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Chapter XII

Contents

CHAPTER XII

THE DIVISION OF LABORATORIES AND INFECTIOUS DISEASES
(Continued)

SECTION OF INFECTIOUS DISEASES; SECTION OF WOUND BACTERIOLOGY

SECTION OF INFECTIOUS DISEASES

In November, 1917, the director of laboratories planned the organization of a subdivision to be called the "subdivision of infectious diseases." It was proposed that this work be placed under the direction of an assistant director of laboratories, who should act as general advisor to the chief surgeon, A. E. F., in all matters pertaining to communicable disease.1 The officer assigned to this position on December 1, 1917,2 had begun the organization and formulation of plans of procedure when, in the following month, he was assigned to the trench fever commission. Thereafter, until midsummer of 1918, he was unable to take an active part in the subdivision of infectious diseases, but being frequently consulted by letter and by personal interview, offered many helpful suggestions.1 In February, 1918, another officer was appointed assistant director in charge of the section of infectious diseases, and with the cooperation of the first incumbent, perfected the organization of the section.1

FUNCTIONS

The functions of this section were outlined as follows:3

The function of the subdivision of infectious diseases is to provide an instrument for the prompt epidemiological and bacteriological investigation of transmissible diseases among troops of the American Expeditionary Forces. It constitutes, therefore, direct liaison between the division of sanitation and inspection and the laboratories, and is grouped with the latter only because its activities require the occasional mobilization of laboratory facilities and because its personnel should be capable of directing on the spot any laboratory work which the thorough study of any given situation may require. While operating from the laboratories as bases, therefore, this subdivision constitutes actually a part of the machinery of sanitation.

The duties of the subdivision of infectious diseases consist in:

1. Epidemiological and laboratory studies of outbreaks of transmissible diseases in the American Expeditionary Forces, having as primary purposes the discovery of source of outbreak, its mode of dissemination, and its control.

2. The study and organization of new prophylactic measures.

3. The investigation of special problems which may arise in connection with the control of epidemics.

4. The inspection of laboratories in so far as their diagnostic work, carrier examination, and epidemiological work are concerned.

5. The organization of mobile laboratories for epidemiological work in base sections.

6. The preparation of circulars and literature concerning infectious disease for submission to the chief of the division of sanitation and inspection, laboratory, and infectious diseases.

7. Advisory cooperation with the various sanitary and medical authorities in the hospitalization and isolation of infectious diseases.

Organization.-There will be a central office of this subdivision at the central Medical Department laboratories, A. P. O. No. 721, American Expeditionary Forces, which will be in charge of officers delegated to this work by the director of laboratories.


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The activities of this office will include:

(a) The selection of personnel to carry on the work of the subdivision.

(b) The supervision of the work of this personnel whenever necessary in a given outbreak.

(c) Periodical inspection of the laboratories of the front area in regard to their work on infectious diseases, and similar inspection of other laboratories of the American Expeditionary Forces when so instructed by the director of laboratories.

(d) The maintenance at the central medical laboratories of records of the activities of this subdivision.

(e) The study of special problems that may arise in connection with transmissible disease.

(f) In the advance section and zone of the advance, the officers assigned to the work will keep in constant touch with the incidence of infectious disease and personally investigate any focus which seems to them or to local authorities to call for investigation. They will personally undertake similar investigations in the base sections when instructed to do so.

There will be assigned to the base laboratory in each base area and to each army laboratory an officer who is ready to carry out similar work in his respective area at the direction of the division of sanitation, inspection, laboratories, and infectious diseases. He will be ready to proceed to any point in the base section when notified by the chief surgeon of the section to do so. His orders will come through the commanding officer of the base laboratory to whom he will be responsible for the proper performance of the laboratory work and the return of the property he may take with him. He will take with him from the base laboratory a mobile laboratory car or any material and personnel he may require for the particular work to be done. If, in the opinion of the authorities concerned, any situation becomes sufficiently grave to require advisory cooperation of the officers in charge of infectious diseases at the central medical laboratories, a telegraphic request will be made on the central medical laboratory and the director of laboratories will send one of the officers in charge of the subdivision of infectious diseases to the point where advice is needed.

In the advance section and zone of the advance similar personnel will be assigned for similar purposes to the Army laboratories. But in addition to this, these areas being directly accessible to the central medical laboratories, the officers assigned as assistant directors for infectious diseases will keep in constant touch with infectious disease occurring in these areas and proceed without further orders to any point where infectious disease is reported, in order to investigate whether further study, segregation, etc., is needed.

Suggested mode of procedure.-When the occurrence of cases seems to call for the detailed study of local conditions, orders will be issued to the officer stationed at the respective base laboratory who will proceed to the station indicated. On arrival, he will report to the local chief surgeon and will familiarize himself with local laboratory facilities and arrange cooperation with local laboratory personnel. He will consult local sanitary officers and obtain a careful history of the outbreak from its beginning, will visit commands and quarters from which cases have been taken, make spot maps of occurrence, trace contacts, and investigate relations of case to case. He will study relations of outbreak to water and food supply and will proceed to organize and carry out any laboratory work or serum tests necessary to elucidate the situation and control the disease.

In consultation with local medical authorities he will inaugurate sanitary measures aimed at control of the disease and on completion of the work will submit a report, incorporating specific recommendations. A duplicate copy of this will be sent to the chief of the division of sanitation and inspection, laboratories, and infectious diseases. One copy will be left with local chief surgeon, and one will be retained as a record of the subdivision of infectious diseases.

In the advance section and zone of the advance, the officers in charge of the subdivision of infectious diseases will supplement this system by visiting as promptly as possible all locations where infectious disease is occurring, and determine by personal investigation whether the situation requires special study.

The duties of this section as finally prescribed were published in Circular No. 40, chief surgeon's office, July 20, 1918. (See Appendix, p. 958.)


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It was not proposed that this section would engage in research, except in so far as the study and suppression of outbreaks of disease necessitated. Its primary purpose was the early discovery of foci of infection, the prompt tracing of cases to the point of their infection, and the suppression of diseases traced in this manner before they could reach epidemic proportions.1

Though the foregoing plans had been formulated for the development of this section of the director's office, no personnel was at first available to carry these into effect.4 Such outbreaks of epidemic diseases as did occur were investigated by field parties sent out from Army laboratory No. 1 at Neufchateau.4 Only four divisions were in France at the end of December, 1917, and the only epidemic diseases requiring investigation by this section were small outbreaks of meningitis, diphtheria, scarlet fever, influenza, and pneumonia.4 Water supply surveys were carried out in very considerable portion of the then existing divisional training areas by field parties from Army laboratory No.1, and it became evident, from these early surveys, that approximately 85 per cent of the water for drinking purposes was contaminated. This initial estimate of the water-supply situation in France was confirmed by surveys at a later date.4

All matters relating to transmissible disease were referred to the section of infectious diseases, for it was concerned mainly in the investigation of epidemics, development of the organization for their control and prevention throughout the American Expeditionary Forces, the preparation of bulletins relating to prevention and control of transmissible diseases, the standardization of methods for combating them, and standardization of the use of therapeutic sera which were of value in this work.4 Reserve personnel for the investigation of epidemics was attached to the central Medical Department laboratory at Dijon, and most of the investigations of epidemics conducted under the control of the director of laboratories and infectious diseases were prosecuted in cooperation with and under the direct supervision of the commanding officer, central Medical Department laboratory.4 The duties assigned to the division of laboratories and infectious diseases by Circular No. 40, chief surgeon's office, and the memorandum quoted above, indicate how closely the central laboratory and the section of infectious diseases were associated.4 In April, 1918, preliminary steps were taken to coordinate the central office of the section of infectious diseases with those engaged in similar service in the several administrative sections of the Services of Supply.4

Because of rapidity with which American troops arrived and of the large territory over which they were distributed, decentralization of the epidemiological service became necessary for proper supervision and prompt action.1 In the original plan it had been contemplated that a standard uniform method of control throughout the American Expeditionary Forces would be adopted and that a selected and trained officer qualified to make epidemiologic and bacteriologic studies of outbreaks of infectious diseases would be stationed in every section of the Services of Supply. Each section epidemiologist was to have available a main laboratory adequately equipped for the performance of any diagnostic or other laboratory work. It was expected that this officer ordinarily would handle problems arising in his section but that in emergencies he would obtain extra personnel and equipment from the director of laboratories


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and infectious diseases.1 Later, after conferences with medical representatives from the various administrative sections of the Services of Supply, and after receipt of their replies to a circular letter sent them concerning the adoption of methods for control of infectious diseases, a somewhat different plan for the organization of epidemiologic service in these sections was formulated.1 This plan, which was generally adopted, with some variations to meet particular local problems, provided that the several sections of the Services of Supply would solve their respective problems.1 However, in each section an epidemiological service with laboratory facilities was established, and though each such epidemiological service operated more or less independently of the central administration of the division of laboratories and infectious diseases, it called upon the central laboratory for advice, personnel, and material, whenever needed, and was in constant communication with it.1

Also it had been planned that in the advance section and zone of the armies the epidemiologic work would be centralized at the office of the director of laboratories and infectious diseases, that through the office of the respective chief surgeon, the director would be kept constantly informed concerning the incidence and location of infectious diseases, and that he would have sufficient personnel and mobile laboratory equipment immediately to give assistance where necessary.5 In point of fact the control of infectious diseases among troops in the army zone remained under the direct supervision of the director of laboratories until the later summer months of 1918.1

Arrangements for the prevention and control of epidemics among the troops in the zone of the armies utilized and expanded resources and methods already provided by Tables of Organization.5 The division sanitary inspector, as assistant to the division surgeon was, as theretofore, primarily responsible for the health of the division. He attended to all ordinary matters affecting sanitation in which duty he was assisted by two officers previously not provided in our service, viz, the laboratory and water supply officers.5 The divisional laboratory officer was in charge of a small laboratory equipped for clinical pathology but inadequate for extensive cultural work; the divisional sanitary inspector of water, who had had some training in general bacteriology, performed examination of water supplies.5 As soon as resources of personnel permitted, these officers, intended for these positions, were given an intensive course of training at the central laboratory at Dijon, before they were assigned to divisions.5

Some divisions came to France without laboratory officers, but they were furnished them after arrival from personnel assembled and equipped by the section of infectious diseases.1

It was intended that the divisional laboratory officer should act not only as a technical laboratory worker for the division but should assist the sanitary inspector in making epidemiologic surveys and sanitary inspections.1 It may be said, in passing, that in many cases this could not be effected because of the lack of transportation.1 This divisional organization was quite adequate under ordinary circumstances to deal with conditions that threatened the health of the troops, but because of insufficient laboratory equipment and shortage of personnel, it was necessary in any considerable outbreak of communicable disease to send reenforcements.1


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The duties of the division sanitary inspector of water were reduced to their simplest forms. He supervised the chlorination of drinking water in the division, gave appropriate instructions, kept in touch with any water problems that arose, and constantly reported concerning the purification apparatus available.1 Laboratories adequately equipped for the examination of all water supplies were not available for issue to the divisions.1

Because of insufficient personnel and laboratory equipment in a division wherewith to combat epidemics, Bulletin No. 32, G. H. Q., A. E. F., May 27, 1918, was issued, which provided that such resources could promptly be augmented whether troops were in the lines or in training areas. This bulletin authorized an army or division surgeon to communicate in emergencies directly with the director of laboratories and to request assistance; the director of laboratories was authorized to send such personnel and equipment as might be necessary, and to cooperate to the extent of his resources.

The section of infectious diseases was active throughout the advance section and assisted in the control of outbreaks of diphtheria, scarlet fever, measles, meningitis, influenza, and diarrhea, employing in this service additional laboratory personnel and equipment; e. g. mobile laboratory cars, constructed and completely equipped according to the English plan (with some modifications) for the investigation of such epidemics as might arise.1 Usually they were manned by one commissioned officer, a driver and a technician, dispatched on telegraphic requests either from the central Medical Department laboratory at Dijon or from Army laboratory No. 1, at Neufchateau (where one of these cars was stationed), according to the area from which the request was received.1 Sometimes the local laboratories of base or evacuation hospitals were utilized, and additional resources were dispatched in response to telegrams to the director of laboratories at Dijon.1

To further meet the requirements of field investigations of outbreaks of epidemic disease the laboratory service began, about April, 1918, to assign to duty at the central Medical Department laboratory special, well-trained medical officers whose primary duty was the direction of field parties engaged in the investigation of epidemics.4 Usually there were from two to four such officers engaged in activities of this character. There were also mobilized at the central laboratory for use by these parties several special laboratory units consisting of equipment packed in chests and two of the motor laboratories mentioned above.4

Laboratory methods securing early diagnosis, detection of carriers, and practical measures of control of infectious diseases were standardized and put into general operation.5

In July, 1918, American troops actively engaged in the Chateau-Thierry sector suffered very extensively from diarrheas and dysenteries.5 During the period from July to November, 1918, the activities of this section were greatly decentralized so that by November its functions were mainly those of adviser to the chief surgeon's office in general policies relating to the prevention and control of transmissible diseases.4


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Meanwhile decentralization had continued so that the several administrative sections of the Services of Supply were relatively independent of central supervision and in each a special base laboratory had been established.1

As American troops concentrated in the advance section and in the zone of the Army, and more and more divisions began to participate actively in combat, other daughter organizations were split off from the central office of the section of infectious diseases, to serve the several corps or armies.1 It was decided, as the result of experiment, that these organizations should belong to armies rather than to corps.1 Therefore a sanitary inspector was assigned to the Second Army and a system similar to that in the administrative sections of the Services of Supply was put in operation but modified to suit moving troops. In consequence, the sanitary organization of an army also became largely independent, (except for personnel and laboratory supplies) of the central office.1 When the Third Army was organized, for the occupation of the American sector on the Rhine, a sanitary division was created, as part of the office of the army surgeon.1 The duties of the section of infectious diseases in so far as the Third Army was concerned, pertained especially to coordination, supervision, inspection, advice, and provision of personnel and equipment.1

As a result of this sectional organization, with trained men in definite areas or assigned to service of bodies of troops, and the aid of mobile laboratories, it was possible to render prompt assistance, make surveys for carriers, correct sanitary defects, and materially aid in the prevention and suppression of epidemics.5 Numerous investigations were made of outbreaks of measles, meningitis, influenza, pneumonia, diarrhea and dysentery, typhoid and paratyphoid fevers, scarlet fever, diphtheria, and similar diseases. The sources were sought out and recommendations for their control made.

Concurrent with the development of its field service the section of infectious diseases prepared circulars pertaining to control of infectious disease, and conducted instructional work.1 This latter activity which at first was limited to consultations with laboratory officers intended for assignment to divisions, developed into a course of instruction in carrier investigation and other technique needed in field work concerning communicable diseases and the supervision of drinking water.1

When the armies had been organized with epidemiological facilities this service, for all the larger units of the American Expeditionary Forces, had become decentralized.1 Thereafter the duties of the section of infectious diseases were more of a supervisory and advisory character than those of actual participation in the solution of problems, as they had been formerly.1

The section of infectious diseases continued to act as adviser of the chief surgeon, A. E. F., in the formulation of broad policies of sanitation, and in the circularization of information relative thereto, until it was abolished.1 Its activities were absorbed into the chief surgeon's office after headquarters of the division of laboratories moved to Tours in June of 1919.1


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SECTION OF WOUND BACTERIOLOGY

After a study of bacteriologic investigation of war wounds as conducted by our allies, and a survey of the organization employed for this purpose, at La Panne, Bouleuse, Epernay, and Chalons, a section charged with the supervision and correlation of such work in the American Expeditionary Forces was established in the division of laboratories in March, 1918.6 Its purpose was to be the dissemination of information on this subject and the determination of the circumstances under which a delayed primary or secondary suture of a wound might best be performed. Secondary and delayed primary closure were being practiced among our allies only after laboratory findings indicated the advisability of such practice and the provision of personnel and equipment for obtaining similar findings in the American Expeditionary Forces was deemed advisable.6

The scientific value of the examination of war wounds was subordinated to practical needs in the organization of this section, for few statistical data apparently were being collected by the laboratories of our allies where research work was being conducted. The prime services rendered by this section were assistance to surgeons who had not had much experience in treatment of war wounds, the provision of a control which would complement professional acumen of the more experienced surgeons, and, in time of stress, would relieve them of making close studies which otherwise would have been necessitated clinically.6

It was planned that a trained wound bacteriologist and an assistant would be assigned to each mobile, evacuation, and base hospital, and that this personnel would be increased as resources in general laboratory personnel permitted. This additional personnel was to be organized in teams which were to be transferred as required. The entire service of wound bacteriology was to be under the control of an assistant to the director of laboratories, who was to provide, train, and distribute these specialists, supervise their activities and conduct appropriate research.6 It was planned that a statistical bureau would collect data concerning the bacteriology of war wounds from all hospitals in the American Expeditionary Forces and that an agency which would distribute literature on this subject would also be established. Studies at the central laboratory were to supplement those in the several hospitals and the central laboratory was to prepare and distribute media and reagents both in order to lessen the work of the laboratories at the front and in order to standardize materials. Such research as was to be
conducted was to be of immediate practical value.6

But these plans did not fully materialize: The paucity of officers did not permit the formation of teams as planned; lack of transportation prevented the central laboratory renewing prepared media, ingredients for media being substituted therefore.

Officers who, in their replies to a questionnaire, were found to have the necessary training in general bacteriology were ordered to the central laboratory at Dijon where they were given an intensive course in wound bacteriology. This comprised laboratory instruction, autopsy demonstrations, and a certain amount of training at the bedside. Classes consisted of about 20 officers, whose course of training lasted two weeks. The number instructed at the central Medical Department laboratory totaled 134.6


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A few officers were trained at other points, viz, 7 at Epernay, 6 at Autochir No. 21, 7 at Evacuation Hospital No. 1, and 4 in hospitals belonging to the Allies. When the armistice was signed, officers trained in wound bacteriology were assigned to all evacuation, mobile and base hospitals except the most recent arrivals and a few of the hospitals serving at hospital centers. The number of wound bacteriologists thus assigned were as follows:6   Evacuation hospitals, 16; mobile hospitals, 13; Red Cross military hospitals, 10; base hospitals operating separately, 18; base hospitals in hospital centers, 66.

Though there was inadequate time to work it out, the plan was to provide one officer trained in wound bacteriology for each 500 surgical beds and recall from time to time officers already instructed to receive further instruction in newer methods and to discuss their several problems, administrative and professional.6

The most difficult problem experienced by this section was the preparation of records and the collection of statistical and other data. Two blank forms were devised, one relatively very brief for use in periods of stress, the other more thorough, to be used in periods of relative quiet, but only a relatively small number of organizations found it possible to collect fairly complete records.6

A monthly statistical report form was also called for but this was utilized by only a small number of organizations. These units, however, went far toward collecting the information desired.6

Special investigations concerning gas gangrene, the use of antigas gangrene and antitetanic sera, and the possible infection of wounds by attendants were undertaken. Research seeking the recovery and identification of organisms concerned in wound infection and the value of certain smears and indicators was also undertaken at the central laboratory.6

On October 29, 1918, the head of this service reported as follows to the director of laboratories:6

At present the central organization of the section of wound bacteriology is still undermanned. While an adequate number (considering the number of laboratory officers in the American Expeditionary Forces and the needs of other sections of this division) of wound bacteriologists for service in the field is now available, the administrative force in the central office is inadequate properly to control the work of the officers in the field, to analyze and arrange the statistical evidence which is rapidly accumulating, and finally to verify the identification of bacterial species recovered from important cases.

The most important single need of this section is an officer with considerable laboratory experience whose duty it will be to make frequent inspections of all the laboratory units engaged in the bacteriologic study of war wounds with a view of determining the efficiency of the workers in this field, of raising the standards of the work done by correcting obvious defects and stimulating enthusiasms for this particular work, both among the laboratory officers and among those engaged in the surgical care of the wounded, and finally of collecting data which might serve as a basis for the improvement of the service. The rapid increase in the number of hospital organizations in the American Expeditionary Forces and the extent of the area which they occupy makes such additional assistance necessary.

Two additional officers to conduct research concerning the bacteria found in wounds, an officer to analyze reports received, and two file and record clerks for headquarters were also required. These needs were obviated by the declaration of the armistice on November 11 and the section as such submitted its final comprehensive report on December 4, 1918.6


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REFERENCES

(1) Report on general plan, organization, and development of the section of communicable diseases, A. E. F. (undated), by Lieut. Col. Hans Zinsser, M. C. On file, Historical Division, S. G. O.

(2) Letter from The Adjutant General of the Army to Lieut. Col. Richard P. Strong, M. C., December 1, 1917. Subject: Appointment as assistant director of laboratories. On file, A. G. O., World War Division, chief surgeon's files, 201 (Strong, Richard P.).

(3) Report on division of laboratories and infectious diseases, subdivision of infectious diseases, A. E. F. (undated), by Lieut. Col. Hans Zinsser, M. C. On file, Historical Division, S. G. O.

(4) Report from Col. J. F. Siler, director of the division of laboratories and infectious diseases, to the chief surgeon, A. E. F. (undated). Subject: Activities of the division of laboratories and infectious diseases, from August, 1917, to July, 1919. On file, Historical Division, S. G. O.

(5) Report from the chief surgeon, A. E. F., to The Surgeon General, U. S. Army, May 1, 1919. Subject: Activities of the chief surgeon's office, A. E. F., to May 1, 1919. On file, Historical Division, S. G. O.

(6) Report on the section of wound bacteriology, A. E. F., December 4, 1918, by Lieut. Col. William J. Elser, M. C. On file, Historical Division, S. G. O.

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