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Excerpts on the Influenza and Pneumonia Pandemic of 1918

ANNUAL REPORTS, WAR DEPARTMENT

FISCAL YEAR ENDED JUNE 30, 1919

REPORT OF THESURGEON GENERAL, U.S. ARMY

TO THE SECRETARYOF 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 oft he 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

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.

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 accommodations 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, athirst 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.

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 paya 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 befurther improved by hospital treatment, provided such soldiers desired further treatment, and in the case of venereal disease to retain them whether theywished 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 militaryforces which have been unable to accomplish the objects for which they wereorganized on account of sickness. To protect the fighting forces frompreventable diseases is, indeed, a very necessary part of the military work, Thealready existing Division of Sanitation in this office was expanded tosuccessfully coordinate the efforts of the sanitarians of the Army. Medicalofficers with

long experience as sanitarians were detailed in this division as sanitaryinspectors. These officers made periodical and emergency inspections at thevarious camps in this country to assist and coordinate the work of the campsanitary officers. The same work was done in France. That this division mighthave timely notice of any outbreaks of any epidemics of infectious diseasesoccurring in camps and be informed as to the general health conditions of, thetroops, brief weekly telegraphic reports giving the data for special epidemicdiseases and for the general rates of all diseases were sent to this office.These weekly telegraphic reports had been first inaugurated by the chief surgeonof the Expeditionary Forces in Mexico (Vera Cruz). The reports were furtherexpanded during the military operations upon the Border and the secondexpedition into Mexico, At the beginning of the war orders were issued requiringthem from the entire Army. In the office of each department Surgeon and in, thatof each camp or division Surgeon a medical officer with experience was detailedas sanitary inspector whose duty was to coordinate the work of the varioussanitarians in the department, division, or camp.

(5) At the beginning of the war the work of procurement and distribution ofall medical and hospital supplies devolved upon the Medical Department. Before1914 many of the drugs and much of the surgical equipment used in this countryhad been imported from Germany. During the years elapsing before the activeparticipation of this country in the War the chemical and drug industry and thatof surgical equipment had been greatly expanded over the prewar status. Furtherexpansion and organization were necessary. The tremendous task of mobilizing theentire productive activities of the drug trade in this country and of the meansfor producing and handling surgical dressings and hospital equipment wassuccessfully accomplished. Medical, surgical, and hospital supplies were rarelyinadequate to fully meet the needs at the various camps or posts either in thiscountry or in Europe. When the supplies were wanting at any place, it was withrare exceptions due to the inability to secure the necessary transportationeither by rail or by ocean vessel that caused the temporary shortage. In theAmerican Expeditionary Forces during active operations there was a shortage ofboth motor and animal drawn transportation. However, that such a large number ofmen with so many supplies and so much equipment should have been successfullytransported over 3,000 miles of submarine-infested ocean was, indeed,remarkable, and that the supplies were not more frequently wanting and thattransportation was not more frequently inadequate was, indeed, a cause forcongratulation to all concerned.

(6) The work of caring for the sick and wounded was, indeed, a tremendousundertaking. During the year the total number of sick officers and enlisted menthat required hospital treatment or treatment in quarters was 2,833,204. Thisnumber does not include soldiers treated for minor ailments and does not includecivilians of various kinds attached to the medical personnel, all of whomrequired and received the attention of medical officers. Of this total number ofcases of sickness 2,422,362 resulted from disease, 182,789 from ordinaryinjuries, 228,053 from battle injuries

¹When the work upon the statistics for the year 1918 was begunduring the latter part of June, this year ad of the material from France had notbeen received. There will, consequently, be an additional number of battleinjuries to add to the number given.

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

Influenza was the leading cause of admission both for officers and enlistedmen, American and native troops, in every country where troops of the UnitedStates were serving. This disease caused for all officers 31.82 per cent of thetotal cases of sickness; for enlisted men, American troops, 28.26 per cent, andfor native troops 36.61 per cent. For officers, bronchitis caused the secondhighest 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 ofthe total, and for native troops (of the specified diseases) measles stoodsecond with 5.31 per cent.

Forty-seven thousand three hundred and eighty-four deaths occurred during theyear 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, andaccording to the reports received from the Central Records Office in France33,711 were killed in action and 648 were lost at sea, (Of those killed inaction only 4,533 were reported to this office.) The total number of deathsaccording to the above figures is 98,978.

During 1917 there were 4,159 deaths, 3,330 of which resulted from disease a d829 from injuries of various kinds, The total number of deaths for the twoyears, which so far has been reported to this office, including the killed inaction was 103,137. Of this number of deaths 50,714 were from disease, 52,423occurred as the result of injuries of various kinds (33,711 were killed inaction, 13,735 died of wounds, 648 were lost at sea, 4,329 were from ordinaryaccidents).

If the same rates for diseases had prevailed during 1917-18 as prevailedduring 1861-62 and 1898-99, there would have been for the 1861-62 figures186,037 deaths, and for the 1898-99 figures 62,215 deaths. It may then again besaid that preventive medicine resulted in the saving of a loss of life fromdisease of 135,323 lives as compared with the Civil War days and 11,501 lives ascompared with the days of the Spanish-American War and Philippine insurrection.Had it not been for influenza and pneumonia, the total rates for the years1917-18 would have, indeed, been very small, both for admissions and for deaths.

For officers and for enlisted men, American and native troops, influenza wasthe leading, cause of death in all countries where United States troops wereserving with the exception of for enlisted men in the Philippine Islands wherelobar pneumonia was the first cause and for native troops in the PhilippineIslands where bronchopneumonia was the first cause. For officers influenzacaused 47.31 per cent of the total number of deaths from diseases; for enlistedmen, American troops, 48.61 per cent and for native troops 42.03 per cent, Forofficers broncho-pneumonia and lobar pneumonia stood second and third causingtogether 26.67 per cent of the total deaths.

The same two diseases stood second and third for enlisted men, causing 32.35per cent of the total deaths, and for native troops also the same two diseasesstood second and third causing 31.40 per cent of the total, Influenza then withlobar 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 forofficers from disease, 80.87 per cent of the total deaths from disease forenlisted men, American troops, and 73.43 per cent of the total for nativetroops.

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 1918was 29 per 1,000.

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

Of the men who were mustered into the military service 115,664 weredischarged for disability. This number includes 9,710 men who after being held afew days in camp for observation were reported as discharged from the draft, Ofthe total number 1,862 were discharged as the result of ordinary injuries and290 of battle injuries. The larger number of discharges for battle injuries willoccur during the present year. For all officers and enlisted men, American andnative troops, in all countries where United States troops were serving,tuberculosis of the lungs was the leading cause of discharge with the exceptionof 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 theorder named was psychasthenia, epilepsy, dementia praecox. For officerstuberculosis of the lungs caused 12.43 per cent of the total discharges. Of thespecified diseases neurasthenia was second with 4.80 per cent. For enlisted men,American troops, tuberculosis of the lungs was also the principal cause with8.35 per cent of the total; mental deficiency second with 7.32 per cent. Fornative troops tuberculosis caused 40.47 per cent discharges; asthma second with8.25 per cent.

Considering these general rates more in detail, we find that the admissionrate 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 theAmerican 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 washighest 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), andfifth for the Hawaiians (707.96). Of the death rates for diseases, the rates forofficers 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 coloredtroops (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 therate 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 inHawaii (21.43). It was highest for colored troops (67.93); second for PortoRicans (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 officerswas again lower than for enlisted men, being 2.92; for enlisted men, Americantroops, 47.34; and for native troops 28.81. As was to be expected the rate washighest in the United States for it was here that the physically unfit wereeliminated (84.68); second in Hawaii (6.20); third in Panama (5.19); fourth inPhilippine Islands (3.52), and fifth in Europe (1.24). It was highest for thecolored 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 firsttwo years of the Spanish-American War and the Philippine Insurrection, both thegeneral rates which have preceded and the few specified diseases which are tofollow, several factors should be considered: (1) The troops in the UnitedStates Army during the Civil War were troops from the Northern and EasternStates with some few from the Western States; (2) there were no colored troopsin the United States Army during 1861-62, or, if there were any, the numberwas too small to consider.

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

from the West. During the Spanish-American War the rates, particularly thosefor 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 respiratorydiseases, and especially the death rates, would be low as compared with thecorresponding rates for all seasons of the year in the United States and inEurope. On the other hand, the rates for fevers and gastrointestinal disorderswould be higher. During the Civil War and, the Spanish-American War it was thegastrointestinal diseases and the specified fevers that caused the high ratesboth for admissions and for deaths, while in 1917-18 it was the acute infectiousdiseases, and particularly the acute respiratory type, that caused them in theUnited States and in Europe. The one disease of this class which was ofparticular importance in this country as well as elsewhere on account of thenumerous deaths which it, together with its complications caused, was influenza,In the preparation of the statistics for this report, statistical tables havebeen 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 casesdiagnosed as primary pneumonia, should have been charged to influenza.Influenza, together with its complications, was charged with 688,869 cases ofsickness, an annual admission rate of 273.52. The admission rate for officerswas 196.35; for enlisted men, American troops, 276.27, and for native troops433.07. For enlisted men, American troops, the admission rate was highest in theUnited 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 therate 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), andfifth for the white troops (265.38).

Considering, for the white and colored from the South alone, the nativityadmission rate, that for influenza was 247.11 for the white and I 54,.58 for thecolored, For the combined pneumonia for the colored it was 39.74 and for thewhite 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 ofdeaths, there were 431 charged to bronchitis; 6,814 to broncho-pneumonia; 8,407to lobar pneumonia; 450 to pneumonia unclassified, and 262 to pleurisy. If thesedeaths 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 theacute respiratory diseases named. The rate would be 15.64 per 1,000. If thisrate 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 thecolored troops (12.69); second for the white (8.83); third for the Porto Ricans(7.80); fourth for the Philip-

pines (2.84); and fifth for the Hawaiians (1.72). While the native troops hadhigher admission rates than the whites, the deaths were lower. This againillustrates the point that the death rate for this type of diseases is lower inthe summer and in the Tropics. The combined death rate for broncho-pneumouia andlobar 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 deathrate for these two pneumonias was 4.89 and for the colored 15.81. The totalnumber of pneumonia cases occurring among the white troops in the United Statesand Europe, counting the cases complicated with measles and influenza, was94.505, with 28,969 deaths. Among the colored troops, enlisted men, there were19,319 cases, with 4,720 deaths. The incidence rate for the white troops was44.11 and for the colored 115.28. The death rate for the white was 13.52 and forthe colored 28.17. The case mortality for the white was 30.6 per cent and forthe colored 24.4 per cent. It is apparent, then, that the- colored has anincidence rate of nearly three times as high as that for the white, a death rateof 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 isoften confused with the common type of respiratory diseases which are followedby virulent types of pneumonia; (2) it was probably present in the camps andassociated with the virulent pneumonias in this country and in Europe during thelatter part of 1917 and the early part of 1918. The epidemic declined during thecold dry weather in the winter, increased again with the advent of the chillydamp weather in the spring, then declined to a comparatively low rate tocontinue throughout the summer and again increased in the autumn of 1918 toreach the height of the great pandemic; (3) it was more prevalent in the UnitedStates among the white troops than among the colored, and particularly moreprevalent among the white troops from the South than among the colored from theSouth; (4) a higher percentage of the cases that occurred among the colored werecomplicated with pneumonia, and as a result a higher percentage died; (5) theadmission rates were higher for the whites from the? South than for thewhites from any other section of the country. The rates for the soldiers fromthe east North Central States were next highest and probably the rates for thesoldiers of the densely populated eastern, States were the lowest, though thenativity table shows that the soldiers from the west and northwest CentralStates had the lowest rates. It is very probable, however, that the nativityrates for these soldiers were lower than they should have been on account of therecent large amount of immigration to these newer States, which as a resultraised 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 acuterespiratory diseases was 1.66 in 1891 and the next highest in 1888 (1.50) theyear before it was recognized that there was an epidemic, when it was 1.50. Onlytwice since 1867 had the death rate for these respiratory diseases reached theheight of 1.66 before 1917, in 1868 and 1891. If the rates for this type ofdisease had been the same during the first two years of the Civil War, therewould

have been 22,312 deaths and if the same as during the first two years of theSpanish-American War and the Philippine Insurrection, there would have been3,162 deaths. As it was, there were 40,471 deaths. During these two years of theCivil War and of the Spanish-American War and the Philippine Insurrection theratios for the acute respiratory diseases were above the average. Influenza waspresent during both wars, and it is very probable that it played a moreimportant 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 southerncamps during the latter part of 1917. After November the incidence rate and thedeath rate both began to decline rapidly. The same was true for the troopsstationed in Europe. While there were some admissions and some deaths throughoutthe year, the disease never reached serious proportion after the year 1918. In1917 it caused in the United States for enlisted men 947 deaths, 31.74 per centof the total, a death rate of 1.70. The rate for deaths in 1918 was 0.87, onabout one-half what it had been in 1917. The admission rate in 1917 for theUnited States was 87.08 and in 1918, 29.34. This disease was better controlledduring 1917-18 even with the white troops from the South and the colored troopsfrom the South than during the first two years of the Civil War. If the samerates that had prevailed as during the first two years of the Civil War, therewould have been 184,918 cases and 6,649 deaths, and with the same rates as in1898-99, 127,979 cases and 1,342 deaths. As it was, there were 98,606 admissionsand 2,455 deaths (all troops). The admission rate for 1861-62 was twice as highas in 1917-18 and for 1898-99 33 per cent higher. The death rate for 1861-62 wastwo and one-half times as high, but only one-half as high in 1898-99. This lowerdeath 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 and1918 than during 1861-62. The death rate for scarlet fever was higher during thelate war as was also that for mumps. The death rate for diphtheria was higherduring 1861-62 and about the same as in 1898-99. Mumps was an especiallyimportant disease on account of the great loss of time occasioned by it. Thetotal time lost for this disease for all classes of troops and officers amountedto 2,926,635 days. It was the gastrointestinal diseases and fevers where thegreat gain was shown, as compared with the rates for the Civil War and theSpanish-American War. With the same admission rates for typhoid fever in 1917-18as in 1861-62 there would have been 226,001 cases and 62,694 deaths; and withthe same rates as in 1898-99, 291,637 cases and 30,916 deaths. As it was, therewere 1,083 cases and 158 deaths. At no time during the year was typhoid fever ofany 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 rapidlyadvancing over battle-swept areas in heavily infected territories. That theartificial immunity of a greater number of men did not break down is, indeed, acause of congratulation and an evidence of the high protective immunityconferred by the typhoid vaccination. For malarial fevers there were 14,087admissions during 1917 and 1918 and 31 deaths. With the same

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 havebeen encamped in such large numbers in sections of the country where malarialinfections prevailed and that such a small number should have been infected isanother link in a chain of evidence that malarial fevers can be eliminated byproper sanitary measures.

For diseases of the intestines, diarrhea, and dysentery, the rate foradmissions in 1917-18 was one-twenty fifth as high as 1861-62, and one-tenth ashigh in 1898-99. With the same rates as in 1861-62 there would have been2,803,134 admissions for this class of diseases and 33,153 deaths, and with thesame rates as in 1898-99, 1,285,577 admissions and 6,170 deaths. For venerealdiseases during 1917-18, 259,612 cases were recorded for enlisted men in theUnited States. From the figures obtained as a result of the physicalexaminations made at the time of the draft, it is probable that 5.6 per cent ofthe men who came into the military service were infected with a venerealdisease. Approximately three and a half million men were drafted or volunteered.After deducting the cases brought into the military service, the incidence inthe United States for the two years was about 1.8 per cent. During the years1917-18 the percentage of men who were detected with a venereal disease whileserving in the United States, counting all those who came into the service witha venereal disease, amounted to 7.4 per cent. About three-fourths of allvenereal diseases in the camps in the United States were brought in from civillife. If the cases for the entire Army for the two years of 1917 and 1918 aretaken, after deducting the number brought in from civil life, the incidence forall troops for two years is 2.93 per cent. If to this is added a certain numberin France, which were not recorded, it would bring the percentage incidence forthe entire Army for the two years up to a little over 3 per cent. As 5.6 percent came in from civil life, it is apparent that nearly twice as much wasbrought in from civil life as was contracted in the Army during the two years.

The disease was approximately seven times as prevalent among the coloredtroops in the United States in 1918 as among the white. The nativity rates forthe white from the South were higher than the rates for the whites from othersections of the country. The nativity rates for the colored from the South, ascompared with the whites from the South, is 232,92 for the colored and 56.89 forthe white. For cases contracted in the service the admission rate in the UnitedStates and in France for the year 1918 was approximately the same, about 40 per1,000. (This admission rate is not a percentage incidence rate calculated forthe entire number of men present at any time during the year, but it is a ratecalculated upon the average for the year.) The loss of time for venerealdiseases for the year amounted to 3,937,710 days. Approximately 46 Negrosoldiers out of each 1,000 of the average number that served in the UnitedStates 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 occurredas the result of battles in Europe. The reports that were received in thisoffice prior to the compiling of this report show that 227,855 wounds werereceived in battle that required admission to hospital, or approximately 109 menout of each 1,000 that were serving in France were wounded; 87 officers out ofeach 1,000; 91 white enlisted men and 26 colored enlisted men; total enlisted220. Of the

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

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

For the entire Army there were 182,789 admissions to sickreport as the result of ordinary traumatisms. Of this number 5.30 per cent werecaused by cutting and piercing instruments, kind not specified; 0.87 per cent byknife; 0.95 per cent by pistol; 1.23 per cent by aeroplane; 2,72 per cent byautomobile; 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 percent by athletic exercises; 3.66 per cent by marching and drilling; 3.90 percent by ill-fitting shoes.

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

CONCLUSION.

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

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

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

4. The total number of days lost from disease for the yearwas 40,692,302; from battle injuries 12,545,442; and from ordinary injuries3,687.060. The average number of men absent each day of the year on account ofsickness and injuries was 155,957. Seventy-one per cent of the time lost wascaused by disease, 6 per cent by ordinary injuries, and 22 per cent by battleinjuries.

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

6. For the first two years of the Civil War, as compared with1917-18, the admission and the death rates for disease was three and one-halftimes as high.

7. Comparing the rates for the Spanish-American War and thePhilippine Insurrection, 1898-99, with those for 1917-18, the admission rate in1898-99 was a little over twice as high and the death rate about 20 per centhigher.

8. The admission rate for the specific fevers and thediseases of the intestines (including diarrhea and dysentery) was 29 times ashigh 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 24times 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 waspractically the same as in 1917-18. The death rate in 1861-62 was two andone-half times as high as in 1917-18, but 8 per cent lower in 1898-99 than in1917-18.

11. The respiratory type, including influenza, pneumonia, andthe common respiratory diseases, had higher admission and death rates for1917-18 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. Theepidemic wave declined during the cold dry winter weather, increased again inthe spring, after which time it again declined, but continued throughout thesummer to rise again to the high point in the autumn months.

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

14. All of the epidemic diseases other than influenza,pneumonia, and the- common respiratory diseases declined after the first part of1918. The rates for most of these diseases were lower during the first part of1918 than during the latter part of 1917.

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

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

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

18. Two-thirds of all that were detected with a venerealdisease in the entire Army, during 1917-18, brought the infection in from civillife.

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

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

21. Practically 70 per cent of the Negro soldiers either hada venereal disease when brought in from civil life or contracted an infectionduring 1918.

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

23. The rate for venereal diseases for the colored incountries other than the United States was slightly higher than the rate for thewhites.

24. The nativity rates for venereal diseases for the Negrosoldier from the South, as compared with the white soldiers from the South, showthat the negro had approximately four times as much venereal disease as thewhites from the same section.

25. The nativity rates for the white soldiers from thevarious sections of the country show that the white soldiers from the South hadhigher rates for venereal diseases than the white soldiers from other sectionsof the country.

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

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

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

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

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

31. As compared with the whites of the South, the Negro had anativity 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.