A touch of France: Sickness and health on the high seas in the 18th century





Christian RÉGNIER, MD
Praticien Attaché Consultant de l’Hôtel-Dieu de Paris
Société Internationale d’Histoire de la Médecine
9 rue Bachaumont 75002 Paris
(e-mail: dr.christian.regnier@wanadoo.fr)


Sickness and health on the high seas in the 18th century

The Former Rochefort School of Naval Medicine and the birth of the French Navy Health Service

by C. Régnier, France



The life of an 18th-century navy man hung by a thread. If he escaped death and mutilation in battle, he still had to contend with accidents, malnutrition, dysentery, typhus, and a host of other ills, all of which accounted for many more deaths than enemy action. Scurvy alone—the “plague of the sea”—killed tens of thousands of sailors in the navies of European nations. In France, the royal navy contracted civilian doctors to care for its sailors until the 1700s, but in the second half of the 18th century the idea took shape of creating a navy medical service. The navy’s need for surgeons coincided with a turbulent period in French naval history marked by a succession of conflicts: the War of the Austrian Succession, the Seven Years’ War, the American War of Independence. Naval battles, epidemics, ignorance of hygiene, and crowding aboard ship meant that injuries were common and diseases rife. The navy thus trained a body of medical men aware of their professional worth and organized an effective navy health service (hospitals, surgeons, hospital ships). The foundation of the three medical schools of Rochefort (1722), Toulon (1725), and Brest (1731), of which Rochefort was the most renowned, symbolized the advent of this medical service within the French navy. Directed by three generations of doctors of the same family, the Rochefort School of Surgery was coupled to the naval hospital of the dockyard. Students there trained rigorously, and on graduation as navy surgeons, most of whom practiced their art aboard ship, they formed an elite medical corps.
Medicographia. 2012;34:477-486 (see French abstract on page 486)


Not yet five years old at his father’s death in 1643, Louis XIV reigned over France for the next 72 years, during what Voltaire dubbed “an eternally memorable age.” Keen to assert the maritime power of his kingdom, to defend the coasts of France, and to develop trading links with colonies in the Americas (Quebec, Louisiana, the West Indies, Guiana), around 1660 Louis ordered the creation of a fine new naval dockyard on the Atlantic coast. The site chosen was Rochefort, a nondescript village in a disease-infested swamp. Centrally located on the Atlantic coast of France, Rochefort had strategic advantages: it afforded protection by the islands of Ré, Aix, and Oléron, as well as being linked by the Charente River to inland forests planted to supply wood for shipbuilding.

The task of building the naval dockyard was entrusted to Nicolas-François Blondel, the Royal Naval Engineer, and to Louis Nicolas de Clerville, Commissioner General of Fortifications, and work started in May 1666. Soon branded the “navy’s grave,” Rochefort was long prey to epidemics of malaria and dysentery that wiped out thousands of shipyard workers, townspeople, and convicts from the local penal colony doing forced labor. Yet, by 1690 the French royal navy boasted the largest war fleet in Europe, with 110 ships of the line and 690 other vessels crewed by 100 000 men. From 1666 to the French Revolution, nigh on 1300 ships were commissioned at Rochefort.1-4









Outbreak of typhus onboard a ship. Woodcut by Lucien Totain,
from a popular medical science book: Hygiene and Medicine of
Both Sexes: Science Made Understandable to All. Published by
Jules Rouff in Paris, 1885.

© BIU Santé Paris.


Life before the mast

Outbreaks of disease were common in the crowded conditions on board ship, notably during the transport of troops or slaves: “malignant fevers,” typhus, dysentery, pneumonia, dermatoses, typhoid. Hygiene was woeful. Rationing of fresh water meant sailors could wash neither their bodies nor their clothes. They slept in steerage, cramped quarters choked with the stench from buckets of excrement. Bilge water stagnated in the hold, a sort of nautical cesspool and breeding ground for insects. Poor preservation of food and drinking water, lack of space for foodstuffs, often led to shortages at sea. Atlantic crossings were interminable, since a squadron of ships could sail no faster than its feeblest laggard. With no ports of calls to take on supplies, want of fresh produce led to vitamin deficiencies, first and foremost scurvy. And to add insult to injury, unlike Spanish sailors, who were issued with warm woolen clothes, French mariners had slow-drying linen garments which soon wore out. Captains reported that by the end of a long voyage their men were in rags, chilled by the rain and cold. On arrival, the sailors, their immune defenses already much weakened, fell victim to endemic and parasitic diseases.

In the mid-18th century, the mortality rate aboard squadrons making the two- to two-and-a-half-month crossing of the Atlantic to the West Indies was an estimated 0.5% to 17.2%, and the morbidity rate ranged from 5.4% to over 32%. These rates depended on age (cabin boys were more resistant) and position (officers were four times less likely to die at sea than ordinary seamen), as well as time of year, length of crossing, crowding (number of sailors per unit area of deck space), and the type of expedition.5,6



Title pages of two major 18th-century naval
medicine treaties. Left:
How to Preserve the
Health of Ship Crews, by Duhamel du Monceau,
published in Paris by H. L. Guérin and
L. F. Delatour, in Paris, 1759. Right: Handbook
of the Most Common Surgical Operations for
the Instruction of Naval Surgical Students of the
School of Brest, by Charon de Courcelles,
published by Romain Malassis, in Brest, in 1756.

© BIU Santé Paris.



Treatises on preserving the health of people at sea led to significant improvements in naval hygiene in the first half of the 18th century. The most famous were those by the botanist Henri Louis Duhamel du Monceau, the navy lieutenant Sébastien François Bigot de Morogues, and the doctors Antoine- Marie Poissonnier-Desperrières and Étienne Chardon de Courcelles, the founder of the naval medical school at Brest. Medical studies on questions of health at sea were formalized in new naval regulations and orders.7

A navy health service is born

Around 1640, the first surgeons sailed on French ships; small hospital ships (fluyts) sailed with squadrons; and a naval hospital opened in Marseille. Soon after, a royal order required sea captains to take on board a good surgeon to tend to the ship’s company. The Tonnay-Charente naval hospital (40 beds), the first of its kind in France, was founded in the Saint-Éloi Priory in 1666. Some 17 years later, having become too small for its purpose, it was transferred to the vicinity of the Rochefort naval dockyard and renamed the Charente Hospital (480 places, ie, 240 beds). Many thousands passed through this hospital over the next 105 years; some 30 000 died there—sailors, of course, but also convicts and locals who succumbed to the ills emanating from the disease-ridden environs.

From 1673, each of the three great ports of war—Brest, Rochefort, and Toulon—had a doctor and a navy surgeon who were “provided for,” to wit, paid a wage. This number soon increased to two doctors and six surgeons, who took turns to embark.



Louis XIV, the Sun King (1638-1715), who ordered the creation
of the Naval Dockyard and Rochefort School of Naval Surgery.

Oil on canvas, 277×194 cm, by Hyacinthe Rigaud (1701), at the
Louvre Museum, in Paris.

© Giraudon/Bridgeman Art Library.




Jean-Baptiste Colbert (1619-1683), chief minister of Louis XIV,
organized the medical service of French naval hospitals and
ships.
Oil on canvas, 630×520 cm, by Pierre Mignard, 1667, at
the Palais de l’Institut, Paris.

© RMN–Grand Palais.



One of Louis XIV’s principal ministers, Jean-Baptiste Colbert, the Controller-General of Finances, issued an order stipulating that all ocean-going ships manned by over 36 men had to have aboard a surgeon (two for crews of more than 50 men), whose skills were tested before embarkation. Surgeons had to attend dissection classes and acquire from a senior doctor knowledge of internal diseases and remedies. In practice, this rule was little applied and the surgeons or “boy surgeons” who went aboard were uneven in their skills.

Colbert sent his son to the naval dockyard at Rochefort with clear instructions to learn what it took to be…the Secretary of State for the Navy. Some years later, having been appointed to this position upon the death of his father in 1683, Colbert the younger promulgated an order which organized the medical service of the naval hospitals and of the fleet. The Colberts, father and son, were of the view that the state should control and supervise rather than organize health care. Colbert the younger expressed his view thus: “I consider it not in the least necessary to increase the number of surgeons. In the past when needed they were found when none were waged, and I am convinced that the same will be true now, all the more so, since as there are already eight waged, fewer will be needed.”3,6-9



Medicine cabinet used by Rochefort Port Pharmacists. 19th-century, Rochefort School of Naval Medicine Museum.

© Musée National de la Marine/Bécot.



The problem arose of differences in status and training between doctors, on the one hand, and surgeons and apothecaries, on the other. The former were university-trained and bore the title of doctor; the latter, often of humbler origin and sometimes illiterate, belonged to the world of guilds and served a short apprenticeship to an older guild member. Surgeons varied greatly in skill and their hierarchy was somewhat ill defined. The best boasted credentials in surgery, served the navy for years, and when their onboard careers came to an end were rewarded with a post in one of the three shipyards as assistant navy surgeon or better still as a “waged surgeon.”

At the end of the 17th century doctors alone were authorized to make diagnoses in internal medicine and to stipulate treatment; they rarely wielded a scalpel. Until the Revolution, surgeons and apothecaries prepared medical prescriptions, and answered to the quartermaster’s office. Owners of their own medicine chests, for which they received an allowance, surgeons were the only medical men on board ship. Placed under the authority of the captain, only the surgeon major was allowed access to the officers’ mess. Not all captains understood or accepted the presence of surgeons on their ship. It is true that the care provided at this time was of limited value in diseases and only surgery (usually amputations) could save lives. The Navy Board was flooded with complaints about the mediocrity of the onboard surgeons, who were accused of rote and artless use of what little they had learnt of anatomy and surgery.7-10 The creation of the Academy of Surgery in 1731 heralded a gradual shift of naval medical training towards joint studies with doctors.



Naval surgeon’s instrument kit. 19th century, Rochefort School
of Naval Medicine Museum.

© Musée National de la Marine/A. Fux.



It was against this background that the first doctor of the port of Rochefort, Jean Cochon-Dupuy, who studied at the Faculty of Medicine in Toulouse, proposed the foundation of a school for the instruction of ship’s surgeons attached to the naval hospital. The Rochefort School of Surgery was inaugurated on 5 February 1722, the first of its kind in the world. Its success was immediate. The Minister of the Navy decided to create schools in Toulon (1725) and Brest (1731), modeled on Rochefort, the three schools developing their own specific features and particular practices.3

The Rochefort School of Naval Medicine and the Cochon-Dupuy dynasty

Jean Cochon-Dupuy opened the Rochefort School of Naval Medicine to students under 15 years of age able to read and write, with good eyesight and healthy hands without deformities. Preference was given to children of the families of waged surgeons or of respectable families attached to the navy. The candidates had to be of the Catholic faith and to pass an entrance examination before the medical authorities of the naval dockyard. The school fees were paid by the navy, except for any auditors allowed to attend. Cochon-Dupuy organized the life of the school according to three successive sets of regulations, and wrote the lecture notes for several courses, notably on anatomy and surgery, which he taught.

The teaching program also included bedside training to learn the techniques of bandaging, bloodletting, and operations, the copying out of medical prescriptions, courses at the pharmacy, and botany classes. (Regularly supplied with seeds and plants brought from overseas, Rochefort’s botanic garden was famous and one of its special features.) The students studied on average for five years, and advancement to the next stage of training was by competitive exam. Those who wished to become waged surgeons had to pass the “double masterpiece” test, which consisted of two randomly selected questions, one on anatomy, the other on surgery.

The school had eight ordinary surgeons and twelve students in 1725. Two years later, the Count of Maurepas, Secretary of State for the Navy, attended in the school’s amphitheater two anatomy classes on the cadavers of galley slaves. Impressed by the organization, he accorded his protection to the school. Apart from the botanic garden, the school had a rich library with some 14 000 volumes, a cabinet of curiosities of the natural sciences and a remarkable anatomy collection of sections and anatomic preparations injected with wax after the manner of the Dutchman Frederik Ruysch. In 1736, a dental surgeon was appointed at the school, notably for the treatment of people with scurvy, and this became a new specialty at Rochefort. From its creation in 1722, the Rochefort School of Surgery continued to the start of the French Revolution, through the reigns of Louis XV and Louis XVI, which were marked by three wars ruinous for the crown and punctuated by maritime disasters: the War of the Austrian Succession (1740-1748), the Seven Years’ War (1756-1763), and the American War of Independence (1775-1783).






Boxwood urns for drawing the names of the candidates and
the questions for medical exams at the Rochefort School of
Naval Medicine.
19th century, Rochefort School of Naval Medicine
Museum.

© Musée National de la Marine/P. Dantec.



The Rochefort hospital saw a huge influx of wounded and sick from the squadrons engaged in the War of the Austrian Succession. A typhus epidemic spread through the town on the return of one such squadron, and of the 2000 navy men who fell sick almost one third died, including 23 socalled “second-class doctors” (who had passed certain examinations, after a six-year apprenticeship with a doctor or five years working in a hospital or three years studying at medical school). The school’s activities and recruitment had to be suspended for a year, as the staff were assigned to care for the sick. The following year another squadron arrived at Rochefort, this time from Canada, and 8000men died of typhus and scurvy.1,3,4,8,10-13

Gaspard Cochon-Dupuy, a graduate of the Paris Faculty of Medicine, took over the running of the school upon the death of his father in 1757. Two years later, as the Seven Years’ War was raging, the school had 400 beds, 30 surgeons, and a 100 or so junior surgeons. 1788 saw the inauguration of the “hospital on the hill,” located high up to guard against “pestilence” and which replaced the now too-cramped Charente Hospital. The school of surgical anatomy was located in one of the wards near the entrance. The same year, upon the death of his cousin Gaspard, the navy surgeon Pierre Jacques Thomas Cochon-Duvivier took over the running of the school. Thus it was that the same family headed the Rochefort School of Surgery from its founding to the start of the French Revolution (1789), by which time the school had trained more than 700 navy surgeons.8,11

The Rochefort legacy

Apart from the goal of training doctors practiced in treating the afflictions of sailors, the naval schools of surgery led to the inclusion of “waged personnel” in a single administration which prefigured a future navy health service. By awarding diplomas through competitive examination, the naval schools gradually established a hierarchy between navy surgeons receiving different emoluments: funded students, assistant surgeon (two classes), second surgeon, ordinary surgeon, aboard or not. From 1750, all commissioned navy surgeons studied at one of the three schools.



Wax model of stomatitis caused by scurvy,
the plague of the seas…
Dermatological
Wax Model Museum of the Saint-Louis Hospital
in Paris (Musée des Moulages Dermatologiques
de l’Hôpital Saint-Louis, Paris).

© F. Marin Musée des Moulages
Hôpital Saint-Louis APHP.






The post of inspector general of the navy hospitals created in 1763 was occupied by Dr Pierre Poissonnier, the inventor of a process of desalination of seawater, who implemented a single set of regulations for the three schools, a joint annual competitive exam for junior surgeons, and the wearing of a uniform (first step towards the inclusion in the military hierarchy that only became effective in 1835).3,7,9,10

The second half of the 18th century saw the formation of a specific and stable body of navy surgeons. Rather closed, it was organized along civilian lines and defined a clear career path. The dominant role of the doctors running the schools was progressively challenged by the surgeons who were far better acquainted with the diseases of sailors and had wider ranging practical experience. “In their [the doctors’] eyes, surgery was a purely mechanical art, they considered that the surgeon was but a skillful workman, armed with iron and fire, who employs one or other as suggested by his own or traditional experience,” lamented the surgeon Étienne Billard in 1790, in an address to the deputies of the Constitutional Convention.

At the end of the American War of Independence (1783), it was reckoned that 859 surgeons and apothecaries of all grades were needed to meet the fleet’s regulatory requirements, but the personnel paid by the King could provide only 155 surgeons. The shortfall was made up by civilian doctors, and volunteer or conscripted surgeons.

On the eve of the French Revolution, the navy’s body of physicians lacking the official title of doctor essentially comprised an estimated 200 well-trained surgeons accustomed to life on board ship. Deploring that they were not integrated into a military career, they exercised nepotism in recruiting for the naval medical schools. What’s more, the body of ”waged surgeons” was aging and becoming costly, a good number were unfit for life aboard, and they kept their post (and their emoluments) until they died.1,4,7-9

Revolution and beyond

During the French Revolution (1789-1799), the royal navy hospital at Rochefort was renamed “Fraternity Hospital,” and the competitive examinations and the surgeons’ certificates were replaced by a nationwide selection process. The medicine and surgery teaching unit was consolidated in the École de Médecine Navale (Naval Medical School) and the program was aligned with that of the medical faculties of Paris, Montpellier, and Strasbourg.



Pathological osteology cabinet. These bones were used as
teaching material at the Rochefort School of Naval Medicine.

© Musée National de la Marine/A.Nilderlinder.




Collection of pathological eye models. Rochefort School of
Naval Medicine Museum. Manufactured by Duplouy, 19th century.

© Musée National de la Marine/A.Fux.



Medical students completed their studies with a doctoral thesis defense in one of the three faculties. Trainee apothecaries began studies in pharmacy, but the naval medical schools were not authorized to award doctorates after the four years of compulsory classes. At the Bourbon Restoration (1814-1830), a bachelor’s degree was required of all those seeking admission to these medical schools. Soon after, classes in exotic diseases and naval medicine were included in the course of study, and as steamships began to supplant sailing vessels the title of “naval surgeon” was replaced by “naval doctor.” Bacteriology and therapeutics were still little known, but the frequency of epidemics of typhus and dysentery and the ravages of scurvy dropped considerably thanks to stricter hygiene aboard ship. The death rate at sea in the French navy decreased tenfold between 1810 (one man in 30) and 1913 (one in 308). A law passed on 11 April 1890 stipulated the setting up of a military health service in Bordeaux, and thereafter students did just the first year of their studies in medicine and pharmacy at Brest, Rochefort, or Toulon, before continuing their studies in Bordeaux. The three schools continued to operate up until 1963, when they were closed. At Rochefort, this ended 241 years of prestigious history, and in 1986 the Ministry of Defense converted the school into a museum under the authority of the National Naval Museum.4,8,9,11,14_

References
1. Memain R. La marine de guerre sous Louis XIV. Paris, France: Hachette; 1937.
2. Desplantes F. Les cinq ports militaires de la France. Limoges, France: Ardant; 1891.
3. Sardet M. L’École de chirurgie du port de Rochefort (1722-1789) – Un modèle sous l’Ancien Régime. Vincennes, France: Service Historique de laMarine; 2000.
4. Begouin P. Le Service de santé de la Marine à Rochefort de sa fondation jusqu’au milieu du XIXe siècle. Medical Doctoral Thesis. Bordeaux, France;1975.
5. Buchet C. Quantification des pertes dans l’espace caraïbe et retombées stratégiques. In : Buchet C et al. L’Homme, la Santé et la Mer. Actes du colloque international, les 5 et 6 décembre 1995, à l’Institut Catholique de Paris. Paris, France: Honoré Champion Éditeur; 1997.
6. Haudrère P. Santé et voyages au long cours : la route du cap au XVIIIe siècle. In : Buchet C et al. L’Homme, la Santé et la Mer. Actes du colloque international, les 5 et 6 décembre 1995, à l’Institut Catholique de Paris. Paris, France: Honoré Champion Éditeur; 1997.
7. Lefèvre A. L’histoire du Service de Santé de la Marine militaire et des Écoles de Médecine navale en France depuis le règne de Louis XIV jusqu’à nos jours (1666-1867). Paris, France: J.-B. Baillière; 1867.
8. Broussolle B, Masson P. La santé dans la Marine de l’Ancien Régime. In: Pluchon P et al. Histoire des médecins et pharmaciens de marine et des colonies. Toulouse, France: Privat; 1985.
9. Suberchicot JL. Le corps des officiers de santé de la marine sous l’Ancien Régime in Buchet C et al. L’Homme, la Santé et la Mer. Actes du colloque international, les 5 et 6 décembre 1995, à l’Institut Catholique de Paris, Paris, France: Honoré Champion Éditeur; 1997.
10. Bahaud P. Les chirurgiens navigants de la marine marchande et de la marine royale à Rochefort dans la deuxième partie du XVIIIe siècle/em>. Medical Doctoral Thesis. Nantes, France; 1971.
11. Suberchicot JL. Le service de santé de la Marine royale (1661-1793). Modern History Doctoral Thesis. Paris IV Sorbonne, France; 1998.
12. Bitaubé P. Les grandes expéditions et le jardin botanique du port de Rochefort, Rochefort, France : Centre International de la Mer; 1988.
13. Rousseau T. Le manuel des opérations de chirurgie par le Dr Cochon-Dupuy. Medical Doctoral Thesis. Nantes, France: 1977.
14. Niaussat P. Les santés à l’épreuve – Marine et Technique au XIXe siècle. Vincennes, France: Service Historique de la Marine; 1988.