Surgery and Medicine in Nelson's Navy
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48 History History The Death of an Admiral - Surgery and Medicine in Nelson’s Navy MKH Crumplin The long war against the French republic (1792-1804) and that had been a long and tortuous evolving therapeutic Empire (1804-1815) cost Britain dearly. Fought all over the journey) and smallpox, with naval hospital mortality globe, in hostile waters and climates, the Royal Navy was significantly diminishing. In 1781, hospital mortality in one pivotal in keeping the seas as clear as possible from enemy large naval hospital fell from one patient in eight demising, shipping and enabling Britain to prosecute military actions to one in thirty by 1812. There were modern and capacious in diverse countries and climates. In today’s terms, the war hospitals at Portsmouth and Plymouth and hospital ships left us with a national debt of around £52 billion sterling were provided for large military expeditions. Vessels and a sacrifice of around 300,000 dead souls of a population requisitioned for this purpose were decommissioned ships of ten million - a larger proportional loss than we suffered of the line, with wards sectioned off to deal with diseases in the Great War of 1914-18 (1). France lost a million men such as scabies, dysentery ‘fevers’ and malaria. Nurses on the world’s battlefields and at sea. Prime Minister Pitt served on these ships. concentrated on financing coalitions and keeping the Navy Although the diet was tedious and inevitably varied, up to strength. By 1804 Britain had 726 ships to serve us. it provided high calorie replacement - almost 5,000 cals/ Of these, 189 were line-of-battle ships and about 204 were diem, at full ration, to men working notoriously tough frigates (2). routines, in all weathers, and where squadrons were Naval duties included occasional fleet actions, patrols perpetually blockading French and Spanish ports (the to seize enemy provisions and ships, escorting convoys, latter until 1808) (5). Thus men were generally well fed. participation in combined operations, but most importantly Only when vessels were on long distance missions and blockading enemy ports - arduous, tedious and essential duties, away from victualling yards and supply ships, did to keep as many French and Spanish vessels bottled up things get hard. and ‘idle’, whilst we, through impressive discipline and It remains to speculate on the training of the navy’s rehearsal kept our sailing and gunnery up to a decent medical men. Schooling ran on until around fourteen or standard. It was these latter two assets that made the Royal fifteen years, when the parents (often professional people) Navy as effective as it was. would accept and agree to paying for their son’s medical Loss of life at sea was largely due to accident, apprenticeship. The cost of this varied from town to city to foundering and disease. Only around 6,500 matelots and country - often cheaper north of the border. The apprentice marines of around 100,000 fatalities in the service, died as would learn good and bad from his master, then often serve a result of enemy action (3). as a pupil, ward-walking, dressing and attending to minor It is not easy to obtain a concept of the overall quality ward duties in a provincial or metropolitan hospital. He of care provided by naval doctors, or of the important would pay for and attend Spring and Autumn courses of relationships that existed between commanders and their lectures on anatomy, material medica, midwifery, surgery surgeons. But we know that reformers and clinicians, such etc. He would read, dissect, attend ward teaching and also as Trotter, Blane, Lind and Gillespie, made an enviable surgical sessions. There were few book illustrations, but inroad into successful public health measures, no doubt osseous specimens, wooden skulls, wax models and body catalysed by the mutinies of 1797. Surgery was clearly parts provided a rudimentary training in surgery, much of at a low-ebb, after the Battle of Camperdown (1797), as which was a far cry in reality from the sick-bay or cockpit. clearly shown by a memorial written to the First Lord of Examinations were taken around the age of twenty-two the Admiralty by the notable Edinburgh surgeon, John years, and apart from dissertations for higher degrees, Bell (4). Reforms of pay, nomenclature and the provision were oral exams only, and were of a fairly basic and practical of proper rank and titles began to restore some dignity to nature (Figure 1). the surgeons serving in the Navy. In these respects naval If the candidate was successful, he attended the Sick reforms lagged behind the British Army. By around 1805, and Hurt Board of the Admiralty and there obtained an there was a much-diminished incidence of scurvy (although appointment warrant to a vessel, according to a further J Royal Naval Medical Service 2012, Vol 98.1 49 imperative to have one surgeon for every type of naval ship, the number of assistants (mates) varied according to rating. For example, Nelson’s flagship at Trafalgar should have had one surgeon and five assistants, as a first rate, but only had two assistants at the battle. This underscores the issue that medical complements were often deficient. Most of the work of the medical staff was day-to- day mundane duty An example of the usual sort of sick rate is given by logged data from one large American frigate (complement around 300 men), patrolling the Mediterranean in 1803. It had, over a few months, around ten to twenty men on the sick list and nil to five new cases per diem. These men were treated, dressed or nursed in the ship’s sick-bay, a compartment, situated forward under the fo’castle on the starboard side of the vessel. Here, chest complaints, bowel disorders, fevers, venereal complaints (sailors were often fined for their indiscretions!), minor injuries and disabilities, were treated by the surgeons, assistant surgeons and their loblolly boys. There had, of course, to be provision for female patients in addition to the crew. Problems such as peritonitis, bladder stones, prostatism and epilepsy attracted a smart ticket, which mandated onshore treatment in hospital. One key issue of interest during combat was that naval casualties were often very close to medical aid - not so for the British soldier, who might be some distance from evacuation and treatment. Injuries sustained in naval action were treated on the orlop deck in the cockpit by the medical team, helped by the lightly injured and sometimes the women on board. They were relatively safe below the Fig. 1 A page from a crib book for Membership examinations ship’s waterline. Here operating conditions were dire, in the Royal College of Surgeons of London (later, England), owing to cramped space, low ceiling height, poor light 1815. (Author’s collection (6)) and interminable noise from the injured and the heavy ordnance on the deck above. Surgery was meted out on a examination by the board. first come first served basis and overall, things appeared a The licensing bodies in the United Kingdom (in total bloody shambles to the uninitiated (Figure 2) the main the London College of Surgeons) had several responsibilities. They not only had a role in training - ‘tho much of this was carried out by extramural anatomy and surgical schools - but also they examined candidates for civil or military diplomas, they determined pensions for wounded officers in the Armed Services (Lord Nelson received a pension for the loss of his eyesight in action three years after the injury, also recompense for expenses relating to his amputation), they inspected surgical instruments for the Navy on a regular basis and finally, along with the Sick and Hurt Board, college officers inspected the surgeons’ routine day-to-day log accounts of men sick or wounded in action. The ship’s surgeon had to be multitasked - acting as surgeon, physician, dispenser, confidant and dietician. The Royal Navy boasted more surgeons than the British Army - around 1,400 in all, whilst the land forces (excluding Fig.2 The orlop deck of HMS Vanguard, during the action at militia surgeons) had only about 1,250. This meant that Aboukir Bay, August 1798 - note the exaggerated height of the roughly there was one medical staff for every 95 sailors to the deck above, the low lighting and the upright position of and marines and one for every 250 soldiers. Whilst it was the patient on the right. (Author’s collection) 50 History Wounds were caused by cannon shot or debris they struck up (around 60%), and less than 20% of injuries were caused by small arms fire. A small percentage of wounds was caused by cutting or slashing injuries and by burns. The reverse was the case in the army - two thirds of wounds being inflicted by small arms fire and around 15-20% by heavy ordnance (7). As to primary on-site care and resuscitation, about ten per cent of navy crew was instructed in the use of the tourniquet. Control of bleeding, bandaging and giving drinking water were the principle first aid measures. Surgery at this time was primitive, but had several strings to its bow - partial or complete limb amputation (no anaesthesia or antiseptic precaution), trepanning (fairly rare and often successful), wound toilet and the excision of foreign matter (soiled and jagged wood shards were often difficult to remove), bandaging, suturing or taping, catheterisation, venesection (commonly practiced then, especially for head and chest injuries) and drainage of almost inevitable sepsis (Figure 3) Often the patient was restrained and operated on in the sitting position. Alcohol was not prescribed for surgery. Sepsis, lack of sanitation, hygiene, transfusion of blood and fluids a lack of understanding of trauma physiology, mitigated against success in surgery.