Until the twentieth century, with a few notable exceptions, there was little science involved in the practice of medicine. Yet there were some attempts made to save the lives of Britain’s seamen, in the early 19th century. “Advancements in Shipboard Care in Nelson’s Navy” is the title of the article I wrote for the 1805 Club’s 2022 issue of The Trafalgar Chronicle.
Emergency care was not a term used in Nelson’s time, nor for a hundred years after Trafalgar. It wasn’t until mid-twentieth century that the term came into being, along with expanded pre-hospital rapid response delivery by paramedics. But first aid saved lives aboard ship during the age of sail, largely through the use of the field tourniquet – some officers and crew were instructed in its use, which could save a man from bleeding to death until the ship’s surgeon could intervene. With one surgeon and perhaps a couple of surgeon’s mates, the surgeries continued well after the cannon fire stopped. The wounds sustained by crew aboard fighting ships in the age of sail were often horrendous and immediately life-threatening. Cannon balls sunk ships or disabled them; Langrage mutilated human beings. If a major artery is severed a person can bleed to death in minutes. Simple mechanical pressure on the artery or a tourniquet to stop bleeding from a severed limb, can buy precious minutes.
The surgeons were quick and strong. They knew their anatomy and they could work in dim light belowdecks on a moving deck. They did not fully understand the causes of post-operative infection, nor did the university educated physicians of the day. By providing more crew with tourniquets and teaching them how to use them, it is likely a few lives were saved, though we have no way of knowing.
What we do know is that better living conditions, better diet, and better nursing care on land-based naval hospitals and hospital ships began to have an effect on the number of men dying from diseases. It was not one silver bullet cure nor an advance in engineering that brought about the decrease in mortality, but better food, hygiene, living conditions and nursing care. In Nelson’s time this was first appreciated, but it was Florence Nightingale’s work and influence mid-century that organized and elevated nursing to a profession. Florence Nightingale is recognized as an English social reformer, statistician, and the founder of modern nursing.
The 12 years I worked as a registered nurse has greatly influenced my writing life and directed my studies in history. I wrote a number of nursing and general health-related articles that were published in various magazines. Yet Angel of Mercy was never my calling. Like Patricia/Patrick of The Patricia MacPherson Nautical Adventures, I was a reluctant loblolly and nurse. And that’s a story that creeps into not only my historical fiction but my fantasy fiction as well. (Nurse Kit Carson’s Knife & Gun Club short fictions, for example, and Water Ghosts, a young adult mashup of nautical adventure, psychological horror, and Chinese history in which my stint in psychiatric nursing comes into play.
“Advancements in Shipboard Medical Treatment in Nelson’s Navy” by Linda Collison was published in the 2022 edition of The Trafalgar Chronicle, with illustrations.
Here is my submitted draft, which was then edited by Dr. Judith E. Pearson before publication in October of last year. The Trafalgar Chronicles is the scholarly flagship publication of The 1805 Club, a non-profit organization with an international membership of scholars and enthusiasts of the Georgian maritime era.
Advances in Shipboard Care in Nelson’s Navy
Linda Collison
Britain engaged in many military conflicts throughout the eighteenth and early nineteenth centuries and many of the scientific and technological advancements made during this time, such as the marine chronometer, copper sheathing, and carronades, benefited Royal Naval operations. Yet throughout the Georgian era and beyond, more British seamen died from disease than from battle wounds. The causes of illness were misunderstood, and the treatments of the day were ineffectual, at best. With typical scathing wit, Voltaire quipped, “Doctors pour drugs of which they know little, to cure diseases of which they know less, into human beings of whom they know nothing.”[i]
There was precious little enlightenment in the field of medicine during the reign of the Kings George; until the twentieth century, with a few notable exceptions, there was little science involved in the practice. The mainstay of treatment consisted of bloodletting, counter-irritation, and purging with strong laxatives to balance the humours. Surgery was often successful, but would have been more so, if it had not been for a high rate of postoperative infection. Not to mention, until ether was first used as a general anesthetic, the only relief for a patient about to go under the knife was an oral dose of alcohol and opium.
(Image 4; bleeding bowl)
While 18th century scientists Edmund Halley, John Hadley and Thomas Godfrey were developing precision octants and better telescopes to observe and compute astronomical sizes and distances, contemporary physicians were prescribing ineffective and often noxious treatments and physicks based on faulty deductions. Captain James Cook’s shipboard astronomer, Charles Green, observed and recorded the transit of Venus in Tahiti, to be used with times from different locations in computing the Earth’s distance from the sun. While the theory was sound, the results weren’t precise and the Royal Society would be disappointed. Such is science. Yet even while the Cook party was using state of the art technology, doctors and surgeons were bleeding, purging, and blistering their patients in a vain effort to balance four bodily “humours” believed to be responsible for life and well-being. Infectious diseases were thought to be caused by miasmas – poisonous vapors emanating from decomposing matter. Human anatomy was known, at least on a macro level, but physiology – the way the body worked to stay alive – wasn’t understood or even studied in a systematic, scientific manner.
Yet there was progress made in naval healthcare during the eighteenth and early nineteenth centuries, and some attempt at improving treatments by the scientific process of observation and controlled trials. William Smellie (1697-1763), a Scottish naval surgeon aboard HMS Sandwich for two years, retired to establish his own medical practice, specializing in obstetrics. Smellie improved the obstetric forceps in use at the time, reducing infant mortality rates. The travelling Englishwoman Lady Wortley Montagu (1689-1762) was among those who promoted the practice of smallpox inoculation as used in Asia. By the end of the century, British physician and scientist, Edward Jenner (1749-1823), discovered a less threatening procedure using a similar, less virulent virus, cowpox. Jenner’s paper describing his experiment and twelve subsequent trials was rejected by the Royal Society, but he was later rewarded by Parliament with a large purse. American Thomas Jefferson wrote to Jenner in 1806, “You have erased from the calendar of human afflictions one of its greatest.”[ii] Yet global eradication would take another 169 years.
Scurvy was an affliction that mariners who spent long periods at sea were particularly susceptible to. It had been suspected for some time that diet played a role in this debilitating, eventually deadly disorder – a deficiency we now know is caused by a lack of ascorbic acid, an essential co-enzyme humans need to make collagen. Cook believed in the importance of fresh, local meat, fish, fruits and vegetables. He resupplied his ship whenever possible and encouraged the ship’s company to eat a varied diet. “Few men have introduced into their Ships more novelties in the way of victuals and drink than I have done; indeed few men have had the same opportunity or been driven to the same necessity. It has however in a great measure been owing to such little innovations that I have always kept my people generally speaking free from that dreadful distemper the Scurvy.”[iii]
Citrus fruits had long been thought by some to cure the symptoms of scurvy. Vasco da Gama wrote that when his sailors were suffering from scurvy in 1498, he sent a boat on shore for oranges. Sir Richard Hawkins, in 1593, when sailing offshore of southern Brazil reported that oranges and lemons seemed to recover the symptoms of scurvy. John Woodall, surgeon-general of the East India Company, reported on the antiscorbutic properties of lemons in his 1617 book, The Surgeon’s Mate, recommending a good quantity of juice of lemons to be sent in each ship. It would take more than a century – almost two – until the Admiralty listened.[iv][v]
Many naval practitioners kept records of their observations and results of treatments. The Scot James Lind (1716-1794) conducted one of the earliest known clinical trials for the treatment of scurvy, a disease that crippled more fleets than any naval battle. As ship surgeon aboard aboard HMS Salisbury (50), Lind selected twelve seamen ill with telltale signs of scurvy, and compared various treatments for their efficacy: cider, elixir of vitriol, vinegar, sea water, oranges and lemons, and a purgative. By the end of the month the men assigned citrus fruit were almost recovered. One had returned to duty and the second helped nurse the others.[vi]
(Image 3; scurvy)
Lind’s A treatise of the scurvy was published in 1753. His observations flew in the face of Cockburn’s Sea Diseases in which scurvy is attributed to bad air, congenital laziness, and indigestible food.[vii] Cockburn was senior physician at Greenwich Hospital at this time. Yet it would be decades before changes reflected Lind’s study and recommendations. A naval surgeon, Lind’s status was not high. In the same year that Lind’s treatise was published, Dr. Anthony Addington (1713-90), the father of the future Prime Minister, recommended the liberal use of sea water and bloodletting. Lind did have a disciple – the French physician Poissoniere who, in 1767, published a book on the diseases of seamen, citing Lind’s study.[viii]
It would take half a century, more costly wars, a threat of invasion, and two mutinies to reconsider the value of a seaman’s health and the worth of a good ship surgeon. Sir Gilbert Blane (1749-1834) and Dr. Thomas Trotter (1760-1832), both Scotsmen, are credited with pushing through reforms including the Admiralty issue of lemon juice in 1795.[ix] (Incidentally, lemons provide more vitamin C than limes, but the co-enzymes we know as vitamins wouldn’t be identified until the twentieth century.)
A good eighteenth century ship surgeon was skilled and effective, if not University educated. Surgical training wasn’t standardized, and apprenticeships were common. Pay for naval surgeons was never generous, and surgeons had to supply their own instruments. At that time naval surgeons were warranted, not commissioned.[x] At sea, surgeons functioned as physicians as well; diagnosing ailments and prescribing medicaments, which they supplied at their own expense until the early nineteenth century. Loblollies served as nurses, assisting the surgeons and making sure the sick were nourished.
Physicians, if not gentlemen born, were scholars with university degrees and therefore higher in pay and social status. Physicians were assigned to fleets, to hospitals, and to hospital ships. Some surgeons later took their medical degrees, becoming physicians. Thomas Trotter, for example, joined the navy as a surgeon’s mate in 1779. He later earned his medical degree at Edinburgh then rejoined the service. In 1805, when there was an increase in half pay for naval surgeons, Trotter applied for an increase in his pension, but the Admiralty refused him.
(Image 2; chart of elements, seasons, humours)
Throughout the Georgian era, the mainstay of medical treatment was based on the principles of what is now called the heroic depletion theory of disease. The basis of medicine for nearly two thousand years, centered around a belief of four bodily humours – blood, phlegm, black bile, and yellow bile – the balance of which was thought to be necessary for health. Like Claudius Galenus, of the first century AD, 18th century naval ship surgeons bled, purged, blistered, and dosed the ship’s company in a mistaken attempt to balance the humours. Only the strong survived the malady – and the treatment. The strong and the lucky. Sometimes even the strong did not survive. As Sir Gilbert Blane observed after tracking the number of deaths in the fleets and hospitals, “Disease was still more destructive than the sword.”[xi]
Surgeries, more grounded in anatomy and mechanics, were often successful –- especially life-saving amputation – but many patients died from postoperative infection. In this pre-Lister era, sterile technique was unheard of. A surgeon was good if he had a strong arm, a quick and steady hand. He may also have been only as good as his assistants, in battle. Good surgeons cut and stitched quickly and effectively. They set bones, trepanned skulls, removed stones from ureters and bladders, amputated limbs to prevent further tissue necrosis. And in action, they made split second triage decisions and directed others in first aid. Ship surgeons saved as many lives as possible with limited supplies, with little, if any assistance, on a moving platform in dark, cramped quarters amid deafening noise and the cries for help.
Early intervention by non-medical crew during battle was advocated by Turnbull and Blane, in 1782. This eighteenth century version of “first aid” or “first responder” action might have helped to reduce death rates. Blane suggested that officers carry tourniquets during battle and Turnbull thought all seamen should be taught how to use a field tourniquet. “He need not be a medical officer; and the only instruction necessary would be to point out to him the situation of the great artery in the thigh and arm, since with this interest alone, the blood might be stopped by a handkerchief tied tight.”[xii]
The use of tourniquets was not new to the eighteenth century, and there are recorded instances of army officers using field straps or make-shift tourniquet devices in battle, on land.[xiii] The surgeon used a Petit screw tourniquet, developed by the French surgeon Jean Louis Petit (1674-1750), to adjust the degree of compression during an amputation.
Despite the conservative nature of the Admiralty and the entrenchment of medicine in the antiquated and unsubstantiated humoral theory, advances in naval medicine and healthcare were made during the Napoleonic Wars. These advances were not the result of improved technology, but in allotting more resources to the seamen’s well-being, including pay, victualling, and accommodations for the sick and injured. The decision to spend more on the seaman was a result of the naval mutinies of 1797. To ensure Britain’s supremacy at sea the Admiralty had to concede that the fighting men who sailed the ships were as important as the vessels themselves, and all the armament they carried. Equally important were the naval hospitals and hospital ships, and those who served them.
Let us not forget the rest of the healthcare team, as we might call it today. Physicians and surgeons don’t work alone, then or now. The surgeon’s mate, the loblolly, the nurse, the dispenser, the apothecary all played a role. The surgeon does his work and if the seaman doesn’t return immediately to duty, he must recuperate either on board, ashore in hospital, or aboard a hospital ship. Recuperation calls for nursing care, then as now. Physicians examine and prescribe medication, surgeons operate, but the sole reason for hospitalization is for nursing care. In the age of Nelson nursing was not yet the organized profession it would later become, yet it was still important for the recovery of the hospitalized seamen. It isn’t always high-tech gadgets or patented drugs that save lives, but speedy intervention followed by supportive care during the recuperative process.
Although some important medical discoveries were made in the nineteenth century, it wasn’t until the twentieth century that real progress in healthcare was made. Germ Theory finally replaced Heroic Depletion and Miasmic Theory, antiseptic technique and antibiotics replaced bleeding, blistering and purging as the mainstay. Yet, significant improvements were made in shipboard health of British ships during the late 18th and more widespread in the early 19th centuries. These improvements were not due to any technological invention or scientific discovery but came about in part because of the Spithead and Nore mutinies, and an increased awareness of the living conditions of British seamen. Not to sooth Britain’s social conscience but to protect the home shores from invasion and to dominate sea trade.
Besides the quick action of the ship surgeon in splinting a broken bone or removing a mangled limb, it was supportive care that made a difference. Supportive care included preventative measures such as a separate, well-ventilated sick berth, and removal to hospital, where nursing care mattered. Aboard ship, it was loblollies who saw that recuperating men were nourished, and may have helped them perform other necessary activities, provided important care, especially in an age where the cure often did more harm than the disease.
Naval hospitals ashore depended on female nurses to deliver medications, change dressings, and maintain cleanliness, and in general, care for the men. At Haslar, the first official Nursing Matron was appointed in 1756. The number of nurses was based on the patient population; generally, one nurse was employed per ten patients. The nurses were involved in pay disputes and conditions of their employment, complaining of being “confined and imprisoned, and never eat a hot meal, and are served the scraps left by the seamen, and badly paid by only having a trifle of the wages at a time when three or four months are due.[xiv]
Shipboard health did begin to improve, especially at the beginning of the nineteenth century. This had nothing to do with scientific discoveries or engineering advancements, and it was not due to any one brilliant man’s invention. Instead, it was due to naval reforms, long called for, and at last implemented. The mortality rate from illness dropped from 1 in 8, in 1780, to 1 in 30 in 1812.[xv] Accommodations for the sick improved, both on board and ashore, and a better medical department was evolving.
Throughout the Georgian era, the practice of medicine by physicians remained stuck in the past. Although the ship surgeons weren’t as highly educated as physicians, it scarcely mattered, since the physician’s medical training was not science-based, with the exception, perhaps, of anatomy. And anatomy is one subject the shipboard surgeon learned firsthand, particularly during action, when presented with mutilating battle wounds. These may have been the ship surgeons’ finest hours, working as quickly as they could under horrendous conditions with little help, and long after the engagement was over.
In 1802 all officers except surgeons and chaplains had their pay raised. Two years later, the Sick and Hurt Board were asked to draw up a plan based on the army’s medical department “to induce well-qualified and respectable persons to enter the service.” Finally, in 1805, the Admiralty put into effect further reforms, including pay raises for surgeons and assistant surgeons. [xvi]
If it wasn’t for the Napoleonic threat of invasion – and the mutinies of Britain’s own seamen – the reforms might not have happened when they did. The changes were made to retain and preserve the most important component of Britain’s naval defense: the officers and the seamen, and the surgeons and assistants who tended them.
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[i] Richard Gordon, Great Medical Disasters. (New York: Dorset Press, 1983), frontmatter.
[ii]Wayne Biddle, A Field Guide to Germs. (New York: Doubleday, 1995), p131.
[iii] Grenfell A. Price, Ed. The Explorations of Captain James Cook in the Pacific: As Told by Selections of His Own Journals 1768-1779. (New York: Dover Publications, 1971), p250.
[iv] Iain, Milne, “Who was James Lind, and what exactly did he achieve. Journal of the Royal Society of Medicine. 2012 Dec; 105(12), 503-508 https://www.jameslindlibrary.org/articles/who-was-james-lind-and-what-exactly-did-he-achieve/ Accessed online 4 July, 2021.
[v] Raymond E. Phillips, “Bite of the Devil – Scourge of the Long-Distance Sea Voyager,” Sea History 172, Autumn 2020, pp30-33. Dr. Phillips also gives a concise explanation of what we now know about the role of vitamin C, essential in the formation of collagen.
[vi] Milne, p503-08.
[vii] Christopher Lloyd and Jack L.S. Coulter, Medicine and the Navy 1200-1900, Volume III – 1714-1815. (Edinburgh and London: E & S Livingstone, LTD, 1961), p299.
[viii] Lloyd and Coulter, p303.
[ix] Lloyd and Coulter, pp320-6.
[x] Peter Willoughby, “Sea Surgeons and the Barbers’ Company of London,” (Great Britain: Seaforth Publishing, 2018) The Trafalgar Chronicle, New Series 3, pp213-28. Dr. Willoughby gives a detailed account of the process of becoming a sea surgeon in the 18th century.
[xi] Lloyd and Coulter, p360.
[xii] Lloyd and Coulter, p62-3.
[xiii] Michael Crumplin, Men of Steel; Surgery in the Napoleonic Wars. (Uckfield, E. Sussex: The Naval and Military Press, Ltd pp81-3.
[xiv] Lloyd and Coulter, pp215, 229.
[xv] Lloyd and Coulter, p36.
[xvi] Lloyd and Coulter, p9.