556

An Introductory LectureTO

A COURSEOF

MILITARY MEDICINE & SURGERY,Delivered at St. Mary’s Hospital,

BY JAMES BIRD, M.D.

(Concluded from p. 532.)

IT is not my intention on this occasion to go much into de- I,tail on the historical progress and improvements of militarysurgery from the time of Ambrose Pare, who, though precededby Guy de Chauliac, the father of French surgery, A.D. 1363,may be nevertheless looked on as the father of French militarysurgery, in its more special military and systematic form.Born at the commencement of the sixteenth century, he accom-panied the French armies in all their campaigns, from 1536 totheir termination with the battle of Moncontour in 1569.While acknowledged by all to be the first military surgeon ofhis age, Pare had for contemporaries, in England, Gale andClowes; in Germany, Gersdorf and Brunswick; as well asAndre Vesale, who followed the armies of Charles V. Underthe reign of Louis XIII., marked by continual wars, no specialdepartment of health appears to have been organized for themedical service of the French armies for nearly twenty years;and at the siege of 1-tochelle, which lasted a long time, thewounded soldiers had neither means of transport nor shelter.During the constant warfare of these unhappy times, however,when the only available provision for treating the woundedsoldiers of the government could be met with at the Hotel Dieuand other public charities, the impropriety of such a state ofthings began to be the subject of general animadversion, andthe necessity of special provision for the medical duties of regi-ments became obvious. Surgeons-major were therefore nomi-nated to the medical charge of regiments, and ordered to treatthe" soldiers under the shelter of canvas. The impossibility,however, under such circumstances, of doing the sick that ser-vice which more permanent establishments were calculated toafford, appears to have suggested to the mind of Richelieu theestablishment of permanent military hospitals. He knew wellwhat care had been taken of the wounded after the battles ofHenry IV., and accordingly he is thought to have first sanc-tioned them during the campaign of Italy in 1630. With theestablishment of hospitals in the villages, the organization ofhospital ambulances became also necessary. All this, as a kindof trial, unaided by any well concerted plan of administration,was but a rough beginning, necessary, in short, as a commence-ment. This new creation, however, admitted soon of variousgrades of surgeons; while at the same time it answered sohappily the end in view, that the government seems to havepublicly manifested its satisfaction with the result, in honour-ing, almost immediately after the first trials, the chiefs of thisservice, the surgeons-major of camps and armies. The physi-cians also shared in these distinctions.The military medical department of health for France,

though in a state of preparation some time previous, obtainedorganization in all its branches during the reign of Louis XIII.Surgery, which after the time of Ambrose Pare had been laidasleep in its cradle, announced itself as again awake, and gavehappy augury of the welfare of the troops, always then in mo-tion, and engaged in the dangers of battle. Under Louis XIV.,whose reign though one of pleasure and brilliant conquest, wasnevertheless one of misery and slavery for the people, thewelfare of the soldiers was a subject of little solicitude to the

government, they being looked upon but as mere instrumentsfor gaining battles. It is known, however, that during hislong reign the arts were protected and that the improvingspirit of the day exercised its influence on all branches ofhuman knowledge. National schools were opened at Paris, towhich strangers flocked to learn practical anatomy, while atthe same time Leyden was conspicuous for the superiority ofits medical school. The schools of Paris and Leyden had thussuperseded the school of Padua, which a little time before hadbeen the place of general resort for medical students from allparts of Europe. Surgery shared in the impulse which hadbeen given to other branches of science. While Dally andTassin, in France, wrote on gun-shot wounds, Richard Wise-man, the Pare of English military surgery, and surgeon to

Charles II., brought forth in A.D. 16T6, his "ChirnrgicalTreatises on Wounds in General, and more particularly Gun-shot Wounds," the practical materials for which had been col.lected from his experience during our own civil wars of thosetimes. Though Wiseman’s work attracted but little attentionat the time, it is one of sterling merit, and abounds in manyjudicious precepts illustrated by remarkable cases. To one ofthese very important precepts Sir George Ballingall makesspecial reference in his own excellent lectures, " that in heatof fight, whether it be at sea or land, the chirurgeon ought toconsider, at the first dressing, what possibility there is of pre-serving the wounded member, and accordingly, if there be nomeans of saving it, to make an amputation at that instant,while the patient is free of fever"-a subject to which we shallhave occasion to refer in the course of these lectures.Towards the end of the seventeenth and beginning of the

eighteenth centuries, France could reckon amongst her armysurgeons Verduc, Beloste, Scipion-Abeille, and Anel, thensurgeon-in-chief of the armies, all of whom were men of greatmerit. Beloste had for a long time accompanied the army ofItaly, before he published his "Le Chirnrgicn d’Hopital," awork which met with much success at the time. But just atthis period France may be said to have excelled all othernations in her military surgery, while she could claim Petit,who improved it so as to give to the art a lustre it had notpossessed since the days of Ambrose Pare. Besides Petit, shecould about the same time boast of several other names ofcelebrity, at those of Faudacq and Ravaton, besides manydevoted to the instruction of pupils, such as Le Dran,Garangeot, and Dionis, who had previously introduced a newmethod of instruction, chiefly suggested to them by the plan ofthe Academy of Sciences. The necessity for precise and exactsurgical learning was soon seen, along with another not lessimportant necessity, that of being prepared and fitted for theseby previous learned studies. The recently established court of-Louis XV. showed itself disposed to second these efforts, andnothing could be more advantageous for bringing about arevolution, that spread rapidly through the schools, than thatindividuals could now behold there, in perspective, the con-sideration due to talent. From this time, the surgeons, whosemerits had caused them to be called to the chief employmentsin the army, both in the hospitals and other military offices,fitly endeavoured to profit from their opportunities, and toawake the boldness of their fellows, and agreed to open amongstthemselves voluntary meetings, where they could test their in-dividual intellectual strength. Such assemblies were formed,not merely for the purpose of acquiring self-reliance, but alsowith the view of rightly estimating the knowledge of theirbrethren, by mutual communication of opinions and principles,so as to give to military surgery, by their labours and dis-coveries, a lustre hitherto unknown. Their covert aim was to

oppose the pretensions of the physicians, then in possession ofsuperior prerogatives, which the surgeons were no longer dis-posed to admit. All these things led to a complete professionalschism, which ended by the institution, in 1731, of theAcademy of Surgery, of which the king was the founder andsupporter. The independence of character and freedom ofaction which the surgeons began to claim, since the institutionof the Academy, led to continual disputes between them andthe physicians, which were only brought to a close at the endof the year 1 i 60. By the institution of the Academy of Sur-gery, however, foreign associates were united with the Frenchfellows, and acting happily together as members of the sameprofession, they communicated to each other and to the worldtheir views and experience on subjects of military surgery.Heister at this time flourished in Germany, and Ranby, theprincipal serjeant-surgeon to George II., brought forth inLondon a treatise on Gun-shot Wounds. At the same period,a son of Le Dran’s, who had acquired much experience, re-turned to Paris, and was anxious to make such public throughthe press. Amongst the celebrated military surgeons of Francewho then flourished, we may enumerate the names of Desports,Bordenaave, Morand, Bagieu, Faure, Bourrienne, and Andouille,whose writings greatly improved surgical art. The subject ofprimary or secondary amputation was brought under discussion,in the memoirs addressed to the French Academy, by Bourde-naave and Bagieu, who maintained opinions adverse to those ofFaure, then disposed to recommend delay. Just at this time

Bilguer, the surgeon-general of the Prussian armies, publiclydefended, at Halie, a strange paradox, to the effect: "Demembrorum amputatione rarissime administranda, aut qnasiabroganda;" and enforces his opinion by the remark, "that tocut off a limb after a bad wound was but to heap new pains ona disordered system." " A hasty and absolute opinion is alwaysdangerous, and most generally an indication of unsound judg-

557

ment ; and when, at the present day, we know how generallythe opinion of surgeons is in favour of primary amputation, wemay well be astonished how Bilguer could have embraced sopalpable an er; or.

Military surgery had thus assumed a systematic form inFrance, during the reign of Louis XV. ; and various arrange-ments were made for the better instruction of young surgeonsdestined for military service with the troops and in the hos-pitals. Similar arrangements and a similar system were

adopted by most other states of continental Europe, and havebeen improved, from time to time, down to the campaigns ofBuonaparte and the work of Baron Larrey; but in this country,then, and even till within the last few years, our Governmenthas been content to benefit from the gratuitous labours of Mr.Guthrie, Hennen, and other military surgeons, whose worksrank their authors amongst the benefactors of mankind; andwho would, in other countries, have been at once honouredand rewarded. The injustice thus done to individual zeal, andthe liberality of professional character, is a subject too painfulfor unmoved contemplation; and the public service has, byrecent events and melancholy revelations, reaped the onlyfruit such indifference could produce.But while the improvement of military medicine and mili-

tary surgery has been almost ignored, if not discouraged inEngland-a nation whose soldiers are exposed to such varietiesof climate, through her vast possessions abroad, and duringher wars both in Asia and Africa, ought by this time to have elearned that mere medical or surgical instruction, relative toordinary diseases, as taught in the civil medical institutions ofthis country, could never convey to the minds of her military,naval, and East India medical officers, that knowledge of thediseases of camps and foreign stations, with which all shouldbe theoretically familiarized, before entering on militaryduties.The history of the two former departments of military medi-

cal knowledge, recognised by continental states as necessaryfor perfecting the instruction of their army medical officers, isa severe, though indirect censure of our national apathy andindifference on such matters. The want, too, of well digestedand systematic teaching in this country, on the subject of thepublic health, or hygiene, both civil and military, in its rela-tion to both political and social economy, is a scarcely lessnational defect, I might almost say disgrace. Dr. MichaelLevy, the eminent and intelligent chief medical officer of theFrench army now in the Crimea, in his very comprehensivetreatise on hygiene, says, the more this science is undecided inits limits, and, so to speak, in the amplitude of the subject, itmore concerns us to return to the exact consideration of the

phenomena of organization in conflict with the agencies of the- external world, and to establish it in its proper place; whichappears to me to be marked out between physiology and thera-peutics. " Since, every malady, in the words of Hippocrates,has’its natural cause, and without such cause no malady is I,produced," it behoves every rational and well educated phy- I,sician to pay not less attention to hygiene than to therapeutics,for the cure of his patients, both individually and collectively;and to give a due amount of consideration, in. all instances, tothe local as well as to the general causes of disease. The

public baths and gymnasia of the Romans; their places ofburial fixed outside the towns; their aqueducts and otherworks exercising a beneficial influence on the public health ; aswell as their municipal magistrates, or ediles, who watchedover the salubrity of the dwelling-houses and towns, show howmuch attention was devoted to different subjects of hygienein those ancient times; though they were afterwards, and forlong lost sight of, during the decline of the empire, and yetmore in the barbarous middle ages of Europe. The science of

hygiene must, it is true, borrow from kindred sciences of che-mistry, meteorology, and other branches of physics, yet itgives in return both a knowledge of the causes and preventionof diseases; and in it, as Dr. Levy says, therapeutics findgreater resources than are met with in the storehouse of phar-macy.Under the Greeks and Romans, the ancient physicians were

but imperfectly acquainted with the principles of physiology,or the real nature of the various bodily functions, though theywere well versed in the effects on the body of various kinds ofalimentation, habitations, and modes of life. Their inquiriesinto the cause of disease, therefore, turned chiefly to theircumfn8a of hygiene, or things that were without the body,and were mainly occupied in determining the effects of variousatmospheric changes associated with seasons and climate.From what could be learned of the nature of such they formedtheir opinions of the medical constitution of the differentseasons-opinions that were subsequently improved and en-

larged by the labours of Boerhaave, Pringle, Sydenham, SthaII,blead, Huxham, Fordyce, and Tissot. Of late years, how-ever, while an improved pathological anatomy and pathologicalchemistry have directed us to a more accurate investigation ofthe effects of morbific action in the organism, too little atten-tion has been paid to connect such effects with those atmo-spheric general and local causes by which they are produced.Now that an improved knowledge of general physics, che-

mistry, and meteorology have made us better acquainted withthe external and internal influence of different hygienic modi-ficators of vital action and organic processes, we have yet a.

wide field of improvement open to us, where accurate hygienicobservations connected with improved therapeutics, can con-duct us to a better practical system of rational medicine. Thework of regeneration must prove equally important to civiland military hygiene, and become the means of saving manyvaluable lives, that would otherwise be lost; but to be trulyuseful to the public or to the social and political economy ofthe State, it cannot, I repeat, be confined to the weak andinefficient hands of sanitary amateurs, unacquainted with theprinciples of medicine, phy.siology, and geneg-al p7Lysics. Morethan fifty years have witnessed the scientific and successfulcultivation of public hygiene in France, based on such princi-ples, and it is now high time that a similar system should beintroduced into the medical schools and the Government in-stitutions of this country.Having now conducted you imperfectly, but tediously, I

fear, through the history and progress of military medicine,military surgery, and hygiene, as provided for in the medicaleducational systems of other countries, and shown the short-comings of a yet limited provisional system of our own, it be-hoves me, as it gives me pleasure, to speak of the noble anddisinterested services of Mr. Guthrie in this field of professionallabour; of the scarcely less eminent services of Sir GeorgeBallingall, who has strenuously contended for the extension ofestablished military chairs of military surgery to other capitalcities of the empire besides Edinburgh; and of the useful butunobtrusive teaching on this subject of Mr. Tufnell, of Dublin.I cannot but approach with hesitation any allusion to my ownintentions in this matter, though I may, I think, confidentlyassert that the Medical School of St. Mary’s Hospital, foundedon the spirit of progress and a desire to supply a system pfmedical and surgical instruction fitted to the requirements ofthe age, will at least expect from me such an extended rangeof military medical instruction on those subjects as come legiti-mately within the field of the army medical officer’s observa-tion. From the extent and importance of the general principlesof instruction required for military surgery and medicine, briefand imperfect must be the exposition of those of hygiene, whichif taught efficiently, and in scientific relation to the two formersubjects, would require a separate and complete course of lec-tures for itself. In collecting together, and for a first course ofmilitary surgery and medicine in a recently established school,I feel, gentlemen, that during the present session I shall re-quire much of your indulgence and forbearance, as scarcely anygreat collections of drawings, casts, or preparations for the illus-tration of such subjects now exist in this country. I have, how-ever, I believe. made no unimportant beginning in this matter,thanks to the friendship and kindness of Sir George Ballingall,who, with the generosity characteristic of his nature, and theopen desire of public good worthy of his profession, has per-mitted me to have a regular series of casts made from Mr. Al-cock’s collection of bones, belonging to the Edinburgh University,as well as from those in his own private collection; all of whichare illustrative of gun-shot injuries of the head, trunk, and ex-tremities. Besides these favours, he has increased my obliga-tions to him, by allowing duplicate drawings to be made for mefrom his own collection on gun-shot wounds, with plans of mili-tary and naval hospitals remarkable for their advantages or de-fects, and a copy of Mr. Alcock’s’ "Catalogue Raisonn6, contain-ing many interesting cases and valuable practical observationson various gun-shot injuries. These, with the useful practicaldrawings and preparations, belonging to the surgical museumof the late Dr. Richard James Mackenzie, who died in theCrimea, after the battle of the Alma, are, I think, no inconsi-derable beginnings for obtaining a proper military surgical col-lection here. What it may now lack of materials for iiistrue-tion on military surgery and the diseases of foreign climates, Ishall endeavour to get supplied from collections in France orother places, and by pathological specimens from India. Andthough the course to be now given must be necessarily imper-fect and defective as a commencement, it is my earnest desireand determination that, should I be spared a few years, it shallbe made more perfect by time.Had military surgery, and its adjuncts military medicine

58

and hygiene, been earlier taught to our army medical officers,as accessory parts of their medical education ; and had thatconsideration from superior military authority due to suchknowledge, been extended to the department, particularly intime of active service, many mischievous consequences mighthave been averted, that have otherwise proved disastrous toour soldiers. If it had been the established system of theBritish army to take advice from the medical staff, in regardto the establishment of camps and hospitals, the site and con-struction of barracks, the amount of fatigue duty, the nature ofthe diet, or the suitableness of clothing for the troops, manyexpeditions rendered fruitless by sickness might have beenprevented, and this country spared a vast amount of useless ex-penditure and military misery. But regret for the past is ofno avail, and we must seek some consolation from our endea-vours to provide for the future. As part of a better system ofarmy medical organization for that future, the teaching ofmilitary surgery, in connexion with military medicine andhygiene, must, I repeat have place.

In conclusion, having pointed out what may be expectedfrom instruction in this school, relative to these subjects, Imay now ask what ought to be expected from Governmentregarding the whole matter? And without hesitation I mayreply, an improved and supplementary system of army andnavy medical education, with better medical organization, cal-culated to secure men’s professional zeal, excite their reason-able feelings of ambition, and to train them up in habits ofresponsible medical independence, not the slaves of routine, asat present, whereby medical intellectual comprehensiveness,in all relative duties to the soldier, would appear completelylost. However well meaning the intentions of ministers ofwar, and those in supreme military authority, may be in ordi-nary times, something more than these is wanted to meet theexigencies and prevent the usual disasters of war. Men inthose situations of national trust and responsibility must,through a master mind, be able to comprehensively grapplewith the whole difficulties of questions relative to the best and

And here let me briefly consider what course of teaching canafford the best promise of securing the full benefit proposed ;namely, the more extended knowledge of the medical officer,and an improved system of medical treatment and preven-tion of diseases amongst the troops. During a first course, atleast, it would be neither prudent nor profitable, I think,to pass at once into matters of pure operative surgery on thefield of battle, and leave unnoticed those abstract and elementalprinciples of knowledge, by which the well-informed medicalofficer is enabled to investigate the nature of disease in all itsphases, and to give an equally sound reason for his practice,whether in a surgical or medical case. Amid unhealthy and mala-rious camps, the army surgeon and physician will have to considerthe effects of those modifiers of vital action and morbid organicprocesses by which sphacelating wounds are presented for thesurgical skill of the former, or sloughing dysentery producedfor the medical treatment of the other. A like precise andcorrect knowledge of principles are necessary for an intelligentcomprehension of the modification of vascular action, whichpromote the healing of wounds and ulcers, or which tend toretard this process, ;and increase the rapidity of destructivechanges associated with this latter state. Arduous and im-portant as the operative art of military surgery may be, it isstill more important to have a nice appreciation of those prin-ciples, on which a sound and correct judgment can only beattained, as to the necessity of its interference. Without athorough knowledge, in short, of the physiology and pathologyof the inflammatory process and its results, modified by thepeculiar contingencies of military life, the military medicalofficer, if called on to treat either external or internal diseases,must frequently find himself, in his professional career, withoutrudder or compass for his guidance. I propose, therefore, inthe earlier lectures, to treat of inflammation, its modificationsand consequences as seen in military life, before proceeding toother more complicated forms of disease and injury, and witha desire to avoid dogmatical opinions of practice, unsupportedby valid principles of the best modern pathology.

In the writings of Mr. Guthrie, Hennen, Sir George Ballin-gall, Mr. C. Hutchinson, Barron Larrey, Hammick, and others,may be found much interesting and valuable information, re-quisite for the guidance of the military surgeon, on most occa-sions of difficulty; and regarding the diseases of the East andWest Indies, the works of Hillary, Mosley, Bancroft, Chisholm,Jackson, Curtis, Annesley, and Martin, may be consulted withmuch advantage. My friend and former assistant, Dr. More-head, who is chief of the Medical College at Bombay, is now inEngland, and is about to publish a work, much required, onthe diseases of India.

most effective organization necessary for carrying out changesand improvements, for the requisite omcial instruction andduties of the general staff and medical department, along witha better arranged commissariat, ambulance, and transportservice.

It would be altogether out of place, on this occasion, shouldI endeavour to develope, in detail, any proposed series of mea-sures likely to secure the object of better working efficiency inthe medical department of the army; and I may content myselfwith saying that the groundwork of better internal usefulnessof the department must be to cultivate a higher and more re-sponsible standard of professional qualification amongst itsofficers, and entrust them with power and means of indepen-dent action, whenever such, under the sanction of superiormilitary authority, may be necessary for the welfare of thesick.

Connected with this subject, the establishment of royalprofessorships of military surgery for Dublin and this metro-polis has been already thought of. In regard to this, however,I quite agree with Mr. Guthrie, that what may be very rightand proper for Edinburgh and Dublin would, with the numerousschools and hospitals of this great metropolis, be altogetherinapplicable here. It should not be given, in London, as aprivate favour to any particular school, but be instituted inconnexion with the Royal College of Surgeons, where the pre-lections of the Professor of Military Surgery, Diseases of ForeignClimates, and Hygiene, should be annual, and given in thesummer season; while, during winter, such professor shouldbe also obliged to deliver clinical lectures, alternately at thedifferent metropolitan hospitals, in which a special ward shouldbe appropriated for the reception of military diseases, and forinjuries and accidents naturally allied to them. Such wouldbe the only way to prevent the means of a proper militarysurgical collection being frittered away, without its utilitybeing made applicable to the general improvement of armyprofessional knowledge, or the benefit of the State. A specialcourse of lectures on particular subjects, such as the militarysyphilitic diseases of British troops, ulcers of soldiers and sea-men, scorbutic forms of disease, and different sections of thedepartment of hygiene, might thus be given at the College of-Surgeons with great professional advantage; and I sincerelyhope Government may be disposed to thus meet the require-ments of the age.

HISTORY OF

A CASE OF PULSATING ENCEPHALOID OFTHE FOREARM.

BY JOHN ERICHSEN, ESQ.,PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE, ETC.

To the Editor of THE LANCET.SzR,-If I needed any additional reason for declining to-

answer questions put by Mr. Syme in what I conceived andstill hold to be a form that is neither in accordance with theusage of the profession or of gentlemen, I should feel myselfjustified by the letter sent by that surgeon to THE LANCETlast week.With one who, " willing to wound, but yet afraid to strike,"

endeavours to traduce the character of his professional brethren.by inuendo and insinuation, I must still decline to hold anydirect communication beyond giving his unworthy imputationsan unqualified denial, as utterly and in every respect untrue.

1 must also adhere to the opinion expressed in my previousletter, that before the details of a private case were publiclybrought before the profession-whether in a clinical lecture ornot matters little-it should have been the duty of Mr. Symeto have ascertained, from one or other of the surgeons consulted,whether the statements he had indirectly received, throughnon-professional channels, of their opinions and practice, werecorrect.

, That one holding the position of Mr. Syme should be so farforgetful of the ordinary courtesies of professional life, of theurbanity that is the characteristic of a gentleman, and of thatdignity and candour of which, as a teacher, he ought to set anexample in his sphere, as to make " reports now current inEdinburgh" the ground of unjust and unfounded insinuationsagainst others, whose characters are too well known to theprofession and the public to need my defence, must be a matterof deep regret to all who are in the habit of associating a keensense of honour, and a love of truth and justice, with the highpositions of our profession.By the accompanying history, which I publish with the per-