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Memoranda

Contents

THE MORE IMPORTANT MEMORANDA PROMULGATED BY THE DIVISION OF LABORATORIES
AND INFECTIOUS DISEASES, A. E. F.

From: The director of laboratories, A. E. F.

To: The division surgeon, --- division.

Subject: Divisional laboratory unit.

1. The accompanying letter of information is intended to define the organization, equipment, and scope of work of the divisional laboratory.

2. The section of infectious diseases of this office has been organized for the instruction of divisional laboratory personnel and the advisory reinforcement of divisional facilities in the control and suppression of communicable disease. Paragraph 4 of the accompanying memoranda states the mechanism by which this reenforcement can be obtained when desired by division surgeons.

3. As the divisional laboratory personnel (mobile laboratories), in many instances, is not coming to France as an integral part of divisions, but arriving as casual units, division surgeons are experiencing some difficulty in locating this personnel.

In order to overcome this difficulty, the chief surgeon, A. E. F., has been requested to automatically order all these units to the central Medical Department laboratory for special instruction, to obtain equipment, and for assignment to divisions.

4. If your divisional laboratory personnel (1 medical officer, 1 Sanitary Corps officer, and 4 enlisted men) did not arrive as an integral part of your division, the personnel and equipment will be supplied by this office, as soon as available, on written or telegraphic request from you.

5. If your divisional laboratory personnel arrived with your division and has not received special instruction and equipment from the central Medical Department laboratory, it is requested that the names of the commissioned officers, two in number, be submitted to this office in order that we may request orders for them to proceed to the central Medical Department laboratory for temporary duty.

(Office letter 5-a (revised), division of laboratories and infectious diseases, July 7, 1918.)


OUTLINE OF ORGANIZATION AND ADMINISTRATION OF LABORATORY ACTIVITIES IN HOSPITAL CENTERS

1. In order that building space, equipment, and personnel may be conserved and at the same time that units comprising hospital centers may be given high-grade laboratory service, it has become necessary to pool the laboratory facilities of such units and to establish a base laboratory which shall serve equally all units comprising the center together with small subsidiary laboratories attached to each unit.

2. The plans of organization contemplate that all highly technical bacteriological, serological, pathological, and medical chemical work shall be done at the base laboratory of the center and that the small subsidiary laboratories shall be equipped for clinical pathological examinations only.
 PERSONNEL
3. The allowance of personnel estimated for in the proposed revision of the Tables of Organization is 6 officers and 18 enlisted men. This is only an estimate, however, and the personnel may be increased, decreased, or distributed to meet local conditions.

4. Laboratory personnel, as outlined above, should be detailed by the commanding officer of the hospital center from the personnel of the units comprising that center. French women should be utilized as laboratory technicians wherever possible, thus releasing enlisted men for other duties. Requests for the employment of such women will be made to the chief surgeon, A. E. F., through the commanding officer of the hospital center and paragraph 3, General Order 13, headquarters A. E. F., July 13, 1917, compiled with.


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5. The laboratory officer of a hospital center will be detached from his unit and attached to the staff of the commanding officer of the hospital center. All other laboratory personnel, commissioned and enlisted, will be attached to the laboratory service for professional duties only and be carried administratively on their unit returns.
 DUTIES OF THE LABORATORY OFFICER, HOSPITAL CENTERS

(a) In charge of base laboratory.

(b) Responsible to the commanding officer of the hospital center in all matters relating to laboratory activities.

(c) General supervision of the subsidiary laboratories.

(d) Direct supervision and control of all laboratory personnel under the commanding officer of the hospital center.

(e) Correlation of the activities of the laboratory service, both central and subsidiary, with those of the clinical service served.

(f) Advisor to the medical supply officer of the center as to issue, distribution, and requisitioning of laboratory supplies for his center.

The name of one medical officer, well grounded in general bacteriology, will be submitted to the director of laboratories and infectious diseases, chief surgeon's office, A. P. O. 721, who will request orders for his transfer to the central Medical Department laboratory for a
two-weeks' course of instruction in wound bacteriology.
 
SUPPLIES

6. All laboratory equipment now on hand at units comprising hospital centers will be pooled and turned over to the medical supply officer of the center and will be redistributed by him on memorandum receipt, after consultation with the laboratory officer, as the latter indicates. Inventories will be prepared showing all items that are not suited for use in the center (such as electric equipment not suited to the current available), together with items that are in excess of the actual needs, and forwarded directly to the office of the director of the division of laboratories and infectious diseases, office of the chief surgeon, A. P. O. 721, who will indicate the disposition to be made of such items.

7. All requisitions for supplies for the laboratory service will be prepared and forwarded by the medical supply officer of the center. Requisitions will be made in quadruplicate, one copy being retained and three copies forwarded. Requisitions for laboratory supplies only should be sent to the director of the division of laboratories and infectious diseases, office of the chief surgeon, A. P. O. 721, and it is desired that as far as possible requisitions be so timed as to permit shipment thereupon to be included in larger shipments made from supply depots on ordinary requisitions. These special requisitions should therefore be sent approximately ten days prior to larger requisitions contemplated and should bear notation that shipment should be held pending the receipt of requisition for general supplies.

8. Laboratory animals (sheep, rabbits, guinea pigs, and mice) will be purchased locally if possible, and if not, required for from the nearest army or base laboratory. In view of the great demand for laboratory animals in France by the Chemical Warfare Service, requisitions for such animals, especially mice, will be reduced to a minimum. Requisitions for white mice will be honored only in cases of great emergency and in small quantities. The Avery method or some other suitable technique as a substitute for the mouse method of pneumococcus type determination should be used.

9. Estimates have been prepared and orders are now being placed for standard items of laboratory equipment, and it is hoped that the laboratory equipment for hospital centers may be standardized in the near future. Until then, medical officers should be guided by the realization that technical apparatus of all sorts is obtained with great difficulty under present conditions and, that in view of the difficulties of transportation, all ordinary demands should be anticipated two or three months in advance.

10. An allotment of $100 per month will, on request, be made by the chief surgeon's office to the medical supply officer of each hospital center to cover purchases of laboratory animals, milk, eggs, meat, and other ingredients of culture media and such other items as are necessary for the proper functioning of the base laboratory, and properly chargeable against Medical Department appropriations.


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TRANSPORTATION

11. Transportation for central laboratories at base hospital centers has not been authorized as yet but this office has recommended that these laboratories be allowed one motor cycle with side car and one bicycle in the proposed revision of the tables of organization.

(Memorandum No. 8, division of laboratories and infectious diseases, July 23, 1918.)


DIVISIONAL LABORATORY UNIT

1. In the organization of the laboratory service for the American Expeditionary Forces provision was made for a divisional laboratory unit to serve with each division.

The personnel, equipment, and proposed transportation for each unit is as follows:

  Personnel:

   1 Captain or First Lieutenant, Medical Corps or Medical Reserve Corps, Medical Department.
   1 Captain or First Lieutenant Sanitary Corps, Medical Department.
   4 enlisted men, Medical Department.

Equipment:

   Chest 1. Standard equipment for clinical pathology.
   Chest 2. Standard equipment for clinical pathology.
   Chest 3. Standard equipment for bacteriological incubator.

Transportation:

   1 light truck (¾-ton Ford or other standard).
   1 motor cycle with side car.

2. It is contemplated that these laboratory units shall constitute a part of the sanitary staff of the division surgeon and that they will be used by the divisional sanitary inspector in the investigation and control of communicable diseases and in the inspection, supervision, and control of sterilization of water supplies. While the question of immediate control of these units is a matter of internal administration, it is deemed advisable to place the medical officer in charge of the divisional laboratories because of the relative importance of the fields covered by the members of these units.

Some division surgeons have found it most practicable to attach the laboratory unit to the divisional sanitary train. When in divisional training or rest areas, it is contemplated that the laboratory unit will be attached to the camp hospital functioning for the division. At the front it is attached to an immobilized field hospital, preferably the one through which infectious diseases and medical cases are evacuated.

3. To properly perform its functions, it is contemplated that the medical officer and officer of the Sanitary Corps attached to this unit shall, on arrival in France, be sent to the central Medical Department laboratory for temporary duty for a brief course of instruction in the epidemiology of communicable diseases and supervision of water supplies respectively and to obtain their laboratory equipment. Further practical instruction will be given these officers by specially trained officers of the infectious diseases and water supply sections of this office, who will visit them from time to time for the purpose of giving aid in the solution of local problems.

4. When an epidemic disease prevails in a division in such proportions as to make it seem desirable to temporarily reinforce the divisional personnel and to have special epidemiological and laboratory studies made for the control of the disease, the division surgeon is authorized by Bulletin No. 32, general headquarters, A. E. F., to communicate directly with the director of laboratories and infectious diseases, who will dispatch special personnel and mobile equipment to reinforce the divisional authorities in controlling the epidemic. In the zone of the advance these units are usually located in close proximity to evacuation and mobile hospitals. These organizations are provided with a complete laboratory equipment, which is available for use by the members of the divisional laboratory units when highly technical laboratory examinations are required.


1060

Many of the evacuation and mobile hospital laboratories are prepared to do Wassermann tests, and the officer in charge of the divisional laboratories should consult with the laboratory staff of the organization to determine whether demands for such examinations can be met.

5. The equipment to be supplied the divisional laboratory unit has been standardized and arranged in chests in order that it may be packed and moved at a moment's notice. Chest 1 (weight 230 pounds, dimensions 24 by 24 by 36 inches), chest 2 (weight 140 pounds, dimensions 21 by 24 by 30 inches), chest 3 (weight 180 pounds, dimensions 39 by 22 by 28 inches) constitute the divisional Laboratory equipment. Chests 1 and 2 contain the equipment and supplies for routine clinical pathology, while chest 3 contains a bacteriological incubator complete, arranged for heating with coal oil. The coal oil is to be secured from the divisional supply officer.

6. With the equipment mentioned above, the following classes of work can be done:

Sputum.-Microscopic examinations of smears for the tubercle, pneumococcus, influenza, and animal parasites.

Urine.-Appearances, color, odor, reaction, specific gravity, and qualitative tests for albumin, sugar, acetone, and diacetic acid. Microscopic examinations of urinary sediments. In suspected cases of typhoid fever about 10 c. c. of the urine should be sent to the central Medical Department laboratory or the nearest base or army laboratory in a bottle of bile medium, for isolation of the suspected microorganism.

Venereal lesions.-Miscroscopical examinations of smears for gonococci and Fontana stained preparations from venereal sores for spirochetes.

Blood.-Hemoglobin estimations (Tallquist), leucocyte counts, red-cell counts, and differential leucocyte counts. Microscopical examinations of stained preparations for pathological changes, plasmedia, etc. In every case of undetermined fever of over 48 hours' duration, 2 to 5 c. c. of blood should be collected in a bottle of bile medium and the culture sent to the general Medical Department laboratory or the nearest base or army laboratory for further study. Sera for agglutination tests, the Wassermann test, etc., should be collected in the serum capsules furnished with this equipment and sent to the nearest of the laboratories mentioned above.

Feces.-Microscopical examinations of fresh specimens for parasites, ova, blood, mucus, and pus cells.

In suspected cases of typhoid fever, paratyphoid fever, or dysentery, about a gram of the feces should be sent to the central Medical Department laboratory, or the nearest base or army laboratory, in a bottle of bile medium, for isolation of the specific microorganism.

Transudates and exudates.-Microscopical examinations of stained specimens for tubercle bacilli, gonococci, spirochetes, etc., and cytological changes.

Spinal fluid.-Microscopical examinations (cytologic and bacteriologic).

7. It is not intended that highly technical bacteriological and serological work shall be done by these units. In epidemics requiring epidemiological study and laboratory control, it is contemplated, as noted in paragraph 3 above, that special personnel and mobile equipment will be sent to reenforce the local authorities on request from the division surgeon.

8. It is not contemplated that the Sanitary Corps officer attached to this unit for supervision of water supplies shall do any extensive chemical or bacteriological laboratory work. In so far as his water work is concerned, it will usually be confined to sanitary surveys of sources of supply, recommendations concerning quality of water, and supervision and instruction of sanitary detachments in the detail of the sterilization of water by chlorination or otherwise. His work will be done under the supervision of the divisional sanitary inspector. Where bacteriological or chemical analyses are deemed advisable, the specimens will be collected by the water supply officer of the laboratory unit and forwarded to the nearest army or base laboratory or mobile water laboratory. A chlorine testing outfit for use in controlling the chlorination of water supplies will be issued to divisional laboratory units. Where extensive surveys requiring laboratory control are necessary, the Medical Department representative on the staff of the water supply officer for the army will be called on for assistance. He has under his control mobile water analysis laboratories designed to carry out such investigations.


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9. Instructions for Sanitary Corps officer attached to divisional laboratory and for other officers concerned in the chlorination of drinking water.

(a) The official method of sterilizing water is by means of calcium hypochlorite. The powder is issued in 1-gram tubes. One tube is usually sufficient to sterilize one Lyster bag full of water. Break a tube of calcium hypochlorite into a clean ordnance cup, moisten the powder with a few drops of water, and mix into a smooth paste. Now fill the cup with water to within 1 inch of the top and mix thoroughly by stirring with clean spoon. Add this solution to a Lyster bag filled with clear water, stir thoroughly and allow to stand 30 minutes before using. After 30 minutes, test a cupful by adding 10 drops of a solution containing 10 per cent potassium iodide and 1 per cent soluble starch (supplied in laboratory equipment). The appearance of a blue color is indication that sufficient chlorine has been added to the water. If no color appears, the water is highly polluted and should be reported immediately to the medical officer having water supplies under his supervision.

(b) In emergency, when a Lyster bag is not available, the hypochlorite method can be applied to smaller containers of known volume, by calculations based on the knowledge that a Lyster bag contains about 36 gallons of water. Thus if a 10-gallon container is available one-quarter of the concentrated solution prepared in the ordnance cup as above can be added, etc. When smaller containers, such as 2-gallon tins, are used the original concentrated solution in the ordnance cup can be diluted by one-half, this dilution again diluted by
one-half in another ordnance cup, and one-quarter of this second dilution added to the tin. By using a little ingenuity, the hypochlorite method can thus be applied to any container of known capacity.

(c) When tubes of calcium hypochlorite are not available and the powder is available in bulk, the following procedure should
be adopted:

(1) An empty shell used in the Colt's 45 automatic pistol will hold 1-gram of powdered calcium hypochlorite when filled level with the top. Always use this empty shell as a measure. Add one shell full of powdered calcium hypochlorite to an ordnance cup and make a solution as described in paragraph (a), filling the cup with water to 1 inch from the top. Part of this solution is used in titrating the water to be sterilized, and the remainder is used for sterilizing the water.

(2) Rinse four ordnance cups with the water to be tested and fill all four cups to 1 inch from the top (500 c. c.) with the water to be tested. From a medicine dropper (to be obtained from regimental medical supplies) or pipette, add 4 drops of the calcium hypochlorite solution to the first cup, 8 drops to the second cup, 12 drops to the third cup, and 16 drops to the fourth cup. Mix the solutions in each cup thoroughly and allow the cups to stand 30 minutes.

NOTE.-Twenty drops delivered from a medicine dropper or a glass tube of 2 or 3 mm. bore is equal to 1 c. c.

(3) After 30 minutes, add 10 drops of potassium iodide-starch solution from a clean medicine dropper or pipette to each of the four cups and mix thoroughly. Some of the cups will show no color, some will show a blue color. The cup that contains the smallest amount of a hypochlorite solution capable of giving a blue color with the potassium iodide-starch solution contains the proportion of chlorine necessary to sterilize the water being tested. Thus, suppose the cup of water to which 8 drops (0.4 c. c.) of this hypochlorite solution was added gives a color with potassium iodide-starch solution, and the sample to which 4 drops (0.2 c. c.) of the solution was added gives no color. The cup to which 8 drops (0.4 c. c.) of the hypochlorite solution was added contains the right amount of chlorine to sterilize the water being tested.

(4) There are 36 gallons, or 288 pints, in the water bag when filled to the white mark on the inside. Since eight drops (0.4 c. c.) of the hypochlorite solution were sufficient to sterilize 1 pint, 115 c. c. of the same solution will be sufficient to sterilize the 288 pints in the Lyster bag. In practice, it is believed to be safer to use twice the amount indicated by the titration, so that in the example quoted 230 c. c. of the hypochlorite solution would actually be added to the water to be treated, or one-half of the concentrated solution, in the cup to which the 1 gram of calcium hypochlorite has been added, could be added to the water in one bag, and the solution prepared from the measure of hypochlorite would be sufficient to sterilize two bags of water.


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(5) The following table shows the amounts of hypochlorite solution to add to a bag of water corresponding to the number of drops used in the titration:

Number of drops

4

8

12

16

20

24

28

32

Amount of hypochlorite solution (cup measure)

¼

½

¾

1

2

NOTE.-In the titration, if the first series of drops do not show a blue color the water requires more than one measure of hypochlorite. The second series of drops will indicate the amount of a second measure of hypochlorite dissolved in a cup of water to be added to the bag in addition to the first cup.

10. In order that troops may be protected from the possibility of contaminated water, it has been ruled that all water not specifically designated as safe by the water-supply division of the Engineering Department shall be regarded as probably polluted and subjected to chlorination in Lyster bags. The ideal to be attained is that eventually no soldier with his unit shall drink untested or unchlorinated water. There are two obstacles not easily overcome, which render the attainment of this purpose difficult. These are chiefly the prevention of drinking at unapproved promiscuous sources, and the proper supervision of chlorination. The former difficulty is a matter of discipline in individual units. The latter can be accomplished only by the utilization of the proper personnel. In each division it is the duty of the Sanitary Corps laboratory officer to supervise the proper handling of Lyster bags and the chlorination of the water. Alone, however, he can not carry out this duty. No special personnel being available for this work, it is suggested that men be selected from the regimental sanitary detachments who can assist the sanitary laboratory officer in these duties. If, in each regimental sanitary detachment, one noncommissioned officer and two men could be assigned to the water service, these men could be instructed in the dosing and perhaps the testing of chlorinated water, under the guidance and supervision of the laboratory officer.

11. Expendable items of the laboratory equipment will be replenished from the central Medical Department laboratory, and spare parts of the nonexpendable equipment are carried in stock at the central Medical Department laboratory and will be supplied on requisition. All replenishment items should be requisitioned for by number as well as by name.

12. At the present time no transportation is provided for these units in Tables of Organization, and request has been made that one motor cycle with side car and one light truck (¾-ton Ford or other standard) be included in the revised tables of organization for this unit. The request has not as yet been approved.

(Memoranda 5 and 7, division of laboratories and infectious diseases, August 14, 1918.)


TECHNIQUE FOR THE "WASSERMANN TEST"

In order that the results of Wassermann tests made on members of the American Expeditionary Forces may be as nearly comparable as possible when different workers in different laboratories are performing the tests, and in consideration of the fact that tests on the serum of the same individual may not always be made in the same laboratory, it is necessary to adopt a uniformity of reagents and a standard method. Moreover, there are not many instances of any two men who use exactly the same methods for performing the test, unless their training in Wassermann work was obtained in the same laboratory. The principal differences have to do with the hemolytic system, the "antigen," the preliminary amboceptor or complement titration, and the total volume of the test. While every laboratory worker naturally feels that his method is either as good or perhaps better than some other, it is advisable that the various workers adapt themselves to the method herein prescribed. However, if there be any suggestions for improvement which will materially benefit the purpose, the director of laboratories will be pleased to receive them in written form and they will be given full consideration.


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REAGENTS

"Antigen"; alcoholic extract of beef heart or calf heart, half saturated with cholestrin.

Hemolytic system: Anti-sheep (amboceptor, or sensitizer).

Complement, or alexin: Guinea-pig serum.

"Antigen" and amboceptor will be prepared and standardized at the central Medical Department laboratory and furnished to laboratories where Wassermann tests are made. Monthly supplies will be forwarded without requisition, and additional supplies will be forwarded on special request by telephone, telegraph, or letter.

Arrangements have been made for each laboratory to be furnished with guinea-pigs and sheep.
 STANDARD METHOD

The total volume of each test is 1.25 c. c., one-fourth that of the original Wassermann.

1. Amboceptor, or sensitizer.-The test is based on the "quarter-unit" amount; i. e., the amboceptor unit is that amount giving complete hemolysis of 0.25 c. c. of 5 per cent sheep cell suspension, in the presence of excess complement, after incubation in water bath at 37.5° C. for one hour. The amboceptor is furnished in glass ampules containing 0.1 c. c. inactivated anti-sheep serum. The dilution stated for any particular lot of serum represents the dilution in the titration containing the amount of serum determined as one unit. For example: It may be stated that a dilution of 1:3,000 is one unit, meaning that this dilution contains the amount of serum which is one unit. Two units are used in the test, so in preparing the reagent a dilution of 1:1,500 will be made; i. e., 0.1 c. c. of serum diluted with 149.9 c. c. of physiological saline will give a reagent each 0.25 c. c. of which represents two units of amboceptor.

2. Complement, or alexin.-Without entering into a controversy about the advisability of whether a preliminary complement or amboceptor titration be made, we feel that the variation in amboceptor is less than that of complement and that it is better to adjust the complement to a given unit of amboceptor.

Two or three guinea pigs should be bled the night before the day the test is done. The blood should be taken from the heart by means of dry sterile needle with syringe or suction apparatus and placed in a dry, sterile, conical centrifuge tube. After clotting has taken place, a stiff sterile wire should be run around the rim of the clot and the tube placed in an ice box until the following morning. The following morning the tube should be centrifuged and the clear serum drawn off. The serum is diluted 1 to 10 with physiological saline for use as complement. Each serum should be tested for hemolytic and complementary properties. For hemolytic properties, 0.5 c. c. of the dilution and 0.25 c. c. of 5 per cent suspension of cells should be incubated in the water bath at 37.5° C. for one hour. Providing each serum has good complementary properties and no hemolytic property, the sera should be cooled and diluted. In titrating for complementary properties the following protocol should be followed:

Protocol for complement titration 

Tube

Guinea pig serum 1-10

Physiological saline

2 units amboceptor

5 per cent sheep cell suspension

C. c.

C. c.

C. c.

C. c.

1

0.15

0.60

0.25

0.25

2

.14

.61

.25

.25

3

.13

.62

.25

.25

4

.12

.63

.25

.25

5

.11

.64

.25

.25

6

.10

.65

.25

.25

7

.09

.66

.25

.25

8

.25

.75

.00

a.25

9

.00

1.00

.00

b.25

10

.00

.75

.25

c.25

aComplement control.
bSaline control.
cAmboceptor control.

The dose for the test is twice the amount in the tube, showing complete hemolysis after incubation in the water bath at 37.5° C. for one hour. With a good serum 0.1 c. c. will usually be this amount and 0.2 c. c. will be the dose for the test.

3. "Antigen."-"Antigen" is adjusted so that 0.1 c. c. of an emulsion in physiological saline will be the dose for the test, the proper dilution will be stated with each lot. It is


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very important that the "antigen" emulsion be prepared as follows: Place the amount of alcoholic extract to be emulsified in a flask, add physiological saline drop by drop, shaking the flask vigorously between drops, until at least 5 c. c. volume is obtained. The balance of the saline may be added in large amounts, the flask shaken well between each addition.

4. The test.-The amount of patient's serum (inactivated) used in each test is 0.05 c. c. In many instances there is sufficient natural and sheep hemolysia in human serum to produce hemolysis of one unit of cells with the amount of alexin or complement used in the test. On account of this, a unit of cell suspension, 0.25 c. c., is added to the test and allowed to incubate 15 minutes. At the end of this time complete or nearly complete hemolysis will have taken place in the control tube (back tube). It will not be necessary to add amboceptor to these tests. To all other tests, 0.25 c.c., representing two units of amboceptor are added to each tube.

First incubation period (for complement fixation), 1 hour.

Second incubation period (for natural hemolytic activity), 15 minutes.

Third incubation period (for hemolysis), 1 hour.

Too much emphasis can not be laid upon the necessity of controls for every reagent, and for their behavior with known negative and positive sera, before the actual test is set up.

The following protocol serves to illustrate the tests:
 [Sera for controls: One serum; one serum; one serum; one (-) serum]

Inactivated patient's serum

Antigen emulsion

Complement

Physiological saline

5 per cent sheep cell suspension

Amboceptor, 2 units, if necessary

C. c.

C. c.

C. c.

C. c.

C. c.

C. c.

Back tube

0.05

0.0

0.2

0.50

0.25

0.25

Front tube

.05

.1

.2

.40

.25

.25


Antigen controls
 

I

II

C. c.

 

C. c.

Known negative serum

0.25

"Antigen" emulsion

0.3

"Antigen" emulsion

.2

Complement

.2

Complement

.2

Saline

.25

Saline

.25

Incubate in water bath at 37.5° C. for 1 hour.

Incubate in water bath at 37.5° C. for 1 hour.

5 per cent suspension sheep cells

.25

5 per cent suspension sheep cells

.25

Incubate in water bath 15 minutes. 
Ambocepter, 2 units if necessary.
Incubate in water bath 1 hour.

Ambocepter, 2 units

.25

Incubate in water bath, etc., for 1 hour.


Protocol for spinal fluid

Tube

1

2

3

4

5

C. c.

C. c.

C. c.

C. c.

C. c.

Spinal fluid

1.0

1.0

0.5

0.25

0.12

"Antigen"

.0

.1

.1

.1

.1

Complement

.2

.2

.2

.2

.2

Saline

.0

.0

.0

.2

.25

Incubate in water bath at 37.5° C. for 1 hour.

Amboceptor, 2 units

.25

.25

.25

.25

.25

5 per cent sheep cells

.25

.25

.25

.25

.25

Incubate in water bath at 37.5° C. for 1 hour. 

Another important control which should be run in the regular test is one for serum specimens showing marked hemolysis when received.

 

C. c.

Inactivated patient's serum

0.05

5 per cent suspension sheep cells

.25

Saline

.95


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The tinge of red imparted to the supernatant fluid will serve as a comparison for reading the result on that particular serum.

INTERPRETATION OF RESULTS

Four symbols will be used to designate results:

+ + (complete fixation).
+ (almost complete fixation).
+ - (partial fixation).
- (complete hemolysis).

Attention is directed to the necessity of having thoroughly clean glassware for serological work.

Reports should be made on Form 55q M. D.

(Memorandum No. 3 (revised), division of laboratories and infectious diseases, August 15, 1918.)


DIRECTIONS FOR USE OF APPARATUS FOR INTRAVENOUS INFUSION OF GUM-SALT SOLUTION

An outfit for the intravenous infusion of standard gum-salt solution is now available for issue and may be obtained for use in all places where gum-salt solution is used. It is the object in putting these sets out to enable the surgeon to use the solution directly from the original bottle and thus avoid an unnecessary transfer from one container to another. The articles composing this outfit are:

1 glass tube with curved end (long).
1 glass tube (short).
2 pieces rubber tubing.
1 rubber stopper (double-hole).
2 needles.

These outfits are furnished to facilitate the use of the gum-salt solution, and are to be considered as permanent property, which may be replaced only under the same conditions that other property is so replaced. The same care must be taken of these parts as of those of the transfusion sets. Great care must be exercised in the care of the needles, as they are scarce and hard to obtain. The use of the paraffin oil furnished with the transfusion sets is recommended for their care.

DIRECTIONS FOR USE

The tubing, stopper, and needle are to be sterilized in the usual manner. If a fine sediment exists at the bottom of the bottle containing the gum-salt solution, introduce the long glass tube carefully, so as not to disturb the sediment (assuring yourself that the opening in the curved end is above any sediment present). Then allow the solution to run out through the long tube to the needle by siphonage, or force the solution out by pressure from the bulb of a blood-pressure apparatus attached to the short tube. In case the solution has no sediment, the long rubber tubing with the needle attached can be connected with the short glass tube and the bottle inverted, so that the fluid flows into the vein by gravity.

The same precautions against introduction of air into the vein must be taken as in the case of blood transfusion.

A supply of these intravenous infusion outfits are available for issue to field, evacuation, mobile, and advanced base hospitals attached to the first Army, at army medical dumps Nos. 1 and 2. Requisitions from other units should be addressed to the commanding officer, central Medical Department laboratory, A. P. O. No. 721. The allotment for each hospital is 6 complete sets and requisitions must be limited to this number.

(Memorandum No. 18, division of laboratories and infectious diseases, September 9, 1918.)


1066

FOOD AND NUTRITION SECTION INSPECTION DATA

1. The following information compiled from Appendix No. 4 of the Quartermaster's Manual, from the new Quartermaster's Inspection Manual, and from other sources, will be of value in connection with the examination of food supplies. Officers of the food and nutrition section should familiarize themselves with Appendix No. 4, Quartermaster's Manual, as well as with the information below. Quotation from new inspection manual:

It should be clearly understood that responsibility of final inspections, upon which depend acceptance or rejection of shipments, rests as heretofore entirely upon the officer in charge at the depot or camp where delivery is made.

2. Sizes of cans now in use in United States supplies.-

No. of can

Diameter

Height

Capacity

No. of can

Diameter

Height

Capacity

Inches

Inches

Fluid ounces

Inches

Inches

Fluid ounces

1

211/16

4

11.6

3

47/8

35

1 tall

211/16

12.3

3

5

35.5

2

23/8

49/16

21.3

3

39

4

411/16

31.2

10

63/16

7

107

3. Inspection of spoiled protein foods.-In recent years there has been an increasing tendency to discount the idea of ptomaine poisoning from spoiled protein material. It is now the opinion of sanitary experts that the intestinal disorders that result from eating such spoiled material are usually due to infection from organisms swallowed with the material and not from organic poisons of the ptomaine character. As Rosenau puts it:

Meat poisoning is not a poisoning as that term is ordinarily understood, but almost always an infection; rarely an intoxication * * * many other foods, as milk, custards, vegetables, and even water may convey the responsible bacteria, which in the great majority of instances belong to the paratyphoid group.

Aside from the paratyphoid group, there is another type of meat poisoning comprised under the name botulism. The bacillus (Bacillus botulinus) generates a toxin as it grows in the meat or other protein media outside the body. Sausages readily become infected by this organism and are responsible for its name. When food infected by this organism is swallowed it is the toxin which produces the evil effects. Fortunately this toxin is killed by heat, if the heat is sufficient and penetrates through the mass.

In view of these facts and in the interest of protection of the health of the troops, the duty in regard to spoilage may be summarized under the following three heads:

(a) "Swells" among canned goods should be rejected; "springers" are also as a rule decomposed, but should be carefully inspected before condemnation. Meats that have a bad odor, after all possible trimming has been done, should be rejected as unfit for human food.

(b) Secure thorough cooking of all protein food to kill the micro-organisms and toxins of the botulism.

(c) Give especial attention to preventing the contamination of food after it is cooked, by flies, dirty hands, or any other agent which could plant in the material the disease-producing organisms.

4. Quartermaster specifications which form the basis of food acceptance for the United States Army.-(1) Canned goods in general.-In sampling take at least three samples from each case. Examine cans for rust; and if found, test spots thoroughly to make sure there are no perforations. Test bent places in the same way. To detect "springers," "knock" the can on a hard surface by striking the end forcibly. If the end springs out the can is improperly processed. This does not necessarily mean spoilage, but in the field such cans should be rejected as much as "swells," as there is neither time nor facility there for analysis. In reporting a faulty brand, give the percentage of spoilage. Also look for nail holes in the cans, which will cause spoilage without swelling.

(2) Canned tomatoes, corn, and peas.-To be sound and ripe, free from artificial coloring matter, packed without addition of water, tomato pulp, or juice. Goods guaranteed against


1067

"spoils" and "swells" until July 1 following date of shipment. "Spoils" and "swells" to be held subject to seller's orders.

Net weight of No. 3 cans, not less than 2 pounds 1 ounce.
Net weight of No. 10 cans, not less than 6 pounds 7 ounces.
Net weight of No. 2½ cans, not less than 1 pound 12 ounces.

(3) Canned fruits.-Prime ripe fruit packed in either 20 or 30 per cent sirup. Orchard run after removal of culls. May have some blemishes. Canned fruits containing pits such as cherries, may swell and still be fit for food. Contents however, should be examined.

(4) Canned vegetables.-Field run of good stock. May be slight discoloration or breaking due to processing. Canned hominy may spoil without swelling the cans; if spoiled, is usually discolored and has a putrid odor.

(5) Canned salmon.-Pink, red, or medium-red salmon. Smell is the best test of unsound salmon. Meat should be firm, with no undue proportion of tips and tails. Packed in 1-pound or ½-pound cans. Bones cooked soft is indication of correct processing.

(6) Canned sardines.-Fish of uniform size and evenly packed. Not all sardines are eviscerated. Army now accepts regular Maine pack. Look out for indications of bellies burst by gas and the presence of red food. Oil must be free of rancid flavor, decay or odor. Very little or no added oil is a cause for rejection. Lack of or leakage of oil can always be determined by shaking the can. Contents will shake about in a solid mass. Net weights: Quarter cans run 3.6 to 3.8 ounces; key cans run 3.5 to 3.7 ounces.

(7) Canned bacon.-Examine condition of the bacon itself for sourness or rancidity. External examination of the containers is all that is necessary, as bacon is not processed. Vacuum drawn simply to facilitate packing. If container is defective, examine the bacon.

(8) Canned lard.-Steam rendered lard for issue. Examine labels. Beef or mutton tallow or vegetable oils, when present, are adulterants. Color should be white, surface smooth and not grainy. Flavor not scorched or burned.

(9) Lard substitutes.-Two sorts allowed: (1) Entirely of vegetable oils (refined cottonseed oil plus 10 to 15 per cent of vegetable stearine or by hydrogenating cottonseed oil); (2) cottonseed oil plus oleo stearine. Both must be firm, white in color, free from water and foreign material.

(10) Meats (beef).-At the front or in the field in general the principal meat problem concerns care of frozen beef. Specifications do not concern us, because all of this beef is United States inspected before shipping. The minimum weight of the carcass is 450 pounds, from which should be deducted 3½ pounds from each hind quarter to compensate for the shank bone, left on for hanging. The difference in weight between a fore and a hind should not exceed 25 pounds the carcass. * * * Beef should always be inspected for the following qualities: (a) Its soundness; (b) its quality; (c) whether it has been properly trimmed; (d) whether it satisfies requirements with regard to weight; (e) whether the limitations as to sex (steers and spayed heifers only allowed) have been satisfied; (f) whether an equal number of fores and hinds is supplied; (g) whether it has been handled in a cleanly manner.

(11) Hash, corned-beef.-Consist of 50 per cent vegetables (potatoes and onions) and 50 per cent corned beef, seasoned with salt and pepper. If the cans when shaken seem to contain much liquid they should be considered as of suspicious quality and opened for further inspection.

(12) Bacon.-Inspect for soundness (10 per cent inspection considered sufficient). Surfaces free of mold, insects, skippers, rancidity, or sourness.

(13) Flour.-Made from sound wheat, free from smut, good color, best quality. When in doubt on this material send sample to office. Weevily condition can be determined by examination of the ears and seams of the bags. Worms also can be found on outside of bag if it is exposed to sunlight for awhile, but generally they are found in the flour; can be sifted out if not excessive.

(14) Hard bread.-Square crackers, flour and water only, thoroughly baked. Other forms which are made in France are also now supplied.

(15) Baking powder.-To be a tartrate phosphate, or alum powder from pure and dry ingredients. Yield not less than 12 per cent CO2 gas.

(16) Beans.-Good beans are plump and firm under pressure. They should not dent when pressed with the thumb-nail. Should not exceed 20 per cent moisture. Should be


1068

clean, of uniform size, and free from disease, especially anthracnose. Beans may be weevily or worm eaten. In either case they can be separated from sound beans by placing in water; unsound beans float readily and can be thus skimmed off, before cooking.

(17) Rice.-Good, clear, fresh milled, head rice. Should be semitransparent, free from grit, dust, or hulls, and presence of broken or dead white grains. Uniform-sized grains. Should also be free from seeds. Rice packed in sacks may get wet, and then cake and mold. If the sack is allowed to dry undisturbed, the moldy part can then be cut through and easily removed without contamination of the balance of the rice.

(18) Potatoes.-Texture firm when pressed by the hand, crisp when cut, and the cut halves when rubbed together briskly and then pressed together firmly should hold together. U. S. Grade No. 1, sound potatoes, practically free from dirt, foreign matter, frost injury, sunburn, second growth, cuts, scab, blight, dry rot, and damage caused by disease, insects, or mechanical means.

(19) Onions.-

Grade

Minimum diameter

Maximum diameter

Tolerance for defects

Additional tolerance for pink-yellow onions

Maturity

Brightness

Dirt or foreign matter

Shape

Variety

Total

Decay

Inches

Inches

Per cent

Per cent

Per cent

U. S. No. 1

2

None

6

1

5

Must be

Must be

Free from

Well

One

U. S. Boiler

1

2

6

1

5

.do.

.do.

.do.

.do.

Do

U. S. No. 2

2

None

10

2

(a)

Need not be

Need not be

Need not be clean

Any

Do

U. S. No. 3

1

None

10

5

(a)

.do.

.do.

.do.

.do.

May be mixed

aNo limitation.

Onions of all grades, except for tolerance, must be sound, free from "doubles," "splits," "bottle necks," and seed stems and practically free from damage caused by moisture, sunburn, cuts, disease, and mechanical means. Sacks, ventilated barrels or crates called for.

(20) Corn goods (hominy, hominy grits, corn meal).-The lowest grade of corn that can be used is No. 4. This grade shall be white corn, shall be sweet, shall contain not more than 19.5 per cent moisture, not more than 5 per cent foreign material and cracked corn, and not more than 8 per cent damaged corn, which may include not more than 0.5 per cent heat-damaged and mahogany kernels. Yellow No. 4 is same specification. Table hominy shall be degerminated hulled corn, thoroughly screened and dusted and shall contain not to exceed 1 per cent fat by ether extraction and not to exceed 14 per cent moisture. Grits shall be made from hominy screened and dusted clean, not over 14 per cent moisture or 1 per cent fat.

(21) Standard meal.-From entire grain, with 10 per cent food removed and 45 per cent feed meal extracted. Not over 11 per cent for export.

(22) Dried fruits.-Should be in good condition and free of insects and decay. Prunes, 50 to 60 per cent; peaches unpeeled. Dried fruits are attacked by weevils and molds. Figs are quite apt to be weevily in the center of the fruit, and while the worm is not often found the web is easily seen. They also mold, and at times both conditions are found. Dates will sour along the edges of the box, and unless promptly looked after sourness will penetrate the entire mass. Apples and peaches may be found moldy or weevily, or both. Prunes may sour and get wormy or moldy, but the moldlike white, sugary formation found on prunes at times is not ground for condemnation and can be readily removed by washing.

(23) Coffee.-Roasted and ground. Porto Rican, Hawaiian, or Central American preferred.

(24) Milk.-Unsweetened, evaporated, in 1-pound cans.

(25) Vinegar.-Cider, 4½ to 5 per cent acetic acid, in half barrels.

(26) Pickles.-Plain, uniform in size, about 40 to the gallon, thoroughly cured, free from nubs and soft stock, in half barrels. All soft pickles, in or out of vinegar, should be rejected.


1069

(27) Oleo.-Must be uncolored, not less than 10 per cent butterfat and 2½ to 4 per cent salt. The coloration must be uniform, not streaked or blotchy. Odor and taste pleasant and resembling butter. Not rancid or sticky or grainy in the mouth. Oleo showing discoloration or dark patches on the sides or ends of the package should be cut into. Mold will usually penetrate the entire mass.

(28) Sirup.-Sugar cane, sorghum, or sugar sirup or blend, of same.

(29) Flavoring extracts.-Lemon, 5 per cent by volume of oil of lemon. Vanilla, 40 per cent by volume absolute ethyl alcohol and at least 2.5 percent true vanilla solids.

* * * * * * *

5. The proper care of subsistence supplies.-In inspection of storage of supplies attention is called to a few important facts to have in mind. In this connection, officers of this section should be familiar with sections 2729 to 2746 of Volume I of the Quartermaster's Manual; also with 2309 to 2313 of the same manual.

(1) Care of beef.-The care of frozen beef in camps is largely a question of treatment and ventilation. The following extract from Weekly Bulletin of Disease, No. 16, issued by the chief surgeon's office, covers the practical points involved:

Whenever a quarter of beef is suspected of taint, first thoroughly wash the quarter with brine, examine the exposed surface, and if these are tainted cut off such portions as are affected. If the covered surfaces seem to be affected, have the butcher remove the covering tissue, taking care not to cut into the flesh. Do not condemn any part of the beef until these preliminary steps have been taken.

To determine whether decay has started within the beef, introduce a probe at the shoulder and hip joints; by the smell at the end of the probe you can determine whether the joints are affected or not. If they are affected, dissect out the bone and trim away the adjacent meat until a sound layer is reached. In no instance is it desirable or necessary to slash the quarter, the object being removal of affected parts with as little waste as possible.

To prevent flyblow, make sure that fly eggs are immediately washed off when the beef arrives. These are usually found on the shank.

The following methods are recommended for the best care of frozen beef:

It is better to hang beef in an airy, well-ventilated place, out of the direct rays of the sun, rather than to store it in damp, dugout refrigerators. Meat safes, covered with cheesecloth to exclude flies and with free access of air, will protect the beef for several days if it is wiped as frequently as moisture accumulates on the surface.

If it is necessary to retain cut-up beef for more than 24 hours, it may be placed in a container and covered with brine, but in cutting up beef require the butcher to first remove any tainted outer skin before he cuts into the meat; this avoids the carrying of the decayed portion into the sound meat.

In some places such safes can be constructed in the sides of the Adrian barracks; in others they have been erected in sheltered places out of the sun and near the kitchen. The cheesecloth that comes around the beef can be used to exclude flies. The main object is to keep the beef surface dry and with a free current of air passing over it.

(2) Bacon.-Excess of supply should not be allowed to accumulate. Note dates on packs and issue oldest bacon first. Keep dry and well ventilated, also cool. If in crates, should not as a rule be removed from them until used.

(3) Canned meats.-Should keep, if properly processed and stored, for many months. Should be kept dry to prevent rusting of containers. While freezing does not injure the contents, it is apt to spring seams through the swelling of the liquids.

(4) Canned goods in general.-All canned goods should be stored in a cool, dry place. Cold has no ill effect unless below freezing point, but freezing tends to bring about a separation of the contents and deterioration of quality. In camps, this sort of goods should be kept as far as possible from the range. Dampness causes rust, which in turn causes perforation. On this account see that they are not left in wet or damp boxes. Acid products should not be kept too long.

(5) Beans, rice, etc.-The greatest danger to these articles are weevils and moisture. Dry storage and good ventilation are essential, and they should never be placed directly on the ground. Also see to it that the old stock does not accumulate at the bottom of the bins. The same recommendations apply to flour, corn meal, hominy, etc.

(6) Vegetables.-Whenever possible these should be in slatted, well-ventilated bins. If it is necessary to keep in sacks, the materials should be often emptied out and sorted to remove


1070

decayed or sprouted material. Potatoes should not be exposed to light any more than is necessary. They may be well stored in dugouts or pits, but not piled high. Onions should not be left in sacks or crates, but emptied out and spread as thinly as possible. They should not be put in pits, as they require air. Carrots and parsnips may be stored in pits and are not injured by slight freezing. The same is true of turnips.

(7) Dried fruits.-The best temperature is 34° to 36° F. It is important that they be protected from insect infection; also from moisture and other conditions that will produce rotting or moldiness.

(8) Coffee.-Requires dry, well-ventilated storage. Should not be kept near pepper, tobacco, or other things from which it can absorb odors, and containers should be kept tightly covered at all times.

(9) Lard and butter.-Keep cool. Melting and rehardening favors rancidity.

(10) Protection from rats.-All goods like flours and meals are often protected from rats if old newspapers are placed between the sacks. The rats use these to make nests of and spare the other materials.

(11) It seems to be an established fact that practically all bread mold can be traced to delayed shipment or unsuitable storage. The bread is a culture medium for mold, requiring merely favorable conditions for its development. Any treatment that makes conditions unfavorable to mold growth represents an optimum treatment for bread. Obviously this means good ventilation, freedom from moisture, the prevention of accumulation of old material, daily cleaning of bread boxes, and the like.

(12) Section 2745, Quartermaster's Manual, gives the insects that are injurious to subsistence supplies and their habits. The lowest and highest temperatures to which certain perishable goods may be subject without injury under the conditions stated are given in the following table:

Perishable goods

Lowest outside temperature, unprotected

Temperature above which injury occurs

° F.

° F.

Cabbage

25

75

Cheese

30

75

Extracts, flavoring

20

---

Fish, canned

18

---

Grapes

34

---

Onions

20

---

Pickles

22

---

Potatoes

33

80

Rice

20

90

Tomatoes, canned

26

---

Vinegar

22

---

6. Members of this section have been familiar for some time with the value of the garbage pail as a basis for diagnosis of mess troubles. With the garrison ration, a secondary and almost equally important place for this purpose is the storeroom. Learn to know the bearing of each article there on the daily menu. If you find excess sugar it means no desserts are being made. Excess flour, the same thing. Lack of fruits or baking powder means a definite reduction in menu possibilities, etc. This correlation between storage and menu possibilities should be a special study of every inspecting officer.

7. A few waste statistics.-(a) Potato peeling: Refuse and waste as ordinarily peeled, 25 per cent; as carefully peeled, 13 per cent; by machine and eyes removed by hand, 12 per cent; peeled by machine, 4.5 per cent; unnecessary waste as ordinarily peeled, 12 per cent.

Ration (80 per cent of 20 ounces) is 16 ounces x 1,750,000 men = 1,750,000 pounds; 12 per cent waste = 210,000 pounds of food for that number of men for 1 day.

Potatoes also supply 55 per cent of all the basic ash in the ration; 12 per cent waste reduces this markedly and increases the acidity of the ration.

(b) Value of beef ration per day for 1,500,000 men is $294,999 in the market at home, without adding the cost of transportation. In one shipment of 25,000 pounds of beef nearly 75 per cent was salvaged by trimming at the station, though the whole had been condemned in the field.


1071

8. Methods of survey and condemnation.-Paragraph 2311, Quartermaster's Manual:

Before shipping subsistence supplies to other points, quartermasters will carefully examine the supplies, opening original packages when there is a doubt as to the sound and serviceable condition of their contents. Damaged or unserviceable articles, or those liable soon to become so, will not be shipped.

This article supplies sufficient authority to prevent depot quartermasters from sending out goods which you find defective, and can be used by you for this purpose.

Paragraph 2787:

If the stores have not deteriorated so as to render them unfit for human consumption, and are not required in the military service, they will be sold at auction.

If the stores have deteriorated to the extent of rendering them unfit for human consumption but are of value for other purposes, they will be sold at auction, and prior to the sale the accountable officer will cause each can, box, bottle, or other container to be stamped or indelibly marked as follows: "Deteriorated military supplies condemned and sold under section 1241, Revised Statutes."

If the stores have deteriorated to such an extent that they are without value for any purpose whatever, they will be destroyed. (Cir. 89, M. D. 1908.) Such stores must be acted on by an inspector or survey officer before being disposed of.

The last sentence of this article calls attention to the necessity of a board survey. In practice, the following methods are used: (a) When meats are to be condemned: As soon as possible after their receipt the commanding officer summons a board of medical inspectors. They may call on a quartermaster meat inspector to aid them, especially to save any part of the carcass fit for consumption. Whatever they condemn, in whole or in part, the quartermaster credits the company for the amount destroyed. In such a case a field officer with his butcher should first ask for the cooperation of a sanitary inspector and take action with a view to saving as much as possible.

(b) Subsistence stores: Canned goods or spoiled goods generally are usually returned to the commissaries by the mess or supply sergeants for exchange or credit. If the quartermaster refuses to accept these articles, the sergeant should report the matter to the mess officer and through him to the commanding officer, who may call a medical board to pass upon the food. It must be remembered (par. 2322): "After rations leave the quartermaster they are in the keeping of the troops, and any loss sustained by subsequent deterioration or avoidable circumstances is theirs." In other words, the quartermaster is justified in refusing to receive back goods accepted by the sergeants, unless they are acted upon by a surveying officer. He may, however, accept prima facie evidence. If he refuses to accept it, the survey board is the only resource of the company.

There are several articles of the Quartermaster's Manual which should be familiar to all our officers. See paragraphs 2309-2313, also 2769-2853. The methods of appointing a surveying officer and his responsibility and method of procedure are covered by paragraphs 710-726 of the Army Regulations, 1913, corrected to April, 1917. Of these articles, 711 covers appointment; 712, his duties; 715, scope of action; 716, his report; and 717 (2), the character of supplies that may be destroyed and the amounts.

In the American Expeditionary Forces there is usually to be found associated with large camps some officer of the salvage service with whom you should get in touch. If none such exists, locate the nearest one and determine what is his relation to your unit. Secure his cooperation in the matter of disposal of condemned goods.

Please report to this office the names of manufacturers and brands of goods which are found to be markedly defective, in order that we may report the same to the chief quartermaster.

The following circular indicates the attitude of the Quartermaster General in regard to disposal of canned foods. It will be noted that this is addressed to the depot quartermaster at New York and applies strictly to conditions in the States. It may be useful, however, for quotation in troublesome cases.

Acting Quartermaster General, May 24, 1918, to depot quartermaster, New York, N. Y.-Disposal of canned foods when containers are of questionable appearance:

1. Some of the containers of canned vegetables, fruits, meat and meat-food products, and other canned goods, delivered to the Army, do not show proper vacuum. The food in such containers may or may not be sound.


1072

2. The contents of these cans, known as "swells" and "leakers," are unsound because of fermentation or putrefaction. The contents of other cans, commonly known as "springers" and "flippers" (those showing loose tin or insufficient vacuum), and overfilled cans usually are found to be sound.

3. To distinguish between these two classes of canned foods, the containers of which have a questionable appearance, requires expert knowledge. It is impracticable to provide special inspectors having expert knowledge of canned foods for the examination of those products at all camps, especially at those where only a few troops are stationed. For this reason canned foods should not be issued to troops unless the containers are in perfect condition and show a good vacuum. Inexperienced persons should not attempt to differentiate between questionable cans, the contents of which may be sound or unsound, but should reject all those packages which are not in perfect condition.

4. The term "good vacuum" means the ends of round cans, large sides of flat cans, and the sides and ends of high four-sided cans should be tightly drawn and should neither show tin nor distention.

5. All canned foods, the containers of which are not in perfect condition, should be held for reclamation. "Swells," "springers," "flippers," "overdefects," should all be included in this class. Immediately after the discovery of canned foods showing any one of these conditions, the facts should be reported to the depot or purchasing quartermaster, in order that arrangements may be made with the contractor to replace the rejected products. (See pars. 809 and 2310, Manual for the Quartermaster Corps.)

By authority of the Acting Quartermaster General:

J. W. MCINTOSH,
Lieutenant Colonel, Quartermaster Corps, N. A.,
   Subsistence Division.

9. Requests.-We are anxious to secure a series of recipes based on practical handling of dried vegetables. Please collect such data and mail as fast as accumulated to this office, that we may publish them for the benefit of all officers.

Also continue to send in recipes which have been found of value and which utilize the components of the garrison ration.

In case your division has special experiences such as troop movement or combat experience, send us all the information you can gather as to the efficiency of the ration under these conditions.

(Memorandum No. 22, division of laboratories and infectious diseases, September 10, 1918.)


PROPHYLACTIC SERUM TREATMENT AGAINST GAS GANGRENE

A test of the prophylactic value of anti-gas-gangrene sera in the human subject is about to be made.

The first serum to be used will be one which protects in the animal experiment against the toxins of both the tetanus bacillus and the Bacillus perfringens (B. Welchii). While the experience of French and British investigators indicates that gas gangrene may be caused by a variety of anaerobic organisms acting alone or conjointly, the high percentage incidence of perfringens infections justifies the thorough trial of the univalent anti-gas-gangrene serum now available in amounts sufficient to conduct such experiments on a large scale.

Polyvalent sera capable of neutralizing the toxins of other anaerobic bacteria concerned in the causation of this condition are now in the process of preparation and will be made the subject of a similar trial where available in adequate amounts. It is proposed to use in every instance sera which protect against the toxin of the tetanus bacillus as well as the toxin of one or more anaerobic bacteria to avoid the necessity of giving several injections, in some instances sera derived from horses immunized against the toxins of two or more pathogenic anaerobes will be employed. In others, the pooled sera derived from several horses each immunized against the toxins of a single anaerobic bacillus will be used. For the present it is our intention to confine the trial to antitoxic sera. Bacteriolytic and combined bacteriolytic and antitoxic sera have been prepared by several French authorities and are now being put to a practical test. The results of these experiments will determine whether similar tests will be undertaken by the medical staff of the American Expeditionary Forces.

To secure reliable results the complete cooperation of all medical officers concerned with the care of the wounded and all laboratory officers taking part in the examination of


1073

these cases is absolutely essential. The development of gas gangrene in patients who have received the prophylactic injections of anti-gas-gangrene serum can not be accepted as evidence against its value unless it is established that the only pathogenic anaerobe present in the case is the microorganism against which the particular antiserum is supposed to protect. In view of the fact, as indicated above, that several anaerobes may be responsible for the condition under consideration, and in view of the further fact that the detection and the recovery of some of the less common pathogenic anaerobes presents many difficulties, it is only by the exercise of the greatest care on the part of the examining bacteriologist that false interpretations can be avoided. Apart from the study of the anaerobes found, special attention should be paid to the Streptococcus hemolyticus owing to the important part which this organism appears to play in favoring the development of the gas gangrene.

To avoid errors, it is proposed to adopt the following precautions:

1. Every case in which the records show that anti-gas-gangrene serum has been administered as a prophylactic measure should be reported to the bacteriologist the moment symptoms of gas gangrene develop, and all cases in which from the nature of the injury or the condition of the wounds such an occurrence might be expected should also be reported so that they may be made the subject of a detailed clinical and bacteriological study even before the symptoms of this disease have developed.

2. In all such cases the bacteriologist should make every effort to isolate in pure cultures all of the anaerobic bacteria present. Such strains should be sent under proper conditions (preferably by courier) to the central Medical Department laboratory for verification of the diagnosis.

3. In addition the original cultivations in cases of gas gangrene should be made in duplicate. One set should be sealed and sent to the central Medical Department laboratory by courier after 24 hours incubation, and the name, number, rank, and organization of the patient and the diagnosis of the case. In view of the good results secured in this laboratory by the use of liver peptone water medium it is recommended that this medium be employed in place of the standard veal or beef broth. The liver peptone water is prepared as follows: Peptone, 10 gr.; sodium chloride, 5 gr.; water, 1,000 c. c.

Boil 30 minutes; neutralize to phenolphthalein, then add 20 c. c. of normal sodium hydrate solution; autoclave for 15 minutes at 115° C.; filter; tube (10 c. c. in each tube) and add approximately 1 gr. of rabbit, beef, or human liver. Autoclave for 15 minutes at 115° C.; incubate for 3 days to insure sterility (if sterile, fluid will remain clear; it may assume a faint yellow color).

Owing to the importance of determining the exact nature of the infection in cases receiving prophylactic injections of the anti-gas-gangrene serum these double checks seem necessary. A report of the findings will be transmitted to the bacteriologist submitting the specimens to the laboratory.

4. In all cases of death of individuals who have received prophylactic injections of anti-gas-gangrene serum, excepting when the cause of death is obviously due soley to the injury and the fatal issue occurs very soon after the injury, a complete autopsy should be performed and detailed bacteriological examination of the blood and internal organs be undertaken to exclude the possibility of death from causes other than a gas bacillus infection.

Method of injecting the serum.-Intramuscular injections should be made in every instance. Concerning the most favorable site for these injections opinions differ. Some French investigators claim that the injection should be given in the neighborhood of the wound. Since this method may have some advantages over the injection of the serum in distant parts, it is recommended that when possible the serum be introduced into the extremity in cases where the most serious wound involves one of the limbs. These injections should be administered on the proximal side of the wound. In all other instances, and where the pressure of work precludes the selection of a particular site, the injection should be given in the region recommended for the administration of tetanus antitoxin. The injections of tetanus antitoxins in the cases that are to serve as controls should also be administered intramuscularly.

Cases that are to receive prophylactic injections.-The original trials will be confined to the wounded of a single division. To secure results of value the recipients will be selected at random. Approximately one-half of the wounded arriving on a given day will receive


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injections of a combined tetanus and anti-gas-gangrene serum, while the remainder will receive usual injections of tetanus antitoxin and will serve as controls. Both the treated and the untreated cases should receive the anti-gas-gangrene card referred to below.

It seems necessary to select the controls from the same division and from the same group of wounded, in view of the fact that the incidence of this complication (gas gangrene) is determined by a number of factors which may vary from day to day. Weather conditions the character of the soil over which the fighting occurs, and the character of the missels employed all may have a determining influence on the incidence of gas gangrene among the wounded.

Records.-For this experiment special antigas-gangrene record cards will be provided. The front face of this card concerns solely the officer administering the anti-gas-gangrene serum and the officer who has charge of the controls. These officers should fill in all of the dates called for on the front face of this card. The back of the card concerns only the medical officers in the evacuation, mobile, and base hospitals. The officers belonging to these organizations should fill in the data called for on the back of this card. All cases showing evidence of gas gangrene at the time the operation is performed or in which the nature of the injury or the condition of the wound suggest the probability of such an occurrence should be reported as already indicated to the laboratory officer, who will begin his bacteriological investigations immediately, if such are indicated, and also begin the collection of all clinical data called for on the standard bacteriological report card, Form No. 3, and all other data which in his opinion may be of interest in the particular case under consideration. When the patient is to be evacuated immediately and the time for bacteriological investigations is not available, it is important that the clinical data be gathered and transmitted with the patient to the hospital organization to which he is sent.

The control cases should also be made the subject of a special study, but only if time and the personnel available permit. Apart from establishing beyond a doubt the occurrence of a gas-gangrene infection in these cases, the results secured in connection with these controls have no bearing on the interpretation of the results of the present experiment.

The gas-gangrene card and a copy of all other laboratory records should accompany the patient. This applies to the recipients of the prophylactic injections as well as to the controls. After death, or as soon as the danger of the development of gas gangrene in convalescents has subsided, these cards and all other laboratory records should be sent to the director of laboratories, American Expeditionary Forces, A. P. O. No. 721.

(Memorandum No. 24, division of laboratories and infectious diseases, October 16, 1918.)


ORGANIZATION OF LABORATORY SERVICE IN HOSPITAL CENTERS

1. The following outline of the organization of the laboratory service in a hospital center has been worked out tentatively in the hospital center at Nantes and is submitted for your information.

2. It is requested that the chief laboratory officer submit to this office a similar statement concerning the arrangement of the laboratory service in his particular center.

OUTLINE OF LABORATORY ACTIVITIES IN HOSPITAL CENTER, NANTES

Clinical microscopy.-All routine work, as urinary analysis, blood counts, sputum for tuberculosis examination of warm stools for amoba, and blood cultures, is to be carried on in the subsidiary laboratories.

Wound bacteriology.-(a) Aerobes: A portion of the material to be examined is first smeared on a slide made sterile by heat, a Gram stain made, and the morphology of the organism and bacterial count noted on the bacteriologic record card. If streptococcus is present, inoculate a portion of the material on agar slant and agari plate. In inoculating plates, a portion of the material is placed in one corner and streaked out on plate with a platinum spatula.

To reduce as far as possible the duplication of work in the subsidiary and central laboratories, the isolated colonies on plates are to be picked, using the original Gram stain as a guide for the different organisms to be sought for, subcultured on plain broth if it is a bacillus, and sent to the central laboratory with the bacteriologic record card for identification. On the other hand, if a staphylococcus is present,
the organism is not isolated and sent to the central laboratory, but held for type determination in the subsidiary laboratory, and recorded on the bacteriologic record card.

iBlood.


1075

Should the isolation be unsuccessful from the first inoculation, and the time is pressing the original agar slant, and if advisable the original agar plate, are to be sent without delay to the central laboratory. In each case note carefully the results of all previous work done.

(b) Anaerobes: For anaerobic cultures, the officer in charge of the subsidiary laboratory is to take the material from the wound to be examined with a Pasteur pipette. After sufficient material is secured, the contents are expelled into a sterile test tube. The pipette is secured in the test tube with a cotton stopper and sent to the central laboratory, wrapped in a bacteriologic record card, or Form 55u.

The subsidiary laboratory is to retain at all times the Form 55u so that preliminary reports can be recorded. On completion of identification, the bacteriologic record card will be sent back to the subsidiary laboratory, where two extra copies will be made; one is to be sent at the end of the month to the central laboratory, the other is to be attached to the clinical brief, while the original copy is to be filed in the subsidiary laboratory for reference.

The same procedure holds true for aerobic identification.

Every effort should be made to secure anaerobic specimens in the forenoon as it will facilitate the distribution of the day's work in the central laboratory.

Miscellaneous examinations.-All specimens are to be sent through the subsidiary laboratories to the central laboratory.

(a) Stool cultures: This work is to be done in the central laboratory. Special specimen bottles are to be used.

(b) Sputum for pneumococcus typing: Sputum from the deep air passages is collected in a sterile Petri dish and sent immediately to the central laboratory.

(c) Throats cultured for diphtheria: Where one or more wards are to be cultured the swabs are taken and sent to the central laboratory for diagnosis. However, if there are only a few cultures to be made, the diagnosis can be made in the subsidiary laboratory.

(d) Urethral smears: These are to be reported on in the subsidiary laboratories.

(e) Chancre and chancroids: These examinations are to be made in the subsidiary laboratories.

(f) Water analysis: This is to be carried out in the central laboratory.

(g) Wassermanns: These are to be done in the central laboratory. The blood is to be sent to the central laboratory before 5 p. m. on Monday and Thursday, with Forms 55u (in duplicate) and 97.

(h) Pleural and spinal fluids: These are to be examined in the subsidiary laboratories.

(i) Carriers for meningococcus: Blood plates are to be inoculated and incubated overnight in the subsidiary laboratory. The plates are then sent to the central laboratory, with Form 55u.

(j) Surgical pathology: Pathological tissue removed at operation is to be wrapped in gauze moistened with saline and sent immediately to the central laboratory, with complete clinical data.

(k) Autopsies: The central laboratory is to be notified by the registrar of a death occurring in a base hospital. The clinical brief is to be brought with the body to the morgue. The central laboratory will notify the adjutant of the time the autopsy is to be held.

It is desirous that the force in the central laboratory will be at all times as busy with laboratory activities as those of the subsidiary laboratories. For that reason the above outline of laboratory activities is to be looked upon as a tentative working arrangement.

If the officer of a subsidiary laboratory is at any time desirous of doing central laboratory work in his laboratory, the necessary material will be gladly furnished by the central laboratory.

(Memorandum No. 28, division of laboratories and infectious diseases, November 23, 1918.)


BACTERIOLOGICAL TECHNIQUE FOR INVESTIGATION OF PNEUMONIA

This technique and blank for tabulating findings (Form No. 11) have been formulated with the idea of obtaining sufficient uniformity in the results of different workers for them to be readily comparable.

It has been attempted to make the methods of examination as simple as possible so that very little extra work should be added to the usual routine bacteriological examination of autopsy material.

If it becomes the consensus of opinion that more detailed studies can be undertaken, the program may be enlarged accordingly.

There will no doubt be differences of opinion concerning the best culture media, proper technical methods, etc., to be used, and you are invited to make criticisms and offer any suggestion you may deem advisable.

In the meantime, however, you are requested to follow as closely as possible the program as outlined. Alterations which meet with general approval may be made subsequently.


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It is the intention to send out to each laboratory taking part in the investigation a monthly compilation of the reports received from all other participants. In this way, all may keep generally informed as to the progress and development of the undertaking.

A. AT AUTOPSY TABLE
1. Material necessary:

(a) Alcohol or gas lamp.
(b) Potato knife or similar instrument for searing surfaces.
(c) Sterile swabs in individual test tubes.
(d) Test tubes containing about 3 c. c. of nutrient broth.
(e) Sterile pipettes.
(f) Sterile slides.

2. Material from the following places will be examined:

(a) Heart (blood).
(b) Large bronchus, right and left lung.
(c) Small bronchi, right and left lung.
(d) Lung tissue, right and left side.
(e) Accessory head sinuses and meninges which may show pathological process.
(f) Pericardial and pleural cavities in case of involvement.

3. The heart's blood will be obtained as soon as the heart is exposed and before it has been opened. The surface will be seared and a sterile pipette plunged through the seared area into the heart cavity, at least 1 c. c. of blood withdrawn and transferred to a test tube.

4. The remainder of the material will be collected by means of tightly rolled cotton swabs. That from the lung tissues will be taken by first searing the cut lung surface and then forcing the swab through the seared area. Two smears from each swab will be made separately upon different slides. The slides will have been previously sterilized in the laboratory. This may be conveniently accomplished by wrapping them in paper and sterilizing in a hot-air oven. The swabs will then be put in the tubes containing the nutrient broth and taken to the
laboratory for culture.
 B. IN LABORATORY

1. Microscopical examination of direct smears.-One set of the smears will be stained with a weak aqueous fuchsin (one-fourth per cent saturated alcoholic solution of fuchsin in distilled water) and the other by Gram's method.

The weak fuchsin stain is selected because it is particularly satisfactory in demonstrating influenza bacilli.

The various morphological types of organisms will be noted and the relative proportion of each estimated.

It is of course obvious that the true nature of the organisms in many instances will be in doubt until cultural studies are completed, but by a comparison of the microscopic and cultural findings it should be possible to link them together and obtain an accurate idea of not only the identity of the organisms but also the approximate percentage of each.

The direct smears will be particularly important in determining the percentage and the cultures in working out the identification.

Cultures.-(a) Heart's blood: One loop full of the heart's blood will be spread on the surface of a blood agar plate and 1 c. c. inoculated into a tube containing at least 10 c. c. of calcium dextrose broth. (The blood agar will consist of a meat infusion agar having a reaction of plus 0.5 to phenolphthalein, to which is added 3 per cent of citrated or defibrinated blood. Human blood will probably be the most convenient to obtain. The broth will be a meat infusion broth, plus 0.5 to phenolphthalein and containing 1 per cent dextrose and 1 per cent calcium carbonate. It must be frequently agitated while tubing so that an equal distribution of the calcium carbonate is obtained.)

(b) The swabs will be stirred about in the broth, rolled over the sides of the tube to squeeze out the excess of fluid, and inoculated over a small area of a blood agar plate. Further spreading is accomplished by a bent wire or glass rod spreader. The importance of a uniform and well-distributed seeding over the plate in identifying B. influenzæ and slow-growing streptococci can not be overestimated.


1077

3. Examination of primary cultures.-(a) After incubation at 37° C. for 18 to 24 hours the plates will be ready for examination.

The different types of colonies on each plate will be studied and their relative numbers noted.

From all different types smears will be prepared and stained by Gram's method.

Subcultures will then be made as indicated.

(b) If no growth is obtained from the heart's blood inoculated upon the plate, a smear will be made from the broth culture and a loopful streaked upon a blood agar plate and further incubated.

4. Methods of study and identification of organisms most likely to be encountered.-(a) B. influenzæ (Pfeiffer's bacillus) appears upon whole blood agar as minute pin-point, dewdrop-like colonies which are very likely to be overlooked unless searched for with a hand glass. They are more easily seen in reflected light.

If such colonies prove to be small Gram-negative bacilli, a diagnosis or B. influenzæ is probably justified, but as further proof transplants may be made to plain and blood agar slants. Failure to grow on plain agar along with the other characteristics, is a distinguising feature of the organism. In some instances, especially if there is an overgrowth of other organisms, the influenza bacillus may fail to develop, in which event opinion as to its presence will have to be based upon the microscopic examination of the direct smears.

Special media have been devised for its growth, but are not so satisfactory as whole-blood agar in distinguishing other organisms, and it has seemed advisable to attempt to select a single primary medium which would be generally adapted to the growth and differentiation of all organisms likely to be met with.

(b) Streptococcus and pneumococcus group.-At least one colony from all of the different appearing types of streptococci or pneumococci developing upon the blood agar plate will be transplanted to calcium dextrose broth (preparation previously described). After 18 to 24 hours' incubation the cultures will be examined microscopically and the following points noted: Size, shape, regularity, and chain formation. It is advisable to always save the plate until the following day so that if growth fails to occur in any of the transplants refishings may be made. Bile solubility test will then be performed by transferring with a sterile pipette 1 c. c. of the culture to an agglutination tube and adding 0.2 c. c. of clear ox bile. After incubating 20 to 30 minutes in water bath or 30 to 45 in incubator the results are read.

From those that are not bile soluble a subculture will be made into plain infusion broth, containing 5 per cent citrated or defibrinated blood, and after 16 to 18 hours' incubation the hemolytic effect will be noted. It is well to shake the culture after about 4 hours' incubation. It is very important that fresh blood be employed, and in all instances a control tube which has not been inoculated should be subjected to the same incubation.

Streptococci will be classified as hemolytic, nonhemolytic, streptococcus mucosus, and streptococcus viridans.

Hemolytic and nonhemolytic streptococci grow on blood agar as small white to grayish colonies. If hemolytic, the degree of hemolytic activity should be recorded as indicated on attached form.

Streptococcus mucosus (or pneumococcus) grow as rather large greenish colonies and may be hemolytic.

Streptococcus viridans appear as small green nonhemolytic colonies.

All bile-soluble cultures will be tested against pneumococcus types sera I, II, and III.

There will usually be sufficiently heavy growth to use the broth culture direct. Utmost care should be used in withdrawing a portion of the culture to prevent agitation of the calcium carbonate, which will have settled to the bottom of the tube.

Strains of pneumococci which are not agglutinated by Type I, II, or III sera will be subcultured to calcium dextrose broth to which approximately 5 per cent of defibrinated blood has been added, and after 10 to 12 hours' incubation will be sealed, properly labeled with name of case and location from which culture was taken, and mailed to the central Medical Department laboratory.

Agglutination tubes containing about 2 c. c. of broth and 2 drops of blood will be found convenient for this purpose. To avoid the loss of strains a subculture of each organism


1078-1080

mailed will be retained until the notification of receipt at this laboratory has been received. Cultures in blood broth should remain viable for several weeks at room temperature after a short primary incubation.

(c) Staphylococci.-The hemolytic effect of the staphylococci should be noted upon the plates, and if any doubt exists it should be further tested in blood broth. The presence or absence of pigment will also be observed and classification made accordingly. It should be borne in mind that pigment frequently does not develop until 48 hours or more.

(d) Gram-negative cocci.-Transplants from colonies of Gram-negative cocci will be made upon Loeffler's blood serum medium or blood ether agar. From the transplants emulsions will be made in salt solution and set up against Rockefeller polyvalent serum 1 to 200 and normal rabbit or horse serum 1 to 100.

Subcultures upon brain medium of all strains agglutinated by the Rockefeller serum will be sent to the central Medical Department laboratory for typing.

The brain medium is prepared as follows: Brain (calf) run through meat grinder, 3 pints; distilled water, 1 pint; tube and autoclave (see office letter No. 30).

5. The necessary diagnostic sera will be obtained from the central Medical Department laboratory.

(Memorandum No. 37, division of laboratories and infectious diseases, February 9, 1919.)


Consolidated report of laboratory work accomplished in the American Expeditionary Forces during the month of January, 1919 ;

[Comprising 11 base-section laboratories, 16 hospital-center laboratories, 70 base-hospital laboratories, 26 camp-hospital laboratories, 22 evacuation-hospital laboratories, 2 mobile-hospital laboratories, 19 divisional laboratories, 3 water-analysis laboratories; total, 169. Number of deaths in hospitals, 948]

EXAMINATIONS MADE

I. Clinical pathology:

Blood-

Erythrocyte counts

1,347

Leucocyte counts

7,361

Differential leucocyte counts

4,933

Hemoglobin estimations

1,384

Malaria examinations

492

Positive examinations

34

Urine-

Urinalyses-

Ordinary chemical

29,976

Ordinary microscopic

20,354

Feces-

For parasites and ova, examinations

745

Positive examinations

96

For Entamebæ examinations

395

Positive examinations

42

Sputum-

For tubercle bacilli, specimens

15,165

Positive specimens

750

For other organisms

881

Positive specimens

508

Gastric contents, examinations of

165

Spinal fluid-

Smears for meningococci

831

Positive

286

Smears for other organisms

73

Cell counts

290

Globulin tests

228

Colloidal gold reactions

1

Venereal specimens-

Smears for gonococci

6,531

Positive

2,548

Examinations for T. pallidum-

Dark field examinations

1,631

Positive

164

Stained specimens

453

Positive

70

Clinico-pathologic examinations not otherwise listed

1,986

 

Total

 

95,222

II. Anatomic pathology:

Operation specimens, macroscopic examinations

257

Autopsies performed

846

Histopathologic examinations

552

Museum specimens prepared

50

Photographs of wounds, specimens, etc.

506

Drawings of wounds, specimens, etc.

77

Anatomo-pathologic examinations not otherwise listed

286

 

Total

 

2,574

III. Bacteriology (specimens examined culturally):

Blood, specimens of

1,546

Urine, specimens of

607

Feces, specimens of-

For dysentery

2,048

Positive

29

For typhoid or paratyhoid

2,983

Positive

263

Sputum, specimens of-

For pneumococci

1,383

Positive

653

Typed by Avery's method

702

Typed by mouse method

52

For other organisms

521

Positive

316

Nasopharynx, specimens from, for B. diphteriæ

21,542

Positive examinations

1,972

For meningococci

5,575

Positive examinations

508

Spinal fluid, specimens of

627

Positive examinations

174

Pus, exudates, etc. (exclusive of wounds)-

Aerobic cultivations

816

Complete identifications (number of stains)

456

Anaerobic cultivations

228

Complete identifications (number of stains)

43

Wounds-

Aerobic cultivations

1,944

Complete identifications (number of stains)

498

Anaerobic cultivations

237

Complete identifications (number of stains)

34

Autopsies, Total original cultures from

983

Milk, total number of specimens of

86

Water, total number of specimens of

3,595

Bacteriologic examinations not otherwise listed

2,322

 

Total

 

48,744

IV. Serology:

Agglutination tests (with bacteria)

2,063

Bloods grouped (for transfusions)

212

Wassermann tests-

Blood

9,265

Double plus, or plus

834

Spinal fluid

127

Double plus, or plus

25

Serologic examinations not otherwise listed

1,453

 

Total

 

13,120

V. Chemistry (specimens analyzed):

Blood

174

Urine, special examinations

1,568

Water

1,280

Milk

3

Drugs, foods, beverages, etc.

32

Chemical examinations not otherwise listed

64

 

Total

 

3,121

VI. Operative procedures (by laboratory staff):

Treatments with salvarsan

753

Treatments with therapeutic sera

839

Treatments with bacterial vaccines

1,172

Schick tests

6,260

Leutin tests

3

Animal inoculations

172

Operative procedures not otherwise listed

1,925

 

Total

 

11,124

Total laboratory examinations not included above

927

 

Grand total

 

174,832

(Memorandum No. 38, division of laboratories and infectious diseases, February, 1919.)

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