These skills are further exercised in unravelling the mystery of Clarissa Oakes, and in so doing Maturin comprehends the relationship between sexual abuse in childhood and aberrant behaviour later on.
. . . for her the sexual act is trivial, of no consequence . . . For her, because of the particularity of her bringing-up, kiss and coition are much the same in insignificance; furthermore, she takes not the slightest pleasure in either. (Patrick O'Brian, Clarissa Oakes)
Dr Maturin's perceptiveness about the mental and behavioural side of medicine is remarkably broad for that period, ranging from madness in syphilitic sailors to what might now be called executive stress, or 'burnout'. He discusses one such case with Dr Harrington, Physician of the Fleet:
'Indeed, the effect of the mind on the body is extraordinarily great,' observed Stephen. 'I have noticed it again and again; and we have innumerable authorities, from Hippocrates to Dr Cheyne. I wish we could prescribe happiness.' (Patrick O'Brian, The Ionian Mission)
Later as Stephen examines Harrington's patient, a chronically overworked Admiral, he finds no diseased organ, 'but rather a general malfunction of the entire being, harassed beyond its power of endurance.' When he tells the Admiral that the cure for his disease would be a naval action against the long-blockaded French fleet, the Admiral cries, 'You are in the right of it, Doctor . . . I am sure you are in the right of it.'
Maturin is more introspective than most men, and far more given to speculation about the natural world than the average physician then or now. He is both an astute observer of the human condition and a shrewd clinician when dealing with the mental and emotional needs of his patients. Of course, these are mostly seafaring men, and Maturin finds them to be so totally adapted to the requirements of life aboard ship, and the necessity to live wholly in the present, that they are incapable of adjusting to normal life ashore. He offers a Minorcan colleague, Dr Ramis, the following conjecture:
'Let us take the whole range of disorders that have their origin in the mind, the disordered or the merely idle mind—false pregnancies, many hysterias, palpitations, dyspepsias, eczematous affections, some forms of impotence and many more that will occur to you at once. Now as far as my limited experience goes, these we do not find aboard ship . . . Now let us turn our honest tar ashore, where he is compelled to live not in the present but in the future, with reference to futurity—all joys, benefits, prosperities to be hoped for, looked forward to, the subject of anxious thought directed towards next month, next year, nay, the next generation; no slops provided by the purser, no food perpetually served out at stated intervals. And what do we find?'
'Pox, drunkenness, a bestial dissolution of all moral principle, gross over-eating: the liver ruined in ten days' time.'
'Certainly, certainly: but more than that, we find, not indeed false pregnancies, but everything short of them. Anxiety, hypochondria, displacency, melancholia, costive, delicate stomachs—the ills of the city merchant increased tenfold. I have a particularly interesting subject who was in the most robust health at sea—Hygeia's darling—in spite of every kind of excess and of the most untoward circumstances: a short while on land, with household cares, matrimonial fancies—always in the future, observe—and we have a loss of eleven pounds' weight; a retention of the urine; black, compact, meagre stools; an obstinate eczema.
Dr Ramis shrewdly observes that Stephen himself (who at the time is suffering from unrequited love, jealousy, and powerful inner conflicts over his duties as a spy) demontrates some significant signs of stress. He responds to his colleague's discourse on sailors with some personal observations:
'You speak of loss of weight. But I find that you yourself are thin. Nay, cadaverous, if I may speak as one physician to another. You have a very ill breath; your hair, already meagre two years ago, is now extremely sparse; you belch frequently; your eyes are hollow and dim. This is not merely your ill-considered use of tobacco—a noxious substance that should be prohibited by government—and of laudanum. I should very much like to see your excrement.'
'You shall, my dear sir, you shall.' (Patrick O'Brian, Post Captain)
Maturin tolerates certain types of purely psychological distress rather poorly and he has a distressing tendency to become reliant on drugs such as laudanum (the alcoholic tincture of opium) and cocaine. (Maturin chews the leaf which is admittedly far less dangerous than modern day use of the purified alkaloid.) He is capable nonetheless of great courage when he encounters life-threatening situations, physical torture, or personal injury. He ministers to his own damaged body with a casual lack of concern. Needless to say, others are amazed at Maturin's insouciance in the face of pain: after escaping from Peru through high mountain passes in the Andes, he remarks in a rather offhand way that he was frostbitten.
'Was it very painful, Doctor?' asked Pullings, looking grave.
'Not at all, at all, until the feeling began to return. And even then the whole lesion was less severe than I had expected. At one time I thought to have lost my leg below the knee, but in the event it was no more than a couple of unimportant toes. For you are to consider,' he observed, addressing his words to Reade, 'that your foot bases its impulse and equilibrium on the great toe and the least. The loss of either is a sad state of affairs entirely, but with the two one does very well. The ostrich has but two the whole length of her life, and yet she outruns the wind.'
'Certainly, sir,' said Reade, bowing.
'Yet though the leg was spared, I could not well travel; above all after I had removed the peccant members.'
'How did you do that, sir?' asked Reade, unwilling to hear though eager to be told.
'Why, with a chisel, as soon as we came down to the village. They could not be left to mortify, with gangrene spreading, the grief and the sorrow.' (Patrick O'Brian, The Wine-Dark Sea)
The old Sophies (now Surprises) are not even astonished when Stephen, wounded while killing Canning in a duel over Diana, designs a special instrument to remove the pistol ball that had lodged in his chest and then performs the extraction—cold sober—on himself.
'Christ, Bonden,' said Jack, 'he opened himself slowly, with his own hands, right to the heart. I saw it beating there.'
'Ah, sir, there's surgery for you,' said Bonden, passing the glass. 'It would not surprise any old Sophie, however; such a learned article. You remember the gunner, sir? Never let it put you off your dinner. He will be as right as a trivet, never you fret, sir.' (Patrick O'Brian, H.M.S. Surprise)
Maturin could be deadly in duels and combat situations. Nowhere is his potential ruthlessness more poignantly contrasted with both his capacity for detached objectivity and his aesthetic sensibility than in the amazing denouement of his long-running conflict with the traitors Ledward and Wray. When Maturin and van Buren, making certain to leave 'no recognizable remains', finally dissect the corpses of Ledward and Wray—thereby providing van Buren with an 'English spleen at last! . . . the most famous of them all!'—it becomes clear that the two cadavers are very likely of Maturin's own making. This in no way distracts him, however, from a dissection that is an anatomist's delight.
They worked steadily, with a cool, objective concentration: each had a clear understanding of the matter in hand—the relevant organs, those that might be useful for later comparison and those that might be discarded—and words were rarely necessary. Stephen had been present at many such dissections; he had carried out some hundreds himself, comparative anatomy being one of his chief concerns, but never had he seen such skill, such delicacy in removing the finer processes, such dexterity, boldness and economy of effort in removing superfluous material, such speed; and with this example he worked faster and more neatly than he had ever done before. (Patrick O'Brian, The Thirteen-Gun Salute)
Doctor Maturin was, however, well aware of the limitations of scientific medicine in his own time. Apart from the bark and steel, lemon juice and linctus (a syrup or paste), opium and alcohol, and a few helpful unguents and herbal draughts, the physician of two hundred years ago had little t
o call upon except his professional commitment and common sense.
Long before the introduction of chemical anaesthesia in the 1840s, heroic measures were required in Maturin's surgical practice to immobilise the patient under the knife and to minimise his suffering. Alcohol was commonly used, opium preparations were employed on occasion, but the greatest reliance was placed on strong men and ropes to keep the patient from squirming, together with something stout to bite on—'biting the bullet'. Experienced clinicians have always known however that fear is a large part of pain; modern research has shown that simple distraction can raise the pain threshold by forty percent. Dr Maturin obviously understood this when he employed the maximum of both distraction and sensory competition when facing an exceptionally unpleasant tooth-extraction—the only kind of operation he hated. 'He was not very good at drawing teeth and he liked his patient to be deafened, amazed, stupefied by a thundering in his ears.' Lacking a drum, the good doctor uses what materials are available and 'the tooth came out—came out at bloody last, piece by piece—to the howling of conchs, the fire of two muskets, and the metallic thunder of several copper pots.' (Patrick O'Brian, Treason's Harbour)
Although appreciative of the dangers of addiction, Maturin does not hesitate to make use of opium when the need arises. When the powerful but inarticulate Padeen saves several shipmates by holding a hot gun, his severely burned hand causes him to weep as he is brought to Maturin.
The Doctor dealt with the pain, the very severe pain, by an heroic dose of laudanum, the alcoholic tincture of opium, one of his most valued medicines. 'Here,' he said in Latin to his mate, holding up a bottle of the amber liquid, 'you have the nearest approach to a panacea that has ever been found out. I occasionally use it myself, and find it answers admirably in cases of insomnia, morbid anxiety, the pain of wounds, tooth-ache, and head-ache, even hemicrania.' He might well have added heart-ache too, but he went on, 'I have, as you perceive, matched the dose to the weight of the sufferer and the intensity of the suffering. Presently, with the blessing, you will see Padeen's face return to its usual benevolent mansuetude; and a few minutes later you will see him glide insensibly to the verge of an opiate coma. It is the most valuable member of the whole pharmacopoeia.'
'I am sure it is,' said Martin. 'Yet are there not objections to opium-eating? Is not it likely to become habitual?'
'The objections come only from a few unhappy beings, Jansenists for the most part, who also condemn wine, agreeable food, music, and the company of women: they even call out against coffee, for all love! Their objections are valid solely in the case of a few poor souls with feeble will-power, who would just as easily become the victims of intoxicating liquors, and who are practically moral imbeciles, Often addicted to other forms of depravity; otherwise it is no more injurious than smoking tobacco.' (Patrick O'Brian, The Letter of Marque)
Another common practice that Maturin frequently employed was to bleed his patients. Maturin's contemporary, the great American physician, Dr Benjamin Rush, was a strong proponent of veniseotion in the treatment of many diseases. For all fevers he advocated 'a low diet, heavy purging with calomel and jalap, 10 grains of each, and bleeding to the point of faintness.' (Ralph H. Major, A History of Medicine) Rush and Maturin had many other beliefs in common, such as opposition to slavery and capital punishment.
Not much was curative at that time for the physician or surgeon to apply, beyond the obvious manual skills and a handful of accidentally discovered remedies—which were often misused. The famous 'bark' (the quinine—containing Peruvian or Jesuits Bark from the cinchona tree) was, and still is, a valuable treatment for certain strains of malaria. However, because of its dramatic effect on the tertian malarial fever, it was widely used on fevers of every kind. In fact, long after its specificity was discovered and proved, quinine was incorrectly touted as an antipyretic. Even up to the present day certain well-known bromo-quinine tablets for the common cold contain 'the bromo for the aches and pains, the quinine for the fever'.
If we find the shops and markets of today still peddling useless remedies over the counter for mankind's minor miseries, consider how much more prominent were folk remedies and proprietary nostrums in Maturin's day. This situation is amusingly illustrated in Killick's treatment of Captain Aubrey's wounded eye after the Surprise's battle with the piratical Alastor.
Unwillingly Killick admitted that they needed no more than the ointment; but when he unrolled the bandage covering the captain's eye he cried, 'Now we shall have to have the drops as well as the salve—a horrid sight: like a poached egg, only bloody—and I tell you what, sir, I shall put a little Gregory into the drops.'
'How do you mean, Gregory?'
'Why, everybody knows Gregory's Patent Liquid, sir: it rectifies the humours. And don't these humours want rectifying? Oh no, not at all. I never seen anything so ugly. God love us!'
'Did the Doctor mention Gregory's Patent Liquid?'
'Which I put some on Barret Bonden's wound, a horrible great gash: like a butcher's shop. And look at it now. As clean as a whistle. Come on, sir. Never mind the smart; it is all for your own good.'
'A very little, then,' said Jack, who had in fact known of Gregory's liquid together with Harris's Guaranteed Unguent, Carey's Warranted Arrowroot, brimstone and treacle on Friday and other staples of domestic medicine, all as much a part of daily life on land as hard-tack and mustering by divisions on Sunday at sea. (Patrick O'Brian, The Wine-Dark Sea)
When other treatments were not appropriate Maturin made amputation his last resort. Amputations by naval surgeons were commonplace enough, but they were often unnecessary from the strictly medical point of view. Prevention of exsanguination, gangrene, or sepsis (blood-poisoning) were frequent rationales, but the superior surgeon, then as now, tried to avoid operating whenever he could. After their capture by the Americans in The Fortune of War Maturin saves Aubrey's arm by exercising such care. The locale for surgery was also a factor because infection was so frequent and very likely to be transmitted from patient to patient in a hospital setting, though the exact mechanisms were not yet understood. In Vienna, Ignaz Philipp Semmelweis published his famous treatise on puerperal fever in 1860; he went to his grave five years later still unsuccessful in persuading his colleagues to wash their hands after examining an infected patient and before handling the next one. It remained for the more respectable Englishman, Joseph Lister, to publish his discovery of antisepsis in 1867 and even then many surgeons resisted the idea until clinical results won general acceptance. Hospitals were extremely dangerous places meanwhile, and Maturin tried to avoid them. The American naval surgeon, Mr Butcher, agrees with him.
Besides, although a hospital is far more convenient for operating, surviving is quite another matter: for my part I had rather be at sea. I have known a whole [hospital] ward of amputations die in a week, whereas several of the men who had to be kept aboard for want of room lived on. Some are living yet. (Patrick O'Brian, The Reverse of the Medal)
On long, quiet passages the 'medical man's daily fare' comprised mainly scurvy, 'obstinate gleets' (urethral discharges caused by gonorrhea) and 'poxes' (skin eruptions caused by syphilis).
Stephen could oblige the seamen to avoid scurvy by drinking lemon-juice in their grog, [but] no power on earth could prevent them from hurrying to bawdy-houses as soon as they were ashore. (Patrick O'Brian, The Wine-Dark Sea)
The treatment for these diseases was of course only symptomatic; the best someone with venereal disease in those days could hope for was that such nostrums as 'draughts of calomel and guaiacum,' which were in themselves harmless, might ease the symptoms a bit and give nature a chance to repair the damage. More strenuous remedies, such as 'the Viennese treatment,' posed serious risks of their own, as Dr Maturin's helper, Mr Martin discovered to his sorrow when he secretly, undertook to treat himself for an imaginary case of syphilis with a terrible overdose of bichloride of mercury (corrosive sublimate).
One of Maturin's earliest experiences of dis
ease at sea occurs when the Sophie encounters a felucca in distress, with only dead bodies in view. Maturin quickly identifies the signs of bubonic plague amongst the victims and is shocked and infuriated when Aubrey sheers off, thereby preventing him from boarding the unfortunate vessel to treat possible survivors. However, Maturin later turns this experience to advantage when the Sophie first encounters the deadly Cacafuego and is lying at grave peril under her guns. It is the quick-witted doctor who, having learned the naval horror of his dread disease, pleads with the Spaniards for help with fictional plague-stricken shipmates and thus neatly sends them hastily away without a shot being fired.
Beyond the more commonplace complaints of seafaring men was the ever-present danger of plague or typhus. In Desolation Island the 'gaol-fever' that kills so many aboard the Leopard in a prolonged epidemic that strains Dr Maturin's personal and medical resources to the limit, is undoubtedly typhus. The vessel is alive with rats—fleas transmit the disease to humans—and the symptoms are all there.
All three patients had broken out in a mulberry- coloured rash, extraordinarily widespread and most ominously dark: there was no possible doubt—this was gaol-fever, and gaol-fever of the most virulent kind. He was certain the moment he saw it, but for conscience' sake he checked the other signs—petechiae, a palpable spleen, brown dry tongue, sordes, raging heat: not one was absent.
Book 9 - Treason's Harbour Page 35