A couple of weeks ago I wrote about my visit to USS Constellation. In that post, I mentioned that the Navy had, fairly early on, instituted a program of quite rigorous examinations for prospective Assistant Surgeons. As a result of this system, I wrote, in the 19th century, Navy surgeons generally were of higher quality than their Army brethren. Shortly after I posted that blog, my friend Army medical historian Sanders Marble wrote to say “… but wait!” Herewith, Sanders’s very heartily welcomed rejoinder.
Last week Tom’s blog included the comment that the quality of Civil War naval surgeons was better than that of army surgeons. That caught my attention, and he’s graciously allowed me some space to discuss that and ask if you have any ideas about one of the underlying causes. First, from the establishment of the Army Medical Department (AMEDD) in 1818 the regulations had allowed for an entrance examination to make sure doctors were qualified. Actual procedures only developed over time, and the first examining board was not until 1832. The AMEDD also had a retention/promotion exam: after 5 years service a doctor had to pass a second exam to be allowed to stay in and be eligible for promotion. That peacetime system continued in the Mexican War. The AMEDD waived age limits on volunteer doctors but continued examinations as the Regular Army was expanded about 50%. The new regiments had to wait up to a year for their surgeons to volunteer, be examined, approved, and arrive. But the war also brought a backdoor: the volunteer regiments, enlisted by the states for the duration of the war, selected their own doctors. The AMEDD was not impressed with them: they didn’t understand sanitation, they didn’t understand Army procedures, and they were profligate with supplies. This pattern was repeated during the Civil War, but on a vastly larger scale. Most of the troops that fought were state volunteers; there were only 44 regiments of regular infantry against hundreds of state regiments. Doctors volunteering for the Regular Army still had to pass the exam, but they were a small percentage of the total serving. This created quality problems, and the AMEDD struggled to close the back door.
Some solutions were at a local level: both Charles Tripler and Jonathan Letterman (as medical directors of the Army of the Potomac) organized boards within the AoP to weed out incompetents. Surgeon General William Hammond won an organizational battle and gained authority to examine surgeons of volunteer regiments. Many were rejected (I lack numbers, but the peacetime Army rejected at least half of applying doctors) and this played into a multifaceted struggle between Hammond and Secretary of War Edwin Stanton. Hammond eventually yielded, lowered the standards, and more doctors passed the examinations. Given the problems in diagnosis and treatment in the period, it’s not clear that stricter or looser examinations made a great deal of difference in patient outcomes. So the AMEDD had quality problems (I won’t deny that) but because it could not exercise adequate quality control over all doctors in the Army. But they found ways to purge the worst offenders and regained control of the personnel system. After that, the perceived quality of Army doctors rose, although whether that had much effect on patient care is unknowable. Now to relate this back to naval medicine. How did BuMed retain control over its personnel system? Structure may be part of the answer: there were not militia and volunteer ships that joined the US Navy as the states sent regiments. Numbers were probably lower, allowing the system to work. The Navy had a more gradual mobilization. But the bottom line is the USN apparently managed to increase the volume of doctors that passed its entrance examination while not (greatly) compromising quality. How? For more, see The Army Medical Department 1818-1865 by Mary C Gillett, online at http://history.amedd.army.mil/booksdocs/civil/gillett2/gillett.html
Sanders Marble studied at William & Mary and King’s College, University of London. He has worked in the U.S. Army’s Office of Medical History from 2003-12 around a period as command historian at Walter Reed Army Medical Center in 2010. He has written and edited a variety of articles, chapters, and books on WWI, military medicine, and the history of technology.
©2012 The Society for the History of Navy Medicine