Navy Medicine in Araby (Episode 3)

This is part 3 of a 7 part series contrasting 19th century Navy medicine with the care today’s navy medical team provides our sailors, Marines and soldiers.

Probably the first-ever designated hospital ship in the U.S. Navy started her life as a ketch built in France in 1798 for service in Napoleon’s Egyptian campaign. Later, she was sold to the Bey of Tripoli and took part in the capture of USS Philadelphia in October 1803. Subsequently taken by LT Stephen Decatur while transporting a cargo of female slaves, she was commissioned into the US Navy as USS Intrepid. She lived up to her name participating in Decatur’s daring action to retake and burn Philadelphia in February 1804. Mediterranean squadron Commodore Edward Preble noted in a diary entry dated 9 July that he had designated the ketch as a hospital ship[1]. According to the ship’s history, this was from 1 June. She served in this role through July,[2] by which time Commodore Preble likely had in hand the Secretary of the Navy’s instructions authorizing him to establish a Naval Hospital ashore, at Syracuse, Malta or some other agreeable place.[3] Thus was the very short career of the first known U.S. Navy hospital ship.

After several months of considering ideal sites (many were rejected because of the ease with which sailors could desert from them), a house large enough to accommodate 100 men was secured in Syracuse, Sicily. Surgeon Cutbush was put in charge of the place in November 1804. About 100 men – sailors, Marines and other soldiers – received their treatment there. A treaty of peace with Tripoli in 1805 made the hospital redundant, and Cutbush was ordered to close the facility in April 1806,[4]

Upon cessation of the War of 1812, the Navy returned to the Mediterranean because the Algerians had resumed their depradations upon American merchant shipping. Navy Secretary Crowninshield intended that a Naval Hospital be established early on. Commodore Chauncy fancied Port Mahon on the island of Menorca off the southeastern coast of Spain, but the Spanish government waxed and waned in its support of the notion. Accordingly, a “hospital of sorts” was established there during the American squadron’s winter-over in 1816-17, only to be taken down when the Spanish essentially kicked us out due to our support of South American independence movements. A hospital established on the River Arna at Pisa, Italy lasted only a short while because it was too far from most Naval activity; it closed late in 1821. Meanwhile, by 1825, relations between the U.S. and Spain warmed sufficiently that a naval base was established at Port Mahon, and with it, a Naval Hospital on Quarantine Island there. This hospital – recently celebrated as the first ever permanent overseas U. S. Naval Hospital – remained in business for nearly 20 years.[5]

The only record of navy medical interaction with the inhabitants of the Barbary states that I’ve been able to find is borne in the journal of Dr Jonathan Cowdery, a Navy surgeon, held captive after the Tripolitan capture of the USS Philadelphia. Within two months of his capture, Dr Cowdery had been summoned to care for the Pascha and his officers, and by early February 1804, was requested to be physician to the Pascha’s family. So impressed was the Pascha with Dr Cowdery’s cure of his very sick son, that Cowdery worried that he would not be released with the rest of the Americans come the time the U.S. government paid the required ransom. At one point, he purposefully bungled a finger amputation on one of the Pascha’s soldiers in hopes that the Pascha would lose faith in his skills. It didn’t work, and in fact, so pleased was the Pascha with Cowdery’s work overall that he at one point he told the doctor he would not take $20,000 for his release, by comparison with $50 for each of the other prisoners, officers and men. Cowdery never mentions caring for Tripolitan commoners but seemed quite comfortable rubbing elbows with Tripolitan aristocracy.[6]

[1] Roddis, Louis H, Naval Medicine in the Early Days of the Republic, Journal of the History of Medicine, V 16 (1961), pp 103-123.

[2] Naval History and heritage Command website, article “Intrepid I (Ketch), http://www.history.navy.mil/research/histories/ship-histories/danfs/i/intrepid-i.html, accessed 1 September 2016.

[3] Roddis, op. cit.

[4] Langley, op. cit., p 97-102.

[5] Langley, op. cit., pp 267-270.

[6] Cowdery, Jonathon, “American Captives in Tripoli”, in Narratives of Barbary Captivity, Allison, RobertJ., ed., Lakeside Press, Chicago, 2007, pp 123-177

(c)2017 Thomas L Snyder

Hypoxia and Aviation

A passel of recent headlines (here, here and here, for instance) have highlighted a persistent hypoxia problem facing pilots of jet aircraft in both the Air Force and the Navy. These or similar episodes, designated “physiological episodes”, are blamed for the deaths of four Naval aviators over the past several years.

“Mountain sickness”, that is, the effects of altitude, were first written about in western literature in the 16th century, most particularly in a description of the syndrome by Father Jose de Acosta, who, in 1590, published his observations on the effects of altitude on men and animals in the Andes mountains of Peru. The British scientist Robert Boyle was the first to identify a vital factor in air that was lacking at altitude. Joseph Priestly identified that vital factor in 1774, and Antoine Lavoissier named it “oxygen” in 1777.

There the matter lay until men started going up in balloons, although apparently the first recorded “altitude-related” hypoxic deaths resulted when three men (two of whom died) were subjected to a simulated altitude of 28,000 feet in a pressure chamber developed by French physiologist Paul Bert, in 1875. As a result of these and other experiments, Bert was able to show that the breathing of supplemental oxygen could prevent the physiological ill effects of altitude.

With the advent of fixed wing aviation, and in particular, military aviation in World War I, the main thrusts of aviation medical research involved the physical safety of pilots (restraining apparatus and the like), and dealing with the cold of altitude. The use of supplemental oxygen apparently was a given, and both gaseous and liquid O2 were used.

Aviation medicine research between the wars depended on a few unsung stalwarts who responded to queries concerning the physiological effects – now including loss of consciousness while pulling gs – from the aviators and engineers who designed ever more capable aircraft. That said, developing oxygen delivery systems for aircraft expected to operate at high altitudes for hours at a time – bombers – was a critical matter. The advent of high performance jet aircraft in the late 1940s led to significant improvements in aircraft oxygen systems.

Physiologists now break the effects of hypoxia out in “stages”, viz.,

STAGES OF HYPOXIA

1. INDIFFERENT STAGE – The only adverse effect is on dark adaptation.
2. COMPENSATORY STAGE – Physiological compensations provide some defense against hypoxia so that the effects are reduced unless the exposure is prolonged or unless exercise is undertaken. Respiration may increase in depth or slightly in rate, and the pulse rate, the systolic blood pressure, the rate of circulation, and the cardiac output increases.
3. DISTURBANCE STAGE – In this stage the physiological compensations do not provide adequate oxygen for the tissues.
   Subjective symptoms may include fatigue, lassitude (state of exhaustion), somnolence (drowsiness, sleepiness), dizziness, headache, breathlessness, and euphoria.
   Objective symptoms include:
       Special Senses – Both the peripheral and central vision are impaired and visual acuity is diminished. 
       Extraocular muscles are weak and incoordinate – Touch and pain are diminished or lost. Hearing is one of the last senses to be impaired or lost.
       Mental Processes – Intellectual impairment is an early sign and makes it improbable for the individual to comprehend his own disability. Thinking is slow. Calculations are unreliable.
   Memory is faulty. Judgment is poor. Reaction time is delayed.
       Personality Traits – There may be a release of basic personality traits and emotions as with alcoholic intoxication (euphoria, elation, pugnaciousness, overconfidence, or moroseness).
   Hyperventilation Syndrome – Over-breathing due to excitement or stress. Cyanosis – Blue discoloration of the skin.
4. Critical Stage – In the critical stage consciousness is lost. Death follows shortly.

Source: http://www.mountainflying.com/pages/mountain-flying/hypoxia.html, accessed 31 July 2017

Which brings us to today. Modern jet combat aircraft – including the T-45 trainer, Navy F/A-18s and E/A-18s, and all F-35s – have very sophisticated on-board oxygen generation systems. Engineers’ attention is now being directed to this commonality, the “OBOGS”, among the aircraft where the “hypoxia-like” episodes have happened. Another factor seems to be altitude: all reported episodes appear to be have occurred above 25,000 feet, and engineers now suspect a malfunction in the oxygen metering device in these systems at these altitudes.

Until the engineers find a solution to the problem, the services are limiting operations in OBOGS-bearing aircraft to below 25,000 feet, introducing oxygen monitoring devices and beefed up supplemental oxygen supplies, and giving aviators additional training in how to recognize symptoms of hypoxia before they reach the “disturbance” stage.

(c)2017 Thomas L Snyder

Navy Medicine in Araby (Episode 2)

This is part 2 of a 7 part presentation contrasting 19th century navy medicine with the care the navy medical team gives our sailors, Marines and soldiers now:

In the early 19^th century the most widely accepted general theory of disease is that it represented an imbalance of the system, either in direction of “excitement” or its opposite, “enfeeblement”. Treatments were therefore aimed at reversing these imbalances. For example, most fevers were interpreted as manifestations of too much excitement, and a common treatment was to tip the balance toward enfeeblement by bleeding the patient, often at a pint or more at a go. Other enfeebling regimens included aggressive catharsis using calomel, a mercury containing compound and inducing vomiting by use of medications like tartar emetic.[1] Very few “targeted” treatments were available, among which was calomel used with success against syphilis, Peruvian bark (which contains quinine, then effective in treating malaria, a disease manifested by cyclical fevers) for treatment of any fever, and after many fits and starts, the juice of citrus for prevention and treatment of scurvy. Interestingly, although lime juice had been part of the recipe for grog in the Royal Navy since 1747 because of its proven antiscorbutic effects, the eminent American Naval surgeon Edward Cutbush, in his 1808 treatise Observations on the Preservation of the Health of Soldiers and Sailors, seems not to have entirely bought into the idea, as he does allow that “[w]hen in countries where limes or lemons and sugar can be purchased cheap, it would be well to … issue sugar and lime …to make punch, which would counteract any tendency to scurvy that may be among the crew.[2]

The first meaningful U. S. naval force arrived in the Mediterranean, ship by ship, throughout 1802. The frigate Chesapeake was the flagship of this squadron. In her sickbay – below decks and generally devoid of natural light and fresh air – the ship’s surgeon and his assistants (an assistant surgeon or surgeon’s mate, and a loblolly boy) would care for sailors who were too ill to work, or who were convalescing from debilitating injuries. In an era when men did not have the benefit of modern scientific knowledge, deaths from disease greatly outnumbered those from combat. Yet common sense and an emerging experience led Cutbush to recommend attention to “the following leading particulars: 1^st. In keeping the ship dry and properly ventilated. 2ndly. In attending to the cleanliness of the crew in their persons and clothing. 3rdly. In their avoiding cold, fatigue and intoxication. 4thly. In keeping them warm by fires in the winter season. 5thly. In preserving an exact and regular discipline, and in furnishing the crew with sound, wholesome provisions and water.

“If a contagious disease appear on board: 1^st. Separate the sick from the well and prevent all unnecessary communication with the sick berth. 2ndly. Keep the ship clean, dry, and properly ventilated. 3rdly. Let the men avoid cold, fatigue and intoxication. 4thly. Dissipate moisture betwixt decks by means of fires. 5thly. Avoid depressing the spirits of the people by unnecessary severity. 6thly. Let the berth deck be frequently whitewashed with lime.”[3] Based on the principles laid down by Cutbush, we may conclude that he placed much emphasis on the prevention of disease by encouraging cleanliness of both ships and men and by providing a more healthful environment and decent food. Although medicos in the early 19^th century had no idea of bacteria or viruses as the cause of disease, or of the mechanisms of contagion, they did get the public health principle of isolating the sick quite right. The beneficial effects of whitewashing appear to be limited to making a dark space like the berth deck seem brighter; that whitewash – essentially lime paint – traps dirt and insect parts, in effect promoting cleanliness, and may have mild antibacterial effects is discussed mainly in modern treatises on buildings.[4]^,[5],[6]

The ship’s cockpit is where the surgeon and his assistants would care for battle casualties. Such care was pretty much limited to stopping hemorrhage with tourniquets or ligature – tying off bleeding vessels – dressing wounds and amputating limbs. The commonest combat injury to sailors in this era was from flying wood splinters, and these produced terrible, shredding-type wounds. In these cases, the surgeon’s task was to remove as many of the splinters as possible, because, it was thought, these splinters were the direct cause of lockjaw[7]. The surgeon would also cleanse the wounds with water and vinegar and apply ointments and dressings. Part of the surgeon’s cockpit kit was a pail of sand that could be spread on the deck so the surgeon and his assistants might keep their footing when it became slippery from spilled blood. According to Professor Langley, American forces lost at least 181 men during the Barbary period, of whom perhaps 45 were combat-related. Three men, including two medical men and one Marine Corps lieutenant, died as a result of duals.[8]

[1] Warner, John Harley, “From Specificity to Universalism in Medical Therapeutics – Transformation in the United States in the 19^th Century”, In Leavitt, Judith Walzer, and Ronald L Number, eds., “Sickness and Health in America: Readings in the History of Medicine and Public Health, Madison, University of Wisconsin Press, 3^rd Edition (Revised), 1997, pp 88, 89.

[2] Cutbush, Edward, Observations on the Means of Preserving the Health of Soldiers and Sailors; and on the Duties of the Medical Department of the Army and Navy, with Remarks on Hospitals and Their Internal Arrangement, Philadelphia, Thomas Dobson, 1808, pp 119. Obtained on line at https://archive.org/details/2548038R.nlm.nih.gov, downloaded as a pdf file on 24 August 2016.

[3] Cutbush, op. cit. p 131, 132.

[4] Resilience.org, “Use Whitewash Instead of Paint for Traditional Look and No Toxins”, http://www.resilience.org/stories/2014-04-29/use-whitewash-instead-of-paint-for-traditional-look-and-no-toxins, accessed 13 September 2016.

[5] GSA, “Properties and Uses of Whitewash Paints”, http://www.gsa.gov/portal/content/112558, accessed 13 September 2016.

[6] 5 Acres & A Dream, The Blog, “Amish Whitewash”, http://www.5acresandadream.com/2014/05/amish-whitewash.html, accessed 13 September 2016. This article in particular cites two sources, from 2005 and 1919, which describe the “mild antimicrobial” effect of whitewash.

[7] Which we now know is caused by the bacterium clostridium tetani, carried into the tissues by the splinters.

[8] Langley, op. cit., p 106

(c)2017 Thomas L Snyder

Your Correspondent on Streaming Radio

Occasionally, a surprise opportunity falls into our laps. This radio interview, broadcast on a streaming service called ReachMD, has me discussing my interest in the history of naval / maritime medicine, the society I co-founded (The Society for the History of Navy Medicine), the history of the Navy’s first hospital on the west coast (at Mare Island in the San Francisco Bay), and the contrast between Navy medicine in the 19th century and the 21st century. The audio clip is 11min29sec long. Learn and Enjoy!

https://www.reachmd.com/programs/clinicians-roundtable/the-history-american-naval-medicine-a-military-doctors-society-mission/9658/

(c)2017 Thomas L Snyder

Navy Medicine in Araby – Then and Now (Episode 1)

Historians, Doctors, and the History of Medicine

I assiduosly follow the listserv MEDMED-L (Medieval Medicine). The list manager is Monica Green, Professor of History at Arizona State University. Professor Green oversees a lively conversation that covers not only the history of medieval medicine, but also a general academic “take” on all matters medicohistorical. It gives me, a non-academic, insight into trends in historiography. She also posts occasional rants or pet peeves.

In her most recent of the latter, Professor Green cites a recent blogpost in which the British classicist Helen King describes “a particularly fine case of Bad History” in a newly published medical textbook. Professor Green takes the story and runs with it, observing that a relevant piece of historical scholarship never made its way into PubMed, a definitive bibliography for medical researchers. She concludes, “So, this is what we’re up against when we’re talking about the invisibility of humanistic work. We’ve talked about this on MEDMED-L multiple times, but even with Google and Google Scholar, it seems that people simply won’t step outside of certain boundaries when it comes to bibliography”. She means that mainstream medical authors don’t do a good job of researching and understanding historical aspects of their discipline.

This state of affairs is ironic because physicians themselves “discovered” medical history in the modern west. Early in the 20th century, men like William Osler, who was classically trained, and Fielding Garrison, a pioneer in the history of military medicine, cited their history direct from Greek and Latin. Two of the most renowned mid-century historians of medicine were physicians: Henry Sigerist mastered 14 languages – including Arabic, Sanskrit and Chinese – which he applied to his study. Unfortunately, he died of a stroke long before he had completed his work. More durable was Owsei Temkin, another physician giant in the history of medicine. Russian born and German trained, Dr Temkin held forth as Professor of History of Medicine at Johns Hopkins, publishing his last book just a year before he died at 99.

By around mid-twentieth century, PhD historians had also discovered medical history, and since that time, have come to dominate all aspects of the discipline, and justifiably so: they bring training in historical techniques, and, almost as importantly, the linguistic skills necessary to probe the ancients. That’s not to say physicians have left the field entirely. For instance, Howard Markel, MD., PhD, Professor of the History of Medicine at the University of Michigan is well known and well regarded, and has published more than 100 articles and reviews, and written or edited 10 books. Nevertheless, it’s pretty clear – despite protestations* to the contrary – that a PhD / MD divide exists in the production (and use?) of medical history. And, at least by the example cited here, MDs may not be doing such a good job of citing their own history, especially if that history is not found in the medical (vice historical) literature.

What to do? Professor Green says that relevant historical writing needs to find its way into standard medical research bibliographies. Surely, if the National Library of Medicine owns a volume, it should be listed in PubMed. In addition, I think that medical editors should, as a matter of policy, insist that works containing historical references be subjected to rigorous peer review – by historians. Professor Green closes, I’m not sure how relevantly, “Hence the value of blogs, which erase the scholarly / popular [shall I say ‘PhD / MD”] divide.”

The perspective physicians and other medical professionals bring to the medicohistorical enterprise  lends a vitality that dry historicism cannot. Even if we don’t have the skills or inclination to research and write medical history, our most human of professions calls on us to portray it with exemplary accuracy, and I might add, with extraordinary passion.  We need to make it part of our way of thinking.

*The American Association for the History of Medicine, “a professional association of historians, physicians, nurses, archivists, curators, librarians, and others…” was founded in 1925 by a group of physicians. Some years ago, I attended the traditional Clinicians Historians’ Breakfast at an AAHM annual meeting. There, much bonhomie was generated around the importance of doctors to the medical historical enterprise. “After all, doctors create the history, and their presence provides verisimilitude to the undertaking”, people seemed to say. I’m not so sure the majority of attendees actually believed this, and I think that’s a good part of why a PhD / MD divide exists.

On the Scurvy

It’s been a long time since I’ve posted here, and I’m sorry for that. Blame it on a very busy life, which can’t be all bad! First, a new grandbaby, born on the Ides of March, to our younger son and his wife, both in the Foreign Service, who had to come home from their posting in Azerbaijan for the happy event. Needless to say, we visited them in Baku last year – a very interesting place worth a post (but in a different blog, for sure!). The past couple of years have also seen me as Commander of the San Francisco Commandery of the Naval Order of the United States, the oldest – and a preeminent – U.S. naval history society.  My command tenure will end in December, and I’m already looking forward to doing some more writing and blogging. Here’s the first salvo—

In January, quite by chance, I came across a New York Review advertisement for a then new book, Scurvy – the Disease of Discovery by Vanderbilt University humanities chair Jonathan Lamb (Princeton University Press, 2017). I quickly added it to my Kindle library, and there, by and large, it has sat. While Professor Lamb does give an up to date description of our current scientific understanding of the cause and pathophysiology of the affliction (well known now to be due to a dietary shortage of ascorbic acid, which by some genetic fluke, humans lost the ability to synthesize many millennia ago), the book has been a slow slog for me. That’s because, at least as far as I’ve gotten into it, it’s really a history of the (non-medical) literature about the disease, made up of descriptions of the horrors of scurvy (and, strangely the “wonders” of it, too) by sufferers and observers from the 15th century forward. The author also makes some interesting side trips into, say, the history of the philosophy of science as it relates to the (mis)understanding(s) of the disease in the centuries leading up to our only relatively recent scientific insights. So far, I’m really disappointed by the author’s treatment of the history of the development of that understanding. His research on this matter seems pretty much limited to the British literature (the Dutch, French and perhaps others DID write about the disease) by way of reruns of the venerable Keevil / Lloyd & Coulter multivolume history of medicine in the Royal Navy. So nothing new here.

I plan to write a more thorough review – if ever I can successfully grind my way all the way through – really: this book is hard work! In the nonce, if any reader wishes to put forward a review earlier than that (whenever it might happen), feel free to send it to me and I’ll happily – even eagerly – post it, with appropriate attribution of course.

Technical Glitch / Learning Opportunity

Yesterday I tried to post a 38 minute video of a talk I gave on the history of Naval Hospital Mare Island, California, the Navy’s first Hospital on the west coast. The video transfer didn’t “take”, however, so back to the drawing board.

The video does appear on a Facebook page of the same name: Of Ships and Surgeons. Go take a look if you can.

Our Shrinking Historical Patrimony

I’ve posted on this topic before, noting that the ravages of time and disasters (both natural and man made) seemingly inexorably erode the historical landscape. I argued that historians should lead (or at least actively support) efforts for the preservation of historical landmarks and other artifacts.

Just recently I learned of the possible imminent demolition of such an artifact – the 1920s Spanish-revival style former Oak Knoll Country Club and Officers’ Club for the Oakland (California) Naval Hospital. 

U.S. Naval Hospital Oakland – “Oak Knoll” to Bay Area locals – sprang into existence in 1942 as part of Navy Surgeon General Ross McIntire’s massive World War 2 expansion of Navy medical facilities.* Even before war broke out McIntire, realized that the Naval Hospital at Mare Island – the Navy’s first on the west coast – was too old, too small and vulnerable to collateral damage from any Japanese air strike on the huge shipyard nearby. He directed 12th Naval District officials to cast about for a replacement location, one that would be convenient to Alameda Island in the San Francisco Bay (where casualties from the war in the Pacific would be landed by ship and later plane), and capacious enough for a very large facility. McIntire’s agents hit upon the Oak Knoll Country Club, a luxurious facility that had gone bankrupt as a result of the Great Depression. Its facilities, including the lovely Club building, had lain fallow for several years. In April 1942, the government began the proceedings necessary to procure the property. The hospital received its first patients in August, and by the end of the war was caring for 3000 or more wounded and sick service personnel. The old Clubhouse was repurposed as the hospital Officers’ Club – a dining facility and watering hole for doctors, nurses and other officers serving in or visiting the facility and the Bay Area.

Oakland Naval Hospital, around 1945. Officers’ Club ? in lower right corner. Naval Hospital San Leandro , purpose-built to care for psychiatric casualties, is in the background.

The hospital flourished, especially after the Mare Island hospital closed in 1957. Its staff of doctors, nurses and corpsmen and corps waves cared for casualties of the Korean and Vietnam wars, and for legions of military family members and retirees. The “temporary” ward buildings you see in the image above were finally replaced with a new “Moderne”-style tower structure in 1968. Your correspondent drilled as a Reservist in one of those “temporary” buildings, in the 1980s. – Ed. The hospital closed in 1996 as part of the “BRAC”^ process that shuttered military bases and facilities all across the country.

Today, all that remains on the 160+ acre site is the Country Club / Officers’ Club. Developers had cleared the land by the early 2000s for a large housing area. At the time they expressed the intent of preserving the structure for use as a community center. This project came to a halt in 2008, a victim of the Great Recession. Now, developers are proceeding, but this time they express the intent to demolish the Club.

Naval Hospital Oakland Officers’ Club building, neglected. Next: demolition?

Facing the possibility that this lovely and historical structure may go away, a group of Oakland residents – Oakland Heritage Alliance – are mobilizing the forces to lobby Oakland city officials for its preservation, restoration and adaptive reuse. A piece of our historical patrimony hangs in the balance. Hearings are scheduled for some time this spring.

*U.S. Naval Hospitals numbered 19 at the outset of World War 2. One, at Cañacao in the Philippines, was lost early to the Japanese invasion. By the end of the war, the Navy was operating 99 hospitals. This number included country clubs, hotels, college dormitories “taken up from trade” or purchased outright (this is another story), and large, semi-permanent base, mobile and fleet hospitals located typically in “exotic” locations like Tutuila, American Samoa (e.g., Mobile Hospital No 3) or Hollandia, New Guinea (e.g., Base Hospital No 17).

^BRAC – [Defense] Base Realignment And Closure – the most recent in a long string of United States military base closures that began shortly after World War II. In all, something like 350 bases and installations went out of business in the five rounds (1988, 1991, 1993, 1995, 2005) of the BRAC process.

(C)2016 Thomas L Snyder, MD

History of Medical Corps Ranks – a Guest Post

by André Sobocinski*

Medical titles for the U.S. Navy were established by the Act of 24 May 1828 for the “Better Organization of the Medical Department of the Navy.”   After 1828, a Navy medical officer could serve as a Surgeon, Passed Assistant Surgeon, and Assistant Surgeon. You also see the term “Acting Assistant Surgeon” which usually denoted temporary service (a la contract) or a physician who was serving aboard a ship but has not yet received a commission or been approved by a Board of Naval Surgeons. It should be understood that Naval medical officers were called “surgeons”, but were qualified nominally to practice both medicine and surgery.

The 1828 Act provided that all candidates for appointment needed to be examined by  a Board of Naval Surgeons (AKA Board of Examiners). Upon
successful completion of the exam, the newly appointed physician would be given the title of “Assistant Surgeon.”   In order to be promoted to
Surgeon, the Assistant Surgeon needed to serve at sea for at least two years and be examined again by the Board of Naval Surgeons.  Successfully passing the board did not mean that he was automatically promoted to Surgeon.  Until vacancies occurred the Assistant Surgeon would be known as a “Passed Assistant Surgeon.”   Medical Officers could serve for years as a Passed Assistant Surgeon. We even have cases of physicians retiring from service as a Passed Assistant Surgeon.

These medical titles did not have an associated rank until 31 August 1846, when new regulations provided for “relative” ranks. Surgeons with more than 12 years of experience held “relative rank” equivalent to Navy line Commanders.  Surgeons with less than 12 years of experience held “relative rank” of Lieutenant Commanders, Passed Assistant Surgeons, as Lieutenants, and Assistant Surgeons were considered roughtly equivalent to Lieutenants (junior grade).

On 3 March 1871, the title structure was again altered.   The Navy Medical Department now had the additional titles of Surgeon General, Medical Director, Medical Inspector, Surgeon, Passed Assistant Surgeon, and Assistant Surgeon.  Each of these conferred additional relative rank (Surgeon General=Commodore (one star), Medical Director=Captain, Medical Inspector=Commander, Surgeon=Lieutenant Commander, Passed Assistant Surgeon=Lieutenant, Assistant Surgeon=Lieutenant (junior grade) or Ensign). In 1899, the Surgeon General/Chief of the Bureau of Medicine and Surgery (“BUMED”) was given relative rank of Rear Admiral (two star).

On 15 August 1918, the concept of relative rank was abolished by General Order 418. Medical Officers were finally accepted in the Naval hierarchy and
looked upon as Naval Officers (the exception to this in 1918 was the Nurse Corps). With this said, the titles Medical Director, Passed Assistant
Surgeon etc continued to be used through 1947, but after WWI were less commonly used.  A Medical Director would typically be called Captain, Passed Assistant Surgeon a Lieutenant Commander, etc.

As for Navy’s medicine’s most senior officers, from 1842-1871, the Chief of BUMED was a Surgeon,  equivalent to Commander; 1871-1899 the Surgeon General/Chief of BUMED was equivalent  to a Commodore (one star); 1899-1918 the Surgeon General/Chief of BUMED had the relative rank of Rear Admiral (two stars); from 1918 to 1965 the Surgeon General/Chief of BUMED had the rank of Rear Admiral. The only exception to this was Ross McIntire who, while serving simultaneously as FDR’s White House physician and Navy Surgeon General, held the three star rank of Vice Admiral. From 1965 to present the Surgeon General/Chief of BUMED holds the rank of Vice Admiral.

The Navy very wisely established Boards of Examiners in a day when medical education in the U.S. was unregulated and quite irregular. To assure a certain level of competence, each candidate for appointment as Assistant Surgeon had to pass a rigorous examination of his knowledge of medicine, surgery, anatomy, obstetrics and gynecology, pharmacy, legal medicine and more. For the convenience of the candidates, the Examining Boards sat at the Naval Asylum at Grays Ferry (Philadelphia), Brooklyn (Naval Hospital/School of Instruction), and later Washington, DC (Naval Museum of Hygiene/Naval Medical School).  In the mid to late 19th century examinations were also conducted  at Norfolk, VA, New Orleans, LA, and at Mare Island Navy Yard, CA.

Image: http://s277.photobucket.com/user/Sheriff__001/media/USNavyOffier.png.html, accessed 27 May 2015. The modern rank of Rear Admiral (lower half) was known as Commodore in earlier years. The Coast Guard retains the rank of Commodore for its one star flag officers.

*André Sobocinski is the Historian in the Communication Directorate at the U.S. Navy Bureau of Medicine and Surgery in Washington DC (his physical location is in Falls Church, VA). André wrote this article in response to a question about medical officer relative ranks put to the Executive Director of the Society for the History of Navy Medicine, Professor Annette Finley-Croswhite.

©2015 André Sobocinski