By Commander Neil Westphalen, RAN
Health care for Australian sailors began in medieval England and the Crusades. In May 1153, a fleet of 36 ships owned by Eleanor of Aquitaine left France to carry her husband Henry II to the English Eleanor’s fleet also brought to England its first maritime laws, which were formally adopted as the Laws of Oléron by her son Richard I (the Lionheart) in 1194. Richard’s Third Crusade was the first English military overseas deployment after the Norman Conquest, and led his successor John to establish England’s first navy in 1209.
The Laws of Oléron were first used for English seagoing battle casualties, after an action off Dover in 1217.They were based on the Maritime Assizes of the Kingdom of Jerusalem, which Eleanor had brought to France from the Second Crusade. They included the responsibilities of ships’ masters with respect to hiring crew, their profit shares, discipline and welfare, and their medical care. The latter stated that if a seaman was injured through drunkenness or fighting, the master could land him forthwith. However, if the injury occurred in the service of the ship, the seaman was to be cured at the owner’s expense.
At that time English ships were open vessels similar to the Viking longships that had invaded Britain for the last time a century earlier. They hardly exceeded 80 tons and were only capable of short coastal voyages in the summer months. The only ‘cabins’ were canvas shelters, while a lack of bilge pumps made conditions very wet. The food was highly perishable, poor quality and typically boiled over a wood fire on deck.
The same ships were used for both peace and war. For the latter they were either hired or ‘impressed’ (requisitioned), and fitted with temporary castles fore and aft. In battle the crew’s job was not to fight but to manoeuvre their ships to a position where the soldiers carried on board could grapple and board, with the losers going over the side whether wounded or not. Although the need for seagoing health care was therefore minimal, it was during a voyage to Palestine in such a ship in 1227that Gilbertus de Aquila (Anglicus) provided the first known written advice on naval medicine.
European medical practice was based on the then thousand-year-old teachings of Hippocrates and Galen. Hippocrates (c460 – c377 BC), was the first Western medical authority to repudiate the concept of illness as a divine punishment. Galen (c129 – c200 AD) developed the theory of Hippocrates that illness reflected changes in the phlegm, blood, bile or black bile. Galen’s ‘humoral’ concept of illness was not completely discarded until the early 19th century. Medical practice was impeded for centuries by Galen’s errors and his reputation for infallibility.
Apart from the individuals concerned this mattered little while the volume of English maritime trade was small, distances were short, and the ability to project military power limited. However, over the next three centuries the number of English trading ships grew, while the distances they travelled gradually extended from across the Channel, to the Baltic and Mediterranean, and ultimately worldwide. Greater distances led to increased ship size and sophistication, and hence carrying capacity. The expansion in maritime trade also increased both England’s ability to project military power overseas, and the need to protect it, initially from pirates, and later from other nation states.
Henry VIII therefore established the permanent Royal Navy in 1509, with purpose-built warships manned by sailors using long-range cannon as their primary armament. These innovations proved a revolution in maritime warfare, and after their first test during the 1588 Armada campaign, they became the basis of English (later British) maritime power for the next three hundred years.
Although the need for seagoing health support for Henry’s navy was quickly recognised, it was only thought necessary to provide treatment services for surgical casualties caused by accident or enemy action. Furthermore, divisions between physicians and surgeons within the English medical profession precluded the latter from providing non-surgical care at sea. As a result, living conditions in Tudor ships (1485 – 1603) killed far more sailors than anything done by the Spanish. Even during the Stuart Navy (1603 – 1714), disease rates were often overwhelming despite innovations such as hammocks, improved bilge pumps, and moving the galley or ‘cookroom’ from the holds to the upper deck.
The Chatham Chest
The ultimate manifestation of the operational limitations posed by these living conditions was Commodore Anson’s 1740 – 44 circumnavigation. Although he was successful in capturing the Acapulco galleon off the Philippines, his voyage cost 1,300 dead from a total force of 1,900 men, of whom only four were killed in action. However, the amount of permanent disability was low, because there were relatively few battle casualties, and seamen either fully recovered or died. The remainder sought refuge in the Chatham Chest, a mutual benevolent fund to which all sailors contributed sixpence a month between 1590 and 1829. Despite frequent corruption scandals, the Chatham Chest eventually became much as its founders intended.
Until 1653 navy casualties were landed at the nearest port with no provision for their subsequent care, when a major influx of battle casualties during the First Dutch War led to the first of several wartime Commissions for Sick and Wounded. These Commissions used contracts to arrange lodging for casualties, allocate surgeons and supplies where they were needed, appoint doctors to return convalescent cases to their ships, and move long term cases to civilian hospitals. Philanthropists also did their part, the best known being Elizabeth Alkin. However, many townsfolk and civilian hospitals eventually refused to lodge Navy casualties, typically because of their longer duration of stay compared to civilians, combined with low payment rates (if paid at all). Increased contracting costs and the failure to stop convalescent sailors deserting resulted in the establishment of navy hospitals at Greenwich in 1696, Haslar at Portsmouth in 1754, and Plymouth in 1762.
Lemon juice and scurvy
In 1745 physician James Lind conducted the world’s first case control study, which found that scurvy could be treated with lemon juice. Over the next fifty years Lind’s protégés and successors, such as Thomas Trotter, Gilbert Blane and William Burnett, saw major advances in seagoing preventive health, in particular the dedicated accommodation spaces (sickbays) for the ill and injured, free clothing to prevent the spread of typhus, and improved victualling, ventilation and sanitation. For centuries the staple victuals were salt meat and biscuit.
Until the first tinned meat factory opened in 1812, the options for meat preservation included salting, drying and smoking. By 1834 tinned meat was available for the sick, but it was not until 1847 that it became a routine issue. However, the technology still had to evolve. The loss without survivors of Sir John Franklin’s 1846 – 48 expedition to the Arctic was ascribed to food poisoning. More recently an autopsy performed on the frozen body of one of Franklin’s men strongly suggests that he died from lead poisoning from that used to seal the tins. Ship’s biscuit or ‘hard tack’ was used, as bread could not be baked at sea until the invention in the 1840s of self-raising flour stored in sealed tin boxes.
Similarly, although distillation apparatus had existed since the 1690s, it was not until the steam age that ships could make their own water, instead of using doubtful sources ashore without the benefit of bacteriological testing. The impact of these advances in preserving Navy manpower was profound. It was estimated that the lives of 145,000 sailors were saved during the Napoleonic Wars (1793 – 1815), a number equivalent to the total number of serving personnel in 1815. This conservation of manpower was a potent contributor to Britain’s maritime dominance. It also contributed to the exploration of Australia from 1770. James Cook and his successors, including Bligh, Vancouver, Flinders, and King, had no losses from scurvy, and relatively few from other medical causes. Furthermore, their surgeons frequently made their own exploratory contributions as ship’s naturalists, while Surgeon George Bass discovered the strait that bears his name.
Manpower conservation also benefited the white settlement of Australia. In contrast To Anson fifty years previously, Captain Arthur Phillip’s First Fleet transported 1,350 people with only 24 deaths. With him were nine Navy surgeons led by John White, who established the first Australian public hospital. Their finest hour came in 1790-91 with the survivors of the Second and Third Fleets, which had 449 deaths from 2,732 convicts (16%). This mortality rate was caused by contracting arrangements that specified a price for transporting convicts, without stipulating that they arrive alive.
Ex-Navy surgeon’s mate William Redfern introduced smallpox vaccination after he became the first Australian-qualified medical practitioner. After the transport Surrey lost 36 of 200 convicts to typhus in 1814, it was his investigation which led to the appointment of Navy surgeon-superintendents to each transport, with specific responsibility for their welfare. As a result, over 160,000 convicts were transported in the 80 years from 1787 with an average mortality rate of less than 2%.
Victoria established the first Australian naval forces in 1865, followed by NSW, Queensland and South Australia. Dr Samuel Knaggs arguably became the first Australian Reserve Navy medical officer when he was appointed to the NSW Naval Brigade in 1872. By 1900 the colonial naval forces each had a small pool of part time medical officers, of whom three served in China during the Boxer Rebellion. The colonial navies were amalgamated into the Commonwealth Naval Forces (CNF) in 1901, but remained state-based until the RAN was established in 1911. The first permanent medical officer (Staff Surgeon Alexander Caw) was appointed in August 1912, and by the outbreak of WWI he had been joined by another six medical officers and a small pool of medical sailors.
Navy’s first (and so far only) hospital ship, Grantala, was converted for the occupation of German New Guinea. After defeating the cruiser Emden, HMAS Sydney’s sickbay staff treated eight shipmates and 65 enemy casualties, while Staff Surgeon Edward Morris RANR served at Gallipoli with the RAN Bridging Train. A total of 33 permanent and 38 reserve Navy medical officers served during WWI, while Surgeon Lieutenant (Dental) Milton Atwill became the first RAN dental officer. In addition, Staff Surgeon Algernon Bean RN became the first Director Navy Medical Services (DNMS) in 1916. The end of WWI saw the Navy’s first humanitarian aid mission, when Encounter deployed to Samoa in response to the 1918 influenza pandemic.
The hospital at HMAS Cerberus opened in 1920, followed by the Navy Ward at the Prince of Wales Hospital in Sydney. The first Australian DNMS was Surgeon Captain Leonard Darby RAN from 1927, with Surgeon Captain William Carr RAN assuming the role from 1932 until 1946. By July 1939 Navy had 19 permanent and 35 reserve medical officers, eight permanent dental officers, four permanent medical administration officers and 59 medical and dental sailors.
Over the next six years, Navy medical personnel served throughout the world afloat and in all Australian capital cities and New Guinea ashore. Personnel shortages led to the establishment of the wartime RAN Nursing Service (RANNS) from 1942 to 1948.
In 1940 – 41, Navy sickbay staff treated enemy survivors from the Italian destroyer Espero and the Iranian sloop Babr. In addition, medical staff from HMA Ships Perth, Vendetta, Parramatta, Napier and Nizam treated Army casualties from the Tobruk Ferry Run and the evacuation from Greece and Crete. Perth’s medical staff also treated casualties from the transport Essex after she was bombed at Malta. The Pacific War began for the NHS in December 1941, when HMAS Vampire rescued survivors from HM Ships Prince of Wales and Repulse. HMAS Yarra rescued 1,804 men from the troopship Empress of Asia during the evacuation from Singapore, while HMAS Hobart’s medics treated casualties from the merchant ship Norah Moller. In February 1942 sickbay staff from HMA Ships Swan, Platypus and Warrego and the shore establishment HMAS Melville treated casualties from the Japanese air raid on Darwin.
In August 1942 HMAS Canberra’s medics treated 24 shipmates at the Battle of Savo Island, while Hobart’s medics treated seven shipmates after she was torpedoed in July 1943. HMAS Australia’s medics treated 77 shipmates after a kamikaze attack in October 1944, plus another 68 shipmates from further kamikaze attacks in January 1945. Navy medical personnel also provided health care aboard the LSIs Kanimbla, Manoora and Westralia for amphibious landings in New Guinea, the Philippines and Borneo. NHS personnel losses during WWII included seven medical and three dental officers, and 17 medics. There were 43 awards, including one DSO, six DSCs, and seven DSMs.
Reconstitution of the post-war Navy began when the aircraft carrier HMAS Sydney commissioned in 1948.This required Navy to develop a seagoing aviation medicine capability. Over sixty years later, Navy’s aviation medicine support continues, with an emphasis on ship’s flight personnel and maritime rotary-wing aeromedical evacuation, supported by the RAAF Institute of Aviation Medicine. The Navy Ward at Prince of Wales Hospital moved to HMAS Penguin in 1950, with Navy hospitals at Cerberus and HMAS Albatross, and smaller inpatient facilities at HMA Ships Nirimba, Leeuwin and later Stirling, and outpatient sickbays at most other shore establishments.
School of Underwater Medicine
The new Clearance Diver branch in 1951 led to the School of Underwater Medicine (now the Submarine and Underwater Medicine Unit – East or SUMU-E) from 1963. The new Oberon class submarines from 1967 led to SUMU also undertaking submarine medicals, and this role expanded to include medical support for submarine escape training, after the Submarine Escape and Training Facility (now the Submarine Escape and Rescue Centre) opened at Stirling in 1989.
The introduction of SUMU-West in 2000 restored the provision of dedicated health support for submariners following the decommissioning of HMAS Platypus. The first submariner medics went to sea in 1999. A shortage of medical sailors led to the re-establishment of the post-war RANNS in 1964. After it was incorporated into the RAN in 1985, Navy nursing officers subsequently became eligible for senior leadership positions on the same terms as their medical, dental and medical administration colleagues.
Navy sustained six wounded in Korea, including three when HMAS Murchison was hit by shore batteries in the Han estuary. During the Vietnam War Perth’s medics treated seven shipmates after she was hit by a shore battery in October 1967, Hobart’s treated another seven shipmates after she was hit in a ‘blue-on-blue’ accident in June 1968, and Perth’s medical officer was transferred to the carrier USS Enterprise in January 1969 after a serious flight deck fire killed 27 and injured another 314. NHS personnel were also attached to the Australian Field Hospital at Vung Tau, and to Australian Clearance Diving Team Three.
On 10 February 1964 the destroyer HMAS Voyager collided with the carrier HMAS Melbourne with 82 dead. A total of 242 survivors were rescued, with treatment provided by sickbay staff in Melbourne as well as ashore at Albatross and Penguin, and at HMAS Creswell.
In addition, LSBA John Wilson was awarded the BEM for treating his shipmates despite his own. In 1969 Melbourne’s medics treated 204 survivors from the destroyer USS Frank E. Evans, after another collision cost 74 lives.
Middle Eastern experience
The response of Australia to Iraq’s invasion of Kuwait in August 1990 included three ships, plus four Task Group Medical Support Elements (TGMSE) for the US Naval Hospital Ship Comfort. TGMSE 1 led by Surgeon Captain Kerry Delaney RAN treated casualties from USS Iwo Jima after an accident fatally wounded four men. Commanders John Parkes and Andrew Robertson RAN were subsequently awarded CSCs for their work with the United Nations in overseeing the elimination of Iraq’s chemical weapons arsenal.
NHS personnel served in HMA Ships Tobruk and Jervis Bay when they transported 1 RAR to Somalia in 1992 and ashore with the Australian health support contingents in Rwanda in 1994-5. They also served at sea in HMA Ships Darwin, Anzac, Adelaide, Success and Tobruk for Australia’s participation in East Timor in 1999, and subsequently in the UN Military Hospital ashore with their Army and RAAF colleagues. The 2003 Gulf War included sickbay staff aboard Anzac and HMA Ships Darwin and Kanimbla. In April 2004 medics from HMAS Stuart led by LCDR Jodi Bailey RAN treated four casualties from USS Firebolt, after her boarding party was hit by a suicide dhow.
NHS personnel also provided humanitarian aid relief for the 1998 earthquake in northern Papua New Guinea, and the 2010 Pakistan earthquake. The largest contribution to date remains the 2004 Indian Ocean earthquake and tsunami, where Kanimbla deployed in support of Army assets in Sumatra. In April 2005 Kanimbla lost nine personnel (including LEUT Matthew Davey RANR and POMED Stephen Slattery) when Sea King 02 crashed while responding to an earthquake disaster at Nias Island.
The fifteen years from 1985 saw the closure of Nirimba, Encounter and HMA Ships Leeuwin, Lonsdale, Moreton, and Huon, the expansion of Stirling, and the upgrading or replacement of health facilities at Penguin, Albatross, Cerberus, and Creswell and HMA Ships Waterhen and Harman. A 1997 review resulted in the amalgamation of the three uniformed health services into the Defence Health Service. The closure of the operating theatre at Penguin resulted in a move to a new Navy Ward at St Vincent’s Hospital in 2008. A review that year resulted in a series of service- and regional-level agreements between the Service Chiefs and a new Commander Joint Health Command (CJHLTH). On 15 December 2011 RADM Robyn Walker became CJHLTH, and Navy’s first female two stars.
The new Primary Casualty Receiving Facilities (now Maritime Role 2 Enhanced) capability aboard Kanimbla and Manoora in 2000 restored a seagoing surgical capability that had been lost when HMAS Stalwart decommissioned in 1990. The new Canberra class LHDs will continue to enhance this capability from 2014. With a history that can be traced back over eight hundred years, the RAN Health Service continues to support Navy’s operational capability in both peace and war, through the provision of maritime health support afloat and ashore.