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Medicine and the Navy
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Post Posted: Sun Jun 17, 2007 1:23 pm    Post subject: Medicine and the Navy Reply with quote

The best book on the subject is:

Medicine and the Navy, 1200-1900.
Volume I (1200-1649) and Volume II (1649-1714). By John J. KEEVIL.
Volume III (1714-1815) and Volume IV (1815-1900). By Christopher LLOYD, F.R.Hist.S., Professor, Royal Naval College, Greenwich, and Jack L. S. COULTER, F.R.C.S., Late Captain, Royal Naval Medical School.
8ı x 6ı in. Pp. xii x 255, with 16 illustrations. Pp. xii +332, with 20 illustrations. Pp. xii+402, with 16 illustrations. Pp. xii+300, with 14 illustrations. Appendices, bibliographies, indices. 1957, 1958, 1961, 1963.
Edinburgh and London: E. & S. Livingstone Ltd.

As these volumes are not easy to find and quite expensive today, I join here some reviews.

The author of the first two volumes, a man of great charm and erudition, a former naval officer of great courage and distinction, was not spared to see the second volume in print, and it was seen through the press by his accomplished wife. The remaining volumes, the work of Professor Lloyd and Surgeon Captain Coulter, are as beautifully written and as full of interest as their forerunners.

Several themes run through the centuries. The first is that conditions in ships were so frightful that manning was largely from the dregs of the community, partly by pressing and sometimes by release from prison. In early times surgeons were provided by the Company of Barber-Surgeons, who were sometimes obliged to press. They examined and approved surgeons and surgeon's mates and for centuries examined and approved their chests of instruments and drugs. The Royal College of Physicians' monopoly for their members of prescribing medicine did not extend to sea-surgeons. Although losses in battle were heavy they were far exceeded by losses from sickness, and the fortunes of war depended on this above all else. Over and over again agile minds suggested relief from the great sea scourges, but general action was prevented by lack of communication, by bureaucratic obstinacy, by medical traditionalism, by polypharmacy, and sometimes, as in victualling, by gross corruption. Examples of leadership not followed are the control of typhus by bathing and reclothing " new entries " (often straight from jail); of dysenteries by filtering water through sand ; of yellow fever by avoiding unnecessary sojourn ashore; of malaria by similar prohibitions and the prophylactic and curative use of quinine ; of scurvy by means that were widely known but not widely adopted; and finally of drunkenness on board, the source of many injuries. The striking exception was smallpox, which was controlled comparatively promptly by the general encouragement of vaccination in the fleet (1800) two years after Jenner's publication (1798). All we can do is to pay credit to the individuals who saw these things before their time, and also to admit that our own ships, with all their shortcomings, were kept much cleaner, drier and better aired than those of any of our enemies.

From medieval times sick and wounded put ashore were dumped on seaport households and in chapels of ease. When Henry VIII dissolved these, civil hospitals (mainly St Bartholomew's, St Thomas's and Bethlem) had to take their place. Any willingness was quickly dissipated by the danger to the populace ashore and the difficulty of getting due payments from the Commissioners of Sick and Hurt or other central authority. If we omit Greenwich Hospital, the naval counterpart of Chelsea. the first home naval hospital in the modern sense to be built was Haslar Royal Hospital (1746-54), the then largest brick building in Europe, followed soon by Plymouth Royal Hospital (1758-62) a stone ensemble of great architectural beauty. It is curious that a bureaucracy that, largely because of corruption, often lacked money to pay the survivors of long voyages or those who sheltered and succoured the sick, nevertheless managed to build hospitals in the grand manner-albeit with the many safeguards necessary to prevent desertion or " running."

Though wounds removed far fewer men than diseases, the carnage of sea battles was dreadfulfrom cannon, small arms, splinters, flash, and, in close fighting, blows, stabs and slashes. In the cockpit the surgeon was concerned in arrest of haemorrhage, removal of foreign bodies, strapping wounds and amputating. Though delay in amputation was favoured by some, much was carried out. upon the spot. A tourniquet was used when possible. The circular method with proximal retraction. allowed division of the muscle proximal to the skin incision, and of the bone higher still. Cauterisation largely gave way to ligation late in the sixteenth century. As in Nelson's case (1797), the ligatures were often left long with the idea of their easy separation when they sloughed out later (a custom that lingered into the first quarter of this present century in the case of piles). Criticism of the custom and advocacy ofcutting ligatures short came from a naval surgeon at Haslar in 1786. The first interscapulothoracic amputation has already been described in this Journal (Keevil 1949), but less well known is the first successful ligation of the common carotid artery by David Fleming in H.M.S. Tonnant. Because loss of blood was the commonest cause of death during an engagement, and because much could be lost in transit to the cockpit, as early as 1782 tourniquets were entrusted to " some intelligent person, a warrant or petty officer " on the quarter deck, and in 1806 wider instruction of the crew was given in the arrest of haemorrhage by tourniquet and by local pressure-forerunner of modern times when, as far as possible, " all officers and men should receive instruction in first-aid."
In the earlier centuries under consideration one cannot escape the thought that surgery was a good deal ahead of medicine, even though the surgeons had less education than the physicians. Both were too addicted to bleeding; but, whereas the physicians, before the great James Lind (17 16-94), traded a mystery with little art or science, the surgeon practised his art with remarkable enterprise when we consider that virtually his only analgesics were rum, unstandardised opium and, in the case of limbs, the tourniquet. Surgeons were of much lower social, educational and professional status than physicians and suffered in the early days from their association-more apparent than real-with barbers. Physicians seldom went to sea except in a hospital ship or in the entourage of some important personage. Until 1843 Assistant Surgeons held warrant rank only. A recruiting pamphlet written in 1866 " to attract more Scottish recruits, the service being so unpopular that only Irishmen were applying," reflects conditions that continued well into the present century but pertain no longer.

H. Jackson

The Journal of Bone and Joint Surgery, vol.47B, no.2,May 1965, pp. 384-385

The rare combination of qualities in Surgeon-Commander Keevil's 'make-up', as well as his distinguished war record, proclaimed him as the appropriate writer of the history of medicine and the Royal Navy. That Sir Henry Dale should have written an introduction to the work must add to the expectant interest with which these volumes have been awaited, and the verdict of civilian and sailor must be that the ready support given by the Wellcome Trustees to tho enterprise has enabled a monumental work to be placed in the hand, of the historian, the Admiralty, as well as the reading public.
The first volume of the work deals with the medieval period, the Tudor period, and the period of the early Stuarts. Not unnaturally the problem of scurvy repeatedly fill, the pages and as the author remarks,
‘perhaps one of the most bewildering aspects of the history of scurvy is the manner in which a cure was repeatedly found, only to be lost again because of a wrong theory of its manner of operation, or because some uncontrolable factor offered a preferable explanation when it came to accounting for deaths which caused the failure of an expedition.’

This was the great period of Drake, the Hawkins, Effingham, and Frohishor and surgeons such as Clowes, Alexander Read, Peter Lowe, Banester and the great Woodall, whose Surgions Mate, appearing in 1617, was addressedd primarily to surgeons serving in East Indiamen. In 1678, two years after his association with the Navy, he published The Viaticum. The contributions of these great men, executive officers and surgeons, are dealt with fully and in delightful prose.

The second volume deal with the Commonwealth and Protectorate period and with that of the later Stuarts. In the preface tho author insists that by the beginning of the eighteenth century many surgeons were beginning to serve in H.M. ships almost continuously and to discover a pride in that service which remains traditional. In the reigns of William III and Anne the need for hospital ships was fully recognized, and not only did they serve for the care of the sick but they constituted a meeting-place where sea-surgeons could come together, and where projects for the advancement of the service could be discussed.

The period with which this volume deals oontained many famous names of admirals and surgeons: Admiral Robert Blake, who though beyond oontemporary surgical aid with a renal calculus, yet put to sea again and died from nephritis two hours before the flagship anchored in Plymouth Sound on 7 August, 1657. We are introduoed to his fleet-surgeon, Haselock, to Richard Wiseman, surgeon to Charles II, sometimes called 'The father of English surgery', to James Yonge, often credited with the priority in the flap method of amputation, for whioh he himself aknowledged his indebtness to Lowdham, of Exeter.

The putative relationship between scurvy and air-pollution and other causes is dwelt upon, and even when Cockburn cured a scorbutic patient with an electuary flavoured with lemonjuice and noted that the man ‘recovered apace and came to his perfect health', he made no deduction from this, and was clearly unfamiliar with all that had been recorded by travellers on the use of this fruit in scurvy.

A valuable feature of this volume, as of its predecessor, is the 'Chronology' at the end, enumerating many of the important occasions of the period under consideration. There is frequent mention of St. Thomas’ Hospital by its distinguished alumnus. The waxing and waning of the influence of the Barber-Surgeons Company and the Society of Apothecaries in the sphere of naval medicine find frequent mention...

Gorden Gordon-Taylor

Medical History 1959 January; 3(1): 83–84.

The harshness and brutality of the seaman's life in past ages are so much a commonplace that it is somewhat surprising to learn that the origins of medical care at sea can be traced back to the last decade of the twelfth century when the Customs of Oleron were incorporated in the law of England. These Customs formed the maritime law of the Duchy of Aquitaine which was added to the English Crown on the accession of Henry II in 1154, and one provision laid it down that, if a seaman incurred sickness or injury in the service of his ship, the master was to pay for his lodging and keep ashore. The weakness of the system was that no one could be compelled to provide this shelter. During the medieval period this difficulty was overcome to a certain extent by private charity. Almshouses and hospitals were provided by religious orders, wealthy noblemen and even by the seamen's guilds themselves. But at the best of times such accommodation was totally inadequate, and, in the sixteenth century following the dissolution of the monasteries, the system of private philanthropy broke down entirely. Poverty and vagrancy existed on an unprecedented scale, and it was not until the great Poor Law Act of 1601 that the State began to fill the gap and acknowledge its responsibility to provide care for the dis- tressed, among whom were the sick and wounded from the sea.

If facilities on shore were inadequate, those on the high seas were virtually nonexistent during much of the period covered by this volume. The sea- surgeon did not become a regular member of a ship's company until the late sixteenth century. The first hospital ship was not commissioned until 1620. In part this was due to a philosophy that a seaman's life must be a hard one, that treatment of the sick was pandering to weakness. It was also the conse- quence of the subservient role played in the national life by the maritime services. For most of this period the Royal Navy consisted largely of merchant ships, requisitioned for particular campaigns for the purpose of transporting troops. If surgeons were provided, their primary duty was to the troops. With the growth of English sea power and in the longer voyages of the sixteenth century, the sea-surgeon was found to be an increasingly useful member of the crew, but with each expedition organized as a single venture, there was no continuity of administration or experience. This was not to come until the formation in 1612 of the East India Company and the appointment of John Woodall as their first surgeon-general. The Company's medical service was to be the pattern for the future naval medical organization.

Dr. Keevil emphasizes the unfortunate effect on the health of the Navy caused by the division of the medical profession ashore into mutually exclusive bodies of physicians and surgeons. Since it was the wounds and injuries of war that most obviously required treatment, it was the surgeon who was first called to serve the fleet and the education and supply of sea-surgeons came to be vested in the Company of Barber-Surgeons of London. Physicians to the fleet were not appointed until the seventeenth century. As the size of ships grew and the voyages lengthened, however, it became apparent that the gunfire of the enemy was less to be feared than the ravages of infectious and deficiency disease. After the defeat of the Armada, the English fleet was itself completely decimated by virulent food poisoning and toxemia, and time and again the voyages of exploration were abandoned or accomplished at great cost in the face of scurvy and tropical disease. Yet the sea-surgeon was forbidden by law to treat internal disease. Captains alone had the right to administer such treatment; a few, such as Sir Richard Hawkyns, were conscientious and en- lightened in this way; the vast majority were uninterested and unskilled, and the lot of the sick seaman was an unhappy one. The need for medical as well as surgical ability on board ship was beginning to be recognized early in the seventeenth century. A "free allowance" was granted to the Navy by Charles I for the supply of physical drugs, and the contents of medicine chests furnished by John Woodall to both the East India Company and the Navy showed great advances on those supplied to mariners of the sixteenth century. But ignorance of the etiology and treatment of sea diseases was to cause a hideous mortality rate in the Navy for many years to come.

F. M. Sutherland

The Bulletin of the Medical Library Association 1958 October; 46(4): 636–638.

The much-lamented death of Surgeon-Commander John Keevil prevented him from finishing the work which he had begun so brilliantly. At the request of the Wellcome Trustees the difficult task of completing Medecine and the Navy has been undertaken by Christopher Lioyd, F.R.Hist.S., and Jack L. S. Coulter, F.R.C.S., and, judging by this volume which deals with the period 1714-1815, no happier choice could have been made.
The story of the medical service in the Navy during the hundred years ending with the year of Waterloo is intensely interesting. The authors have not adopted a purely chronological approach but have succeeded in painting an excellent composite but detailed picture from four different points of view. The first section paints in the background, telling us tbe size and structure of the wooden ships, the positions and nature of the medical quarters and equipment, the variety and function of the medical personnel (physicians, surgeons and apothecaries) and the system of victualling which so easily lent itself to vicious irregularities. The second section gives a vivid and graphic account of the Navy and its medical service in action in the wars of the eighteenth century, and what a terrible picture, those wars reveal, After reading the gruesome account of the scene in the wardroom during an action given by Samuel Leech we can but echo his comment -'Such Scenes of suffering I saw in that wardroom I hope never to witness again. Could the civilized world behold them - it seems to me they would for ever put down the barbarous practices of war by universal consent.' This section also includes a special chapter on the illnesses and wounds sustained by Nelson.
The third section is devoted to an historical account of the building development and administration of the big naval hospitals at Greenwich, Haslar and Plymouth. Much in this section will be quite new to most readers.
The final section is medical and deals with the Common diseases which afflicted seamen in the eighteenth century. The thirty-five pages dealing with scurvy ought to be read by every medical man. Seldom can the ravages of that disease have been so graphically presented and never till we read this account could we understand why the controlled experiments of Lind were so long in being accepted and his treatment practised. This sentence remains in our memory - 'Scurvy was so rife that the crews of many ships were reduced by two-third, and so many dead were thrown overhoard that the citizens of Plymouth dared not eat any fish for over a month.' The late acceptance of lemon-juice as a remedy was partly explained by Blane in these word.- ‘The cure sounded too simple to be true.' Probably psychologically correct.
When one considers the class of men who were often pressed into the naval service, the coarse nature of the diet provided for them and the cramped ill-ventilated quarters in which they lived and died, it seems remarkable that the Navy achieved so muoh in the eighteenth century. As the authors write 'with their ancient hulls, rotting timbers, low deck space (5 feet, 10.5 inches) and grim atmosphere, they can never have been very salubrious craft.' How bad the air could be can be judged by Nathaniel Bedford's comment - 'When the hold was first opened every man who assisted in it was seized with fever within 24 hours.’
Here and there the authors give us a light touch. We should certainly have liked to ht present at that cricket matoh in the grounds of Greenwich Hospital in 1796 between an eleven of one-armed agaimt an eleven of one-legged men, Who won? You will find the arnwer on page 204 of this valuable, entertaining and most informative volume. It was a gracious, but appropriate act to dedicate the book to John Keevil.

Zachary Cope

Medical History 1962 April; 6(2): 192–193.

Professor Lloyd and Mr.Jack Coulter have completed the fourth and last volume of Medicine and the Navy with commendable speed and have produced another collection of interesting, informative and in some cases remarkable essays. In support of this way of writing history they quote Gibbon to the effect that 'the seeming neglect of chronological order is compensated by the superior advantage of interest and per- spicuity'. Certainly it works well in this instance.

The book opens with a rather brief account of the administrative chiefs during the period considered. Harness and Weir were followed by Burnett, Liddell, Bryson, Armstrong, Watt Reid and Dick, of whom Burnett made the greatest impression. The next chapter deals with the naval surgeon and the gradual raising of his status. The life of a naval surgeon in the early days of last century was a hard and often disagreeable experience, and it was no wonder that the quality of the candidates, particularly for the post of assistant surgeon, was very poor. It took many years for the status of the naval surgeon to be raised,whereupon the standard ofqualification was at once improved. In 1872 naval surgeons were sent to the Army Medical School at Netley for further instruction, and it was not till 1881 that the naval school at Haslar was opened.

The problems of hygiene, ventilation, and the preservation of food in ships on long voyages were difficult to solve a hundred years ago, and the chapters devoted to those subjects make instructive reading. Not every reader will know that the origin of the term 'bullybeef' is from the word bouilli which was stamped on the early tins because the patent for the process was taken out by a Frenchman.

The story of the convict ships deals with an unsavoury subject and gives one some idea ofthe terrible conditions which prevailed on some of the ships.On the other hand our admiration is called forth by the surgeon naturalists who did splendid scientific work under difficult conditions, and by the naval surgeons who took part in the arctic expeditions and did their sometimes unavailing best to prevent the scourges of scurvy. Not till the beginning of thiscentury was the essential cause of scurvy finally revealed.

The terrible losses of our Army during the first winter of the Crimean War have often been related; it is good to read in Chapter Ten of this book that the naval forces in that war were better cared for and had a comparatively good health record.

Interesting chapters are devoted to the Naval Nursing Services, Fevers, and 'Other Diseases', the Royal Naval Hospitals,and the Health of the Navy. We are also given an account of the men who won the Gilbert Blane Medal, the highest honour which can be bestowed on a naval surgeon; readers will be pleased to note the name of one of the authors among the medallists.

The saddest chapter in the book is that concerned with the West African Squadron, for that squadron for a long time fought a losing battle against the slave-traders, and while doing it lost a really terrifying proportion of the sailors. As they used to say:
'Beware and take care of the Bight of Benin
There's one comes out for forty goes in.'
When a naval hospital was built to look after the sick, the mortality 'continued to be higher than anywhere else in the world. It was a joke among the sailors that the standing order swere"Gang No.1 to be employed digging graves as usual. Gang No.2 making coffins until further orders".'

Even more tragic was the story of the ship Rodeur whose crew and slave-cargo were nearly all blind from ophthalmia and were hailed by a Spanish ship whose crew were also all blinded with the same disease. 'The Rodeur reached Guadaloupe with the surgeon and 11 men irrevocably blind, the captain and 4 others blind in one eye'. It is good to know that that by modern methods and remedies that deadly region has been rendered comparatively healthy.

Zachary Cope

Medical History 1963 October; 7(4): 393–394.
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