Principles of military surgery, comprising observations on the arrangement, police, and practice of hospitals, and on the history, treatment, and anomalies of variola and syphilis. Illustrated with cases and dissections

Front matter

I

TRANSFERRED TO

YALE MEDICAL LIBRARY

Preface

THE SECOND EDITION.

From the favourable reception whieh the first edition of the following work met with, both among surgeons in civil life, and those for whom it was more particularly designed, I have been induced to offer a second to their attention. My respectable publishers originally intended to print the book in two volumes; but the desire of making it more portable, and less expensive, afterwards led them to adopt a compressed and comprehensive page.

The want of Engravings having been much complained of, I have introduced a selection from the numerous original drawings, plates, and preparations within my reach or in my possession. These have been executed by an artist already known by his excellent anatomical delineations.

In the preface to the first edition, which was published under the title of " Observations on some

XX11 PREFACE.

Important Points in the Practice of Military Surgery," &c. I acknowledged my obligations to several friends, and I here most willingly repeat them. Mr. Vance, one of the surgeons of Haslar Royal Naval Hospital, allowed me constant access to his excellent specimens of Morbid Bones; and he rendered the permission still more valuable, by his numerous communications in illustration of every point on which I consulted him, during the period of my superintendence of the Portsmouth district; but as this experienced surgeon may on some future occasion favour the world with descriptions of his preparations, and with his professional opinions, I have expunged from this edition the very cursory allusions which I made to them in the former. To Dr. Denmark, Physician to the Fleet, I owe the use of many beautiful preparations during my residence at Portsmouth ; and from him I readily received permission to make drawings, some of which illustrate the following pages. Mr. Hammick, Surgeon of the Royal Naval Hospital of Plymouth, allowed me to examine the whole of his collection, and politely offered me permission to make drawings from any part of it. To these gentlemen, and to Drs. Dickson and Johnson, of the same service, my sincere thanks are offered; but much as I am indebted to the naval surgeons, I could not presume to hold out in my title-page, a promise of information upon a branch of

PREFACE. XX111

service with which I was only acquainted through the medium of others.

To some of my military friends it will be seen, that I owe considerable obligations ; and I take the present opportunity to offer my acknowledgments particularly to the junior classes, who have served with me on various occasions, and whose zeal and personal exertions have amply repaid me for my endeavours to acquire their friendship and confidence. To Dr. Thomson, Surgeon to the Forces, and Regius Professor of Military Surgery in the University of Edinburgh, I am under great literary obligations, for the unreserved use of his preparations and his books, and for the numerous sources of information (not hitherto generally accessible to officers of the army) to which he has directed my inquiries. The peculiar opportunities, however, which military surgeons now enjoy, facilitated as they are by the Director- General, open a very wide field for improvement, and afford the promise of much future benefit. Under these circumstances, therefore, I have oftener referred to the works of the older surgeons, and of foreigners, than I otherwise should have done ; - for while I deprecate the literary dishonesty of quoting without acknowledgment, I think the fastidiousness of never availing ourselves of the labours of others, is often as injurious to science; and in many cases, while an

XXiv PREFACE.

author labours to secure for himself an acquittal from the charge of pedantry, he may entail on his readers the penalties of ignorance.

It now remains for me to mention what I have done towards rendering the present work more worthy of notice. To the Cases, Observations, and Illustrations, I have made several important additions. If I may be considered as somewhat diffuse on many preliminary points regarding the police and establishment of hospitals, it is because I conceive these details to be of the greatest practical importance ; and I have enlarged my historical notices, under the impression that much has always been learned in every department of science from a knowledge of its history, and an acquaintance with what has already been done on the subject. I have added three entirely new Chapters, comprising Remarks on the Examination of Recruits ; on the Detection of Feigned Diseases; on Medical Topography; on Vaccination ; and on Syphilis. This last chapter, I trust, will be found an useful, as I can conscientiously say it is a faithful statement of facts. I could with much greater ease to myself have dilated it into a volume, than compressed it as I have done into a few pages. The materials are from sources inaccessible to the majority of practitioners, and my intention in collecting them has neither been to support, nor to contro-

PREFACE. XXV

vert, the opinions of any particular set of men, but to advance the purposes of science and of humanity, and thus to lay the surest basis for promoting the real interest of the profession at large.

Upon the whole, I can assert, that I have spared neither time, labour, nor expence, to enhance the value of every part of this work, by re-considering all the cases which have occurred in my own practice, or in the hospitals under my superintendence, and by comparing them with the communications of living practitioners, and the details of preceding writers. These improvements will, I trust, justify the change which I have been induced to make in the Title of the present volume.

In one part of my task, I have been most essentially assisted by the free access which my excellent and learned friend Dr. Duncan junior, Professor of the Institutes of Medicine in the University of Edinburgh, has allowed me to the Library of the College, for which my warmest gratitude is due. To other Professors in the University I am also greatly indebted. Dr. Monro opened his Museum unreservedly to me. Dr. Home communicated his numerous collections upon the history of Mercury; and Dr. Hope pointed out and explained to me those useful contrivances in the domestic arrangement of hospitals which he has

XXVI PREFACE.

introduced into the Royal Infirmary, and which have so essentially contributed to the utility of that noble charity, that nothing seems now wanting of which its original structure will admit. To these eminent individuals, and to many other medical and surgical friends in the " intellectual city," I owe much for their uniform kindness, and I feel more than I can here express.

I have only further to remark, that, whatever doctrinal errors or omissions may be found in the following pages, they are to be charged solely upon the author ; for in neither the plan nor the execution has he received any assistance (beyond the mechanical helps afforded by some of his literary friends) which he has not acknowledged, either in these prefatory lines or in the body of the work.

Edinburgh, Is* June, 1820.

Contents

PACE

Preparatory Steps on taking the Field 22

General Nature and First Treatment of Wounds 30

Chapter I. Preparatory Steps On Taking The Field

To enable the young army surgeon the more effectually to apply his professional talents to the relief of the suffering soldier, it will be necessary to direct his attention to some preliminary points, a knowledge of which can be derived from field practice alone; without a due observation of these, his best regulated plans, and most zealous endeavours to do good, will often end in severe and sometimes fatal disappointment. Were he always under the eye of his more experienced seniors, it would be superfluous to dwell on these points ; but the exigencies or the casualties of actual service will often throw him at a distance from all professional aid, and leave him totally dependent on the resources of his own mind, and on the scanty supplies to which original deficiency or subsequent expenditure may frequently reduce him. In this point the military surgeon is far less favourably circumstanced than his naval brethren. Their hospitals, their medical stores, their provisions, and all their little comforts, are as perfectly within their reach, after the most protracted engagement, as if no such event had taken place; their patients suffer none of the heart-rending privations of a soldier, lying wounded on the field of battle, without bedding, food, or shelter ; and, when he is removed, torn from his comrades, and sent to distant hospitals by a precarious and uncomfortable conveyance over broken-up roads, or intricate mountain passes. In short, the sailor fights at home. Could a general fix upon his own ground, the medical officer, at the head of his staff, could easily determine on the necessary buildings for the sick and the wounded : but their shelter and their convenience are inseparably connected with the movements of their commanders, and with the facilities of transport which the seat of war may afford, and the commissariat can procure, in addition to the unemployed cavalry and waggons of the army.

The supply of hospital stores, which should accompany an expedition, rests in the hands of those who immediately communicate with the government; and has seldom heretofore been, and it is to be hoped and believed never will hereafter be, deficient, either in its quantity or its selection. In apportioning it off, however, to the various divisions or corps of an army, or to the different stationary hospitals, great attention and discrimination are necessary ; and the skill and experience of a medical officer are in few particulars more strongly evinced than in making his requisitions on the great depots, for his field and hospital supplies, with judgment and selection. With this in his view, the first and peculiar care of the medical officer, on commencing a campaign, should be carefully and minutely to examine his Medical and Purveyor's stores, with a view to their completion in every respect. Whether in charge of a corps of the army, of a regiment, or of a detachment, so much of the success of the Surgical Campaign depends upon this, that too great pains cannot be bestowed upon it. He should therefore, however circumstanced, calculate his mode and quantity of transport, as well as the comparative necessity or utility of different articles of medicines, instruments, surgical materials, bedding, utensils and medical comforts, necessary for his situation. If the articles are to be supplied on a large scale, the estimate will be best made by a board of intelligent and experienced Medical Officers ; and by no means should it be left at the discretion of an Apothecary or Purveyor, who cannot be supposed to be adequate judges of what are necessary on such occasions. For want of this precaution, I have more than once seen whole cart-loads of useless rubbish put in requisition to be forwarded to the army, while the most necessary articles for the field abounded at the stores of the dep6ts.

Indisputably, the best mode of packing stores for the field will be, either in wicker baskets covered with skins or leather, fitted for carriage on horses' or mules' backs, and commonly called field-panniers ; or in wooden boxes, of such a size as may easily be adapted to a similar mode of conveyance; and instead of filling several of these with duplicates of the same articles, a small proportion of each of the most indispensable medicines and materials ought to be placed in each pair of panniers, or boxes, and an invoice of the contents of each should be pasted within the lids. Inconsiderable as this precaution may appear, the additional trouble it gives to the packer is amply compensated by the convenience and utility to the medical officers in the field.

Each Regimental or Staff Surgeon is allowed by the government a horse or mule, or its full price, with a pair of field panniers and pack saddle, for the carriage of his field stores. The articles of the latter description generally served to the army, from their weight, clumsiness, and bad finish, completely defeat the purpose for which they are designed ; and no animal can carry the necessary load for the shortest march without injury to his back, sometimes so irretrievable as to render him utterly useless for the remainder of a campaign. No pains should therefore be spared to render the pack-saddle as light, pliable, and easy to the animal as possible; and, when in movement, every precaution should be taken accurately to balance the panniers, and reduce the load within a moderate bulk. To these ordinary articles of equipment, a few bearers, a camp kettle, a camp stool, and a water bucket, will be found most useful additions.

Foreign armies often allow carts and waggons for the carriage of what they denominate their Field Hospital : but the improved plan of British equipment does not recognize them on the line of march, and only a proportion of spring waggons, for the use of each division, is allowed to accompany the army; and that solely for carrying the sick and wounded. It does not enter into my plan, at present, to enlarge upon the ambulance volante of the French armies, described at such length by M. Larrey, and found so useful; although an establishment of that kind, duly modelled, would no doubt be of important service in our field arrangement. I shall therefore confine myself to some hints on the purpose of the transports, and the selection of the stores usually allowed by the British regulations.*

Lint, surgeon's tow, sponges, linen both loose and in rollers, silk and wax for ligatures, pins, tape, thread, needles, adhesive plaster ready spread and also in rolls, opium both solid and in tincture, submuriate of mercury, antimonials, sulphate of magnesia, volatile alkali, oil of turpentine, &c. &c. are among the articles of indispensable necessity in the panniers; and, perhaps, as useful an article of convenience as the surgeon can possess, is a supply of wax candles, with phosphoric matches, or some other contrivance for procuring instant light; for want of which J have known some very distressing accidents occur; in one case in particular, several months of the patient's life were rendered uncomfortable in consequence of a large plexus of nerves having been included in the ligature. Every surgeon will naturally have the best instru-. ments he can procure ; but it may not be amiss to remind him that his knives will often loosen, and his scalpels, more particularly, break from their handles, if not firmly riveted through at least the half of their length ; an indispensable addition to his case will be a good strop to touch them

* See Larrey's Memoires de Chirurgie Militaire, passim. Beckmau's History of Inventions, by Johnson, vol. iv. 2d edit. London, 1814. Article, Infirmaries &c. p. 467. The article " Despotat," in the " Dictionnaire de Sciences Medicales," and Millingen's Army Medical Officer's Manual," for full information on the history and practical details of this subject.

on when blunted. The hone sometimes put into surgical instrument-cases is of but little use, as it requires an acquaintance with the peculiar mode of using it, without which the instruments are often totally spoiled: he should have one or two spare blades to his saws, and a set of Hey's saws, which are now usually put in by the instrument-makers ; and if the chain-saw, invented by Professor Jeffray, of Glasgow, were substituted for, or added to, the metacarpal saw, I conceive it would be an addition of serious importance.* The straps of the screw tourniquet, usually put in instrument-cases, are often defective, and their buckles unsafe ; they should be carefully proved before using, lest they should give way at a critical period of an operation. The clumsy pieces of leather added to some are entirely useless ; but a neat small pad, secured with a bit of tape, may be retained ; and if the handles are rounded, and properly padded, as recommended by one of the most experienced field surgeons of our day, Mr. Guthrie, nothing else will be wanting to command the arteries in the shoulder-joint operations, for the very few seconds that tbey require pressure. The tenaculum of Assalini, and the arteryforceps with a slide, will be found very useful. The bulletforceps in general use might be much improved, by being rendered less bulky, and its blades made to separate occasionally, or join, as in the midwifery forceps ; or the very useful forceps of M. Percy substituted in its stead. + Some flexible catheters, and some flexible tubes for conveying food or medicine into the stomach, in case of injuries of the bladder and of the oesophagus, may be advantageously added to the field equipment, as they are light and portable, and the distance from the field to the fixed hospitals, where they are

* See Cases of the Excision of Carious Joints, by H. Park and P. F. Morcau ; with Observations by James Jeffray, M.D. Glasgow, 1806. t Manuel du Chirurgien d'Armee, par M. Percy, Paris, 1792.

usually kept iu abundance, is in some cases considerable : they are not, however, articles of immediate or urgent necessity.*

To keep his instruments in perfect and serviceable order, must be the wish of every surgeon. Some wrap them fn lint, or bibulous paper ; some dust them with absorbent powders, as starch or magnesia ; others smear them with mercurial ointment ; and some with simple oil, as fresh as they can procure it. The latter carefully applied, and afterwards gently rubbed off, I prefer to all other modes; but whatever precaution is adopted, the instruments should be frequently examined, and the case covered with patent leather, or some other water-proof substance, and the whole loading of the baggage animal carefully secured with painted canvass.

About his own person each medical man, of course, carries a pocket case of instruments ; and I would strenuously recommend that he never omits a canteen of good wine, or spirits diluted. Many men sink beyond recovery for want of a timely cordial before, during, and after operations ; and many of the primary operations would be rendered much more favourable in their results, by the administration of a single glass of wine.

It is usual also to issue a certain number of what are called field tourniquets to the officers, and to some of the non-commissioned officers, drummers, and other non-combatants. Tn many instances life has been preserved by these instruments ; but too great caution cannot be employed in guarding against superfluous and long-continued pressure ; and the attendants, as well as the wounded individuals, should be warned to apply as soon as possible to the medical assistants, in order that they may examine the state of the parts in which the circulation is confined.

* An instrument of late invention, and of pre-eminent utility, the patent syringe of Mr. Read, will be an addition of the most serious importance, and will not occupy more room than the clumsy pewter syringe, usually put in the field panniers.

As the staff and regimental pannier mules or horses should never be overloaded, and as there is often a necessity fur taking on forage for the use of the animals, the supply of materials must be limited to a certain weight : two hundred pounds, including instruments, panniers, and barley, &c. &c. should be, in general, the maximum. The duty of having in readiness a reserve supply is one of the most serious importance ; this, however, as always devolving on the head of the medical staff, who must be supposed perfectly prepared for all contingencies, it is unnecessary to enlarge upon here. The most portable articles of medicines, and materials ; of medical comforts, as tea, sugar, wine, chocolate, portable soup, lemon juice, &c. ; the least cumbersome cooking apparatus, aad some necessary articles of bedding, must, of course, constitute the store. The distribution also of the various ranks of medical officers to the different corps, divisions, and brigades of the army, rests with the same authority ; and however superfluous the number of professional men may appear before a battle or a series of movements, it will very seldom be a source of complaint after these operations. In the selection of field necessaries, and of Staff-Officers, circumstances of course must very materially influence every arrangement.

We shall suppose, however, that the army has taken the field, or opened the trenches; each of its divisions furnished with a due proportion of the general Hospital Staff with their stores ; the field-panniers of the regiments and of the Staff-surgeons complete ; their surgeons and assistants present ; and an arrangement made with the Commissariat for the transport of the wounded to the fixed hospitals in the rear; The usual and most rational plan for providing against the casualties that will naturally succeed to the opening of the fire in the field, is that laid down by Ranby ; * viz. to form in small parties, at a convenient distance in the rear, out of the immediate

* Method of treating Gun-shot Wounds, London, p. 1744.

reach of shot and shells, where the field-panniers are fixed as a sort of table, and where some of the regimental non-combatants, the drummers, band, &c. are prepared to act as orderlies. Where, however, it can be conveniently done, especially at a siege two, three, or more points of rendezvous, at a house, farm, church, or marquee, ought to be appointed to carry the wounded to in the first instance. In either of these situations the first dressings ought to be applied, and the primary operations performed ; here, also, the wounded should be selected for conveyance to the receiving hospitals in the rear; those who can walk selected from those who require mules, horses, or waggons, and the whole sent off under a proper escort, with a careful assistant, and with a due supply of rations, in such proportions as the nature of circumstances may point out. Every article, however, of this kind, particularly spirits or wine, is to be kept on a separate waggon or mule, and never entrusted to the soldiers. The most clamorous and troublesome among the wounded iu the field, or before the walls of a besieged town, are generally the worst characters of the army, and the most slightly injured. Great discrimination, therefore, should be used in placing the wounded in the carts, or on the mules, &c. destined to carry them 1o the nearest hospital. Several even affect being contused, or stunned by the recoil of their pieces, or by the wind of the balls or shells ; their object being too frequently plunder, in pursuit of which, the rations and medical comforts of their suffering fellow-soldiers are often the first object of their rapacity.

Chapter II. General Nature And First Treatment Of Wounds, Course Of Balls, &c

Since the invention of gunpowder, war, which was formerly decided by muscular strength, has been conducted upon more scientific principles, deduced from theory, and confirmed by actual experiments. Generals are not only aware of the strength of the army they command, but can, to a certain extent, estimate its probable reduction by the effects of the fire of the enemy; hence we find, that, prior to the French Revolution, when the adoption of an entirely new system of tactics put all calculations at defiance, there was a certain scale upon which the casualties of a campaign were usually computed ; it was supposed, that, on taking the field, three men in every hundred would be upon the sick list; — that, in the middle of a campaign, this number would be doubled, — and that, towards the close of operations, it might be increased to ten or twelve per cent, exclusive of the effects which might arise from any epidemic disorder.* The wounded after a general engagement were calculated at the rate of ten per cent.; and we even find, that the proportion which the wounds of different parts of the body bore to each other were also estimated. Dr. Zetzell, in a discourse on the diseases of the Swedish army.f read before the Royal Academy at Stockholm, states, that in a battle between two armies com-

* Ravaton, p. 635.

f Tal era Sjuklighetcn e faelt, 4to. Stockholm, 1779.

COURSE OF BALLS. 31

posed of infantry, the upper part of the body is most in danger, and that, for two shot in the belly, three or four will take effect in the neck or breast, seven in the head, ten in the arms and hands, four in the hips, five in the legs, one in the knee, and two in the feet. This, however, is a division altogether arbitary, and must necessarily vary according to the position of the contending parties.

It may not be uninteresting to detail a few circumstances which can be calculated with a considerable degree of accuracy, and which, without leading us far into the doctrine of projectiles, may throw some light upon injuries from gunshot. The Chevalier Folard, in his account of the Catapultae, Balistse, and other engines of the ancients, states, that their powers were little inferior to those of our modern instruments of destruction, and, indeed, in the works of Celsus, (lib. vii. chap. 5,) we find that the effects of leaden balls and stones, projected from the engines then in use, were by no means unknown ; but of their precise velocities we know little or nothing. By the calculations of D'Antoni,* it appears that the initial velocity of a cannon-ball is nearly two thousand feet in a second, and that of a musket about seventeen hundred ; but these velocities rapidly diminish from the moment the ball quits the mouth of the gun, and are also greatly influenced by the quantity and quality of the powder, the force used in ramming the wads, the elevation of the gun, and the length of the bore; the weather also influences the velocity of a ball, for, in a very dry state of the atmosphere, it is a seventh greater than when it is loaded with vapour. In sieges, balls of very heavy metal (321b.) are employed; in engagements in the open field, the largest shot seldom exceed 12 lb., and go down to lib. ; the other species of shot are the common Musket Ball, fired singly

* Treatise on Gunpowder, &c. by D'Antoni, translated by Thomson, 8?o. London, 1789.

32 FIRST TREATMENT OF WOUNDS.

from muskets, or discharged in cases from field-pieces ; Grape, which consists of small iron balls, disposed in linen bags fastened to a wooden bottom, in the middle of which is a spindle, round which the balls are secured by cord or wire ; or Caseshot, which consists of the same small iron balls put into tin cylinders, the bases of which are closed by two circular pieces of wood. The last kind of projectiles are shells, or hollow iron spheres, filled with powder, which may act either before or after their explosion. The closer the contending parties are to each other, the more deadly will be the effects of all these balls; thus, according to D'Antoni, a 321b. shot may pierce a file of 70 men, a 161b. a file of 48, an 81b. a file of 40; a 13 oz. shot a file of 20, a 6 oz. a file of 16, a 1 oz. a file of 4; if very close to them, and propelled by a certain degree of force, — while a shell will pass through from two to five men, and will kill or wound by its splinters from six to nine; the distance and the resistance will of course produce great variation in the action of all these missiles. It must be confessed, however, that, much as the artillerist and engineer are interested in ascertaining these points with correctness, it leads to little improvement in surgery, except in as far as.it shows the enormous violence with which the bones may be fractured, and their fragments dispersed either into the medullary cavities or the surrounding soft parts.

Among the ancient surgeons, who had learned and abstruse theories to support, respecting " the burnings," and " the poisonings," and " the concussations," of gun-shot wounds, every little accidental variation in the external appearance of the shot-hole, and every shade of mental agitation in the wounded man, were fondly dwelt on as illustrative of their own particular doctrine ; and even to the present hour some writers enlarge on these appearances, as if they were at all essential to the treatment, and puzzle themselves with definitions, as if every practitioner acquainted with the subject, even from books, did not know that a gun-shot injury is a violent

COURSE OF BALLS. 33

contusion, with or without solution of continuity, suddenly and rapidly effected by a solid body projected from fire-arms ; — and nothing more, so far at least as definition is concerned.

The effects of a gunshot wound differ so materially in different men, and the appearances are so various, according to the nature of the part wounded, and the greater or lesser force with which it has been struck, that no invariable train of symptoms can be laid down as its necessary concomitants. If a musket or pistol ball has struck a fleshy part, without injuring any material blood-vessel, we see a hole about the size of, or smaller, than the bullet itself, with a more or less discoloured lip, forced inwards ; and, if it has passed through the parts, we find an everted edge, and a more ragged and larger orifice at the point of its exit ; the haemorrhage is in this case very slight, and the pain inconsiderable, insomuch that in many instances the wounded man is not aware of his having received any injury. If, however, the ball has torn a large vessel, or nerve, the haemorrhage will generally be profuse, or the pain of the wound severe, and the power of the part lost. Some men will have a limb carried off or shattered to pieces by a cannon ball, without exhibiting tbe slightest symptoms of mental or corporeal agitation ; nay, even without being conscious of the occurrence ; and when they are, they will coolly argue on tbe probable result of the injury : while a deadly paleness, instant vomiting, profuse perspiration, and universal tremor, will seize another on the receipt of a slight flesh wound. This tremor, which has been so much talked of, and which, to an inexperienced eye, is really terrifying, is soon relieved by a mouthful of wine or spirits, or by an opiate ; but, above all, by the tenderness and sympathizing manner of the surgeon, and his assurances of his patient's safety. Where some important or vital organ is injured, considerable pain and much anxiety is a general consequence ; these will be more particularly considered in treating of the wounds of particular parts.