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Nelson and His Navy - Surgey in the Royal Navy

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During this period, as with the medical Profession generally, surgery in the navy was still looked upon as non scientific, and its practitioners, despite their acknowledged technical skill, having a far lower status compared to that of the physician. Some considerable time was to pass before the surgeon was given access to the clinical world then exclusively occupied by the physician. Until given this access, the surgeon was deprived of the opportunity to develop his theories by practical proof. With this lack of opportunity must also be added the absence of anaesthetics and the general ignorance of asepsis (septicaemia), which combined together to limit surgery as a very hazardous practice indeed.
However, the general standard of naval surgeons was greatly increased during the latter part of the 18th century. Many of these young men were from north of the border, newly qualified with degrees from the newly established Scottish medical schools of Aberdeen, Glasgow and Edinburgh universities. Lind, Trotter, Robertson and their contempories not only raised the standard of medical care to new heights in the navy but also became luminaries in the history of general medicine.

The role of the surgeon on board ship was akin to that of a floating GP. He was responsible for everything medical from childbirth to dentistry. 95% of his time would be taken up with treating the usual ailments and infections consistent with those affecting any group of men living in a tight, closely knit society for months on end. The subject of this article, however, is his surgical skills, usually required during and immediately after action in battle. Considering the conditions under which the naval surgeon performed his operations, either ashore or afloat, as a surgical technician he was unsurpassed. His skill was combined with that knowledge of anatomy and speed of performance, which were vital if the patient were to stand any chance of surviving the degree of shock involved.
Post-operative infection was anticipated as a matter of course, and even in the most successful of cases, suppuration of the affected areas was regarded as quite normal. These wound infections were generally recorded as “inflammation” in the copious records made by the individual surgeons and required by The Sick and Hurt board for inspection on completion of the surgeons tour of duty. Every treatment and operation had to be recorded in minute detail, including the result. If the surgeon was found wanting in medical knowledge or skill, his warrant could be withheld. The two specific inflammations, dreaded by surgeons were gangrene and particularly, tetanus. Gangrenous tissue was usually cut away, tetanus and its development into lockjaw was however, a different matter. It was generally accepted that lockjaw was more likely to follow wounds in a warm climate. Treatments for lockjaw varied, a seaman of the ‘Montague’ recovered within 9 days, having been treated with warm baths for half an hour, twice a day, and from 3 to 5 grains of opium by mouth each day in divided doses. A seaman from the ‘Magnificent’ developed lockjaw five days after an extensive wound of the upper arm in which there was wide suppuration. The surgeon in this case applied a plaster containing twelve ounces of opium to the patients jaws and the patient was able to open his mouth one half inch within 3 days. He was also treated with large doses of Peruvian bark (later the base material from which quinine was extracted), combined with an ounce of nitre and a diaphoretic (perspiration inducing) drought of 20 drops thebaic tinct. with 30 drops of antimonial wine!.

By far the greatest cause of death or mutilation in a firefight between the ships of the period were flying splinters. Naval surgeons found that close fought actions produced less casualties than actions conducted between opposing ships at a distance. In close fought actions, the velocity of cannon balls was so great that that in penetrating the side of a ship a clean aperture was produced, with few splinters. But a spent ball, travelling from a distance usually produced a jagged aperture with numerous deadly splinters by which more men were killed or wounded than by the ball itself.
A curious phenomenon was also noted by naval surgeons of the time called “wind of ball”. This injury occurred when a cannon ball, in flight, passed close to any part of the body. It was considered most serious when passing close to the stomach, leaving no obvious marks, but often causing almost instantaneous death. Remarkably, it was also noted that “wind of ball” was never fatal when the ball passed close to the head.

Burns and flash burns were also common injuries on the gun deck. Treatments for this were a variety of applications to the affected area including linseed oil, lime water, cerusa, olive oil and compresses of vinegar. Another more controversial treatment was a preparation of lead to the local area, with the warning that such applications should be limited in order to minimize the danger of lead poisoning through absorption through the affected area. Amazingly, although surrounded by seawater, the routine use of saline solution did not suggest itself to the surgeons of the time. Shock, in association with burns, was recognised, as was the febrile reaction connected to the inevitable infection expected to these types of wounds. The universal treatment for this was opiates in large doses by mouth.
Generally speaking, wounds to cavities were regarded as to be so dangerous as to classify the patient as beyond all hope. Consequently in the navy, abdominal and thoracic penetrations were accepted as fatal. Copious bleeding was the only treatment in an attempt to reduce the haemorrhage at the site of the injury. The wounds themselves came to be classified as gunshot wounds, incised wounds and puncture wounds. These were treated in three stages, firstly, that of first aid, being the cleansing of the wound, removal of foreign bodies and the arrest of haemorrhage. This was followed by inevitable infection and suppuration of the wound, hopefully allowing the free discharge of “laudable puss” which it was hoped would encourage the further evacuation of any retained foreign bodies. The final stage assuming that the patient had survived thus far, was the process of healing, usually a long process of granulation as the infection subsided.

With gonorrhoea and its complications almost endemic to the life of the seamen of the time, naval surgeons were well accustomed to coping with retention of urine due to strictures of the urethra and surgical measures for reliving this condition included perforation of the bladder via the passage of a trocar, either through the perinaeum or sometimes via the rectum.
Most naval surgeons had a wide experience of treating fractures, particularly of the extremities, whilst many were well versed in the use of the trephine and the elevation of depressed fractures of the skull, a very common injury in the navy of the time.

The most frequent surgical operations to be performed in action were of course amputations of the limbs. It is in the performance of these cases that the naval surgeon of the time was perhaps seen at its best. When it is considered that they were performed without anaesthetics, and that post-operative infection was accepted as a matter of course, the successes, which were achieved, can only be viewed as remarkable to the 21st century mind. The process of amputation was, as it is today i.e., control of the artery, cutting the muscle tissue to the bone, pulling back the muscle to reveal the bone, sawing the bone, releasing the muscle tissue, locating the divided (severed) arteries and blood vessels and applying ligatures to the same. The difference to today was the sheer speed at which these operations were completed. A competent surgeon of the time would complete the above in considerably less than two minutes. They knew that not allowing for any compromise on their skill factor, the quicker these operations were completed the better chance of a full recovery for the patient. Having completed his part of the operation, the patient was passed on to a surgeons mate for the preparation of the stump. These were either sutured immediately or left open for a few days to assist in the evacuation of gangrene gas, depending on the opinion of the surgeon concerned as to which method was more conducive to the full recovery of the patient. The ligatured arteries were usually left protruding out of the stump and would drop off in the fullness of time.

Another remarkable operation was that of an interscapular-thoratic amputation, which involves the total removal of the arm, shoulder blade and collarbone. First performed by Surgeon Ralph Cuming at the naval hospital in Antigua in 1808. A twenty-one year old sailor had been hit by a cannon ball. Cuming subordinated every consideration to that of speed in order to minimise pain and shock. Having nowhere to place the tourniquet and no forceps to hand, he held the great vessels (arteries and large blood vessels) between thumb and forefinger whilst his assistant tied silk ligatures around them. Cuming then held the edges of the wound together by means of adhesive straps and applied a poultice dressing which was also held in place by adhesive plaster. The patient made a complete recovery and on his return home was shown to medical students in Bath.

The success of the Royal Navy during this period and its total mastery of the seas was due in no small measure to the ability of the naval medical department to give the best of current medical care to its seamen.
We are very fortunate in still having access to many surgeons’ journals and reports of the time. These primary documents allow us to listen to the past, first hand, and to fully understand the calibre of these men, certainly as regards their professional skills, but what also speaks to us loudly and very clearly is the sheer humanity and care for their patients extended both to their own side, and their erstwhile enemies. The drunken butchers of myth certainly did exist in the navy of the mid 1750’s but by the turn of the 19th century the surgeons of the Royal Navy had earned the respect of their crews and the gratitude of their country.

Tony Harrison, Surgeon., Historical Maritime Society.