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THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Washington: Government Printing Office, 1919

Excerpts on the Influenza and Pneumonia Pandemic of 1918

ANNUAL REPORTS, WAR DEPARTMENT

FISCAL YEAR ENDED JUNE 30, 1919

REPORT OF THE SURGEON GENERAL, U.S. ARMY

TO THE SECRETARY OF WAR

1919

IN TWO VOLUMES

VOLUME I

WASHINGTON: GOVERNMENT PRINTING OFFICE, 1919


LETTER OF TRANSMISSION

OCTOBER 8, 1919.

I have the honor to submit herewith the annual report of the Surgeon General of the Army, containing the statistics for the calendar year 1918, and the account of the general activities of the Medical Department, together with the financial statement for the year ending June 30, 1919.

The period covered by the report of 1918 and by this one has been one of the most memorable in the history of this country. It has witnessed the inauguration, the full development, and the successful ending of the unparalleled activities of the War Department and of the Nation as a whole. Never before in the history of this country has the Government put so large an armed force into the field as during the year 1918. During the Civil War the maximum strength of the United States Army, including both Regulars and Volunteers, was approximately 860,000. Of this number 300,000 were absent from duty for various causes, The maximum forces for the United States Army, excluding the Navy and Marine Corps, were, in October, 1918, over three and a half millions. This number included all troops, both American and insular, The strength of the Army, as furnished this office, was less than number given above, but the total strength for all the troops, and particularly for all troops traveling on transports, was never furnished.

At the beginning of 1917, or practically at the beginning of the war, the strength of the Army was less than 100,000. To increase this small Army to one of over three and one-half million, to properly clothe, equip, and train it, and to transport something over 2,000,000 soldiers with all the necessary modern equipment, supplies, and transportation to the battle fields in Europe, over 3,000 miles of submarine-infested ocean, was, indeed, an undertaking worthy of the efforts of a great Nation, That this gigantic undertaking should have been successfully accomplished; that, since the cessation of hostilities on November 11, 1918, practically all of this immense army in Europe should have been returned safely to this country; and that these soldiers, together with those in the large army remaining in the United States, should have been discharged from military service so promptly, is a cause for congratulation not only to the military and naval authorities, but to the entire country. It was only by the concentrated and combined efforts of the country as a whole that the undertaking was successfully accomplished.

The part that the Medical Department of the Army and the medical profession of the country had to play in this great drama is partially outlined in the report of 1918 and in the present one. Practically the entire medical profession of the United States became


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the Medical Department of the Army and Navy. This vastly enlarged Medical Department, enriched by the great professional and administrative ability of the leaders of the profession, as well as by the noble, unselfish and patriotic efforts of its rank and file, received the combined assistance of many associated organizations. The American Red Cross the Young Men's Christian Association, the Knights of Columbus, the Young Men's Hebrew Association, the Salvation Army, the Young Women's Christian Association, and other societies patriotically devoted their great influence to the welfare and the humanitarian interest of the fighting forces., They vied one with the other in their unselfish efforts to accomplish the greatest good where most needed.

The work of the Medical Department consisted in brief in the following:

(1) The procurement and training of the Medical Department personnel. The large number of qualified physicians needed had to be secured, the physically and professionally unfit eliminated, and those. selected given a brief intensive course of training to fit them for their duties in the military establishment. The same was true of the Dental, Veterinary, Sanitary, and Army Nurse Corps. In addition to the commissioned officers, a large enlisted personnel, with the proper qualifications, had to be secured and trained so that it could successfully play its part in the great world drama.

At the beginning of the war the entire Medical Department, including commissioned officers, contract surgeons, Army nurses, and civilian employees, numbered 8,634. This personnel reached a maximum of 354,796, almost three times the strength of the entire Army a few years before the beginning of the war, The Medical Corps increased from 833 to 30,591; the commissioned ambulance service from 0 to 209; the commissioned Dental Corps from 86 to 4,620; the commissioned Veterinary Corps from 62 to 2,002; contract surgeons from 181 to 939; the commissioned Sanitary Corps from 0 to 2,919; the Army Nurse Corps from 403 to 21,480; the enlisted personnel from 6,619 to 281,341; civilian employees from 450 to 10,695.

(2) The hospital facilities in this country had to be expanded from the needs of an army of less than 100,000 to the needs of one of nearly 2,000,000. The facilities had to be adequate to care not only for the sick occurring from the various ordinary causes in the camps in this country, but to care also for the large number of additional sick resulting from epidemics of ordinary infectious diseases that always sweep through the camps containing a large number of recently assembled men, and also the large additional number that occurred as a result of the overwhelming and unparalleled epidemic of influenza with pneumonia. In addition, hospitalization had to be provided for the sick and wounded returned to this country from the forces overseas.

In the American Expeditionary Forces it was necessary to provide not only hospital accommodations for the usual percentage of sick and injured, but also for the great number of wounded necessarily resulting when the large American Army engaged in active military combat with the well-organized and resourceful enemy. How well this work was accomplished is now a matter of history. Hospitals of 1,000 to 2,000 beds, or larger, sprang into existence almost overnight.


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In the camps, during the early period of the war, there was, unfortunately, some suffering among the sick occasioned by the fact that the hospitals could not be completed and equipped before the troops were assembled. The early and severe winter of 1917-18 increased and intensified this suffering, which was, fortunately, of brief duration. Since that time the hospital accomodations have, as a rule, been adequate. During the great influenza epidemic, in practically all the camps in this country and in a considerable number in Europe, it was necessary to extemporize emergency hospitals by the use of barracks and tents, to care for the unusual and unexpected number of sick. Never before in the history of this country, so far as the records show, either in the Army or in civil life, had the hospitals been so overwhelmingly crowded, In the American Expeditionary Forces, where a small division of troops had landed during the late spring and early summer, there sprang into existence from nothing a total of about 300,000 hospital beds, including the emergency beds and those in convalescent camps. At the time of the armistice a little less than 195,000 of these beds were occupied. There was thus provided in the American Expeditionary Forces hospital facilities, again including the emergency beds and those in the convalescent camps, for 15 then out of every 100. One of the special developments in the American Expeditionary Forces was the hospital center, These centers were hospital cities where a number of base hospitals were assembled. The beds in some of them numbered 25,000 or more.

(3) One of the most important duties of the Medical Department was the physical examination of the men who voluntarily enlisted or who were drafted into the military service, A soldier who is physically unfit to perform his duties is not only of no use, but is an actual hindrance, for he requires the attention of others-perchance in the time of stress of an already overworked Medical Department. The remarks of Surg. Gen. Lawson at the time of the Mexican War are just as appropriate now as they were then:

This state of things, it is apprehended, will ever exist with volunteer troops, or undisciplined men employed on distant service and in a foreign clime; more particularly with volunteer corps, gotten up under the impulses of the moment.

Old men forget their age-young men think not of their physical disabilities. Impelled by a feeling of patriotism, a thirst after military fame, or the spirit of adventure, many of them recklessly enter the ranks and undertake to perform the duties of a soldier, the toils, the privations, nor the self-restraint attendant on which are they in a frame of mind or of body to endure.

It is not until they have embarked in the enterprise, have journeyed several hundred miles at great expense to the government, and much to their own discomfort, that they find out there is something more required to constitute an efficient soldier than patriotism, chivalry, and valor, Then, for the first time, they understand that the labor and, exposure, the watching and fasting, their self-denial and self-restraint, they have to undergo, and for which neither nature, nor education, nor habit has fitted them, are beyond passive endurance.

In this vexed state of mind they readily take sick, then become melancholy and despondent, with a corresponding aggravation of the diseases; so that, should they not sink under the accumulated weight of mental and physical infirmities ,both, they seldom after being once stricken down, return to the duties of the field.


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By the time that they have been restored to their feet again, the battle has been fought and the laurels already borne off; and then, though it has not been their good fortune to, attain the object of their high aspirations (a triumphant conflict with the enemy), they have exhibited, at the sacrifice of their health, their zeal in their country's cause, and are anxious to return home.

The correctness of these remarks will, it is believed, be admitted by the volunteers themselves, many of whom enrolled their, names with the prospects of wearing a commission: but, having failed in their competition for the station of commissioned officer, are obliged to serve in the ranks as a private soldier.

It is proper to state here that one-third, and more, of all the men who offer to enlist in the Regular Army, are rejected; and it is reasonable to suppose that very many of those who are enrolled for the volunteer service would, if critically examined, be pronounced physically incapacitated for the arduous duties of a soldier.

As far as I understand the matter, the Government has, under the present state of things, virtually to pay a hundred men, while they realize the services of but fifty.

What with the extraordinary expenses attending the concentration of the individuals at a point, their organization into companies and corps, then their outfit and transportation to the theater of war, together with the expenses of their return home before the expiration of their term of service, on a sick ticket, or on a certificate of discharge, the volunteers have cost the Government 100 per cent more per man than the men of the Regular Army.

But this is not all-the presence of a numerous body of invalids seriously embarrasses the service; for, besides consuming the subsistence and other stores required for the efficient men, they must have an additional number of surgeons and men to take care of them and a guard to protect them, which necessarily lessens the disposable force, the available force, for active operations in the field.

From the foregoing statement of facts, it may readily be conceived that measures ought to be taken to prevent the introduction into the volunteer corps, the same as in the regular army, of men who, from disease or original constitutional defectibility, are disqualified to perform the active duties of a soldier.

The physically unfit had to be eliminated and for the protection of the Government and the soldiers; such defects as those had who were notwithstanding accepted for military service had to be made a matter of record. Upon demobilization it was also necessary to have accurate records of all defects or diseases, With the records of the physical examination upon entrance, with the medical history during the military service, and with the record of the physical examination upon demobilization, the Government is in possession of reliable data for each individual soldier. Each claim for compensation can be adjusted with fairness and justice to the individual and to the Government. It was also arranged to retain in the military service at demobilization soldiers with certain diseases or conditions which might be further improved by hospital treatment, provided such soldiers desired further treatment, and in the case of venereal disease to retain them whether they wished or not.

(4) Any army to successfully engage in any campaign for which it is, organized should be a healthy one. History abounds in illustrations of military forces which have been unable to accomplish the objects for which they were organized on account of sickness. To protect the fighting forces from preventable diseases is, indeed, a very necessary part of the military work, The already existing Division of Sanitation in this office was expanded to successfully coordinate the efforts of the sanitarians of the Army. Medical officers with


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long experience as sanitarians were detailed in this division as sanitary inspectors. These officers made periodical and emergency inspections at the various camps in this country to assist and coordinate the work of the camp sanitary officers. The same work was done in France. That this division might have timely notice of any outbreaks of any epidemics of infectious diseases occurring in camps and be informed as to the general health conditions of, the troops, brief weekly telegraphic reports giving the data for special epidemic diseases and for the general rates of all diseases were sent to this office. These weekly telegraphic reports had been first inaugurated by the chief surgeon of the Expeditionary Forces in Mexico (Vera Cruz). The reports were further expanded during the military operations upon the Border and the second expedition into Mexico, At the beginning of the war orders were issued requiring them from the entire Army. In the office of each department Surgeon and in, that of each camp or division Surgeon a medical officer with experience was detailed as sanitary inspector whose duty was to coordinate the work of the various sanitarians in the department, division, or camp.

(5) At the beginning of the war the work of procurement and distribution of all medical and hospital supplies devolved upon the Medical Department. Before 1914 many of the drugs and much of the surgical equipment used in this country had been imported from Germany. During the years elapsing before the active participation of this country in the War the chemical and drug industry and that of surgical equipment had been greatly expanded over the prewar status. Further expansion and organization were necessary. The tremendous task of mobilizing the entire productive activities of the drug trade in this country and of the means for producing and handling surgical dressings and hospital equipment was successfully accomplished. Medical, surgical, and hospital supplies were rarely inadequate to fully meet the needs at the various camps or posts either in this country or in Europe. When the supplies were wanting at any place, it was with rare exceptions due to the inability to secure the necessary transportation either by rail or by ocean vessel that caused the temporary shortage. In the American Expeditionary Forces during active operations there was a shortage of both motor and animal drawn transportation. However, that such a large number of men with so many supplies and so much equipment should have been successfully transported over 3,000 miles of submarine-infested ocean was, indeed, remarkable, and that the supplies were not more frequently wanting and that transportation was not more frequently inadequate was, indeed, a cause for congratulation to all concerned.

(6) The work of caring for the sick and wounded was, indeed, a tremendous undertaking. During the year the total number of sick officers and enlisted men that required hospital treatment or treatment in quarters was 2,833,204. This number does not include soldiers treated for minor ailments and does not include civilians of various kinds attached to the medical personnel, all of whom required and received the attention of medical officers. Of this total number of cases of sickness 2,422,362 resulted from disease, 182,789 from ordinary injuries, 228,053 from battle injuries

1When the work upon the statistics for the year 1918 was begun during the latter part of June, this year ad of the material from France had not been received. There will, consequently, be an additional number of battle injuries to add to the number given.


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If the same rates for admissions had prevailed during 19 17-18 as during the first two years of the Civil War (1861-62) there would have been 9,759,847 admissions for disease, and with the same, as during the Spanish-American War and the Philippine insurrection (1898-99) 6,385,683 admissions. It may then be said that preventive medicine resulted in the saving of 6,869,571 cases of sickness as compared with the Civil War and 3,495,407 as compared with the Spanish-American War.

Influenza was the leading cause of admission both for officers and enlisted men, American and native troops, in every country where troops of the United States were serving. This disease caused for all officers 31.82 per cent of the total cases of sickness; for enlisted men, American troops, 28.26 per cent, and for native troops 36.61 per cent. For officers, bronchitis caused the second highest number of admissions, 10 per cent of the total. For enlisted men, American troops, mumps stood second as a cause of sickness with 7.15 per cent of the total, and for native troops (of the specified diseases) measles stood second with 5.31 per cent.

Forty-seven thousand three hundred and eighty-four deaths occurred during the year as a result of disease; 3,500 as the result of ordinary injuries; 13,735 (so far reported to this office) as the result of wounds received in action, and according to the reports received from the Central Records Office in France 33,711 were killed in action and 648 were lost at sea, (Of those killed in action only 4,533 were reported to this office.) The total number of deaths according to the above figures is 98,978.

During 1917 there were 4,159 deaths, 3,330 of which resulted from disease a d 829 from injuries of various kinds, The total number of deaths for the two years, which so far has been reported to this office, including the killed in action was 103,137. Of this number of deaths 50,714 were from disease, 52,423 occurred as the result of injuries of various kinds (33,711 were killed in action, 13,735 died of wounds, 648 were lost at sea, 4,329 were from ordinary accidents).

If the same rates for diseases had prevailed during 1917-18 as prevailed during 1861-62 and 1898-99, there would have been for the 1861-62 figures 186,037 deaths, and for the 1898-99 figures 62,215 deaths. It may then again be said that preventive medicine resulted in the saving of a loss of life from disease of 135,323 lives as compared with the Civil War days and 11,501 lives as compared with the days of the Spanish-American War and Philippine insurrection. Had it not been for influenza and pneumonia, the total rates for the years 1917-18 would have, indeed, been very small, both for admissions and for deaths.

For officers and for enlisted men, American and native troops, influenza was the leading, cause of death in all countries where United States troops were serving with the exception of for enlisted men in the Philippine Islands where lobar pneumonia was the first cause and for native troops in the Philippine Islands where bronchopneumonia was the first cause. For officers influenza caused 47.31 per cent of the total number of deaths from diseases; for enlisted men, American troops, 48.61 per cent and for native troops 42.03 per cent, For officers broncho-pneumonia and lobar pneumonia stood second and third causing together 26.67 per cent of the total deaths.


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The same two diseases stood second and third for enlisted men, causing 32.35 per cent of the total deaths, and for native troops also the same two diseases stood second and third causing 31.40 per cent of the total, Influenza then with lobar pneumonia and broncho-pneumonia, many of the cases of which, no doubt, occurred also with influenza, caused 73.97 per cent of the total deaths for officers from disease, 80.87 per cent of the total deaths from disease for enlisted men, American troops, and 73.43 per cent of the total for native troops.

As the total number of men who were mustered into the military service, excluding the Marine Corps and the Navy, was about three and one-half million, the approximate number of men who died from various causes during 1917 and 1918 was 29 per 1,000.

The total time lost as a result of sickness and injuries during the year 1918 amounted to 56,924,804 days. Of this loss of time 40,692, 302 days were on account of disease, 12,545,442 days as a result of battle injuries (including days for these cases during 1919), 3,687,060 days as the results of ordinary injuries. The average number of men absent each day from duty of the entire military force was about 155,957, or approximately six divisions of troops. Of diseases influenza was the most important cause of loss of time among officers and enlisted men for both American and native troops, in all countries where United States troops were serving with the exception of that of American troops in the Philippine and Hawaiian Islands where gonorrhea was the first cause. For officers influenza caused 22.76 per cent of the total loss of time for disease; for enlisted men, American troops, 22.21 per cent, and for native troops 27.92 per cent of the total. Bronchitis was the second important cause of loss of time for officers; tuberculosis of the lungs third. These two diseases caused 7.17 per cent and 4.58 per cent of the total, respectively. For enlisted men, American troops, mumps was the second most important cause of loss of time, causing 7.35 per cent of the total, and gonococcus infection was third with 5.88 per cent. For native troops influenza caused a loss of 27.92 per cent of the total; gonococcus infection 6.71 per cent; tuberculosis of the lungs 5.25 per cent.

Of the men who were mustered into the military service 115,664 were discharged for disability. This number includes 9,710 men who after being held a few days in camp for observation were reported as discharged from the draft, Of the total number 1,862 were discharged as the result of ordinary injuries and 290 of battle injuries. The larger number of discharges for battle injuries will occur during the present year. For all officers and enlisted men, American and native troops, in all countries where United States troops were serving, tuberculosis of the lungs was the leading cause of discharge with the exception of for officers in Europe, enlisted men in Europe, American troops in Panama, native troops in Porto Rico. For these the principal cause of discharge in the order named was psychasthenia, epilepsy, dementia praecox. For officers tuberculosis of the lungs caused 12.43 per cent of the total discharges. Of the specified diseases neurasthenia was second with 4.80 per cent. For enlisted men, American troops, tuberculosis of the lungs was also the principal cause with 8.35 per cent of the total; mental deficiency second with 7.32 per cent. For native troops tuberculosis caused 40.47 per cent discharges; asthma second with 8.25 per cent.


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Considering these general rates more in detail, we find that the admission rate for officers for diseases was 617.02 for each 1,000; for enlisted men, American troops, it was 960.27, and for native troops 1,182.94, Among the American troops, enlisted men, the rate was highest in the United States (1,293.62); second in the Philippine Islands (1,029.67); third in Panama (946.29) fourth in Hawaii (605.24), and fifth in Europe (576.72). The rate was highest for the colored (1,539.14); second for the Porto Ricans (1,501.10); third for the Philippine troops (1,022.74); fourth for the white (892.99), and fifth for the Hawaiians (707.96). Of the death rates for diseases, the rates for officers were also lower than that for the enlisted men, For officers it was (9.03); for enlisted men, American troops (19.37), and for native troops (11.72). For American troops the rate was highest in the United States (21.93); second in Europe (16.01); third in Philippine Islands (4.34); fourth in Panama (3.02), and fifth in Hawaii (1.24), The death rate was highest for the colored troops (35.01); second for the white troops (16.81); third for the Porto Ricans (13.65); fourth for the Philippine troops (13.21), and fifth for the Hawaiians (4.60), For days lost the rate for officers was 24.83; total enlisted men, American troops, 45.33; and for native troops 34.65. For American troops the rate was highest in the United States, being (51.88); second in Europe (38.17); third in Philippine Islands (42.80); fourth in Panama (28.15), and fifth in Hawaii (21.43). It was highest for colored troops (67.93); second for Porto Ricans (44.10); third for white troops (42.35); fourth for Philippine troops (29.65); and fifth for Hawaiians (20.93). For discharges the rate for officers was again lower than for enlisted men, being 2.92; for enlisted men, American troops, 47.34; and for native troops 28.81. As was to be expected the rate was highest in the United States for it was here that the physically unfit were eliminated (84.68); second in Hawaii (6.20); third in Panama (5.19); fourth in Philippine Islands (3.52), and fifth in Europe (1.24). It was highest for the colored troops (105.33); second for the Hawaiians (42.25); third for the white (34.77); fourth for the Porto Ricans (26.08), and fifth for the Philippines (24.74).

In comparing the rates for the first two years of the Civil War and the first two years of the Spanish-American War and the Philippine Insurrection, both the general rates which have preceded and the few specified diseases which are to follow, several factors should be considered: (1) The troops in the United States Army during the Civil War were troops from the Northern and Eastern States with some few from the Western States; (2) there were no colored troops in the United States Army during 1861-62, or, if there were any, the number was too small to consider.

During 1917-18 the colored troops from the South had much higher admission rates for pneumonia, tuberculosis, and venereal diseases, with much, higher death rates for pneumonia and tuberculosis and higher discharge rates for venereal diseases. The rates for the white troops from the South were higher than those from other sections of the country, and especially so for infectious diseases, Consequently it follows that armies composed of troops from the North and South, including both white and colored soldiers, would have much higher rates, conditions being the same, than for white troops drawn from the North and East, with only a few scattered ones


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from the West. During the Spanish-American War the rates, particularly those for respiratory diseases, are not fairly comparable with those of the late war. The Spanish-American War and the Philippine Insurrection was a war of the, summer ,periods of the Tropics. Consequently, the rates for respiratory diseases, and especially the death rates, would be low as compared with the corresponding rates for all seasons of the year in the United States and in Europe. On the other hand, the rates for fevers and gastrointestinal disorders would be higher. During the Civil War and, the Spanish-American War it was the gastrointestinal diseases and the specified fevers that caused the high rates both for admissions and for deaths, while in 1917-18 it was the acute infectious diseases, and particularly the acute respiratory type, that caused them in the United States and in Europe. The one disease of this class which was of particular importance in this country as well as elsewhere on account of the numerous deaths which it, together with its complications caused, was influenza, In the preparation of the statistics for this report, statistical tables have been prepared showing the occurrence of influenza, broncho and lobar pneumonia, and the common respiratory diseases, separately and combined in one total. Probably many of the ordinary acute respiratory diseases, as well as many cases diagnosed as primary pneumonia, should have been charged to influenza. Influenza, together with its complications, was charged with 688,869 cases of sickness, an annual admission rate of 273.52. The admission rate for officers was 196.35; for enlisted men, American troops, 276.27, and for native troops 433.07. For enlisted men, American troops, the admission rate was highest in the United States (361.21); second in Panama (336.95); third in Philippine Islands (189.95); fourth in Europe (167.19), and fifth in Hawaii (118.81). For race the rate was highest for the Porto Ricans (527.30); second for the Philippine troops (395.19); third for the colored (296.50); fourth for the Hawaiians (275.94), and fifth for the white troops (265.38).

Considering, for the white and colored from the South alone, the nativity admission rate, that for influenza was 247.11 for the white and I 54,.58 for the colored, For the combined pneumonia for the colored it was 39.74 and for the white 18.03, being more than twice as high for the colored as for the white.

Influenza caused 23,007 deaths, a rate of 9.14. In addition to this number of deaths, there were 431 charged to bronchitis; 6,814 to broncho-pneumonia; 8,407 to lobar pneumonia; 450 to pneumonia unclassified, and 262 to pleurisy. If these deaths were added to the deaths from influenza, the total would be 39,371. Approximately 82 per cent of all the deaths during 1918 were attributed to the acute respiratory diseases named. The rate would be 15.64 per 1,000. If this rate be deducted from the total rate for the Army, 18.82, it would have a low, rate of 3.18 for the year. The rate for officers was 4.27; for enlisted men, American troops, 9.41; and for native troops 4.92.

For enlisted men, American troops, it was highest in the United States (12.02); second in Europe (6,07); third in Panama (1.09); fourth in Hawaii (0.55); and fifth in Philippine Islands (0.14). For race it was highest for the colored troops (12.69); second for the white (8.83); third for the Porto Ricans (7.80); fourth for the Philip-


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pines (2.84); and fifth for the Hawaiians (1.72). While the native troops had higher admission rates than the whites, the deaths were lower. This again illustrates the point that the death rate for this type of diseases is lower in the summer and in the Tropics. The combined death rate for broncho-pneumouia and lobar pneumonia for officers was 2.41; for enlisted men, American troops, 6.25; and for native troops 3.68. In the United States for enlisted men it was 6.28; in Europe 6.08; and it was low in the Tropics. For the white troops the death rate for these two pneumonias was 4.89 and for the colored 15.81. The total number of pneumonia cases occurring among the white troops in the United States and Europe, counting the cases complicated with measles and influenza, was 94.505, with 28,969 deaths. Among the colored troops, enlisted men, there were 19,319 cases, with 4,720 deaths. The incidence rate for the white troops was 44.11 and for the colored 115.28. The death rate for the white was 13.52 and for the colored 28.17. The case mortality for the white was 30.6 per cent and for the colored 24.4 per cent. It is apparent, then, that the- colored has an incidence rate of nearly three times as high as that for the white, a death rate of nearly twice as high, but a case mortality rate of 20 per cent lower.

The points that stand out with particular distinctness are (1) influenza is often confused with the common type of respiratory diseases which are followed by virulent types of pneumonia; (2) it was probably present in the camps and associated with the virulent pneumonias in this country and in Europe during the latter part of 1917 and the early part of 1918. The epidemic declined during the cold dry weather in the winter, increased again with the advent of the chilly damp weather in the spring, then declined to a comparatively low rate to continue throughout the summer and again increased in the autumn of 1918 to reach the height of the great pandemic; (3) it was more prevalent in the United States among the white troops than among the colored, and particularly more prevalent among the white troops from the South than among the colored from the South; (4) a higher percentage of the cases that occurred among the colored were complicated with pneumonia, and as a result a higher percentage died; (5) the admission rates were higher for the whites from the̓ South than for the whites from any other section of the country. The rates for the soldiers from the east North Central States were next highest and probably the rates for the soldiers of the densely populated eastern, States were the lowest, though the nativity table shows that the soldiers from the west and northwest Central States had the lowest rates. It is very probable, however, that the nativity rates for these soldiers were lower than they should have been on account of the recent large amount of immigration to these newer States, which as a result raised the number of men inducted from them. This gave a higher strength and, without a corresponding increase in the cases, lower ratios.

During the epidemic of 1889, and 1890, the highest death rate for these acute respiratory diseases was 1.66 in 1891 and the next highest in 1888 (1.50) the year before it was recognized that there was an epidemic, when it was 1.50. Only twice since 1867 had the death rate for these respiratory diseases reached the height of 1.66 before 1917, in 1868 and 1891. If the rates for this type of disease had been the same during the first two years of the Civil War, there would


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have been 22,312 deaths and if the same as during the first two years of the Spanish-American War and the Philippine Insurrection, there would have been 3,162 deaths. As it was, there were 40,471 deaths. During these two years of the Civil War and of the Spanish-American War and the Philippine Insurrection the ratios for the acute respiratory diseases were above the average. Influenza was present during both wars, and it is very probable that it played a more important part as a cause of pneumonia and deaths than has been recognized.

The next most important cause of deaths during 1917 and 1918 was measles, This disease had swept through the camps and particularly through the southern camps during the latter part of 1917. After November the incidence rate and the death rate both began to decline rapidly. The same was true for the troops stationed in Europe. While there were some admissions and some deaths throughout the year, the disease never reached serious proportion after the year 1918. In 1917 it caused in the United States for enlisted men 947 deaths, 31.74 per cent of the total, a death rate of 1.70. The rate for deaths in 1918 was 0.87, on about one-half what it had been in 1917. The admission rate in 1917 for the United States was 87.08 and in 1918, 29.34. This disease was better controlled during 1917-18 even with the white troops from the South and the colored troops from the South than during the first two years of the Civil War. If the same rates that had prevailed as during the first two years of the Civil War, there would have been 184,918 cases and 6,649 deaths, and with the same rates as in 1898-99, 127,979 cases and 1,342 deaths. As it was, there were 98,606 admissions and 2,455 deaths (all troops). The admission rate for 1861-62 was twice as high as in 1917-18 and for 1898-99 33 per cent higher. The death rate for 1861-62 was two and one-half times as high, but only one-half as high in 1898-99. This lower death rate in 1898-99 was due to the service in the summer and in the Tropics.

Scarlet fever, diphtheria, and mumps all had higher rates during 1917 and 1918 than during 1861-62. The death rate for scarlet fever was higher during the late war as was also that for mumps. The death rate for diphtheria was higher during 1861-62 and about the same as in 1898-99. Mumps was an especially important disease on account of the great loss of time occasioned by it. The total time lost for this disease for all classes of troops and officers amounted to 2,926,635 days. It was the gastrointestinal diseases and fevers where the great gain was shown, as compared with the rates for the Civil War and the Spanish-American War. With the same admission rates for typhoid fever in 1917-18 as in 1861-62 there would have been 226,001 cases and 62,694 deaths; and with the same rates as in 1898-99, 291,637 cases and 30,916 deaths. As it was, there were 1,083 cases and 158 deaths. At no time during the year was typhoid fever of any serious importance except during the latter part of the year 1918 in France, A number of cases appeared among the troops who had been operating and rapidly advancing over battle-swept areas in heavily infected territories. That the artificial immunity of a greater number of men did not break down is, indeed, a cause of congratulation and an evidence of the high protective immunity conferred by the typhoid vaccination. For malarial fevers there were 14,087 admissions during 1917 and 1918 and 31 deaths. With the same


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rates as in 1861-62, there would have been 1,526,572 cases and 12,084 deaths, and as in 1898-99, 1,906,066 cases and 5,594 deaths. That troops should have been encamped in such large numbers in sections of the country where malarial infections prevailed and that such a small number should have been infected is another link in a chain of evidence that malarial fevers can be eliminated by proper sanitary measures.

For diseases of the intestines, diarrhea, and dysentery, the rate for admissions in 1917-18 was one-twenty fifth as high as 1861-62, and one-tenth as high in 1898-99. With the same rates as in 1861-62 there would have been 2,803,134 admissions for this class of diseases and 33,153 deaths, and with the same rates as in 1898-99, 1,285,577 admissions and 6,170 deaths. For venereal diseases during 1917-18, 259,612 cases were recorded for enlisted men in the United States. From the figures obtained as a result of the physical examinations made at the time of the draft, it is probable that 5.6 per cent of the men who came into the military service were infected with a venereal disease. Approximately three and a half million men were drafted or volunteered. After deducting the cases brought into the military service, the incidence in the United States for the two years was about 1.8 per cent. During the years 1917-18 the percentage of men who were detected with a venereal disease while serving in the United States, counting all those who came into the service with a venereal disease, amounted to 7.4 per cent. About three-fourths of all venereal diseases in the camps in the United States were brought in from civil life. If the cases for the entire Army for the two years of 1917 and 1918 are taken, after deducting the number brought in from civil life, the incidence for all troops for two years is 2.93 per cent. If to this is added a certain number in France, which were not recorded, it would bring the percentage incidence for the entire Army for the two years up to a little over 3 per cent. As 5.6 per cent came in from civil life, it is apparent that nearly twice as much was brought in from civil life as was contracted in the Army during the two years.

The disease was approximately seven times as prevalent among the colored troops in the United States in 1918 as among the white. The nativity rates for the white from the South were higher than the rates for the whites from other sections of the country. The nativity rates for the colored from the South, as compared with the whites from the South, is 232,92 for the colored and 56.89 for the white. For cases contracted in the service the admission rate in the United States and in France for the year 1918 was approximately the same, about 40 per 1,000. (This admission rate is not a percentage incidence rate calculated for the entire number of men present at any time during the year, but it is a rate calculated upon the average for the year.) The loss of time for venereal diseases for the year amounted to 3,937,710 days. Approximately 46 Negro soldiers out of each 1,000 of the average number that served in the United States during 1918 had to be discharged for disability for a venereal disease.

It is too early to give the complete statistics of the injuries that occurred as the result of battles in Europe. The reports that were received in this office prior to the compiling of this report show that 227,855 wounds were received in battle that required admission to hospital, or approximately 109 men out of each 1,000 that were serving in France were wounded; 87 officers out of each 1,000; 91 white enlisted men and 26 colored enlisted men; total enlisted 220. Of the


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cases admitted to hospital for wounds 148 were the result of aeroplane bombing, 181 of bayonets, 71,453 of gas, 870 of hand grenades, 12 of saber, 144,682 of gunshot missile. Of the gunshot wounds, 13.50 per cent were from rifle balls, 22.64 per cent from shrapnel, 11.57 per cent from shell, 52.12 per cent from gunshot missile, kind not specified; of the total wounded, gas caused 31.36 per cent.

The reports that have been tabulated show that 18,268 died in hospital as the result of battle injuries. Approximately 9 men out of each 1,000 men in France died of wounds; 7 officers and a fraction over 9 enlisted men. Of the deaths recorded 10 were the result of bayonet, 1,200 of gas, 70 of hand grenade, and 12,526 gunshot missiles. Of the total deaths gas caused 6.57 per cent. Of the deaths from gunshot missiles 7.82 per cent were the result of rifle ball; 16.43 per cent of shell; 16.56 per cent of shrapnel; 59.04 per cent of gunshot missile, kind not specified.

For the entire Army there were 182,789 admissions to sick report as the result of ordinary traumatisms. Of this number 5.30 per cent were caused by cutting and piercing instruments, kind not specified; 0.87 per cent by knife; 0.95 per cent by pistol; 1.23 per cent by aeroplane; 2,72 per cent by automobile; 1.30 per cent by motorcycle; 0.79 per cent by railroad accident; 4.80 per cent by animals; 15.76 per cent by falls of various kinds; 10.48 per cent by athletic exercises; 3.66 per cent by marching and drilling; 3.90 per cent by ill-fitting shoes.

Three thousand five hundred died as the result of ordinary traumatisms. Of this number of deaths 1.74 per cent was caused by cutting and piercing instruments, kind not specified; 1.40 per cent by knife; 7.71 per cent by rifle ball; 13.06 per cent by aeroplane; 4.49 per cent by automobile; 2.20 per cent by motorcycles; 6.77 per cent by railroad accidents; 1.06 per cent by animals; 4.69 per cent by falls of various kinds, Three hundred and thirty-four suicides were reported, 10 per cent occurred among officers, 76 per cent among white enlisted men, 2 per cent among colored enlisted men, 10 per cent for colored not stated, 0.2 per cent for native troops.

CONCLUSION.

1. The total number of admissions during 1918 for diseases for officers and enlisted men, American and native troops, was 2,422,362; for ordinary injuries, 182,789; and for battle injuries, 227,855.

2. The total number of deaths from disease was 47,384; from wounds received in battle (cases treated in hospital), 13,735; killed in action and lost at sea, 34,359; from ordinary traumatisms, 3,500.

3. Including the deaths from 1917, there were 50,714 from disease and 52,423 ,as the result of injuries of various kinds, including wounded, killed in action, and lost at sea.

4. The total number of days lost from disease for the year was 40,692,302; from battle injuries 12,545,442; and from ordinary injuries 3,687.060. The average number of men absent each day of the year on account of sickness and injuries was 155,957. Seventy-one per cent of the time lost was caused by disease, 6 per cent by ordinary injuries, and 22 per cent by battle injuries.


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5. Since the soldiers of the Civil War for the United States Army were drawn only from the Eastern and Northern States, with a few from the Western States, if other conditions had been the same, the rates should have been lower for the first two years of the Civil War than the corresponding rates for the Army in 1917-18, which was made up of troops from all sections of the country, including the colored.

6. For the first two years of the Civil War, as compared with 1917-18, the admission and the death rates for disease was three and one-half times as high.

7. Comparing the rates for the Spanish-American War and the Philippine Insurrection, 1898-99, with those for 1917-18, the admission rate in 1898-99 was a little over twice as high and the death rate about 20 per cent higher.

8. The admission rate for the specific fevers and the diseases of the intestines (including diarrhea and dysentery) was 29 times as high in 1861-62 as in 1917-18, and the death rate was 258 times as high.

9. For these diseases for 1898-99 the admission rate was 24 times as high and the death rate 125 times as high as in 1917-18.

10. For the acute infectious diseases (excluding influenza, pneumonia, and the common respiratory type) the admission rate for 1861-62 was practically the same as in 1917-18. The death rate in 1861-62 was two and one-half times as high as in 1917-18, but 8 per cent lower in 1898-99 than in 1917-18.

11. The respiratory type, including influenza, pneumonia, and the common respiratory diseases, had higher admission and death rates for 1917-18 than for either 1861-62 and 1898-99.

12. Influenza, probably associated with virulent pneumonia, was epidemic during the latter part of 1917 in this country and in Europe. The epidemic wave declined during the cold dry winter weather, increased again in the spring, after which time it again declined, but continued throughout the summer to rise again to the high point in the autumn months.

13. Influenza, combined with pneumonia and respiratory diseases, caused 17.33 per cent of the total admissions for diseases and 82 per cent of the total deaths. This type of disease was the most important cause of loss of time.

14. All of the epidemic diseases other than influenza, pneumonia, and the- common respiratory diseases declined after the first part of 1918. The rates for most of these diseases were lower during the first part of 1918 than during the latter part of 1917.

15. Approximately 5.6 per cent of the men who came into the military service from civil life had a venereal disease.

16. Approximately 7.4 per cent of all the men in the Army were detected with a venereal disease some time prior to their leaving the United States.

17. Of this number three-fourths had contracted the infection prior to coming into the military service.

18. Two-thirds of all that were detected with a venereal disease in the entire Army, during 1917-18, brought the infection in from civil life.

19. The occurence rate in Europe and in the United States of new cases of venereal diseases in the Army was approximately the same.


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20. The Negroes in the United States had an admission rate for venereal diseases of seven times as high as the whites.

21. Practically 70 per cent of the Negro soldiers either had a venereal disease when brought in from civil life or contracted an infection during 1918.

22. Of the average number of colored soldiers who served in the United States duving the year 1918, 4.6 per cent had to be discharged for a venereal disease.

23. The rate for venereal diseases for the colored in countries other than the United States was slightly higher than the rate for the whites.

24. The nativity rates for venereal diseases for the Negro soldier from the South, as compared with the white soldiers from the South, show that the negro had approximately four times as much venereal disease as the whites from the same section.

25. The nativity rates for the white soldiers from the various sections of the country show that the white soldiers from the South had higher rates for venereal diseases than the white soldiers from other sections of the country.

26. The nativity rates show that the white soldiers from the South have higher rates for measles, mumps, cerebrospinal meningitis, broncho-pneumonia, lobar pneumonia, and influenza, and that the soldiers from the West and Northwest have higher rates for scarlet fever, diphtheria, and German measles.

27. The soldiers from the Eastern States had lower nativity rates for mumps and measles, but the soldiers of the West and Northwest had lower rates for influenza, broncho-pneumonia and lobar pneumonia and meningitis. This low standing of these latter States may possibly be due to the recent immigration to them.

28. The Negroes have lower admission rates than the white of the country at large for measles, German measles, scarlet fever, diphtheria, and influenza, and much lower rates for these diseases than the whites from the South.

29. The Negroes have higher rates for meningitis and tuberculosis than the whites from the entire United States, but approximately the same rates for them as the whites from the South,

30. The incidence rate for all forms of pneumonia, both primary and secondary, was nearly three times as high for the colored as for the whites of the entire country. The death rate was more than twice as high, but the case mortality was 20 per cent lower.

31. As compared with the whites of the South, the Negro had a nativity rate for the combined pneumonias of more than twice as high.

Very respectfully,

M. W. IRELAND,

Surgeon General United States Army.

The SECRETARY OF WAR.