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Stephen Maturin and Naval Medicine in the Age of Sail

Stephen Maturin and Naval Medicine in the Age of Sail

 

I. Worth Estes

 

In Patrick O'Brian's novel H.M.S. Surprise, Dr. Stephen Maturin la­ments, "Medicine can do very little; surgery less. I can purge you, bleed you, worm you at a pinch, set your leg or take it off, and that is very nearly all." Although he gives 18th-century surgery less credit than it probably deserves, he is not far off the mark when it comes to the practice of what we now call internal medicine. Matu­rin and his contemporaries relied largely on bitter remedies, some introduced as many as 2,500 years earlier. In fact, almost all medi­cines prescribed during the last years of the Enlightenment were ineffective by modern criteria. Nevertheless, Jack Aubrey and his crews placed unqualified faith in Dr. Maturin, even if he was skepti­cal of the worth of his own prescriptions. One must wonder why they did so.

 

Doctors and the Royal Navy

When Maturin joined the Royal Navy, its ranks included about 720 Surgeons. By 1814, as the Napoleonic Wars neared their end, 14 Physicians, 850 Surgeons, and 500 Assistant Surgeons were caring for 130,000 men on shore and at sea. Doctors who aspired to Royal Navy service had to pass oral exams, but the exams were perfunc­tory and few doctors managed to fail them. Depending on where they had obtained their training, and on their social status, Navy doctors were ranked as Physicians, Surgeons, Apothecaries, or As­sistants (Mates). Because Surgeons and Apothecaries were consid­ered to be craftsmen, or artisans, they ranked below Physicians, who, unlike Maturin, generally did not deign to use their hands.

The most prestigious medical education in Britain and France, leading to standing as a Physician, was obtained at universities. Although Edinburgh was often recognized as the premier medical school in the English-speaking world, only Oxford and Cambridge could offer their medical graduates the qualification necessary for licensure in London (however, other doctors did practice there). Many Royal Navy Surgeons were trained at the universities of Edin­burgh, Glasgow, or Aberdeen; the rest were probably trained as apprentices, and some of those obtained additional training by tak­ing university courses, by attending private lectures and demonstra­tions given by leading practitioners such as John Hunter in London, or by "walking the wards" of major London hospitals under the tutelage of senior medical staff.

It is not entirely clear how or where Dr. Maturin obtained his professional credentials. He seems to have acquired his premedical education at Trinity College in Dublin. Maturin told Dr. Butcher, of the Norfolk, that he had studied medicine in France, presumably in Paris. Indeed, Maturin says he "has dissected with Dupuytren." If so, it must have been while they were both students, because Guil-laume Dupuytren (1777-1835) would have been a bit younger than Maturin, and he did not achieve his reputation as an innovative surgeon until several years after Maturin first met Captain Aubrey.

Shortly after Maturin joined the Navy, his partner at a dinner party asked him, "How come you to be in the navy if you are a real doctor [i.e., a physician]?" Maturin's reply was probably more heav­ily dosed with modesty and puns than his contemporaries in the real world would have given: "Indigence, ma'am, indigence. For all that clysters [i.e., enemas] is not gold on shore. And then, of course, a fervid desire to bleed for my country."

Until the Navy's medical services were reorganized in 1806, Surgeons were warranted by individual ship Captains, not commis­sioned by the Admiralty. Nevertheless, they were billeted along with the other officers in the wardroom. Their base salary was Ј5 per month, plus Ј5 for every 100 cases of venereal disease they treated, along with an equipment allowance of Ј43 and an allow­ance for a personal servant. Thus the Surgeon of a third-rate war­ship might earn more than Ј200 when his share of prize money was factored in. The venereal disease component of this was financed by fining men with gonorrhea ("gleet") or syphilis ("pox" or "great pox"). Because Naval Physicians, who, unlike Surgeons, held academic degrees in medicine, were regarded as gentlemen, they were not required to be examined before acceptance into the Navy and were better paid. Moreover, they had some authority over Surgeons.

In addition to caring for the sick and wounded, Surgeons were responsible for maintaining cleanliness on the ship. They saw to it that pressed men, often dirty and poorly clothed, were properly cleaned. They fumigated the sick-bay and whole decks when neces­sary, usually by burning brimstone (sulfur), and they oversaw the ventilating machines that supplied fresh air to lower decks and kept them dry. Although Surgeons knew that inadequate food was a major contributor to shipboard illness, strict monetary limitations hampered their ability to improve rations. Most were also concerned about shipboard drunkenness, but seamen insisted on retaining the grog perquisite, amounting to a half pint of rum mixed with one quart of water twice daily. However, it was not only the seamen's preference that kept rum as standard issue: They needed liquids, and beer and water did not keep well at sea.

Naval Surgeons worked in three principal venues. They saw most of their patients in the sick-berth, or sick-bay, to which loblolly boys escorted ambulatory patients to have their skin ulcers or wounds dressed daily. The sick-berth could be an area partitioned off by fixed walls or canvas between decks or sometimes just an area between two guns. Some sick-bays were quite large and had their own cooking and latrine facilities. The H.M.S. Centaur's, for exam­ple, had 22 hanging beds as well as a drug dispensary. But the contemporary U.S.S. Constitution's had only four beds and no sepa­rate dispensary.

During sea battles, the Navy Surgeon's workplace was the cock­pit, a space permanently partitioned off near a hatchway down which loblolly boys and other crew could carry the wounded for triage and treatment. Not all ships had such a space, so planks were sometimes laid across guns to serve as operating tables. The cockpit deck was strewn with sand prior to battle so that the Surgeon and his Mates would not slip in the blood that invariably accumulated there despite the sand-filled buckets positioned to catch it.

A third possible work site for naval doctors was a hospital ship, usually a reconditioned ship of the line no longer suitable for fight­ing. Each had a Physician and a Surgeon, three Assistant Surgeons, ancillary personnel such as nurses, cooks, and washers, and occa­sionally an apothecary. The best-appointed hospital ships had wards for separating patients with the various fevers, diarrhea! dis­eases, venereal diseases, and itches, as well as for the dying.

A few doctors served at Navy hospitals ashore. By the end of the Napoleonic Wars, hospitals had been established in every major overseas base. Service there was more profitable than at sea; hospital Surgeons were paid Ј500 a year and given a free residence. Dr. Maturin saw several patients at Haslar, the first major naval hospital in Britain, near Portsmouth on the south coast. Designed for 1,800 patients when built in the 1760s, its population grew to over 2,100 in the 1780s and was still growing in 1800. Its patients were attended by two Physicians, one Apothecary and his two Assistants, and two Surgeons with seven Surgeon's Mates and three Assistants. Proba­bly the largest hospital in the world at the time, Haslar had 84 medi­cal and surgical wards, plus special wards for contagious diseases. The other major hospital for the Home Fleet was at Plymouth. When construction began in 1758, it was planned for 600 men, but it had 1,250 beds in 1795 and more by its completion in 1806.

The Navy's overseas hospitals had the worst reputations, espe­cially those in the West Indies, to which the Admiralty routinely sent poorly qualified doctors. There were exceptions, such as the hospitals at Malta and Minorca, both visited by Maturin, who, like his historic counterparts, sent seriously ill patients there when nec­essary and possible. But most naval hospitals, like many civilian hospitals, were notoriously dirty, uncaring to patients, and staffed by drunk and debauched nurses who stole whatever they could. Until 1805, when they were prohibited from maintaining their own private practices, even the doctors were frequently inattentive to their charges.

 

The Disease Burden of the Royal Navy

Reforms in medical staffing and victualing procedures by the Navy between 1780 and 1800, many the work of Dr. Sir Gilbert Blane, a Royal Navy Commissioner for the Sick and Wounded beginning in 1795, helped lower its sick rate from about one in three in 1780 to about one in eight by 1804, and one in eleven in 1813. Death rates from nonsurgical illness fell accordingly. But medical theories changed little during that time.

Doctors trained in the 18th century often argued about the "im­mediate causes" of specific diseases. They debated whether some were caused by "miasmas," unseen products assumed to be trans­mitted through the air from garbage, swamps, and other sources of unpleasant odors, or by direct "contagion," equally unseen effluvia thought to migrate from one person to another. Whatever the cause of a given illness, doctors postulated that it produced symptoms by creating physiological imbalances.

Since at least the fifth century b.c., physicians had explained ill­ness in terms of the "four humors": blood, phlegm, black bile, and yellow bile. Each humor was associated with two qualities that could be assessed by observable symptoms: blood with heat and moisture, phlegm with moisture and cold, black bile with cold and dryness, and yellow bile with dryness and heat. That is, symptoms were thought to be the result of humoral imbalances, manifested as excessive or deficient body heat or moisture. The humoral theory of illness held that in order to restore health and stability to the sick body, its imbalances had to be counteracted with drugs or foods with appropriately opposite properties.

A new theory emerged in the 1690s, postulating that illness can also represent imbalances in the solid fibrous components of blood vessels and nerves, as expressed by their tone—their innate strength and elasticity. Both vessels and nerves were considered to be hollow tubes propelling their contents through the body with forces propor­tional to the tone of their fibers. The body was healthy when blood or the "nerve fluids" could circulate freely, or when sweat, urine, and feces could be expelled freely, and so forth. Effective therapies were, therefore, those that enhanced defective tone or calmed hyper-activity in affected vessels or nerves. Medical historians have la­beled this the "solidist theory" to distinguish it from the older humoral theory. The two were not mutually exclusive, and most therapies were interpreted within the frameworks of both.

Finally, the process of figuring out the chemistry of respiration that began in the 1770s made it easy to interpret rapid breathing as one more manifestation of increased "combustion" within the fe­vered body. Thus, the discovery of oxygen and carbon dioxide led to the conclusion that the body "burns" food by combining it with oxygen (which actually means "acid-forming") to make carbon di­oxide. When doctors added these chemical concepts to their previ­ous theories, they could focus on a new set of balances—between acids and bases—allowing them to explain the apparent reciprocal actions of basic and acidic drugs.

A fast pulse was the hallmark of fever, the most common serious illness of the 18th century. The increased body heat of fever was attributed to increased arterial irritability, a secondary response to some unseen miasma or effluvium. The physician's first goal was to reduce the irritability or hyperactivity of the heart and arteries, as evidenced by the fast pulse. Initial treatment consisted of the so-called depletive or evacuant regimen, using drugs with emetic, an-tispasmodic, cathartic, and narcotic properties to rid the body of whatever noxious factors had disrupted its balances and to calm hyperactive fibers. Therapy also relied on avoiding whatever would "feed" the internal fires of the inflammation, such as red meat and exercise, on "cooling" drugs, and on measures designed to reduce tension and tone in the arteries, especially bleeding.

The second major therapeutic mode consisted of stimulating, or "tonic," measures, remedies thought to strengthen the heart and arteries, in order to speed removal of whatever pathogenic factors had weakened the body, especially during convalescence from a fever, once its "crisis" had passed. Such methods included a wide variety of tonic drugs, as well as cold water and electricity, all of which were assumed to speed recuperation by increasing the pa­tient's depleted strength.

Dr. Maturin's chief task was to restore the balances among his patients' humors, the tensions within their nerves and blood vessels, and the acids and bases their bodies generated from food. Diet was as important as drugs for these purposes. Foods were evaluated not only in humoral terms as hot, cool, wet, or dry, but also for their stimulating or sedative properties, and for their acid, alkali, and salt content. Because fever exemplified heightened tones, it was treated with a "low diet" (meatless) that was easily digested and lacked "stimulating" properties. Patients with "colds," on the other hand, were fed foods, such as red meat, that would increase their body heat; both notions are still implicit in the admonition to "feed a cold and starve a fever."

Humors and tones were often adjusted to prevent illness. For instance, Maturin liked to bleed all men as they crossed the Tropics of Cancer or Capricorn toward the equator, "as a precaution against calentures [fevers] and the effects of eating far too much meat and drinking far too much grog under the almost perpendicular sun." He preferred the hands to eat a meatless diet while sailing between those latitudes.

Although sailors were predominantly healthy young men, they were still susceptible to most acute contagious diseases. In addition, chronic illness contributed to the loss of considerable manpower at sea. In the medical journal of U.S. Navy Surgeon Peter St. Medard, kept on board the 36-gun frigate New York during a cruise to the Mediterranean from 1802 to 1803 (during the Barbary Wars), St. Medard recorded—as all U.S. Navy Surgeons had been directed to do by the Secretary of the Navy—the name, rank, diagnosis, treat­ment, and result for each patient he saw among the 350-man crew over a 16-month period.

As on Aubrey's ships, the most frequent diagnoses on St. Medard's cruise were the catarrhs (i.e., bad colds), influenza, con­sumption (tuberculosis), and pneumonia; these respiratory ailments accounted for nearly 50 percent of all diagnoses made in the British or American navies. Other leading diagnoses included malaria (then called intermittent fever because the typical attacks of shaking, chills, and fever recurred every 24 or 48 hours), diarrhea, dysentery (i.e., painful and bloody diarrhea), and bilious fever (characterized by jaundice and correctly attributed to some primary disorder of the liver). Syphilis and gonorrhea, predictable risks of shore leave al­most everywhere, completed the list of the most common illnesses, although rheumatism and related debilitating conditions such as lumbago and sciatica could remove significant numbers from a ship's work force for weeks on end.

As Jack Aubrey was well aware, the most frightening illnesses (except for scurvy) were exotic tropical infections, especially ma­laria, yellow fever, cholera, and perhaps plague. Most Commanders and their Surgeons considered some of these to be hazards of spe­cific stations visited by the Royal Navy. For instance, yellow fever was associated with the West Indies, dysentery and liver disease (probably hepatitis) with the East Indies, malaria with both stations, and respiratory illnesses with the cold home waters of the British Isles. The worst of the continued fevers (so called to differentiate them from intermittent fever) was typhus, also known as ship fever or gaol fever. All of these, as well as the common respiratory ill­nesses, were potentially fatal, and so was scurvy, although it took much longer to kill.

 Scurvy was a special hazard at sea, chiefly on ships not suffi­ciently provisioned with fresh fruits and vegetables. Considered a result partly of damp decks and clothes, it was also thought to be contagious because the number of afflicted crew increased steadily (until a source of vitamin C was provided). After 1795, when the Royal Navy's ships were regularly well supplied with citrus fruit, scurvy was unusual.

Maturin and Aubrey were confronted with several outbreaks of scurvy. One occurred on the Leopard, and Maturin easily recognized the typical symptoms: The four afflicted men were glum, listless, and apathetic; their gums were spongy; their breath was offensive; their old wounds reopened; and blood seeped from capillaries in their skin. Knowing that the men were getting their "sovereign lime-juice" mixed into their daily grog, Maturin was baffled by the outbreak—until he discovered that the victims had been trading their grog rations for tobacco.

Another problem Navy doctors had to contend with was mental illness, which was thought to afflict one in a thousand seamen—a rate seven times greater than that among the general population. Doctors often attributed insanity to head injuries, which, in turn, were blamed on intoxication. Because the symptoms of intoxication could resemble generalized hyperactivity, alcohol was assumed to be a stimulant, not the general depressant we now know it to be.

 

The Medicine Chest

Medicine chests for Navy ships contained up to one hundred of the more than two hundred remedies prescribed by doctors on land and sea; the specific contents of each ship's chest differed somewhat, according to the Surgeon's preferences. All the drugs that Dr. Matu­rin gave his patients are known to have been used throughout the Royal Navy—and in the U.S. Navy—although some, such as pow­der of Algaroth, Lucatellus's balsam, polypody of oak, and polychrest, were considered archaic by 1800.

The most frequently used remedies were tonics, which according to solidist thinking strengthened the body when it had become weakened by disease, especially during convalescence from a fever.

For this purpose, the favored drug was cinchona, also called Peru­vian bark. It had entered medical practice in the late 17th century as a cure for malarial fevers (indeed, today we know that it contains quinine, which is still used to treat malaria), but it would have been ineffective against other fevers, for which physicians also came to use it.

The next most frequently prescribed drugs were cathartics, which were assumed to flush out unbalanced humors with the feces and to relax the abnormal tensions that had constricted patients' intestinal fibers, causing constipation. Typical of this class of drugs were calo­mel (mercurous chloride), jalap, medicinal rhubarb, castor oil, and cremor tartar (sodium potassium tartrate), a strong cathartic that was the most active ingredient of Maturin's black draught.

Doctors also gave emetics, drugs that induce vomiting, to remove foul humors from the stomach, as well as to strengthen what they took to be weak stomach muscle fibers. Tartar emetic (antimony potassium tartrate) was administered for this purpose, as was ipe­cac, which we still use to remove poisons from the stomach.

Diaphoretics, which Maturin called "anhidrotics," made patients "sweat out" their unbalanced humors. At the same time these drugs —especially those made with antimony, like James's Powder, a pa­tent medicine that Maturin sometimes prescribed—were assumed to strengthen the blood vessels that supplied the sweat glands in the skin.

Opium and opium preparations such as laudanum (an alcoholic solution of opium also known as Thebaic tincture), were correctly regarded as sedative, antidiarrheal, and analgesic. The addictive properties of opium were well known. Maturin, who used lauda­num frequently as an escape from his worries, appears to have been addicted, and it is unclear how he managed to wean himself from it. He believed that the coca leaves he discovered in Peru helped him overcome his reliance on opium, a common misconception even in the late 19th century.

Because syphilis was almost an occupational hazard of sailors, Navy Surgeons stocked various mercury salts to treat it. Most vic­tims required prolonged therapy with oral mercury preparations, such as calomel or Maturin's "blue pill" (mercuric chloride, also known as corrosive sublimate) and with unguents made with the latter. All mercurials were cathartic and diaphoretic, providing clear routes for the elimination of the contagious factor responsible for the affliction. However, it seems unlikely that such treatments could have eradicated the syphilis organism.

Most doctors, Maturin included, reserved two forms of treatment for their most seriously ill patients, especially those with the worst fevers or injuries. The first was the drug class called blisters, or epispastics, usually alcohol solutions of powdered cantharides bee­tles (sometimes called Spanish flies). When placed on the skin, this preparation raises a large, painful blister. In humoral theory it was thought to draw foul humors into the blister fluid; solidist reasoning concluded that the blister would also neutralize the naturally occur­ring inflammation that had caused the patient's symptoms by the process Maturin called "counter-irritation."

The other relatively drastic treatment doctors favored was bleed­ing, on the humoral grounds that it removed chemically or other­wise unbalanced blood-producing symptoms, and on the solidist grounds that it reduced tension of the hyperactive fibers of the fe­vered cardiovascular system. That is, releasing some of the patient's blood was assumed to reduce the friction (between the blood and the walls of the arteries) that was producing the patient's increased body heat. Doctors usually removed 12 ounces at a time but up to twice that amount from their sickest patients.

Maturin's remedies were not designed to counteract well-defined disease processes as modern drugs do. Instead, he and his contem­poraries used drugs to adjust or fine-tune a patient's internal equi­libria, his physiological balances, regardless of what might have disrupted them in the first place. The occurrence of catharsis, vomit­ing, sweating, or blisters after the administration of a drug simply confirmed that the remedy had indeed altered the humors, tones, and acid-base balance of the body in the intended way. However, few of these treatments could have provided truly effective cures.

 

Trauma and Surgery

During the ten years of naval warfare with France that culminated at Trafalgar in 1805, the Royal Navy had 1,483 men killed and 4,266 wounded in battle. That is only about 6 percent of the Navy's total losses; those from disease and individual accidents accounted for 82 percent, and major accidents (e.g., sinking) 12 percent. Thus, al­though the Navy called most of its doctors Surgeons, because their principal task was to repair battle injuries, their surgical skills were required far less frequently than their general medical skills.

Although Maturin was trained as a Physician, not a Surgeon, he had at least read the most influential works on naval surgery that had been published by the time he met Aubrey, including the works of Gilbert Blane, James Lind, William Northcote, and Thomas Trot­ter. Thus, he did not feel ill-prepared to take up a career as a naval Surgeon (although he never did become fully accustomed to the motion of ships).

Among the common occupational risks of life at sea that might require manipulative surgical treatment were burns; inguinal her­nias; falls from aloft; limbs crushed under falling barrels, ropes, or chains; and injuries incurred during fights. Burns, which occurred not only in battle but also when guns misfired during exercises, were usually cleaned and dressed with olive oil. Hernias were re­duced by manipulating the loop of intestine that had been forced into the scrotum so that it returned to the abdominal cavity, where it could be retained with a truss. Surgeons removed wens and superfi­cial tumors and incised and drained large boils and abscesses. They occasionally cut through the lower abdomen and into the bladder to remove stones, as Maturin did on the Polychrest, and some removed cataracts from the eye, although most sailors were not old enough to need this operation.

Because dentistry had not yet separated from regular medical practice, doctors were also often called upon to pull teeth, one of Maturin's least favorite chores. For this purpose they used a claw-like device called a turnkey, or pelican, that gave them maximum leverage.

Navy Surgeons were also often required to examine men con­demned to be flogged to ascertain whether they were fit for the punishment, and to treat their back wounds afterward.

Doctors of Maturin's time understood the basic principles of in­flammation, even if some of their methods for dealing with it now seem bizarre. For instance, believing that blood could turn to pus during the inflammatory process, they bled seriously ill or wounded patients to reduce the accumulation of pus. The bacteria that actu­ally cause its formation had not been discovered. But generally, surgeons applied sound principles to wound treatment: They con­trolled hemorrhage by tying off bleeding arteries, removed foreign bodies from wounds, and cleaned the wound sites. They thought some chemicals, such as^iitrates, had "antiseptic" (literally, "anti-inflammatory") properties, but they had no sure way of preventing infection. They attempted to close wound edges by clearing them of dead tissue and suturing them together. Afterward they inspected and changed dressings as often as possible to minimize inflamma­tion and pus.

Ironically, more battle wounds occurred when ships fought at a distance than in close engagements. Cannonballs that had traveled a long distance caromed off masts and railings, creating dangerous large splinters. If surgeons could get to the arteries severed by these flying splinters, they could usually tie them off to stop the bleeding. For instance, during the fight with the Algerine pirate ship Dorthe Engelbrechtsdatter, Maturin tied off the "spouting femoral artery" in the leg of one of the Sophies.

Surgeons removed bullets with a specially constructed "bullet forceps," sometimes probing blindly through a muscle mass or into a wound in the chest or abdomen. They almost never opened those body cavities because they were well aware that the risk of fatal inflammation (i.e., infection) at those sites was nearly 100 percent. Men who were seriously burned by misfired guns, by explosions, or by missiles that brushed their skin were treated with olive oil and ointments to soothe the affected areas and to prevent exposure to air.

During sea battles, the decks and cockpits could grow nightmar­ish. The following excerpt comes from the journal of Robert Young, a surgeon on H.M.S. Ardent at the battle of Camperdown, which began at about one p.m. on October 11, 1797. It is a clear picture of what sailors and Surgeons in Nelson's—and Aubrey's—Navy knew to expect when ships engaged in battle:

 

“I was employed in operating and dressing till near 4.0 in the morning. ... So great was my fatigue that I began several amputations under a dread of sinking before I should have secured the blood vessels. [Dr. Young had no Surgeon's Mates to assist him.]

Ninety wounded were brought down during the action. The whole cockpit deck, cabins, . . . together with my [operating] platform and my preparations for dressing were covered with them. So that for a time they were laid on each other at the foot of the ladder where they were brought down, and I was obliged to go on deck to the Commanding Officer to ... apply for men to go down the main hatchway and move the foremost of the wounded further forward . . . and thus make room in the cock­pit. Numbers, about sixteen, mortally wounded, died after they were brought down. . . . Joseph Bonheur had his right thigh taken off by a cannon shot close to the pelvis, so it was impossi­ble to apply a tourniquet [to stop the bleeding]; his right arm was also shot to pieces. The stump of the thigh, which was very fleshy, presented a dreadful and large surface of mangled flesh. In this state he lived near two hours, perfectly sensible and inces­santly calling out in a strong voice to me to assist him. The bleed­ing from the femoral artery [the main artery of the leg], although so high up, must have been very inconsiderable, and I observed that it did not bleed as he lay. All the service I could render this unfortunate man was to put dressings over the [wound] and give him drink. . . .

Melancholy cries for assistance were addressed to me from every side by wounded and dying, and piteous moans and be­wailing from pain and despair. In the midst of these agonising scenes, I was able to preserve myself firm and collected, and . . . to direct my attention where the greatest and most essential ser­vices could be performed. Some with wounds, bad indeed and painful, but slight in comparison with the dreadful condition of others, were most vociferous for my assistance. These I was obliged to reprimand with severity, as their voices disturbed the last moments of the dying. ...

An explosion of a salt box with several cartridges abreast of the cockpit hatchway filled the hatchway with flame and in a moment 14 or 15 wretches tumbled down upon each other, their faces black as a cinder, their clothes blown to shatters and their hats afire. A Corporal of Marines lived two hours after the action with all the [buttocks] muscles shot away, so as to excavate the pelvis. Captain Burgess' wound was of this nature, but he fortu­nately died almost instantly.

After the action ceased, 15 or 16 dead bodies were removed before it was possible to get a platform cleared and come at the materials for operating and dressing, those I had prepared being covered over with bodies and blood, and the store room blocked up. I have the satisfaction to say that of those who survived to undergo amputation or be dressed, all were found the next morn­ing in the gunroom, where they were placed, in as comfortable a state as possible, and on the third day were conveyed on shore in good spirits.”

(From Christopher Lloyd and Jack L. S. Coulter, Medicine and the Navy, 1200-1900 (4 vols.), vol. 3, 1714-1815 [Edinburgh: E. & S. Livingstone Ltd., 1961], pp. 58-60.)

 

Another firsthand account, by seaman Samuel Leech on the Mace­donian when she was defeated by the American frigate United States in October 1812 focuses more on the Surgeon:

 

“The first object I met was a man bearing a limb, which had just been detached from some suffering wretch. . . . The surgeon and his mate were smeared with blood from head to foot: they looked more like butchers than doctors. Having so many patients [36 were killed and 68 wounded], they had once shifted their quarters from the cockpit to the steerage; they now removed to the wardroom, and the long table, round which the officers had sat over so many a feast, was soon covered with the bleeding forms of maimed and mutilated seamen. . . .

Our carpenter, named Reed, had his leg cut off. I helped to carry him to the after wardroom, but he soon breathed out his life there, and then I assisted in throwing his mangled remains over­board. ... It was with exceeding difficulty I moved through the steerage, it was so covered with mangled men and so slippery with blood.

We found two of our mess wounded. We held [one man] while the surgeon cut off his leg above the knee. The task was most painful to behold, the surgeon using his knife and saw on human flesh and bones as freely as the butcher at the shambles.”

(Ibid., p. 61.)

 

As is clear from these accounts, hemorrhage was the greatest immediate hazard of battle wounds, especially those made by swords, bayonets, or large splinters. Bleeding from limbs was stopped by canvas tourniquets, tightened by turning a screw to compress a brass plate positioned over the bleeding artery. Bleeding from the head and torso could be controlled only by compression bandages. Only after bleeding had been minimized could the sur­geon proceed to correct the damage.

Eighteenth-century surgeons could perform a wide range of op­erations. The most frequent of the capital operations (those with the greatest risk of death) were amputations. Simple fractures and dislo­cations of arms and legs were reduced and splinted, but compound fractures associated with open wounds were likely to be followed by gangrene, which required amputation. By 1800 some surgeons were able to cut through the muscles of the thigh and saw through the femur beneath them so rapidly that patients felt the excruciating pain for no more than two minutes.

Some operations were not standard, of course—on the contrary, they had to be improvised according to the nature of the patient's wound. For instance, a few surgeons made successful extemporane­ous attempts to remove the entire arm along with the shoulder blade and collarbone; other joints were also removed, but rarely.

Trepanning, or trephining, was another rare capital operation. It involved cutting a disk about an inch or so in diameter from the skull to remove bone that had been fragmented by blunt trauma or shot and to relieve pressure on a swelling brain. Dr. Maturin won his reputation during his first voyage with Aubrey by this opera­tion, which he later said he had performed "many times" without failure. Indeed, not long after he trepanned Joe Plaice for a de­pressed skull fracture, the Surgeon himself was knocked out when his head struck a gun on a Pacific island controlled by potentially hostile American whalers. Mr. Martin, the Chaplain, could feel no underlying fracture and diagnosed a blood clot as the cause of Mat-urin's continuing coma. The Americans' Surgeon, Dr. Butcher, was preparing to trepan Maturin in order to remove the clot when the patient was mercifully and humorously jolted into consciousness by a bit of snuff accidentally falling into his nostrils.

Because general anesthesia was not invented until 1846, surgeons had to strap their patients into place or have them held down during major operations. They may have used rum or opium to minimize the patient's response to pain and to relax his muscles, but evidence of the routine use of such general depressants is diffi­cult to find. Of course, many patients became suitably unrespon­sive after going into shock when the pain became sufficiently intense.

Olive oil was usually applied to burns to keep the skin soft while it healed. The more complex ointments commonly applied to surgi­cal sites were made with mixtures of oils and fats; lead salts were included in some of them because they were thought to help keep the wound dry. If that succeeded, and if the wound could be kept clean, surgical patients had a good chance of actually benefiting from their doctors' skills, even though the doctors were unaware of the relationship between bacteria and pus.

 

What Good Could Dr. Maturin's Medicine Do?

With the exception of a small handful of drugs, such as opium and cinchona, it is clear that Maturin and his contemporaries were un­able to provide truly effective remedies for the majority of their nonsurgical patients. Nevertheless, most of them recovered. Fairly early in his naval career, Dr. Gilbert Blane concluded:

 

“There is a tendency in acute diseases to wear themselves out, both in individuals that labour under them, and when the infec­tion is introduced into a community [such as the crew of a ship]. Unless there were such a vis medicatrix [healing power of nature], there would be no end to the fatality of these distempers . . . and those who happen not to be infected at first, become in some measure callous to its impression, by being habitually exposed to it. ... Thus the most prevailing period of sickness is when men are new to their situation and to each other.”

(From Sir Gilbert Blane, Observations on the Diseases Incident to Seamen [London: Cooper, 1785], pp. 66-67.)

 

Blane, a strong proponent of keeping and examining naval medi­cal statistics, was right. In the absence of devastating epidemics of diseases like smallpox and yellow fever, about 90 to 96 percent of adult patients in the 18th century, civilian or naval, recovered after being treated by their doctors, regardless of what the physicians did.

Dr. St. Medard's clinical notes on the U.S.S. New York bear this out. His patients with bad colds recovered the most rapidly, fol­lowed by those with uncomplicated diarrhea. Dysentery cases re­covered more slowly, as did those with "bilious disorders" (probably hepatitis). Patients with typhus and other severe infec­tions recovered the most slowly and the least frequently. But the great majority did recover, even though the only truly effective drug St. Medard had was the quinine in the cinchona he gave patients with malaria, who recovered about as promptly as those with bad colds.

The only major illness on the New York that her Surgeon could not treat successfully was scurvy, because he had no lemons, limes, and oranges on board. The other illnesses eventually disappeared, thanks chiefly to the body's built-in immune and tissue-repair mechanisms. Scurvy was the only condition whose course could not possibly have been affected by the body's usual repair mechanisms. It has only one cure or preventive, namely Vitamin C.

The concept of the healing power of nature was not unknown to either Peter St. Medard or Stephen Maturin. Indeed, they and their colleagues saw their task as helping nature accomplish its job. Be­cause their contributions to the restoration of balances in humors, tones, and acidity were effective in 19 out of 20 patients, neither doctors nor their patients had any reason not to believe that they had contributed to their patients' recovery.

It probably would have been hard to convince Jack Aubrey, who had such confidence in Stephen Maturin's professional skills, that it was chiefly the surgical skills of Navy doctors that contributed to the survival of wounded men at sea and that the drugs they pre­scribed according to unproven (and unprovable) theories were effec­tive only because the body is often able to heal itself. But perhaps that unblemished confidence worked to Aubrey's and his crews' benefit.


Stephen Maturin and Naval Medicine in the Age of Sail

Stephen Maturin and Naval Medicine in the Age of Sail

 

I. Worth Estes

 

In Patrick O'Brian's novel H.M.S. Surprise, Dr. Stephen Maturin la­ments, "Medicine can do very little; surgery less. I can purge you, bleed you, worm you at a pinch, set your leg or take it off, and that is very nearly all." Although he gives 18th-century surgery less credit than it probably deserves, he is not far off the mark when it comes to the practice of what we now call internal medicine. Matu­rin and his contemporaries relied largely on bitter remedies, some introduced as many as 2,500 years earlier. In fact, almost all medi­cines prescribed during the last years of the Enlightenment were ineffective by modern criteria. Nevertheless, Jack Aubrey and his crews placed unqualified faith in Dr. Maturin, even if he was skepti­cal of the worth of his own prescriptions. One must wonder why they did so.

 

Doctors and the Royal Navy

When Maturin joined the Royal Navy, its ranks included about 720 Surgeons. By 1814, as the Napoleonic Wars neared their end, 14 Physicians, 850 Surgeons, and 500 Assistant Surgeons were caring for 130,000 men on shore and at sea. Doctors who aspired to Royal Navy service had to pass oral exams, but the exams were perfunc­tory and few doctors managed to fail them. Depending on where they had obtained their training, and on their social status, Navy doctors were ranked as Physicians, Surgeons, Apothecaries, or As­sistants (Mates). Because Surgeons and Apothecaries were consid­ered to be craftsmen, or artisans, they ranked below Physicians, who, unlike Maturin, generally did not deign to use their hands.

The most prestigious medical education in Britain and France, leading to standing as a Physician, was obtained at universities. Although Edinburgh was often recognized as the premier medical school in the English-speaking world, only Oxford and Cambridge could offer their medical graduates the qualification necessary for licensure in London (however, other doctors did practice there). Many Royal Navy Surgeons were trained at the universities of Edin­burgh, Glasgow, or Aberdeen; the rest were probably trained as apprentices, and some of those obtained additional training by tak­ing university courses, by attending private lectures and demonstra­tions given by leading practitioners such as John Hunter in London, or by "walking the wards" of major London hospitals under the tutelage of senior medical staff.

It is not entirely clear how or where Dr. Maturin obtained his professional credentials. He seems to have acquired his premedical education at Trinity College in Dublin. Maturin told Dr. Butcher, of the Norfolk, that he had studied medicine in France, presumably in Paris. Indeed, Maturin says he "has dissected with Dupuytren." If so, it must have been while they were both students, because Guil-laume Dupuytren (1777-1835) would have been a bit younger than Maturin, and he did not achieve his reputation as an innovative surgeon until several years after Maturin first met Captain Aubrey.

Shortly after Maturin joined the Navy, his partner at a dinner party asked him, "How come you to be in the navy if you are a real doctor [i.e., a physician]?" Maturin's reply was probably more heav­ily dosed with modesty and puns than his contemporaries in the real world would have given: "Indigence, ma'am, indigence. For all that clysters [i.e., enemas] is not gold on shore. And then, of course, a fervid desire to bleed for my country."

Until the Navy's medical services were reorganized in 1806, Surgeons were warranted by individual ship Captains, not commis­sioned by the Admiralty. Nevertheless, they were billeted along with the other officers in the wardroom. Their base salary was Ј5 per month, plus Ј5 for every 100 cases of venereal disease they treated, along with an equipment allowance of Ј43 and an allow­ance for a personal servant. Thus the Surgeon of a third-rate war­ship might earn more than Ј200 when his share of prize money was factored in. The venereal disease component of this was financed by fining men with gonorrhea ("gleet") or syphilis ("pox" or "great pox"). Because Naval Physicians, who, unlike Surgeons, held academic degrees in medicine, were regarded as gentlemen, they were not required to be examined before acceptance into the Navy and were better paid. Moreover, they had some authority over Surgeons.

In addition to caring for the sick and wounded, Surgeons were responsible for maintaining cleanliness on the ship. They saw to it that pressed men, often dirty and poorly clothed, were properly cleaned. They fumigated the sick-bay and whole decks when neces­sary, usually by burning brimstone (sulfur), and they oversaw the ventilating machines that supplied fresh air to lower decks and kept them dry. Although Surgeons knew that inadequate food was a major contributor to shipboard illness, strict monetary limitations hampered their ability to improve rations. Most were also concerned about shipboard drunkenness, but seamen insisted on retaining the grog perquisite, amounting to a half pint of rum mixed with one quart of water twice daily. However, it was not only the seamen's preference that kept rum as standard issue: They needed liquids, and beer and water did not keep well at sea.

Naval Surgeons worked in three principal venues. They saw most of their patients in the sick-berth, or sick-bay, to which loblolly boys escorted ambulatory patients to have their skin ulcers or wounds dressed daily. The sick-berth could be an area partitioned off by fixed walls or canvas between decks or sometimes just an area between two guns. Some sick-bays were quite large and had their own cooking and latrine facilities. The H.M.S. Centaur's, for exam­ple, had 22 hanging beds as well as a drug dispensary. But the contemporary U.S.S. Constitution's had only four beds and no sepa­rate dispensary.

During sea battles, the Navy Surgeon's workplace was the cock­pit, a space permanently partitioned off near a hatchway down which loblolly boys and other crew could carry the wounded for triage and treatment. Not all ships had such a space, so planks were sometimes laid across guns to serve as operating tables. The cockpit deck was strewn with sand prior to battle so that the Surgeon and his Mates would not slip in the blood that invariably accumulated there despite the sand-filled buckets positioned to catch it.

A third possible work site for naval doctors was a hospital ship, usually a reconditioned ship of the line no longer suitable for fight­ing. Each had a Physician and a Surgeon, three Assistant Surgeons, ancillary personnel such as nurses, cooks, and washers, and occa­sionally an apothecary. The best-appointed hospital ships had wards for separating patients with the various fevers, diarrhea! dis­eases, venereal diseases, and itches, as well as for the dying.

A few doctors served at Navy hospitals ashore. By the end of the Napoleonic Wars, hospitals had been established in every major overseas base. Service there was more profitable than at sea; hospital Surgeons were paid Ј500 a year and given a free residence. Dr. Maturin saw several patients at Haslar, the first major naval hospital in Britain, near Portsmouth on the south coast. Designed for 1,800 patients when built in the 1760s, its population grew to over 2,100 in the 1780s and was still growing in 1800. Its patients were attended by two Physicians, one Apothecary and his two Assistants, and two Surgeons with seven Surgeon's Mates and three Assistants. Proba­bly the largest hospital in the world at the time, Haslar had 84 medi­cal and surgical wards, plus special wards for contagious diseases. The other major hospital for the Home Fleet was at Plymouth. When construction began in 1758, it was planned for 600 men, but it had 1,250 beds in 1795 and more by its completion in 1806.

The Navy's overseas hospitals had the worst reputations, espe­cially those in the West Indies, to which the Admiralty routinely sent poorly qualified doctors. There were exceptions, such as the hospitals at Malta and Minorca, both visited by Maturin, who, like his historic counterparts, sent seriously ill patients there when nec­essary and possible. But most naval hospitals, like many civilian hospitals, were notoriously dirty, uncaring to patients, and staffed by drunk and debauched nurses who stole whatever they could. Until 1805, when they were prohibited from maintaining their own private practices, even the doctors were frequently inattentive to their charges.

 

The Disease Burden of the Royal Navy

Reforms in medical staffing and victualing procedures by the Navy between 1780 and 1800, many the work of Dr. Sir Gilbert Blane, a Royal Navy Commissioner for the Sick and Wounded beginning in 1795, helped lower its sick rate from about one in three in 1780 to about one in eight by 1804, and one in eleven in 1813. Death rates from nonsurgical illness fell accordingly. But medical theories changed little during that time.

Doctors trained in the 18th century often argued about the "im­mediate causes" of specific diseases. They debated whether some were caused by "miasmas," unseen products assumed to be trans­mitted through the air from garbage, swamps, and other sources of unpleasant odors, or by direct "contagion," equally unseen effluvia thought to migrate from one person to another. Whatever the cause of a given illness, doctors postulated that it produced symptoms by creating physiological imbalances.

Since at least the fifth century b.c., physicians had explained ill­ness in terms of the "four humors": blood, phlegm, black bile, and yellow bile. Each humor was associated with two qualities that could be assessed by observable symptoms: blood with heat and moisture, phlegm with moisture and cold, black bile with cold and dryness, and yellow bile with dryness and heat. That is, symptoms were thought to be the result of humoral imbalances, manifested as excessive or deficient body heat or moisture. The humoral theory of illness held that in order to restore health and stability to the sick body, its imbalances had to be counteracted with drugs or foods with appropriately opposite properties.

A new theory emerged in the 1690s, postulating that illness can also represent imbalances in the solid fibrous components of blood vessels and nerves, as expressed by their tone—their innate strength and elasticity. Both vessels and nerves were considered to be hollow tubes propelling their contents through the body with forces propor­tional to the tone of their fibers. The body was healthy when blood or the "nerve fluids" could circulate freely, or when sweat, urine, and feces could be expelled freely, and so forth. Effective therapies were, therefore, those that enhanced defective tone or calmed hyper-activity in affected vessels or nerves. Medical historians have la­beled this the "solidist theory" to distinguish it from the older humoral theory. The two were not mutually exclusive, and most therapies were interpreted within the frameworks of both.

Finally, the process of figuring out the chemistry of respiration that began in the 1770s made it easy to interpret rapid breathing as one more manifestation of increased "combustion" within the fe­vered body. Thus, the discovery of oxygen and carbon dioxide led to the conclusion that the body "burns" food by combining it with oxygen (which actually means "acid-forming") to make carbon di­oxide. When doctors added these chemical concepts to their previ­ous theories, they could focus on a new set of balances—between acids and bases—allowing them to explain the apparent reciprocal actions of basic and acidic drugs.

A fast pulse was the hallmark of fever, the most common serious illness of the 18th century. The increased body heat of fever was attributed to increased arterial irritability, a secondary response to some unseen miasma or effluvium. The physician's first goal was to reduce the irritability or hyperactivity of the heart and arteries, as evidenced by the fast pulse. Initial treatment consisted of the so-called depletive or evacuant regimen, using drugs with emetic, an-tispasmodic, cathartic, and narcotic properties to rid the body of whatever noxious factors had disrupted its balances and to calm hyperactive fibers. Therapy also relied on avoiding whatever would "feed" the internal fires of the inflammation, such as red meat and exercise, on "cooling" drugs, and on measures designed to reduce tension and tone in the arteries, especially bleeding.

The second major therapeutic mode consisted of stimulating, or "tonic," measures, remedies thought to strengthen the heart and arteries, in order to speed removal of whatever pathogenic factors had weakened the body, especially during convalescence from a fever, once its "crisis" had passed. Such methods included a wide variety of tonic drugs, as well as cold water and electricity, all of which were assumed to speed recuperation by increasing the pa­tient's depleted strength.

Dr. Maturin's chief task was to restore the balances among his patients' humors, the tensions within their nerves and blood vessels, and the acids and bases their bodies generated from food. Diet was as important as drugs for these purposes. Foods were evaluated not only in humoral terms as hot, cool, wet, or dry, but also for their stimulating or sedative properties, and for their acid, alkali, and salt content. Because fever exemplified heightened tones, it was treated with a "low diet" (meatless) that was easily digested and lacked "stimulating" properties. Patients with "colds," on the other hand, were fed foods, such as red meat, that would increase their body heat; both notions are still implicit in the admonition to "feed a cold and starve a fever."

Humors and tones were often adjusted to prevent illness. For instance, Maturin liked to bleed all men as they crossed the Tropics of Cancer or Capricorn toward the equator, "as a precaution against calentures [fevers] and the effects of eating far too much meat and drinking far too much grog under the almost perpendicular sun." He preferred the hands to eat a meatless diet while sailing between those latitudes.

Although sailors were predominantly healthy young men, they were still susceptible to most acute contagious diseases. In addition, chronic illness contributed to the loss of considerable manpower at sea. In the medical journal of U.S. Navy Surgeon Peter St. Medard, kept on board the 36-gun frigate New York during a cruise to the Mediterranean from 1802 to 1803 (during the Barbary Wars), St. Medard recorded—as all U.S. Navy Surgeons had been directed to do by the Secretary of the Navy—the name, rank, diagnosis, treat­ment, and result for each patient he saw among the 350-man crew over a 16-month period.

As on Aubrey's ships, the most frequent diagnoses on St. Medard's cruise were the catarrhs (i.e., bad colds), influenza, con­sumption (tuberculosis), and pneumonia; these respiratory ailments accounted for nearly 50 percent of all diagnoses made in the British or American navies. Other leading diagnoses included malaria (then called intermittent fever because the typical attacks of shaking, chills, and fever recurred every 24 or 48 hours), diarrhea, dysentery (i.e., painful and bloody diarrhea), and bilious fever (characterized by jaundice and correctly attributed to some primary disorder of the liver). Syphilis and gonorrhea, predictable risks of shore leave al­most everywhere, completed the list of the most common illnesses, although rheumatism and related debilitating conditions such as lumbago and sciatica could remove significant numbers from a ship's work force for weeks on end.

As Jack Aubrey was well aware, the most frightening illnesses (except for scurvy) were exotic tropical infections, especially ma­laria, yellow fever, cholera, and perhaps plague. Most Commanders and their Surgeons considered some of these to be hazards of spe­cific stations visited by the Royal Navy. For instance, yellow fever was associated with the West Indies, dysentery and liver disease (probably hepatitis) with the East Indies, malaria with both stations, and respiratory illnesses with the cold home waters of the British Isles. The worst of the continued fevers (so called to differentiate them from intermittent fever) was typhus, also known as ship fever or gaol fever. All of these, as well as the common respiratory ill­nesses, were potentially fatal, and so was scurvy, although it took much longer to kill.

 Scurvy was a special hazard at sea, chiefly on ships not suffi­ciently provisioned with fresh fruits and vegetables. Considered a result partly of damp decks and clothes, it was also thought to be contagious because the number of afflicted crew increased steadily (until a source of vitamin C was provided). After 1795, when the Royal Navy's ships were regularly well supplied with citrus fruit, scurvy was unusual.

Maturin and Aubrey were confronted with several outbreaks of scurvy. One occurred on the Leopard, and Maturin easily recognized the typical symptoms: The four afflicted men were glum, listless, and apathetic; their gums were spongy; their breath was offensive; their old wounds reopened; and blood seeped from capillaries in their skin. Knowing that the men were getting their "sovereign lime-juice" mixed into their daily grog, Maturin was baffled by the outbreak—until he discovered that the victims had been trading their grog rations for tobacco.

Another problem Navy doctors had to contend with was mental illness, which was thought to afflict one in a thousand seamen—a rate seven times greater than that among the general population. Doctors often attributed insanity to head injuries, which, in turn, were blamed on intoxication. Because the symptoms of intoxication could resemble generalized hyperactivity, alcohol was assumed to be a stimulant, not the general depressant we now know it to be.

 

The Medicine Chest

Medicine chests for Navy ships contained up to one hundred of the more than two hundred remedies prescribed by doctors on land and sea; the specific contents of each ship's chest differed somewhat, according to the Surgeon's preferences. All the drugs that Dr. Matu­rin gave his patients are known to have been used throughout the Royal Navy—and in the U.S. Navy—although some, such as pow­der of Algaroth, Lucatellus's balsam, polypody of oak, and polychrest, were considered archaic by 1800.

The most frequently used remedies were tonics, which according to solidist thinking strengthened the body when it had become weakened by disease, especially during convalescence from a fever.

For this purpose, the favored drug was cinchona, also called Peru­vian bark. It had entered medical practice in the late 17th century as a cure for malarial fevers (indeed, today we know that it contains quinine, which is still used to treat malaria), but it would have been ineffective against other fevers, for which physicians also came to use it.

The next most frequently prescribed drugs were cathartics, which were assumed to flush out unbalanced humors with the feces and to relax the abnormal tensions that had constricted patients' intestinal fibers, causing constipation. Typical of this class of drugs were calo­mel (mercurous chloride), jalap, medicinal rhubarb, castor oil, and cremor tartar (sodium potassium tartrate), a strong cathartic that was the most active ingredient of Maturin's black draught.

Doctors also gave emetics, drugs that induce vomiting, to remove foul humors from the stomach, as well as to strengthen what they took to be weak stomach muscle fibers. Tartar emetic (antimony potassium tartrate) was administered for this purpose, as was ipe­cac, which we still use to remove poisons from the stomach.

Diaphoretics, which Maturin called "anhidrotics," made patients "sweat out" their unbalanced humors. At the same time these drugs —especially those made with antimony, like James's Powder, a pa­tent medicine that Maturin sometimes prescribed—were assumed to strengthen the blood vessels that supplied the sweat glands in the skin.

Opium and opium preparations such as laudanum (an alcoholic solution of opium also known as Thebaic tincture), were correctly regarded as sedative, antidiarrheal, and analgesic. The addictive properties of opium were well known. Maturin, who used lauda­num frequently as an escape from his worries, appears to have been addicted, and it is unclear how he managed to wean himself from it. He believed that the coca leaves he discovered in Peru helped him overcome his reliance on opium, a common misconception even in the late 19th century.

Because syphilis was almost an occupational hazard of sailors, Navy Surgeons stocked various mercury salts to treat it. Most vic­tims required prolonged therapy with oral mercury preparations, such as calomel or Maturin's "blue pill" (mercuric chloride, also known as corrosive sublimate) and with unguents made with the latter. All mercurials were cathartic and diaphoretic, providing clear routes for the elimination of the contagious factor responsible for the affliction. However, it seems unlikely that such treatments could have eradicated the syphilis organism.

Most doctors, Maturin included, reserved two forms of treatment for their most seriously ill patients, especially those with the worst fevers or injuries. The first was the drug class called blisters, or epispastics, usually alcohol solutions of powdered cantharides bee­tles (sometimes called Spanish flies). When placed on the skin, this preparation raises a large, painful blister. In humoral theory it was thought to draw foul humors into the blister fluid; solidist reasoning concluded that the blister would also neutralize the naturally occur­ring inflammation that had caused the patient's symptoms by the process Maturin called "counter-irritation."

The other relatively drastic treatment doctors favored was bleed­ing, on the humoral grounds that it removed chemically or other­wise unbalanced blood-producing symptoms, and on the solidist grounds that it reduced tension of the hyperactive fibers of the fe­vered cardiovascular system. That is, releasing some of the patient's blood was assumed to reduce the friction (between the blood and the walls of the arteries) that was producing the patient's increased body heat. Doctors usually removed 12 ounces at a time but up to twice that amount from their sickest patients.

Maturin's remedies were not designed to counteract well-defined disease processes as modern drugs do. Instead, he and his contem­poraries used drugs to adjust or fine-tune a patient's internal equi­libria, his physiological balances, regardless of what might have disrupted them in the first place. The occurrence of catharsis, vomit­ing, sweating, or blisters after the administration of a drug simply confirmed that the remedy had indeed altered the humors, tones, and acid-base balance of the body in the intended way. However, few of these treatments could have provided truly effective cures.

 

Trauma and Surgery

During the ten years of naval warfare with France that culminated at Trafalgar in 1805, the Royal Navy had 1,483 men killed and 4,266 wounded in battle. That is only about 6 percent of the Navy's total losses; those from disease and individual accidents accounted for 82 percent, and major accidents (e.g., sinking) 12 percent. Thus, al­though the Navy called most of its doctors Surgeons, because their principal task was to repair battle injuries, their surgical skills were required far less frequently than their general medical skills.

Although Maturin was trained as a Physician, not a Surgeon, he had at least read the most influential works on naval surgery that had been published by the time he met Aubrey, including the works of Gilbert Blane, James Lind, William Northcote, and Thomas Trot­ter. Thus, he did not feel ill-prepared to take up a career as a naval Surgeon (although he never did become fully accustomed to the motion of ships).

Among the common occupational risks of life at sea that might require manipulative surgical treatment were burns; inguinal her­nias; falls from aloft; limbs crushed under falling barrels, ropes, or chains; and injuries incurred during fights. Burns, which occurred not only in battle but also when guns misfired during exercises, were usually cleaned and dressed with olive oil. Hernias were re­duced by manipulating the loop of intestine that had been forced into the scrotum so that it returned to the abdominal cavity, where it could be retained with a truss. Surgeons removed wens and superfi­cial tumors and incised and drained large boils and abscesses. They occasionally cut through the lower abdomen and into the bladder to remove stones, as Maturin did on the Polychrest, and some removed cataracts from the eye, although most sailors were not old enough to need this operation.

Because dentistry had not yet separated from regular medical practice, doctors were also often called upon to pull teeth, one of Maturin's least favorite chores. For this purpose they used a claw-like device called a turnkey, or pelican, that gave them maximum leverage.

Navy Surgeons were also often required to examine men con­demned to be flogged to ascertain whether they were fit for the punishment, and to treat their back wounds afterward.

Doctors of Maturin's time understood the basic principles of in­flammation, even if some of their methods for dealing with it now seem bizarre. For instance, believing that blood could turn to pus during the inflammatory process, they bled seriously ill or wounded patients to reduce the accumulation of pus. The bacteria that actu­ally cause its formation had not been discovered. But generally, surgeons applied sound principles to wound treatment: They con­trolled hemorrhage by tying off bleeding arteries, removed foreign bodies from wounds, and cleaned the wound sites. They thought some chemicals, such as^iitrates, had "antiseptic" (literally, "anti-inflammatory") properties, but they had no sure way of preventing infection. They attempted to close wound edges by clearing them of dead tissue and suturing them together. Afterward they inspected and changed dressings as often as possible to minimize inflamma­tion and pus.

Ironically, more battle wounds occurred when ships fought at a distance than in close engagements. Cannonballs that had traveled a long distance caromed off masts and railings, creating dangerous large splinters. If surgeons could get to the arteries severed by these flying splinters, they could usually tie them off to stop the bleeding. For instance, during the fight with the Algerine pirate ship Dorthe Engelbrechtsdatter, Maturin tied off the "spouting femoral artery" in the leg of one of the Sophies.

Surgeons removed bullets with a specially constructed "bullet forceps," sometimes probing blindly through a muscle mass or into a wound in the chest or abdomen. They almost never opened those body cavities because they were well aware that the risk of fatal inflammation (i.e., infection) at those sites was nearly 100 percent. Men who were seriously burned by misfired guns, by explosions, or by missiles that brushed their skin were treated with olive oil and ointments to soothe the affected areas and to prevent exposure to air.

During sea battles, the decks and cockpits could grow nightmar­ish. The following excerpt comes from the journal of Robert Young, a surgeon on H.M.S. Ardent at the battle of Camperdown, which began at about one p.m. on October 11, 1797. It is a clear picture of what sailors and Surgeons in Nelson's—and Aubrey's—Navy knew to expect when ships engaged in battle:

 

“I was employed in operating and dressing till near 4.0 in the morning. ... So great was my fatigue that I began several amputations under a dread of sinking before I should have secured the blood vessels. [Dr. Young had no Surgeon's Mates to assist him.]

Ninety wounded were brought down during the action. The whole cockpit deck, cabins, . . . together with my [operating] platform and my preparations for dressing were covered with them. So that for a time they were laid on each other at the foot of the ladder where they were brought down, and I was obliged to go on deck to the Commanding Officer to ... apply for men to go down the main hatchway and move the foremost of the wounded further forward . . . and thus make room in the cock­pit. Numbers, about sixteen, mortally wounded, died after they were brought down. . . . Joseph Bonheur had his right thigh taken off by a cannon shot close to the pelvis, so it was impossi­ble to apply a tourniquet [to stop the bleeding]; his right arm was also shot to pieces. The stump of the thigh, which was very fleshy, presented a dreadful and large surface of mangled flesh. In this state he lived near two hours, perfectly sensible and inces­santly calling out in a strong voice to me to assist him. The bleed­ing from the femoral artery [the main artery of the leg], although so high up, must have been very inconsiderable, and I observed that it did not bleed as he lay. All the service I could render this unfortunate man was to put dressings over the [wound] and give him drink. . . .

Melancholy cries for assistance were addressed to me from every side by wounded and dying, and piteous moans and be­wailing from pain and despair. In the midst of these agonising scenes, I was able to preserve myself firm and collected, and . . . to direct my attention where the greatest and most essential ser­vices could be performed. Some with wounds, bad indeed and painful, but slight in comparison with the dreadful condition of others, were most vociferous for my assistance. These I was obliged to reprimand with severity, as their voices disturbed the last moments of the dying. ...

An explosion of a salt box with several cartridges abreast of the cockpit hatchway filled the hatchway with flame and in a moment 14 or 15 wretches tumbled down upon each other, their faces black as a cinder, their clothes blown to shatters and their hats afire. A Corporal of Marines lived two hours after the action with all the [buttocks] muscles shot away, so as to excavate the pelvis. Captain Burgess' wound was of this nature, but he fortu­nately died almost instantly.

After the action ceased, 15 or 16 dead bodies were removed before it was possible to get a platform cleared and come at the materials for operating and dressing, those I had prepared being covered over with bodies and blood, and the store room blocked up. I have the satisfaction to say that of those who survived to undergo amputation or be dressed, all were found the next morn­ing in the gunroom, where they were placed, in as comfortable a state as possible, and on the third day were conveyed on shore in good spirits.”

(From Christopher Lloyd and Jack L. S. Coulter, Medicine and the Navy, 1200-1900 (4 vols.), vol. 3, 1714-1815 [Edinburgh: E. & S. Livingstone Ltd., 1961], pp. 58-60.)

 

Another firsthand account, by seaman Samuel Leech on the Mace­donian when she was defeated by the American frigate United States in October 1812 focuses more on the Surgeon:

 

“The first object I met was a man bearing a limb, which had just been detached from some suffering wretch. . . . The surgeon and his mate were smeared with blood from head to foot: they looked more like butchers than doctors. Having so many patients [36 were killed and 68 wounded], they had once shifted their quarters from the cockpit to the steerage; they now removed to the wardroom, and the long table, round which the officers had sat over so many a feast, was soon covered with the bleeding forms of maimed and mutilated seamen. . . .

Our carpenter, named Reed, had his leg cut off. I helped to carry him to the after wardroom, but he soon breathed out his life there, and then I assisted in throwing his mangled remains over­board. ... It was with exceeding difficulty I moved through the steerage, it was so covered with mangled men and so slippery with blood.

We found two of our mess wounded. We held [one man] while the surgeon cut off his leg above the knee. The task was most painful to behold, the surgeon using his knife and saw on human flesh and bones as freely as the butcher at the shambles.”

(Ibid., p. 61.)

 

As is clear from these accounts, hemorrhage was the greatest immediate hazard of battle wounds, especially those made by swords, bayonets, or large splinters. Bleeding from limbs was stopped by canvas tourniquets, tightened by turning a screw to compress a brass plate positioned over the bleeding artery. Bleeding from the head and torso could be controlled only by compression bandages. Only after bleeding had been minimized could the sur­geon proceed to correct the damage.

Eighteenth-century surgeons could perform a wide range of op­erations. The most frequent of the capital operations (those with the greatest risk of death) were amputations. Simple fractures and dislo­cations of arms and legs were reduced and splinted, but compound fractures associated with open wounds were likely to be followed by gangrene, which required amputation. By 1800 some surgeons were able to cut through the muscles of the thigh and saw through the femur beneath them so rapidly that patients felt the excruciating pain for no more than two minutes.

Some operations were not standard, of course—on the contrary, they had to be improvised according to the nature of the patient's wound. For instance, a few surgeons made successful extemporane­ous attempts to remove the entire arm along with the shoulder blade and collarbone; other joints were also removed, but rarely.

Trepanning, or trephining, was another rare capital operation. It involved cutting a disk about an inch or so in diameter from the skull to remove bone that had been fragmented by blunt trauma or shot and to relieve pressure on a swelling brain. Dr. Maturin won his reputation during his first voyage with Aubrey by this opera­tion, which he later said he had performed "many times" without failure. Indeed, not long after he trepanned Joe Plaice for a de­pressed skull fracture, the Surgeon himself was knocked out when his head struck a gun on a Pacific island controlled by potentially hostile American whalers. Mr. Martin, the Chaplain, could feel no underlying fracture and diagnosed a blood clot as the cause of Mat-urin's continuing coma. The Americans' Surgeon, Dr. Butcher, was preparing to trepan Maturin in order to remove the clot when the patient was mercifully and humorously jolted into consciousness by a bit of snuff accidentally falling into his nostrils.

Because general anesthesia was not invented until 1846, surgeons had to strap their patients into place or have them held down during major operations. They may have used rum or opium to minimize the patient's response to pain and to relax his muscles, but evidence of the routine use of such general depressants is diffi­cult to find. Of course, many patients became suitably unrespon­sive after going into shock when the pain became sufficiently intense.

Olive oil was usually applied to burns to keep the skin soft while it healed. The more complex ointments commonly applied to surgi­cal sites were made with mixtures of oils and fats; lead salts were included in some of them because they were thought to help keep the wound dry. If that succeeded, and if the wound could be kept clean, surgical patients had a good chance of actually benefiting from their doctors' skills, even though the doctors were unaware of the relationship between bacteria and pus.

 

What Good Could Dr. Maturin's Medicine Do?

With the exception of a small handful of drugs, such as opium and cinchona, it is clear that Maturin and his contemporaries were un­able to provide truly effective remedies for the majority of their nonsurgical patients. Nevertheless, most of them recovered. Fairly early in his naval career, Dr. Gilbert Blane concluded:

 

“There is a tendency in acute diseases to wear themselves out, both in individuals that labour under them, and when the infec­tion is introduced into a community [such as the crew of a ship]. Unless there were such a vis medicatrix [healing power of nature], there would be no end to the fatality of these distempers . . . and those who happen not to be infected at first, become in some measure callous to its impression, by being habitually exposed to it. ... Thus the most prevailing period of sickness is when men are new to their situation and to each other.”

(From Sir Gilbert Blane, Observations on the Diseases Incident to Seamen [London: Cooper, 1785], pp. 66-67.)

 

Blane, a strong proponent of keeping and examining naval medi­cal statistics, was right. In the absence of devastating epidemics of diseases like smallpox and yellow fever, about 90 to 96 percent of adult patients in the 18th century, civilian or naval, recovered after being treated by their doctors, regardless of what the physicians did.

Dr. St. Medard's clinical notes on the U.S.S. New York bear this out. His patients with bad colds recovered the most rapidly, fol­lowed by those with uncomplicated diarrhea. Dysentery cases re­covered more slowly, as did those with "bilious disorders" (probably hepatitis). Patients with typhus and other severe infec­tions recovered the most slowly and the least frequently. But the great majority did recover, even though the only truly effective drug St. Medard had was the quinine in the cinchona he gave patients with malaria, who recovered about as promptly as those with bad colds.

The only major illness on the New York that her Surgeon could not treat successfully was scurvy, because he had no lemons, limes, and oranges on board. The other illnesses eventually disappeared, thanks chiefly to the body's built-in immune and tissue-repair mechanisms. Scurvy was the only condition whose course could not possibly have been affected by the body's usual repair mechanisms. It has only one cure or preventive, namely Vitamin C.

The concept of the healing power of nature was not unknown to either Peter St. Medard or Stephen Maturin. Indeed, they and their colleagues saw their task as helping nature accomplish its job. Be­cause their contributions to the restoration of balances in humors, tones, and acidity were effective in 19 out of 20 patients, neither doctors nor their patients had any reason not to believe that they had contributed to their patients' recovery.

It probably would have been hard to convince Jack Aubrey, who had such confidence in Stephen Maturin's professional skills, that it was chiefly the surgical skills of Navy doctors that contributed to the survival of wounded men at sea and that the drugs they pre­scribed according to unproven (and unprovable) theories were effec­tive only because the body is often able to heal itself. But perhaps that unblemished confidence worked to Aubrey's and his crews' benefit.