Developments in the Nineteenth Century

Progress
There was an enormous decline in the incidence of sea diseases in the nineteenth century - so great that before its close sickness had fallen almost to the low level it stands at today. The proportion sent to hospital in all parts of the world in 1782 was as high as 1:3.3. In 1795 it was 1:4, but by 1813 it had fallen to only 1:10.75 which is one-third of the sickness prevailing in 1782. There was an increase in 1819 to 1:8.8, and in 1829 to 1:8.9, but this was due to the great prevalence of yellow fever at the time. In the 'Health of the Royal Navy of 1862' it is stated that:

'... a very large proportion indeed of the sick rate in the Royal Navy is derived from boils, abscesses, ulcers and injuries of a more or less trivial nature, and from simple catarrhs and sore throat, and that the ratio of sickness from disease properly so called is in reality very small.'

The death rate likewise fell dramatically and continued to fall in the next century as these figures show:

More progress
Even as early as 1800, when the Fleet blockaded Brest, it consisted of 24 ships of the line, besides smaller vessels, under Lord St Vincent, and kept at sea from 27 May till 28 September without one of them being in port. The history of the fight against disease at sea clearly shows how it was the great improvements in naval hygiene and preventive medicine rather than the advances in clinical medicine that reduced mortality and sickness; but during the nineteenth century other important factors were operating; they included the following:

a. Fewer wars during this century and a consequent reduction in the naval force.

b. Changes in the method of recruitment. After 1815 impressment as such ceased and was replaced by voluntary recruitment continuous service in 1823, and so many of the hard restrictions, such as no shore leave, could be abolished.

c. Many of Blane's recommendations were brought into effect, such as improved cleanliness and inspection by commanding officers.

d. Thorough cleansing of clothing of men suffering from infection.

e. By 1815 water was stored in iron tanks which were cleaned and whitewashed inside.

f. Victualling was reorganized and catering taken out of the hands of private contractors and controlled by a Director of Victualling. The art of canning was first tried out in the Navy in 1814, and fresh beef and vegetables added to the diet. Salt beef and pork were only issued when these were not available. Fresh bread was substituted for biscuits and allowances of tea, sugar and chocolate made. The spirit ration was reduced; formerly the issue was beer, but when this was not available each man received one half pint of spirits in lieu in the form of brandy or rum. This was reduced to one quarter pint in 1825 and again to one eighth pint in 1850. Sick messes and medical comforts were instituted in 1835.

g. The introduction of steam into ships was through the stages of sailing ship and auxiliary steam engine, composite wood and iron sailing steamship, all- iron sailing steamship and finally the iron ship propelled by steam alone. The introduction of steam led to great improvements. The old windsail and fixed cowls fitted in the latter days of sail were inadequate and the steam fan provided a far better means of ventilation. Cold storage compartments became available and steam ensured an adequate supply of drinking water by distillation and a better system of heating. Later the development of electrical power provided good lighting, improved heating and the modern system of ventilation by the plenum system.

Setbacks
Small outbreaks of scurvy persisted from time to time in the nineteenth century, still due to ignorance but also to the unfortunate substitution of limes for lemons. From 1860 preserved lime juice was made the official antiscorbutic and this led to a serious outbreak in 1875 in the ALERT and DISCOVERY in the Arctic. To bring the long story of scurvy up to date it should be added that even during the last war there were reports of preclinical or subclinical states of scurvy among some ships, especially submarines on long patrols in the Arctic when no fresh provisions could be provided. An investigation, however, showed that all cases of bleeding gums reported were in fact due to Vincent's angina, and there was no evidence of scurvy. The lemon and orange juice now issued to the Navy is fortified with ascorbic acid up to 0.4 per cent. And finally it was a naval surgeon who gave his name to a well-known drink when he persuaded naval officers to put lime in their gin and it has been called a 'Gimlette' ever since.

Statistical information
Careful statistics of the incidence of disease were now being kept and were issued regularly as reports on the 'Health of the Navy'. Gilbert Blane wrote 'A brief statement of the progressive improvement of the health of the Royal Navy at the end of the eighteenth and beginning of the nineteenth century', which was published in 1830. The report on the 'Health of the Navy' by John Wilson for the years 1830 to 1836 was published in 1841. In this the incidence of disease was given separately for the different commands at that time - the South American, West Indian and North American, Mediterranean and Peninsular commands. In this report Wilson gives perhaps the first recorded instance of industrial disease in the Navy, when he describes the methods of cleaning decks. He writes:

'The ordinary methods employed are washing, wet and dry stoning. In the first, large quantities of sea water with friction by brushes is used; in the second, a small quantity of water is poured on the decks, which are then diligently rubbed with smooth, flat stones generally of sandstone designated holy-stones by the seamen, for the purposes of removing stain spots, grease, etc. In the third, the same kind of stones are used for rubbing, but instead of water they are applied directly on the decks...'

Wilson goes on to comment on the objections to wet washing between decks but also observed:

when very friable (sometimes calcareous) stones are employed, a good deal of dust is disengaged in the process which irritates the eyes, settles on the clothes and insinuates itself into the chests, bags, etc, and is therefore to a certain extent annoying.'

He was of course referring to the sea chests of seamen and not to the lungs, but considerable quantities of dust must also have been inhaled.

Psychology
Wilson had some very modern notions on the concept of social medicine and the reaction of the mind on health. He considered that a happy and cheerfully occupied state of mind was conducive to the preservation of health, while gloom and discontent, the offspring of the want of innocent and healthy occupation lead to its subversion. He thought that more was needed in the training and instruction of the mind than issuing bibles, prayer books and religious tracts. About this time libraries were in fact established in ships and a fit person appointed to give elementary education. Wilson concludes his report:

'The time has passed when utter ignorance of everything but his immediate duty, with all the debauchery and destructive effects of savage ignorance, is thought essential to the character of a British seaman - implicit obedience, indomitable courage and love of country.'

Summary
At the close of the eighteenth century and during the nineteenth there were remarkable changes in conditions of life for the seaman and a great fall in the incidence of disease. As early as 1840 Wilson wrote:

'Of the many improvements which have taken place within the last 50 years in the pbysical and social condition of the people, none is to be compared with that effected in the health of seamen in the public service, because none approached it in magnitude and importance.

Stressing this wider aspect of medicine, Macdonald Critchley, in his Croonian lecture in 1945 said:

'Naval medicine can be visualized as the closest approximation to what we now choose to call social medicine, for in the Service the total environment of our personnel comes under the close study and care of the medical branch.'