Very Perilous: A sword wounds compendium by the surgeon Ravaton

 

By Maxime Chouinard

In the few years I spent as a medical museum curator, I was brought to read and examine many different period sources on the subject of health care. One of those is Hugues Ravaton’s Chirurgie d’armée, a seminal work in the history of European surgery and one which is also of great interest to the subject of this blog. I decided to translate and publish parts of this treatise here which I hope you will also find useful. This will be part of an upcoming book on the medical context of HEMA, or how medical knowledge was applied to martial arts as well as to the results of their deadly use.

At the time of publishing his book in 1768, Ravaton had worked as a military surgeon for 36 years, and was then Surgeon Major of the Landau hospital. Landau was then a French possession at the easternmost extremity of the Kingdom. The hospital was one of the main evacuation hospitals for the army, and Ravaton would have been at the forefront of the War of Austrian Succession and the Seven Years War.  He is now mostly known for pioneering the double flap method of amputation but also for authoring his treatise Chirurgie d’armée, which stayed a reference for more than a century. The book is in two parts, the first dealing with wounds from firearms, and the second from swords.

What makes his work especially interesting for people studying historical fencing  is that, according to Edmond Delorme, Ravaton presents the first and most extensive work on cold steel wounds, with 217 pages and 35 observations.[1] And contrary to previous authors, Ravaton does not focus his work on curious and rare cases, but rather on relatively common ones so that surgeons may learn from his experience. He gives us a sobering look at what swords can do to the human body, a reality that we often forget in the abstract practice that is HEMA.

But why examine a nearly 300 year old book? Why not just ask a modern trauma surgeon? First, because it serves as a medical context to fencing, both in terms of what could be done to heal those wounds, and what certain wounds could do. It is possible that a fencer would try to inflict wounds that may reliably kill or rather simply incapacitate his opponent, and the state of medicine at the time might directly or indirectly influence what he chose to do. The popularization of artery ligatures, for example, in the mid 16th century made the survival rate from cutting wounds jump while thrusts remained as difficult to heal.

Secondly, while modern medicine is leagues apart from what was done back in the mid 18th century, and where even a novice surgeon has more theoretical understanding of the human body than Ravaton ever had, his practical experience with sword wounds is something that is unknown to any surgeon today. In 36 years of practice as a military surgeon, Ravaton treated a number of blade wounds that is probably difficult to imagine today in a world where swords and bayonets injuries are but medical oddities. Knives are still common, more so in certain areas than others, but perhaps less so than in a Seven Years War battlefield, and their effect is going to be much different than that of a sword. It is then interesting to read the take of a man who practiced under such a different context.

On this last part, you will notice a few things. Thrusts to the cranium very rarely penetrate, even with a bayonet, but can cause severe brain trauma if done with force. The brain is fairly well protected against thrusts which can only enter by a few passages of the skull. Thrusts to the body are, by far, the deadliest, even more so to the heart. Thrusts to that organ are, according to the author, simply never brought to the attention of the surgeon. Ravaton follows the prevailing opinion of the time that thrusts are deadlier than cuts; at least to those that are brought before him.

This point is somewhat important to remember. You will not see in this treatise cases of decapitation, or of heads and bodies split in two. Even though he briefly discusses a few invariably mortal wounds, he mostly develops on those that may be treatable as this is obviously a surgery manual and not a forensic medicine one. For this reason, details of the fights themselves are unfortunately very sparse, unless they affected the treatment.

Ravaton is impressive in his knowledge of anatomy, no doubt developed through countless surgeries but also through dissections, many he describes in his book. He gives us a different outlook on the 18th century surgeon that goes beyond the butcher caricature that we are often presented with.[2]

In view of the massive work that this treatise represents, I chose to only translate parts that I found to be relevant to fencing, and for this reason, I only summarized patient cases and avoided presenting treatments which would be interesting to a health care historian but not so much for our own study. If you do read this part of the treatise, I would of course not recommend that you try any of his treatments at home and seek medical attention if, perish the thought, you are ever presented with such situations.

Finally, I would like to warn the reader that this treatise can be extremely graphic in nature. Faint-hearted be warned!

 

For the entire treatise in its original language[3], click here.

 

Of sword thrusts to the head

 

Sword thrusts to the head that are given with force can penetrate the brain, through the orbit, the nose or the mouth and cause a swift death.

Two sergeants of the Louvigny Regiment, fenced in a cabaret with their swords in the scabbard. One of them received a thrust in the nostril and fell dead. I opened him and found that the tip had broken the spungic bone (i.e. concha) and penetrated well into the brain.

Some time later was brought in this hospital a soldier of Tallart who just received a similar thrust in the mouth. He had lost consciousness and fell into convulsions and died three hours later. I opened him and found that the tip of the scabbard had penetrated the brain by the grand hole of the occipital.[4]

Two officers had fought in the woods near Landau to end an old quarrel. One of them received a sword thrust that entered right above the inner cantus of the right eye near the nose and fell dead. The outside opening was so small that, even with the opinion of the Surgeon Major of the regiment, his comrades doubted that this was the only cause of death. I was queried, opened the brain, and found it punctured from one side to the other.

Those thrusts that are not penetrating can hit the bones of the skull violently enough to cause complications. If, on the contrary, they only affect the muscles, membranes, the tongue, etc, and are without any hemorrhage, the complications are then less. We can presume that if the eyeball is affected you could lose the use of that organ.

Sword thrusts to the collar, with lesions of the spinal cord, of arteries and nerves of a certain volume are deadly or very perilous.

Those that interest the esophagus and the trachea present difficulties. All the other thrusts to the collar that only affect the flesh or fatty tissues usually heal well.

I saw many bayonet thrusts on the bones of the skull which, even though superficial, gave many difficulties to the healing process, because the violence of the strike had shaken the brain and tore the periosteum.

Ravaton describes an Irish soldier from Dilon’s Regiment who received a bayonet thrust to the crown of the head which uncovered part of the parietal bone. Infection had set in and things looked grim, but after some treatment he showed major improvements after the third day.

A soldier of the Queen’s Regiment received during a duel a sword thrust to the right eye which broke the lacrimal bone. He showed up with his eye bulging and inflamed and was only given a bandage. Ravaton examined him on the following day as things were taking a turn for the worse. He examined the eye and removed bone splinters. After treatments, the soldier’s eye was saved.

In September 1736, an officer from the de la Mark Regiment received a thrust during a duel which entered by the middle of the right cheek and went out underneath the left ear. The officer was losing a lot of blood through his mouth. After several days of bandages and treatments, the wound was closed but the movement of the neck remained difficult.

A soldier from the Alsacian Regiment received during a duel a sword thrust underneath the right ear near the jaw’s articulation. This was followed by violent blood loss. Ravaton used every trick in the book to try to stop the bleeding for 7 long hours, including powders of vitriol, dragon’s blood (a plant resin) bandages and touchwood, all to no avail. The man died in his arms. The autopsy revealed that the thrust had cut the carotid artery clean off.

A dragoon of the Beaufremont regiment received a sword thrust in the mouth in March of 1735. The sword had gone through the esophagus and exited right next to a neck vertebrae on the left side with minimal hemorrhage. The soldier believed himself lost, but healed up very quickly and was out in a few days. Ravaton cites two other cases of soldiers who healed quite rapidly from thrusts to the neck, including one which pierced the trachea.

One thing to take out from these cases is how difficult it is to reach the brain with a thrust (using smallswords, broadsword, sabres or bayonets, obviously this does not concern warhammers or crossbow bolts). The skull is fairly impervious to them, and the few cases presented by Ravaton where the blade managed to find its way there seem to be incredible feats of luck (or rather bad luck) with the blade managing to pierce certain parts of the eye socket, the concha or – by an incredible throw of the dice – through the mouth while the opponent held his head in a favorable angle for it to reach the occipital hole. A very skilled fencer might be able to reach the eyes, but the other targets seem rather too difficult to even contemplate.

Of sword thrusts to the chest

 

Sword thrusts to the chest are superficial or penetrating. The superficial ones must be regarded as simple wounds, those that penetrate in the chest cavity can have an infinity of different directions, and affect many essential parts so we must regard them as very perilous. (…)

Sword thrusts to the chest which open the heart’s ventricles or the large blood vessels are never brought to the attention of surgeons, and by consequence do not merit any details. Those that attack the spinal cord are untreatable.[5]

Those that open blood vessels and cut nerves of a lesser volume, that affect the esophagus, the trachea, the pericardium or the superficies of the heart’s fibers, although very severe, are not without solutions.

We very often heal wounds to the lobes of the lungs and to the chest cavities. If the thoracic canal or the azygos vein was to be opened, the wounded languishes, dries and dies of internal bleeding.

The following section of his book deals with thrusts to the chest. I will not go into too much detail on them here, but Ravaton does make it quite clear how deadly they could be, with a multitude of cases ending with the death of the patient. In an era with no anesthesia, operating on the chest was a difficult if not impossible venture. Right up to the First World War, penetrating chest wounds were still considered to be among the deadliest and in many cases impossible to treat. [6]

Some interesting cases are a soldier from the Lorraine Regiment, who in a duel received a sword thrust in each thigh, before receiving one to the body which dropped him. The two wounds to the thighs healed easily. The wound to the abdomen went right through the right hypochondrium and exited through the left lumbar square. The man was in great pain, suffered from jaundice and excreted a lot of blood but was able to leave more or less after 15 days. Ravaton cites it mostly as a medical curiosity.

 

Of Sword thrusts to the abdomen

 

Thrusts on the lower abdomen are generally more severe than those of the chest, not because of the nature of the lesion, neither due to the particular composition of these parts, but of the difficulty to evacuate the liquids that are spilled.

Sword thrusts to the abdomen that open the aorta, the vena cava, the iliac veins and arteries and the coeliac trunk, the renals, the portal vein near the liver and an infinity of other veins of great volumes, that cut big nerve trunks or which penetrate the spinal cord leave so little solutions for healing that it would be dishonest to enter in any details on their subject. Those that pass from the lower abdomen to the chest are very perilous, especially if the tendinous part of the diaphragm was affected due to its extreme sensibility and the complications that accompany it. (…)

It is not the same with thrusts that affect the epiploon, the liver, the spleen, the pancreas, the kidneys, the bladder, the stomach and the intestines. They can be healed if the thrusts are only touching their surface, but if the Glisson’s capsule is opened, as well as the gallbladder, the spleen, the scissure opening to the blood vessels and nerves, the pancreas, the kidneys, the ureters and renal pelvis, the superior or inferior openings of the stomach, the opening of the bladder and the seminal vesicles; those may lead to irremediable complications.

 

Of sword thrusts to the limbs in general

 

Sword thrusts to the upper and lower limbs that open the brachial or crural arteries above their divisions demand that the limb be amputated without delay to secure the life of the wounded.

The opening of the main arteries of the forearm or the leg and the lesion of the big nerve trunks cut at their source become often irremediable if fever appears because the hemorrhage will often renew, that it gives much anxiety and pains to the surgeon, and puts the wounded in pressing danger. The rupture of the great nerve trunks destroys sensibility, movement, and causes the limb to dry out.

Thrusts to the extremities that penetrate the articulatory cavities with rupture of the ligaments and tendons are always very unfortunate. The plurality of these sections, the situation and the spread of the wound will aggravate the illness.

Ravaton describes the case of a cornet from the Beaucaire Regiment, returning from the German Wars in 1736, fought a duel with a lieutenant. The cornet received a thrust to the right thigh. The hemorrhage was violent and the Surgeon Major had the wounded brought to a peasant’s house nearby. Ravaton arrived and found the wounded in intense pain. Ravaton was extremely surprised that none of the officers present thought to put a ligature over the wound to stop the bleeding, which could have saved his life. He instantly used his bloodletting ligature and gave him spirits, but it was too late and the patient passed away. The autopsy revealed that the femoral vein and artery had been opened.

Ravaton describes the case of a Grenadier of Perigord who received, in March 1731, a thrust to the right thigh. The soldier only visited the hospital five days later complaining of intense pain and suffering from a high fever. Ravaton tried many treatments on the soldier, with little success, until he opened a bulge under the fascia lata, from which a lot of pus came out. Inside the opening, he found, to his great surprise, a piece of the sword, half an inch in length lodged in the bone. He managed to remove it. The patient eventually recovered. Ravaton comments on how rare it is to find a foreign body lodged in the bone, and that very few mentions are made of such cases in the annals of surgery.

A Swiss soldier in the regiment of Brendelé received a sabre thrust to the inside of the middle of the right arm which opened the brachial artery. As the patient was young and otherwise in good health, he hesitated in amputating. Instead, he decided to simply ligature the artery and bandaged the wound. In the morning, the soldier’s arm was infected, pale and bloated. He decided to finally amputate. The soldier was up on his feet after a month.

In March 1747, Sieur Legrand, a comedian of the Palatine Court, had received, 22 days earlier, a sword thrust to the wrist entering by the artery and showing no sign of an exit wound. The blood loss continued even though all was tried to stop it. Ravaton was then sent to see him. After some treatment, the patient appeared to be out of danger, but just as he was about to leave, the hemorrhage started once more and this time nothing could stop it until Legrand expired. Ravaton did an autopsy in front of many surgeons and physicians and found that the thrust had gone all the way through the arm and into the chest, following the artery which was completely detached from neighboring tissues.

 

Wounds from cutting weapons

 

Cutting wounds are in general less severe than thrusts because they cause wounds on the surface of the body of which the entry is larger than the base and so the surgeon can see on the first look what he needs to do. (…)

Cutting wounds that affect only the skin are more or less severe depending on their directions and the affected parts. Their direction will make them severe if the skin is cut sideways, that is to say, contrary to the creases of the skin.

The affected parts are also different from each other. The wounds of the skin covering the elbow, the hand, the knees and the foot are more severe than other parts. Those of the face demand particular attention to avoid deformities. (…)

The fleshy body of the muscles might have been totally cut or in part, depending on the direction of the fibers, or sideways. The danger augments in proportion to the plurality of the division and the function of the muscles cut.

A lesion of the extensor and flexor tendons of the leg, the Achilles tendon, the extensors of the foot and the fingers, the flexor of the forearm, the extensors and extensors of the hand and the fingers form very severe wounds, that are often accompanied by great complications and which bring infinite difficulties in their healing.

There is a principle of the School, which is still followed today, which says that a tendon cut halfway causes disastrous complications which can only be avoided by finishing to cut the tendon.

This principle is false, because when you want to reunite a cut tendon you need to flex the limb to connect the ends, and so it follows that the alleged tugging must cease. But what answers the question without a doubt are the infinite number of reunions of tendons, more or less considerable, that I had the opportunity of doing. I never had recourse to this cruel method even when I observed, before closing a wound, that many tendons had been cut halfway. (…)

Cutting wounds that cut bones suppose the entire section of the flesh, vessels, tendons and ligaments that cover them and meet in their direction. These complex wounds are more or less severe following their localization, the number of fleshy parts divided and the volume of vessels opened, etc. They present different curative indications from the others because the hemorrhage demands first the ligature of the opened vessels, dabbing or the application of astringents styptics. The wound of the bone can also be accompanied by splinters that have to be removed before the wound is closed.

Pieces of skin and flesh that are partly separated only demand that you reunite them. Those with parts of bones attached to them demand a particular examination to recognize if parts of the bone are divided, as in this case you will need to delicately extract the splinters and then close the wound.

Limbs entirely separated from the body demand no explanation as experience often convinced me of the impossibility of their reunion.

 

Wounds to the skull, the chest and the belly in general, done by cutting instruments

 

Cuts that hit the skull with force and violence are very severe, even if the wound to the skin is light. Those that form great wounds and which hew through the skull  are infinitely less. The reasons for this difference are that in the first case the skull might have been shaken and that there might be an effusion of blood on the brain which is often ignored for quite some time. While in the second case the shock on the brain is less to fear and that you quickly see what you need to do. This is why penetrating wounds to the skull are less severe than those that deeply affect the bones.

Cutting wounds to the face are often less severe than those of the skull. They can be limited to the flesh, affect the bones and separate entirely one from the other.

Those of the collar are more or less severe depending on the parts that are affected. The section of the carotids is fatal, that of the trachea, the oesophagus and the flexor muscles of the head are very severe.

I have seen chest wounds made by sabres that cut the clavicles, the scapulas, others one or many ribs or the sternum with no lesions to the parts contained within, or which affected more or less the lungs.

Cutting wounds that open the cavity of the lower abdomen are generally very severe because of the evacuation of the intestines or the epiploon which always accompany them, and the lesions to these viscera. Wounds situated in the hypogastric region are more severe than those above, by the section of the aponeuroses of the muscles that never reunite, and to which always follow hernias.

Those that cut the straight muscles diagonally are, to say it simply, irreparable, by the precipitated fall of a big section of intestines, by the difficulty to contain them, and by the movement that this cavity opposes to the reunion of this division.

Ravaton describes many strikes to the head. Some affect the brain in various ways, the patient surviving or not. The skull being definitely easier to cut than it is to pierce. One interesting case is that of two Grenadiers of the Saint Germain Regiment who hacked each other. The first had received a sabre cut along the sagittal suture which did not reach the brain, two cuts on the right side of the coronal which caused splinters, the right ear was gone, the nose was half cut, two cuts on his right hand with lesions to the tendons and three on the elbow along with two fingers of the left hand cut off. After treatments he left the hospital after sixty-five days.

The other grenadier also had a cut on his right parietal which had shattered a small part of the bone, two light cuts on the chin, a light one on the left wrist and another that cut through several tendons of the right hand. The wounds of the hands healed quickly, but after a few days he suffered from numbness in his left arm, cold sweat and pressure in his head and soon the limbs of the left side were paralyzed, the jaw and the tongue also became numb. The patient fell unconscious and died in convulsions. Ravaton noticed that blood had accumulated on the brain. These symptoms might sound like an intracerebral stroke. Ravaton was surprised by the result since he thought the first in more immediate danger than the second. His hypotheses were that either the first patient had a thicker skull, or that the sabre was sharper and had penetrated the skull more than it shook the brain, causing, ironically, less damage.[7]

Ravaton also describes several other wounds to the face, of which he says he repaired a prodigious amount, including detached noses, ears, cheeks and even eyelids and lower jaws. Cuts to the neck are also described, including patients surviving cuts to the jugular vein or the trachea. On the latter, Ravaton assures us that wounds to the trachea tend to heal well unless they are accompanied by lesions to the neighboring blood vessels.

 

Of cuts to the limbs in general

 

I saw so many sabre cuts to the extremities that it would be abusing the reader’s indulgence to report them all. I will limit myself by choosing those that seem the most interesting and the most proper to the instruction of young surgeons.

Sabre cuts to the upper limbs, as well as the lower ones, can follow an infinite number of directions and form divisions more or less deep and wide. These divisions can only affect the skin, or the fat, the flesh, the vessels, the tendons, the bones and even take out the whole limbs as I saw many times.

The wounds going across are generally more severe than those made in the direction of the muscle fibers and the wrinkles of the skin. Those that are accompanied by the opening of the brachial artery, or the crural above their division, necessarily lead to the loss of the limb. If the great branches of nerves were destroyed in their origin, the limb will wither, become weaker, lose movement, feeling, etc.

The more ordinary sabre cuts that are still very severe, are those that after cutting numerous tendons and bones open the articulations. I saw an infinite number of this kind on the wrist. Wounds across the elbow, that open the articulation, also oppose a lot of resistance.

 

Of sword cuts to the upper limbs in particular

 

Sabre cuts to the upper limbs are generally less severe than those of the lower ones, supposing a lesion equal on both parts. It is easy to sense this difference if we are aware that the return of the blood is made more easily to the arm than the leg because the leg supports the weight of the body, that it has more volume and length While the arm can be supported by a sling the leg can only receive this salvation through the bed. Other than the volume of blood that is circulating in it, the difficulty of its return forces it to go against its own weight.

Ravaton cites a few cases here that are very interesting to people practicing military sabre, as the arm is often a primary target. The first is a sergeant, fencing master in the Saint-Germain Regiment, which enters into a duel with the Espadon Master of Grenadiers Battalion of the Montpellier Militia. The sergeant received a sabre cut to the upper part of the right arm which separated a great piece of the deltoid muscle and cut through the bone of the arm. Ravaton thought the arm had to be amputated because of the great hemorrhage which could have indicated that the brachial artery was cut. He went to explore the wound (I leave you to imagine the horrible experience of the poor sergeant) and discovers that it is not the case. He successfully treats it, and the sergeant is sent home. His hand and elbow articulations stayed weak, and the overall arm emaciated.

A Hussar of the Berchiny Regiment received a sabre cut in a duel that cut the left arm’s cubitus near the elbow. Ravaton removed some of the bone slivers. The wounded recovered in 53 days.

In 1732, a Grenadier of the Aunis Regiment named Bonne-Nouvelle (Good News) received a cut to the lower outside part of the right forearm. This cut went through the lower condyle of the cubitus as well as the extensor tendons of the carpi and finger muscles. The sabre was not very sharp, and tore through these parts rather than cut. Ravaton went through a series of treatments that I will not describe here, except for one very original one: the patient had to regularly put his hand through the neck of a recently slaughtered bull. The treatment did not do much (as could be imagined) and the soldier was regrettably sent home. Nevertheless, 14 years later, Ravaton encountered the man again who had completely healed.

A similar case is given in 1747 of a soldier of the Alsatian Regiment who received a cut this time to the inside of the forearm, with much the same results. The recovery was much quicker, possibly because infection did not set in, but the hand remained weak after a month. Three months later, the patient had almost completely recovered.

Jacob, another soldier of the Alsatian Regiment, received to his right hand a cut from the back edge of a sabre’s point which started to divide the hand under the trapezium bone. This cut went through the annular ligament, all the flexor tendons of the fingers and partly those of the hand. This soldier was not as lucky, as most of the affected ligaments had to be cut out. The wound healed in 18 days.

 

Of cuts to the lower limbs

 

Cuts to the lower limbs that open the crural artery lead quickly to its loss. That is to say, the necessity of the amputation of the thigh. Those that cut the muscles across, particularly the fascia lata demand a considerable time for their healing. Those that affect the patella, the extensor tendon of the leg or that open the articulation of the knee are accompanied by great problems, and the wounded will take a long time to heal. The lesion of the leg’s bones, of the membrane that covers the external part of the muscles, that of the Achilles tendon, of the annular ligament, of the extensor tendons of the foot and fingers always cause many problems and great length to their healing. This healing only restores partly the movement of the limbs.

 

Thank you to Jean-Philippe Wojas for proofreading.

 

 

[1]  DELORME, Edmond. Traité de chirurgie de guerre. Volume 1, 1893.

[2] Contrary to a popular assumption, dissections were not always frowned upon before the 18th century. Cities and countries had different and evolving views on the subject all throughout European history.

[3]  One curious thing about this treatise is that it is exactly 666 pages long.

[4] This is the first time I have seen mentions of soldiers fencing with their swords in the scabbard, but it was apparently not an isolated case. This might also explain why some swords were fitted with scabbard drags to turn them into drilling swords in the 19th century.

[5] We are often led to believe that the foil fencing rule of targeting exclusively the chest and particularly the heart while leaving the head off target was some sort of sportive practice which concerned mostly the safety of the fencers. Yet, when reading treatises such as Ravaton, we are left to see that a thrust to the heart was the surest and quickest way to kill an opponent and that thrusts to the body were among the most lethal. After 36 years of experience, Ravaton is very clear that thrusts to the heart are invariably fatal. In my research, I have so far found very few mentions of someone not being killed immediately by such an injury, the most popularly cited being a case reported by Ambroise Paré in his treatise of 1585 of a man who was stabbed through the heart in a duel and was able to pursue his opponents over 200 steps before falling dead. Other such cases spread over time from Antiquity to the 1820s are listed by Dupuytren, but seem to be rare medical curiosities. These results also seem to line up with the morgue reports analyzed by Brioist, Drevillon and Serna in Croiser le fer. Champ Vallon, 2008.

[6] Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: a historical review. Clin Orthop Relat Res. 2009;467(8):2168–2191.

[7] This case is interesting in many ways. Firstly in how many severe cuts were dealt to each combatant. It is hard to say which one ended the fight, but we can presume that the fighters were able to keep fighting through most of them.