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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Development of the United States Army Dental Service
ORGANIZATION OF THE ARMY DENTAL CORPS PRIOR
Dentistry, during the pioneer days of the profession in the United States, had no military status; and there exist only a few unofficial references to dental treatment in the accounts of the first wars in which the country was engaged. A notable exception, however, was the dental treatment accomplished for General George Washington, who experienced dental difficulties during the time he served as Commander in Chief of the Colonial Army and later during his terms as President. Records reveal that Washington had several dentures made by civilian dentists and that he was very much pleased with his dental service.1
Almost one hundred years passed after the Revolutionary War before there was any official Army recognition of dentistry or legislative action to initiate the organization of an Army Dental Corps. During these hundred years the profession continued to develop and to broaden its scope.
The first organized effort to secure dentists for an army was the conscription of these to serve in the Confederate Army in 1864.2 The soldiers of the Confederate armies could not pay for dental treatment in the depreciated currency of the Confederacy since the fee for one gold filling was more than 6 months' pay of a private. Consequently, the Confederate States Congress passed a law for the conscription of dentists who were to have the rank, pay, and allowances to which their position in the Army entitled them, and in addition extra duty pay for extraordinary skill as allowed by The Surgeon General. The rank and pay offered the Confederate dental officers is not recorded. Each dentist furnished his own instruments, but other equipment and supplies were purchased from hospital funds.
After the Civil War, a. number of years passed before there developed another wave of concerted interest in making dental service available to the Armed Forces. Members of the dental profession and the National Dental Association initiated and sponsored legislative measures to provide for the appointment of dental surgeons for service in the United States, Army. The
1Robinson, J. B. : The foundations of professional
dentistry. In Maryland State Dental Assoc., and Am. Dent. A.: Proceedings
Dental Centenary Celebration, 1840-1940. Baltimore, Waverly Press, Inc.,
first such legislation approved by The Surgeon General and the War Department was enacted 2 February 1901. This bill authorized the employment of a maximum of 30 dental surgeons, on a contract basis, to serve the officers and enlisted men of the Regular and Volunteer Army.3
One of the first dentists so appointed was Dr. John S. Marshall who formulated the plans for the organization of the dental service.4 Dr. Marshall, who was one of the most active, versatile, and forward-looking men in the new service, served as senior dentist until 1911. His continual efforts to promote a better dental service for the Army and to effect a more favorable status for the contract dental surgeon are reflected in the legislative acts and Army regulations which have appeared in the years since 1901. These are tributes to Dr. Marshall and the small group of original dental surgeons who were willing to sacrifice position, pride, and income to demonstrate the real value of dentistry to the military service.
Initially, the contract dental surgeons were attached to the Medical Department and assigned to duty by The Surgeon General or chief surgeon of a military department. In 1908, they were authorized by law to become a part of the Medical Department5 and finally, in 1911, a bill which included a provision for the commissioning of dentists was enacted into law. That part of the act of 3 March 1911 (36 Stat. 1054), pertaining to dentistry, reads:6
Hereafter there shall be attached to the Medical Department a dental corps, which shall be composed of dental surgeons and acting dental surgeons, the total number of which shall not exceed the proportion of one to each thousand of actual enlisted strength of the Army; the number of dental surgeons shall not exceed sixty, and the number of acting dental surgeons shall be such as may, from time to time, be authorized by law. All original appointments to the dental corps shall be as acting dental Surgeons, who shall have the same official status, pay, and allowances as the contract dental surgeons now authorized by law. Acting dental surgeons who have served three years in a manner satisfactory to the Secretary of War shall be eligible for appointment as dental surgeons, and, after passing in a satisfactory manner an examination which may be prescribed by the Secretary of War, may be commissioned with the rank of first lieutenant in the dental corps to fill the vacancies existing therein. Officers of the dental corps shall have rank in such corps according to date of their commissions therein and shall rank next below officers of the Medical Reserve Corps. Their right to command shall be limited to the dental corps. The pay and allowances of dental surgeons shall be those of first lieutenants, including the right to retirement on account of age or disability, as in the case of other officers: Provided, That the time served by dental surgeons as acting dental or contract dental surgeons shall be reckoned in computing the increased service pay of such as are commissioned under this Act. The appointees as acting dental surgeons must be citizens of the United States between twenty-one and twenty-seven years of age, graduates of a standard
3GOs and Cirs. 1901, Hq of the Army, GO 9,
6 Feb 1901, sec 18, p. 8. SG: 1027.
dental college, of good moral character and good professional education, and they shall be required to pass the usual physical examination required for appointment in the Medical Corps, and a professional examination which shall include tests of skill in practical dentistry and of proficiency in the usual subjects of a standard dental college course: Provided, That the contract dental surgeons attached to the Medical Department at the time of the passage of this Act may be eligible for appointment as first lieutenants, dental corps, without limitation as to age: and provided further, That the professional examination for such appointment may be waived in the case of contract dental surgeons in the service at the time of the passage of this Act whose efficiency reports and entrance examinations are satisfactory. The Secretary of War is authorized to appoint boards of three examiners to conduct the examinations herein prescribed, one of whom shall be a surgeon in the Army and two of whom shall be selected by the Secretary of War from the commissioned dental surgeons.
The following were appointed dental surgeons with the rank of first lieutenant, after the act of 3 March 1911: 7
A number of the men among this group played important roles in the further development of the Corps and participated actively in both the First and Second World Wars.
Forty-seven dental surgeons entered into contract with The Surgeon General during the period from 1901 to 1911. Contracts of 3 were terminated as a result of death and 15 were annulled, 10 at the dentists' own request and 5 for miscellaneous reasons.10
7Memo, SG for CofS, 8 Feb 11, Dental surgeons
in the U. S. Army, with list of dental surgeons, and their years of service,
attached. Natl Archives, SG: 106047.
Early in 1915, the Association of Military Dental Surgeons submitted to The Surgeon General a "Bill to Increase the Efficiency of the Dental Corps, U. S. Army."11 The Adjutant General informed The Surgeon General 5 February 1915 that the Secretary of War did not approve of any legislation for the Dental Corps.
However, the Legislative Committee, National Dental Association, whose chairman was Dr. Homer C. Brown, continued to initiate and support legislative measures which would increase the efficiency of the Dental Corps. Late in 1915, recommendations which provided for the organization of a Dental Reserve Corps, and for the increase in rank in the Dental Corps to captains, majors, and one chief with the rank of colonel, were submitted to The Secretary of War and to The Surgeon General.
The Surgeon General, in response to the recommendations made by the Legislative Committee, directed a memorandum to the Chief of Staff in which he declared that the Dental Corps as organized then did not attract the best men graduating from the various dental colleges, and that he was in favor of the various grades with the exception of colonel. The Surgeon General believed that the grade of colonel and a chief of the Dental Corps was unnecessary. The organization of a Dental Reserve Corps, however, was deemed advisable.
The next development was the receipt by The Surgeon General on 20 February 1916 of the following telegram:12
The National Dental Association of nearly 20,000 members and an equal number in other dental organizations must vigorously oppose the contract status and the relative rank for dental corps as proposed in your recently published bill. We consider this discrimination as unnecessary and humiliating and must insist that our representatives in Army be accorded dignified recognition and actual rank in keeping with importance of service rendered. We prefer to cooperate with you and will greatly appreciate your support but under herein-mentioned conditions we have no choice. Wire collect if your attitude is misunderstood or any change in situation.
In his reply to Dr. Brown, The Surgeon General stated that: "My desire is to increase the efficiency of the Dental Corps and provide a proper flow of promotion. The question of titles given to the various grades is, I believe, a matter of secondary importance. There is no objection upon my part to the same provision regarding rank as is now authorized for the Medical Corps."13
Finally, after much activity on the part of the National Dental Association the Association of Military Dental Surgeons, state, and city societies, legislation was enacted on 3 June 191614 which provided for the organization
11Ltr, Pres, Assoc of Mil Dent Surgs, to SG,
12 Jan 15. Natl Archives, SG : 90384-I.
of a Dental Corps in the National Guard, and for the establishment of an Officers' Reserve Corps. Included in this legislation was the following section which gave further advantages to the Army Dental Corps:
The President is hereby authorized to appoint and commission, by and with the advice and consent of the Senate, dental surgeons, who are citizens of the United States between the ages of 21 and 27 years, at the rate of one for each 1,000 enlisted men of the line of the Army. Dental surgeons shall have the rank, pay, and allowances of first lieutenants until they have completed 8 years' service. Dental surgeons of more than 8 but less than 24 years' service shall, subject to such examinations as the President may prescribe, have the rank, pay, and allowances of captains. Dental surgeons of more than 24 years' service shall, subject to such examinations as the President may prescribe, have the rank, pay and allowances of major; Provided, That the total number of dental surgeons with rank, pay, and allowances of major shall not at any time exceed 15: and provided further, That all laws relating to the examination of officers of the Medical Corps for promotion shall be applicable to dental surgeons.
The act of 3 June 1916 authorized the President through the governors of States and Territories and the Commanding General of the District of Columbia to appoint and commission dental surgeons as first lieutenants at the rate of one for each thousand enlisted men of the line of the National Guard. However, only the President was authorized to appoint and commission reserve officers in the various sections of the Officers' Reserve Corps. The act provided that the proportion of officers in any section of the Officers' Reserve Corps should not exceed the proportion for the same grade in the corresponding army, corps, or department of the Regular Army, except that the number commissioned in the lowest authorized grade in any section was not to be limited.
According to The Surgeon General's annual report to the Secretary of War, 30 June 1918, the National Guard included 249 dental officers on 5 August 1917. By 30 June 1918 the number had increased only to 253, of whom 251 were first lieutenants. There were only two who were promoted to the rank of captain, and this was not accomplished until March 1918.15
The same report indicated that by 31 July 1917 there were 598 commissioned in the Reserve Corps, while on 30 June 1918 there were 5,372. The distribution of rank in the total number of dental reserve officers commissioned and on duty on the latter date was as follows: majors-36, captains-244, and first lieutenants-5,092.16
With the advent of World War I,17 the rapid mobilization of the Army and with it the Dental Corps led to many additional responsibilities for the dental surgeons. The National Dental Association, various state dental societies, as well as individual officers of the Dental Corps made requests for increased rank
15Annual Report of The Surgeon General, U.
S. Army, 1918, Washington, Government Printing Office, 1918 (cited hereafter
as Annual Report ... Surgeon General).
and privileges commensurate with these responsibilities.18 19 The Surgeon General was favorable to the request that the Dental Corps be given equal status with that of the Medical Corps, and this status was achieved by the passage of H. R. 4897, the act of 6 October 1917, which provided that:
Hereafter the Dental Corps of the Army shall consist of commissioned officers of the same grade and proportionally distributed among such grades as are now or may be hereafter provided by law for the Medical Corps, who shall have the rank, pay, promotion, and allowances of officers of corresponding grades in the Medical Corps, including the right to retirement as in the case of other officers, and there shall be one dental officer for every thousand of the total strength of the Regular Army authorized from time to time by law: Provided further, That dental examining and review boards shall consist of one officer of the Medical Corps and two officers of the Dental Corps: Provided further, That immediately following the approval of this Act all dental surgeons then in active service shall be recommissioned in the Dental Corps in the grades herein authorized in the order of their seniority and without loss of pay or allowances or of relative rank in the Army: Provided further, That no dental Surgeon shall be recommissioned who has not been confirmed by the Senate.
Much credit for the passage of this bill was reflected upon Dr. Homer C. Brown, chairman of the Legislative Committee of the National Dental Association20 for his untiring efforts to place dentistry on a plane equal to that of medicine in public service. The Journal of the Association of Military Dental Surgeons of the United States in commenting on the splendid work of Dr. Brown said:
In regard to credit, much credit for wholehearted, unselfish, untiring devotion to this cause is due to several of a small coterie of men. Some of these have been laboring to this end for years; others for months only, but for once in the history of dental politics all had a hold on the same end of the rope in the final tug of war, and by pulling together achieved the result.21
In the period between the two World Wars, enactment of various legislative measures22 did not significantly change the status of the Dental Corps. It was not until the United States was actively engaged in the hostilities of World War II that attempts were again initiated to enact legislation specifically designed to accomplish this. The primary basis for such action was the increasingly frequent charge that the morale of dental officers and the efficiency of the Dental Service suffered from the so-called "domination" of the Dental
18Ltr, Hon Ambrose Kennedy, Cong f rom R. I.
to SecWar, 12 Apr 17 with incl R. I. Dental Society Resolutions. Natl Archives,
SG: 106047, Pt II-84.
Corps by medical officers.23 24 Since such charges were made by responsible persons, and since they received wide publicity, a discussion of medicodental relations, as reflected in the subsequent legislative proposals, is necessary in spite of its highly controversial nature.
A certain amount of friction between the professions concerned with health care is, of course, nothing new. By nature the professional man is usually independent, and the long years of training necessary to master his subject fosters the attitude that no outsider can understand his particular problems or be competent to exercise control over his treatment of patients. Historically, both medicine and dentistry were originally practiced by persons of low standing in the community, but medicine attained professional status much earlier than dentistry, which remained largely a mechanical art to the end of the 19th century. As the health implications of dentistry were recognized, and as the educational background of dentists improved, the latter began a rapid climb toward professional, social, and economic equality. Nevertheless, relations with medicine were occasionally marred by the physician's conservative tendency to regard dentists as upstarts in the health field, and by the dentist, as a member of a profession fighting for recognition, to suspect discrimination where none was intended. Also, the physician irritated the dentist by telling his patients that they should have their teeth extracted, and the dentist reciprocated by advising that dental treatment would cure general medical conditions.
As both professions gained experience they realized that their patients would receive, better care if the physician and the dentist cooperated to use their special skills to the utmost, and such teamwork has become routine. But in the process of adjustment dentistry has rigidly maintained its independence and has fully shared medicine's traditional objection to control from outside the profession. As late as 1945 the Committee on Dental Education of the American Dental Association (ADA) withdrew its approval of a large and respected dental school because it had been integrated with a. medical school and placed under the general supervision of a medical educator, justifying
23Articles on this subject appeared in the
dental press almost continuously after 1943. The following were typical:
(1) Rank without authority. Oral Hyg. 33: 932-937, July 1943; (2) Freedom
for the Dental Corps. Ibid. 33: 960-961, July 1943 ; (3) The score of discrimination.
Ibid. 33: 1230, September 1943.
this action with the statement that any interference by medicine in the field of dental education was considered dangerous.26
In the Armed Forces the position of both the professional services has necessarily been less independent than in civilian practice. All activities of a military organization must be directed toward a common objective and subject to the orders of a commander responsible for the results achieved. At some level both medicine and dentistry must come under lay control since the highest staff positions must be filled by combat officers. So far as the dental service was concerned, therefore, the question at issue was not: "Were dental officers tinder the supervision of nondentists?" but: "Was the nature of the supervision such as to hamper their activities unnecessarily?"
On the basis of Army regulations and directives alone, the dental officer certainly exercised less control over the dental service than officers of most other branches did over their respective activities. This situation resulted from the two following circumstances: (1) As a staff officer the dental surgeon did not enjoy the usual privilege of presenting his views and recommendations directly to the executive authority; (2) while all medical treatment was given in installations under the direct command of medical officers, dentists did not command dental installations.27
As a subordinate of the surgeon, the dental surgeon was limited to submitting recommendations only to that officer; if they were approved they were submitted to the commander secondhand by an officer who might be neither completely familiar with the matter under discussion nor personally interested in supporting the dentist's views against opposition from other staff members. If the surgeon did not approve the dentist's proposals they could be dropped without formality, and if he chose to substitute his own recommendations the lay commander did not necessarily know that they were not the views of the dental surgeon.
The practical effect of this situation of course depended upon the attitude of the surgeon. Many surgeons with long experience as staff officers gave loyal and effective support to their dental surgeons, and in some cases their reputation and standing even enabled them to get more consideration for the dental service than the dental surgeon could have himself obtained, especially when the latter was a junior officer. It was also held by some that the medical officer would generally show more understanding and sympathy toward dental problems than would a line officer. On the other hand, it could not be denied that the dentist was one step removed from the authority which made decisions, and this fact inevitably resulted in some delay even when action was favorable; the dental surgeon's proposals had to be approved by two officials rather than one. The more severe critics of the dental surgeon's status held
26Dental Education at Columbia University.
J. Am. Dent. A. 32: 1150, 1 Sep 45.
that medical officers could not have a full understanding of dental problems and requirements, and that at times they were actually in competition with the dental service for personnel and funds. The fact that lack of direct staff representation did entail some disadvantage was pointed out by The Surgeon General in 1943 when he protested that service command surgeons were being hampered in their duties by the necessity for presenting their recommendations to the commanding general through a subordinate staff officer. At that time he noted that:28
... the Medical Department has continued to function in the service commands and to produce excellent results as a whole. I feel, however, that these results have been obtained from extra efforts and personal contacts rather than from that at which we are aiming; namely, simplified procedure and efficiency.
Officially, the dental surgeon was an adviser to the surgeon, without formal authority even within the dental clinic. Here again, the actual status of the dental surgeon depended upon the attitude of the surgeon. Many medical officers routinely consulted the dentist on matters concerning the dental service and accepted his advice in the absence of important reasons to the contrary. On the other hand, it cannot be denied that a determined surgeon could, by invoking his authority to make out efficiency reports, completely dominate the dental service, even in respect to determining treatment or assigning personnel within the dental clinic, matters which were specifically reserved to the dental officer by regulation.29 The dentist was not inclined to demand even his legal .rights if he could expect, as a result, to receive a poor efficiency rating and be transferred to an undesirable post because he was "uncooperative."
The mere fact that the dental service functioned with reasonable efficiency during the war is strong evidence that medical officers generally showed considerable restraint and good judgment in their supervision of dental activities. The editor of Oral Hygiene, who was a constant critic of the status of the Army and Navy Dental Corps, conceded this when he wrote:
It is true that the relationship between many individual dental officers and medical officers is characterized by cordiality, understanding, and faithful cooperation in caring for the soldiers and sailors of the United States,. It is the exceptional case in which the medical officer actually attempts to dominate or exert authority over the dental officer.30
However, it was too much to expect that all of the 45,000 medical officers in the Army would have the necessary experience and judgment to administer the dental service wisely. Some of them were junior officers who had been promoted rapidly to important positions in connection with the expansion of the defense forces; others were former civilian physicians who did not understand that staff supervision did not imply detailed interference in routine matters of internal administration. When medical officers of these types felt
28Rpt. Conference of CGs, SvCs, ASF, 22-24
Jul 43. HD: 337.
called upon to "run" the dental service the results could only be unhappy. The Surgeon General himself pointed out that "special problems related to the professional dental service as well as to the special skills and techniques common only to dentistry are best understood and administered by those trained in that field."31
Some of the more specific aspects of the problem of medicodental relations are discussed in the following paragraphs.
Effect of the Administrative Status of the Dental Service on Morale
The fact that the morale of dental officers at the end of the war left much to be desired is discussed in chapter IV. This situation is significant here because it was widely blamed on unsatisfactory relations with medical officers. This subject covers a wide field, however, and it is necessary to consider complaints on a more specific basis.
One of the common causes of criticism was lack of opportunity for promotion in the Dental Corps compared with the Medical Corps. In April 1945 the proportion of medical and dental officers in each grade was as follows: 32
It is clear that the dental officer had much less chance to reach field grades, but the extent to which this was the fault of the Medical Department is not so clear. The Surgeon General had only advisory authority over the allotment of grades within the service commands, in the Air Force, in tactical units, or in theaters, leaving a negligible part of the Army in which his influence was decisive. Also, the War Department itself was slow to approve increases in ratings for dental officers in table-of-organization units due to the tradition that high grades should go only with the command of large numbers of troops. Common sense had of course forced many modifications of this principle; the chief of staff of an army was at least a major general though he did not command any soldiers, and the chief of the surgical service of a large hospital was likewise a colonel, while the commander of a collecting company, with a hundred men, was only a captain. Obviously, responsibility should be the criterion for the allotment of grades, not mere numbers of troops commanded. Nevertheless, this attitude cropped up whenever advanced rank
31Ltr, Col Robert J. Carpenter to CG ASF, 12
Apr 45, sub: Revision of AR 40-15. SG: 300.3.
for staff positions was mentioned. The Surgeon General supported successful efforts to speed the promotion of dental lieutenants in tactical outfits; he recommended the promotion of the chief of the Dental Division to the grade of major general; and he made a sincere and fairly successful effort to obtain the same grades for the chiefs of hospital dental services as were held by the corresponding chiefs of the medical or surgical services.33 Occasionally, however, the Medical Department appeared to foster the view that dental officers had no responsibilities beyond the rendering of treatment at the chair on an individual basis. Thus, when a representative of the Surgeon General's Office testified against legislation to provide additional general officers in the Dental Corps by stating that so far as he knew no dentist ever commanded more than one man (his dental assistant) , he ignored the fact that a colonel of the Dental Corps would have been held directly responsible for any defects of the dental treatment rendered by more than 4,000 dental officers in Europe alone.34 It is pertinent to note, in this connection, that the Medical Corps had itself carried on a similar fight for increased rank for medical officers during World War I, claiming that line officers ignored the advice of junior medical officers, and that such increases had been opposed by line officers on the ground that physicians had no command responsibilities!35
Dental officers also complained of discrimination when they were held for 36 months of total service following the war, while medical officers were released after only 30 months. The president of the ADA wrote:36
From time to time during the war period, there has been considerable resentment from the dental officers due to the present Army regulations. These complaints were. minor and few compared to the protests that are arriving now. These men have developed a bitterness toward the American Dental Association, threatening to resign and form a new association. They are also bitter in their condemnation of the Government and the several branches of the service.
Basically, the need to hold dentists arose from a single action: the termination of the dental Army Specialized Training Program (ASTP) in July 1944. The War Department decided to discontinue the dental ASTP in spite of opposition by The Surgeon General who had supported the recommendation of the Dental Division that the ASTP be continued and that sufficient older officers be released to create the necessary vacancies for younger graduates.37 Nor does this decision indicate any conscious discrimination on the part of the War Department itself. At the time it was taken the Dental Corps was at maximum authorized strength, while the Medical Corps was desperately scrambling for manpower. The General Staff felt that in view of the critical need
33Final Rpt for ASF, Logistics in World War
II. HD: 319.1-2 (Dental Division).
for men to carry the war to an end, the dental ASTP could no longer be justified, while the need for the continuance of the medical ASTP was obvious. It may or may not be held that a mistake was made, but there is no evidence of any intent to treat the Dental Corps unfairly in this instance.
Evidence is more definite that, justifiably or not, the morale of the dental officers suffered from the belief that the Dental Service was unnecessarily subordinate to the will of medical officers. A senior dental officer who conducted an official investigation of the Dental Service in Europe reported that:38
With the exception of one or two dental officers interviewed, all were either Reserve or AUS. The majority of these officers were very bitter as to the treatment or discrimination towards the Dental Corps by medical officers. Most of them stated that they would take action through their local dental societies on return to. the states. As one officer expressed it, they were "damned sick of being kicked around by medical officers."
The editor of Oral Hygiene reported that the number of dentists who blamed the ADA for not taking more vigorous corrective action was so large that it threatened the future of that organization.39 The dean of one of the larger dental schools warned that returning officers were advising young dentists to stay out of the armed services Dental Corps,40 and the ADA charged that personnel troubles encountered after the war were largely due to the resentment of dentists at their status during hostilities.41 This latter claim appears exaggerated since the unusually large income to be made in private practice during the period of postwar inflation was also an important factor, but it is significant that such a charge should be made by a reputable organization.
It is difficult to determine the exact extent to which this widespread feeling of resentment was justified. Wartime conditions inevitably led to some confusion and injustices, and even the ADA admitted that some of the instances of failure to assign officers to duty for which they felt they were fitted, or of failure to provide warranted promotions, were probably unavoidable.42
Presumably some dentists failed to understand the need for more supervision in the Army than in private practice and suspected discrimination where it did not exist. It is further possible that many criticisms arose over relatively minor incidents. Such was the case when a captain of the Dental Corps and a lieutenant of the Medical Corps started for a supply center in a jeep; the captain climbed into the front seat and was promptly ordered into the back seat by the lieutenant because the latter, as surgeon, was the dentist's commanding officer.43 Such instances were merely exhibitions of bad judgment on the
38Pers ltr, Col James B. Mockbee to Lt Col
George F. Jeffcott, 8 Sep 46.
part of inexperienced officers but they inevitably received considerable publicity and tended to create resentment even on the part of officers who had never known such treatment personally.
But after discounting many claims of arbitrary treatment at the hands of medical officers, it must be admitted that Surgeons possessed the authority to dominate the dental service if they so desired, and it seems probable that this authority was exercised unwisely in some cases. Responsible members of the organized dental profession denied categorically that the letters they received came from any minority group of malcontents.44 The fact that both the Director of the Dental Division, SGO, and The Surgeon General recommended certain administrative changes designed to give dental officers increased authority supports the belief that discontent was based on something more than emotional and groundless resentment.
Effect of the Status of the Dental Service on Efficiency
Failure to Consult Dental Surgeons on Matters Affecting Their Dental Service. In December 1944 the Director of the Dental Division reported the following situation to The Surgeon General: 45
Information continues to reach this office that there are some stations where the Post Surgeon does not give proper consideration to the Dental Service and, instead of coordinating the Dental Service with the Medical Service, he places it in a subordinate position and in many instances ignores the chief of the Dental Service and his recommendations, even to the extent of recommending dental officers for promotion without consulting the Camp Dental Surgeon. Such conditions as this should not and would not exist if the Service Command Surgeons concerned would not condone such action by their Post or Station Surgeons.
The Dental Corps is an integral part of the Medical Department and should always remain as such. It is unfortunate that there are still some medical officers, who, apparently, do not realize this and that the Dental Corps desires to assist in every way possible and assume its share of the responsibility in carrying out the mission of the Medical Department.
The attitude of some few medical officers, who apparently are determined to subordinate the Dental Corps, tends to offset the wonderful attitude of comradeship and friendliness exhibited by the majority of Medical Corps officers. These acts of subordinating the Dental Corps by the few officers reach the civilian profession through dental officers on duty, and have caused much agitation by a certain group for a complete separation from the Medical Department. I am entirely opposed to any such action as it would lessen the efficiency of both the Medical and Dental Corps.
I am sure The Surgeon General desires that Service Command Surgeons correct any subordinated status of the Dental Corps which may exist at their headquarters, and in their taking steps to pass this on down to the lower echelons.
The Surgeon General's disapproval of this undesirable situation which did exist in some cases was confirmed by the Director of the Dental Division
44See footnote 24 (2), p. 7.
in his remark that "General Kirk is fully cognizant of the administrative problems in some of the lower echelons of command and accordingly plans for a change in Army regulations are now under Way."46 He also stated that The Surgeon General had "offered every assistance and approval for more administrative control of dental affairs by dental officers in the lower echelons,"47 and further, that "General Kirk . . . has given the Dental Division a free hand in the direction of its policies and personnel. . . . If a comparable relationship could be obtained throughout all the channels of command, the primary objections now raised by many. . . would be erased . . . . "48
Lack of Effective Control of Dental Personnel. One of the most frequent causes of complaint by dental officers was their inability to control dental personnel. Under unfavorable conditions the surgeon could, and did, take the following actions detrimental to the morale and efficiency of dental officers:
1. Failed to allot sufficient dental officers to the dental clinic.49
2. Failed to provide adequate grades for the dental service so as to make possible reasonable promotion.50
3. Used dental officers in unimportant nonprofessional duties.51 At times this latter abuse was carried to fantastic lengths. Thus when the surgeon of a service command was directed to send 12 Medical Department officers to the Medical Field Service School he sent 12 dental officers because he held that medical officers could not be spared, and on their return these dentists were used in administrative functions because they alone had the necessary training.52 Even worse, the same dentist was occasionally sent to the Medical Field Service School twice to avoid losing the services of a medical officer.53 These were, admittedly, extreme examples, and the misuse of dental officers was largely eliminated in the United States by the determined efforts of The Surgeon General. Overseas, however, it continued to exist to some degree until the end of hostilities.
4. Granted leaves of absence to dental personnel without consulting the dental surgeon.
5. Promoted dental personnel against the advice of the dental surgeon.54
6. Rendered efficiency reports on dental officers without consulting the dental surgeon.55
46Major General Mills prefers changes in regulations
to legislation to correct inequalities in the Dental Corps. J. Am. Dent.
A. 32: 489, 1 Apr 45.
7. Failed to assign enlisted assistants in sufficient numbers and in appropriate grades. Dental enlisted assistants were assigned to the dental clinic by the surgeon, they were promoted by the surgeon, and they could be withdrawn at any time. Lack of a permanent corps of enlisted men, with adequate ratings, was one of the most serious deficiencies noted by the Director of the Dental Division after the war.56
8. Removed enlisted assistants from the dental clinic for outside duties on short notice. This situation was of course unavoidable in an emergency, but practically paralyzed the dental service when it occurred.57
Professional Interference. It was reported that surgeons sometimes prohibited dental surgeons from committing patients to the hospital, using general anesthetics, or prescribing certain drugs legally used by dentists.58 It is believed, however, that this difficulty was more commonly encountered in the Navy; it appears to have been a matter of minor concern to Army dentists.
Extent of Medical Interference in Dental Administration
The extent to which the efficiency of the Dental Service actually suffered from medical supervision, if at all, is extremely hard to determine. Wartime conditions varied so much from camp to camp that it is impossible to compare the actual output of clinics operating under different degrees of medical control, and neither medical nor dental officers were impartial enough to render completely unbiased opinions in the, matter. Editorials in the dental press would indicate that medical interference was almost universal, but closer contact with individual dentists revealed that many of them were angry at injustices they had heard about rather than experienced. Further, while almost every dental officer felt that some interference had occurred, some of them were not sure that they would not have encountered equal restrictions under line officers. It is certain, however, that most dental officers, from the Chief of the Dental Division down, felt that a clearer definition of the responsibilities and rights of dental officers was imperative.59 60 61
LEGISLATIVE AND ADMINISTRATIVE ACTION REGARDING
One of the first moves to improve the status of the Dental Service was the campaign of the ADA to get advanced rank for the Director of the Dental
56See footnote 33, p. 11.
Division who was then (April 1943) a brigadier general. When The Surgeon General of that period stated that "the Dental Corps had all the representation in the higher brackets to which it was entitled"62 bills were introduced in Congress to provide that the Director of the Dental Division should have the grade of major general and that the Dental Corps should be allotted brigadier generals in the same ratio as the Medical Corps.63 Before these bills could be acted upon a new Surgeon General had taken office and the ADA made new efforts to get action informally, without legislation. The new Surgeon General was apparently somewhat lukewarm to certain aspects of the idea, but he agreed to make the Director of the Dental Division a major general and to consider the possibility of appointing one or more brigadier generals in the Dental Corps.64 Attempts to pass legislation were then dropped. The promotion of the Director of the Dental Division was announced shortly, but no brigadier generals were appointed until 4 January 1945, and the single officer so promoted was again reduced to the grade of colonel on 1 December 1945. (A bill to provide for a rear admiral in the Dental Corps of the Navy had become law in December 1942.)65
About the same time The Surgeon General personally initiated efforts to get more administrative authority for dental officers within the framework of the existing Medical Department organization. In July 1943 he sent the following letter to the commanding generals of all service commands:66
1. The Dental Corps is an integral part of the Medical
Department, and must function as such. But dentistry, being a specialty
of which few medical officers have ample knowledge, can function more efficiently
if members of the Dental Corps are consulted and their advice sought on
all matters pertaining to the Dental Service.
Results of this action were not too encouraging. Protests in the dental press grew in volume and the Director of the Dental Division reported at the end of 1944 that conditions in the field were far from satisfactory.67
62See footnote 42, p. 12.
Early in 1944 the ADA began to consider seriously the introduction of legislation to change the status of the, Dental Service. Its Committee on Legislation finally advised against such action, however, for the following reasons:
1. It was believed that the new Surgeon General should be given a chance to bring about the desired changes through administrative procedures.68
2. The Director of the Dental Division advised against legislative action because he felt that administrative correction was preferable and possible, and because he felt that the introduction of permanent legislation in the middle of the war was neither appropriate nor likely to receive favorable action.69
The attitude of the Committee was expressed as follows in February 1944:70
He [The Surgeon General] has been very cooperative with the members of the Dental Corps and [he has] stated that beneficial changes will be made.
With such cooperation, the Committee on Legislation will grant every opportunity for the correction of inadequacies by the department itself before seeking correction by legislation. The Surgeon General of the Army and the chief of the Army Dental Corps are in agreement that no legislation should be sought at the present time. This Committee is satisfied to place this responsibility for adjustment in their hands.
The aims of the ADA at this time were stated in very general terms, but they appear to have included two principal objectives:
1. The right of the dental surgeon to take his problems and recommendations directly to the commander of any installation. It was desired that:
. . . dental officers be permitted to present their cases and problems, without lesser intervention, to the officer generally responsible for the activity. In a hospital, this would be the medical officer in charge. In a line organization, this would be the commanding officer. These officers, by virtue of their position and wider responsibility, would bring to their decisions the impartial viewpoint that now does not always characterize such decisions.71
2. "Autonomy" for the Dental Service. This word was of course open to many interpretations and it undoubtedly meant different things to different persons. It was defined by the Committee on Legislation of the ADA as "the power, right or condition of self-government, or, in its secondary meaning, as practical independence with nominal subordination."72
The condition of "practical independence with nominal subordination" was the one already envisaged in Army regulations. The surgeon of an installation had "nominal" authority, but it was hopefully expected that he would use it principally to arbitrate in matters where the interests of the Dental Service touched those of other activities, leaving the dental surgeon free to handle all routine administration. The fault in this conception was expressed
68See footnote 42, p. 12.
by the chef who said "there is no such thing as a little garlic." In view of the accepted military tradition that responsibility must be matched by authority there is no such thing as "nominal subordination" in the Army. As long as the surgeon was in command of dental activities and responsible for their success the War Department rightly objected to any efforts to diminish his final control over those activities. It might recommend very strongly that the surgeon consult the dental officer, but it could not logically direct him to accept the latter's advice; nor could the surgeon excuse his errors by stating that he had taken the dentist's recommendations, for if be felt that the dental surgeon's views were faulty he was not only allowed, but expected, to reject them. Even the authority to go directly to the commanding officer when the surgeon disapproved the proposals of the dental officer would have been a precedent-shattering departure from accepted staff procedure. On the other hand, to give the occasional authoritarian type of officer "nominal authority" is to give him a powerful weapon with instructions not to use it; sooner or later the temptation to "show who is boss" becomes overpowering. It would seem, therefore, that attempts to give the Dental Service actual independence while keeping it under nominal supervision could not be expected to prove uniformly successful.
The "power of self-government" was more definite, although further qualification was needed even here. The Committee on Legislation, ADA, generally agreed, as did the Director of the Dental Division and The Surgeon General, that a completely independent Dental Corps was not necessary or desirable. It was stated that "The profession of dentistry, as a unit, has no hesitation in serving under a surgeon general who is a, member of the profession of medicine. This plan, dictated by the close association of dentistry and medicine in the interests of general health, is satisfactory."73 Again, "From some quarters, there is an insistent demand for a separate Dental Corps. Since the work of the Medical Corps and that of the Dental Corps is so closely allied it is felt by those who have made a close study of the problem that a complete separation of the Dental Corps from the Medical Department in both the Army and the Navy would hinder the effectiveness of both corps."74 On the other hand, the Committee on Legislation did not agree with those who felt that authority to go to the commanding officer with dental problems would be sufficient.75 It also wanted to be assured that local surgeons would not in-tervene in purely dental affairs. This attitude was expressed as follows by the head of the Canadian Dental Service, which was completely independent, under the Adjutant General of the Canadian Defense Forces:76
We all admire the Medical Service for what it knows and what it does, but there are two great reasons why it is difficult to understand why it should retain control
of the Dental Service. First, it has a tremendous job on its hands to deal efficiently with the great number of medical problems of the Forces. For this reason alone it is imperative that the Dental Service should carry its own burdens. Second, most Medical Officers admit that they are not trained as Dental Officers and are not qualified to "run the dental show" as is often stated.
Probably the clearest statement of the objective of the ADA was the following:77
We can agree that The Surgeon General must be the final and overall authority in regard to all matters having to do with the health of the soldier. However, as regards dentistry, once certain fundamental policies have been agreed upon, the Dental Corps, under its own chief, should be free to carry out those policies. This is our conception of autonomy in, the Dental Corps.
Apparently the aim of the ADA was subordination to The Surgeon General at the major policy-making level, with administrative independence at all lower echelons. The application of such a plan involved some administrative difficulties since the dentist had to commit patients to the hospital, he used clinic space which was generally within the area controlled by the surgeon, and his activities could not altogether be divorced from those of the Medical Corps in the operating installations. Also, the dental surgeon might find him-self responsible for personnel administration, the procurement of supplies, and other matters which had previously been handled by the surgeon and his assistants. Such separation of functions was administratively possible, however, and it was later actually carried out in the Navy.
Efforts to secure changes in Army regulations progressed slowly. In April 1945 the ADA stated that unless action was soon taken it would sponsor legislation to bring about the desired modifications.78 At about the same time he Surgeon General submitted the draft of a revised Army regulation which represented his views on the matter of increased responsibility for dental surgeons.79 This draft was amended several times before it was submitted, apparently on the basis of informal consultations with ASF, and it is possible hat it already represented some compromise between what The Surgeon General wanted and what he thought he could get. As submitted by The Surgeon General this tentative regulation provided that matters affecting the Dental Service as a whole would be administered by The Surgeon General, with the assistance of the Director of the Dental Division. In lower echelons, however, dental affairs were to be administered by the dental surgeon, though the latter was bound to consult the surgeon and seek his concurrence before action was en. Any matter on which an agreement could not be reached was to be referred to The Surgeon General, though this provision was changed in subsequent drafts to allow settlement of conflicts by the local commanding officer.
77See footnote 42, p. 12.
The War Department, in turn, eliminated some desired features80 before the regulation was finally published in August 1945.81
In its published form the regulation provided that "matters relating to the dental service as a whole are administered by the Director, Dental Division, an assistant to The Surgeon General, through The Surgeon General," giving at least the appearance of greater authority for the Director of the Dental Division than had been implied in the original phrase "by The Surgeon General with the assistance of the Director of the Dental Division." Similar wording was used to describe the authority of subordinate dental surgeons, as follows: "In a theater, service command, or any other headquarters, matters relating to the dental service are administered by the dental surgeon, through the surgeon." All recommendations initiated by the dental surgeon were to be routed through the surgeon, who was required to forward them to the commanding officer with his comments. The dental surgeon was also given authority to render efficiency reports on his own personnel.
The ADA claimed that the new regulation did not make any substantial change in existing relations, asserting that "the causes of frequent complaints by dental officers have been wrapped up with new words but considerable care has been exercised not to remove them. The domination of the Dental Corps by the Medical Corps may have been gently disturbed but, by and large, it remains complete and unshaken."82 General Mills admitted that he had "had to make some concessions,"83 but he maintained that the new regulations were a great improvement over the old and that they provided "more for our Corps than we could get if we were a small, separate branch." It would appear that there was some truth in each of these statements. The new regulations gave official approval to a general principle for which the ADA was working, but their practical effect was likely to be negligible. The right to present dental problems to the commanding officer, for instance, meant little as long as the surgeon had to be consulted and as long as the latter initiated efficiency reports on the dental surgeon. (The dental surgeon made out the reports for his officers, but his own efficiency report was made out by his immediate superior, the surgeon.) Only a very intrepid dental surgeon would insist on taking a recommendation to the post commander against the expressed opposition of the surgeon when the latter would subsequently report on the dental surgeon's efficiency, including his "cooperativeness," during the year.
At the end of hostilities it appeared that the ADA and the Army would not be able to come to a voluntary agreement concerning changes to be made in the status of the Dental Corps, and the former went ahead with its earlier plan to attain the desired objective through legislation.84
80See footnote 60, p. 15.
During the above period, however, other legislation which proposed the removal of the command restriction provision of the law of 1911,85 a limitation. which had not been placed on the Medical Administrative, Pharmacy, Veterinary, or Sanitary Corps, was approved by The Surgeon General and The Adjutant General. On 29 June 1945, an act was passed to grant dental officers the same command privileges enjoyed by other officers of the Medical Department.86 While passage of this legislation did not affect the provision of Army regulations that only Medical Corps officers might command organizations dealing with the treatment, hospitalization, or transportation of the sick or wounded87 it did make dental officers eligible for administrative positions which had previously been closed to them for what seemed to be inadequate reasons.
40-15 authorized many of the modifications which had been
recommended by the ADA and by dental officers. This revision promised much
for long-term improvement in the operation of the Dental Service.-Ed.