"Stephen Maturin and Naval Medicine in the Age of Sail" - читать интересную книгу автора (King Dean)
I. Worth Estes
In Patrick O'Brian's novel H.M.S. Surprise, Dr. Stephen Maturin laments, "Medicine can do very little; surgery less. I can purge you, bleed you, worm you at a pinch, set your leg or take it off, and that is very nearly all." Although he gives 18th-century surgery less credit than it probably deserves, he is not far off the mark when it comes to the practice of what we now call internal medicine. Maturin and his contemporaries relied largely on bitter remedies, some introduced as many as 2,500 years earlier. In fact, almost all medicines prescribed during the last years of the Enlightenment were ineffective by modern criteria. Nevertheless, Jack Aubrey and his crews placed unqualified faith in Dr. Maturin, even if he was skeptical of the worth of his own prescriptions. One must wonder why they did so.
Doctors and the Royal Navy
When Maturin joined the Royal Navy, its ranks included about 720 Surgeons. By 1814, as the Napoleonic Wars neared their end, 14 Physicians, 850 Surgeons, and 500 Assistant Surgeons were caring for 130,000 men on shore and at sea. Doctors who aspired to Royal Navy service had to pass oral exams, but the exams were perfunctory and few doctors managed to fail them. Depending on where they had obtained their training, and on their social status, Navy doctors were ranked as Physicians, Surgeons, Apothecaries, or Assistants (Mates). Because Surgeons and Apothecaries were considered to be craftsmen, or artisans, they ranked below Physicians, who, unlike Maturin, generally did not deign to use their hands.
The most prestigious medical education in Britain and France, leading to standing as a Physician, was obtained at universities. Although Edinburgh was often recognized as the premier medical school in the English-speaking world, only Oxford and Cambridge could offer their medical graduates the qualification necessary for licensure in London (however, other doctors did practice there). Many Royal Navy Surgeons were trained at the universities of Edinburgh, Glasgow, or Aberdeen; the rest were probably trained as apprentices, and some of those obtained additional training by taking university courses, by attending private lectures and demonstrations given by leading practitioners such as John Hunter in London, or by "walking the wards" of major London hospitals under the tutelage of senior medical staff.
It is not entirely clear how or where Dr. Maturin obtained his professional credentials. He seems to have acquired his premedical education at Trinity College in Dublin. Maturin told Dr. Butcher, of the Norfolk, that he had studied medicine in France, presumably in Paris. Indeed, Maturin says he "has dissected with Dupuytren." If so, it must have been while they were both students, because Guil-laume Dupuytren (1777-1835) would have been a bit younger than Maturin, and he did not achieve his reputation as an innovative surgeon until several years after Maturin first met Captain Aubrey.
Shortly after Maturin joined the Navy, his partner at a dinner party asked him, "How come you to be in the navy if you are a real doctor [i.e., a physician]?" Maturin's reply was probably more heavily dosed with modesty and puns than his contemporaries in the real world would have given: "Indigence, ma'am, indigence. For all that clysters [i.e., enemas] is not gold on shore. And then, of course, a fervid desire to bleed for my country."
Until the Navy's medical services were reorganized in 1806, Surgeons were warranted by individual ship Captains, not commissioned by the Admiralty. Nevertheless, they were billeted along with the other officers in the wardroom. Their base salary was Ь5 per month, plus Ь5 for every 100 cases of venereal disease they treated, along with an equipment allowance of Ь43 and an allowance for a personal servant. Thus the Surgeon of a third-rate warship might earn more than Ь200 when his share of prize money was factored in. The venereal disease component of this was financed by fining men with gonorrhea ("gleet") or syphilis ("pox" or "great pox"). Because Naval Physicians, who, unlike Surgeons, held academic degrees in medicine, were regarded as gentlemen, they were not required to be examined before acceptance into the Navy and were better paid. Moreover, they had some authority over Surgeons.
In addition to caring for the sick and wounded, Surgeons were responsible for maintaining cleanliness on the ship. They saw to it that pressed men, often dirty and poorly clothed, were properly cleaned. They fumigated the sick-bay and whole decks when necessary, usually by burning brimstone (sulfur), and they oversaw the ventilating machines that supplied fresh air to lower decks and kept them dry. Although Surgeons knew that inadequate food was a major contributor to shipboard illness, strict monetary limitations hampered their ability to improve rations. Most were also concerned about shipboard drunkenness, but seamen insisted on retaining the grog perquisite, amounting to a half pint of rum mixed with one quart of water twice daily. However, it was not only the seamen's preference that kept rum as standard issue: They needed liquids, and beer and water did not keep well at sea.
Naval Surgeons worked in three principal venues. They saw most of their patients in the sick-berth, or sick-bay, to which loblolly boys escorted ambulatory patients to have their skin ulcers or wounds dressed daily. The sick-berth could be an area partitioned off by fixed walls or canvas between decks or sometimes just an area between two guns. Some sick-bays were quite large and had their own cooking and latrine facilities. The H.M.S. Centaur's, for example, had 22 hanging beds as well as a drug dispensary. But the contemporary U.S.S. Constitution's had only four beds and no separate dispensary.
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 could carry the wounded for triage and treatment. Not all ships had such a space, so planks were sometimes laid across guns to serve as operating tables. The cockpit deck 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.
A third possible work site for naval doctors was a hospital ship, 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 separating patients with the various fevers, diarrhea! 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 there was more profitable than at sea; hospital Surgeons were paid Ь500 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 the 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. There were exceptions, such as the hospitals at Malta and Minorca, both visited by Maturin, who, like his historic counterparts, sent seriously ill patients there when necessary and possible. But most naval hospitals, like many civilian hospitals, 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 their own private practices, even the doctors were frequently inattentive to their charges.
The Disease Burden of the Royal Navy
Reforms in medical staffing and victualing procedures by the Navy between 1780 and 1800, many the work of Dr. Sir Gilbert Blane, a Royal Navy Commissioner for the Sick and Wounded 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. Death rates from nonsurgical illness fell accordingly. But medical theories changed little during that time.
Doctors trained in the 18th century often argued about the "immediate causes" of specific diseases. They debated whether some were caused by "miasmas," unseen products assumed to be transmitted through the air from garbage, swamps, and other sources of unpleasant odors, or by direct "contagion," equally unseen effluvia thought to migrate from one person to another. Whatever the cause of a given illness, doctors postulated that it produced symptoms by creating physiological imbalances.
Since at least the fifth century B.C., physicians had explained illness 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 observable symptoms: 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 of illness held that in order to restore health and stability to the sick body, its imbalances had to be counteracted with drugs or foods with appropriately opposite properties.
A new theory emerged in the 1690s, postulating that illness can also represent imbalances in the solid fibrous components of blood vessels and nerves, as expressed by their tone?their 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, or when sweat, urine, and feces could be expelled freely, and so forth. Effective therapies were, therefore, those that enhanced defective tone or calmed hyper-activity in affected vessels or nerves. Medical historians have labeled this the "solidist theory" to distinguish it from the older humoral theory. The two were not mutually exclusive, and most therapies were interpreted within the frameworks of both.
Finally, the process of figuring out the chemistry of respiration that began in the 1770s made it easy to interpret rapid breathing as one more manifestation of increased "combustion" within the fevered body. Thus, 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. When doctors added these chemical concepts to their previous theories, they could focus on a new set of balances?between acids and bases?allowing them to explain the apparent reciprocal actions of basic and acidic drugs.
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, as well as cold water and electricity, all of which were assumed to speed recuperation by increasing the patient's depleted strength.
Dr. Maturin's chief task was to restore 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 admonition to "feed a cold and starve a fever."
Humors and tones were often adjusted to prevent illness. For instance, 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 preferred the hands to eat a meatless diet while sailing between those latitudes.
Although sailors were predominantly healthy young men, they were still susceptible to most acute contagious diseases. In addition, chronic illness contributed to the loss of considerable manpower at sea. In 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), 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 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 or 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 (i.e., painful and bloody diarrhea), and bilious fever (characterized by jaundice and correctly attributed to some primary disorder of the liver). Syphilis and gonorrhea, predictable risks of shore leave almost everywhere, completed the list of the most common illnesses, although rheumatism and related debilitating conditions such as lumbago and sciatica could remove significant numbers from a ship's work force for 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 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 of 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, and so 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 well supplied with citrus fruit, scurvy was unusual.
Maturin and Aubrey were confronted with several outbreaks of scurvy. One occurred on the Leopard, and Maturin easily recognized the 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 that among the general population. Doctors often attributed insanity to head injuries, which, in turn, were 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 one hundred of the more than two hundred remedies prescribed by doctors on land and sea; the specific contents of each ship's chest differed somewhat, according to the Surgeon's preferences. All the drugs that Dr. Maturin gave his patients are known to have been used throughout the Royal Navy?and in the U.S. Navy?although some, 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, which according to solidist thinking strengthened the body when it had become 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 late 17th century as a cure for malarial fevers (indeed, today we know that it contains quinine, which is still used to treat malaria), but it would have been ineffective against other fevers, for which physicians also came to use it.
The next most frequently prescribed drugs were cathartics, which were assumed to flush out unbalanced humors with the feces and to relax the abnormal tensions that had constricted patients' intestinal fibers, causing constipation. Typical of this class of drugs were calomel (mercurous chloride), jalap, medicinal rhubarb, castor oil, and cremor tartar (sodium potassium tartrate), a strong cathartic that was the most active ingredient of Maturin's black draught.
Doctors also gave emetics, drugs that induce vomiting, to remove foul humors from the stomach, as well as to strengthen what they took to be weak stomach muscle fibers. Tartar emetic (antimony potassium tartrate) was administered for this purpose, as was ipecac, which we still use to remove poisons from the stomach.
Diaphoretics, which Maturin called "anhidrotics," made patients "sweat out" their unbalanced humors. At the same time these drugs ?especially those made with antimony, like James's Powder, a patent medicine that Maturin sometimes prescribed?were assumed to strengthen the blood vessels that supplied the sweat glands in the skin.
Opium and opium preparations such as laudanum (an alcoholic solution of opium also known as Thebaic tincture), were correctly regarded as sedative, antidiarrheal, and analgesic. The addictive properties of opium were well known. Maturin, who used laudanum frequently as an escape from his worries, appears to have been addicted, and it is unclear how he managed to wean himself from it. He believed that the coca leaves he discovered in Peru helped him overcome his reliance on opium, a common misconception even in the late 19th century.
Because syphilis was almost an occupational hazard of sailors, Navy Surgeons stocked various mercury salts to treat it. Most victims required prolonged therapy with oral mercury preparations, such as calomel or Maturin's "blue pill" (mercuric chloride, also known as corrosive sublimate) and with unguents made with the latter. All mercurials were cathartic and diaphoretic, providing clear routes for the elimination of the contagious factor responsible for the affliction. However, it seems unlikely that such treatments could have eradicated the syphilis organism.
Most doctors, Maturin included, reserved two forms of treatment for their most seriously ill patients, especially those with the worst fevers or injuries. The first was the drug class called blisters, or epispastics, usually alcohol solutions of powdered cantharides beetles (sometimes called Spanish flies). When placed on the skin, this preparation raises a large, painful blister. In humoral theory it was thought to draw foul humors into the blister fluid; solidist reasoning concluded that the blister would also neutralize the naturally occurring inflammation that had caused the patient's symptoms by the process Maturin called "counter-irritation."
The other relatively drastic treatment doctors favored was bleeding, on the humoral grounds that it removed chemically or otherwise unbalanced blood-producing symptoms, and on the solidist grounds that it reduced tension of the hyperactive fibers of the fevered cardiovascular system. That is, releasing some of the patient's blood was assumed to reduce the friction (between the blood and the walls of the arteries) that was producing the patient's increased body heat. Doctors usually removed 12 ounces at a time but up to twice that amount from their sickest patients.
Maturin's remedies were not designed to counteract well-defined disease processes as modern drugs do. Instead, he and his contemporaries used drugs to adjust or fine-tune a patient's internal equilibria, his physiological balances, regardless of what might have disrupted them in the first place. The occurrence of catharsis, vomiting, sweating, or blisters after the administration of a drug simply confirmed that the remedy had indeed altered the humors, tones, and acid-base balance of the body in the intended way. However, few of these treatments could have provided truly effective cures.
Trauma and Surgery
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