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Annals of the Royal College of Surgeons of (I975) vol 57

The injuries of four centuries of

Surgeon Vice- Sir James Watt KBE QHS MD MS FRCP FRCS Medical Director-General (Naval), Ministry of Defence

Introduction bowl. The College of Surgeons, after its foun- In the year I540 Henry VIII was persuaded dation in i 8oo, continued to examine surgeons by his Serjeant-Surgeon, Thomas Vicary, to on entry to the Royal until I 843', found the Company of Barber-Surgeons and when the link was severed until happily re- thereby control the practice of the art, an stored in I964 by the establishment of a joint event commemorated in the fine cartoon chair in naval surgery at the Royal College by Hans Holbein which hangs in the Royal of Surgeons of England and the Royal Naval College of Surgeons of England showing Hospital, Haslar. Thomas Vicary receiving the Charter from the King's hand. The Charter granted by The fighting Charles I in I 629 included a requirement The year I 540 was also of importance to to examine surgeons and surgeon's mates for the for it marked the recom- the Navy. The Court of Examiners sub- missioning of the great ship Henry Grace a sequently assuimed the additional responsibil- Dieu after an extensive reconstruction to ac- ity of reviewing injuries sustained in naval commodate the new heavy ordnance de- actions and allowing the expenses of the cure. veloped through Henry's liaison with Hans The need to do so had been apparent no Poppenruyter, the gun maker of Mechlin, doubt from such unfortunate affairs as that whom Henry, characteristically, omitted to of Sir Martin Frobisher, who, after blockading pay. Similar guns were recovered from the Brest in 1594, had been struck by a ball from wreck of the in I836. They were the of a Spanish soldier which breech-loading, wrought-iron bombards lodged against the 'hucklebone'. It did not built up of longitudinal bars with en- prevent him pressing home the assault, but his circling metal rings, I0 feet in length and surgeon, who had extended the wound to ex- of 8 inch calibre. There were also muzzle- tract the ball, failed to remove the wad which loading brass and , similar had been carried in with it. Gas gangrene ap- to those in use at Trafalgar4, except that the pears to have determined the fatal outcome",2. I8o5 guns were of cast-iron, first introduced The Barber Surgeons' Company played a into England in I5435. key role in the provision of surgeons for the The Henry Grace a' Dieu exemplified the fleet and, in I704, Queen Anne expressed innovation which was a distinguishing fea- her appreciation by the gift of a punch ture of Henry's reign. When first com-

Thomas Vicary Lecture delivcred on 3Ist October I974 4 Sir James Watt

FIG. I 'Embarquement du Roi Henry VIII a' bord du Henry Grace-a-Dieu, I522.' Copy by Bouterwerke, I844, of a painting attributed to Vincente Volpe showing the ship lying immediately beyond the tower prior to her reconstruction. (Muse'e de la Marine, Paris.) missioned in I 5 I 4 she is shown in Volpe's injuries in action were sustained as the result painting (Fig. i) as an impressive but none- of close fights, from the arrows of archers, theless typical mediaeval clinker-built vessel from iron bars, darts, spears, and even stones with ill-assorted armament, depending chiefly hurled from the castles and, after grappling upon the bows of archers and primitive ser- and boarding, from swords, pikes, and toma- pentine guns in her high fore and after castles to rake exposed enemy decks and repel board- ers. Henry's influence, however, can be seen in ports for heavier guns in the ship's stem and side which Henry had compelled his shipwrights to breach against their better judgment. The Anthony Anthony Rolls' show that, on completion of her refit in I540, the Henry Grace a Dieu emerged with two tiers of gun ports and a formidable heavy armament (Fig. 2), the forerunner of the British which was to dictate the tumblehome construction of in order to distribute the weight of their ord- nance and to endure as the principal tactical FIG. 2 The Henry Grace-a-Dieu following of surface ships until the Second her reconstruction. From the Anthony An- World (Fig. 3). thony Rolls, I546. (Magdalene College, Prior to the introduction of guns to ships Cambridge.) The injuries of four centuries of naval warfare 5 in I588, Howard wisely exploiting the handi- ness and greater gun range of his little ships

FM-f=fffml to harry and outsail the Spaniards, conscious Aormp-qr- -m 0 i m m of the danger of close action in which the I I I advantage would lie with the enemy, whose 0, D, high castles were teeming with soldiers. These .:.jjjjjjjjjjFjjp..---.------...... tactics proved successful, for the Spaniards' shot was spent before it reached the English I ships and casualties were few, 'not above one hundred', although Drake's ship was 'pierced with shot above forty times'. 'The greatest danger', wrote Sir Richard Hawkins, 'that, as I remember, they caused to any of our FIG. 3 Midship section of a fourth-rate, shipps, was to the Swallow of her majestie, i684. (.) which I had in that action under my , with an arrow of fire shott into her beake- hawks (Fig. 4). Head and upper extremity head, which we saw not, because of the sayle, injuries therefore predominated, but as no till it had burned a hole in the nose as bigge quarter was asked for and none given, casual- as a man's head; the arrow falling out, and ties were swept overboard into the and driving alongst by the shippes side'7. These there was no need for surgeons. early arrow projectiles were bound in leather to fit into the bore, but were quickly suc- The ceeded by stone, then cast-iron round shot8. The arrival of the gun coincided with the The significance of that incident was not great voyages of discovery and the need to lost upon Wylliam Clowes, who appears to protect English overseas interests. The ship, have been in Howard's , the Ark therefore, became a self-sufficient fighting Royal (Fig. 5), and was no doubt highlighted unit. The first test of British gunnery and for him at Gravelines when Howard sent in seamanship came with the Spanish Armada fireships to drive the terrified Spaniards to

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FIG. 4 A close fight at sea in the 4th century. (MSS ioE, IV. .) 6 Sir James Watt

FIG. 5 The Ark Royal, Howard's flagship in the against the Spanish Armada, I588, bought by Queen Elizabeth from Sir Walter Raleigh. (The Mansell Collection, Lon- don.)

sea in confusion. It is therefore scarcely sur- loading guns with ejection of the hot breech prising, in that Armada year, that Wylliam box, and burn wounds of the body from hot Clowes9 should publish An Approved Practice fragments of exploding cast-iron muzzle- for all Yong Chirurgians concerning Burnings loaders. with . . . Clowes distinguished Burns continued to dominate the writings of between partial and full-thickness skin loss, naval surgeons for the next century. To John using wet, cooling lotions for superficial bums Woodall'0 we owe the principle of enzym- and oily dressings or creams for full-thickness atic debridement and the important instruc- loss, with attention to fluid replacement with tion to 'take away all the powder that sticketh 'boyled water' in the initial stages and to to the flesh, for it hindereth the cure' and to nutrition during convalescence. His results John Moyle"1, who was then describing appear to have been successful and rehabilita- severe contractures following bums at sea, tion was not neglected, for the recently healed the early surgical debridement practised to- bum was gently massaged with egg yolks and day. A century later, however, Blane"2 and almond oil. Turnbull"3 were reporting a high bums mor- tality and it is interesting to speculate that Burns toxic absorption of 'cerussa', a lotion of lead The Armada drew attention to the com- dissolved in vinegar then in general use in plicated nature of bum injuries. There were the Navy as a local application, was respons- superficial flash bums from the accidental ible for this. ignition of powder horns used for priming The enormity of the bums problem was the guns or of loose powder strewn over the even more evident to the enemy as whole . There were localized full-thickness ships' companies disappeared in terrifying bums from sudden bulging of over-heated explosions. L'Orient at the Battle of the brass , bum wounds of the head and threw great burning beams over Alexander face from misfire of wrought-iron breech- and Swiftsure and John Nicol, a seaman in The injuries of four centuries of naval warfare 7 HMS Goliath, describes the scene which met (a cylindrical tin case containing small, loose, his eyes when he went on deck after iron balls), langrage (a tin filled with scrap the action: 'The whole bay was covered and iron bars), and grape or quilted shot with dead bodies, mangled, wounded and (iron balls arranged round an iron column scorched, not a bit of clothes on them except in a canvas bag). They also proved useful in their trowsers'14. Charles McPherson15 records cutting chain plates, stays, and shrouds'7 that, at Navarino in I827, pieces of burning (Fig. 6). wood and showers of burned rice and olives rained in profusion from burning Turkish The number of compound fractures and ships and that 'a Turkish traumatic avulsions of limbs made naval sur- exploded showering iron, wood and nails' geons adept at amputation and, contrary to over the . popular opinion, the arrest of haemorrhage was by forceps or ligation and not by the Ship- and man-destroying missiles red hot cautery roundly condemned by The Dutch of the 17th century provided James Yonge'8 in his Currus Triumphalis from actions at sea which published in I679 while surgeon at the a pattern of injury Naval Hospital, . He also con- changed little during the era and Wiseman"6, writing just after the third Dutch demned the practice of blood-letting, and the war, drew attention to the gross soft-tissue work is noteworthy on two accounts. He de- injuries then being experienced. 'In our sea- scribes controlled experiments in dogs show- fights, oftentimes a buttock, the brawn of the ing the superiority of oil of turpentine over the calf of the are shot the ligature in the arrest of haemorrhage, thigh, leg torn by which and splinters. All these are contused wounds he assessed by measuring clotting times and look black and do often deceive the in- and by microscopic evidence of vessel and he them clot retraction. He also devised a posterior experienced chirurgeon, taking by flap technique for amputation of the lower their aspect to be gangrened.' Going on to limb describe their subsequent course, he observes which, he claimed, accelerated healing that they 'look like flesh long hang'd in the and avoided bone necrosis and ulceration of air, of a dry, blackish colour, yet they have the stump. Another notable improvement in warmth'. They subsequently discharged - amputation technique was the cutting of liga- sive sloughs leaving indolent ulcers and huge tures short, first practised by Lancelot Haire19 at Naval Hos- tissue defects. while an assistant surgeon the Because of its weight and velocity, solid pital, Haslar, in 1786. round shot became the principal ship-destroy- The British usually double-loaded with ing projectile. It also splintered and solid shot and grape or canister with the ob- masts to provide secondary anti-personnel ject of smashing the enemy's hull and killing missiles. Double-headed bar, telescopic, and or wounding her gunners. They therefore chain shot were intended to cripple enemy fired on the downward roll, while the enemy, sailing power, but were not much favoured intent on immobilizing the British ships, by the British because of their inaccuracy. aimed bar and chain shot at yards or rig- They were, however, responsible for many of ging on the upward roll20. These different the injuries sustained by British seamen aloft tactics, as we shall see, were to determine the or on the exposed upper deck. Primary man- different casualty patterns of the combatants destroying missiles were canister or case shot in the wars with . 8 Sir James Watt

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FIG. 6 Shot used in naval cannon during the sailing ship era. (H Tomkins after an illustration by R Wood- -111j~~O_Shot-l.J ward.)

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Round shot Round shot, of course, while, if the shot grazed the abdomen, it was the most mutilating, causing dismember- could prove instantly fatal without the least ment and evisceration. McPherson2" de- mark of injury24. John Nicol25 describes a scribes how, at Navarino, he saw a mid- typical case at the : 'One shipman knocked clean out of the top, hang- lad who was stationed by a salt-box, on which ing by the intestines from the boat's davits, he sat to give out cartridges, and keep the and Gardner22 recalls that 'one of our poor lid close-it is a trying berth-when asked fellows was cut in two by a double-headed for a cartridge he gave none, yet he sat up- shot on the main deck, and the lining of his right; his eyes were open. One of the men stomach (about the size of a pancake) stuck gave him a push; he fell all his length on on the side of the launch'. A similar fate be- the deck. There was not a blemish on his fell de Brueys in L'Orient, his flagship at the body, yet he was quite dead, and was thrown Nile, when a shot carried off both legs. He overboard'. Dillon2" tells how he was had himself placed in an armchair on deck knocked unconscious at the Battle of the with tourniquets on both stumps until a can- in just such a man- non ball cut him in half23. ner and in the painting by Mather Brown of that battle (Fig. 7) Sir Andrew Snape 'Wind of a bail' An injury which Douglas (far right) is swaying unsteadily, greatly puzzled the naval surgeon was what temporarily concussed by a near miss, while he described as 'wind of a ball' or the near Neville of the Queen's Regiment miss of a cannon ball which caused the (right centre) is shot through the chest and affected part to become 'livid and benumbed' mortally wounded. The injuries of four cenlturries of naval warfare 9

FIG. 7 Lord Howe on the quarterdeck of the Queen Charlotte at the Battle of the Glorious First of June, 1794. (Painting by Mather Brown in the National Maritime Museum.)

Grape shot Patrick Renny, surgeon of pale and said "Oh Sir, it is my right arm". the Coventry at the Battle of Quiberon Bay, He was taken below and the arm amputated, I 759, describes his visit after the battle to but the next day Dr Hillyer found the bone the French prize Formidable, whose star- splintered higher up . . . and it was taken board side had been 'pierced like a cullender' out of the socket. . . At the naval hospital, by British shot. She had over 500 casualties , he had lockjaw but got over it'. and the grand chamber was strewn with Robert Mercer Wilson29 in his journal de- wounded officers, tourniquets still screwed on scribed the action in the Bay of in amputation stumps, and every space below June I809 between the French Ceres decks crammed with wounded soldiers and and the English ship Cyane where 'the grape- sailors. Renny was asked to advise on the shot flew like hailstones' and Ce'res had over wound of an officer caused by grape shot 50 men killed. Descamps, who accompanied which had penetrated the thigh, fractured Murat on his visit to the ship after the ac- the femur, ballooned the scrotum, and carried tion, graphically depicted some of the in- away the rectum with the buttock27. This juries in a painting which hangs in the Musee was unusually severe, and those who survived de la Marine, Paris (Fig. 8). The surgeon is grape-shot wounds more often sustained dressing a sucking wound of the chest with localized compound fractures of the ex- a pad and bandage, a barrel bandage has tremities. been applied to a fractured jaw, and there Boteler28 at Navarino describes a typical are a grave abdominal wound and head case: 'Young Grey . . . was in the act of wounds. It was following this battle that giving the Captain of the Gun some grape- Murat told : 'C'est le premier shot, when he turned round, laughing to see de marine que j'ai vu et j'avoue qu'il the grape scattered on the deck. I saw what ne faut pas etre moins brave sur mer que it was, and he too directly also. He turned sur terre'. Io Sir James Watt

FIG. 8 Painting by Des- camps who accompanied AMurat (centre) on board Ceres after her battle with Cyane in the Bay of Naples, 27th June I809. (Musee de la Marine, Paris.)

Splinters Hutchinson30, writing at the fleet which, in times of war, remained at end of the , draws a distinc- sea for long periods. This led to a number tion between the localized wounds from of complications such as generalized oozing grape shot and musket balls inflicted by con- from amputated stumps, adding greatly to fronting armies and the extensive injuries the anaemia resulting from initial blood loss. caused by a direct hit from the round shot Cumming32 appears to have treated a num- of a ship's cannon or by 'ragged fragments ber of patients with this complication after of timber violently rent from the planks or in I8oi and was compelled to sides of the ship'. He adds, 'wounds inflicted use graduated tow compresses and firm roller by splinters of wood are always more exten- bandaging to control bleeding from the sive, accompanied with frightful contusions stumps. A greater problem, however, was the and lacerations of the soft parts', and Wise- traumatic ischaemic contracture resulting man31 had pointed out that even if the splin- from collections of blood below the deep ter had insufficient velocity to cause a wound fascia, often confused with gangrene. Amputa- 'it sometimes bruiseth the skin to the flesh tion usually resulted, although Tumbull33 so forcibly as to extinguish the naturall heat attempted to treat the condition by burying and make it black', producing an eschar the limb in earth-perhaps the original mud which would separate to leave an indolent pack! Hutchinson34 finally recognized the ulcer, possibly of 'Meleney' type, and finally true nature of the condition, which he called an ugly scar. A painting by Drummond of 'erysipelas phlegmonodes' and distinguished the Battle of Camperdown clearly displays it from 'erysipelas oedematodes', which hypertrophic and keloid scars in seamen of seems to have been gas gangrene. He rightly the period (Fig. 9). adduced the stiffness and rigidity resulting The extensive contusions and blackened, from the former as due to adhesion between unhealthy nature of wounds, to which fre- the muscles, tendons, and their sheaths as the quent reference is made, was due largely result of effused blood and, at the naval hos- to the prevalence of scurvy in the British pital at Deal, practised multiple incisions The injuries of four centuries of naval warfare I I Boarding The of Barfleur and La Hougue in I692, which frustrated the attempt by the ex- iled James II to invade England with the help of the French fleet, contained all those ingredients of naval actions to provide the broadest possible spectrum of injury. At Bar- fleur Tourville was decisively beaten by Shovell's superior gun power and, under Rooke, an arm.ada of 200 small boats from the British fleet swept into La Hougue har- bour two days later, in the face of murderous fire from the protecting batteries, to board and fire six French three-deckers and set the harbour ablaze. No doubt with that episode in mind John Moyle3" wrote his Chirurgus Marinus, for it turns out to be a description of the cockpit of a man-of-war and a case book of injuries dealt with by the surgeon and his mates, typ- ical of just such an action. The chief interest is in wounds sustained by boarding parties from cutting or hacking and small arms such as muskets and pistols (Fig. io). The typical cutlass wound is described as an FIG. 9 Detail from a painting by Drum- oblique incision across the wrist dividing ves- mond of the Battle of Camperdown, iith sels and nerves and requiring immediate su- October I797, showing large keloid scars ture which must avoid picking up nerve or of left forearm and shoulder in a seaman tendon. Wounds from the tomahawk carried aboard the Venerable, of Admiral by boarding parties were confined to the head flagship cheek from Duncan. (National Maritime Museum.) and face and might slice the away the bone. Pikes were commonly run through the chest and, if they missed vital organs, left through skin and deep fascia followed by a track which required daily syringing and gentle massage and active movements. His adequate drainage. A rapier or the bullet of patients all recovered, free from infection, a pistol often passed through the throat, re- quiring through-and-through drainage with with full restoration of function. He was over haemorrhage difficult to control unless the I00 years ahead of his time, although John blood pressure was dangerously lowered by Moyle"5 had recorded a similar surgical ap- blood-letting. proach in a single case of subfascial haema- Among contemporary accounts of boarding toma which formed in the leg of a sailor episodes Wilson37 describes how sailors from caught in the bight of a cable over i oo the frigate Unite boarded Turkish vessels in years previously. the port of Durazzo in the Adriatic through 12 Sir James Watt

FIG. I 0 'Progress of a '. Cartoon in the National Maritime Museum of pirates board- ing one of HM ships.

a of grape shot and musketry, run- following a violent fit of coughing, he ning the enemy through with their boarding 'brought up part of a check shirt and flan- pikes, normally a defensive weapon. Boteler"8 nel waistcoat after which he daily continued recalls that, at Navarino, the spritsail better'. of a Turkish frigate crossed Albion's poop. But height also had its problems and con- Immediately the first lieutenant led a party tributed to the casualty list. Apart from ac- of volunteers with swinging cutlasses and the cidental falls in relatively fit men aloft there butts of marine muskets to sweep the deck were problems for the wounded seamen of Turks, who continued shooting from be- reaching the deck below. Stenhouse40, surgeon low until the boarders seized cannon balls of the Glasgow at the Battle of Algiers, de- and rained them down upon their hapless scribes the case of the captain of the fore- victims. A Turk in the foretop picked off top who had his leg carried away by a the arm of the boatswain with a musket shot cannon ball except for a strip of tissue by and three British sailors sprang nimbly up which it was attached. He grabbed a rope to the and threw the Turks overboard. lower himself on deck, but half-way down Later the surgeon of Albion came across a his flail limb became entangled among the Turk who had apparently followed the board- rigging and he was obliged to pull himself ers back. He was dying from a typical toma- up with his arms and disengage the wounded hawk wound which had sliced through the limb with the assistance of the sound one. He occiput. Height was still, on occasion, as im- then quietly descended on deck and reached portant as in the old castellated ships. Nelson the cockpit at the moment when the bugle- was shot through the chest at Trafalgar by man's wife, who was attending the wounded, a marksman in Redoubtable's top (Fig. iI), heard her husband had been killed by a and a similar injury befell a mariner in cannon ball. The wounded seaman was quick Ardent at Camperdown in I797 but with a to comfort her: 'Come on, Poll', he said, happier result for, according to Young39, the 'cease to grieve; you shall not remain a widow ship's surgeon, about a month afterwards, long'. And he kept his promise! The injuries of four centuries of naval warfare I 3

FIG. II Victory at Trafalgar I805 by Dighton (National Maritime Museum). Nelson wounded by a bullet from a rifled musket fired from the mizzen-top of the French flagship Redoubtable which penetrated the left lung and injured the left pulmonary artery and spinal cord. Accidents most fainting from fatigue, he struggled man- Throughout the sailing ship era accidents fully through the amputations in the stiflingly continued to contribute significantly to the hot atmosphere when, he writes, 'an explosion casualty rate. A typical incident is related by of a salt box with several cartridges abreast Samuel Leech4' in his account of the battle of the cockpit hatchway filled the hatchway between the Macedonian and the American with flame and, in a moment, fourteen or frigate in I8I2. A powder boy fifteen wretches tumbled down upon each on the quarter deck was killed when 'his other, their faces black as a cinder and clothes powder caught fire and burnt the flesh almost torn to shatters and the rags on fire . . .' off his face. In this pitiable situation the There were 4I killed and I07 wounded out agonised boy lifted up both his hands, as if of a ship's company of 485, a casualty rate imploring , when a passing shot instantly of 30.5%. cut him in half'. Such accidents also led to Blane42 informs us that 'in the battles of mass casualties. At Camperdown (Fig. I 2) I780 and I78I, one-fourth part of the whole Young39, surgeon of the Ardent and without killed and wounded was from the explosion an assistant, found himself dealing with go of gunpowder; but on the gth and I 2th casualties piled one upon the other at the April 1782 (Battle of the Saints), only two of the ladder leading to the cockpit. Al- accidental explosions of gunpowder happened 14 Sir James Watt

FIG. I 2 Battle of Cam- perdown, I797, by Wil- liam Huggins in the Army and Navy Club, Pall Mall, . The of Ardent can just be seen in the background, left of centre.

in the whole fleet, by one of which, one life fleet in 1779, often set on fire the ship's own was lost, by the other, two'. He attributed and rigging. Albion was twice set on this to the better training of guns' crews and fire by her own at the Battle of safety measures introduced by Sir Charles Navarino, and Boteler44 records that all gun- Douglas. They included wetting the wads ners invariably overloaded, 'nearly always which, when the weather side of the ship with two shot, sometimes with three'. One was engaged, used to blow back and ignite was even found with four round shot. Not the gunpowder, replacement of the large ox surprisingly 'the guns were very lively spring- horns which held the loose powder by goose ing back from their breachings and jumping quill tubes, and small priming boxes. It was off the deck'. When a hide lanyard broke, Douglas, too, who first used gun locks at sea, which fired the flintlocks then in use, Mid- which increased operational safety. shipman Boys jumped to the breech and The mishandling of guns was the other pulled the trigger, only to be struck in the main cause of accidental injuries. According stomach by the gun's violent recoil. Though to Inman43 too great a charge and over- he was 'long unconscious', the surgeon could loading of guns caused straining of the car- find no trace of external injury. The casual- riage, breaching, tackles, and side bolts and ties resulting from such incidents were by increased recoil, while overheating resulted no means insignificant, for Edward Daubeny, from the rapid rate of firing achieved by the in a letter to his father from HMS Bellona highly efficient British gunners. Failure to after the Battle of Copenhagen in I 8oi, ram home the shot on the head of the cart- writes that 'we have besides above eighty ridge in the heat of action caused the gun killed and wounded by the bursting of our to burst or to be dismounted. There is abun- guns'45. Midshipman Anderson, who was also dant evidence that all these factors operated on board Bellona, explains the sequence of in sea battles and caused numerous burns, events in wlhich he himself was injured by wounds, and fractures, while shot fired from shrapnel from one of them4". Although only the short muzzles of the deadly British car- a soft-tissue injury, the surgeon, evidently ronades or 'smashers', introduced into the from long experience, warned him that it The injuries of four centuries of naval warfare I 5 would be three months before he fully sel and 26.3% in the English), the ratio of recovered. killed to wounded amongst the French was I: I but among the English it was I :4, an indication of the destructive potential of the British and the fighting qual- The explosion of guns had a disastrous effect ities of the British seaman in hand-to-hand upon the morale of the ship's company47. encounters. When one of the I 2-pounder guns burst in Entanglements, of course, were inevitable the British frigate Ambuscade while engaging in close engagements, yards and rigging often the French Bayonnaise in December locked inextricably, a fate which befell I 798 I I men were wounded and the ship seri- Seraphis off Flamborough Head in 1779 ously damaged. The French, who had already when she engaged the Bonhomme Richard suffered heavily from the English broadside, commanded by the American privateer, John rammed Ambuscade (Fig. I 3) and French Paul Jones. The two ships found themselves soldiers swept her deck with musketry. Five bow to stern, gun muzzle to gun muzzle, officers were killed or wounded by bullets and which drove Jones's men from their guns to the purser took command. At that moment the tops, while the i8-pounders of Seraphis an explosion of cartridges on the head blasted through their own closed gun ports blew out Ambuscade's stern and so demoral- to reduce the American's hull to shivers and ized the crew that French boarders were able set her own starboard side fiercely ablaze. to charge across the spritsail yard to carry After boarding and counter-boarding, height Ambuscade's deck. Yet such was the destruc- again proved useful to an American seaman tion wreaked upon the French vessel that who climbed out along his own yard to drop the captured English frigate had to tow its a bucket of hand grenades down the main captor back to Rochefort! Casualty statistics hatchway of Seraphis and into her gun are revealing for, while the casualty rates room, where they caused a violent explosion were comparable (24.0% in the French ves- which ran aft between the rows of guns, dis-

| , _ i FIG.,f I3< The. French. Nthcor- vette Bayonnaise ramming and boarding the English igate Ambuscade December I798. (Painting by L-Ph Crlpin in the Muse'e de la Mar'ine Paris.) i 6 Sir James Watt abling, five and scorching and wounding 38 board the various ships and persuaded the men48. The Americans, taking advantage of Commissioners for Transports to send a ques- the dismay and shock, rushed the deck of tionnaire to each of the surgeons asking them Seraphis to win the day, although Bonhomme to specify the number and nature of wounds Richard was so battered that she soon sank. requiring amputation, whether amputation The casualtv rate was 38.4% in the victorious was immediate or deferred, the duration of Bonhomme Richard and 48.8% in Seraphzs, delay in minutes, hours, or days, the num- with a killed to wounded ratio of 2 :3 in both ber who recovered or died, and the period ships, indicating comparable standards of of survival. gunnery and fighting qualities. What emerged was interesting. By far the Sir Gilbert Blane49 in his Health of the greatest number (83%) had been injured by Royal Navy considered that the superior cannon shot and only 8.5% by splinters and physique, courage, and discipline of the 8.5% by musket balls-no doubt indicative of English seamen gave them the edge over the the effect of high-velocity round shot from French in close action, where more shot were the cannon of the defending forts. The sur- effective. He gave the ratio of killed to geons who practised immediate amputation wounded in the French wars as I :3, but not only dealt with more serious injuries but varying according to distance and the charge also carried out more amputations per pa- of powder. This observation is borne out by tient, yet their mortality rate (33.3%) was casualty patterns in six of the major battles significantly lower than that of the delayed of the Nelson era for, while the casualty rate group (45.8%) (Table II). Moreover, two varied considerably, the ratio of killed to deaths in the immediate group were caused wounded remained at about I :3 (Table I). by conditions other than the amputation. Hutchinson50 made important recommenda- tions for amputation, including obliteration The Battle of Algiers of dead space and transverse closure of the This interest in casualty patterns is exem- stump instead of the usual vertical closure, plified by Hutchinson's50 well-documented which tended to open an infected track in- record of the Battle of Algiers in I8I6. He feriorly. Although 'the locked jaw' was a com- was struck by the marked difference in mortal- mon and usually fatal consequence of wounds ity rates following amputations performed on in action, Hutchinson"0 records only one case, TABLE I Casualty patterns in six major battles in the Nelson era involving ships of the line (I794-i805) Battle Force Killed Wounded Ratio Casualty killed:wounded rate (%) First of June, 1794 I7 241 287 8ii 1:3 6.37 St Vincent, 1797 I I 046 73 227 I :3 2.72 Camperdown, I 797 8221 203 622 1:3 10.03 The Nile, I 798 7985 2I8 678 1:3 11.22 Copenhagen, i80i 8565 253 688 I 3 I0.99 Trafalgar, I 805 17 772 449 1242 13 9.51 Total 70 830 I483 4268 1:3 8.12 The inljuries of four centuries of naval warfare I7 probably because of the low incidence of o l l l | ^ , ^ | cz splinter wounds, but at the Saints Blane5' states that 15 of 67 wounded seamen who died on board their ships after the battle died l l l from tetanus and that some surgeons held that ligatures were responsible and so pre- ferred the 'tenaculum'. C4I - Cs - End of an era 1-i < gD - ~~~I I Ie CX e Wilson52, writing at the end of the sailing I ship era, paints a picture of the cockpit little different from that of Moyle in I69336: 'Death and wounds in every shape, limbs lacerated or torn off-wounds from muskets -< - - - X ^ or splinters bayonet or cutlass wounds, everything, in short, appalling or horrible and all, probably, in a few minutes, in the midst I<,I >> o > X ^ n of bustle, the noise of guns, the close atmosphere and . . . candlelight'. This caused him to propose a system of sorting of casual- > I I I o I l l l l ties into three categories-slight, serious, and LO fatal. His recommendations have a strikingly i<,, modern ring for he argued that immediate life-saving surgery could be brought to severely injured casualties only if treatment ;4 t + ~ > > ~ ^ O > for slight injuries vas deferred and only pal- liative measures adopted for injuries likely to prove fatal. Had this advice been followed I:; - -^ in the century of the iron it would have saved many more lives. Before leaving the age of , however, it LO , +^sis_necessary> + to pay tribute to two other naval surgeons-David Fleming, who carried out the first successful ligation of the common on board HMS Tonnant in Ln > + ~co co carotid artery i 8o3, and Ralph Cumming, who in i8o8 performed the first successful forequarter amputation at the Naval Hospital, Antigua"4. To these names, I believe, should be added 03wO>ris . i X that of James Lind55, the most illustrious of -e A XE them all, who conquered scurvy and pro- EU(3 ¢ G? E U w claimed the principles of hygiene which pro- vided captains with the fit men they needed 8 Sir James Watt to win their battles. Blane" considered that in the tturret surviving". This led to a return over 6,ooo lives lhad been saved each to breech loading with its attendant acci- year by these measures. Lind was a remark- dents-hands jammed in the breech or men able man and two of his inventions, had struck by parts of the mechanism. they been accepted by the Admiralty, might Accidents in the new engine and have revolutionized naval warfare of that era. rooms pointed to a high incidence of burns They were distillation of water at sea and from burst or fractured steam pipes. of guns'. When one of the boilers burst in HMS Thunderer in I876 I3 men were killed and The age of transition 49 admitted to the Royal Naval Hospital, The Battle of in I862 be- Haslar, with what Fleet Surgeon Harkan"9 tween two mastless ironclads, the converted described as 'the most severe scalds that could Confederate frigate Merrimack and her tur- possibly be sustained, the skin being mostly retted Federal opponent , proved dissected away and hanging in flaps about the value both of plate and the re- their body; face and eyelids completely de- volving turret. Britain, quick to learn, stroyed in the majority of cases and many launched the first mastless , HMS sinking rapidly uinder the shock'. A similar Devastation, in I87I, the forerunner of all catastrophe befell the Bullfinch in subsequent warship construction, her four I899. While she was travelling at 30 knots muzzle-loading I12-inch guns firing 700-lb a high-pressure connecting rod broke, the cyl- shells supplied to the steam-revolving turrets inder fractured, and a bolt was shot through by the Armstrong hydraulic system. the bottom of the ship. Eleven men in the By the end of the century naval surgeons compartment were scalded to death60. Burns had had enough experience of the new ship remain one of the most serious injuries in construction to recognize the nature of the modern . hazards to which men would be subjected in action. The piercing power of the had The First doubled to expose men, now concentrated in The Medical Director General of the Navy the confined spaces of turrets and their sup- ply routes (Fig. 14) and in the new engine and boiler rooms, to splinters of steel, blast from explosions, and the disintegrating forces of a direct hit. Men would now be hurled against steel bulkheads and projecting machinery or struck by detached components acting as secondary missiles. Rivets might be stripped and their heads showered over the ship's compan7y5 and, in HMS Furious, this even occurred when she fired her own i 8-inch guns. Guns could still misfire but with far worse consequences, and when a I 2-inch FIG. I4 Carrying an injured sailor from the gun muzzle exploded in HMS Thunderer, upper battery of HAIS Alexandra during the to Devastation, in I879 nine men of , i88i. (Well- were killed and 35 injured, only one man come Institute of the of Medicine.) The injuries of four centuries of naval warfare I9 at the outbreak of war in 1914 found the wounds and burns received in action became prospect of casualty management so daunt- septic because, in those coal-burning ships, ing that he recommended nothing more than 'patients are in an indescribably dirty con- first aid during action and the landing of dition, in spite of . . . donning clean clothing casualties immediately afterwards"', a return before action.... The mess decks and accom- to mediaeval folly which disregarded entirely modation passages are covered with one to the lessons of Algiers and the observations twelve inches of water; the men are con- of Wilson that immediate treatment saved stantly splashing through this; they are hot lives. At Jutland Sir David Beatty watched and perspiring; the consequence of being with mounting apprehension as three of his struck by a shell is clouds of dust and smoke lightly armoured battle blew up when . . .clothing is scorched'. German shells struck their turrets, igniting cor- Ash and Wakeley"7 described the com- dite, the flash froin which shot down to the pound fractures with huge muscle defects, magazines, which exploded. The Germans reminiscent of sailing ship days, in patients had already learnt the lesson at Dogger Bank admitted to the Royal Naval Hospital, South the previous year and the gunpowder detona- Queensferrv. They included patients suffer- tors of their cordite bags were protected in ing from nitrous fumes which resulted from brass containers"', a precaution that might incomplete combustion of cordite. The mix- have helped save the Hood from a similar ture of oxides of nitrogen so formed reacted fate in I941"3. HMS Lion, Beatty's flagship, with the moisture of the respiratory tract was hit on the midship turret and, according to form nitric and nitrous acids, leading to to Surgeon McLean"4, there were I46 fatal pulmonarv oedema, and oxygen does casualties, a casualty rate of i I.9% of Lion's not appear to have benefited the condition"'. complement and a ratio of killed to wounded Fairlie"" drew attention to the latent period of nearly 9: i, a reversal of that in sailing before the onset of symptoms and recently ship days. Delay in treatment nevertheless Hampton7" has shown that smoke in the cost some lives. Sixty-four of the 95 killed closed compartments of ships causes similar and 30 of the 51 woulnded were burned, and complications, even in the absence of fire. McLean distinguiishes between the superficial Carbon monoxide was, of course, the other flash burns of survivors and the severe cordite accompaniment of explosions and fires in con- burns of the fatally injured, which were asso- fined spaces which Ellis7' has shown was asso- ciated with chest complications. Twenty-five ciated with damage by torpedoes in both per cent of casualties sustained fractures and world wars. 45% soft-tissue injuries, 54% had been in- The treatment of burns dominated naval jured by splinters-now jagged metal and medical literature after the Battle of Jut- in 27% wounds were multiple. land, and Wakeley72, then a surgeon lieu- The action over, McLean and Stephens"' tenant, established sound principles based rigged a temporary operating theatre in the upon the extent and depth of the burn. He captain's bathroom and undertook lifesaving used intravenous and subcutaneous electrolyte surgery using Listerian antiseptic principles solutions for fluid replacement and exposed his on 28 anaesthetized patients, glad of the assist- bums to the open air, condemning picric ance of an executive lieutenant since 44%, acid, the local application popular at the of the medical staff had been lost. Fleet Sur- time, as toxic and locally destructive. He geon Muir"", of HMS Tiger, explains that practised early skin grafting and prescribed 20 Sir James Watt urinary antiseptics, vaccines for persistent infection, and digitalis to support the heart, with excellent results. His principles were years in advance of contemporary thinking and it is noteworthy that Pearce-Gould and Archer", who were also temporary naval sur- geons, described the cutting of skin grafts under local and regional anaesthesia, a tech- nique 'rediscovered' after World War II. It was also a suirgeon who proposed preventive measures; Penfold"4 recommended the wear- ing of fire-proofed anti-flash masks and gaunt- m~~~~~~~~~~~~~~~~~~~~~ ... s lets by guns' crews, which appears to have FIG. 15 Attack on the Bismarck with the been somewhat tardily adopted by the author- Dorsetshire in the background. (C E ities. However, this was standard practice in Turner, Illustrated London News.) World War II and, where followed, signi- no protection to the wearer, peaked the ficantly lowered the incidence of burns. casualty rate in some instances. In the Scharnhorst action of November I943 anti- The Second World War flash gear was not worn by the crew of 'X' In the Second World War ships had become turret in the cruiser Norfolk, all of whom more technically complex and electronic aids suffered severe burns, but at the Battle of had assisted naval gunners to pinpoint their the Plate in 1939, although HMS target, but surface actions brought little Exeter took tremendous punishment and had change in the pattern of injury, with the a casualty rate of nearly 23%, with good solitary exception of burns. This can be attri- protection burns were minor. What did buted directly to the effectiveness of protective change in surface actions was the more clothing, although too often the tropical uni- favourable rate of killed to wounded (Table form of shorts and shirt, giving absolutely III), which can be attributed to a return

TABLE III Comparison of casualty patterns resulting from sutrface actions in World War II and Fractures Wounds Burns Multiple Shrapnel Casualty Killed: (%) (%) (%) (%) (%) rate (% wounded complement) ratio World War II- surface action 11 (D) 25.5 32.7 3.6 21.8 47.3 6.25 I:I Onslow (D) 8.3 70.8 - i 6.6 100.0 7.74 2 3 Exeter (C) 41.5 36.6 17.7 29.3 63.2 22-59 2:3 Ajax (C) 6.6 93-3 - 20.0 I00.0 2.42 1:2 Norfolk (C) 30.2 34.9 34.9 20.9 48.7 8.o 1:5 World War I- Jutland Lion (B) 25.5 45.1 56.8 27-4 54-9 1 1.9 9:I B = battleship, C = cruiser, D = destroyer 7The injuries of four centuries of naval warfare 2 I to the principle of immediate resuscitation Burns and blast injury were surprisingly rare. and surgery for the seriously injured, and The ratio of killed to wounded was approx- ships were far better equipped to do it. For in- imately i: i. That was also generally true stance, HMS Warspite received 59 casualties of attacks, but in both cases gas from in the second Battle of Nar- poisoning appears to have been a not un- vik (I 940). Resuscitation by intravenous trans- common accompaniment. For instance, in fusion and X-rays of injuries were carried H'MS Phoebe casualties suffered from nitrous out prior to operation on board the battle- fumes, in HMS Albatross from nitrous, car- ship and Beaton, her principal medical bon monoxide, and carbon dioxide poisoning, officer, even illustrated the X-ray appearances and in HMS Stevenstone from fumes of in his journal. Four casualties died almost im- methyl chloride resulting from damage to the mediately, buLt all the rest were transferred to ship's refrigeration system79. a I 2 days later in very good Air attack, however, changed the whole shape75. character of . Surgeons in World Deaths continued to occur from nitrous War I had brief, intensive periods of activity fumes, toxic smokes, and carbon monoxide and prolonged inactive intervals. The sur- poisoning. Desmond and Frazer76 described geons in World War II, particularly if a cordite explosion in a . The accompanying Atlantic, Mediterranean, or survivors reported that after the gun had Arctic convoys and later in the Pacific, lived fired flames shot from the breech when it under constant threat of sudden unexpected was opened, filling the turret. There was an air bombardment which might be continued orange-red, intensely hot, central core sur- for days on end. The effect of a rounded by a multicoloured aura which bomb between decks was devastating, frac- merged into a peripheral zone of fine particu- tures and blast injuries predominating, but late smoke. Sailors in the central core were splinters from near misses would strike the severely burned and those in the outer zone ship some 20 feet above the water line and suffered toxic and respiratory complications even penetrate the ship's side, causing mul- after a latent interval of 2-24 hours. Ellis71 tiple shrapnel wounds from the waist up'o. reported Haines's description of the lung his- The carrier Illustrious was under al- tology in such cases: acute vasodilatation, most continuous bombardment in the vicinity ruptured lung alveoli, and eosin-staining, of Malta from i oth to i gth January 194 I coagulated oedema fluid in some alveoli, sim- and sustained 276 casualties, of whom I48 ilar to appearances reported in the traumatic survived. Her principal medical officer, wet lung of Vietnam casualties. Wakeley77, Keevil81, whose magnificent action medical now a surgeon rear-admiral, understanding organization undoubtedly reduced the mortal- the significance, treated his burns cases with ity rate, described in his journal the great cortisol, and Surgeon Lieutenant- severity of wounds complicated by blast from John Bunyan78 invented the envelope method bursting bombs, although burns were minor of treating burns. because of the enforced use of protective Two new factors in World War II were clothing. One precaution he did not take, the magnetic mine and air bombardment. however, was to guard against damage bv Mines produced a characteristic pattern of broken glass in the sick bay, a danger to injury, with simple lower extremity and which Wilson82 had drawn attention in I846. lower dorsal spine fractures predominating. Keevil's description of the dismemberment, 20 Sir James Watt evisceration, death, and destruction in the Epilogue hangar is analogous to that on the gun deck Mr President, you have done me the honour of HMS Genoa after the Battle of Navarino of electing me Thomas Vicary Lecturer. It in I827 described by Charles McPherson ', is also an honour for the Service I represent. and it is interesting to note that Genoa's I hope therefore that the contributions made killed to wounded ratio ran contrary to the by naval surgeons during four centuries of usual pattern and was I: i, like that of niaval warfare have been such as would have Illustrious. won the approval of Thomas Vicary and his colleagues, Thomas Gale and Wylliam Toll of the sea Clowes, a naval surgeon himself, who to- Yet, when all is said and done, it is the cruel gether founded the school of English surgery. sea itself which takes the greatest toll. The In my search for historical details I havc reccivecd Spanish Armada survived disease amongst its help from sources too numerous to mcntion, but crews, it escaped from the English in the sevcral individuals have made my task casicr. They Channel, it survived the fire ships at include Miss V Riley, of the Naval Historical Library, Mr D V Proctor and Mr A W H Pearsall, Gravelines, yet when a south-west gale drove of the National Maritime Museum, Mr E H Cor- the proud into the over nelius, Librarian of the Royal College of Surgeons, half the vast Armada was lost. Lcwisxi has Mr S Watkins, of the Wellcome Institute of the pointed out that in the wars with France History of Mledicine, Mr C T Parsons, Librarian, Royal Naval Hospital, Haslar, Mrs J Reynolds and from 1797 to I805 only io ships were lost Mr H 'romkins of the Institute of Naval Medicine, as the result of enemy action, while no less M-iss J Orman, of the Department of the Medical than 9I foundered or were wrecked. If we Director-General (Naval), and Capitaine de Vaisseau Paris. now exclude from the Jutland casualty figures Herve Cras of the Musee de la Marine, ships that were sunk during the action, the References casualty rate is reduced from I I.14% to I,ediard, T (I735) The NavJal History of Eng- o.83% and the ratio of killed to wounded land, vol I, p 308. London, John Wilcox. 2 McFee, W Sir Martin Frobisher, 267- from 9 to 3 In II (1928) PI) i :-. World War Talbot"4 268. London, Bodley Head. concluded that approximately two-thirds of 3 Lloyd, C, and Coulter, J L, S (I963) Medicine all fatalities in ships of the Royal Navy re- and the Navy, vol 4. p 23. Edinburgh and sulted not directly from injuries sustained London, Livingstone. during enemy action but from failure to sur- 4 Popc, D (i969) Guns, p 6i. Londoni, Hamlyn. 5 Oppenheim, M (I896) A IIistorv of the Admin- vive the marine environment8'. Survivors may istration of the Royal Navy, p 96. London, have absorbed oil and detergents into their Bodley Head. lungs in the vicinity of the ships, blast in- 6 The Anthony Anthony Rolls (1546) Magdalene juries of abdomen and lungs certainly resulted College, Cambridge. from depth charges exploding in the area, but 7 Hawkins, R (I593) in The Hawkins Voyages (I878), ed. Markham, C R, pp 222-223. London, we nowr know that hypothermia accounted Hakluyt Society. for the majority of the lives lost. It is towards 8 Wilkinson-Latham, R (I973) British the prevention of hypothermia and the effects on Land and Sea, I790-I820, p 24. Newton of noxious gases in closed compartments that Abbot, David and Charles. 9 Clowes, W (1588) An Approved Practice for all attention must now be directed if lives are Yong Chirurgians concerning Burnings with to be saved in future conflicts. Gunpowder, ist edn, pp 2-5, 59. The injuries of four centuries of naval warfare 23 io Woodall, J (1617) The Surgeon's Mate, Ist edli, 30 Hutchinsoni, A C (I8I6) Some Practical Obser- pp 145-I46. vations in Surgery, Ist edn, p 22. ii Moyle, J (i693) Chir-urgus Marinus, Ist edll, 31 Wisemain, R (I686) Several Chirurgical Trea- pp 48, 49, 96-98. tises, p 408, London. 12 Blane, G (1799) Observations on the Diseases 32 Cumming, R (I804) Aledical and Physical Jour- of Seamen, 3rd edn, pp 578-579. nal, p 390. 13 Turnbull, W (i8o6) The Naval Surgeon, Ist 33 Turnbull, W (i8o6) The Naval Surgeon, Ist edn, cdn, p 259. ) 8o. 14 Howell, J (i822) The Life and Adventures of 34 Hutchinson, A C (I8I6) Some Practical Obser- John Nicol, Mariner, pp I86-i87. vations in Surgery, Ist cdni, pp 76-I0I. 15 IvcPherson1, C (1929) Life on Board a Man-of- 35 Moyle, J (I693) Chirurgus Marinus, ist edn, War, including a full account of the Battle of pp 90-9 I . Navarino by a British Seaman (Charles Mc- 36 Moyle, J (I693) ibid., pp 50-83. Pherson.), pl) 148, I5I. Glasgow, Blaikie, Fullerton. 37 Wilsoni, R M (195I) Navy Records Society, XCI, 241. I6 Wiseman R (i686) Several Chirurgical Trea- tises, p 428. London. 38 Botcler, J H (1883) ibid., LXXXII, I90-I9I. 17 Iniman, J (I828) An Introduction to Naval Gun- 39 Young, R (I797) Surgeon's Journal of HMS nery, Portsea, p 30. Ardent, Adm. Io1/85. by Hutchinson, A C, i8 Yonge J (i679) Currus Triumphalis e Tere- 40 Stenhouse, W (i8i6) quoted in Some Practical Observations in Surgery, Ist bintho, Pl) I3, 14, 33, 40-47, II0-I 19. London, Martyn. edn, p 34- 19 Haire 1 (1786) London Medical Journal, 7, 41 Leech, S (I843) Thirty Years from Home, or A from the Main Deck, p Boston. 377. Voice I3I. 20 Lewis, M A (1960) A Social History of the 42 Blanc, G (I799) Observations on the Diseascs Navy 1793-1815, pp 369-I8I5. London, Allen of Seamen, 3rd edn, p 579. and Unwvin. 43 Inman, J (i828) An Introduction to Naval Gun- 2 McPherson, C (1928) Life on Board a Man- nery, Portsea. pp 30, 31. of-War including a full account of the Battle 44 Botcler, J H (I883) Navy Records Society, of Navarino by a British Seaman (Charles Mc- LXXXII, 192-193. I'lherson,", pp 148, I51. Glasgow, Blaikie, T ibid., XVIII, Io8. Fullerton. 45 Sturgess-Jackson, (I900) 22 Gardnier, J A (I906) Navy Records Society, *46 Bonner Smith, D (1929) The Mariner's Mirror, XXXI, 3I. I5, 238. 23 Pocock, -f (I968) Nelson and His World, p 70. 47 Laird Clowes, W (I899) The Royal Navy-A L,ondon, Thames and Hudson. History from the Earliest Times to the Present, vol 4, pp 517-5I9. London. 24 Turnbull, W (i8o6) The Naval Surgeon, Ist edn, p 259. 48 Laird Clowes, W (I899) ibid., Pp 33-39. 25 fHowell, J (1822) The Life and Adventures of 49 Blane, G (I830) A Brief Statement of the Pro- John Nicol, Mariner, p i86. gressive Improvement of the Health of the 26 Dillon, WV H (1953) Navy Records Society, Royal Navy, p 40. London. XCIII, 131-I32. 50 Hutchinson, A C (I817) Some further obser- 27 Long, WV H (I899) Naval Yarns 'The Journal vations on the subject of the proper period for of a Naval Surgeon', pp 76-78. Londoni, amputating in Gun-S/lot Wounds, pp i-64. Gibbings. 51 Blane, G (1799) Observations on the Diseases 28 Boteler, J H (I883) Navy Records Society, of Seamen, 1st edn, p 555. LXXXII, i88. 52 Wilson, J (I846) Outlines of Naval Surgery, 29 Wilson, R M (1951) ibid., XCI, 264-270. pp 20, 24-26. Edinburgh. '24 Sir James Watt 53 Colcy, R NV (I8I7) Medico-Chirurgical Jour- 68 Bunton, C (19I5) Journlal of the Royal Naval nal and Review, vol 3, no 13, P I. Medical Service, 3, I5. 54 Keevil, J J (I949) Journal of Bone and Joint 69 Fairlic, W M (1920) ibid., 6, 66. Surgery, 3iB, 589. 70 Hampton, T R W (I97I) ibid., 57, 4. 55 Lind, J (1772) A Treatise on the Scurvy. 7I Ellis, F P (I944) ibid., 30, 69. L,ondon. London. ~~~~~~~72Wakelcy, C P G (I9I 7) ibid., 3, I56. 56 Blanc, G (I822) Select Dissertations on Several 7 W C Subjects of A'Iedical Science, PP 2I-22. London. S73 Pearce-Gould, E, and Archer, C W (1915) Brit- ssh Medi cal Journal I, 52L 57 Attwood, E L (i9IO) WarshiPs, 4th edn, p 175. Pcnfold E oA(na7 Jr oh y N Lodn Logmns 74 Penfold, E A (I917) lournzal of the Royal Naval London,Longmans. Medical Service, 3, 44. 58 Laird Clowes, W (1903) The Royal Navy-A History from the Earliest Times to the Death 75 Beaton, D H (I940) Surgeon's Journal of HMS of Queen Victoria, vol 7, pp 298-299. London. Warspite. Med Recs. MOD(N). 59 Harkan, H (1876) Surgeon's Journal of HMS 76 Desmond, A M, and Frazer, P K (I'94) Jour- Asia. RNH Haslar. nal of the Royal Naval Medical Service, 29, Library, I 6. Go Smith, C (I938) A Short History of Marine C G Engineering pp 269-270. London, Cambridge 7 Wakeley, I Pc94I)Surgery, IO, 207- University Press. 78 Bunyan, J (1940) Proceedings of the Royal So- Gi May, A W (1914) British Medical Journal Sup- ciety of Medicine, 34, 65. plement I,I I5 i79Coulter, J L S (1956) The Royal Naval Med- plement,*05- ical Service, vol 2, PP 497-506 (in Medical His- 62 Cowburn, P (I968) The Warship in History, tory of the Second World War). London, HMSO. p 274. London, Macmillan. 8o Coulter, J L S (1956) ibid., p 341. 63 Archibald, E H H (I97i) The Metal Fighting 8i Keevil, J J (940 Surgeon's Journal of HMS Ship in the Royal Navy, i860-i970, p 93. Lon- Illustrious. Med Recs. MOD (N). don, Blandford Press. Blandford Press. don, 82 NVilson, J (I846) Outlines of Naval Surgery, p 64 NMcLean, A (I9I6) Surgeont's Journal of HMS 32. Edinburgh. Lion. 83 Lewis, M A (I960) A Social History of the Navy 65 McLean, A, and Stephen, H E R (I9I6) Jour- I793-18I5, P 348. London, Allen and Unwin. nal of the Royal Naval Aedical Service, 2, 421. 84 Talbot, A G (1946) The Talbot Committee on 66 MIuir, J R (i9i6) ibid., 2, 405. Life Saving. Admiralty Papers. 67 Ash, XV M, and Wakeley, C P G (I9I6) Lancet, 85 Golden, F St C (974) Journal of the Royal 2, 56. Naval Aedical Service, 6o, 8-i6.