returns, records, and regulations of the American
Expeditionary Forces......................................................3
Third and fourth weeks:
For all sanitary troops -
School of the detachment and company..................................................2
Field training (same as in program third and fourth weeks, second month).......................24
Application of the Thomas splint.............................................................2
First aid treatment of gassed cases..........................................................2
Total.........................................................................30
For medical officers only (in addition to time allotted for other instruction) -
Military medicine (psychology, psychiatry, malingering, special diseases, including
gas poisoning and treatment).......................................3
Military surgery (sepsis and treatment; infections by anaerobes - treatment; shock;
special methods of treatment, including prophylaxis, and treatment of trench foot............3
For noncommissioned officers only -
Same as preceding two weeks...................................3
Special training: In addition to the combat and technical training or organizations given in this program additional training will be given as follows -
For all troops (daily except Sunday), physical training (minimum), 20 minutes.
For all buglers, manual of the bugle, 30 minutes.
For mess sergeants and cooks (including one alternate mess sergeant and two alternate cooks), course to be given at a convenient time during the earlier weeks of the training period by a visiting field party of the Medical Department food and nutrition section which will carry with it a rolling kitchen and equipment for establishing a center of instruction within the divisional training area. Subjects of course: Food principles and values; selecting and balancing the diet; storage and preservation of foods; arrangement of the kitchen; care and cleaning of kitchen and equipment; cooking and service; use of the rolling kitchen and equipment; improvisation of cooking devices; food conservation and salvage of kitchen wastes; kitchen sanitation.
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Instruction for drivers of motor transportation (center of instruction to be established within the division area by the commander of trains). Subjects of instruction: Cleaning and oiling; starting and stopping; shifting gears; making road repairs; driving; moving in train; parking; traffic regulations; towing; troubles.
The application of the scheme given above to the training of the Medical Department with divisions can be shown by the following extract from program of training for 86th Division:
SANITARY TROOPS
First week: Hours
Close order drill; the loaded litter and first aid......................3
Defense against gas..........................................................2
Personal hygiene; venereal prophylaxis, care of feet, shoes, trench feet..............1
General hygiene; march, camp, trench, combat, disposal of the dead.................3
Water and food; supply examination, treatment, preservation, in trench and field.................1
Clothing; laundries, bathing, supplies, methods of cleaning, devices, delousing,
insecticides..........................2
Disposal of wastes and demonstration of sanitary devices - human, animal, kitchen
and camp garbage, in field and trench warfare.....................2
Organization of the American Expeditionary Force...............1
Disposition of combatant and auxiliary troops; march, attack, defense, retirement,
trench warfare....................................................................3
Artillery and infantry weapon; effects....................................1
Intrenching (instructions for the defensive combat of small units)......................5
Attached sanitary troops - construction of shelter for battalion and regimental aid
stations in connection with work of rifle companies and battalions, construction of
shelter for advanced groups of litter bearers, dressing stations, etc. March (a day’s march of
not less than 10 miles); attached sanitary troops will march and function as sanitary troops
under the assumed situations of the organization to which attached (see general program)..6
Total...................................................................30
Second week:
Close order drill; handling patients without litters.........................3
First aid and Thomas splint........................................................3
Defense against gas..................................................................2
Shelter--selection, improvization, construction of huts--barracks, billets, and their
sanitary inspection.......................................................................2
Field orders................................................................................1
Field sketching and map reading..................................................6
Intrenching..................................................................................4
Organization of the sanitary service - battalion and regimental detachments, camp
infirmaries, camp hospitals, the sanitary train, the sanitary column, and other
establishments and their units of the line communications; their personnel, functions
and equipment for open and trench warfare..................................3
March (a practice march as required in program for first week).....6
Total........................................................................30
Division terrain exercises . - The division surgeon, commanding officer, sanitary train, and directors of ambulance companies and field hospital sections will participate in all division terrain exercises.
Third week:
Close order drill and the ambulance..............................................................3
First aid and use and application of the Thomas splint....................................8
Defenses against gas.....................................................................................2
Casualties; classification and disposal.............................................................1
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Third week - Continued.
Field training -
For battalion and regimental detachments -
(a)Practice and training in methods and duties pertaining to the sanitary service of
units to which attached..................................................10
(b)Open warfare: Sanitary service of the march, camp, attack, defense, retirement,
advance, and rear guard. Solution and execution of problems independently, and
combined with the organizations to which attached. Solutions to cover recommendations
as to sanitary procedures and sanitary orders; selection of sites for unit stations;
selection of routes of approach and sanitary evacuation; actual establishment of casualty
lists, with patients represented by tagged individuals.
(c)Trench warfare: Solution of problems given above under open warfare together
with actual construction of shelter and adaptation of equipment and procedures to
changed conditions due to types of action.
For divisional units - Field training as given in (b)and (c)under conditions assumed,
appropriate for the unit.......................................10
A. B. C.: Battalion, regimental surgeons and all sanitary units will participate in terrain
exercises with the units to which attached in connection with the general program.
March: A practice march as required in program for first week..........................6
Division terrain exercises: The division surgeon, commanding officer, sanitary train,
and directors of ambulance companies and field hospital sections will participate in
all division exercises.
Fourth week:
Close order drill, the loaded litter, the ambulance........................................6
Defense against gas..............................................2
First aid and use and application of the Thomas splint........6
Field training -
For battalion and regimental detachments -
(a) Practice and training in methods and duties pertaining to the sanitary service of
the units to which attached as given for third week..............................10
For divisional units -
As given for third week...............................................................10
March (as required in program for first week)..................................6
N0TE. - The instruction will consist of conferences, practical exercises, demonstrations, and
problems for the purpose of training the personnel of the sanitary service in its duties, both
in open and trench warfare, and must be thorough and practical. Instruction in sanitation,
medicine, and surgery will be limited to preparations for the mastery of the problems presented
by the service conditions which may be encountered by the American Expeditionary Forces
in open and trench warfare.
DURING THE TRAINING PERIOD
For medical officers only, in addition to time alloted for other instruction:
1. Military surgery - sepsis, antisepsis, infection by anaerobes, shock, special
methods of treatment including prophylaxis and treatment of trench feet..........................10
2. Military medicine - psychology, psychiatry, malingering, special diseases, including
gas poisoning and treatment...............................................................10
Division terrain exercises: The division surgeon, commanding officer, sanitary train, and
directors of ambulance companies and field hospital sections will participate in all division
terrain exercises.
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MEDICAL DEPARTMENT SCHOOLS
Medical Department schools in the American Expeditionary Forces comprised the Army Sanitary School, Langres (Medical Corps School; Dental Corps School); corps schools; special schools (gas school, Gondrecourt; First Replacement Depot Sanitary School, St. Aignan-Noyers).4 The Army Sanitary School, Langres, is the subject of a separate chapter.
CORPS SCHOOLS
The first of the corps schools to be established was the First Corps school, which began operations at Gondrecourt, France, as the First Corps center of instruction, and was intended to cover the 1st, 2d, 26th, and 42d Divisions training in the vicinity. It contained a field service school for medical officers established under the name of First Corps Sanitary School, October 15, 1917.4 The course was planned to cover five weeks; however, owing to an epidemic of scarlet fever at Base Hospital No. 18, where the school was established, the course was abandoned after three weeks.4 The director was relieved from duty November 3, 1917, and ordered to the Army schools at Langres for duty as commandant of the Army Sanitary School to be opened thereat.4
After the abandonment of the first course, the First Corps Sanitary School began another course in January, 1918, with only a few medical officers in attendance. Because of the scarcity of shelter, material, and personnel in the American Expeditionary Forces, neither equipment nor special shelter could be secured, consequently the school was unsatisfactory as to results and no further courses were held.
In February, 1918, a sanitary school was established at the Second Corps school organized at Chatillon sur Seine, where better facilities for housing and instruction existed. However, because of the shortage of medical officers in the American Expeditionary Forces this sanitary school completed only one course of four weeks. As the shortage of medical officers was not remedied, it was found that the Army Sanitary School at Langres could accommodate all the medical officers coming with advance detachments and the few others that could be spared from combat divisions and the Services of Supply, and no other corps sanitary schools were established. This was the only Medical Department field service school operated after February, 1918. 4
The following program was prepared for tentative use in connection with Medical Department training in corps sanitary schools : 4
TENTATIVE PLAN FOR CORPS SANITARY SCHOOL
There will be five principal subjects treated in the corps school, which will he a five weeks’ course. Two weeks of this should be devoted to war surgery and military medicine. The other three weeks should be spent at the school, where, in contact with divisional troops, attendants will be taught the other three subjects:
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WAR SURGERY
1 General principles of surgery.
2. Emergency surgery at the front and general treatment of wounded
3. Special surgery:
(a) Wounds of face and neck.
(b) Wounds of chest and abdomen.
(c)Wounds of head, brain, and nervous system.
(d)Wounds of blood vessels.
(e) Fractures and joint injuries.
4. Roentgenology.
5. Venereal diseases and genitourinary surgery.
MILITARY MEDICINE
1 Influence of war in producing diseases not infectious.
2. The psychology and psychiatry of war, malingering.
3. The remedial agents supplied by the Medical Department.
4. The field laboratory.
5. Nursing.
6. Special pathology, symptoms and treatment of gassed cases.
7. The communicable diseases.
8. Preventive medicine and carriers of pathogenic organisms.
9. The importance of mild respiratory infections, their nature, probable etiology and means of prophylaxis; pneumonia.
10. Infections in general, and their treatment.
11. Transfusions.
12. Diseases of the skin.
MILITARY HYGIENE
1. Morbidity and mortality in the military service.
2. Insecticides.
3. Physical culture.
4. The march; the camp.
5. Personal hygiene.
6. Water.
7. Food, dietetics, and cooking.
8. Clothing and equipment.
9. Shelter and the construction of military hospitals.
10. Heating and lighting.
11. Disposal of wastes and latrines.
12. Disinfection, disinfectants, and quarantine.
13. Hygiene of the battle field.
14. Sanitary appliances.
MILITARY MEDICAL ADMINISTRATION
1. Army Regulations.
2. The Field Service Regulations; organization of the land forces of the United States; Tables of Organization.
3. Manual for the Medical Department.
SANITARY TACTICS
1. Field orders.
2. Map reading.
3. Ballistics.
4. Casualties.
5. Means and mode of evacuation.
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6. Summary of personnel, equipment, and supplies of Medical Department organizations from front to rear.
7. Collection and evacuation of sick and wounded.
8. The ambulance company:
(a)Composition.
(b) Equipment.
(c) Administration.
(d) Duties in camp, on the march, and in battle.
9. The field hospital:
(a)Composition.
(b) Equipment.
(c)Administration.
(d)Duties in camp, on the march, and in battle.
10. The dead, and the role of the medical officer.
11. Hippology.
12. Automobiles, their engines, construction, repairs, and spare parts.
13. Sanitary engineering - dugouts, trenches, bombproofs, and construction of their shelter and of sanitary appliances.
14. Gas defense.
SUMMARY
Didactic course: Hours
1. War surgery.............................................40
2. Military medicine............................................25
3. Military hygiene.............................................25
4. Sanitary tactics.............................................50
5. Medical military administration......................................25
6. Gas defense and chemistry...........................................25
Total.........................................190
Practical course:
Field exercises............................................36
Visit to the front................................................24
Visit to base hospital..............................................8
Clinics...............................................8
Hygiene..............................................10
Hippology.............................................3
Automobiles...........................................4
Sanitary engineering............................................5
Total.........................................98
Total, 288 hours, course of 6 weeks, working 8 hours a day for 6 days a week.
Upon this tentative program, the following course of instruction was formulated and given at the First Corps Sanitary School.4
COURSE OF INSTRUCTION FOR THE SANITARY SCHOOL, FIRST CORPS CENTER OF INSTRUCTION FOR THE PERIOD OCTOBER 15 TO NOVEMBER 3, 1917
Monday, Oct. 15, 1917:
6.45 a. m.............................Medico-military administration.
8.45 a. m.............................Sketch of Medical Department organization in war.
9.45 a. m ............................The sanitary officer.
10.45 a. m ..........................The collection and evacuation of wounded.
1.30 p. m ............................The regimental sanitary organization in general and its equipment.
2.30 to 4.30 p. m.................Examination of equipment and discussion of its mode of application.
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Tuesday, Oct. 16, 1917
8.45 a. m..............................The battalion surgeon in trench warfare.
9.45 to 11.45 a.m.................Sanitary inspection.
1.30 p. m..............................The regimental surgeon in trench warfare.
2.30 p. m..............................Personal hygiene.
3.30 p. m..............................Food
Wednesday, Oct. 17, 1917:
7.45 a.m...............................Medico-military administration..
8.45 a.m...............................Problems, battalion sector, trench warfare.
9.45 a.m...............................The ambulance company.
10.45 a.m.............................The duties of an ambulance company on the march, in battle, and in camp
1.30 p.m...............................Water .
2.30 p.m...............................The standard United States Army litter; the wheeled litter; the carrying of wounded by hand and by the trench litter.
3.30 p.m...............................Comparison of French, English, and German regimental organizations with our own.
Thursday, Oct. 18, 1917:
7.45 a. m...............................Medico-military administration.
8.45 a. m...............................The administration of an ambulance company.
9.45 a. m...............................The application of our ambulance company to present methods of warfare.
10.45 a. m..............................Clothing and equipment.
1.30 p. m...............................Dugouts.
2.30 to 4.30 p. m...................Examination of trenches and dugouts, training section.
Friday, Oct. 19, 1917:
8.45 a. m...............................The equipment of our ambulance companies.
9.45 to 11 a. m......................Demonstration of equipment of ambulance company.
2.30 p.m................................Garbage and waste.
3.30 p. m...............................The motorized and animal-drawn ambulance company
Saturday, Oct. 20, 1917:
7.45 a.m................................Medico-military administration.
8.45 a.m................................The dressing station.
9.45 a.m................................The litter bearer group.
10.45 a.m..............................Shelter, hearing, and ventilation.
1.30 p.m................................Military administration: Troops, batteries, and companies: interior economy of companies; messing and cooking; company and mess funds; roster; daily service.
2.30 to 4.30 p.m....................Problem, sanitary tactics, trench warfare, battle of the Somme.
Monday, Oct. 22, 1917:
7.45 a.m. to 4.30 p.m............Practical gas instruction.
Tuesday, Oct. 23, 1917:
7.45 a.m. to 4.30 p.m............Practical gas instruction.
Wednesday, Oct. 24, 1917:
7.45 a.m. to 4.30 p.m............Practical gas instruction.
Thursday, Oct. 25, 1917:
7.45 a.m................................Medico-military administration.
8.45 a.m................................The administration of a field hospital.
9.45 a.m................................The duties of a field hospital in camp, on th march, and in battle
10.45 a.m...............................The application of our field hospital to present methods of warfare.
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Thurday, Oct. 25, 1917 - Continued
1.30 p.m....................Consideration in equipment and supplies of a field hospital
2.30 p.m....................The prevention of typhoid fever, paratyphoid, cerebrospinal meningitis, and diphtheria.
3.30 p.m....................Excreta
Friday, Oct.26, 1917
8.30 a.m. to 4.30 p.m............................................Field exercises. French problem on maneuver ground “Lafayette” with field hospital, ambulance company, and regimental unit in liaison.
Saturday, Oct. 27, 1917:
7.15 a.m.................................................................Medico-military administration.
8.45 a.m.................................................................Military administration: The chief of staff; intelligence. officer; the adjutant; military correspondence; orders; muster rolls, returns of troops; battle reports, casualties; records; personnel and efficiency reports.
9.45 a.m.................................................................Occupation of buildings extemporized as shelter for a field hospital.
10.45 a.m...............................................................Prevention of venereal disease.
1.30 p.m.................................................................Military administration: Arrest, confinement, and courts; the laws of war.
2.30 p.m.................................................................The specialization of field hospitals in trench warfare - French, English, and German methods.
3.30 p.m.................................................................Disinfection, disinfectants, and quarantine.
Monday, Oct. 29, 1917:
7.45 a.m.................................................................Medico-military administration.
8.45 a.m.................................................................The evacuation hospital and its transport.
9.45 a.m.................................................................Recent advances in prevention of infectious diseases; insecticides and practical methods of delousing.
10.45 a.m...............................................................The field hospital and duties of directors of field hospitals and ambulance companies.
1.30 p.m.................................................................Hippology.
2.30 to 4.30 p.m....................................................The saddles and bridles of horses and demonstration of the pack saddle.
Tuesday, Oct. 30, 1917:
7.45 a.m.................................................................Medico-military administration.
8.45 a.m.................................................................New sanitary appliances.
9.45 a.m.................................................................The dead and the role of the medical officer.
10.45 a.m...............................................................Education and training of Medical Department personnel.
1.30 p.m.................................................................Marches and camps.
2.30 to 4.30 p.m....................................................Automobiles, their engines, construction, repairs and spare parts; demonstration.
Wednesday, Oct. 31, 1917:
7.45 a.m.................................................................Medico-military administration.
8.45 a.m.................................................................New ordnance in its relation to medical units.
9.45 a.m.................................................................Morbidity and mortality in the military service.
10.45 a.m................................................................Military administration: Duties of medical officers; the register and report of sick and wounded.
1.30 to 4.30 p.m.....................................................Review.
Thursday, Nov. 1, 1917:
7.45 a.m.................................................................Medico-military administration.
8.45 a.m..................................................................Field orders.
9.45 a.m..................................................................Maps.
10.45 a.m.................................................................Military administration: The sanitary service in war - organization, objects, and duties; the American Red Cross.
1.30 p.m...................................................................Field Service Regulations: Security; marches; combat.
2.30 to 4.30 p.m......................................................Sanitary inspection, demonstration of bath, and delousing apparatus,
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Friday, Nov. 2, 1917:
8.30 a. m. to 4.30 p. m...........................................Maneuvers--ground “Lafayette.”
Saturday, Nov. 3, 1917:
7.45 a. m................................................................Medico-military administration.
8.45 a. m................................................................Military administration: Medical Department correspondence, reports, records, and returns in time of war.
9.45 a. m................................................................Battle-field casualties.
10.45 a. m..............................................................Medical supplies in time of war.
1.30 to 3.30 p. m...................................................Field Service Regulations: Tables of Organization; administration of zone of interior, of theater of operations, zone of advance, and line of communication; communication; transportation.
SPECIAL SCHOOLS
GAS SCHOOL, FIRST CORPS CENTER OF INSTRUCTION
As noted above, under the program of instruction for the sanitary school, First Corps center of instruction, practical instruction was given in gas warfare. The gas school for this purpose was a part of the center and was under the direction of a medical officer who started instruction on the date the center of instruction was established.3 This gas school was the only one of the gas schools in which the Medical Department participated.5
SANITARY SCHOOL, FIRST DEPOT DIVISION, ST. AIGNAN-NOYERS
To meet the requirements of the general training program of the American Expeditionary Forces, which called for training newly arrived members of the American Expeditionary Forces in a depot division, a training school was established in the 1st Depot Division, St. Aignan-Noyers, on March 10, 1918.6
Sanitary troops passing through the division to the front, and those on duty in the division, were given instruction in first aid, drill, etc.
Camp Hospital No. 26 maintained a large dental clinic, when in the late spring of 1918 a course of instruction was instituted for enlisted dental assistants.6 From here, enlisted dental assistants were distributed throughout the American Expeditionary Forces.6
PROFESSIONAL INSTRUCTION
Professional instruction, being entirely intradepartmental, was not considered under the head of training; therefore it was not covered by the activities of G-5, general headquarters, A. E. F., but was conducted in the Services of Supply by the professional services.4
Formal courses of professional instruction were conducted at the central Medical Department laboratory, Dijon,4 and at the School of Pharmacy of the University of Paris.7
CENTRAL MEDICAL DEPARTMENT LABORATORY, DIJON, FRANCE
One of the important activities of the central Medical Department laboratory, a which was established January 1, 1918,8 was concerned with the instruction of medical personnel in certain phases of laboratory technique in
a For an account of the organization and work of the central Medical Department laboratory, other than its instructional activities, see Vol. II, Chap. X, of this history.
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order that more efficient service might be rendered by officers so instructed in whatever hospital or other organization they might be detailed to serve. To this end special courses were organized for instruction in (1) the bacteriology of epidemic diseases; (2) the bacteriology of war wounds; (3) shock and resuscitation; (4) water supply work; (5) serology (Wassermann reaction).
BACTERIOLOGY OF EPIDEMIC DISEASES
One of the first subjects to engage the attention of the director of the division of laboratories and infectious diseases was the collection of definite informtion concerning the transmissible diseases prevailing in the allied armies on the Western Front and likewise in the civilian population in France.8 It was learned that we might expect typhoid fever, paratyphoid fever, bacillary dysentery, epidemic cerebrospinal meningitis, the pneumonias, diphtheria, venereal diseases, and other diseases of bacterial origin. The specific etiology and methods of transmission of trench fever were unknown at that time, and it was not anticipated that protozoal infection would give us any particular concern. As all the diseases mentioned above except trench fever, were quite generally distributed throughout the United States, it could be safely inferred that a considerable percentage of the personnel would be familiar with their bacteriology and, furthermore, special courses of instruction covering the bacteriology of these diseases was being given at the Army medical schools at Washington, D. C., Fort Leavenworth, Kans., and Yale University, New Haven, Conn., and at Rockefeller Institute, New York City.8 It was presumed, therefore, that the laboratory personnel in general would be fairly well equipped for the bacteriological work connected with infectious diseases. However, while there was no necessity for general routine training in this respect, a careful review of the special qualifications of a considerable number of officers who had been listed as laboratory specialists, indicated that scune of them Inight well take such a course as the one under consideration, with profit to themselves and to the service.8 Particular attention in this respect was given to the personnel assigned to divisional laboratories and, when milirary requirements permitted, to the personnel of base hospitals, practically all of which were provided with men well qualified for the work.8
BACTERIOLOGY OF WAR WOUNDS
The organization of a special course in the bacteriology of war wounds was instituted by reason of the fact that soon after our entry into the war the French surgical service had been able to demonstrate that débridemant of war wounds offered a very distinct advance in operative procedure, permitting early closure of wounds. 9 Many of their surgeons controlled their closures by bacteriological examinations. In January, 1918, the surgical advisors of the chief surgeon’s office requested that the laboratory service be prepared to do this work for them.9 This phase of laboratory activities was developed at the central Medical Department laboratory, and the special course of instruction given consisted of a two-weeks’ period of study of aerobes, anaerobes, and streptococci.9
This instruction was begun in the central Medical Department laboratory in June, 1918.9 Previous to that time various groups of men had been sent to
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the Pasteur Institute, Paris, to the center for surgical research of the French Medical Department, at Epernay, to Belfort, and to Dunkirk. The information which formed the basis of the instruction given at the central Medical Department laboratory was obtained from visits, by the director of the course, and other medical officers, to the above-named places, and to La Panne, Boulogne, and Chalons, from published books and reports on the subject, and from reports of the courses of instruction given at the places visited, and from current periodical literature.9
The first course in wound bacteriology was a six-day series of lectures and practical work.9 The course was lengthened later to two weeks. Nine courses were given, with a total attendance of 138. 9
It was planned to have in every evacuation and independent base hospital at least one officer, and in each hospital center one or more conversant with this type of work, and when the armistice went into effect this had been accomplished . 9
The student officers were shown different types of wounds.9 They were taught how to obtain Specimens from the wounds, and were shown retarded primary suture and secondary sutures. When evacuation was fairly rapid, wounded soldiers arrived at Base Hospital No. 17 (Dijon), within two or three days after injury, sometimes with field dressings unchanged. The student officers were then given an opportunity to see excision and débridement of wounds and to study the bacteriology of the débrided margins of wounds. When amputation was performed for wound infection or gaseous gangrene the amputated limb was taken to the laboratory, dissected before the class, and its bacteriology studied. The same was done with fatal cases of gaseous gangrene, which were autopsied before the class and the bacteriology of wound and the heart blood studied. Wound exudates obtained in this way were taken to the laboratory. Each student officer was required to determine the bacterial count according to the Carrel method, and to isolate the bacteria present and to report on the cytology of the wound exudate. He was further required to give an opinion as to whether his results permitted wound closure or contra-indicated it.
The officers reported only on wounds that they saw clinically and had personally examined later at the laboratory.9 Methods for rapid isolation and identification of the organisms whose presence were particularly dangerous in wounds were gone over in detail and applied to the diagnosis of these wound exudates. The classes were all furnished pure cultures of the 20 organisms studied and were required to study their morphology in the hanging drop and smears stained with Gram and special stains so as to demonstrate the presence of capsules in capsulated organisms, flagella, and spores wherever these were present. Each organism was studied with regard to its cultural characteristics in agar, Veillon agar, broth, milk, liver peptone, water, potato, glucose, lactose, maltose, saccharose, mannite, and glycerine. The cultures were studied at 24-hour intervals for 3 days, and the growth was examined in hanging drop and stained smears. Various methods of anaerobic culture were described in detail and the technical difficulties of each method explained. Owing to the lack of the complicated anaerobic apparatus suggested by various workers, and their impractica-
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hility under war conditions, it was decided to concentrate upon the technique suggested by Veillon and developed by Weinberg, and to use Veillon agar for solid media and liver peptone water medium for the isolation of all anaerobes in fluid cultures. Other fluid media were boiled previous to use, cooled and calcium sulphide added after inoculation and then covered with sterile paraffin oil.
In this way they were able to isolate nearly all of the organisms described as occurring in wounds and to identify them by means of the culture media and apparatus available under actual war conditions. The serologic characteristics of these organisms were studied, the officers being required to identify various anaerobes by means of agglutinating serum. Neutralization of toxin and of toxic cultures by specific antitoxins were demonstrated. Guinea pigs and white mice were inoculated with lethal quantities of cultures of the various anaerobes and the specific lesions demonstrated. The officers were required to study the bacteriology of the muscle exudate and heart blood of these animals after death. The last three days of the course were devoted to the identification of unknown mixed cultures. These unknown mixtures contained two aerobes and three anaerobes, and the officers were rated, first, according to their technique; second, according to their theoretical knowledge of the subject, as determined by oral examinations held at the end of each week’s course; and, finally, upon their identification of the unknown.
Other factors pertaining to the study of wounds were touched on in various lectures. A lecture on ballistics and also on the chemistry of certain antiseptics used in wound treatment were given. Pathological physiology of wounds and the pathological histology of wounds were similarly included so that the student officers could have a general knowledge of the subject plus the special training in the natural history of the bacteria found in wounds. The general principles underlying the preparation and effects of toxin and antitoxin were reviewed, and their application to the treatment of wound infection was described. Wound treatment was gone over very briefly and its relationship to wound bacteriology pointed out. In addition, a certain amount of instruction was given in the preparation of bulb pipettes, sealing of tubes and other manipulations of glass were essential in anaerobic bacteriology.
The course of lectures on wound bacteriology given to the classes during each session, is outlined below:9
OUTLINE OF LECTURES ON WOUND BACTERIOLOGY
LECTURE I
a.Program of course.
b. Introduction. General discussion:
(a)Aseptic wound and war wound.
(b) Evolution of subject; wounds of the Balkan wars; wounds of the first year of present war; Carrel’s experiment on transplantation; vaccine treatment; introduction of use of Labarraques solution; introduction of Carrel-Dakin method of treatment.
(c) Wound production; factors that enter into the production of wounds.
(1) Projectiles--bullets, shell casing, hand grenade, secondary projectiles (wood, stone, hard tissues--bone and teeth).
(2) Tissues destroyed--soft parts, bony tissues, viscera, serous cavities, vascular tissues.
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b.Introduction. General discussion - Continued.
(d)Structural details and histology of wounds--character on cross section (macroscopic, microscopic).
(e) Wound infection.
(1) Source of infection--projectile, clothing, skin.
(2) Type of infection--wound contamination, early, selective; secondary, adaptation, extension; symbiotic; latent.
(3) Physical factors favoring bacterial development.
(f)Bacteria found in war wounds--pathogenic, aerobic, anaerobic; saprophytic; bacterial associations.
LECTURE II
a. Method of obtaining specimens:
(1) Direct smear.
(2) Cellophane method.
(3) Pipette.
(4) Tampon.
(5) Excised tissue muscle; granulations; skin; bone.
(6) Foreign bodies: Projectiles; clothiisg debris; bone fragments.
b. Where obtained:
(a)Wound--different parts.
(b) Surrounding tissue; débridement; vesicle: muscle.
(c) Blood culture:
(1) Vein.
(2) Post-mortem--heart, peripheral veins.
c.Technical precautions.
d.Bacterioscopy:
(a)Direct smear.
(b) Hanging drop.
(c) Spread.
(d) Sealed pipette.
(e) Staining.
e.Diagnosis of stained smear:
(a)Morphology of bacteria.
(b) Staining reactions.
LECTURE III
(Second day - a. m.)
Ballistics:
(1) Muzzle velocity.
(2) Shell velocity.
(3) Disseminated energy.
(4) Composition of projectiles.
LECTURE IV
a.Pathologic physiology aiicl hiochemnistry of wounds:
(1) Aseptic; operative, and war.
(a) Necrobiosis.
(b) Autolysis.
(c) Leucocytic proteolysis.
(d)Blood clot.
(e)Foreign bodies.
(f) Bacterial products - toxins anti ptomaines.
b.General significance:
(1) To wound.
(2) To life.
(3) To utility--neuritis, atrophy, painful scars.
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LECTURE V
a.Bacterial counts:
(1) Carrel technique--preferable.
(2) Modified technique--personal equation.
b. Cytological examination:
(1) Leucocyte curve.
(2) Leucocytic index.
(3) Mononucleosis.
(4) Eosinophilia--significance, technique.
c. Significance of bacterial enumeration:
(1) In retarded primary suture.
(2) In secondary suture.
(3) Pus--retention and secondary infection.
(4) Chemical disinfection.
(5) Autovaccination; experience at La Panne.
d.Comparison of bacterial charts.
e.Colony enumeration:
(1) Slant agar.
(2) Veillon tube.
(3) Vignal tube.
(4) Elser tube.
LECTURE VI
General methods of bacterial isolation and identification:
(1) Isolation.
(a)Aerobic.
(b) Anaerobic.
(c)Filterable microorganisms.
(2) Identification.
(a)Morphology in solid media.
(b) Cultural characteristics.
(c) Biochemical properties.
(1) Carbohydrate fermentations.
(2) Protein fermentations.
(3) Peptolytic properties.
(d) Serologic reactions--agglutinations, neutralization experiments, complement fixations.
(e) Pathogenicity tests--total cultures, filtered or centrifuged toxin.
(f)Lesions produced.
LECTURE VII
Aerobic bacteria found in wounds belonging to coccus group:
(1) Streptococcus.
(a)Hemolyticus.
(b) Viridans.
(c) Nonhemolyticus.
(2) Staphylococcus albus, aureus (hemolyticus, nonhemolyticus) citreus, micrococcus candid us.
(3) Pneumococus.
(4) Enterococcus.
(5) Diplococcus Griseus nonliquefaciens.
LECTURE VIII
Aerobic bacteria found in wounds belonging to bacillary group:
(1) Organisms of the colon group.
(a) Bacillus coli communis.
(b) Bacillus Friedlander.
(2) Proteolytic group.
(a) Bacillus proteus vulgaris.
(b) Bacillus pyocyaneus.
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LECTURE IX
Aerobic bacteria found in wounds belonging to bacillary group:
(1) Spore bearing aerobe group.
(a) B. subtilis.
(b) B. myscoides.
(c) B. mesentericus.
(d ) B. anthracoides.
(2) Coryne-Bacterium group.
(a) B. cutis communis.
(b) B. diphtheria.
(3) Differential characteristics.
(a)Staining reactions.
(b) Cultural characteristics.
LECTURE X
a. Preparation of general and special media:
(1) Egg albumin glucose peptone media (Weissenbach).
(2) Blood media.
(3) Liver peptone media (Jablons and Pease).
(4) Egg albumin media.
(5) Meat media for spores.
(6) Veillon media.
(7) Sterilization.
b. Conservation of strains.
LECTURE XI
Methods for anaerobic bacterial isolation and identification:
(1) Anaerobiosis.
(a)Exclusion of air.
(b)Displacement of air.
(c)Vacuum formation.
(d)Absorption of air.
(2) Apparatus for anaerobic work.
(a)Paraffin layer tubes.
(b)Wright tube.
(c)Buchner tubes.
(d) Pinoy tubes.
(e)Anaerobic jar (Bullock, Novy).
(f) Vacuum apparatus.
(g)Hydrogen apparatus.
(h)MacIntosh arid Fildes apparatus.
(i) Anaerobic plates.
(j)Vignal tubes.
(k)Elser tubes.
(1)Fermentation tubes (Dunham and Fleming).
LECTURE XII
a.Anacrobes encountered in wounds:
(1) Anacrohes of primary inportance.
b. Welchii (B. perfrinqens).
(1) History.
(2) Methods of isolation.
(3) Methods of identification.
(4) Morphology.
(a)Staining characteristics.
(b)Motility.
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b. Welchii (B. perfringens) - Continued.
(5) Cultural characteristics.
(6) Biochemical properties--saccharolytic, proteolytic, peptolytic.
(7) Serological characteristics.
(8) Pathogenicity (total culture and toxins).
(9) Experimental infection: Symptoms, lesions.
LECTURE XIII
a. Vibrion septique (relationship to B. malignant aedema):
(1) History.
(2) Methods of isolation.
(3) Methods of identification.
(4) Morphology.
(a)Staining characteristics.
(b)Motility.
(5) Cultural characteristics.
(6) Biochemical properties--saccharolytic, proteolytic, peptolytic.
(7) Serological characteristics.
(8) Pathogenicity (total culture and toxins).
(9) Experimental infection: Symptoms, lesions.
LECTURE XIV
a. Bacillus of toxic edema (B. Aedematiens, B. bellonensis, B. gas aedem (Aschoff), Type XIII, British Research Committee):
(1) History.
(2) Methods of isolation.
(3) Methods of identifications.
(4) Morphology.
(a) Staining characteristics.
(b)Motility.
(5) Cultural characteristics.
(6) Biochemical properties--saccharolytic, proteolytic, peptolytic.
(7) Serological characteristics.
(8) Pathogenicity (total culture and toxins).
(9) Experimental infection: Symptoms, lesions.
LECTURE XV
a. Proteololytic anaerobes of secondary importance:
(a) B. sporogenes.
(b) B. putrificus.
(c) B. bifermentans.
(d) B. histolyticus.
(1) Morphology.
(2) Cultural characteristics.
(3) Biochemical properties.
(4) Serologic characteristics.
(5) Pathogenicity.
LECTURE XVI
Anaerobes of unusual occurence in wounds:
(a) B,fallax.
(b) B. aerogoetidus.
(c) B. tertius.
(1) Morphology.
(2) Cultural characteristics.
(3) Biochemical properties.
592
LECTURE XVII
a.Anaerobic streptococci - significance.
b.Occurrence of the above alone and in symbiosis.
c.Conditions under which they become dangerous.
d. Suggestions for the practical examination of unknown exudates.
LECTURE XVIII
Serious wound infections:
(1) Gas gangrene.
(a) Bacteriology.
(b)Older conceptions.
(c)Recent conceptions.
(d)Symptomatology.
(e)Pathology.
(f)Treatment.
LECTURE XIX
a. Toxin production:
(1) In different media.
(a) Bull and Pritchett (B. Welch).
(b)Nicolle and Frasey (Vibrion septique).
(c)Weinburg and Sequin (B. aedematiens).
b.Antitoxin production:
(1) Anti-Welch.
(2) Anti-Vibrion septique.
(3) Anti-aedematiens.
(4) Anti-Bellonensis.
(5) Polyvalent sera.
c.Animal pathogenicity:
(1) Lesions produced locally.
(2) Symptoms of intoxication.
d.Agglutination tests:
(1) Against antibacterial serum.
LECTURE XX
Serious wound infections (continued):
(1) Streptococcemia.
(2) Tetanus.
(a) Acute.
(b)Late.
(c)Post-serum.
LECTURE XXI
Wound treatment:
(1) Surgical disinfection.
(a)Primary suture.
(b) Retarded primary.
(c)Secondary.
(2) Chemical disinfection.
(a)Carrel-Dakin.
(b) Eusol.
(c)Mestrezat--acid hypochlorite.
(d)Dichloramin-T paste.
(e) Phenol.
(f) Iodine.
(g)Formalin.
(h)Dyes--methylene blue, flavine, acroflavine, B. I. P. (bismuth-iodoform paste).
(i) Wright hypertonic solution.
(j) Alkali.
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Wound treatment - Continued.
(3) Biologic therapy.
(a)Serotherapy.
(1) Curative.
(2) Prophylactic.
(b)Antistreptococcus.
(c) Leclainche and Vallee--polyvalent.
(d) Bull--antitoxin.
(e)Weinberg--mixed.
(f)Sacquepee--antibellonensis.
(4) Physical therapy.
(a)Irrigation.
(b)Heliotherapy--Sun, Finsen ray, electric lamp, ultra-violet ray.
(c)Hot-air therapy.
(d)Cautery.
(e)Ionization.
(5) Physiologic rest.
LECTURE XXII
a.Preparation and titration of Dakin’s solution.
b.Determination of antiseptic power of different antiseptics:
(1) Phenol coefficient.
(2) Thread method.
(3) Elser diffusion method.
LECTURE XXIII
a.Collection of statistical information.
b.Practical suggestions in case of active work.
c.Practical suggestions in case of lull in activity.
SHOCK AND RESUSCITATION
Classes of instruction in shock and resuscitation were organized as part of the work of the laboratory of surgical research, which was established as one of the activities of the central Medical Department laboratory. 10 The purpose of this instruction was to give special and essential training to “shock teams” Serving in the forward areas. 10
One of the first facts brought out in the course of the early research on shock and hemorrhage was that as blood pressure falls a critical level is reached, below which the circulation becomes so greatly retarded that there is an insufficient oxygen supply to the tissues. Evidence for this was gained through an examination of the blood, which showed that as the’ pressure fell below the critical level there was an accumulation of acid in the blood which diminished the alkali reserve, and that this diminution was greater the further the pressure fell below the critical level. It is well known that nerve cells are particularly sensitive to lack of oxygen, and it seemed natural to expect, therefore, that when blood pressure is below the critical level damage is being done to nervous structures. Such damage was early demonstrated by the experiments performed in the surgical research laboratory. From these observations it was evident that, in addition to the usual treatment of shock by warmth, rest, and fluid by mouth, there was indicated, in case the blood pressure was not raised through these agents, the necessity of raising it artificially to a point above the critical level in order to avoid progressive damage to important structures.
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At the time the foregoing facts were obtained a medical officer on the laboratory staff had begun teaching classes the methods of matching the blood of donor and recipient for transfusion and the use of the transfusion set recently adopted by the Army. Late in May the course in resuscitation was organized, and from that time forward, until November 1, 1918, with few interruptions, classes ranging from 6 to 21 members appeared each week to receive instruction in methods of resuscitation.
The three-day schedule which followed was the basis of the preliminary training for resuscitation work:
COURSE OF INSTRUCTION FOR PRELIMINARY TRAINING IN RESUSCITATION WORK FOR THE WOUNDED
FIRST DAY
9 a. m. (amphitheatre, main laboratory building):
Introduction - Discussion of circulation in relation to shock and hemorrhage.
10.30 a. m. (physiological laboratory):
Demonstration -
Blood pressure instruments.
Standardization of instruments.
Determination of systolic and diastolic pressures.
Artificial respiration--Schaefer method--Bellows.
2 p. m. (physiological laboratory, laboratory building B):
Lecture and demonstration -
Hemorrhage with blood pressure records -
Natural recovery.
Critical further bleeding.
Treatment with salt solution.
Reinjection of blood.
Hemorrhage with replacement by gum-salt solution.
Amount of blood replaceable by gum-salt solution.
Aseptic operation.
SECOND DAY
9 a. m. (physiological laboratory, laboratory building B):
Lecture and demonstration -
Shock blood pressure -
1. Effects of rebreathing and ether.
2. As a cause of acidosis.
3. As a cause of damage to circulatory control.
4. As influencing the effect of ether.
2 p. m. (physiological laboratory, laboratory building B):
Lecture and demonstration -
Treatment of shock -
1. Adrenalin--temporary.
2. Normal salt solution--temporary.
3. Rebreathing expired air.
4. Gum-salt solution (and blood?).
Resuscitation of the stopped heart.
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THIRD DAY
9 a. m. (amphitheater, maims laboratory building):
Lecture -
Blood transfusion -
1. General consideratiomss.
2. Direct methods.
3. Indirect methods -
Unmodified blood.
Modified blood.
Preserved red blood cells.
Use of anticoagulants.
4. Sodium citrate blood mixture.
5. Incompatibility of bloods. Methods of determination
6. Indications for transfusion.
7. Blood transfusion method adopted for A. E. F.
8. Organization of work.
10.30 a. m.:
Practical work (laboratory building B) -
Grouping of donors.
Practical work (surgical laboratory, laboratory building B) -
Preparation of serum for group determinations.
General conference (amphitheater, main laboratory building).
Naturally, as more and more experience was obtained in teaching, in research, and in the work of the resuscitation teams at the front, the methods of instruction became amplified and improved. The following account is based upon the above program, which was followed during the latter part of the period : 10
Three days were devoted to the instruction. On the first day the director of the research laboratory met the members of the class and gave them an outline of the work which they were to perform. He described to them the characteristic features of shock, and brought it into relation with hemorrhage. He then emphasized three points which had practical importance in the treatment of shock: (a) Distribution of blood, (b) acidosis, and (c) sensitiveness to anesthetics. In connection with the concentration of blood in the capillaries, the effect of cold in causing similar concentration afforded a rational explanation of the deleterious influence of loss of heat in augmenting the condition of shock, and gave opportunity for discussing the various means which may be employed to check loss of heat, and to restore to the shocked man the heat which has already been lost. The development of acidosis in shock, when the pressure has fallen below the critical level mentioned above, was the basis for considering the physiology of the circulation in relation to tissue needs, and the importance of keeping the head of pressure in the arteries high, in order to provide a circulation adequate to these ends. The fall of pressure accompanying anesthesia and operation made the basis for discussing the methods of obviating the influences dangerous to the shocked man which attend operation, and the aid which the resuscitation officer may give the surgeon when about to operate on such a man.
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After this introductory discussion of shock and hemorrhage, the classes reported to the laboratory, and there had demonstrated the various means of measuring arterial blood pressure. The members of the class were then required to determine blood pressure on a subject, and their results were compared with the results of an expert. If some members made observations markedly discrepant, they were asked to repeat their readings till a common judgment was agreed upon by all. The class was then given instruction in various methods of providing artificial respiration. The work thus far described consulned the morning of the first day.
The afternoon of the first day was devoted to a study of hemorrhage. The method employed was that of gathering the class about a demonstration table, and showing them the blood pressure being recorded directly from an animal under anesthesia. During the course of the demonstration, the effect of hemorrhage in causing a fall of blood pressure was shown and discussed by the class, as was also the natural recovery which usually follows, except in the most severe bleeding. The class was also shown how, after such recovery, the loss of even a small amount of blood might turn the scales against recovery, and the moral of this in teaching, that every effort should be made to avoid absolutely any unnecessary loss of blood from wounded men, was strongly emphasized. After the blood pressure had been seriously lowered by hemorrhage, the purely temporary effect of salt solution injected into the veins was compared with the permanent effects which could be obtained when the blood taken from the animal was reinjected. Later, hemorrhage was again produced, until the pressure was very low, and the volume thus substracted from the animal was replaced by Bayliss’s solution of gum acacia 6 per cent in sodium chloride 0.9 per cent. The permanent rise of pressure which this solution gave was compared with the temporary rise resulting from the injection of pure salt solution. The difference between the two afforded opportunity for discussing with the class the claims made by Bayliss for his colloidal preparation.
In order that the possibilities of the use of guru-salt solution as a substitute for blood volume might be realized, 60 percent of the estimated blood volume was removed by venesection, with aseptic precautions, from a dog under anesthesia, and the amount replaced by the warm colloidal solution, introduced slowly. With only two exceptions in the whole series of demonstrations it was possible to show the animal the next morning to the students, and even two or three weeks later, in perfectly normal condition. The importance was pointed out by using the artificial solution to replace blood as early as possible after the blood was lost.
The second day was wholly devoted to demonstrations as to the nature of shock, and to discussions between the instructor and the members of the class regarding the phenomena as they occurred. Two methods were employed to bring about the state of shock. Early in the instruction shock was induced by a persistent low pressure caused by increased intrapericardial pressure. Later, shock was induced as a result of tissue damage. By testing with the Van Slyke apparatus samples of blood taken before shock was induced, and after a low pressure had been developed, the influence of low pressure in causing acidosis was demonstrated. In this connection the critical level of a falling
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blood pressure, and the urgency of not permitting the pressure to remain long below this level, were again emphasized. The failure of blood pressure to rise after it had been kept low through prolonged intrapericardial pressure, showed the damage to the control of the circulation induced by the insufficient supply of oxygen. Naturally, these demonstrations required some hours for their completion. During this time the physiology of the circulation, the function of high arterial pressure, the change in the circulation wrought by low pressure, the effects of a low pressure in diminishing the oxygen delivered to the tissues, the nature of the consequent acidosis, and the theories of shock were discussed by the instructor and by the members of the class. The exercise was as informal as possible, and, when the classes were small, there was no restraint manifested by the members in asking questions, and in bringing out points which seemed to require further consideration. There was definite advantage thus obtained by giving time for observations and ideas to get a firm setting in the minds of the students.
During the afternoon of the second day the treatment of shock was considered, and, as far as possible, demonstrations were given on various suggested agencies. The temporary influence of adrenalin was recorded as well as the temporary rise obtained by injecting normal salt solution. The rebreathing of expired air was shown to have no value or even a harmful effect. The rise of blood pressure through the use of colloidal solution or blood was then discussed. If the state of shock had not continued for too long a period, so that tissues were disastrously injured, it was possible to demonstrate the permanent rise of arterial pressure which could be obtained by the injection of such fluid.
The effect of ether in causing a striking fall of arterial pressure, when it is administered even to a degree which is barely sufficient to abolish simple reflexes in the shocked organism, was demonstrated. To some classes the markedly different effect of nitrous oxide and oxygen as an anesthetic was shown; through this agency it was possible to produce the same degree of anesthesia as that produced by ether with no fall of blood pressure whatever.
Finally, the animal, which had been in a state of shock even for 15 or 16 hours, was killed by asphyxiation; the recording apparatus showed that the blood pressure had fallen to zero, and that the heart and respiration had ceased acting. Now adrenalin in salt solution was injected into the carotid artery, the heart was massaged through the chest wall, and artificial respiration was administered, and in a few moments the blood pressure usually mounted to 150 mm. of mercury, where it was sustained sometimes for many minutes, with no indication of cardial failure. This demonstration was made the basis for considering the use of a therapy sometimes employed in stimulating the heart in order to raise arterial pressure. It seemed clear from the demonstration that there was no indication of cardiac failure as an essential causal factor in shock.
After the first two days had been spent in becoming acquainted with the physiology of hemorrhage and shock and with the essential disturbances wrought in the organism by conditions which these states induced, the classes were taught, on the third day, the practical methods of dealing with these states. The instruction consisted in discussion of the fundamental principles underlying the transfusion of blood, especially with reference to the tech-
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nique employed, and to reactions which might result if donor and recipient do not belong in proper blood groups in relation to one another. The surgical service had previously selected the method of employing citrated blood; the principle of this method was described, and the transfusion set used in carrying out the method was demonstrated. Since the ease of transfusion depends largely on the condition of the needles which are used, the care of the needles was described in full. The indications for transfusion were then again considered with reference not only to the experimental work of the previous days, but also with the reference to other resuscitation measures which are employed; and finally the proper organization of activity in a resuscitation ward was presented.
After hearing this discussion the class went to the laboratory, where they were divided into groups; one group engaged in matching their own blood against type sera, another in sharpening needles and learning practically the method of keeping needles in proper condition, and another in using the transfusion set on an anesthetized animal. In this last experience the blood was removed from the jugular vein on one side and introduced into the jugular vein on the other. A long exposure of the veins permitted many repetitions of the experience on the same animal. After these exercises there was no reason why any member of the class should have excuse for not being able to employ intelligently the transfusion set.
In the afternoon of the third day the class was taken to Base Hospital No.17, Dijon, where they engaged in grouping the blood of patients, and, when possible, in withdrawing blood which was later used for the preparation of the sera sent out in the transfusion sets. Thus such members of the class as had not had previous experience in “needling” human veins had opportunity of learning under supervision.
The members of the resuscitation teams were almost exclusively selected from the medical personnel of base hospitals. The theory of this arrangement was that these men would return to their stations, and there each one would associate with himself an orderly and a nurse, who would go to a forward hospital in times of activity to from one of two teams to work in the resuscitation ward of that hospital. Practically, this scheme worked well in certain cases; in other cases, however, the prospective activity was anticipated by the commanding officer of the base hospital, and objection was raised to the separation of the medical officer for forward work at a time when the staff of the base hospital might be heavily burdened. The consequence was that, in spite of the large number of men from base hospitals who were trained, it was difficult to get a sufficient number of resuscitation teams, and in some degree the shock wards of forward hospitals were manned by persons who had not been trained in this laboratory.
Ever since the evidence had been obtained in May, 1918, of the progressive damage done to the control of the circulation through persistence of low blood pressure, emphasis was laid on the early treatment of shock. Late in May the director of the laboratory visited the divisions then in the line, the 26th, 42d, and 32d, and spoke to the medical officers of these divisions on the importance of dealing early with the conditions presented by the shocked men. Fortunately, the simple measures of rest, warmth and hot fluids given by mouth are often
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highly effective, and can be used near the fighting lines. These measures, with proper blanketing, will greatly reduce the degree of shock, and if consistently employed will give the badly wounded the best opportunity in the stress of transportation. Repeated efforts were made to bring instruction to the medical officers of divisions—the first officers to care for the badly wounded--but these efforts were largely fruitless. Reports coming from several sources revealed that during the cold weather of late October and November the wounded were being sent on long ambulance journeys with improper blanketing, due, not to lack of blankets, but to improper arrangement of them. Clearly there might have been more satisfactory treatment of the wounded if methods of resuscitation had been more thoroughly taught to the divisional medical officers.
To some extent it was possible to reach these officers in the classes at the Army Sanitary School, Langres; every month one or other member of the teaching staff presented to these classes a brief summary of the work which was given in detail to the classes that came to the laboratory. Late in October, 1918, arrangements were made to have these classes sent in squads to Dijon for more thorough instruction.
In connection with the activity of resuscitation teams, it was deemed advisable to have some sort of oversight of the use of the information which had been given them and the methods which they had been taught. For this reason visits were made to hospitals north of Chateau Thierry in August and in the neighborhood of the St. Mihiel salient in September by the director. The hospitals in the region west of Verdun were visited by an officer of his staff. It was early found that the corps consultants in medicine naturally took upon themselves the function of continuously overseeing the work of the resuscitation teams. By their cooperation, and also by the visits made to the front by members of the laboratory staff, information was obtained as to difficulties which were being encountered, and suggestions were offered as to means of meeting these difficulties.
WATER SUPPLY
After September 27, 1918, when the water-supply section of the central Medical Department laboratory was organized, special training in water-supply work was given to the division water-supply personnel.11 The instruction was practical in character and related more particularly to water surveys, proper methods of determination of water supplies, and the simple chemical tests to be used to check and supervise chlorination.8
SEROLOGY
The special course in serology was instituted for the purpose of standardizing, so far as possible, the Wassermann technique and giving instruction to laboratory officers who would be required to do this work as part of their routine duties.9 The centralization of Wassermann work in a few laboratories was desirable, but the unavoidable delays in mails and lack of transportation for courier service prevented the degree of centralization that was desirable.
b For a full discussion of this subject see Vol. VI, Sanitation, sec. “In the American Expeditionary Forces,” Chap. VII - Ed.
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GAS INSTRUCTION FOR DIVISION MEDICAL GAS OFFICERS
It proved necessary to give to medical officers who were to become divisional medical gas officers instructions in the professional care of gas casualties. This was authorized August 29, 1918.7 Subsequently, as division medical gas officers were appointed, each was sent to the school of pharmacy of the University of Paris (Ecole de Gaz) for a four-day course of instruction before being assigned to his respective division for duty.
For details concerning this school course, as well as additional instructions which medical gas officers received, consult Volume XIV of this history.
REFERENCES
(1) G. O. No. 8, H. A. E. F., July 5, 1917; also G. O. No. 31, G. H. Q., A. E. F., February 16, 1918.
(2) General organization project, A. E. F., July 10, 1917. On file, general headquarters, A. E. F., Washington, D. C.
(3) Report of the assistant chief of staff, G-5, G. H. Q., A. E. F., on the operations of G-5, made to the chief of staff, A. E. F., June 30, 1919. On file, general headquarters, A. E. F., Washington, D. C.
(4) Report on Medical Department training in the American Expeditionary Forces, undated, by Col. B. K. Ashford, M. C. On file, Historical Division, S. G. O.
(5) History of the Chemical Warfare Service, American Expeditionary Forces, Vol. I, 8. Copy on file, Historical Section, Army War College. Also: Personal record, Maj. Walter M. Boothby, M. C. On file, Personnel Division, S. G. O.
(6) Report of the Medical Department activities, First Depot Division, St. Aignan-Noyers, undated, made to the chief surgeon, A. E. F., by Col. O. G. Brown, M. C. 0n file, Historical Division, S. G. O.
(7) G. O. No. 144, G. H. Q., A. E. F., August 29, 1918.
(8) Report from Col. J. F. Siler, XI. C., director of laboratories and infectious diseases, A. E. F., to the chief surgeon, A. E. F., undated. Subject: Activities of division of laboratories and infectious diseases, from August, 1917, to July, 1919. 0n file, Historical Division, S. G. O.
(9) Report from Maj. B. Jablons, M. C., to office of director of laboratories, A. E. F., American Post Office No. 721 France (through commanding officer, central Medical Department laboratory), May 14, 1919. Subject: Report on teaching of wound bacteriology.
(10) Historical Record of the Services of the Laboratory of Surgical Research, American Army, at Dijon, 1918, by W. B. Cannon. On file, Historical Division.
(11) Report of water analysis work at the central Medical Department laboratory, Dijon, France, January 25, 1919, by Capt. H. B. Hommon, S. C. On file, Historical Division S. G. O.
