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

The injuries of four centuries of

naval warfare

Surgeon Vice-Admiral Sir James Watt KBE QHS MD MS FRCP FRCS

Medical Director-General (Naval), Ministry of Defence

IntroductionIn the year I540 Henry VIII was persuadedby his Serjeant-Surgeon, Thomas Vicary, tofound the Company of Barber-Surgeons andthereby control the practice of the art, anevent commemorated in the fine cartoonby Hans Holbein which hangs in the RoyalCollege of Surgeons of England showingThomas Vicary receiving the Charter fromthe King's hand. The Charter granted byCharles I in I 629 included a requirementto examine surgeons and surgeon's mates forthe Navy. The Court of Examiners sub-sequently assuimed the additional responsibil-ity of reviewing injuries sustained in navalactions and allowing the expenses of the cure.The need to do so had been apparent no

doubt from such unfortunate affairs as thatof Sir Martin Frobisher, who, after blockadingBrest in 1594, had been struck by a ball fromthe arquebus of a Spanish soldier whichlodged against the 'hucklebone'. It did notprevent him pressing home the assault, but hissurgeon, who had extended the wound to ex-tract the ball, failed to remove the wad whichhad been carried in with it. Gas gangrene ap-pears to have determined the fatal outcome",2.The Barber Surgeons' Company played a

key role in the provision of surgeons for thefleet and, in I704, Queen Anne expressedher appreciation by the gift of a silver punch

bowl. The College of Surgeons, after its foun-dation in i 8oo, continued to examine surgeonson entry to the Royal Navy until I 843',when the link was severed until happily re-stored in I964 by the establishment of a jointchair in naval surgery at the Royal Collegeof Surgeons of England and the Royal NavalHospital, Haslar.

The fighting shipThe year I 540 was also of importance tothe Royal Navy for it marked the recom-missioning of the great ship Henry Grace aDieu after an extensive reconstruction to ac-commodate the new heavy ordnance de-veloped through Henry's liaison with HansPoppenruyter, the gun maker of Mechlin,whom Henry, characteristically, omitted topay. Similar guns were recovered from thewreck of the Mary Rose in I836. They werebreech-loading, wrought-iron bombardsbuilt up of longitudinal bars with en-circling metal rings, I0 feet in length andof 8 inch calibre. There were also muzzle-loading brass cannon and culverin, similarto those in use at Trafalgar4, except that theI8o5 guns were of cast-iron, first introducedinto England in I5435.The Henry Grace a' Dieu exemplified the

innovation which was a distinguishing fea-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 theship lying immediately beyond the tower prior to her reconstruction. (Muse'e de laMarine, Paris.)

missioned in I 5 I 4 she is shown in Volpe'spainting (Fig. i) as an impressive but none-theless typical mediaeval clinker-built vesselwith ill-assorted armament, depending chieflyupon the bows of archers and primitive ser-pentine guns in her high fore and after castlesto rake exposed enemy decks and repel board-ers. Henry's influence, however, can be seenin ports for heavier guns in the ship's stemand side which Henry had compelled hisshipwrights to breach against their betterjudgment. The Anthony Anthony Rolls'show that, on completion of her refit in I540,the Henry Grace a Dieu emerged with twotiers of gun ports and a formidable heavyarmament (Fig. 2), the forerunner of theBritish broadside which was to dictate thetumblehome construction of sailing shipsin order to distribute the weight of their ord-nance and to endure as the principal tacticalweapon of surface ships until the SecondWorld War (Fig. 3).

Prior to the introduction of guns to ships

injuries in action were sustained as the resultof close fights, from the arrows of archers,from iron bars, darts, spears, and even stoneshurled from the castles and, after grapplingand boarding, from swords, pikes, and toma-

FIG. 2 The Henry Grace-a-Dieu followingher reconstruction. From the Anthony An-thony Rolls, I546. (Magdalene College,Cambridge.)

The injuries of four centuries of naval warfare

II

I I

FIG. 3 Midship section of a fourth-rate,i684. (National Maritime Museum.)

hawks (Fig. 4). Head and upper extremityinjuries therefore predominated, but as noquarter was asked for and none given, casual-ties were swept overboard into the sea andthere was no need for surgeons.

The Spanish ArmadaThe arrival of the gun coincided with thegreat voyages of discovery and the need toprotect English overseas interests. The ship,therefore, became a self-sufficient fightingunit. The first test of British gunnery andseamanship came with the Spanish Armada

in I588, Howard wisely exploiting the handi-ness and greater gun range of his little shipsto harry and outsail the Spaniards, consciousof the danger of close action in which theadvantage would lie with the enemy, whosehigh castles were teeming with soldiers. Thesetactics proved successful, for the Spaniards'shot was spent before it reached the Englishships and casualties were few, 'not above onehundred', although Drake's ship was 'piercedwith shot above forty times'. 'The greatestdanger', wrote Sir Richard Hawkins, 'that,as I remember, they caused to any of ourshipps, was to the Swallow of her majestie,which I had in that action under my charge,with an arrow of fire shott into her beake-head, which we saw not, because of the sayle,till it had burned a hole in the nose as biggeas a man's head; the arrow falling out, anddriving alongst by the shippes side'7. Theseearly arrow projectiles were bound in leatherto fit into the bore, but were quickly suc-ceeded by stone, then cast-iron round shot8.The significance of that incident was not

lost upon Wylliam Clowes, who appears tohave been in Howard's flagship, the ArkRoyal (Fig. 5), and was no doubt highlightedfor him at Gravelines when Howard sent infireships to drive the terrified Spaniards to

m;iitr c 44(1 fu19 mfllnIt fl)MWkI

w n D ¢ v} - ¢t; n) [1{1X,. X .* aazlv,S:*8X>ttS U m>tXl

w tt+f^t awe1naWnIx

FIG. 4 A close fight at seain the 4th century. (MSSioE, IV. British Museum.)

FM-f=fffmlormp-qr- -m 0 i m m

0, D,.........:.jjjjjjjjjjFjjp..---.-----

A

5

-.............

...... ........

6 Sir James Watt

FIG. 5 The Ark Royal,Howard's flagship in thebattle against the SpanishArmada, I588, bought byQueen Elizabeth from SirWalter Raleigh. (TheMansell Collection, Lon-don.)

sea in confusion. It is therefore scarcely sur-prising, in that Armada year, that WylliamClowes9 should publish An Approved Practicefor all Yong Chirurgians concerning Burningswith Gunpowder . . . Clowes distinguishedbetween partial and full-thickness skin loss,using wet, cooling lotions for superficial bumsand oily dressings or creams for full-thicknessloss, with attention to fluid replacement with'boyled water' in the initial stages and tonutrition during convalescence. His resultsappear to have been successful and rehabilita-tion was not neglected, for the recently healedbum was gently massaged with egg yolks andalmond oil.

BurnsThe Armada drew attention to the com-plicated nature of bum injuries. There weresuperficial flash bums from the accidentalignition of powder horns used for primingthe guns or of loose powder strewn over thedeck. There were localized full-thicknessbums from sudden bulging of over-heatedbrass culverins, bum wounds of the head andface from misfire of wrought-iron breech-

loading guns with ejection of the hot breechbox, and burn wounds of the body from hotfragments of exploding cast-iron muzzle-loaders.

Burns continued to dominate the writings ofnaval surgeons for the next century. To JohnWoodall'0 we owe the principle of enzym-atic debridement and the important instruc-tion to 'take away all the powder that stickethto the flesh, for it hindereth the cure' and toJohn Moyle"1, who was then describingsevere contractures following bums at sea,the early surgical debridement practised to-day. A century later, however, Blane"2 andTurnbull"3 were reporting a high bums mor-tality and it is interesting to speculate thattoxic absorption of 'cerussa', a lotion of leaddissolved in vinegar then in general use inthe Navy as a local application, was respons-ible for this.The enormity of the bums problem was

even more evident to the enemy as wholeships' companies disappeared in terrifyingexplosions. L'Orient at the Battle of the Nilethrew great burning beams over Alexanderand Swiftsure and John Nicol, a seaman in

The injuries of four centuries of naval warfare

HMS Goliath, describes the scene which methis eyes when he went on deck afterthe action: 'The whole bay was coveredwith dead bodies, mangled, wounded andscorched, not a bit of clothes on them excepttheir trowsers'14. Charles McPherson15 recordsthat, at Navarino in I827, pieces of burningwood and showers of burned rice and olivesrained in profusion from burning Turkishships and that 'a Turkish ship of the lineexploded showering iron, wood and nails'over the Genoa.

Ship- and man-destroying missilesThe Dutch wars of the 17th century provideda pattern of injury from actions at sea whichchanged little during the sailing ship era andWiseman"6, writing just after the third Dutchwar, drew attention to the gross soft-tissueinjuries then being experienced. 'In our sea-fights, oftentimes a buttock, the brawn of thethigh, the calf of the leg are torn by shotand splinters. All these are contused woundsand look black and do often deceive the in-experienced chirurgeon, he taking them bytheir aspect to be gangrened.' Going on todescribe their subsequent course, he observesthat they 'look like flesh long hang'd in theair, of a dry, blackish colour, yet they havewarmth'. They subsequently discharged mas-sive sloughs leaving indolent ulcers and hugetissue defects.

Because of its weight and velocity, solidround shot became the principal ship-destroy-ing projectile. It also splintered hull andmasts to provide secondary anti-personnelmissiles. Double-headed bar, telescopic, andchain shot were intended to cripple enemysailing power, but were not much favouredby the British because of their inaccuracy.They were, however, responsible for many ofthe injuries sustained by British seamen aloftor on the exposed upper deck. Primary man-destroying missiles were canister or case shot

(a cylindrical tin case containing small, loose,iron balls), langrage (a tin filled with scrapand iron bars), and grape or quilted shot(iron balls arranged round an iron columnin a canvas bag). They also proved useful incutting chain plates, stays, and shrouds'7(Fig. 6).The number of compound fractures and

traumatic avulsions of limbs made naval sur-geons adept at amputation and, contrary topopular opinion, the arrest of haemorrhagewas by forceps or ligation and not by thered hot cautery roundly condemned byJames Yonge'8 in his Currus Triumphalispublished in I679 while surgeon at theNaval Hospital, Plymouth. He also con-demned the practice of blood-letting, and thework is noteworthy on two accounts. He de-scribes controlled experiments in dogs show-ing the superiority of oil of turpentine overthe ligature in the arrest of haemorrhage,which he assessed by measuring clotting timesand by microscopic evidence of vessel andclot retraction. He also devised a posteriorflap technique for amputation of the lowerlimb which, he claimed, accelerated healingand avoided bone necrosis and ulceration ofthe stump. Another notable improvement inamputation technique was the cutting of liga-tures short, first practised by Lancelot Haire19while an assistant surgeon at the Naval Hos-pital, Haslar, in 1786.

The British usually double-loaded withsolid shot and grape or canister with the ob-ject of smashing the enemy's hull and killingor wounding her gunners. They thereforefired on the downward roll, while the enemy,intent on immobilizing the British ships,aimed bar and chain shot at yards or rig-ging on the upward roll20. These differenttactics, as we shall see, were to determine thedifferent casualty patterns of the combatantsin the wars with France.

7

8 Sir James Watt

Blor dowSht

-111j~~O_Shot-l.J

itWl.r3Shot C_orCurmShot

Round shot Round shot, of course,

was the most mutilating, causing dismember-ment and evisceration. McPherson2" de-scribes how, at Navarino, he saw a mid-shipman knocked clean out of the top, hang-ing by the intestines from the boat's davits,and Gardner22 recalls that 'one of our poor

fellows was cut in two by a double-headedshot on the main deck, and the lining of hisstomach (about the size of a pancake) stuckon the side of the launch'. A similar fate be-fell de Brueys in L'Orient, his flagship at theNile, when a shot carried off both legs. Hehad himself placed in an armchair on deckwith tourniquets on both stumps until a can-

non ball cut him in half23.

'Wind of a bail' An injury whichgreatly puzzled the naval surgeon was whathe described as 'wind of a ball' or the near

miss of a cannon ball which caused theaffected part to become 'livid and benumbed'

FIG. 6 Shot used in navalcannon during the sailingship era. (H Tomkins afteran illustration by R Wood-ward.)

while, if the shot grazed the abdomen, itcould prove instantly fatal without the leastmark of injury24. John Nicol25 describes atypical case at the Battle of the Nile: 'Onelad who was stationed by a salt-box, on whichhe sat to give out cartridges, and keep thelid close-it is a trying berth-when askedfor a cartridge he gave none, yet he sat up-right; his eyes were open. One of the mengave him a push; he fell all his length onthe deck. There was not a blemish on hisbody, yet he was quite dead, and was thrownoverboard'. Dillon2" tells how he wasknocked unconscious at the Battle of theGlorious First of June in just such a man-ner and in the painting by Mather Brownof that battle (Fig. 7) Sir Andrew SnapeDouglas (far right) is swaying unsteadily,temporarily concussed by a near miss, whileCaptain Neville of the Queen's Regiment(right centre) is shot through the chest andmortally wounded.

The injuries of four cenltur

Grape shot Patrick Renny, surgeon ofthe Coventry at the Battle of Quiberon Bay,I 759, describes his visit after the battle tothe French prize Formidable, whose star-board side had been 'pierced like a cullender'by British shot. She had over 500 casualtiesand the grand chamber was strewn withwounded officers, tourniquets still screwed onamputation stumps, and every space belowdecks crammed with wounded soldiers andsailors. Renny was asked to advise on thewound of an officer caused by grape shotwhich had penetrated the thigh, fracturedthe femur, ballooned the scrotum, and carriedaway the rectum with the buttock27. Thiswas unusually severe, and those who survivedgrape-shot wounds more often sustainedlocalized compound fractures of the ex-tremities.

Boteler28 at Navarino describes a typicalcase: 'Young Grey . . . was in the act ofgiving the Captain of the Gun some grape-shot, when he turned round, laughing to seethe grape scattered on the deck. I saw whatit was, and he too directly also. He turned

ries of naval warfare 9

FIG. 7 Lord Howe on thequarterdeck of the QueenCharlotte at the Battle ofthe Glorious First of June,1794. (Painting by MatherBrown in the NationalMaritime Museum.)

pale and said "Oh Sir, it is my right arm".He was taken below and the arm amputated,but the next day Dr Hillyer found the bonesplintered higher up . . . and it was takenout of the socket. . . At the naval hospital,Malta, he had lockjaw but got over it'.

Robert Mercer Wilson29 in his journal de-scribed the action in the Bay of Naples inJune I809 between the French frigate Ceresand the English ship Cyane where 'the grape-shot flew like hailstones' and Ce'res had over50 men killed. Descamps, who accompaniedMurat on his visit to the ship after the ac-tion, graphically depicted some of the in-juries in a painting which hangs in the Museede la Marine, Paris (Fig. 8). The surgeon isdressing a sucking wound of the chest witha pad and bandage, a barrel bandage hasbeen applied to a fractured jaw, and thereare a grave abdominal wound and headwounds. It was following this battle thatMurat told Napoleon: 'C'est le premiercombat de marine que j'ai vu et j'avoue qu'ilne faut pas etre moins brave sur mer quesur terre'.

Io Sir James Watt

FIG. 8 Painting by Des-camps who accompaniedAMurat (centre) on boardCeres after her battle withCyane in the Bay ofNaples, 27th June I809.(Musee de la Marine,Paris.)

Splinters Hutchinson30, writing at theend of the Napoleonic wars, draws a distinc-tion between the localized wounds fromgrape shot and musket balls inflicted by con-fronting armies and the extensive injuriescaused by a direct hit from the round shotof a ship's cannon or by 'ragged fragmentsof timber violently rent from the planks orsides of the ship'. He adds, 'wounds inflictedby splinters of wood are always more exten-sive, accompanied with frightful contusionsand lacerations of the soft parts', and Wise-man31 had pointed out that even if the splin-ter had insufficient velocity to cause a wound'it sometimes bruiseth the skin to the fleshso forcibly as to extinguish the naturall heatand make it black', producing an escharwhich would separate to leave an indolentulcer, possibly of 'Meleney' type, and finallyan ugly scar. A painting by Drummond ofthe Battle of Camperdown clearly displayshypertrophic and keloid scars in seamen ofthe period (Fig. 9).The extensive contusions and blackened,

unhealthy nature of wounds, to which fre-quent reference is made, was due largelyto the prevalence of scurvy in the British

fleet which, in times of war, remained atsea for long periods. This led to a numberof complications such as generalized oozingfrom amputated stumps, adding greatly tothe anaemia resulting from initial blood loss.Cumming32 appears to have treated a num-ber of patients with this complication afterCopenhagen in I8oi and was compelled touse graduated tow compresses and firm rollerbandaging to control bleeding from thestumps. A greater problem, however, was thetraumatic ischaemic contracture resultingfrom collections of blood below the deepfascia, often confused with gangrene. Amputa-tion usually resulted, although Tumbull33attempted to treat the condition by buryingthe limb in earth-perhaps the original mudpack! Hutchinson34 finally recognized thetrue nature of the condition, which he called'erysipelas phlegmonodes' and distinguishedit from 'erysipelas oedematodes', whichseems to have been gas gangrene. He rightlyadduced the stiffness and rigidity resultingfrom the former as due to adhesion betweenthe muscles, tendons, and their sheaths as theresult of effused blood and, at the naval hos-pital at Deal, practised multiple incisions

The injuries of four centuries of naval warfare

FIG. 9 Detail from a painting by Drum-mond of the Battle of Camperdown, iithOctober I797, showing large keloid scars

of left forearm and shoulder in a seaman

aboard the Venerable, flagship of AdmiralDuncan. (National Maritime Museum.)

through skin and deep fascia followed bygentle massage and active movements. Hispatients all recovered, free from infection,with full restoration of function. He was over

I00 years ahead of his time, although JohnMoyle"5 had recorded a similar surgical ap-

proach in a single case of subfascial haema-toma which formed in the leg of a sailorcaught in the bight of a cable over ioo

years previously.

BoardingThe Battles of Barfleur and La Hougue inI692, which frustrated the attempt by the ex-iled James II to invade England with thehelp of the French fleet, contained all thoseingredients of naval actions to provide thebroadest possible spectrum of injury. At Bar-fleur Tourville was decisively beaten byShovell's superior gun power and, underRooke, an arm.ada of 200 small boats fromthe British fleet swept into La Hougue har-bour two days later, in the face of murderousfire from the protecting batteries, to boardand fire six French three-deckers and set theharbour ablaze.No doubt with that episode in mind John

Moyle3" wrote his Chirurgus Marinus, for itturns out to be a description of the cockpitof a man-of-war and a case book of injuriesdealt with by the surgeon and his mates, typ-ical of just such an action. The chief interestis in wounds sustained by boarding partiesfrom cutting or hacking weapons and smallarms such as muskets and pistols (Fig. io).The typical cutlass wound is described as anoblique incision across the wrist dividing ves-sels and nerves and requiring immediate su-ture which must avoid picking up nerve ortendon. Wounds from the tomahawk carriedby boarding parties were confined to the headand face and might slice the cheek away fromthe bone. Pikes were commonly run throughthe chest and, if they missed vital organs, lefta track which required daily syringing andadequate drainage. A rapier or the bullet ofa pistol often passed through the throat, re-quiring through-and-through drainage withhaemorrhage difficult to control unless theblood pressure was dangerously lowered byblood-letting.Among contemporary accounts of boarding

episodes Wilson37 describes how sailors fromthe frigate Unite boarded Turkish vessels inthe port of Durazzo in the Adriatic through

I I

1 2 Sir James Watt

FIG. I 0 'Progress of a

Midshipman'. Cartoon inthe National MaritimeMuseum of pirates board-ing one of HM ships.

a barrage of grape shot and musketry, run-ning the enemy through with their boardingpikes, normally a defensive weapon. Boteler"8recalls that, at Navarino, the spritsail yardof a Turkish frigate crossed Albion's poop.Immediately the first lieutenant led a partyof volunteers with swinging cutlasses and thebutts of marine muskets to sweep the deckof Turks, who continued shooting from be-low until the boarders seized cannon ballsand rained them down upon their haplessvictims. A Turk in the foretop picked offthe arm of the boatswain with a musket shotand three British sailors sprang nimbly upthe rigging and threw the Turks overboard.Later the surgeon of Albion came across aTurk who had apparently followed the board-ers back. He was dying from a typical toma-hawk wound which had sliced through theocciput. Height was still, on occasion, as im-portant as in the old castellated ships. Nelsonwas shot through the chest at Trafalgar bya marksman in Redoubtable's top (Fig. iI),and a similar injury befell a mariner inArdent at Camperdown in I797 but with ahappier result for, according to Young39, theship's surgeon, about a month afterwards,

following a violent fit of coughing, he'brought up part of a check shirt and flan-nel waistcoat after which he daily continuedbetter'.

But height also had its problems and con-tributed to the casualty list. Apart from ac-cidental falls in relatively fit men aloft therewere problems for the wounded seamenreaching the deck below. Stenhouse40, surgeonof the Glasgow at the Battle of Algiers, de-scribes the case of the captain of the fore-top who had his leg carried away by acannon ball except for a strip of tissue bywhich it was attached. He grabbed a rope tolower himself on deck, but half-way downhis flail limb became entangled among therigging and he was obliged to pull himselfup with his arms and disengage the woundedlimb with the assistance of the sound one. Hethen quietly descended on deck and reachedthe cockpit at the moment when the bugle-man's wife, who was attending the wounded,heard her husband had been killed by acannon ball. The wounded seaman was quickto comfort her: 'Come on, Poll', he said,'cease to grieve; you shall not remain a widowlong'. And he kept his promise!

The injuries of four centuries of naval warfare

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 ofthe French flagship Redoubtable which penetrated the left lung and injured theleft pulmonary artery and spinal cord.

AccidentsThroughout the sailing ship era accidentscontinued to contribute significantly to thecasualty rate. A typical incident is related bySamuel Leech4' in his account of the battlebetween the Macedonian and the Americanfrigate United States in I8I2. A powder boyon the quarter deck was killed when 'hispowder caught fire and burnt the flesh almostoff his face. In this pitiable situation theagonised boy lifted up both his hands, as ifimploring relief, when a passing shot instantlycut him in half'. Such accidents also led tomass casualties. At Camperdown (Fig. I 2)Young39, surgeon of the Ardent and withoutan assistant, found himself dealing with gocasualties piled one upon the other at thefoot of the ladder leading to the cockpit. Al-

most fainting from fatigue, he struggled man-fully through the amputations in the stiflinglyhot atmosphere when, he writes, 'an explosionof a salt box with several cartridges abreastof the cockpit hatchway filled the hatchwaywith flame and, in a moment, fourteen orfifteen wretches tumbled down upon eachother, their faces black as a cinder and clothestorn to shatters and the rags on fire . . .'There were 4I killed and I07 wounded outof a ship's company of 485, a casualty rateof 30.5%.

Blane42 informs us that 'in the battles ofI780 and I78I, one-fourth part of the wholekilled and wounded was from the explosionof gunpowder; but on the gth and I 2thApril 1782 (Battle of the Saints), only twoaccidental explosions of gunpowder happened

I 3

14 Sir James Watt

FIG. I 2 Battle of Cam-perdown, I797, by Wil-liam Huggins in the Armyand Navy Club, PallMall, London. The sternof Ardent can just be seenin the background, left ofcentre.

in the whole fleet, by one of which, one lifewas lost, by the other, two'. He attributedthis to the better training of guns' crews andsafety measures introduced by Sir CharlesDouglas. They included wetting the wadswhich, when the weather side of the shipwas engaged, used to blow back and ignitethe gunpowder, replacement of the large oxhorns which held the loose powder by goosequill tubes, and small priming boxes. It wasDouglas, too, who first used gun locks at sea,which increased operational safety.The mishandling of guns was the other

main cause of accidental injuries. Accordingto Inman43 too great a charge and over-loading of guns caused straining of the car-riage, breaching, tackles, and side bolts andincreased recoil, while overheating resultedfrom the rapid rate of firing achieved by thehighly efficient British gunners. Failure toram home the shot on the head of the cart-ridge in the heat of action caused the gunto burst or to be dismounted. There is abun-dant evidence that all these factors operatedin sea battles and caused numerous burns,wounds, and fractures, while shot fired fromthe short muzzles of the deadly British car-ronades or 'smashers', introduced into the

fleet in 1779, often set on fire the ship's ownsails and rigging. Albion was twice set onfire by her own carronades at the Battle ofNavarino, and Boteler44 records that all gun-ners invariably overloaded, 'nearly alwayswith two shot, sometimes with three'. Onewas even found with four round shot. Notsurprisingly 'the guns were very lively spring-ing back from their breachings and jumpingoff the deck'. When a hide lanyard broke,which fired the flintlocks then in use, Mid-shipman Boys jumped to the breech andpulled the trigger, only to be struck in thestomach by the gun's violent recoil. Thoughhe was 'long unconscious', the surgeon couldfind no trace of external injury. The casual-ties resulting from such incidents were byno means insignificant, for Edward Daubeny,in a letter to his father from HMS Bellonaafter the Battle of Copenhagen in I 8oi,writes that 'we have besides above eightykilled and wounded by the bursting of ourguns'45. Midshipman Anderson, who was alsoon board Bellona, explains the sequence ofevents in wlhich he himself was injured byshrapnel from one of them4". Although onlya soft-tissue injury, the surgeon, evidentlyfrom long experience, warned him that it

The injuries of four centuries of naval warfare

would be three months before he fullyrecovered.

MoraleThe explosion of guns had a disastrous effectupon the morale of the ship's company47.When one of the I 2-pounder guns burst inthe British frigate Ambuscade while engagingthe French corvette Bayonnaise in DecemberI 798 I I men were wounded and the ship seri-ously damaged. The French, who had alreadysuffered heavily from the English broadside,rammed Ambuscade (Fig. I 3) and Frenchsoldiers swept her deck with musketry. Fiveofficers were killed or wounded by bullets andthe purser took command. At that momentan explosion of cartridges on the rudder headblew out Ambuscade's stern and so demoral-ized the crew that French boarders were ableto charge across the spritsail yard to carryAmbuscade's deck. Yet such was the destruc-tion wreaked upon the French vessel thatthe captured English frigate had to tow itscaptor back to Rochefort! Casualty statisticsare revealing for, while the casualty rateswere comparable (24.0% in the French ves-

sel and 26.3% in the English), the ratio ofkilled to wounded amongst the French wasI: I but among the English it was I :4, anindication of the destructive potential of theBritish carronade and the fighting qual-ities of the British seaman in hand-to-handencounters.

Entanglements, of course, were inevitablein close engagements, yards and rigging oftenlocked inextricably, a fate which befellSeraphis off Flamborough Head in 1779when she engaged the Bonhomme Richardcommanded by the American privateer, JohnPaul Jones. The two ships found themselvesbow to stern, gun muzzle to gun muzzle,which drove Jones's men from their guns tothe tops, while the i8-pounders of Seraphisblasted through their own closed gun portsto reduce the American's hull to shivers andset her own starboard side fiercely ablaze.After boarding and counter-boarding, heightagain proved useful to an American seamanwho climbed out along his own yard to dropa bucket of hand grenades down the mainhatchway of Seraphis and into her gunroom, where they caused a violent explosionwhich ran aft between the rows of guns, dis-

FIG. I3 The French cor-vette Bayonnaise rammingand boarding the English

igate Ambuscade

| , _ i ,f < . . Nth

December I798. (Paintingby L-Ph Crlpin in theMuse'e de la Mar'ineParis.)

I 5

i 6 Sir James Watt

abling, five and scorching and wounding 38men48. The Americans, taking advantage ofthe dismay and shock, rushed the deck ofSeraphis to win the day, although BonhommeRichard was so battered that she soon sank.The casualtv rate was 38.4% in the victoriousBonhomme Richard and 48.8% in Seraphzs,with a killed to wounded ratio of 2 :3 in bothships, indicating comparable standards ofgunnery and fighting qualities.

Sir Gilbert Blane49 in his Health of theRoyal Navy considered that the superiorphysique, courage, and discipline of theEnglish seamen gave them the edge over theFrench in close action, where more shot were

effective. He gave the ratio of killed towounded in the French wars as I :3, butvarying according to distance and the chargeof powder. This observation is borne out bycasualty patterns in six of the major battlesof the Nelson era for, while the casualty ratevaried considerably, the ratio of killed towounded remained at about I :3 (Table I).

The Battle of AlgiersThis interest in casualty patterns is exem-

plified by Hutchinson's50 well-documentedrecord of the Battle of Algiers in I8I6. Hewas struck by the marked difference in mortal-ity rates following amputations performed on

board the various ships and persuaded theCommissioners for Transports to send a ques-

tionnaire to each of the surgeons asking themto specify the number and nature of woundsrequiring amputation, whether amputationwas immediate or deferred, the duration ofdelay in minutes, hours, or days, the num-

ber who recovered or died, and the periodof survival.What emerged was interesting. By far the

greatest number (83%) had been injured bycannon shot and only 8.5% by splinters and8.5% by musket balls-no doubt indicative ofthe effect of high-velocity round shot fromthe cannon of the defending forts. The sur-

geons who practised immediate amputationnot only dealt with more serious injuries butalso carried out more amputations per pa-

tient, yet their mortality rate (33.3%) was

significantly lower than that of the delayedgroup (45.8%) (Table II). Moreover, twodeaths in the immediate group were causedby conditions other than the amputation.Hutchinson50 made important recommenda-tions for amputation, including obliterationof dead space and transverse closure of thestump instead of the usual vertical closure,which tended to open an infected track in-feriorly. Although 'the locked jaw' was a com-

mon and usually fatal consequence of woundsin action, Hutchinson"0 records only one case,

TABLE I Casualty patterns in six major battles in the Nelson era involvingships of the line (I794-i805)

Battle Force Killed Wounded Ratio Casualtykilled:wounded rate (%)

First of June, 1794 I7 241 287 8ii 1:3 6.37St Vincent, 1797 I I 046 73 227 I :3 2.72Camperdown, I 797 8221 203 622 1:3 10.03The Nile, I 798 7985 2I8 678 1:3 11.22Copenhagen, i80i 8565 253 688 I 3 I0.99Trafalgar, 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 whodied on board their ships after the battle died

l l l from tetanus and that some surgeons heldthat ligatures were responsible and so pre-ferred the 'tenaculum'.

C4I - Cs -

1-i End of an era< gD - ~~~I I Ie CX e

Wilson52, writing at the end of the sailingI ship era, paints a picture of the cockpit little

different from that of Moyle in I69336:'Death and wounds in every shape, limbslacerated or torn off-wounds from muskets

-< - - - X ^ or splinters bayonet or cutlass wounds,everything, in short, appalling or horrible andall, probably, in a few minutes, in the midst

I<I >, > o > X ^ n of bustle, the noise of guns, the closeatmosphere and . . . candlelight'. This causedhim to propose a system of sorting of casual-

> I I I Io l l l l ties into three categories-slight, serious, andLO fatal. His recommendations have a strikinglyi<,, modern ring for he argued that immediate

life-saving surgery could be brought toseverely injured casualties only if treatment

;4 t + ~ > > ~ ^ O > for slight injuries vas deferred and only pal-liative measures adopted for injuries likelyto prove fatal. Had this advice been followed

I:; - -̂ in the century of the iron warship it wouldhave saved many more lives.

Before leaving the age of sail, however, itLO , _ > ++̂ sis necessary to pay tribute to two other naval

surgeons-David Fleming, who carried outthe first successful ligation of the common

Ln co> + ~ co carotid artery on board HMS Tonnant in

i 8o3, and Ralph Cumming, who in i8o8performed the first successful forequarteramputation at the Naval Hospital, Antigua"4.To these names, I believe, should be added

03w> r isO . i X that of James Lind55, the most illustrious of-e A XE them all, who conquered scurvy and pro-

(3E ?U ¢ 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 thatover 6,ooo lives lhad been saved eachyear by these measures. Lind was a remark-able man and two of his inventions, hadthey been accepted by the Admiralty, mighthave revolutionized naval warfare of that era.They were distillation of water at sea andrifling of guns'.

The age of transitionThe Battle of Hampton Roads in I862 be-tween two mastless ironclads, the convertedConfederate frigate Merrimack and her tur-retted Federal opponent Monitor, provedthe value both of armour plate and the re-volving turret. Britain, quick to learn,launched the first mastless battleship, HMSDevastation, in I87I, the forerunner of allsubsequent warship construction, her fourmuzzle-loading I12-inch guns firing 700-lbshells supplied to the steam-revolving turretsby the Armstrong hydraulic system.By the end of the century naval surgeons

had had enough experience of the new shipconstruction to recognize the nature of thehazards to which men would be subjected inaction. The piercing power of the shell haddoubled to expose men, now concentrated inthe confined spaces of turrets and their sup-ply routes (Fig. 14) and in the new engineand boiler rooms, to splinters of steel, blastfrom explosions, and the disintegrating forcesof a direct hit. Men would now behurled against steel bulkheads and projectingmachinery or struck by detached componentsacting as secondary missiles. Rivets might bestripped and their heads showered over theship's compan7y5 and, in HMS Furious, thiseven occurred when she fired her own i 8-inchguns. Guns could still misfire but with farworse consequences, and when a I 2-inchgun muzzle exploded in HMS Thunderer,sister ship to Devastation, in I879 nine menwere killed and 35 injured, only one man

in the tturret surviving". This led to a returnto breech loading with its attendant acci-dents-hands jammed in the breech or menstruck by parts of the mechanism.

Accidents in the new engine and boilerrooms pointed to a high incidence of burnsfrom burst boilers or fractured steam pipes.When one of the boilers burst in HMSThunderer in I876 I3 men were killed and49 admitted to the Royal Naval Hospital,Haslar, with what Fleet Surgeon Harkan"9described as 'the most severe scalds that couldpossibly be sustained, the skin being mostlydissected away and hanging in flaps abouttheir body; face and eyelids completely de-stroyed in the majority of cases and manysinking rapidly uinder the shock'. A similarcatastrophe befell the destroyer Bullfinch inI899. While she was travelling at 30 knotsa high-pressure connecting rod broke, the cyl-inder fractured, and a bolt was shot throughthe bottom of the ship. Eleven men in thecompartment were scalded to death60. Burnsremain one of the most serious injuries inmodern warships.

The First World WarThe Medical Director General of the Navy

FIG. I4 Carrying an injured sailor from theupper battery of HAIS Alexandra during thebombardment of Alexandria, i88i. (Well-come Institute of the History of Medicine.)

The injuries of four centuries of naval warfare

at the outbreak of war in 1914 found theprospect of casualty management so daunt-ing that he recommended nothing more thanfirst aid during action and the landing ofcasualties immediately afterwards"', a returnto mediaeval folly which disregarded entirelythe lessons of Algiers and the observationsof Wilson that immediate treatment savedlives. At Jutland Sir David Beatty watchedwith mounting apprehension as three of hislightly armoured battle cruisers blew up whenGerman shells struck their turrets, igniting cor-dite, the flash froin which shot down to themagazines, which exploded. The Germanshad already learnt the lesson at Dogger Bankthe previous year and the gunpowder detona-tors of their cordite bags were protected inbrass containers"', a precaution that mighthave helped save the Hood from a similarfate in I941"3. HMS Lion, Beatty's flagship,was hit on the midship turret and, accordingto Staff Surgeon McLean"4, there were I46casualties, a casualty rate of i I.9% of Lion'scomplement and a ratio of killed to woundedof nearly 9: i, a reversal of that in sailingship days. Delay in treatment neverthelesscost some lives. Sixty-four of the 95 killedand 30 of the 51 woulnded were burned, andMcLean distinguiishes between the superficialflash burns of survivors and the severe corditeburns of the fatally injured, which were asso-ciated with chest complications. Twenty-fiveper cent of casualties sustained fractures and45% soft-tissue injuries, 54% had been in-jured by splinters-now jagged metal andin 27% wounds were multiple.The action over, McLean and Stephens"'

rigged a temporary operating theatre in thecaptain's bathroom and undertook lifesavingsurgery using Listerian antiseptic principleson 28 anaesthetized patients, glad of the assist-ance of an executive lieutenant since 44%,of the medical staff had been lost. Fleet Sur-geon Muir"", of HMS Tiger, explains that

wounds and burns received in action becameseptic because, in those coal-burning ships,'patients are in an indescribably dirty con-dition, in spite of . . . donning clean clothingbefore action.... The mess decks and accom-modation passages are covered with one totwelve inches of water; the men are con-stantly splashing through this; they are hotand perspiring; the consequence of beingstruck by a shell is clouds of dust and smoke. . .clothing is scorched'.Ash and Wakeley"7 described the com-

pound fractures with huge muscle defects,reminiscent of sailing ship days, in patientsadmitted to the Royal Naval Hospital, SouthQueensferrv. They included patients suffer-ing from nitrous fumes which resulted fromincomplete combustion of cordite. The mix-ture of oxides of nitrogen so formed reactedwith the moisture of the respiratory tractto form nitric and nitrous acids, leading tofatal pulmonarv oedema, and oxygen doesnot appear to have benefited the condition"'.Fairlie"" drew attention to the latent periodbefore the onset of symptoms and recentlyHampton7" has shown that smoke in theclosed compartments of ships causes similarcomplications, even in the absence of fire.Carbon monoxide was, of course, the otheraccompaniment of explosions and fires in con-fined spaces which Ellis7' has shown was asso-ciated with damage by torpedoes in bothworld wars.The treatment of burns dominated naval

medical literature after the Battle of Jut-land, and Wakeley72, then a surgeon lieu-tenant, established sound principles basedupon the extent and depth of the burn. Heused intravenous and subcutaneous electrolytesolutions for fluid replacement and exposed hisbums to the open air, condemning picricacid, the local application popular at thetime, as toxic and locally destructive. Hepractised early skin grafting and prescribed

I9

20 Sir James Watt

urinary antiseptics, vaccines for persistentinfection, and digitalis to support the heart,with excellent results. His principles were

years in advance of contemporary thinkingand it is noteworthy that Pearce-Gould andArcher", who were also temporary naval sur-

geons, described the cutting of skin graftsunder local and regional anaesthesia, a tech-nique 'rediscovered' after World War II. Itwas also a suirgeon who proposed preventivemeasures; Penfold"4 recommended the wear-

ing of fire-proofed anti-flash masks and gaunt-

lets by guns' crews, which appears to havebeen somewhat tardily adopted by the author-ities. However, this was standard practice inWorld War II and, where followed, signi-ficantly lowered the incidence of burns.

The Second World WarIn the Second World War ships had becomemore technically complex and electronic aidshad assisted naval gunners to pinpoint theirtarget, but surface actions brought littlechange in the pattern of injury, with thesolitary exception of burns. This can be attri-buted directly to the effectiveness of protectiveclothing, although too often the tropical uni-form of shorts and shirt, giving absolutely

TABLE III Comparison of casualty patternsII and World War I

m~~~~~~~~~~~~~~~~~~~~~ ... s

FIG. 15 Attack on the Bismarck with thecruiser Dorsetshire in the background. (C ETurner, Illustrated London News.)

no protection to the wearer, peaked thecasualty rate in some instances. In theScharnhorst action of November I943 anti-flash gear was not worn by the crew of 'X'turret in the cruiser Norfolk, all of whomsuffered severe burns, but at the Battle ofthe River Plate in 1939, although HMSExeter took tremendous punishment and hada casualty rate of nearly 23%, with goodprotection burns were minor. What didchange in surface actions was the more

favourable rate of killed to wounded (TableIII), which can be attributed to a return

resulting from sutrface actions in World War

Fractures Wounds Burns Multiple Shrapnel Casualty Killed:(%) (%) (%) (%) (%) rate (% wounded

complement) ratio

World War II-surface action

Narvik 11 (D) 25.5 32.7 3.6 21.8 47.3 6.25 I:IOnslow (D) 8.3 70.8 - i 6.6 100.0 7.74 2 3Exeter (C) 41.5 36.6 17.7 29.3 63.2 22-59 2:3Ajax (C) 6.6 93-3 - 20.0 I00.0 2.42 1:2Norfolk (C) 30.2 34.9 34.9 20.9 48.7 8.o 1:5

World War I-JutlandLion (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

to the principle of immediate resuscitationand surgery for the seriously injured, andships were far better equipped to do it. For in-stance, HMS Warspite received 59 casualtiesfrom destroyers in the second Battle of Nar-vik (I 940). Resuscitation by intravenous trans-

fusion and X-rays of injuries were carriedout prior to operation on board the battle-ship and Beaton, her principal medicalofficer, even illustrated the X-ray appearances

in his journal. Four casualties died almost im-mediately, buLt all the rest were transferred toa hospital ship I 2 days later in very goodshape75.

Deaths continued to occur from nitrousfumes, toxic smokes, and carbon monoxidepoisoning. Desmond and Frazer76 describeda cordite explosion in a gun turret. Thesurvivors reported that after the gun hadfired flames shot from the breech when itwas opened, filling the turret. There was an

orange-red, intensely hot, central core sur-

rounded by a multicoloured aura whichmerged into a peripheral zone of fine particu-late smoke. Sailors in the central core were

severely burned and those in the outer zone

suffered toxic and respiratory complicationsafter a latent interval of 2-24 hours. Ellis71reported Haines's description of the lung his-tology in such cases: acute vasodilatation,ruptured lung alveoli, and eosin-staining,coagulated oedema fluid in some alveoli, sim-ilar to appearances reported in the traumaticwet lung of Vietnam casualties. Wakeley77,

now a surgeon rear-admiral, understandingthe significance, treated his burns cases withcortisol, and Surgeon Lieutenant-CommanderJohn Bunyan78 invented the envelope methodof treating burns.Two new factors in World War II were

the magnetic mine and air bombardment.Mines produced a characteristic pattern ofinjury, with simple lower extremity andlower dorsal spine fractures predominating.

Burns and blast injury were surprisingly rare.The ratio of killed to wounded was approx-imately i: i. That was also generally trueof torpedo attacks, but in both cases gaspoisoning appears to have been a not un-common accompaniment. For instance, inH'MS Phoebe casualties suffered from nitrousfumes, in HMS Albatross from nitrous, car-bon monoxide, and carbon dioxide poisoning,and in HMS Stevenstone from fumes ofmethyl chloride resulting from damage to theship's refrigeration system79.

Air attack, however, changed the wholecharacter of war at sea. Surgeons in WorldWar I had brief, intensive periods of activityand prolonged inactive intervals. The sur-geons in World War II, particularly ifaccompanying Atlantic, Mediterranean, orArctic convoys and later in the Pacific, livedunder constant threat of sudden unexpectedair bombardment which might be continuedfor days on end. The explosive effect of abomb between decks was devastating, frac-tures and blast injuries predominating, butsplinters from near misses would strike theship some 20 feet above the water line andeven penetrate the ship's side, causing mul-tiple shrapnel wounds from the waist up'o.The aircraft carrier Illustrious was under al-most continuous bombardment in the vicinityof Malta from i oth to i gth January 194 Iand sustained 276 casualties, of whom I48survived. Her principal medical officer,Keevil81, whose magnificent action medicalorganization undoubtedly reduced the mortal-ity rate, described in his journal the greatseverity of wounds complicated by blast frombursting bombs, although burns were minorbecause of the enforced use of protectiveclothing. One precaution he did not take,however, was to guard against damage bvbroken glass in the sick bay, a danger towhich Wilson82 had drawn attention in I846.Keevil's description of the dismemberment,

2 I

20 Sir James Watt

evisceration, death, and destruction in thehangar is analogous to that on the gun deckof HMS Genoa after the Battle of Navarinoin I827 described by Charles McPherson ',and it is interesting to note that Genoa'skilled to wounded ratio ran contrary to theusual pattern and was I: i, like that ofIllustrious.

Toll of the seaYet, when all is said and done, it is the cruelsea itself which takes the greatest toll. TheSpanish Armada survived disease amongst itscrews, it escaped from the English in theChannel, it survived the fire ships atGravelines, yet when a south-west gale drovethe proud galleons into the North Sea overhalf the vast Armada was lost. Lcwisxi haspointed out that in the wars with Francefrom 1797 to I805 only io ships were lostas the result of enemy action, while no lessthan 9I foundered or were wrecked. If wenow exclude from the Jutland casualty figuresships that were sunk during the action, thecasualty rate is reduced from I I.14% too.83% and the ratio of killed to woundedfrom 9 i to 3:-. In World War II Talbot"4concluded that approximately two-thirds ofall fatalities in ships of the Royal Navy re-sulted not directly from injuries sustainedduring enemy action but from failure to sur-vive the marine environment8'. Survivors mayhave absorbed oil and detergents into theirlungs in the vicinity of the ships, blast in-juries of abdomen and lungs certainly resultedfrom depth charges exploding in the area, butwe nowr know that hypothermia accountedfor the majority of the lives lost. It is towardsthe prevention of hypothermia and the effectsof noxious gases in closed compartments thatattention must now be directed if lives areto be saved in future conflicts.

EpilogueMr President, you have done me the honourof electing me Thomas Vicary Lecturer. Itis also an honour for the Service I represent.I hope therefore that the contributions madeby naval surgeons during four centuries ofniaval warfare have been such as would havewon the approval of Thomas Vicary andhis colleagues, Thomas Gale and WylliamClowes, a naval surgeon himself, who to-gether founded the school of English surgery.In my search for historical details I havc reccivecdhelp from sources too numerous to mcntion, butsevcral individuals have made my task casicr. Theyinclude Miss V Riley, of the Naval HistoricalLibrary, Mr D V Proctor and Mr A W H Pearsall,of the National Maritime Museum, Mr E H Cor-nelius, Librarian of the Royal College of Surgeons,Mr S Watkins, of the Wellcome Institute of theHistory of Mledicine, Mr C T Parsons, Librarian,Royal Naval Hospital, Haslar, Mrs J Reynolds andMr H 'romkins of the Institute of Naval Medicine,M-iss J Orman, of the Department of the MedicalDirector-General (Naval), and Capitaine de VaisseauHerve Cras of the Musee de la Marine, Paris.

ReferencesI,ediard, T (I735) The NavJal History of Eng-land, vol I, p 308. London, John Wilcox.

2 McFee, W (1928) Sir Martin Frobisher, PI) 267-268. London, Bodley Head.

3 Lloyd, C, and Coulter, J L, S (I963) Medicineand the Navy, vol 4. p 23. Edinburgh andLondon, Livingstone.

4 Popc, D (i969) Guns, p 6i. Londoni, Hamlyn.5 Oppenheim, M (I896) A IIistorv of the Admin-

istration of the Royal Navy, p 96. London,Bodley Head.

6 The Anthony Anthony Rolls (1546) MagdaleneCollege, Cambridge.

7 Hawkins, R (I593) in The Hawkins Voyages(I878), ed. Markham, C R, pp 222-223. London,Hakluyt Society.

8 Wilkinson-Latham, R (I973) British Artilleryon Land and Sea, I790-I820, p 24. NewtonAbbot, David and Charles.

9 Clowes, W (1588) An Approved Practice for allYong Chirurgians concerning Burnings withGunpowder, 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,pp 145-I46.

ii Moyle, J (i693) Chir-urgus Marinus, Ist edll,pp 48, 49, 96-98.

12 Blane, G (1799) Observations on the Diseasesof Seamen, 3rd edn, pp 578-579.

13 Turnbull, W (i8o6) The Naval Surgeon, Istcdn, p 259.

14 Howell, J (i822) The Life and Adventures ofJohn Nicol, Mariner, pp I86-i87.

15 IvcPherson1, C (1929) Life on Board a Man-of-War, including a full account of the Battle ofNavarino by a British Seaman (Charles Mc-Pherson.), pl) 148, I5I. Glasgow, Blaikie,Fullerton.

I6 Wiseman R (i686) Several Chirurgical Trea-tises, p 428. London.

17 Iniman, J (I828) An Introduction to Naval Gun-nery, Portsea, p 30.

i8 Yonge J (i679) Currus Triumphalis e Tere-bintho, Pl) I3, 14, 33, 40-47, II0-I 19. London,Martyn.

19 Haire 1 (1786) London Medical Journal, 7,377.

20 Lewis, M A (1960) A Social History of theNavy 1793-1815, pp 369-I8I5. London, Allenand Unwvin.

2 McPherson, C (1928) Life on Board a Man-of-War including a full account of the Battleof Navarino by a British Seaman (Charles Mc-I'lherson,", pp 148, I51. Glasgow, Blaikie,Fullerton.

22 Gardnier, J A (I906) Navy Records Society,XXXI, 3I.

23 Pocock, -f (I968) Nelson and His World, p 70.L,ondon, Thames and Hudson.

24 Turnbull, W (i8o6) The Naval Surgeon, Istedn, p 259.

25 fHowell, J (1822) The Life and Adventures ofJohn Nicol, Mariner, p i86.

26 Dillon, WV H (1953) Navy Records Society,XCIII, 131-I32.

27 Long, WV H (I899) Naval Yarns 'The Journalof a Naval Surgeon', pp 76-78. Londoni,Gibbings.

28 Boteler, J H (I883) Navy Records Society,LXXXII, i88.

29 Wilson, R M (1951) ibid., XCI, 264-270.

30 Hutchinsoni, A C (I8I6) Some Practical Obser-vations in Surgery, Ist edn, p 22.

31 Wisemain, R (I686) Several Chirurgical Trea-tises, p 408, London.

32 Cumming, R (I804) Aledical and Physical Jour-nal, p 390.

33 Turnbull, W (i8o6) The Naval Surgeon, Ist edn,) 8o.

34 Hutchinson, A C (I8I6) Some Practical Obser-vations in Surgery, Ist cdni, pp 76-I0I.

35 Moyle, J (I693) Chirurgus Marinus, ist edn,pp 90-9 I .

36 Moyle, J (I693) ibid., pp 50-83.37 Wilsoni, R M (195I) Navy Records Society,

XCI, 241.

38 Botcler, J H (1883) ibid., LXXXII, I90-I9I.39 Young, R (I797) Surgeon's Journal of HMS

Ardent, Adm. Io1/85.40 Stenhouse, W (i8i6) quoted by Hutchinson, A C,

in Some Practical Observations in Surgery, Istedn, p 34-

41 Leech, S (I843) Thirty Years from Home, orA Voice from the Main Deck, p I3I. Boston.

42 Blanc, G ( I799) Observations on the Diseascsof Seamen, 3rd edn, p 579.

43 Inman, J (i828) An Introduction to Naval Gun-nery, Portsea. pp 30, 31.

44 Botcler, J H (I883) Navy Records Society,LXXXII, 192-193.

45 Sturgess-Jackson, T (I900) ibid., XVIII, Io8.

*46 Bonner Smith, D (1929) The Mariner's Mirror,I5, 238.

47 Laird Clowes, W (I899) The Royal Navy-AHistory from the Earliest Times to the Present,vol 4, pp 517-5I9. London.

48 Laird Clowes, W (I899) ibid., Pp 33-39.49 Blane, G (I830) A Brief Statement of the Pro-

gressive Improvement of the Health of theRoyal Navy, p 40. London.

50 Hutchinson, A C (I817) Some further obser-vations on the subject of the proper period foramputating in Gun-S/lot Wounds, pp i-64.

51 Blane, G (1799) Observations on the Diseasesof Seamen, 1st edn, p 555.

52 Wilson, J (I846) Outlines of Naval Surgery,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 Navalnal 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 CSubjects of A'Iedical Science, PP 2I-22. London. 73 Pearce-Gould, E, and Archer, C W (1915) Brit-S

sh Medi cal Journal I, 52L57 Attwood, E L (i9IO) WarshiPs, 4th edn, p 175.

s

Pcnfold E oA(na7 Jr oh y NLodn Logmns 74 Penfold, E A (I917) lournzal of the Royal NavalLondon,Longmans. Medical Service, 3, 44.

58 Laird Clowes, W (1903) The Royal Navy-AHistory from the Earliest Times to the Death 75 Beaton, D H (I940) Surgeon's Journal of HMSof 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. Library, RNH Haslar. nal of the Royal Naval Medical Service, 29,

I 6.Go Smith, C (I938) A Short History of Marine

Engineering pp 269-270. London, Cambridge 7 Wakeley, C I G 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 I5 i79Coulter, J L S (1956) The Royal Naval Med-plement,I, *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 HMSShip in the Royal Navy, i860-i970, p 93. Lon- Illustrious. Med Recs. MOD (N).don, Blandford Press. don, Blandford Press.

82 NVilson, J (I846) Outlines of Naval Surgery, p64 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 on66 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 Royal2, 56. Naval Aedical Service, 6o, 8-i6.