CHAPTER II
Early Development of Medical Records in the Army
With the development of the Army Medical Department and the concentration of responsibilities in an administrative head of the Department, it naturally followed that communications developed between the medical officers in the many posts throughout the country and their chief. In fact, as the Surgeon General sought constantly to make the Medical Department a more adequately functioning division of the Army, a more organized information service was constantly being developed. Moreover, the appreciation of the adequacy of medical records was continually being broadened with an expanding field of usefulness.
When the United States secured its independence, and for a number of years thereafter, no country in the world possessed trustworthy and detailed information concerning the health of its military and naval forces. It appears, however, from the meager records which have been preserved, that, during the War of the American Revolution and the War of 1812, medical officers were required to submit to the commanding general of their own force brief numerical reports of the sickness among the troops served by them. Due to the slow communication system existing at that time, it is apparent that only very general supervision was possible.
To be sure, Joseph Lovell, the first Surgeon General to be appointed, recognized the importance of sick and wounded records as a guide for disease prevention. In an order issued on 21 April 1818, it was directed that all reports, returns, and communications connected with the Medical Department be
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made to the Surgeon General`s Office in Washington and also that all orders and instructions relative to the duties of the several officers in the medical service be issued through the Surgeon General. It was through this order that it became possible for the Medical Department to record its experiences from which lessons might be learned.
In addition, General Lovell prepared a revision of the Medical Regulations, since the existing ones were not in accord with the new organization or with the provisions of the order just referred to. Among other things, the regulations required that each station surgeon submit a quarterly report to the Surgeon General on the important activities of the medical service. From these reports, the Surgeon General was able to submit a health report of the Army to the Secretary of War. Furthermore, all station surgeons were required to submit information on weather conditions, in addition to that on the incidence and causes of disease in their quarterly reports. The information relative to the weather conditions was in fact the beginning of the present Weather Bureau.
The first health report from the Surgeon General to the Secretary of War was dated 1 November 1818 and was for the quarter ending June 1818. A similar report was made for each quarter until the report of January 1832 which contained statistics for the quarter ending June 1831. None of the quarterly reports was published, but they were recorded in the Surgeon General`s Office. The first published annual report was issued in 1822. It covered the fiscal year ending on 30 June 1822 and was published in the report of the Secretary of War. Thereafter, the Surgeon General`s annual report was published with that of the Secretary of War until 1843, when it was printed separately. Publication since that date continued without interruption, except during the Mexican War, until the outbreak of World War II in 1941.
Surgeon General Lovell and Lawson, who succeeded him, manifested a very great interest in the welfare of the Army. In fact, in practically every one of the early reports there were protests against existing conditions such as the inhuman treatment of the enlisted men by the officers or the large amount of intemperance resulting in part from the whisky ration. In addition, the necessity for the more careful physical selection of
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recruits and for the improvement in hospital construction was stressed. The report of 1 November 1818 contained the following:
But few of the deaths were accounted for, most of which were from excessive intoxication; and it may be proper to state that one Surgeon has reported three deaths from this cause (the only cause), in one quarter and closed his remarks by stating that of a company noted for drunkards `these three might be said to lead the van,` an observation which indicates no small relaxation in general police in a garrison at a convenient distance from the intrusion of citizens.
From the report dated 1 November 1819:
Being fully convinced from this as well as many other reasons of the priority and even necessity of striking the whiskey altogether from the ration, I have made many inquiries during the summer of the probable effect of such a change, and have received but one opinion from all those whose experience entitles them to full faith on this subject, and which authorized the most unequivocal recommendation of the measure. The objections usually made to it appear to be altogether groundless. Upon the recruiting service it can have no effect but a beneficial one; the man with whom rum is an inducement to enlist is not worth having; such recruits are the pests of the Army, both by their practice and their example; and the manner in which the whiskey is generally disposed of by the soldiers proves that this change would only be objected to by those who ought on every account to be deprived of it altogether, and who are only useful at those times, when it is stopped from them by way of punishment. Most of the efficient men do not drink at all, they either sell it to the sutler, who makes an abundant profit on the articles he furnishes to them in return, or to their intemperate comrades who thereby obtain the means of continual intoxication, or else it is kegged, as they term it, i. e., kept until it amounts to a sufficient quantity to allow of a drunken debauch, always followed by numerous irregularities and frequent punishments; and often gives rise to a career of intemperance. Too, generally, it is issued in the morning, and used as a dram: the most pernicious of all modes of disposing of it, in fine, the last use it is put to in the Army is that of a stimulating drink with the soldiers` meals, the only one it could have been intended for.
In confirmation of the above, it has been frequently remarked by officers of experience from all parts of the country that whenever the supply of whiskey has failed the men have universally been more healthy, obedient to orders, regular in their habits, contented with their situation than at any other time; and as heretofore stated, it has often been stopped at the request of the Surgeons, when diseases of the bowels have prevailed and in all cases with the most beneficial results, and without any of those marks of discontent so often anticipated.
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In a former report it was suggested that beer, or tea, sugar and coffee might be substituted for it; upon further inquiry and reflection, however, I am not convinced that these plans would be found practicable or beneficial to the soldier. These articles could not be furnished by the commissaries department of a good quality in active service, and their issue would be attended with much trouble and waste. If money were allowed, and they were obtained from the sutler, it would merely be an addition to the pay which would always be spent by the intemperate for ardent spirits and would only add to the sutler`s profit, and the soldiers irregularities.
The whiskey will average about one-eighth of the ration; this at sixteen cents would give a company of 100 men $60 per month, and if in lieu of it an estimate of it to the same amount were made for vegetables, etc., of different kinds to be purchased by the issuing commissary according to circumstances, the soldier would not only cheerfully acquiesce in the arrangement, but it would tend to render the supplies much better adapted to his situation and his wants.
In the quarterly report of 1 February 1822 is found the following extract from the Surgeon at St. Marks, Fla.:
My Hospital is very bad and more or less wet at every rain. On the 16th of September, the tide rose uncommonly high which nearly inundated this place and the whole of the adjacent country; the water was a foot deep in the hospital; in fact, I visited my sick and went through it in a canoe; the bunks were high which keep the men out of the water; but this as well as the wet from the rains, had a very injurious effect on my patients, particularly those labouring under dysenteries and diarrhoea,
This place is generally damp, being all made ground, the barracks of the men are of stone and very damp. We are compelled to use the river water, which is not very good, and which is brought from about three miles above this in barrels. The police of the Garrison bad; when the tide is high the men are compelled to go through the water to the privy, which is very injurious, particularly to the sick.
Surgeon Lovell, receiving such reports, made every effort to bring about changes. He was largely instrumental in the passage by the Congress of a bill by which unsuitable and inefficient officers could be eliminated by action of a board of officers. More than any other person, he was responsible for the abolition of the whisky ration which made some men drunkards in the Army. From his personal observations, he was able to make recommendations which brought about considerable improvement in the food ration and clothing of the soldier.
General Lovell`s service included also an interest in scientific achievement. His encouragement of Surgeon William
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Beaumont in the study of gastric physiology resulted in an outstanding contribution. In the fall of 1824, Beaumont sent a report of the famous case of Alexis St. Martin to Surgeon General Lovell. In March 1833, Beaumont made an abstract report of his observations to the Surgeon General and in the same year published his Experiments and Observations on the Gastric Juice and Physiology of Digestion.
Both Surgeon General Lovell and Surgeon General Lawson were persistent in their efforts to better the welfare and health of the troops. By frequent recommendations to the Secretary of War they did much to improve the diet, water supply, waste disposal, housing, clothing, and working conditions in the Army. By the use of vital statistics compiled from the quarterly and monthly numerical reports, they were able to stress the importance of their suggestions and to point out the improvement in the health of the Army that followed the approval of sanitary measures recommended by them.
In addition, the reports made to the Surgeon General resulted in a most important statistical and historical volume, Army Medical Statistics, prepared by Assistant Surgeon Samuel Forry and published in 1839. It included (1) the vital statistics and a discussion of the sickness and mortality of the Army from 1819 to 1839, (2) the medical topography and meteorology of the various posts, (3) the construction and condition of barracks and hospitals, and (4) information with reference to prevailing diseases and their treatment. A second volume, which included items (1) and (4), above, was prepared by R. H. Coolidge and appeared in July 1856; and the third volume for the period 1855-60, by the same author, was published in 1860. Other important contributions to science were the meteorology registers of 1822-25, 1826-30, and 1831-42. Subsequent publications continued the observations through 1855. The reports received in the Surgeon General`s Office from various expeditions often contained facts of great interest on the topography, diseases, climate, and the physical characteristics of the country and its animal population.
At the same time that numerical reports were required for disease control, records to adjudicate pension claims were kept in each hospital in a large book known as the hospital register. Entered into this book was the name of each patient, with the diagnosis, disposition, and other pertinent information. The
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data recorded were gradually amplified until they included name, rank, company, regiment or staff corps, age, race, nativity or birthplace, length of service, date of admission, diagnosis, line of duty, intercurrent diseases, results or disposition, date of disposition, and number of days lost. Requests from the Pension Office to the Surgeon General for such medical records were forwarded until 1840 to the hospital where the treatment had been given. At that time, the demands that pension data be furnished more promptly became sufficiently insistent to influence the War Department to direct that the sick and wounded reports include the names and diagnoses of soldiers who were discharged for disability or who had died during the period covered by the report.
After hostilities with Mexico began, the senior medical officer of each American force was directed to have prepared and forwarded to the Surgeon General`s Office sick and wounded reports as required of various stations during peace. However, a very careful and extended examination of the reports furnished showed that, although a majority of medical officers had attempted to comply with the instructions issued, it was found impossible, due to the loss of many returns in transit and to the incompleteness of many others, to compile correct abstracts from these reports of the sickness and mortality which occurred during the war. Consequently, compilations were not attempted in the Surgeon General`s Office. As a result, the only vital statistics table which was compiled to show the deaths that occurred from diseases and battle injuries was included in a group of strength and organizational tables prepared by The Adjutant General in compliance with a congressional resolution calling for information relative to the military forces in the Mexican War. It was published in 1849, and the tables were reprinted in the second volume, prepared by Richard Coolidge,1 the Acting Surgeon General.
In 1862, during the Civil War, instructions were issued directing that the quarterly sick and wounded reports to the Surgeon General`s Office, be discontinued and that the consolidation of the monthly reports from the department surgeons be forwarded to that office. Subsequently, the department surgeons were authorized to forward the monthly reports to the
\t1So far \tas the authors are aware, this volume is the only place where these data can \tbe found.
\t
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Surgeon General`s Office without consolidation. It was also directed in 1862 that a nominal list of all of those wounded or killed in action be prepared by each unit surgeon and forwarded to the Surgeon General`s Office. In addition to the hospital registers, each regimental surgeon was furnished a pocket field register. It was from the numerical reports of sick and wounded, the nominal list of battle casualties, and bed cards, supplemented by many valuable case histories and reports of epidemics, that Woodward, Otis, Huntington, and Smart were able to abstract the necessary data for the preparation of the monumental Medical and Surgical History of the War of the Rebellion, that still excites the wonder and admiration of all who are interested in medical history and in war medicine and surgery.
Following the Civil War, there was a tremendous increase in the number of claimants for pensions. Apparently, the members of the peacetime Army became more acutely pension conscious, and discharged soldiers, or their beneficiaries, lost no time in filing claims. After the close of the war, all register books, including the pocket field registers, were forwarded from hospitals and dispensaries to the Surgeon General`s Office. However, the only records that showed the hospital or dispensary where a soldier had received treatment were the muster rolls of the Adjutant General`s Office. Consequently, when there was a claim for pension, it was necessary first to search the muster rolls to find the places of treatment before the register books could be consulted to obtain verification of the injury and the diagnosis, undoubtedly a time-consuming and costly operation. To add to the difficulties and expense, the register books were worn out by frequent use and consequently had to be recopied.
The demands for prompt information from medical records in order to satisfy pension claims became so insistent that in 1883 an order was issued from the Adjutant General`s Office2 directing that the reports of sick and wounded which heretofore had been numerical with a nominal list only of men discharged for disability or who had died, include the names of all patients admitted for treatment during the month, with detailed information in regard to each one. Large sheets were provided for transcribing the data recorded in the register book. The
2Headquarters of the Army, Adjutant General`s Office, General Orders No. 42, 1883.
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data furnished, as a result of this order, were satisfactory and comprehensive, not only for pension purposes but also for compiling vital statistics. Unfortunately, however, the forms were inconvenient to handle, and it was always a time-consuming and sometimes impossible undertaking to trace from them the history of cases transferred from one hospital to another.
To circumvent this difficulty, the Surgeon General then directed that all of the nominal list of casualties be carded. However, it was not until late in the 1880`s that the idea was conceived that it might be possible to card the register books. The undertaking was too stupendous, and in the meanwhile it was becoming impossible to keep abreast of the constantly increasing requests for pension data. The Surgeon General`s Office, that had custody of the records, was 6 or 8 months in arrears. In addition, the administration was much harrassed by the assertions of at least some of its political opponents that the party in power was deliberately delaying action on the just claims of deserving veterans. Maj. Fred Ainsworth, Medical Corps (later General Ainsworth, The Adjutant General), who had assumed charge of this work, decided that the register books could and must be carded. He was able to complete the work in less than 1 year. After the cards were arranged in alphabetical order, it was an easy task to assemble the information for any claimant. All requests were current within a short time, and one more source of political accusation was eliminated.
In 1892, the diagnosis tag was authorized. This was the first individual identification record for the soldier that was authorized in this country and was indeed a very important innovation. The diagnosis tag was to be attached to a wounded soldier upon the battlefield, or when treatment was first administered. It gave information as to the original injury and the nature of the emergency treatment administered.
In 1894, with the recommendation of the Surgeon General, the War Department directed that the diagnosis tags be bound in books. The original tag, that was to be attached to the wounded soldier, was followed by a carbon and second sheet upon which a record was made to be retained by the medical officer or enlisted man, when he detached the original one. This carbon copy was important for checking organizational losses and also as an additional record for the Surgeon General`s Office.
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Unfortunately, the diagnosis tag was used only occasionally during the Spanish-American War and apparently not at all during the Philippine Insurrection that followed it. As a consequence, when patients were evacuated from Cuba through Montauk Point to civilian hospitals in the New York metropolitan area, the identity of many was lost temporarily on account of their delirium. Much confusion resulted. Several years later, the opinion was expressed that no sick or wounded soldier should be evacuated within or from a theater of operations without a suitable record`s being attached securely to his clothing.
When the Spanish-American War began, there was no sick and wounded report from which vital statistics experience could be assembled rapidly and efficiently. Fortunately, the war was a short one. Unchecked and uncontrolled pestilential diseases, as in all previous wars, exacted a heavy toll, with much unnecessary suffering and the loss of many lives. No vital statistics were necessary to tell the sad story of the failure of the medical service.
A great advance in the medical records was made in 1904. Amended regulations directed that individual sick and wounded report cards (3? inches by 8 inches) replace the nominal report of sick and wounded on the large sheets adopted in 1883. In other words, all of the data formerly recorded on the report sheets were entered on individual cards. Their preparation in the hospital, without increasing the work there, relieved the War Department of the necessity of copying them and at the same time expedited the compilation of vital statistics.
To insure the continuity of the record of each case and also of the treatment of a patient sent from one hospital to another, the War Department directed that when a patient was so transferred a copy of the report card be prepared by the transferring hospital and forwarded to the receiving one. This card was known as a transfer card. At the end of the month, all transfer cards received by a hospital were forwarded with its sick and wounded report for that month to the Surgeon General`s Office.
The sick and wounded report included, in addition to the individual sick and wounded cards, a report sheet and a nominal check list. The report sheets furnished a census of the military population by rank, race, and color, and also a statement
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of the military units at the station. The census as reported was a daily average for the month. Material variations in the daily numbers occur during mobilization and demobilization at the various camps. Obviously, without population or strength figures it would be impossible to reduce the vital statistical data to rates for comparative purposes. The inclusion of the military units on the report sheet was exceedingly important, since it enabled the Surgeon General`s Office to follow the movement of each military unit and to check that each one was reported each month, and especially that it was reported only once.
Two years later, in 1906, the hospital register book was replaced by a card system. That change greatly simplified the preparation of medical records in hospitals, since the register cards were carbon copies of the report cards.
Another record of material importance in the preparation of the sick and wounded report, and also in the professional care of the patient, is the clinical record. This record was greatly improved and amplified about 1910. Its size and shape were made to conform to the vertical filing system in use at that time, each sheet being approximately 3? inches by 8 inches. In addition to the use of this record in the treatment of the cases in fixed hospitals in peace, in the Zone of Interior in war, and in preparation of sick and wounded report cards, it is available for the later study of treated cases and a source of additional detailed information for the adjudication of compensation claims.
Following the Spanish-American War, with the awakened activity of the War Department and the perfection of better methods of communication, it became feasible for departmental surgeons and the Surgeon General in Washington to exercise more current supervision over the medical service in the field and to furnish advice and assistance in the control of epidemic diseases. Although the sick and wounded reports, as authorized in 1904, furnished excellent records for pension purposes and for vital statistics for general information and guidance in sanitary matters, it was impracticable to compile statistics from them promptly enough for current use. Consequently, when the necessity for such information became acute at Vera Cruz in 1914, the Chief Surgeon directed that some form of current weekly or daily numerical statistical report be started. It furnished a summary of all casualties, of the more important communicable diseases, and of the bed status. This report was
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rendered by each hospital and command with the expedition. It proved to be so valuable that it was utilized in 1916 by the United States forces on the Mexican border. Subsequently adopted as a War Department form, it was used in this country and in France for the AEF (American Expeditionary Forces) during World War I. With some modification, this valuable record has been continued.
One of the most important aspects of military and medical care is the keeping of careful records of existing morbidity and mortality and the analysis of these records in order that preventive measures might be applied. Without doubt, an excellent system of record collecting had been developed for use in World War I, but the analysis of these records was practically impossible since the huge number of records collected during World War I could not be handled by the means available.
It must be remembered that, with conscription for World War I an accepted fact, with 24 million men from which to choose those best able to serve their country, the Army Medical Department faced a stupendous responsibility in functioning for the 4 million chosen.3 It was immediately clear that reorganization was necessary and that methods must be developed to adequately handle the information constantly being received in the Surgeon General`s Office.
References
Annual reports of the Surgeons General of the Army, for each fiscal year from 1819 to 1910.
Coolidge, Richard H.: Statistical Report on the Sickness and Mortality in the Army of the United States. Compiled from the records of the Surgeon General`s Office. Embracing the period of 16 years, from January 1839 to January 1855. Prepared under the direction of Brevet Brig. Gen. Thomas Lawson, Surgeon General, U. S. Army, Ex. Doc. No. 96, 34th Congress, 1956. Washington: A. O. P. Nicholson, 1856.
_____, ibid. Embracing the period of 5 years, from January 1855 to January 1860. Prepared under the direction of Brevet Brig. Gen. Thomas Lawson, Surgeon General, U.S. Army.
3Including Selective Service registrants, volunteers, and men in the National Guard.
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Ex. Doc. No. 52, 36th Congress, 1860. Washington: George W. Bowman, 1860.
Forry, Samuel: Statistical Report on the Sickness and Mortality in the Army of the United States. Compiled from the records of the Surgeon General and Adjutant General`s Office. Embracing the period of 20 years, from January 1819 to January 1839. Prepared under the direction of Thomas Lawson, Surgeon General, U.S. Army. Washington: Jacob Gideon, Jr., 1840.
