J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

JR A rmy Med CUrp5. 1985; 13 1: 109· 115

'The Smart of the Knife' - Early Anaesthesia in the Services

Surgeon-Captain RNR (Ret'd) John A Shepherd VRD, MD, FRCS

In October 1846 \Villiam Morton gave ether to a Plymouth, a Naval surgeon, inlroduced the flap techni· patient operated upon by John Warren of Massachuseus. que, but it was to be long before the more rapid guillotine Accounts of the event reached England in mid·Dcccmber. amputation was discarded. In 1786 Haire, also a naval On December 21st of United College su rgeon, advocated that ligatures on major vessels should Hospital amputated at the thigh under etber. The scene be cut shofl and not, as was the custom, left long. But is recorded in a well· known picture. for long accepted this advance was also slow lO be generally adopted. as accurate in detail (Fig. I). There are (WO alleged spec­ The conditions under which the Service surgeons work· la[Ors. At the foot of the table Thomas Spencer Wells cd were primitive and scarcely conducive to any is depicted, in white trousers and a short jacket suggesting refi nements. The naval surgeon in evitably operated on naval uniform. Then aged 29. he was a surgeon in the board ship. When a ship was about to go into action it Royal Navy. But the features are those of Wells many was traditional to set up a receiving and operating area by guest. Protected copyright. years later. To his right is , then aged 19, in the cockpit, a small space below the waler·line, nor· and a student at UCH. But the likeness is of a much morc mally the unhealthy living quarters of the midshipmen mature Lister. In fact the group was painted 40 years after and the surgeon's mates. If casualties were severe, the the event. Spencer Wells was not present for he was then cockpit became a shambles. The transfer of the wound· serving in Malta; his inclusion however has some ed to the cockpit was not easy, there were no stretchers relevance. It is doubtful if Lister was there; he was at the and the injured seamen were manhandled through the hat· time a preclinical studem and there is other evidence which ches and down steep ladders. refutes his presence. No Army or Navy medical officer It has been recorded that considering the conditions witnessed this operation, which was at once well publicis· under which the naval surgeon peformed his operations ed and which triggered off an almost in stantaneous adop· as a surgical technician he was unsurpassed . This may tion of ether anaesthesia in civilian practice. be rather an exaggerated statement although a few did Before 1846 the surgeon's repertoire was limited. Am· acquire remarkable dexterity. In the novel "Roderick putations of the limbs were the most frequent major Random" Smollett writes of his experience during an ac· operations. Abdominal procedures were limited almost tion. "Our patients had increased to such a number that entirely to explorations for ovarian cysts. Ligations of we did not know which to begin with, and the first mate the major arteries for aneurysm were not infrequent. It plainly told the surgeon, that, if he did not get up im·

is surprising what had been attempted without mediately and perform hi s duty he would complain of http://militaryhealth.bmj.com/ anaesthesia, for example, in 1816 Astley Cooper tied the his behavio ur to the Admiral ... " (The surgeon was abdominal aorta. In civilian practice the patients were meanwhile prostrate on the deck in fear of his own strapped to the table and were given sips of wine. Some safety) ... "This remonstrance eventually aroused the were remarkably stoical but for most the experience was surgeon, who was never deaf to an argument in which harrowing, and their best hope was that they should faint he thought hi s own interest was concerned. He therefore right out. rose up, and in order to st rengthen his resolution, had If the patient had to be tough. so too had the surgeon. recourse more than once to a bottle of rum ... being Liston was one who had achieved remarkable success thus supported he went to work and arms and legs were before anaesthesia, courageous, of iron nerve , and, hewed down without mercy" ]. perhaps, callous to some extent. His sound anatomical There are many other such descriptions which bring knowledge, his skill in ligating the large vessels, and his out the atrocious environment in which casualties were physical strength allowed the essential of completing an [reated, the crudeness of most of the and the for· on September 28, 2021 operation in a matter of minutes. Not all surgeons were titude of the injured sailor. Conditions were little better so able. Of a contemporary, in the Quest of a virtuoso when Nelson was taken below in the "Victory", to sur· performance, it is said, "with onc sweep of his knife Cut vive only a few hou rs after a penetrating wound of the off a limb. as well as three fingers of his assistant and chest. In 1854 the cockpit was still the operating area. the coat tails of a spectator." The Army surgeon in the pre-anaesthetic era had some The Service surgeons before 1846 had Hale experience advantages. At least he operated on dry land and not on of major surgery in peacetime. They came into their own a rolling ship, in a stuffy, i11·lit space rendered almost in war and their ability was measured largely by their suc· intolerable by an increasing stench of blood and the cess in performing amputations. Before 1700 Yonge of smoke of battle. But his equipment was sparse. He had

Fanlnnlc: A l":1ptT @ivclI to the ~l il ila T~' Suriical Socrtty 3lh November. 1983. J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

110 'The Smart of the Knife' - Early Anaesthesia in the Services

ing the teaching of J ohn Hunte r). In the Navy early am­ putation was accepted much earl ier. The Naval surgeon, of course, unlike the Army surgeon, received casualties wit hin minutes of injury. In 1732 John Atkins recom­ mended immediate removal of the severely damaged limb. He wrote: " The heat and surprise in ac ti on made il Ihe properest time for amputation, men meeting their mi sfor­ tune with greater strength and resolution than when Ihey have spent a night in thought and reflection"J. Atkins, quite unwittingly, was preaching the meri ts, now so well understood, of the early excision of damaged tissue, as a means of preventing gangrene and of reducing secon­ dary shock. But there were no refinements of resuscita­ tion or pain relief. Indeed venesection was often done for the exsanguinated patient: some saw th is as a means of Fi~. 1. - USfoll'S Amputation under Ether relievi ng shock and pain. It was all too readily accepted, both in civilian and ser­ his case of instruments. ligature material, dressings and vice practice, that pain was a necessary accompaniment

a tourniquet. On or near a baulefield simple regimelllai o f any opera tion. Liule was done for its relief. In thby guest. Protected copyright. e hospitals or aid posts were established in requisitioned Navy it is the tradition that a strong tot of rum was of­ buildings or in tents, but the wounded were not always fered but the practice was nOl universal. The soldier was brought to these units and the surgeon frequently given a bullet on wh ich to bite! It must be said that there operated, as at Waterloo, in the open, with the patient was, in an era of vicious flogging a nd harsh discipline, on the ground. He was usually single-handed and Ihere little regard for the feelings of the wounded sail or or were no trained orderlies. Even in general hospitals behind ~~. the lines there was no room set aside for operating and After 1846 the Service doctors were slow 10 recognise . the surgeon worked with hi s patient on a bed, if there the potential value of general anaesthesia. In 1847 the were beds, or on a makeshift. table . medical journals were inundated with reports of the suc­ An observer in the Peninsular War describes a general cessful appli ca tion of erher, from every corner of the hospital thus: " ( saw two hundred soldiers waiting to have British Isles. Only onc report can be found frolll a Ser­ their limbs amputated ... the smell from the gun-shot vice source. The young Naval surgeon Spencer Wells was wounds was dreadful ... There they sat wailing for their quick to seize upon the new technique (Fig 2). He was turn to be carried to the amputating table. A little fur­ then serving in the Naval Hospital at Bighi, Malta, and ther on, in an inner court. were the surgeons. They were had already proved one of the brightest of the younger stripped to their shirts and bloody: a number of doors, naval doctors. Soon after hearing of Li ston's success

placed on barrels. served as temporary operating tables: Wells se nt 10 London for a Hooper's inhaler, one of the http://militaryhealth.bmj.com/ to the right and left were arms and legs flung here and earliest devices for administering ether. He reported a suc­ there wi thout distinction, and the ground was dyed with cessful dental ex traction and demonstrated the apparatus blood"'. to the Maha Medical Society on March 6th, 1847. By June As in the Navy the surgical experience and training of he had recorded more than a hundred cases in which he the military surgeon was sparse. Not until Guthrie ap­ had used the method, including major operations. His peared on the scene was there any real advance in the resu lts we re published locally and appeared also in the management of war casualties. By the end of the Penin­ British journals". Sadly this pioneer effort attracted no sular War, at Toulouse, his results following amputation attention in the Na .... y at the time. (Leaving the Navy in were unsurpassed. Regrettably at Waterloo the lessons 1856 \Vells, of course, became a prominent figure in • he had taught were forgotten. Operations on the bat­ British surgery.) tlefield were done largely by inexperienced young No record can be found of any Arm y doctor using cthcr on September 28, 2021 surgeons. In the base hospitals at Brussels, not far dis­ in 1847 . Camlic suggests that general anaesthesia was used tant, there were more experienced men, but as so often in the treatmem of the wounded in the Kaffir Wars in the case, the transport from the battle front was ineffi­ 1847 but the incident he quotes is that of a Dist rict cient and infection or gangrene had supervened before Surgeon William AtherSlOne performing an amputation treatment was given. under ether in June successfullys. Two Army doctors The early history of wound surgery is best studied in were present at this operation, Hadaway and Irwin. Both relation to amputation. For more than (WO centuries an subsequently served in the Crimean \VaT but neither seem argument has raged concerning the respective merits of to have taken much note of Athcrstone's early success. early or delayed amputation. In the Army Guthrie had Meanwhile in had come down on the side of urgent operation (thus defy- been quick to ex ploit ether. In 1847 he circulated a ques- J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

J A Shepherd 111

An attempt has been made to discover the extent with which was used in the Services between 1847 and 1854. One may search reports of the management of war wounds in the revolutions and wars of the period, assuming that someone in authority, in either Service, might have taken note of any reference to anaesthesia. In the Paris Revolution of 1848 ch loroform was used for the \vounded in the street fighting. Reports from the French surgeon Velpeau appeared in the British Journals". These were discouraging for Vclpeau con· sidered that chloroform was dangerous for the shocked patient. At the time the Paris School of Surgery had con· siderablc influence and Velpeau's opinion carried great weight in Britain. In the Oanish·Prussian War in 1850 chloroform is said to have been used wilh success, but no contemporary repor! appeared in Britain. In the French Wars in North Africa it can be conjectured that chloroform was used with good effect, for the French

iVfedical Service adopted it without hesitation at the star! by guest. Protected copyright. of the Crimean War. The Bri ti sh fought some minor campaigns between 1848 and 1853 , in South Africa, India and Burma. No contemporary reiXlrt s of the use of chloroform have been found, but these may be hidden somewhere in Service ar· chives. There is however belated reference to general anaesthesia For the wounded in the Punjab campaign in 185 1. Some years later it was reported that 53 major operations were done under chloroFor..!TI. but in 47 without anaesthesia the mortality was lower ' . It is possible that Fig. 2 - Spencer Well s as a Yo un g Man this experience discouraged the Arm)' authorities. A record is contributed 10 the "Lancet" in April 1851 tionnaire (0 most of the British hospitals. From the by an obscure Assistant-Surgeon in the Indian Medical answers he was able to show that the mortality rate in Service, William McEgan (1817·1857). amputations for which ether was used was much lower " The cases I now enclose for insertion in THE than that in the pre-anaesthetic period. It is difricult to LANCET may be highly interesting as regards miltary believe that Simpson did not write 10 the Service hospitals: surgery. In the action where these wounds were innicted http://militaryhealth.bmj.com/ Haslar, for example, at the time, had a high reputation. there were 125 of the enemy kil led, and 49, as per list However, if he did seek information from the Services enclosed wounded; whilst we, on our side, had four none was forthcoming, and this may imply that there was European officers and 16 men wounded; none killed. no experience of ether to report. This occurred against the imposter Appa Sahib, where On November 10th Simpson announced his discovery I accompanied my regiment, the 2nd Nizam's Cavalry, of the anaesthetic properties of chloroform. The reper­ into action, having my horse cut down under me, so cussions were even greater on civilian practice than those that we doctors are not at all rimes exempt From the after the introduction of ether. In SCOlland and in the good things going. After attending my own wounded, provinces in England ether was almost completely discard· I proceeded to those of the enemy, and out of 49 cases, ed for chloroform. In London the profession were equally I had 18 amputations to perform, alt under the in· divided in their support for the two agents. At the time

Iluence of chloroform; and, with the exception of three on September 28, 2021 the proportion of Scottish or Scotlish·trained doctors in cases every man recovered"s. the Services was remarkably high (both Dircctors·General, This is the only positive suggestion to be found, prior Smith and Burnett were Edinburgh graduates). This 10 1854, that chloroform should have a place in military makes it more surprising that chloroform was not quickly surgery. accepted in the Services. Chloroform was mor~ likely t~an McEgan served in the Indian Medical Service for II ether to have appealed to the doctor on actlve servIce. years, lO die heroica lly in the Mutin y in 1857. The only The quantity of chloroform required for a case was less: recognition he received was a brief notice in the "Lancet", it was not inflammable: it was much easier to induce a " Massacred with his wife, Or McEgan had some rough patient wilh chloroform than with ether, using a simple service with the 2nd Nizam's Cavalry in the Deccan". "rag and bottle" technique. Operation records for the period from Service hospitals J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

112 The Smart of the Knife' - Early Anaesthesia in fhe Services

do not seem to have survived. Lloyd and Coulter in their of touch with modern medicine. He was greatly cri tici s­ Naval Medical History note that chloroform was first ed when the order was reprinted in the "Illustrated used at Haslar in 1852 but give no evidence for this. London News". The influential Professor Syme of Edin­ Service doctors were quite prolific contributors to the burgh at once wrote a ponderous letter to the " Times", medical journals, although more oftcn on medical mat­ pouring scorn on what Or Hall thought on the subject. te rs than surgical topics. A search has revealed few Symc affirmed that exhaustion or shock did not increase references of significance. In 1853 Steele, surgeon to HMS thc risks of operation under chloroform; he stated " pain, 9 Arethusa, reported the use of chloroform at sea . An instead of being a powerful stimulant, injuriously ex­ Army report of an operation by Mitchell, in the Plymouth hausts the nervous energy of the patient"] . Hall, often Regimental Hospital, in the same year, is of an amputa­ unjustly maligned for many of the medical blunders of tion at the thigh 10. There is no mention of anaesthesia the \Var, was to fa ce much more criticism for hi s state­ but, "the patient a man of great resolution bore the opera­ ment, even to be accused of gross inhumanity. lion well", which suggests that he rem ained awake! No Richard Mackenzie, a young and prominent Edinburgh doubt however many younger Service doctors, who had surgeon, was serving as a volunteer with the 79th Regi­ learned (0 use anaesthetics in their medical sc hools, did ment (Fig 4). He was perhaps the best trained and most use chloroform despite the apathy of their se niors. experienced surgeon at the Battle of the Alma. He is said It is interesting to look at the sparse directives given to have performed 27 major amputations on the wound­ to Service officers at the onset of the Crimean War. In ed. Exhausted by his efforts he succum bed to cholera two the Army regimental medical officers were instructed, by days later. Shortly before the action he had sent a letterby guest. Protected copyright. Smith, to purchase the latest edition of Guthrie's "Com­ home. " There is some truth in the use of chloroform be­ mentaries". If they did read this all to be found wa s a ing attended with risk in gunshot wounds. But surely the brief paragraph mentioning chloroform, but no recom­ surgeons of the Army have sufficient sense not to give mendation for its use in battle casualties. In the Navy the it when a man is in a state of collapse bordering upon directives from Burnetl were based largely on the belated death . Dr Hall's order is intended to discourage the use publication of a report of the experience of a medical of­ of it altogether. No one, I should think, will take any 11 ficer at the Baule of Navarino, in 1827 • The onl y hint notice of it "14. of chloroform comes in the in structions for preparing the The Army after landing at Eupatoria marched south cockpit for action, fo r chloroform is mentioned as a drug towards Sebastopol to fight the first major battle since to be available on the surgeon's table. But there are no Waterloo, on the banks of the River Alma. In less than directions as to who should give it, or how, or when. The three hours the British lost 362 killed and about 1,500 ship's chaplain was given the specific task of administer­ wounded. It took three days to deal with the wounded ing wine or brandy to the wounded! Burnett did however and to transfer survivors to the ships which took them ensure that supplies of chlorofo rm went to most warships. to Scutari. The operating conditions were primitive and Clearly its use depended on individual initiative. a so-called general hospital was established in a farm on \Vhen war was declared against Russia in March t 854 the North bank of the river. Straw was laid on the floor the British Expeditionary Force was built up in the Dar­ and there were no operating tables. It was reponed "thehttp://militaryhealth.bmj.com/ danelles and transferred to Bulgaria in June, where it saw postures of the operators were a source of great no action . In September the Allied Armies embarked at irkso meness and fatigue. " Many operations were done Varna for the Crimea. John Hall , the Principal Medical in the open on the field of battle. Officer anticipating a major battle after landing, iss ued Hall's directive did not prevent a majority of surgeons instructions concerning casualty organisation (Fig 3). For using chloroform. The main limitation was a shortage of the first time there was an official directive about the drug. Smith had, in fa ct, sent out 240 Ibs of chloroform: chloroform between April and September (sufficient to " Dr Hall takes this opportunity of cautionin g anaesthetise more than 3,000 patients). But it must be medical officers against the use of chloroform in the remembered that chloroform \\'as used in prescriptions severe shock of serious gunshot wounds, as he thinks for many medical conditions, including cholera, that some

few will survive where it is used. But as public opinion, of the supply went to Scutari, and that much was lost on September 28, 2021 founded perhaps on mi staken philanthropy, he knO\ ...·s or left behind in Varna, with ot her medical stores. is against him , he can only caution med ical officers, Despite the difficult conditions after the Balllc of Alma and entreat they will narrowly watch its effects; for, the value of chloro form was apparent. Subsequently in however barbarous it may appear, the smart of the the much more bloody Battle of Inkerman chloroform knife is a powerful stimulant; and it is mu ch better to was used extensively, and in the long siege of Sebastopol hear a man bawl lustily than to see him sink silently which followed. There had been harsh criticisms in the into the grave" n. medical press of an alleged failure of the Army doctors Hall's advice was seen by many of the younger medical to use chloroform routinely. In fact a prooortion. officers almost as a prohibition of the use of chloroform often senior officers, still preferred to operate without in the severely wounded, and as evidence that he was out anaesthesia. In November one was Quoted in the "Medical J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

J A Shepherd 113

tion did not prove so injurious as I expected), it affords great facilities to an inexperienced operator, and prevents any necessity for hurrying an operation,,16. Although t.here wa') no shortage of medical officers some anaesthetics were given by non·qualified persons. The Reverend Osborne, a philanthropist who was a firm ally of , reponed, "Chloroform was always used and, it appeared to me, with the greatest suc· cess, which I attribute a great deal to the practice of ad· ministering it on a handkerchief held lightly to the face instead of using some instrument which whilst it secured the inhalation of the anaesthetic excluded too much of the atmospheric air,, 17. (Simpson would have approved of this observation.) Osborne nOt only assisted at some operations but on occasions he gave the anaesthetic: he wrote of one instance at which he officiated, "I am afraid to say the length of time the patient was under the in­ nuence of chloroform. His head was on my knee the greater part of the time and I had to keep up the ad­ ministration of this estimable agent ... I was left with by guest. Protected copyright. one of the surgeons to try and recover him from the tor· por under which he had without pain borne a most severe application of the knife etc. As a last resort 1 found out hi s name and had him sharply spoken to by it. So strong was the force of habit that he made just sufficient effort to waken, to enable us to order him to drink the wine we gave him. Keeping up the same sharp military tone of voice we got more and more swallowed and he soon recovered ... ,, ]7. Despite such amateur anaesthesia and Fig. 3. - John Hall methods of resuscitation, according to Osborne, no anaesthetic deaths were reported in this period at Scutari. Despite all criticisms it did seem that by the end of the war chloroform \Vas established as an essential adjunct Times and Gazetcc" , writing alter Inkerman. "~I hear to war surgery, but this was not entirely the case. The there is a great cry against our not using ch loroform: but Army doc[Qrs had formed a Crimean Medical and the more I see the more strongly I am convinced that it Surgical Society in which to discuss their problems. On

is not of much value in the field: it reduces the number April 19th 1856 under the chairmanship of John Hall, http://militaryhealth.bmj.com/ of medical men available for duty. It would be simply the Society met in the C rimea to listen to a paper on l8 murder to leave the administration of it to any but chloroform by Deputy· lnspector Mouat . He opened educated hands and seldom can you gel more t.han one with the statement that the profession at large looked to doctor to assist at an operation ... Another reason is the Army doctors to contribute their experience towards (hat the shock of a wound which requires immediate am­ the settlement of the important question as to whether putation is so great, that ch loroform depresses a chloroform should or should not be given to the severely paticm,, 15 , wounded. He said "I much fear that they will be In the hospitals at Scutari chloroform was used in all somewhat disappointed in our results and conclusions." major cases. There was no problem of wound shock. Or He made much of a few fatal cases following minor PyelTIont Smith, a civilian working in Scutari at the end operations, which had been attributed to chloroform. He of 1854 wrote, "The celebrated manifesto of Dr Hall supported Hall in his directive against using the drug in against chloroform had not much attention paid to it at the shocked patient. He affirmed that Simpson's teaching on September 28, 2021 Scutari. I had been accustomed to the use of chloroform, had no relevance as he had used chloroform almost en· but certainly had never seen it given to the extent that tirely in obstetric cases and considered that civilian it was employed there. An operation was never corn· surgeons, like Syme, dealt with cases in no way similar menced before the patient was fully under the influence to those with se vere gun·shot wounds. But he offered no of chloroform. \\'here a patient can, without injury to statistics to prove his points, listing only a few selected health or life, be brought into this state (and I must cases in which, without anaesthesia, major amputations acknowledge that I did not see or hear of anyone dying had proved successful or in which, with anaesthesia, the under the influence of chloroform, and this extreme ac· shocked patient had died. He concluded that, firstly, J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

114 'The Smart of the Knife' - Early Anaesthesia in the Services by guest. Protected copyright.

Fig. 4. - Jamcs Mackenzie Fig. 5. - Sir C H B Macleod 0828-1892)

Many lessons were learned in the Medical Services dur· ch loroform was highly injurious in the severely injured iog the Crimean war, not least the necessity of caring for and shocked casualty and, secondly, that "in the moral the sailor or soldier in a more humane manner. to which sense it should never be used for a minor operation." Florence Nightingale contributed so much. The accept·

There was a long discussion in which Mouat received ance of general anaesthesia in the Services. howeverhttp://militaryhealth.bmj.com/ considerable support for his views. But some spoke out belated, stands out as one of the few success stories of against him, mostly the more junior docrors. Or McLeod, the Crimean \Var. a young man (later to be Professor of Surgery in Glasgow), appointed as a civilian surgeon to the Army REFERENCES 1 Hospitals in the East. was the most vociferous critic (Fig I. S~10LLET T. "Roder!ck Random" London 190.3 Vol Il; 45. 5). He expressed regret that Mouat's statements would 2. CAl\TUE N, "A HI story of the Army MedIcal Depart· I ment" Edinburgh 1974; 1:328-329. go forth 10 the world: he believed them to be completely 3 . ATKINS J. "The naval surgeon or a practical system of I erroneous and not representing the general opinions of surgery" London 1732. the majority of Army surgeons. Like other speakers he 4. \\fELLS T S. "Remarks on the results of inhalation of ether considered that most fatalities attributed to chloroform in 106 cases". Land Med Gaz 1847; 40: 547-549. 5. BURROWS EH. "A in South Africa" were due to the ignorance of the correct technique of

Capetown 1950170-172. on September 28, 2021 using the anaesthetic. Mouat's paper was reproduced in 6. Lancet 1848; 2: 3-4. 1857 in the comprehensive Medical History of the War 7. Med Times & Gaz 1856; 2: 253. published in 1857, thus representing the offical view. 8. Lancet 1851; 2: 396. 9. STEELE D. "Extraction of loose cartilages from elbow Despite such adverse comment it is clear that the ex· joint" Med Times & Gaz 1853; 2: 391. perience in the Crimean War resulted in acceptance of 10. MITCHELL 1. "Case of amputation at thigh" Med Times general anaesthesia in military practice. Meanwhile in the & Ga, 1853; 2: 105·106. 11. L IDDELL 1 . "On {he medical preparations for naval action, navy, without any opposition or discussion, the and on the casualties at the Battle of Navarino, 1827" Med anaesthetic had come to stay. Times & Gaz 1854; 1: 312-314 et seq. J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from

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12. CANTLlE N. "A History of the Army Medical Depart­ 16. SMITH GP. "On military medical practice in the East" ment" Edinburgh 1974; 11: 40. Lancet 1855; 1: 648. 13. "Times" Oct 12th 1854. 17. OSBORNES G. "Scutari and its Hospitals" London 1855. 14. (Memoir of Mackenzie) Monthly J Med Science 1854; 19: 18. Report on Crimean Medical and Surgical Society Med 474-478. Times & Gaz 1856; 2: 225-228, 252-254. 15. Med Times & Gaz 1854; 2: 671.

Footnote: For the general background to this paper free use has been made of KEEVIL J J, LWYD C, COULTER J L S. "Medicine and the Navy" Edinburgh 1963 Vols. l/-IVand CANTLIE N. HA History of the Army Medical Depart­ ment" Edinburgh 1974 Vols. loll. by guest. Protected copyright. http://militaryhealth.bmj.com/ on September 28, 2021