If the Bureau of Navigation were to abolish the present system of enlistment records and issue an order that an enlistment journal should thereafter be kept on board every ship and at every station, in a very short time letters would be received from the various commanders-in-chief and commandants respectfully inviting the attention of the bureau to certain objectionable features attending the keeping of such a journal. Chief among these objections would be, that, unless some record accompanied a man upon his various transfers, in the course of his four years of service his enlistment record would become widely scattered and hopelessly confused. Imagine a man, transferred five times during his four years of service, with his record of promotions and punishments carefully recorded on the installment plan on as many different journals. Captain M, on the Asiatic Station, would know very little about Tom Jones, ordinary seaman, coming to him from the North Atlantic Station, with a memorandum slip that read as follows:
Jones, Thomas, O. S.
Born, July 16, 1880, at Rome, N. Y.
Enlisted, December 1, 1899, at New York, N. Y.
Eyes, brown. Hair, black. Complexion, ruddy.
Enlistment, first.
ENLISTMENT RECORD.
Name of Vessel. Days on Board Punishments Commanding Officer
U. S. S. Minneapolis 50 1
U. S. S. Olympia 400 2
IL S. F. S. Kentucky 320 0
U. S. S. Albany 216 1
U. S. S. Vicksburg 12 0
The medical officer then has for his immediate use the record of every man on board his ship. Whenever a man appears at sick call, his record is taken from the files, and an entry made of his present condition. Should he be admitted to the list, entries can be made from day to day of the progress of the case, as well as the treatment prescribed.
The suggested record would greatly simplify the medical journal. The name and diagnosis, required in making out statistical reports, are all that would be necessary, because the health record would contain the data, now supplied by the enlistment record, as well as the origin and history of the disease or injury.
When a transfer is made from a ship to a hospital it is at present absolutely necessary to have a hospital ticket accompany the patient, but with the full history of the case recorded on the proposed health record, which would accompany the patient, the hospital ticket would not be required.
Upon the arrival of a patient at the hospital, the medical officer to whom the case is assigned, must now make out a case paper from the data obtained from the hospital ticket, and then from day to day record the history until the patient is discharged, when the case paper is forwarded to the department. If the history were to be written on the proposed health record, the case paper would no longer be necessary.
Syphilis is a disease which requires a long and continued course of treatment for its successful cure. It not infrequently happens that a man under treatment for syphilis on one ship is transferred to another, and almost invariably he thinks it a fine opportunity to free himself from the clutches of the doctor and start with a clear record, so he does not appear for treatment. Just such cases, which are neglected through no fault of the doctor, often terminate badly, and there is very little reason to doubt that many a good man has been lost to the service through this cause. With the suggested health record in use, such a mistake could not well occur, for the medical officer has before him, as soon as a man is transferred to his ship, the entire health record from the time of the man's entry into the service. Some medical officers try to better our health record a little by disregarding the printed instructions on the enlistment record. They write in the column reserved for such words as "Excellent, Very Good, and Fair," the name of the disease. This helps a little, but it has one serious objection attached to it. Health records should be strictly confidential, but if diagnoses are boldly written on the backs of the enlistment records, where every yeoman and writer on the ship can read them, they become public property.
Briefly, the advantages to be gained from the proposed health record as follows:
1. That part of the enlistment record marked health record could be used for other purposes.
2. The medical journal would be reduced to a brief record of admissions, discharges, and those continued on the list, to be used in making out the statistical reports.
3. The health record would do away entirely with the hospital ticket.
4. The hospital case paper would disappear.
5. A complete, continuous, and compact medical history of every man in the service would be secured.
6. Immediately upon the discharge of a man, his record would be sent to Washington to be filed, where it would always be on hand to facilitate the work of the Pension Bureau.
7. The record could be written on the typewriter, thus greatly increasing its legibility and clerical accuracy.
8. It would greatly assist the medical officer in making proper diagnoses in obscure cases, and would facilitate treatment in many cases which would otherwise be neglected.
9. It would assist the medical officer making the examination at the time of discharge as to his recommendation for re-enlistment.
The objection that the records are liable to go astray, maybe answered at once. No records are absolutely safe on board ship, but certainly those proposed are no more subject to loss than the enlistment records, which have stood the test of time.
There ought to be a health record for officers, modelled on the above plan, but modified to suit the conditions. Upon entrance to the Naval Academy the usual data should be entered in a small leather covered book, and during the six years as a midshipman, the health record could be kept in it. After passing the physical examination for ensign, the old record could be filed in the department, and a new book issued for the grade of ensign. A new book could be issued in this manner for each grade. Of course these records would be kept by the medical officer, and would necessarily be confidential. A great many officers take pride in keeping their names off the sick list, but the practice sometimes becomes retroactive, as many a retired officer could testify. The plea for compact and complete records is especially emphasized in the case of officers, because of the great number of years most of them remain in the service. Under our present system, it is quite a task to collect the medical history of an officer who has been in the service for forty years.
The writer again wishes to ask the readers of this article for their criticism, be it adverse or favorable, for by this means only can a decision be reached as to the actual merits of the proposed record, and whether or not it is of sufficient value to warrant its formal submission to the Bureau of Medicine and Surgery.
In closing, I wish to take this opportunity to thank Hospital Steward C. E. Alexander, U. S. N., who is responsible for the form of the descriptive list, and at whose suggestion the duplicate stub was added, so that an accurate carbon copy is made and the stub detached and forwarded to the Bureau of Medicine and Surgery.
DISCUSSION.
Medical Inspector HOWARD E. AMES, U. S. Navy.—The importance of this question is so marked that it deserves the support of every well-wisher of the service. After careful consideration of the paper as a medical officer, I find all my thoughts centered on the one conclusion, that the sooner it is adopted the better for the service, particularly for the medical section. I do not believe any experienced medical officer can logically support the present system that is now used. It is so meager, so misleading, and generally unsatisfactory that one is surprised that it has continued so long.
It is common to see under "Health record" "days on sick list," under the heading "State of Health" while on board, "bad"; which is not correct, for an investigation shows that most of that time the man's sick days were due to an injury—say a fracture or sprain. Some medical officers will add this fact, so many days fracture or sprain. This clears matters somewhat, showing that it was not bad health, but it does not give the origin, whether injury was due to the breaking of a hawser while on duty or was caused by a drunken brawl in which he was thrown from a window. These are important points to know, they show his health, his misfortunes, and his habits.
Daily, hourly, throughout the service all over the world surveys are held on men with a long medical history unobtainable. Medical boards are then obliged to vainly grope in the dark, to find some cogent reason to guide them in their findings; the absence of the medical history of the man or officer leaves you stranded. You cannot expect the patient to help you throw light upon his condition, particularly if it is against him. How annoying to afterwards have some brother officer, who knew the patient's previous history, smilingly inform you how cleverly the patient worked the board. Of course, we can insert a saving clause, "In absence of medical history," and "According to patient's statement," etc., etc. These (justly) protect the medical board, but how about the service personnel? In many, many cases it suffers.
This medical history and health record would show up the unworthy and rid the service of many dead beats. It will be of great value in not only expediting the transfer of cases, but save an immense amount of useless work, as the author points out, in the doing away with the hospital tickets, and abolishing that useless and laborious grind of making out the case papers in our hospitals. Any change that can eliminate or reduce the immense amount of paper work in the service should be encouraged, and, I feel, would be hailed with delight.
What a boon it would be to the bureau in hunting up pension cases! what a saving to the Government in money and time to have at hand the whole medical history (as they would be filed together for the individual's life career in the navy). Now, it is a laborious job to get the abstracts from the numerous medical journals of the ships the man has served.
I ask indulgence in submitting the following extract from my annual report of the Naval Academy; as it was not printed in the Surgeon-General's Report, it will be at least new reading. It is painful reading but absolutely true. As it covers the ground fairly well and bears so directly upon Assistant Surgeon Earl Brown's papers, I beg that it be printed:
"The law is explicit regarding physical soundness but these mandatory statutes are constantly being violated; no doubt unintentionally, but the fact remains that we are not sustained in our findings; and year after year, waivers are issued that cover almost every kind of physical defect. This leads to future complications which I will endeavor to crudely indicate.
"In recommending the rejected candidate for continuance for two years in the service after leaving the Academy, I respectfully call attention to the probabilities of his being continued after that time. This is due to the fact that the physical record of the midshipman has always been kept at the Academy. Now, the four years' graduate leaves the institution, and all his physical and medical records are left behind him. No matter what his record, whether he be rejected or not, nothing is placed before the medical board at his final graduating examination.
"We know, from experience, that the examinations on foreign stations and on ships are not of that rigid character that they should be. This is largely due (I frankly admit in my own experience) to a false assumption that he was physically sound when he left the naval school. There is nothing to guide the board in judging of the previous condition and, as a rule, a favorable report is made. We further know that a notice of the acceptance of the candidate is noted at the Navy Department; and rarely indeed are inquiries made beyond this last return, and the party is continued.
"Then it is often the fact that the physically defective person rejected from the first entrance into the school to the present moment, is continued in the service. To overcome this serious defect, I would suggest that a full report of the scholastic officer be sent to every station or ship to which he may be assigned, with instructions that a careful medical history with the dental record, be attached to his original academy record to be laid before the Medical and Mental Examining Board, to guide them in estimating the worthiness of the candidate for continuance in the service.
"This break in the medical record did not exist prior to the year 1899. Since that time, the records have been incomplete; beyond the department's notice that the candidate has passed. It is apparent that this error is far reaching. The medical record of an officer begins at the time he begins his official career, at the time of his final graduation. It is then the medical journal of the department begins. We then enter 'in line' or 'not in line of duty.' The breakdowns or troubles that invalid him or put him on the retired list, may have originated prior to this time, back to his original appearance for entry into the academy; but such evidence is not consulted; it lies buried in the forgotten records of this institution. The subjoined list will give an idea. The names are omitted but the fact remains indisputable. In some cases several defects existed in the same individual, any one sufficient to reject, but all were passed. Further comment is unnecessary.
"List of rejections occurring during the past five years, from 1898 to 1903, in which the defects have been waived, and the parties retained in the service:
Cause of rejection. No. of cases.
Heart disease 17
Defective vision 22
Defective hearing 10
Poor development 8
Undersize 3
Varicocele 3
Enlarged tonsils 3
Deformity and poor development 2
Defective teeth 2
Underheight 1
Kidney disease 1
Hemorrhoids 1
Enlarged testicle 1
Deformity and lateral curvature 1
Defective speech 1
Total number of rejections 76
"Note: The above represents 63 individual cases—13 were rejected for more than one disqualification."