CHAPTER V
Medical Records and Statistics in World War I
Personnel.-With the advent of World War I, the offices of the Government expanded rapidly, and a shortage of personnel developed. The Medical Records Section, with the adoption of the electrical tabulating equipment for the processing of the World War I records, also found it necessary to secure and train personnel in the use of the machines. Many young women came from various parts of the country to Washington to fill these jobs, and it was not long before the housing in Washington was inadequate for those who came. There can be no doubt that not all the heroic work during World War I was done by the soldiers on the battlefields in Europe. The clerical personnel in Washington also did heroic work and suffered many hardships.
The Medical Statistics Section was able to obtain from New York City about 25 young women who had been trained as punch operators for the Hollerith key punch during a military census that had been held in New York a short time previously. This was fortunate since not only is considerable training time required for one to learn to punch accurately and rapidly but there was, at that time, no training school for punch operators in Washington.
In addition, women were needed for coding the cards; that is, transferring the information from the medical report cards to the statistical cards. They also had to be trained, since there was no training school for such purposes. To facilitate the training of these women, the coders were divided into three sections. One section was known as the nonprofessional coders who transferred the information regarding the men`s former civilian or present military status; second, the medical-professional coders who handled medical cases; and third, the traumatism
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or injury coders who similarly transferred the information in regard to injuries occurring in battle or elsewhere from the medical cards to the statistical cards. In this way, it was not necessary for any coder to learn too many code numbers. After they had worked with the code for some time, it was remarkable how rapidly they could transfer the material and how few errors were found. When the coders were first assigned to this work, it was obviously necessary to supervise their work carefully and to point out errors that had been committed by them. After that time, all the checking that was necessary was to spot check; that is, checking samples from each coder`s work from time to time.
Preparation of material.-The induction of selective service men and mobilization of the National Guard had started early in September 1917. Since it was October before coding could be begun, sick and wounded reports of considerable volume were coming into the office from the mobilization camps of the National Guard and the training camps of the selective service men. It was apparent that there were a number of steps that were necessary and that these steps should be taken as promptly as possible in order to handle the work that was accumulating rapidly. Listing them in the order of their priority, these steps were (1) recording the receipts of the reports, (2) examining the reports as submitted, (3) filing of the cards, (4) preparating the code, and (5) drawing up of a statistical card for the tabulating machines.
Before discussing the steps just listed, reference must be made to the change in the system of medical reporting found necessary for the AEF. The medical officers who arrived in Europe soon after the entry of the United States into the war recognized that the peacetime system of reporting sick and wounded would be unsatisfactory for use in a theater of operations where patients were transferred rapidly from the front or fighting area to a hospital in the rear areas. This had been recognized before, but no solution had been found. Consequently, the chief surgeon of the AEF directed a board consisting of Cols. James D. Fife, Arnold D. Tuttle, and Daniel W. Harmon to investigate and report upon some modification of the sick and wounded report for the AEF. The Medical Department and the entire Army is under lasting obligation to these officers for the recommendation that the field medical record, including
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the field medical card and field medical envelope, then used by the British, be modified and adopted for the AEF. The British card was folded in two parts, but the board recommended that the card be folded in three parts so as to conform in width with the sick and wounded report card. The first page of the card contained space for the patient`s name, military number, other military and sociological data, diagnosis, important items of treatment, and so forth. There were five additional pages for entries at other hospitals in the chain of evacuation. The envelope, including the card and the diagnosis tag that were removed from the patient when the field medical card was prepared, was attached to the clothing of the patient and followed
FIGURE 6.-Sick and Wounded Report (Form 52) used in AEF
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him throughout his hospitalization in Europe. These cards constituted a brief but continuous record of medical care, insuring the continuity of treatment and the identification of the patient at all times. Not until the patient was transferred to the United States and arrived at a hospital where definitive treatment was to be given was the record detached. The name of the hospital receiving the patient and the date of arrival were stamped upon the card which was then forwarded to the Surgeon General`s Office, where it was the one and only record in the War Department of the address of the patient that had been returned to this country for treatment.
The instructions for the sick and wounded report, as modified
FIGURE 7.-Sick and Wounded Report (Form 52) used in United States
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FIGURE 8-Diagnosis tag used by AEF
by the AEF, required that each hospital, including field and camp hospitals, submit a monthly report to consist of the sick and wounded report cards as used by hospitals in the United States (figs. 6 and 7), the diagnosis tag (fig. 8), and the field medical cards (figs. 9 and 10) in the field medical envelopes (fig. 11), and the nominal checklist. When the field medical cards and envelopes were received in the Surgeon General`s Office, they were filed in the general alphabetical file with the cards received from the stations in the United States and other oversea stations.
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FIGURE 9.-Field Medical Card used by AEF (front)
FIGURE 10.-Field Medical Card used by AEF (back)
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FIGURE 11.-Envelope for Field Medical Card used by AEF
Card files.-After the reports were received from the various stations and a record of such receipt was made and the report was examined, a system of filing of the cards had to be developed. Since patients are so frequently transferred from one hospital to another in the United States and overseas or transferred from the theater of operations in Europe and other oversea stations to the United States, it was obvious that the filing of the cards by stations, as had formerly been done, would be unsatisfactory. Consequently, it was decided to arrange all cards into one general alphabetical file. This was usually done by a group of months-2 or 3, depending on the volume of cards received. In this way, the cards for one patient came together no matter where the treatment was received or no matter how often the patient was transferred. During the coding process, cards for incompleted cases were returned to the alphabetical section for arrangement in a subsequent file.
In addition, the card files were available for search for
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information.1
This furnishing of information became a very important part of the work during the war period. As many as 300 to 400 requests a day were received from the Office of the Adjutant General for information about men who were sick in hospitals either in the United States or overseas.
Coding.-The next step, in order of priority, was the preparation of a code. It is apparent from figure 12 that the statistical perforated card used for the tabulating machines is a numerical one. Consequently, the information on the sick and wounded cards had to be transferred to some numerical code. It is apparent also from the card in figure 12 that the extent of coverage of any items in any code would be determined by the number of columns on the card devoted to that purpose. For example, under diagnosis, where three columns were allowed in the diagnosis so-called field, there was the possibility of 999 diagnoses.
Since there were only 44 columns of digits available on the card, one being used for the code numbers, economy was necessary in the selection of the data to be transferred to the card and in the number of digit columns assigned to each item, such as diagnosis. As Dr. Charles W. Mayo said, `These cards are very human and you get from them only so much as you put
FIGURE 12.-Punchcard record. Admission and treatment of a patient in a hospital in the United States
1Dr. Charles B. Davenport in a letter to Love in 1941 said: "I well recall the time when you were home with the flu and I sat at your desk with about fifteen anxious mothers and sweethearts who had come to get some information about their boys in France. The records which you had organized were able to give then the information which they sought.`
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on them.` In the same sense, the code is very human and you get from it only so much as you put in it. Consequently, in drawing up cards and preparing the code, one must visualize the possible requirements quite clearly.
In the preparation of the code, all the material available was used, such as the lists of diagnoses of specialist groups furnished by their representative in the Surgeon General`s Office; the one formerly used in the Army; the one then being used in the Navy; and even one obtained from the French War Office overseas. As the work progressed, many changes were required. Unused terms were omitted and others added as the need arose.
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Figure 12 shows the divisions of the available space on cards and the subjects covered in the medical case.2 An examination of this card and figure 13 will show to the reader, more clearly than can be done by words, the large amount of material that could be transferred successfully. It was considered important to show, in addition to the diagnosis, any concurrent or associated disease that occurred during the patient`s treatment in a hospital. Further, to amplify the physical diagnostic terms without unduly lengthening the original list, it was thought desirable to include one field of three columns to show the anatomical locations or the organs of the body that were affected by the diseased condition. Also, to further amplify the possibility of the diagnosis, two columns were assigned for qualifying terms, such as right or left, upper or lower, and acute or chronic. Provisions were made also to include such social and military data as where the patient had formerly lived, his age, and the length of time he had been in the service, since previous environment did affect his susceptibility to infectious diseases. In addition, it was deemed advisable to show where the disease or condition first became apparent, so that information
2With the round hole perforations, there was space for only 45 columns on the Hollerith card. When a punch was developed, a number of years later, with a small rectangular punch hole or perforation, 80 columns were possible.
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could be obtained in regard to the effect of camp environment upon disease occurrence.
Similarly, figure 14 illustrates the card and coding of the data for a soldier wounded in action. This card and code were used also for injuries received in other ways than in action. It will be noted that it included what is known as the principal and secondary regions, such as the abdomen or upper or lower extremity. These were necessary, as multiple wounds occurred frequently. Further, two additional fields of two columns each were provided for the anatomical parts of the body and tissue injured.
Method of operations.-In many statistical offices, the code numbers are written on the original returns. This could not be done with medical report cards since, first, there were frequently a number of cards for one case; second, often no space was available; and third, the official records could not be marred. Consequently, it was necessary to transfer the information to some other card. Originally, a separate card was drawn up and used, but after a short time it was decided that it would be more satisfactory in every way to eliminate this intervening card and transfer the information direct to the punchcard.
Figure 15 shows the punch used in the Surgeon General`s Office during that period, with the Hollerith cards in position. It is apparent that the left margin of the card was covered by the punch or keyboard when it was first put into the machine. Consequently, it was necessary to begin the coding or to put the first part of the coded material on the right side of the card, to the right of the heavy black line (fig. 12). The coding was started at that point, proceeded to the right, then along the left
FIGURE 15-Key punch for Hollerith cards
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margin of the card, and finally on top from left to right until the black line was reached again. As the card was punched by the operator, it was pushed automatically by the machine from right to left until it was completed. Thus, the code along the top and margin of the card was visible to the punch operators at all times during the operation of the card. It was necessary, however, when the code was written on the card itself, to lose the first column of digits to the left, since otherwise there was not sufficient space upon which to enter the numerical
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code that was to be transferred to the cards by the punch machine.
There was also a verifying punch which operates in the same manner, but the key points are noncutting. As the operator proceeded, the card is pushed to the left by the keys which strike in the previously made perforations. If punched improperly, the numbers and the perforations do not coincide with the written code, and the card will not automatically feed but will clog the machine. It was necessary to verify all cards that were punched, since punch operators are human and, like all other people, make mistakes. A capable punch operator could average about 1,500 cards per day. An operator using a verifying punch could average a slightly greater number.
In addition to the key punch (fig. 15) and verifying punch, the Medical Records Section used a gang punch for the purpose described on page 40, a vertical sorting machine (fig. 16),
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and a tabulating machine (fig. 17). The method of operation of the machine is explained in the legend. The principle of an electric contact through a perforation remains the same as in the 1888 machine, but the operation was automatic and quite rapid. The first counter or bank of the tabulating machine was used for counting cards or cases which they represented; the second and third, for days lost in quarters, both subtotals and totals; and the fourth and fifth, for days lost in hospital, subtotals and totals.
After the cards were coded and punched with verification, they were passed to the machineroom where they were sorted by machine into predetermined groups. Finally, they were passed to the tabulating machines. As information was counted and integrated or added on the tabulating machines, the totals for each code number for diagnosis were entered on the card as shown in figure 18. This card shows the type of information entered on it. After the information had been written on the cards, they were sent to the Statistical Section where the International numbers or grouping numbers were entered by the use of a cross-reference file. The data for the one or more code numbers in the grouping number or International number were totaled and the data entered on the statistical sheets. The individual cards were the permanent record of all injuries
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FIGURE 19.-Continued. Back of Daily Report of Casualties and Changes
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or diseases, many of which could not be included in the published tables.
Use of machines, AEF.-In the AEF, an order was issued directing that Form 22, AGO, SD, AEF (Daily Report of Casualty and Changes) (fig. 19) be made out in six copies by each hospital for all patients admitted and for all changes of diagnosis or status. This report was forwarded by hundreds of hospitals showing the data as stated for every one of the patients. The Central Records Office, AEF, had been made responsible for these records by General Orders. It was thought, however, that the chief surgeon of the AEF should have all available information concerning patients in hospitals and should be able to furnish it promptly upon demand. Therefore, these essential records were kept there also. Experience proved the wisdom of such action, and this office was able to answer hundreds of inquiries coming daily from the central records office and other official and civilian agencies.
To handle this tremendous volume of business, tabulating machines were requisitioned. This requisition was received in the Surgeon General`s Office by cable, March 1918. Orders were immediately placed with the Tabulating Machine Company for the shipment to the Chief Surgeon`s Office in France of the required number of punch machines, verifying machines, sorters, and tabulating machines. Lt. Robert H. Delafield, assistant in the Office of the Medical Records Section of the Surgeon General`s Office, was detailed to go abroad with the machines to assist in their installation and use. In addition, a properly qualified and trained man, who had worked with the Tabulating Machine Company in installing and servicing such equipment, was selected from the men who had been drafted into the Army and was sent abroad by the order of the War Department. So far as can be determined, the Chief Surgeon`s Office was the only one in the AEF using this equipment.
The daily reported changes were transferred by numerical code to the cards for either disease or injury, as the case might be. The cards gave such data as name, rank, number, organization, diagnosis, disposition date, and hospital transfer. The cards for injury gave, in addition to the cause of injury, its anatomical location and nature. When the cards had been coded, clerks perforated them on the machines. After being
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perforated and verified, the cards were passed through sorting machines where they were sorted for the required data. Cards were run through the machines for one kind of data, then for another. After all tabulations were made, cards were finally sorted by name, manually, so that each man`s card was filed in the proper alphabetical order. This file constituted the master file for all cases reported in all hospitals in Europe; at the end of hostilities it contained 4 million cards. It was a complete directory and news agency for all sick and wounded in the AEF.
Reports.-The punchcards made from the original medical report cards were preserved and reworked from time to time as additional information was required. Depending upon the type of question to be answered, the appropriate cards were drawn from the file and rerun through the tabulating machines. For example, in 1928, when information was required for war casualties from the AEF cards for a breakdown of days lost by periods of 5 days each, the cards containing the necessary data were taken from the file and rerun. In a similar manner, numerous studies were made of the data on the cards.
Annual Report of the Surgeon General.-One of the earliest beneficial effects of the use of electrical tabulating machines was manifested in the Annual Report of the Surgeon General for the war years. As stated previously, the law before and during World War I required that the report of each bureau chief should be available for printing on or before the first of October. These reports included statistics for the preceding calendar year and a discussion of the administrative affairs in the office for the fiscal year ending the preceding 30 June. Consequently, during a war period, considerable speed was required so that the statistical tables and material might be ready for inclusion in the report on or before the date mentioned. The reports of the Surgeon General included large statistical tables with such statistical data as were available, smaller statistical explanatory tables, with discussions, in addition to an account of the administrative affairs of the office during the fiscal year covered. During the war years, an effort was made to include also an abstract of such material as could be obtained from the AEF. The reports for the year 1919 appeared in two volumes. The second volume was devoted largely to abstracts of
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reports submitted by surgeons of divisions, corps and armies, and commanding officers of hospitals. It was hoped that these reports, being in the nature of firsthand documents, would be of value in the years to follow. In each of the 3 war years, such battle casualty figures or statistics were included as could be prepared in time for inclusion in the report. Fairly complete statistical battle casualty tables were contained in the 1920 annual report.
Dr. Charles B. Davenport was of great assistance in the preparation of the 1918 report. He was especially helpful in the statistical analysis and discussion of the disease conditions that prevailed in the training camps during the fall of 1917 when the camps were largely regional training camps in character. Grouping of the men by regions made it possible to include considerable material of epidemiological value, such as the occurrence of diseases among men from urban as compared with those from rural areas.
Dr. Walter Willcox, of Cornell University, a statistician of national and international reputation, also assisted in the summer of 1918 in the preparation of the annual report. His contribution, included in the first part of the 1918 report, contained a historical review of the health of the Army from the time of appointment of the first permanent Surgeon General in 1818.
In addition to the statistical material included in the three reports referred to, detailed analysis of the data, together with tables with reference to war casualties, was published in the history of the Medical Department of the Army in World War I.3 The statistical material was subsequently used in War Casualties and in the tables showing the losses by divisions by engagements for gunshot missiles and poison gases and in engagements by divisions.
3(1) The Medical Department of the United States Army in the World War. Surgery. Washington: Government Printing Office, 1924, vol. XI, pt. II. (2) The Medical Department of the United States Army in the World War. Medical Aspects of Gas Warfare. Washington: Government Printing Office, 1926, vol. XIV. (3) The Medical Department of the United States Army in the World War. Statistics. Washington: Government Printing Office, 1921, vol. XV, pt. II.
