No feature of the preparatory phase of the war has been more important than the various schools for the intensive training of candidates for commissions.

Three such schools for the training of medical officers have been in existence during the year past, at Fort Oglethorpe, Fort Riley, and Fort Benjamin Harrison. All have proved their great value in preparing the physicians direct from civil life for the varied and unaccustomed duties of the medico-military practitioner and administrator.

The courses given at these training camps have been thoroughly and systematically carried out by competent instructors and earnestly and enthusiastically followed by the student officers, who have been prompt to recognize the necessity and advantage of special instruction in the great field relating to the care and protection of troops in camp and in campaign.

The health of the Army both at home and overseas has been excellent and lower probably than in any similar body of troops in the history of warfare.

Infectious diseases-measles, scarlet fever, pneumonia, epidemic meningitis prevailed during the winter months in the various cantonments and were, as a rule, well handled, with the minimum of mortality, considering the serious character of the diseases and the necessary circumstances of rapid mobilization.

Venereal disease has been vigorously dealt with, as heretofore, in the Army. Special legislation and earnest measures taken by civil communities adjoining camps and cantonments, under the direction of the Federal authorities, have been potent means of controlling this menace which, as often stated before, originates, with rare exceptions, entirely outside the jurisdiction of the military authorities.

The first considerable body of expeditionary troops to Europe, comprising about a division of Regulars, arrived in France in May. 1917. They were preceded by certain Medical Department units, constituting an advance force of the American Army.

Since then there has been a steady flow of men and munitions across the Atlantic, and at this time an Army of a million and a half is fighting successfully on French soil. The work of the officers and men of the Medical Department overseas, under the skilled leadership of experienced and highly efficient chief surgeons, has elicited and deserved the highest praise.

The same can be fairly said of those who have remained in the United States performing faithfully and well the all-important tasks assigned to them of organization, supply, and training.

Speaking more in detail, the mean strength of the Army at the beginning of 1917 was only 217,272 officers and men, all branches included. By December, 1917, it had risen to 1,538,203 officers and men. Since December 31 the increase in the size of the Army has continued.

The mobilization of the National Guard, the concentration and the hurried recruiting of the Regular forces, the mobilization of the National Army, the great force of drafted men suddenly called from home life to new environments-all these conditions have required great expansion of the Medical Department, with the application of

the total professional knowledge of the country to the vast and relatively new sanitary problems involved.

The mobilization of such a large number of men has required a large amount of work for the physical examinations. Making physical examinations on so great a scale was a new experience for most of the physicians engaged. There were not in this country enough medical men of proper training to do the work adequately. It was very often necessary for medical officers to examine many more men during a given period of time than could be done by them with the proper degree of care. This was a military necessity. It was necessary to assemble such a large number of men in a short space of time and to examine them promptly.

During the first few months the work of making the physical examinations at the camp was on a basis of emergency work. It was done by a hastily assembled and frequently changing personnel. The examinations were conducted in any sort of a building that could be spared from the pressing need of shelter for troops or of anticipated medical need.

Consequently, it must be recognized that it was impossible for the number of experienced men available under the conditions as they existed to make the examinations of the number of men required properly in the time allotted so as to exclude all diseases or detect all defects.

Consequently, many men were inducted into the military service with diseases or defects undetected and unnoted. Hence the opinion that has frequently been advanced that because a man has been passed by his local board, advisory board, and the board at the mobilization camp, he was of necessity physically sound when he entered the military service is open to very serious criticism.

The work at the various camps and military posts in preventive medicine and the medical care of the sick or injured has required a large amount of work.

The following tabulation shows the expansion in brief of the Medical Department:

A large number of hospital buildings in this country and abroad have been built, organized, and equipped. The bed capacity in hospitals in the United States available at the present time is 73,066. In addition to this number, 16,799 additional bed capacity is now under construction.

Reports of the various divisions of the Surgeon General's Office are to be found in the body of the report. In addition to the reports of the various divisions is a short report of the American Red Cross. While the American Red Cross, as it is needless to say, is not attached 87894-18 -2

to the Surgeon General's Office, still, so much assistance has been rendered by this organization that a short summary of its work in connection with the Medical Department was thought desirable. The necessity of military secrecy renders it advisable to include only a brief discussion of the work of the Medical Department with the American Expeditionary Force.

In the report of the Division of Sanitation will be found a brief discussion of some of the infectious diseases with a limited statistical discussion of the health of the Army for the first few months of 1918.

Speaking now of the calendar year 1917, the health of the Army was satisfactory. Had it not been for the extensive epidemics of infectious diseases which occurred in the camps throughout the country, and especially in the southern camps, and more especially among the southern troops in the southern camps, the figures would have been very satisfactory.

Many of the camps have been visited by epidemics of these diseases more or less peculiar to great aggregations of men. During the period a large number of men was assembled in our camps and held for extensive training, and some were sent overseas. These men came from every section of the great country, from every class, without reference to previous social status, educational quali fications, or personal habits. They came from infected and uninfected localities. Immunes, susceptibles, infected, have been brought together in the close contact that is a necessity in every military organization. To accomplish this great task without more or less spread of infection was an impossibility. Fortunately, advances in general sanitation, in water purification, in garbage and sewage disposal, in protective measures against typhoid fever by vaccinations, have largely eliminated from armies the intestinal diseases.

If the morbidity from typhoid fever had been as great in the Army during the year 1917 as during the Spanish-American War for each 1,000,000 men there would have been 140,000 cases and 1,400 deaths. Actually, the mean annual strength of the Army was 678,579. Thus there would have been expected 136,000 cases and 13,600 deaths. As it was, there were 297 cases and 23 deaths. The insanitary conditions seen at Camp Alger, at Jacksonville and Chickamauga in 1898 do not exist in the country to-day.

It was seen long before the assembly of troops had been begun that the acute respiratory diseases would be the greatest factors in morbidity and mortality. With this in view this office insisted that at least 45 feet of floor space and 500 cubic feet of air space should be allowed each soldier. It was necessary, however, for military reasons, these reasons being, namely, the urgent necessity of assembling, organizing, and equipping as large a force as possible of men in the given period of time to overcrowd the facilities of the camps. Many of the deaths from the diseases to be discussed could, no doubt, have been prevented if the country and the department had been willing to purchase that advantage by delaying the calling and training of the soldiers until thoroughly satisfactory arrangements for clothing, housing, and caring for them had been matured. But such an advantage would have been dearly purchased if it had protracted the war or diminished the chance of a successful out

come.

It is necessary to realize that to diminish the great loss upon

the field of battle which would result from the delayed organization of the military forces of this country we must be prepared to accept a certain increased loss from deaths from infectious diseases that occur as a result of overcrowding the camps in this country.

Pneumonia, whether primary or secondary, caused approximately 65 per cent of the deaths from all causes in the United States. A large number of these deaths from pneumonias have been charged to measles, with which disease these pneumonias were complications. This places measles at the head of the list of the causes of deaths from disease in the United States for the year 1917. The international rule for the classification of deaths has been followed.

A large proportion of the infectious diseases, especially the pneumonias and measles, occurred in southern camps among southern troops. We find that the same conditions existed during the Civil War. While the northern troops suffered from epidemics of both. pneumonias and measles the morbidity and mortality of these diseases was much more extensive among the southern troops.

The general admission rate for diseases for enlisted men serving in the United States for the year 1917 showed an increase over the corresponding rate for 1916. The rate in 1917 was 886.81, being an increase of 270.70 over the year 1916.

The death rate in 1917 also showed an increase over the corresponding rate for 1916 for diseases for enlisted men in the United States. In 1917 the rate was 5.34, which is an increase of 2.56 over that for 1916. An examination of the tables in the body of the report shows that for the special infectious diseases, namely, broncho-pneumonia, lobar pneumonia, measles, and cerebrospinal meningitis, the death rate for 1917 was 3.93. The corresponding death rate for these diseases in 1916 was 0.72. The increase, consequently, for the year 1917 over the year 1916 for these diseases was 3.21 per 1,000. Had this great increase not occurred in 1917, the death rate for diseases would have actually been less in 1917 than in 1916. Excluding these diseases the figures would then have been 1.41 for 1917 and 2.08 for 1916 per 1,000. It is shown also by an examination of the tables that in camps the death rate for the diseases mentioned was 5.59 per 1,000, while the corresponding rate for posts other than the large camps was 2.50. Thus, the death rate in the camps for these special infectious diseases was more than twice as high as for posts other than the camps.

In the same way as the death rate was increased in the camps so in a like manner though not in a corresponding degree the admission rate was increased.

The discharge rate for disability for enlisted men serving in the United States was considerably increased in 1917 over the corresponding rate for 1916. The chief surgeon, Western Department, remarks: The hasty and superficial examinations given by inexperienced and indifferent medical examiners to applicants for enlistment, immediately following the declaration of war, is reflected in the enormous increase in discharges for disability existing prior to enlistment."

It was the opinion of the medical officers who signed the certificate of discharge for disability of the 15,882 such recommendations in the United States during 1917, that 14,774 were not in line of duty, and only 1,108 were in line of duty. ·

The noneffective rate for diseases, that is, the number of men absent each day from duty on account of diseases per 1,000 in the United States for 1917, showed a decrease from the year 1916, the rate in 1917 being 22.21 as compared with 26.30 in 1916.

For the American Expeditionary Forces the health conditions were entirely satisfactory. Since there was comparatively little fighting there were only a few deaths as a result of battle injuries. In the tropical countries where American troops were serving the health rates were all satisfactory.