J Royal Naval Medical Service 2012, Vol 98.2 39

Dental Branch History The Harvey-Fletcher Medal and Prize

Grant E J

Introduction to the Medical Director General. The first book covering the history of the Royal Naval Harvey’s ‘memorial’ to the MDG, which he entitled The Dental Service (RNDS) from its inception in 1905 to 1964 Blue Jackets’ Teeth (3), was based on research that he had was published in 1995 to coincide with the celebration of the undertaken while he had been serving in the Royal Naval Branch’s 75th Anniversary (1). Barracks at Sheerness. He carried out dental examinations A follow-up volume covering the years 1964 to 1995 has on 1,022 sailors over the age of twenty, who had originally just been published (2) and the text of this article, covering joined the Navy as Boy Seamen. He found that more than the history of the Harvey- Fletcher medal and prize, borrows one seventh of the total number of teeth had been extracted unashamedly from both volumes of these histories. or had decayed and from this concluded that “every seventh Acknowledgment is made that the References annotated man in the Navy is toothless”; a number he considered in the first two sections of this article derive from the strikingly large. meticulous research carried out by the late Surgeon Harvey believed that there were three main causes for Commander (D) Nick Daws for the 1995 publication. this dental disease: first, a want of cleanliness; second, a lack of employment for the teeth (the sailors’ diet had got softer Staff Surgeon Christopher Harvey by the 1880s); and third, insufficient professional attention The Harvey-Fletcher medal, the most prestigious to the teeth. award in the gift of the Director Naval Dental Services, For the first two of these, Harvey recommended that commemorates the two founding fathers of the RNDS. “a toothbrush, or better still a pointed stick of soft wood, The first of these was Staff Surgeon Christopher Harvey. be used by friction up and down, after the manner of the Harvey, a far-sighted naval doctor, was concerned about the natives of India” and that soft food be avoided. To rectify poor dental health of the sailors in the Fleet, a matter which the third cause, Harvey stressed at great length, the need he brought to the attention of the Medical Director General for professional dentists to be employed by the of the day. He had assumed that the dental treatment of and he urged that: “at the large Home of Haslar, sailors was being carried out by medical officers and he was Plymouth and Chatham, skilled dentists be permanently appalled to discover that it was not. He wrote: attached, whose sole duty should be to attend to the teeth of the men”. “It is unquestionable that formerly, medical officers It was, sadly, to be another fifteen years with further themselves had a great tendency to neglect the teeth of the men pressure from other authorities, including the British under their charge and to relegate the duties of extraction to Dental Association, before the Admiralty finally and formally the sick berth stewards, men who too frequently abused such accepted that there was a need for dental surgeons to care improper powers”. for the personnel of the Royal Navy. Yet, even then it was to be 1905 before the first appointments were made and Harvey had been serving in HMS Warrior in 1870, when the the following advertisement appeared in the British Dental sick berth steward had proudly presented him with two large Journal: Lazenby’s Pickle bottles, one full, the other, two thirds full “The services of three DENTAL SURGEONS are of teeth that he had extracted over a period of ten months, required for duty with the Naval forces in the United Kingdom without the knowledge of the ship’s medical officer. from April next. They will be required to devote their whole The thought of the pain and suffering associated with time to their duties, and they will receive an inclusive salary these extractions had such a profound effect on Harvey that of £1 per diem, and, when necessary, travelling expenses. he decided to investigate the true extent of dental problems The period of engagement will be for one year, and under in the Navy. conditions specified in the contract. The necessary dental The vagaries of service appointments prevented him appliances will be provided. The Dental Surgeons will be from carrying out his research until 1880. For the same stationed at Portsmouth, Plymouth and Chatham, but will reason, it was not until 1886, by which time he was stationed be required to give attendance elsewhere as directed by the at the RN Yokohama, that he presented his findings Naval Commander-in-Chief. Application, by letter, should 40 General

be addressed to the Director General, Medical Department were given commissions in the RNVR, while the existing of the Navy, 18 Victoria Street, London S.W., not later than dental surgeons, to their embarrassment, retained civilian MARCH 7TH, and should be accompanied by evidence status. Jellicoe acted promptly, with the result that dental of age and qualifications, and by not more than two recent surgeons serving at sea were granted commissions in the testimonials.” (4) temporary rank of Dental Surgeon RNVR. Those, however, Despite this slow start, the Admiralty continued to drag who did the same work ashore continued as civilian dental its heels on the matter of ‘in Service’ provision of dental surgeons and, not unreasonably, felt that they too should be care and by 1910, the number of civilian dental surgeons granted commissions (8). employed within the Royal Navy numbered only twelve (5): Fletcher considered resigning over the issue of commissions, but eventually decided that he could best Royal Naval Hospital Haslar 1 serve the Navy and influence the outcome by remaining in Royal Naval Barracks Portsmouth 2 Devonport. Royal Naval Barracks Chatham 2 The Admiralty became aware that public ridicule, or Training Establishment Shotley 2 worse, scorn, might be directed at the non-uniformed HMS Impregnable (& Plymouth Hospital) 1 dental surgeons and attempted to protect them from it, Royal Naval Barracks Devonport 2 rather bizarrely, by not providing uniforms and issuing each Depot Deal 1 man with a card indicating that the bearer was engaged in Chatham Hospital 1 essential war work! Representations on this issue continued to be made, Edward Ernest Fletcher not only by the civilian dental surgeons, but by the BDA and It was at this time that one Edward E Fletcher applied even in the House of Commons, but to no avail (9). for one of the above positions and, after undergoing the By the time of the Armistice, there were 84 uniformed selection process, was appointed to the Royal Naval Barracks dental officers serving at sea, but together with their civilian Devonport as one of two dental surgeons, working on the colleagues, these were far from the numbers required top floor of the Sick Quarters – the other being W Grant to provide an effective dental service to the hundreds of Oliver LDS. thousands of naval personnel. Indeed, so poor was the By 1914, the conditions of service, under which the dental health of the Fleet that the busiest members of the civilian dental surgeons were employed, which had been dental teams were the dental mechanics making dentures questioned by the BDA in 1905, were giving rise to such to replace the sailors’ teeth as fast as the dental officers dissatisfaction that they petitioned the Admiralty for could extract them! Towards the end of the war, the dental improvements to be made (6). mechanics were granted the rate of Chief Petty Officer. Fletcher showed early tendencies of becoming the Fletcher and others continued to agitate on the issue spokesman for and champion of naval dentistry and the of commissions and, finally, in February 1918, the civilian outbreak of war later that year did lead to some changes, dental surgeons were given temporary RNVR commissions, some of which were to lead to further discontent. backdated to March 1915 (10). The large increase in the number of personnel in the Until 1918, uniformed dentists wore identical uniforms Royal Navy, caused by the mobilisation of the Royal Naval to their medical colleagues, with the same scarlet distinction Reserve, the Royal Fleet Reserve and the Royal Naval cloth. It was then decided, with the King’s approval, that the Volunteer Reserve at the beginning of the First World War, RNVR dental surgeons should wear orange distinction cloth. led to an increased demand for dental treatment which Fletcher took credit for the choice of colour. Later in 1918, clearly could not be handled by the (then) twenty-nine the uniform and rank of ‘non-executive’ officers was changed civilian dental surgeons employed by the Admiralty. to bring them more into line with executive officers. The This situation led to the appointment of a number of ‘Executive Curl’ was adopted on the gold lace of the rank dental surgeons, both to hospital ships and to ships in the insignia and the Temporary Dental Surgeons RNVR became (7). Temporary Surgeon Lieutenants (D) RNVR (11). The initial appointments at sea were given to newly The role played by naval dental surgeons during the War, entered civilian dental surgeons with no previous naval did not go unnoticed. Several, including Edward Fletcher, experience or training, leading to some resentment among were awarded the OBE. the previously employed civilian dentists. This situation The need for dental treatment of naval personnel was was unintentionally made worse by the action of the now recognised and accepted and the status of dental Commander-in-Chief of the Grand Fleet, Admiral of the officers had become established. Fleet Sir John Jellicoe. In December 1918, the MDG(N), Surgeon Vice Admiral Jellicoe had received dental treatment aboard one of the Sir William Norman KCB submitted a report to their ships and asked the dental surgeon if there was anything Lordships, suggesting the formation of a Royal Naval Dental he could do for the Dental Service. The dentist pointed Service. The MDG realised that all the dentists were on out that newly entered medical officers in the hospital ships temporary commissions and would therefore shortly J Royal Naval Medical Service 2012, Vol 98.2 41

be demobilised with a consequent loss of considerable of dental officers could be set at one to every 800-1,000 men. expertise to the Naval Service. The sanction of the Lords Although the first five years of the Royal Naval Dental Commissioners of the Treasury was given to the formation Service had been something of an uphill struggle, by 1925 of the RNDS in December 1919 and the establishment of approval had been given for the rank of Surgeon Commander the Dental Branch of the Royal Navy was given the Royal (D) and the establishment of 48 dental officers. However, Assent and laid down by Admiralty Order in Council on 22 although the need for regular dental examinations and January 1920 (12). treatment were by now generally accepted, it had become Once again, Fletcher was not sure that he should clear that such a task could not be handled by the agreed continue to work for the Navy and he sought advice from number of dentists. Fletcher submitted a paper to the the Secretary of the British Dental Association and other MDG(N) proposing an increase in the establishment of eminent colleagues. With their support, he allowed his name dental officers to 60. He also proposed that one sixth of to go forward for transfer and his name was included among the Branch strength should be Surgeon Commanders (D) those of eighteen whose appointments to the Permanent and that one Surgeon Captain (D) should be borne on List was Gazetted on 11 March 1920. MDG(N)’s staff. With the refusal of the Treasury to sanction the rank of After due consideration by the Interdepartmental Surgeon Commander (D) the RNDS had got off to a shaky Committee on the Medical Branches of the Fighting start. Despite this and with the encouragement of senior Services, Fletcher’s proposals were accepted and the colleagues in the BDA, Fletcher accepted an appointment Treasury authorised their implementation with effect from on the staff of MDG(N) and reported for duty in the Medical 1 July 1926. Directorate on 13 April 1920. As the only dental officer with any administrative The Editor of the British Dental Journal wrote, in experience, MDG(N) immediately put forward Fletcher’s recognition of the importance of Fletcher’s appointment name for promotion. Following a Promotion Board, chaired by that this: “…marked, it may confidently be hoped, the the MDG(N), three dental officers were promoted Surgeon opening of a new era in the Naval Dental Service. With a Commander (D) and were appointed as the Senior Dental dentist at the Admiralty responsible under the Director Surgeons in the three main naval barracks at Portsmouth, General for the organisation of the dental service on the Plymouth and Chatham. Fletcher, unsurprisingly, found same lines and under the same conditions as the Naval himself promoted Surgeon Captain (D) at the age of forty. Medical Service, we may hope for great things” (13). He had risen to this rank from that of Surgeon Lieutenant Although there was, at first, a significant shortage of (D) in only six years! dental officers, Fletcher planned for the time when: “the At that time, new applicants to the RNDS faced a requisite number of Officers are available, every new entry competitive examination, the first part of which was held at might be made dentally fit and by the systematic examination the Royal Dental Hospital in London and the second at the at definite periods, their teeth may be kept in a perfectly fit Royal Naval Hospital, Haslar. The successful candidate with condition….” the highest marks was awarded the “London and Haslar On 4 August 1920, Fletcher was among the first batch Gold Medal”. The medal, struck at the Royal Mint from of dental officers, whose seniority had been backdated 23 carat gold, weighed four ounces (115 gm) and was said to 5 August 1914, to be promoted Surgeon Lieutenant to have cost the Admiralty £50, a considerable sum in those Commander (D). days. The name of the recipient and the date of the award After further correspondence between MDG(N) and were engraved on the rim. The face of the medal showed the Treasury, the latter agreed “with some hesitation”, that King George V while the obverse showed St Apollonia, the one officer, with the rank of Surgeon Commander (D), patron saint of dentistry, surrounded by the words “Royal could be borne on the staff of MDG(N) (14). Fletcher was Naval Dental Service For Merit’’. Winners of the Gold promoted to the higher rank in January 1921. Medal were distinguished by a bold letter “M” after their names in the Navy List. During the years that followed, Fletcher and his mentors By 1922, there were thirty serving dental officers. In the worked to put in place a Branch structure which would same year, a medical officer, Surgeon Commander D H attract and retain talented dental surgeons and by 1931, the Given, undertook a survey of 575 randomly chosen naval RNDS was recruiting up to its permitted strength. personnel, believing that “no man who is dependent upon All was not well, however, in the Royal Naval Medical artificial teeth is fighting fit”. He was concerned that few Service in which there was such a shortage of medical officers sailors voluntarily visited the dentist, except when they had that the government appointed a committee under Sir Warren toothache. He believed that the major problem was the Fisher to suggest improvements to be made in the RNMS. shortage of dentists and that, ideally, there should be one The Warren Fisher report had little to say about the dental dentist for every 700 men (15). services, other than that “the condition is not unsatisfactory”. Fletcher was asked to comment on Given’s paper and Despite this, the BDA, having studied the Report, wrote to stated that, once the arrears had been overcome, the number the Admiralty, the War Office and the Air Ministry, stating 42 General

its view that conditions in the three dental services were far with great efficiency, but under considerable pressure by from satisfactory. The BDA felt that the Royal Navy needed Fletcher and his small staff. ninety three dental officers; that the Director should bear the In April 1940, the BDA once again took up cudgels on rank Surgeon Rear Admiral (D); that there should be nine behalf of the RNDS and its Director. On this occasion, Surgeons Captain (D); that the age for retirement should be amongst other proposals, it suggested that the head of raised and that pay and allowances should achieve parity with Branch should be promoted to Surgeon Rear Admiral those enjoyed by medical officers (16). (D) to give him equivalent rank to his Army and RAF These proposals mirrored those in a report written by colleagues. Fletcher was eventually awarded the acting Fletcher for the MDG in October 1933. Needless to say, rank in June 1943. the Treasury balked at all these recommendations until The end of the war, in 1945, found Fletcher busy working 1935, when the Abyssinian crisis saw a large concentration on the new structure of the RNDS to meet the requirements of the Mediterranean Fleet in Alexandria harbour. Here, of a much reduced, post-war Navy. at last, the need for proper dental facilities in a Fleet afloat was recognised. A handful of dental officers, supported by one dental mechanic from Bighi Royal Naval Hospital in , were expected to meet the requirements of this huge Battle Fleet. Conditions of Service were revised and were published in December 1935 (17), but to the chagrin of naval dental officers, no provision was made for a rank higher than Surgeon Captain (D), despite a decision that the Army Dental Corps would be led by a Major General. Fletcher, still in the rank of Surgeon Captain (D), continued to direct the RNDS with great dedication beyond September 1939 and the outbreak of the Second World War, with its consequent rapid expansion of all three Services. This massive expansion in the number of RN personnel, not only created problems for the Dental Branch, but it also brought about a shortage of trained medical staff. Hence, the Sick Berth Attendants who had been assisting dental officers at sea, were now required for medical duties. Ashore, the pensioner Dental Surgery Assistants and civilian dental mechanics could not easily be relocated. To overcome these problems, Fletcher recommended that two new categories be established within the RN Medical Services. These were Dental Surgery Attendants – SBA(D) – and Dental Mechanics – SBA(DM). They would be kept on separate rosters from other sick bay ratings and would not be available for general sick bay duties (18). The supply of dentures (still a common requirement) for those at sea had also become a problem and Fletcher directed that dental laboratories be established in all repair and depot ships. The sheer scale of dental problems amongst the men mobilised as Hostilities Only (HO) ratings was huge. The Surgeon Rear Admiral E E Fletcher CBE KHDS dental health of the majority of recruits was extremely poor MDS(Dunelm), Deputy Director-General for RN and in the several additional New Entry establishments set Dental Services 1920-1946 up to cope with the influx, a large number of dental officers worked long hours to render them dentally fit for service. February 1946 saw the retirement of Surgeon Rear Admiral This situation was mirrored in the main Naval Barracks (D) E E Fletcher, the man who had become and still is such as HMS Victory (now HMS Nelson) where the dental known as the ‘Father’ of naval dentistry. He had devoted his departments strove to cope with the dental needs of naval working life to the improvement of conditions and efficiency personnel awaiting sea drafts. in the RNDS. He had served continuously in the Medical The creation of a Dental Branch of a size to meet all Department of the Admiralty for nearly 26 years. He had of these challenges progressed at some speed, managed raised the level of dental awareness among naval personnel J Royal Naval Medical Service 2012, Vol 98.2 43

and had constantly striven for improvements been contested by dental officers sitting the in conditions of service for his dental Branch entry examination before the officers. Second World War. The obverse would He had been appointed OBE bear the title of the Prize and the date for his services during the First and name of the recipient. World War and had been advanced Early medals were struck in to Commander of the Order in silver and were made in the 1937. In 1945 he was appointed Command Dental Laboratory, Honorary Dental Surgeon to Portsmouth. Later work was to the King. He retired in the war be carried out by the Royal Mint. substantive rank of Surgeon Rear Although Admiral Forrest Admiral (D) and was also made an initiated the work leading up to Officer of the Legion d’Honneur the establishment of the Harvey- for services to Free French forces. Fletcher Prize, it was carried forward Shortly after his retirement, Fletcher by his successor as DNDS, Surgeon was elected a Fellow in Dental Surgery of Rear Admiral (D) John Hunter. the Royal College of Surgeons of England. Following an appeal both within and outside the Branch, the Trust Fund was set up in 1973 The Harvey-Fletcher Medal and Prize under the auspices of the United Services Trustee. It is ‘Fast forward’ to the year 1972, when the then Director of not generally known that the fund was initially primed by Naval Dental Services, Surgeon Rear Admiral (D) W I N generous donations from both admirals. It was decided that Forrest was nurturing the idea of inaugurating a prestigious an Award Committee would meet every three years, but the prize within the Dental Branch, to recognise outstanding first award was not made until 1980. scientific or administrative achievement by Royal Navy The first recipient of the Harvey-Fletcher Medal and dental officers. Prize was Surgeon Lieutenant Commander (D) Geoffrey It was his thought that such a prize should also Myers, Royal Navy in recognition of his outstanding service honour the founding fathers of the RNDS, Staff Surgeon whilst appointed to HMS Tamar in Hong Kong. Geoff Christopher Harvey, who was the first to recognise the need Myers was himself to become Director of Naval Dental for a Naval Dental Service and Surgeon Rear Admiral (D) Services. Tragically whilst serving in that appointment E E Fletcher, who set up the RNDS and who nurtured it with great distinction, he lost his life in a road traffic to maturity during his long years of service. Thus was the accident. Harvey-Fletcher Prize conceived. The Medal and Prize have been awarded approximately The gestation period of the Prize was protracted and every three to four years since then. The awards serve not required the setting up of a trust fund and the approval of only as a reminder of the excellence with which the modern the Admiralty Board. The Prize was to comprise a medal Dental Branch serves the Naval Service and the Fleet, but and a sum of money. The Medal was to bear the image of St also as a reminder of the foresight and energy of those two Apollonia, the patron saint of dentistry, as originally designed officers who were the founding fathers of the RNDS. Their for and used on the London-Haslar Gold Medal which had legacy lives on!

Reference 9. Parliamentary Debates, House of Commons, 1915; 76; 846-7 1. Surg Cdr (D) Daw/Holland initial history 10. Admiralty Monthly Order 1965/18 2. The Toothwright’s tale: A History of Dentistry in the Royal navy 1964 11. Admiralty Order in Council, 8 November 1918, 48 – 1995. E J Grant 12. Admiralty Order in Council 87/CW/20 3. Harvey, W The Blue Jackets’ Teeth, reprinted in Br Dent J 1941: 70: 13. Notes. The Navy. Br Dent J 1920; 41: 375 77-81 14. Pay Rates. Admiralty Fleet Order 2282/21 4. Br Dent J 1905: 26: iv 15. Given, D H C. Dental Efficiency in the Navy. J R Nav Med Serv 5. Navy List. London HMSO, 1910 1922; 8: 42 6. Representative Board BDA. Br Dent J 1914; 35: 1160-67 16. Dental Branches of the Medical Services. Br Dent J 1933; 55:630-35 7. Wood, G.E. Dentistry. J R Nav Med Serv 1920; 20; 92-5 17. Admiralty Order in Council and Admiralty Fleet Order 2885/35 8. Fletcher E E . Private Papers 18. Admiralty Fleet Order 2666/40

Edward J Grant 44 Book Reviews

Book Reviews Basic Statistics and Epidemiology: A Practical Guide Anthony Stewart. ISBN 9781846194115 3rd Edition 2010 Radcliffe Publishing Ltd, UK This book is a basic text for the reader who needs to know obligatory link to an on-line calculator for sample power. the elements of statistical and epidemiological methods, The second section of the book provides a simple overview illustrated by practical examples from the public health of epidemiology and measurement approaches in a similar arena. First published in 2002, this third revised edition also simple fashion. The chapters link well progressing gently from includes new material on statistical power and sample size. measuring disease frequency through to experimental design The explanatory approach is clear and assumes no prior and screening. The final section provides a series of exercises knowledge; indeed it deliberately avoids theoretical detail using examples from health and epidemiology. which often serves as a deterrent to the reader. Each chapter Whilst some topics may seem over-simplistic or unnecessary, gives a short and concise explanation, with relevant examples for example the chapters on presenting data and types of data, and general principles. In this respect it is a good introductory these are discussed in just a few short pages and the reader is text which will engage with a student audience or those who quickly moved on to the next topic in an engaging and brisk style. need to have a simple but clear overview. I would recommend this book to students in health To those who already have a grasp of the fundamental sciences or medicine, particularly those who are about to issues of sampling, distribution statistics, confidence intervals engage in research and have found statistics confusing and hypothesis testing, this text will seem over-simplistic. The rather than illuminating. It is, as the title suggests, a basic new section on power and sample size is particularly clear and practical starting point which will engage, inform and helpful, since this important topic is often omitted or delivered encourage – good preparation for any research enquiry. through a theoretical consideration of critical size effects and probability. The inclusion of nomograms to calculate sample Dr Adrian Allsopp size is refreshing since these simple tools are very quick and Head of Environmental and Medical Sciences easy ready-reckoners. This section also provides the now Institute of Naval Medicine Mental Health Across Cultures: a practical guide for health professionals J Benson & J Thistlethwaite ISBN 9781846192197 This is a well written text by authors who clearly have an in professionals would gain from reading Chapter 2. depth understanding of this area. Although not likely to be of Section B is of use to mental health professionals and, wide general interest to the readership of this journal, there are in particular, Chapter 4 that deals with modified Cognitive some very useful sections of this book for health professionals in Behavioural Therapy in the cross cultural setting. Chapter 10 the Royal Navy. For historic reasons and our continued central on cross cultural pharmacotherapy is also a well-written and role in the Commonwealth, there is a significant number of General Practitioners in particular would benefit from reading serving personnel from different cultures in the Royal Navy. it. Although it has great value in understanding the nuances Also, in times of humanitarian crisis the Royal Navy is frequently of prescribing across cultures, it also provides a succinct and involved in the first line response, bringing us into contact with eloquent description of approaching prescribing of psychotropic diverse cultures. The authors propose a good model for working medication in general. across cultures which, in summary, revolve around making On the whole, this is a considered publication that efforts to understand the culture of the individual one is working addresses an area that is frequently neglected in mental health, with through self-reflection, networking and mentoring and and perhaps also in general medical practice. However this is leadership being shown at management level. a specialised field and the general usefulness of reading this The “Cultural Awareness Tool” suggested for use in book cover to cover is limited for the majority. The insights Chapter 2 is a simple method for approaching an assessment in cross cultural working in Chapter 2 would benefit all in a way that raises awareness of cultural perceptions. health professionals. For those working within mental health, Important for this Journal’s readership is the understanding particularly where there is a large cross-section of cultures in that in some cultures emotional distress is experienced as the population, the utility of this publication greatly increases physical distress as there may be no words for psychological and is recommended for study. illness in the language, or may be how people understand their illness, thus representing the only way in which the Surgeon Commander Rik Coetzee patient can communicate how they are feeling. All health Consultant Psychiatrist