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. Nelson was a front leader in combat, often wounded, once escaping severe injury in a boat action off Cadiz and being extremely fortunate in not being wounded off Fig. 4 Captain Horatio Nelson struck in the right eye by stone Copenhagen in 1801. Nelson was first damaged by enemy debris, during the siege of Calvi, July 1794.(Author’s collection) action when above the town of Bastia in April 1794. In a combined operation, Britain needed to gain another from HMS Agamemnon, to batter the walls of the citadel foothold in the Mediterranean and she chose Corsica. of Calvi. Captain Nelson was standing near a parapet in Standing with a guide and other officers, a round shot front of a battery at about 0700 hrs on 10th July 1794 when striking near him hurled him to the ground. He was merely a round shot smashed into the wall and threw up chips of bruised and went on after Bastia had fallen, to mastermind stone that penetrated his face, neck and right eye (figure 4) a naval bombardment, using sled-hauled naval ordnance In severe pain and essentially blinded in that eye, Nelson could, it seems, eventually only perceive light from dark. His iris was distorted and, no doubt, he had suffered an intraocular foreign body. After his eye injury, he was examined by the Fleet Physician, Dr Harness and was eventually given a disability pension. He later acquired mild cataracts and pterygia. His eyes clearly suffered from much exposure to wind, sun and rain. He eventually wore a crescentic green cloth rim eyeshade on the front of his weather hat. Little much is known about the later outcome of Commodore Nelson’s wound sustained at the Battle of Cape St Vincent, on 14th February 1794. In his usual style, he led a boarding party of soldiers, sailors and marines over the 80- gun Spanish ship, the San Nicolas, to board the larger 112-gun San Joseph, taking the surrender of both. Whilst boarding, a wooden shard from a tackle block smashed into his abdominal wall, which caused much bruising and transient retention of urine (from clot retention). The resultant haematoma, Fig. 3 An above knee amputation c. 1821, taken from the coupled with crushed muscle tissue gave rise to a hernia, the ‘Illustrations of the Great Operations of Surgery’ by Sir ‘size of a fist’, which clearly would have troubled him, but Charles Bell. (Author’s collection) fortunately, never became irreducible (8). J Royal Naval Medical Service 2012, Vol 98.1 51

Fig. 5 Nelson is struck down. (Author’s collection) Flying langridge (metal debris) from a French 74’ struck his silk stock and covered the admiral’s wound to hide the Rear Admiral Nelson on the forehead, above the right eye, bleeding. The boat pulled away and rowed out towards the on the 1st August 1798, at the Battle of the Nile. During this moored attack vessels. Before reaching surgical aid, Nelson daring evening combat, at around 2000 hrs, Nelson stood on ordered survivors from a sunken cutter to be pulled inboard the quarterdeck of HMS Vanguard and was thrown back by the and later the boat pulled on to HMS Theseus, where force of the blow. Steadied by his flag captain (Captain Berry), Surgeons Eshelby and Remonier, amputated Nelson’s arm he went below, where Surgeon Jefferson probed, sutured or high above the elbow (10). Refusing any assistance, bar a taped his wound and bound it up (9). The captain neither lost rope, as the Admiral clambered aboard, he stoically suffered consciousness, nor had a skull fracture nor apparently had any the surgery and ordered the severed limb to be cast into the retrograde amnesia. After he was dosed with some opiate draft, hammock-shroud of a dead sailor who had died near him. he was partially recovered and wrote the dispatch concerning He commented on the cold feeling of the instruments on the the battle, in the ship’s bread room. After this wound, he was skin during the surgery and ordered all squadron surgeons to greatly troubled by sleep deprivation, fatigue, seasickness and warm their instruments prior to use! He rallied well enough, distressing headaches. Whether any subsequent behavioural but remained depressed about his disability. He apparently anomalies around the city and court of Naples could be root- received three post-operative doses of tincture of opium. caused to this wound, we will never certainly know. Unfortunately, during the operation, a ligature had been Nelson was hit by small arms fire twice, the second time inadvertently passed around Nelson’s median nerve along proving fatal. On the first occasion, in July 25th 1797, whilst with the brachial artery. This gave him severe pain foe several involved in a combined operation to capture Santa Cruz on months, until the ligature was finally loosened by sepsis. Tenerife, Nelson was one of the first ashore. As he clambered Nelson’s final and fatal wound was inflicted at around onto the mole on the town harbour, he was shot, a ball from 1315 hrs on the 21st October 1805, off Cape Trafalgar, after a musket entered his right arm above the elbow, shattering the Victory had crossed the enemy fleet’s battle line. His the humerus and injuring his brachial artery. His stepson, flagship was locked in with the French 74’ Le Redoutable, Josiah Nisbet, bound the arm with a tourniquet made from commanded by the gallant Captain Lucas (Figure 5) 52 History

Fig. 6 The angle of strike and penetration of Nelson’s body by the Fig. 7 The approximate angle of the fatal ball, traversing French ball (Courtesy of the late Professor Leslie Le Quesne.) Nelson’s thorax at around the T6/7 level. (Author’s collection) Our Hero was shot (probably in a random way) from the mizzen-top of the Redoutable. The ball was fired from an angle of around 45 degrees above and from a distance of about 21 metres. The missile entered Nelson’s chest only about fifteen degrees off his left lateral plane, so making it almost a side shot. The ball scuffed the tip of his acromion, broke two ribs anteriorly and passed through two segments of his left lung. It exited posteriorly, breaking two more ribs and dividing the spinal cord at T6/7 level, finally coming to rest in the muscles of his right back (Figure 6) He fell on the quarterdeck and a marine sergeant and some matelots helped him below. Surgeon Beatty visited him a few times and the patient and the surgeon finally agreed that the wound had resulted in paraplegia and was fatal. Nelson had previously witnessed (in the Atlantic) a case of paraplegia in a sailor who had suffered a fatal fall. Asking for the Reverend Scott to fan him, rub his chest, which was painful, and give him lemonade or cordials to sip, Nelson suffered severe pain and continued anxiety about the outcome of the action and the fate of his family - particularly Emma and Horatia, their daughter. But he took three-and-a-quarter hours to die. He was not apparently particularly breathless, but clearly had a significant haemopneumothorax. When Beatty performed Nelson’s post mortem on the Victory, on the 11th December 1805 at the Nore, he found not as much bleeding as he had expected (11). So why did the Admiral die of a wound that many other servicemen had survived. The answer lies in the pathophysiology of his spinal transection. Unable to Fig. 8 Nelson’s funeral cortege arriving at St Paul’s properly compensate for his blood loss with his spinal cord Cathedral, 9th February 1806. (Author’s collection) J Royal Naval Medical Service 2012, Vol 98.1 53

cut at T6/7, he succumbed from an otherwise survivable 1806, attracted the largest crowd in London ever assembled injury and blood loss. It was largely the spinal cord damage - the peoples’ grief, had seemingly overridden the brilliant that killed Nelson (12). (Figure 7). victory gained by Nelson’s fleet (Figure 8) His body was stripped and his hair cut away. Placed The surgeons could have done little more for Nelson, in a leaguer of brandy, topped up at Gibraltar with spirits but their contributions to the health of thousands of our of wine and camphor, his corpse was brought home to be sailors and marines were more far-reaching than we often decently interred. His state funeral on the 9th February mine imagine.

Reference 1 Crumplin M, Men of Steel - Surgery in the Napoleonic Wars, 2007, 8. Adkin M, The Trafalgar Companion, p.166. Quiller Press, p.10. 9. Oman C, Nelson, 1947, Hodder and Stoughton, pps. 294/4. 2. Adkin M, The Trafalgar Companion - a Guide to History’s Most 10. Adkin M, The Trafalgar Companion, p. 220. Famous Sea Battle and the Life of Admiral Lord Nelson, 2005, 11. Nicholas NH, The Dispatches and letters of Vice Admiral Lord Arum Press, p27. Viscount Nelson, Vol. VII, 1846, published by Colburn H, p. 262. 3. Crumplin M, in Health and Medicine at Sea 1700-1900 (Eds. 12. Crumplin M, The Most Triumphant Death - the Passing of Vice- Haycock, DB, Archer S), 2009, The Boydell Press p.64. Admiral Lord Horatio Nelson, 21st October 1805, in the Journal of 4. Ibid, pps.63/4. the Royal naval medical Service, Vol 91.2, 2005, pps. 92-5. 5. MacDonald J, Feeding Nelson’s Navy, 2004, Chatham Publishing, 14  Day, A.J., Brasher, K., & Bridger, R.S. (2011). A survey of accidents pps. 177/8. in the Royal Navy in relation to measures of stress and cognitive 6. Hooper R, Examinations in Anatomy, Physiology, Practice of demands. INM Report 2011.023. Physic, Surgery Materia Medica, Chemistry and Pharmacy for the 15  Bennett, A., Brasher, K., & Bridger, R.S. (2011). Body mass index use of students who are about to pass the College of Surgeons or and changes in body mass in Royal Naval personnel 2007-2011. the Medical or Transport Board, 1815, printed for Collins and Co. INM Report 2011.044. 7. Crumplin M, Men of Steel, p. 41.

MKH Crumplin FRCS (Eng. and Ed.) FHS FINS