In this work is included the physical and mental examination and training of recruits, the supervision of the water supplies, the inspection of foods to be served, the disposition of wastes, sanitation of cantonments and camps, care of sick and wounded, including proper records of all cases, the operation of field, base, and convalescent hospitals, reeducation of the permanently crippled and the handling of the necessary medical supplies and equipment for all this work.

The total number of hospital beds will be placed on a basis of 25 per cent of the strength of the Army.

In preparing for the great task devolving upon the Medical Department, as outlined above, this office is having the earnest and wholehearted support of the entire medical profession of the United States, which has responded promptly and placed at the disposition of the Surgeon General of the Army the services of the most distinguished specialists in all branches of medical endeavor.

These distinguished men of the medical profession enrolled as members of the Council of National Defense, and as commissioned officers of the Medical Reserve Corps, are rendering a service to the Army and to the country which can not be overestimated and which will ever be held in grateful remembrance.

GENERAL HEALTH OF THE ARMY.

The general health conditions of the United States Army for the calendar year 1916 were in all respects satisfactory and in view of the unusual circumstances connected with the mobilization on the border and the expedition into Mexico, may be fairly regarded as specially creditable to those directly associated with the management of all matters pertaining to the health and sanitation, particularly of the troops serving in the Southern Department.

The mean strength (corrected for time) of the entire Army, American and native troops, including the National Guard, was 176,803 for the year 1916. Its noneffective rate from all causes in the year was 24.26 per 1,000 and for disease alone, 20.55, both of which ratios were slightly lower than for the previous year, 25.22 and 20.85, respectively.

The admission rate for the Army, including the National Guard, for 1916, was 858.87, as compared with 726.22 for 1915; the discharge rate was 15.22, as compared with 14.06 for the previous year, and the death rate was 4.39, as against 4.45 per 1,000 of mean strength. The mean strength of the entire Regular Army for the calendar year 1916 upon which the statistics contained in the annual report are based, was 110,454.

The noneffective rate for the entire Regular Army for 1916, from all causes, was 26.99 per 1,000 and for disease alone 22.63, being slightly higher than for the previous year, 25.22 and 20.85, respectively, but much lower than the average of these rates for the decade, 34.99 and 29.65, while that for the year 1906 was 47.86 per 1,000 from all causes.

The admission rate for the entire Army for 1916 was 726.45, as compared with 726.19 per 1,000 for 1915.

The death rate of the entire Army for 1916, from all causes, was 5.19 per 1,000, compared with 4.45 for 1915, which was slightly

higher than the lowest mortality rate in the Army for many years, 4.40 for 1914. The death rate from disease was 2.71 per 1,000 for 1916, as compared with 2.53 for 1915; the average for the decade was 2.94 and for the year 1906, 3.77.

The discharge rate for the year 1916, from all causes, was 15.98 per 1,000 as against 14.06 for 1915 and 12.78 for 1914; while the rate for this year is slightly higher than for the two years previous, it was less than the discharge rates prior to 1910 when they ranged from 16.64 upward.

The total losses of the Army from all causes-deaths, discharges, and retirements-was 20.92 per 1,000 for 1916 and 18.03 per 1,000 for 1915; for the year 1914 the rate was 16.86, the lowest in the past decade.

Malarial fevers show a noneffective rate of 0.62 for 1916, as compared with 0.54 for 1915, the lowest noneffective rate in the history of the Army. In 1906 the noneffective rate for malarial fevers alone was 2.55 per 1,000. The decade following has demonstrated the effectiveness of the antimalarial measures that have been unceasingly employed by the sanitary officers of the Army each year, exhibiting, with but two exceptions, a marked decrease in the incidence of the disease.

The entire force in the Philippines, including native troops, gave an admission rate of 715.87 for 1916 as compared with 853.65 for the previous year, and noneffective rates, respectively, 23.27 and 24.72. This record is especially creditable, as compared with former years, though here, as in the Canal Zone, the Medical Department has been at some disadvantage, through lack of screening or other antimosquito requisites, due to insufficient appropriation of funds for this important work. There should be no further delay in properly screening all buildings in the Tropics occupied as hospitals, barracks, or quarters.

The highest noneffective rate, for disease alone, for 1916 was among the troops stationed in China, 28.22 per 1,000. The rate is slightly lower than last year, when it was 31.78 per 1,000. Then follows in order: United States with 25.51; Canal Zone with 23.45; Porto Rico with 22.53; Philippine Islands with 19.86; Hawaii with 15.23; Mexico with 12.79; and Alaska had a rate of only 6.23, which is slightly higher than that for last year, 6.02.

Typhoid fever.-Typhoid fever has always held an important place in relation to the health and efficiency of armies. Its widespread occurrence in civil communities has caused in the past its prompt appearance among recently recruited levies of troops, especially those of youthful age from rural districts.

The history of typhoid fever in the United States Army is now a matter of common knowledge. The ravages of the disease in the volunteer organizations encamped in the South during the summer and autumn of 1898, the year of the Spanish-American War, is well remembered. Improved methods in camp sanitation, the special care given to food and water supplies, and the disposal of refuse and excreta all contributed to the marked reduction in the incidence of typhoid fever among the Regular troops during the decade following the War with Spain.

It was not, however, until the introduction of vaccination against typhoid, a procedure made compulsory in the United States Army

in 1911, that this disease ceased to become a distinct menace in our service whenever any considerable body of troops were mobilized under the conditions usually prevailing in the field.

With the thorough vaccination of the Army, typhoid fever has appeared only sporadically, usually less than a dozen or two cases a year-this among troops serving in many climates and countries halfway round the world-in fact, has been regarded as a remarkable record and unquestioned proof of the value of typhoid vaccination. During the past year there were 96 cases of typhoid fever in the entire Army with 5 deaths resulting. Of this number 16 cases among Regulars and 71 in the National Guard, a total of 87, occurred within the continental limits of the United States; of the 9 other cases, 7 were in Hawaii and 2 in Mexico.

The results following compulsory vaccination in the Army are now well known and are exemplified by the record of the present year when compared with those for the year 1898 when the Army was operating under similar disadvantages.

The observations of competent observers have proved conclusively that the triple typhoid vaccine, adopted for immunizing the entire Army against typhoid and paratyphoid fevers, gives as good results in immunization as does the typhoid alone and that neither the general nor local reactions following its injection are different in any degree from those occurring after the inoculation of simple typhoid vaccine. The results, both from a practical and theoretical point of view, are all in favor of combining the three organisms in a single vaccine, and it is believed amply justify the use of the triple typhoid vaccine in immunizing our troops against the typhoid and paratyphoid fevers.

Paratyphoid fever.-Paratyphoid fever had been but little known and rarely diagnosed and reported in our military service prior to the year 1916. Many such cases had undoubtedly been reported as fevers of undetermined causation.

There were 410 cases of this disease reported in the entire Army114 for Regulars and 296 for the National Guard.

During the mobilization of the Regular Army and National Guard on the Mexican border and during the expedition into Northern Mexico, paratyphoid fever was recognized quite frequently, and in two forms caused by distinct bacilli known as paratyphoid "A" and paratyphoid "B," the former being the causative agent in the very large proportion of cases.

Vaccination against the disease was rigorously instituted by the Acting Surgeon General with the result that several outbreaks of the disease in the Southern Department were immediately checked, all troops in the infected divisions being fully immunized against the disease. There were 410 cases of paratyphoid fever reported, 2.32 per 1,000 of mean strength, of which over 95 per cent were of the "A" type. These cases were distributed as follows: The Regular Army furnished 114 cases, of which number 22 occurred in the United States, 91 in Mexico, and 1 in China. The National Guard had 296 cases which, with the 22 for Regulars, made 318 in the year for the United States.

Vaccination against both typhoid and paratyphoid fever is now accomplished by the use of a mixed vaccine, recently adopted and known as "The Triple Vaccine" from the fact that it is made from

the bacillus typhosus, the bacillus paratyphosus A, and bacillus typhosus B.

This vaccine prepared, as have been all the Government vaccines in the past few years, in the laboratories of the Army Medical School, Washington, D. C., is given in a single series of three doses, the first containing c. c. and second and third doses 1 c. c. each, with an interval of approximately 10 days between each administration.

Malarial fevers. As in previous years, this disease shows a marked decrease throughout the Army, with the possible exception of certain of the garrisons in the Philippine Islands situated in malarious districts, and with many carriers among the local native population. The admission rate in 1916 for this disease in the entire Regular Army was 23.61, slightly lower than for the previous year, when it was 25.16 per 1,000 of mean strength. The noneffective rate was 0.62 as against 0.54 for the previous year. The National Guard had a case rate of 31.50 with 0.64 noneffective per 1,000 of mean strength.

Measles. Regular troops serving in the United States (continental) year 1916 furnished 1,247 cases of measles and 9 deaths, proportionately 19.35 and 0.14 per 1,000 of mean strength, as compared with 12.86 and 0.14 for the National Guard. The entire Army, Regulars and National Guard, all stations, home and abroad, had 2,168 cases and 18 deaths, respectively, 12.24 and 0.10 per 1,000 of strength. The rates for Regulars in 1915 were, respectively, 8.33 and 0.29.

The recruit depots, particularly at Columbus Barracks and Jefferson Barracks, Mo., were frequently overcrowded during the winter and early spring months, with the result that has invariably attended such congestion. Many cases of measles occurred, chiefly among the highly susceptible material from the southern rural districts, the cases not infrequently being complicated with middle ear diseaseempyema and broncho-pneumonia; all were very serious complications, particularly the latter, and as in civil life resulted fatally in a considerable number of instances.

In this connection it is a timely thing to again utter the earnest warning against the overcrowding of troops, particularly recruits and fresh levies in their tents, camps, barracks, and cantonments.

Overcrowding and close contact of the well with the sick in the early stages of illness is the prime cause in rapid spread of practically every disease, but more especially is this true of those affecting the naso-pharynx and the respiratory system, including tuberculosis, measles, mumps, scarlet fever, pneumonia, and epidemic meningitis. The occurrence of measles in epidemic form among certain organizations in camp on the Mexican border gave an opportunity for competent observers to investigate the disease under the conditions obtaining in the field and led to the conclusion of a well-known authority that not only are measles epidemics preventable, but that in the future they should be prevented not only in the field but also in barracks and recruit depots, the result being assured, if proper ventilation and other facilities are provided and attention given to the important matter of the prevention of overcrowding; to the prompt isolation of contacts, and to the careful segregation of the nonimmune, all under rigid and repeated inspections by trained medical officers. Tuberculosis.-Pulmonary tuberculosis continues to hold a very important position among the cause for disability discharge from the

Army, and the desirability of early recognition of the disease, particularly at recruit stations and depots in applicants for enlistment, is at once apparent, and the matter has been given careful consideration.

As at present provided, all candidates for the military service will be given not only the usual strict physical examination always required under the existing regulations but will be further brought under the observation of a special board of experts chosen from the distinguished clinicians of the Medical and Medical Reserve Corps of the Army. The duties of these special examiners are most important and are included under the following general heads: (1) To exclude cases of manifest tuberculosis from the Army; (2) to hold to service men who allege tuberculosis as a ground for exemption under the selective draft, or discharge on the basis of insufficient or incorrectly interpreted signs and symptoms; (3) to determine in cases of soldiers accepted for the military service the existence of pulmonary tuberculosis and to decide whether or not the disease has been incurred in the line of duty. Definite and explicit instructions to govern these examiners have been prepared and issued by this office.

Venereal disease.-It has often been assumed by well-meaning but ill-informed critics that illicit sexual intercourse and venereal diseases are more common in the military forces of the United States than in civil life.

That this is an erroneous conclusion is well known to most of the medical practitioners of the country, and one resulting principally from the fact that the statistics of these diseases are collected by the Surgeon General of the Army and frankly published, whereas the corresponding figures for civilian life are incomplete and inaccessible. Recent legislation giving to the Secretary of War and the military commanders authority to control not only, as heretofore, the military reservations and cantonments, but also the civil communities immediately adjacent, in all matters relating to prostitution and the sale of alcoholic drinks, will do much to bring about the desirable conditions long sought for by the Army sanitarian.

It should be repeated that venereal diseases have never had their origin in military reservations, where strict discipline and constant inspections have rendered it impossible, but rather in the laxly governed civil communities surrounding many Army posts, where ignorance of conditions and indifference, or something even worse on the part of local authorities, have conduced to widespread infection, not only of the civil population but the soldiery as well.

The law referred to, which marks such a great step forward in the matter of military sanitation and hygiene in our country, was promulgated May 24, 1917, as sections 12 and 13 of Bulletin No. 32, War Department, as follows:

SEC. 12. That the President of the United States, as Commander in Chief of the Army, is authorized to make such regulations governing the prohibition of alcoholic liquors in or near military camps and to the officers and enlisted men of the Army as he may from time to time deem necessary or advisable: Provided, That no person, corporation, partnership, or association shall sell, supply, or have in his or its possession any intoxicating or spirituous liquors at any military station, cantonment, camp, fort, post, officers' or enlisted men's club, which is being used at the time for military purposes under this act, but the Secretary of War may make regulations permitting