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Section II, Chapter XIII

Contents

373

SECTION II.

CHAPTER XIII.

DIVISION OF INTERNAL MEDICINE.

While the modern development of specialism has greatly increased the sum of medical knowledge, from a military point of view it has the disadvantage that if the best results are to be attained medical officers can not be indiscriminately assigned to duty, nor can members of a profession which consists so largely of specialists always be trusted, in making examinations for entrance into the Army, to give proper consideration to conditions outside of their specialty. It seemed desirable, therefore, that specialists should supervise the appointment of examiners of recruits and select the medical officers to be detailed to positions of medical importance. Such considerations led to the establishment of the Division of Internal Medicine in the Surgeon General's Office shortly after the United States entered the war. (See Chart XIV.) *No formal order was issued for the organization of this division.

TUBERCULOSIS SECTION.

The Tuberculosis Section, the first to begin work, was inaugurated on June 6, 1917, when the officer assigned to take charge of the section reported for duty.1 The war experience having convinced the allied nations of the necessity of expert revision of the diagnosis of tuberculosis, it was decided to reexamine the Army of the United States for tuberculosis.2  This work was done by boards of three or more medical officers who were especially selected for the purpose on the advice of the leading internists of the country.

After some delay, which arose chiefly from the difficulty of promptly obtaining men with the necessary qualifications, a sufficient number of boards to provide for the examination of the larger organizations was created. In March, 1918, the work was practically completed so far as the forces in the United States were concerned, as many as 600 examiners having been engaged upon it.3 A total of 1,200,990 men had been examined, and of these 9,648 were recommended for discharge on account of tuberculosis. Of the total just mentioned, 190,398 belonged to the mobile troops of the Regular Army with 1,444 rejections, a percentage of 0.758; 466,157 to the National Guard with 4,905 rejections, a percentage of 1.099; and 399,429 to the National Army with 2,597 rejections, a percentage of 0.65.3 With the increment of the draft called March 26, 1918, the primary examination after entrance into the military service was undertaken by the tuberculosis examiners so far as the lungs were concerned.

The total number of drafted men rejected for tuberculosis by Army examiners was 12,597 out of 2,040,051 examined, or 6,174 per million. The grand

    * During the greater part of the war period this division was designated, as in the text, Division of Internal Medicine. The Cardiovascular Section and the Section of Gastroenterology, at the time covered by this chart, were administered under General Medicine.


374

Chart XIV.--Division of General Medicine, Surgeon General's Office, June, 1918.


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total of examinations, including both reexaminations and primary examinations, by special tuberculosis examiners, up to January 1, 1919, was 3,288,669,the total number rejected by these boards being 22,596, or 6,871 per million.3 After November, 1918, the examining boards were chiefly engaged with the examinations for demobilization, 2,500,662 men having been examined up to June 30, 1919, of whom 1,356 were found to be tuberculous, or 542 per million. 4

The work of reexamination could not be organized in time to examine the first army of Pershing. More than 44,000 men of the first expedition did not receive a reexamination for tuberculosis.3 There were likewise some organizations sent abroad at a later time, as, for example, the hastily assembled negro stevedore regiments, which it was not practicable to examine by special boards, the difficulty being in part, failure to learn in time of the existence of the organizations in question, partly the scarcity of competent examiners, all those available being fully occupied at the larger camps.

As to the utility of the reexaminations it was evident that cases of tuberculosis occurred chiefly among soldiers who had not been specially examined in the United States, and that although negroes constituted but a small fraction of the American Expeditionary Forces they contributed 14 per cent of the cases of pulmonary tuberculosis returned to this country.

The primary examinations of drafted men were made under great difficulties on account of the large numbers which arrived in rapid succession and which were required to be examined without delay. The reexaminations had been conducted in a leisurely manner. Each examiner had been expected to go over at least 50 men on each day of examination, but with practice the more alert soon found that they could make 100 examinations in a day. But in the second draft it became necessary to much exceed this number, reaching in some instances figures which seem almost incredible. Thus one team of three examined 1,763, 1,854, and 1,944 men, respectively, in three successive days. Many others nearly equaled these figures. 3 Of course such speed was not desirable. It prevented detailed study of the individual case and could not be expected to reveal more than the manifest and active cases. But that the work was not too fast to accomplish a definite objective result is shown by the fact that, when large numbers were concerned, the percentage of rejections was always between 0.5 and 0.6 of 1 per cent. 3

These facts are believed to be worthy of record in a history of administration in that they show the need of a closer liaison between the Medical Department and the executive officers of the War Department. It was not a military advantage, but quite the reverse, to send men into camps more rapidly than they could be properly handled. Only the fact that special methods for rapid examination had been taught permitted the examiners to accomplish what they did in the way of lung examinations when so overwhelmed with work.

It was soon found to be advantageous to institute courses of instruction in the physical diagnosis of lung affections, especially tuberculosis, not only with a view to increasing the skill of the examiners but also in order to observe their work and to classify them according to their proficiency. 5 Instruction of this kind was given at the Army Medical School and at the three medical officers' training camps, at Fort Oglethorpe, Ga., Fort Riley, Kans., and Fort Benjamin Harrison, Ind. A school was also in operation at the U. S. Army


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General Hospital No. 16, New Haven, Conn., in which, in addition to courses in physical diagnosis, instruction was imparted in hospital management and in the treatment of tuberculosis with a view to the training of medical officers for service at tuberculosis hospitals. Courses of physical diagnosis were given by traveling instructors to the medical officers of various camps and hospitals.

In addition to the tuberculosis examiners, a tuberculosis specialist was assigned to the base hospital of each of the division camps and to some of the general hospitals. A division tuberculosis specialist was also attached to the mobile troops of many of the divisions. It having been learned, however, that these specialists, when sent abroad, were detached from their divisions and assigned to other duties, it was thought best, because of the scarcity of qualified experts, to discontinue the practice.

The incidence of tuberculosis in the Army in France was small. It was smaller, indeed, than would appear from the number of men sent home with that diagnosis, for the reason that many cases were being returned as tuberculous in which there was either no genuine evidence of active disease at all or a nontuberculous affection, such as unresolved pneumonia, was present. To remedy this evil an expert was sent abroad. 6 Upon consulation with the medical authorities of the American Expeditionary Forces, it was decided to follow the example of the French and of the Italian Armies in the establishment of diagnostic centers, through which patients who had been pronounced tuberculous were required to pass before being sent to this country. Accordingly, three centers were established, one at Base Hospital No. 8, Savenay, one at Base Hospital No. 20, Chȃtel Guyon, and another at Base Hospital No. 3, Vauclaire.7 This action rapidly reduced to a minimum the number of cases in which the diagnosis could not be sustained upon arrival in the United States. After the signing of the armistice, however, there was again a relaxation of the necessary precautions, a fact of less importance when the main object was to return those disabled as speedily as possible, irrespective of the diagnosis. In order to sift out the nontuberculous, disembarking patients were evacuated as quickly as practicable to the tuberculosis hospital nearest to the port of arrival, thus practically transferring the centres du triage to the United States. Up to August 1, 1919, the total number of patients who had been returned from Europe with the diagnosis of tuberculosis was 6,693. 4

In view of the wide differences in the interpretation of the physical signs of tuberculosis and in the nomenclature that describes these signs, it was apparent from the outset that there was need of a standard as to what signs should be regarded as normal, what as evidence of disease, and what as a cause for rejection, and also as to the manner in which the tuberculous lesions found should be described. Uniformity of practice and of nomenclature, in other words, was felt to be necessary. Instructions were issued 8 for this purpose. At first they were regarded with disfavor by some of the examiners. The standardization, however, really amounted to the creation of a basis of mutual understanding, so that each examiner not only knew what the others meant by certain language, but had a guide as to the position of the Surgeon General's Office with regard to the criteria for acceptance and rejection, which fact soon became apparent to the examiners. The course of instruction in physical diagnosis also helped the standardization, for it not only taught a technique


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and ascertained the capabilities of the pupils, but served to interpret and enforce the provisions of the circular of instructions, and thus to secure a more general and implicit adoption of the principles which were contained in it.

The example set by the publication of this circular was soon followed by the Cardiovascular Section 9 and the Neuropsychiatric Section 10 in publishing circulars as guides to their examiners. At a later time a board, composed of representatives of all the specialties in the Office of the Surgeon General, prepared a manual for the use, in the first place, of the draft boards, and, in the second place, as a recruiting manual 11 for voluntary enlistments.

The insertion into the medico-military organization of groups of experts who assumed the responsibility of revision was at best a temporary makeshift. The commanding officers had natural objections to the interruption of training caused by reexaminations. The most obvious objection was that the reexaminations came too late-men who had been unnecessarily rejected were already lost to the service. Hence the examiners functioned chiefly in rejecting men whom others had accepted, and the idea was not unnaturally prevalent that the object of the examination was primarily to apply more rigid rules with a view to elimination, the result of which might be an unnecessary diminution of the forces. The utilization of specialists in the primary Army examinations of the second draft was a great step in advance, not only because their work no longer interrupted military training but because unnecessary rejections were prevented in these examinations.

Hospital care was provided for tuberculous patients in six institutions, with a total of 6,750 beds. 5 Full details of these institutions are given in Volume VI, Hospitals, United States. The number of deaths from pulmonary and miliary tuberculosis reported in the Army for the period from September 1, 1917, to June 25,1919, is 1,607. Taking as the strength of the Army the figures reported for May 1, 1919--namely, 2,121,396 men--the death rate for the period is found to be 758 per million.4 But since tuberculous patients were retained in the service after their organizations were demobilized, the deaths really occurred in a strength of over 3,000,000 men, so that the rate just given is too high. On the other hand, some tuberculous patients were discharged who subsequently died of the disease, hence the rate should be somewhat increased on their account, if it were possible to determine their number. The figures given are therefore only a rough approximation to the actual mortality. The total number of cases of pulmonary tuberculosis under treatment at tuberculosis hospitals in the United States on June 30, 1919, was 4,882. 5

CARDIOVASCULAR SECTION.

ORGANIZATION.

In June, 1917, an officer was assigned to duty in the Surgeon General's Office for the purpose of organizing the entire work of the Army which concerned diseases of the heart and blood vessels. 12 This was the beginning of the Cardiovascular Section of the Division of Internal Medicine, which exercised control under the Surgeon General, of this work until September 9, 1919, when the Division of Internal Medicine, along with the Division of Surgery, was transferred to the Hospital Division. 13


378

CARDIOVASCULAR EXAMINATIONS.

The decision to have the special examination of the Army for tuberculosis include an examination of the circulatory system carried with it the obligation to provide for this purpose examiners specially trained and experienced in cardiovascular diagnosis. The duties of the Cardiovascular Section during the summer and autumn of 1917 were concerned chiefly with the procuring of properly qualified examiners, the directions of the examinations in the various camps, the standardization, as far as possible, of the methods of examination and the criteria of diagnosis, and the collection and tabulation of reports and records. A circular 11 was issued for the instruction of the cardiovascular examiners as to the methods of examination, the standards of diagnosis, and the policy governing the acceptance or disqualification of the examined soldiers.

After the reexamination of the soldiers of the Regular Army and the National Guard, the cardiovascular examiners were assigned to the task of assisting in the physical examination of the men drafted for the National Army upon their arrival at the mobilization camps. This work was continued almost uninterruptedly until the signing of the armistice brought recruiting to a close. The method of conducting the cardiovascular examinations was not everywhere the same. In most camps every recruit was examined by the Cardiovascular Board, but in a few camps the routine heart examinations were made by the tuberculosis examiners at the time of the lung examination, only doubtful and suspicious cases being referred to the cardiovascular examiners for disposition. Experience showed that the former method, although requiring a somewhat larger number of examiners, was much the more satisfactory.

Throughout the early period of the war the various special boards of examiners were quite independent of each other and were responsible only to their respective divisions in the Surgeon General's Office. The obvious disadvantages of this arrangement led, in September, 1918, to the abolition of the separate special boards as such, and the formation, at each camp receiving draft increments, of a general examining board, which included all the necessary special examiners, and which was under the control of the camp surgeon and the Division of Sanitation of the Surgeon General's Office. 14 This arrangement, while a great improvement over the earlier one, was open to the serious objection that it removed from the direction and supervision of the special professional divisions of the Surgeon General's Office the professional activities of officers especially chosen and trained by them for this work. This difficulty was soon overcome, however, by an understanding between the Division of Sanitation and the professional divisions whereby the purely professional aspects of the work of the special examiners, as well as the responsibility for the procuring and training of such examiners, remained in the hands of the professional divisions, and requests for orders relating to changes in personnel and to transfers originated in the professional division concerned but required the approval of the Division of Sanitation.

STATISTICS OF CARDIOVASCULAR EXAMINATIONS.

The percentage of rejections for cardiovascular disease varied considerably in different camps and also varied at different periods of the war. In general, the rejection rate was higher during the later drafts than in the early months


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of the war; this increase conforming to the somewhat stricter requirements of the Selective-Service Regulations of that period.

Among 1,000,000 cardiovascular examinations of drafted men, the percentage of rejections was 1.15 while 0.88 per cent of those accepted for military service were assigned to limited service. 15 In different camps the rate of rejections ranged from 0.15 per cent to 4 per cent, but in general it fluctuated between 0.5 per cent and 1.5 per cent, and these latter figures, it is believed, may be looked upon as representing the normal percentage limits of rejections for cardiovascular disorders among troops of corresponding age and recruited under conditions such as obtained in our drafts, where the more obvious cases of heart disease had already been eliminated by the physical examinations of the local draft boards.

An analysis of the causes of disqualification among the 11,562 recruits rejected for cardiovascular defects in the 1,000,000 examinations gives the following results: 15

                                                                                                                Per cent.

Chronic valvular disease ..............................................................................  49

Other organic diseases (including myocarditis, cardiac hypertrophy,

congenital defects, aortic aneurism, etc.) ......................................................   19

Functional disorders (including the irritable heart or effort syndrome,

tachycardia, "hyperthyroidism," etc.) .............................................................. 23

It thus appears from these figures that 68 per cent of all the men disqualified by reason of cardiovascular disorders were the victims of organic heart disease. Such a conclusion, however, is by no means warranted for the reason that there is evidence of various kinds to show that there was constantly a tendency on the part of examiners to classify functional conditions, such as the irritable hearts, as instances of organic disease. Frequently such conditions were diagnosed as myocarditis and, more frequently still, as mitral insufficiency or mitral stenosis.

In the boards manned by examiners of the greatest experience and soundest judgment, the rejections for organic heart disease ran quite uniformly at from 0.2 to 0.4 per cent. 16 Where the disqualification rate was about 1 per cent, it seems safe to assume that not more than one-third of the number were suffering from organic heart disease. The propriety of rejecting the remaining two- thirds is not questioned, for they represented the more severe and intractable cases of functional disorder, but it was erroneous to classify them as cases of organic disease.

INSTRUCTION.

It was early determined that the medical staff of each of the large base hospitals should include a "cardiovascular specialist"; 17 that is, an officer with adequate training in the modern aspects of cardiac diagnosis, including familiarity with the use of the polygraph and the electrocardiograph. In order to supplement the supply of officers with these qualifications, a course of instruction was given at the hospital of the Rockefeller Institute in the summer and autumn of 1917. l8 Considerable difficulty was experienced in securing a sufficient number of properly qualified cardiovascular examiners, so that it was soon found necessary to establish special courses of training for such examiners at the medical officers' training camps (Fort Riley, Kans., and Fort Oglethorpe, Ga.). 18 The courses were short and intensive, lasting


380

from two to three weeks, and were designed to meet the special diagnostic requirements of the cardiovascular examinations. Upon the opening, in June,1918, of General Hospital No. 9, at Lakewood, N. J., with its special heart service, courses of instruction in cardiac diagnosis and in the management and physical training of the functional heart disorders were begun and were con-tinued up to the closing of the hospital. 18

A great need arose for specially trained officers to take over the management of the large numbers of cases of irritable heart which were accumulating in the camps, both in this country and in France, since the results of treatment were found to depend largely upon the skill and special training of the officer assigned to this work. By an arrangement made with the British authorities, a certain number of our medical officers, selected for such special work in the American Expeditionary Forces, were given a few months of valuable training in the Army Heart Hospital at Colchester, England, before proceeding to their stations in France. 18

HOSPITAL CARE.

The problem of the hospital care of the heart patients, especially of those returned from overseas, came in for much consideration and discussion. It was finally met by the decision not to attempt to concentrate all heart patients in special heart hospitals but to designate a number of general hospitals to which heart patients might be sent, and to use one hospital (General Hospital No. 9, Lakewood, N. J.) for the special study of that form of heart disorder which constituted the real heart problem of the Army, namely, functional disorders known as the irritable heart of soldiers. For this purpose a special heart service was established in this hospital, with thoroughly equipped laboratories and a staff of specially trained assistants. Following the lead of the British Army, methods of treatment by means of graded physical exercises were developed and standardized.

Although the duties of the Cardiovascular Section at the start were merely those connected with cardiovascular examinations, the section gradually took over various other activities relating to internal medic ne. Among the first and most important of these was the procurement of properly qualified officers to man the medical services in the 32 base hospitals then in process of organization for the camps of this country and later for the many general hospitals, for the overseas base hospitals, and for the evacuation hospitals. This required a systematic canvassing of the entire country for trained internists who might enter the service, and the adoption of some method of grading and training those already in the service.

In the successful prosecution of these plans, a point of fundamental importance was the adoption by the Surgeon General's Office of the policy that officers highly qualified in any special branch of medicine or surgery should be assigned to the corresponding professional division or section of the Surgeon General's Office and should thereafter be under the control of such division or section. 19 This made it possible to secure many highly trained internists for the Army who in all probability would not otherwise have applied for a commission unless they could be assured that their work in the Army would be of the kind to which they were accustomed and for which they were specially qualified.

In the enormously rapid expansion of hospital facilities, the need for highly trained men to fill the more important positions in the medical services became so great that much attention had to be given to the training of men in


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the hospitals. Medical instruction, therefore, became an important part of the work of nearly all the great base hospitals. A special school for chiefs of medical service, 20 established at the base hospital at Camp Jackson, Columbia, S. C., proved to be of great usefulness. To this school were sent newly commissioned officers who were believed to possess the necessary professional qualifications for the position of chief of medical service, for intensive training in the administrative duties of the position, and for a practical test of their ability to administer a large medical service.

SECTION OF GASTROENTEROLOGY.

The Section of Gastroenterology was established largely as a result of the efforts of a committee from the Section on Gastroenterology of the American Medical Association, appointed at the meeting in New York in June, 1917. Its members had a number of conferences with the Surgeon General and with the Division of Internal Medicine. In August, 1917, it was agreed that a gastroenterologist should be assigned for duty at each of the camp hospitals. 21 These gastroenterologists were to look after patients with digestive disorders in the hospitals and were also to assist the chiefs of the medical services in the hospitals in the general medical work.            
           
In October the Section on Gastroenterology was actually created in the Surgeon General's Office. 22 The first duty of the section was to select and assign a gastroenterologist to each of the 33 base hospitals and to outline the work which they were to perform.22

In the meantime the epidemics of measles and pneumonia which occurred in the winter of 1917-18 filled the hospitals with acute cases, and all the gastroenterologists were very properly called upon to assist in the emergency. There-fore, but little was accomplished in organizing the work in gastrointestinal diseases before the spring of 1918. An effort was made to standardize the work in gastrointestinal diseases in all the hospitals, which by that time was making good progress, there having been established in a few of the hospitals a gastrointestinal ward with a gastroenterologist in charge.

In April, 1918, a memorandum on the examination of gastrointestinal patients was formulated and promulgated. 24 This memorandum outlined suggestions for the anemnesis and the diagnostic methods generally employed by gastroenterologists, including history taking, physical examination, laboratory tests, and X-ray examination in connection with test breakfasts.            

The Section of Gastroenterology was discontinued July 1, 1918. 25

REORGANIZATION OF DIVISION OF INTERNAL MEDICINE.

As a part of the reorganization of the Office of the Surgeon General, effected in November, 1918 (see Organization Chart XXIV), 26 the three Divisions of Internal Medicine, Neuropsychiatry, and Psychology were consolidated into the Division of Medicine, which in turn was composed of the following four sections: Internal Medicine, Tuberculosis, Neuropsychiatry, and Psychology. This reorganization was for the purpose of convenience in office administration only and changed in no essential the scope or character of the work or the personnel of the divisions.

CONSULTANTS IN INTERNAL MEDICINE.

In an effort to improve the character of the professional work and tobring the personnel of the medical services of the hospitals into close touch


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with the Division of Medicine, the Surgeon General, in November, 1918, authorized the appointment of five medical officers as consultants in internal medicine. 27 Each of these consultants was assigned to one of the five geographical districts into which the country was divided for this purpose, and each occupied his time in visiting the various hospitals in his district, in supervising, the work done, in learning to know the personnel of the medical services, and in establishing closer and more personal relations between these officers, and the, Office of the Surgeon General. The success of this arrangement was immediate and striking, and the benefits of the officers of the medical services of the hospitals and to the Division of Medicine of the Surgeon General's Office were many and real.

On September 9, 1919, the Division of Medicine was transferred to the hospital Division. 13

PERSONNEL. a

(April, 1917, to December, 1919.)


Brooke, Roger, Col., M. C., chief.

Bushnell, G. E., Col., M. C., chief.

Conner, L. A., Col., M. C., chief.

Longcope, W. T., Col., M. C., chief.

Barrett, F. J., Lieut. Col., M. C.

Butler, Glenworth R., Lieut. Col., M. C.

Cohn, Alfred E., Lieut. Col., M. C.

Foster, Nellis B., Lieut. Col., M. C.

Harris, Seale, Lieut. Col., M. C.

Irons, Ernest E., Lieut. Col., M. C.

Balling, R. H., Maj., M. C.

Hall, Josiah N., Maj., M. C.

Herrick, W. M., Maj., M. C.

Howland, John, Maj., M. C.

Janeway, Theodore C., Maj., M. C.

McLean, Franklin C., Maj., M. C.

McKellar, H. R., Maj., M. C.

Miller, H. M., Maj., M. C.

Peabody, Francis W., Maj., M. C.

Pemberton, R., Maj., M. C.

Phares, W. L., Maj., S. C.

Rinehart, S. M., Maj., M. C.

Williams, F. E., Maj., M. C.

Talbot, E. S., Capt., M. C.

Lincoln, Edward A., First Lieut., S. C.

May, M. A., First Lieut., S. C.

Mertz, Paul A., First Lieut., S. C.

Metcalf, J. T., First Lieut., S. C.

Sutton, Don C., First Lieut., M. C.

McKnight, Mary Pearson, Contract Surg.

Morgan, Audrey, Contract Surg.

    a In this list have been included the names of those who at one time or another were assigned to the division during the period. Aprl1 6,1917, to December 31, 1919.

There are two primary groups-the chiefs of the division aid the assistants. In each group names have been arranged alphabetically, by grades, Irrespective of chronological sequence of service.


383

REFERENCES.


(1) S. O., No. 120, W. D)., May 24, 1917, par. 38; S. 0., No. 143, W. D., June 21, 1917, par 50. Letter from Col. George E. Bushnell, M. C., to Col. Charles Lynch, M. C. On file, Historical Division, S. G. O.

(2) Telegram, September 17, 1917, from the Surgeon General to division surgeon (of six different camps ordering a special reexamination. On file, Record Room, S. G. O., 172229 (Old Files).

(3) Reports, tuberculosis boards. On file, Record Room, S. G. O., 730.

(4) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1071.

(5) Weekly reports, Tuberculosis Section, Division of Internal Medicine. On file, Weekly Report File, S.G.O.  Annual Report of the Surgeon General, United States Army, 1919, Vol. II , 1072.

(6) Cablegram No. 832, par. 3, February 24, 1918, from the Surgeon General to General Pershing.Cablegram No. 661, February 28, 1918, from General Pershing to the Surgeon General. Cablegram No. 889, par. 15, March 5, 1918, from Surgeon General to General Pershing. On file, Record Room, S. G. O., Cablegram File.

(7) Tuberculosis in the A. E. F. Report from senior consultant in tuberculosis, A. E. F. On file, Record Room, S. G. O., 710 (T. B., A. E. F., France) (Y).

(8) Cir. No. 20, S. G. O., June 13, 1917.

(9) Cir. No. 21, S. G. O., July 14, 1917.

(10) Cir. No. 22, S. G. O., Aug. 1, 1917.

(11) Instructions for the Physical Examination of Drafted Men at National Army Cantonent, (issued by the War Department, 1917, and including various memoranda and circulars, S. G. 0.) On file, Record Room, S. G. O., Document File.

(12) S. O., No. 151, W. D., June 30, 1917, par. 18.

(13) Office Order No. 777, S. G. O., September 9, 1919.

(14) Letter from The Adjutant General to all department commanders, commanding generals of all divisions and ports of embarkation, and commanding officers of all camps, recruit depots, and excepted places, August 22, 1918. Subject: Special Examiners. On file, Mail and Record Division, Adjutant General's Office, 342.15 (Misc. Div.).

(15) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1078.

(16) Memo. for the Provost Marshal General from the Surgeon General, September 17,1917, quoting telegrams sent division surgeons at six National Army camps. On file, Record Room, S. G. O., 172229 (Old Files).

(17) Memo. No. 7, S. G. O., August 23, 1917. Cir. No. 21, S. G. 0., July 14, 1917.

(18) Annual Report of the Surgeon General, United States Army, 1918, 346.

(19) Memo., S. G. O., October, 1917. On file, Record Room, S. G. O., 024.2 (Administrative Division) 1917.

(20) Letter from the commanding officer, base hospital, Camp Jackson, S. C., to the Surgeon General, August 1, 1918, inclosing course for Chiefs of Medical Service. On file, Record Room, S. G. O., 353 (B. H., Camp Jackson) (D).

(21) Letter from the Surgeon General to The Adjutant General of the Army, June 26, 1917, par. 2. Subject: Detail of Officers in Medical Reserve Corps for Duty as Specialists in Army Camps. Approved, July 10, 1917. On file, Record Room, S. G. O., 189010 (Old Files). Letter from Col. George E. Bushnell, M. C., to Dr. Martin E. Rehfuss, August 20, 1917. Subject: Gas- troenternologists in Camps of National Guard and National Army. On file, Record Room S. G. O., 203147-D (Old System).

(22) S. O., No. 226, par. 100, W. D., September 28, 1917. Annual Report of the Surgeon General, United States Army, 1918, 348.

(23) Letter from Maj. Seale Harris, M. C., to Lieut. Col. Henry Page, Camp Greenleaf, October 21, 1917, par. 1. Subject: Selecting a Gastroenterologist in Each of the 33 Hospitals. On file, Record Room, S. G. O., 211 (Gastroenterologists).

(24) Memo., S. G. O., April 15, 1918. On file, Record Room, S. G. O., 730 Gastroenterology).

(25) Memo., No. 53a, S. G. O., July 1, 1918. On file, Record Room, S. G. O. 730 (Gastroenterology).

(26) Office order No. 97, S. G. O., November 30, 1918.

(27) Correspondence, Memo. from Col. L. A. Connor to the Surgeon General, United States Army November 16, 1918. Subject: Medical Consultants. On file, Record Room, S. G. O., 211 (Consultants).