A Sea of Words

by Dean King

  A set of amputating knives and bone saws and a Petit tourniquet, tightened by a brass screw to prevent blood loss during an amputation. Reproduced from William Turnbull, The Naval Surgeon, Figure 3 (courtesy of the Boston Medical Library, Boston, Massachusetts).

  The medical day aboard warships was determined by both custom and regulation. The Surgeon’s Mate visited the sick-bay before breakfast to attend to the patients’ needs. At eight o’clock—which was the end of the morning watch and after the gun deck had been cleaned—the loblolly boy rang a bell on each deck to summon to sick call those who were slightly indisposed, or were under treatment for venereal disease, or had superficial ulcers; men who were injured or who fell seriously ill during the day could report to the Surgeon at any time. He took morning sick call at the mainmast, where he and his Mate examined those who presented themselves. Then they made their daily rounds of men already in the sick-bay, while the boy fed, washed, and shaved the bedridden patients. The Purser or his steward sometimes dispensed drugs to those who had continuing prescriptions for them, or to men who simply thought they needed a little something to make them feel better.

  The Mate spent the rest of his day preparing and administering medicines in the sick-bay, dressing wounds and skin ulcers, and bleeding men who needed it. He was also responsible for maintaining the ship’s surgical instruments, for keeping accurate records of medicines and expenditures, for inspecting the cook’s pots and pans, and for supervising the loblolly boy. In addition to supervising the care of the sick and injured, the Surgeon’s routine duties included overall responsibility for his Mates and boys, personally visiting every patient at least twice a day, and, depending on who was in charge at the Admiralty or at the Sick and Wounded Board, keeping accurate records on each patient admitted to his care.

  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 members could conveniently carry the wounded for triage and treatment. Not all ships had such a space, so planks were sometimes laid across unused guns to serve as operating tables. The deck of the cockpit 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 during amputations.

  Serving on Board Hospital Ships or at Hospitals

  The hospital ship was 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 segregating patients with the various fevers, diarrheal 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 was more profitable there than at sea; hospital surgeons were paid £500 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 that 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. Two of the best overseas hospitals were those at Malta and Minorca, where Maturin, like his historic counterparts, sent seriously ill patients when possible and necessary. But most naval hospitals, like many civilian hospitals at the time, 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 private practices, even the doctors were frequently inattentive to their charges.

  Finally, a small handful of Navy doctors served as official naturalists on both warships and those sent on missions of exploration. Maturin’s continued attempts to observe new species of plants and animals, and to collect specimens and reports to send home, is in that tradition.

  The Disease Burden of the Royal Navy

  Reforms in medical staffing and victualling procedures by the Navy between 1780 and 1800, many of them the work of Dr. Sir Gilbert Blane (1749-1834), a Royal Navy Commissioner for the Sick and Wounded Board 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. Certainly a portion of this accomplishment can be attributed to Blane’s introduction of limes as a scurvy preventive soon after he took office in 1795.

  The pathophysiologic theories on which Dr. Maturin and other physicians trained in the 18th century were unlike our own ideas of specific diseases with specific causes and specific treatments. Several levels of factors were said to cause disease. To begin with, “predisposing causes” related to the seasons, the weather, and the patient’s constitution (body build, gender, age, inherited traits, and way of life). For instance, in the case of seamen, according to Dr. Charles Turner Thackrah, one of the earliest physicians to be concerned with occupational health:

  [Sailors] are generally very healthy and robust, hardy and enterprising. Living well, and enjoying good air and exercise, their diseases are few, and commonly of an inflammatory kind, as ... Pneumonia & c ... the most prevalent complaints, as the cause of death, are the sequelae of [such] diseases ... next to these I may mention disorders of the bowels, as Colic, Diarrhea, and Dysentery. (The Effects of Arts, Trades, and Professions on Health and Longevity, 2d ed. [1832; reprint, Canton, Mass.: Science History Publications, 1985], p. 71)

  The second level of causes of a patient’s symptoms, their “antecedent causes,” included two kinds of airborne factors: “miasmas,” invisible disease-producing particles that emanated from decaying animal and vegetable matter—from rotting carcasses, privies, and swamps for example—which were contrasted with “contagions,” or “effluvia,” equally invisible particles generated by and emitted from patients afflicted with any of a number of fevers. The sepsis that often killed men wounded in battle, even after successful amputation, was among the Surgeon’s most serious encounters with contagions.

  Disturbances in amount or quality of what were called the “six non-naturals”—air, kinds of food and drink, amount of diet, sleep, exercise, and mental state—formed the third level of causes of symptoms. Abnormalities or mere changes in any of these factors could produce illness, by, for instance, obstructing natural routes of elimination or by increasing or suppressing normal physiological activities.

  One or more of these three factors—predisposing causes, antecedent causes, disturbances in the six non-naturals—was assumed to bring about a patient’s “immediate causes” of illness, the disturbances in body function that produced the symptoms on which a physician based his diagnosis. Diseases were not then diagnosed or classified according to their etiologies, as they are today; instead the patient’s symptoms were the doctor’s diagnosis.

  Illness was described principally in terms of imbalances. The earliest, but still widely held, theory that governed 18th-century physicians’ interpretations of their patients’ symptoms had emerged from a concept of disease causation first elaborated in ancient Greece in the fifth century B.C., when physicians explained their patients’ symptoms 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 observation: 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, still accepted in Maturin’s time, held that in order to restore health and stability to the sick body, its imbalances had to be counteracted with drugs or foods with opposite properties.

  But there was another set of factors to consider too. A new theory emerged in the 1690s, postulating that illness can also represent imbalances in the irritability of the solid fibrous components of blood vessels and nerves, as expressed by their tone (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, and when sweat, urine, and feces could be expelled freely, and so forth. On the other hand, paralysis was attributed to weak nerves, while the increased body heat associated with fevers, the most common serious illnesses of the 18th century, was attributed to increased arterial irritability or tone. In short, a fast pulse became the hallmark of fever. Medical historians have labeled this the “solidist theory.”

  Finally, the study of the chemistry of respiration that began in the 1770s led to the interpretation of rapid breathing as one more manifestation of fever. That is, 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. Adding these chemical concepts to their previous theories, doctors now looked at a new set of balances—between acids and bases—allowing them to explain the apparent reciprocal actions of basic and acidic drugs. These three concepts—humoral, solidist, and chemical—were not mutually exclusive, and most therapies were interpreted within the frameworks of all three simultaneously.

  In the case of fever, the physician’s first therapeutic 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, evacuant, or antiphlogistic regimen. For instance, Maturin often prescribed emetic, antispasmodic, cathartic, and narcotic drugs to rid the body of whatever noxious factors had disrupted its balances and to calm hyperactive fibers. Such therapy also relied on avoiding anything that 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 including red wine, one of Maturin’s favorites, as well as cold water and electricity: all were assumed to speed recuperation by increasing the patient’s depleted strength.

  Dr. Maturin’s chief task was to restore to normal 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 ancient admonition to “feed a cold and starve a fever.”

  Humors and tones were often adjusted to prevent illness. For instance, although bleeding was generally reserved by most doctors for the worst cases of fever or injury, 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 also preferred the hands to eat a meatless diet while sailing between those latitudes.

  Although sailors were predominantly young, healthy men, they were still susceptible to most acute contagious diseases. In addition, chronic illness contributed to the loss of considerable manpower at sea. 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), provides us with factual insights into the medical thinking of Maturin’s day. In it, 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 on New-York, 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 and 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 (painful and bloody diarrhea), and bilious fever (characterized by jaundice and correctly attributed to some primary disorder of the liver). Syphilis and gonorrhea, which were predictable risks of shore leave almost anywhere, completed the list of the most common illnesses in all navies of the time, although rheumatism and related debilitating conditions such as lumbago and sciatica could remove significant numbers of men from a ship’s work force for many 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 occupational 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 surrounding 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, as 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 supplied with citrus fruits, scurvy was unusual, but it still occurred, particularly on long voyages when resupply was impossible.

  Maturin and Aubrey were confronted with several outbreaks of scurvy. One occurred on the Leopard, and Maturin easily recognized its 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 among the general population. Doctors often attributed insanity to head injuries, which, in turn, they 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 100 of the more than 200 remedies
prescribed by doctors on land and sea; the specific contents of each ship’s chest differed somewhat according to the Surgeon’s personal preferences. All of the drugs that Dr. Maturin gave his patients are known to have been used throughout the Royal Navy as well as in the American Navy, although some of Maturin’s remedies, 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 that, according to solidist thinking, strengthened a body 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 early 17th century as a cure for the intermittent fevers—that is, malaria (indeed, today we know it contains quinine, which is still used to treat malaria). Because it was so successful for that purpose, doctors came to prescribe the bark for virtually all other fevers, although we now know that it would have been completely ineffective against them.

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