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Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Clinical Emergency Radiology

Second Edition
This book is a highly visual guide to the radiographic and advanced imaging modalities –
such as computed tomography and ultrasonography – that are frequently used by physicians
during the treatment of emergency patients. Covering practices ranging from ultrasound at
the point of care to the interpretation of CT scan results, this book contains more than 2,200
images, each with detailed captions and line art that highlight key findings. Within each
section, particular attention is devoted to practical tricks of the trade and tips for avoiding
common pitfalls. This book is a useful source for experienced clinicians, residents, mid-level
providers, and medical students who want to maximize the diagnostic accuracy of each
modality without losing valuable time.

J. Christian Fox received his undergraduate degree at University of California, Irvine, and his MD at
Tufts Medical School. Since joining the UC Irvine faculty in 2001 as Chief of the Division of Emergency
Ultrasound, he has directed the Ultrasound Fellowship. In 2010 he created a fully integrated four-year
ultrasound curriculum at the School of Medicine. He is the editor of Clinical Emergency Radiology as
well as Atlas of Emergency Ultrasound, and has authored over eighty articles on ultrasound.

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Clinical Emergency Radiology

Second Edition

Edited by
J. Christian Fox
University of California, Irvine

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

University Printing House, Cambridge CB2 8BS, United Kingdom

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Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107065796
© J. Christian Fox 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2008
Second edition 2017
Printed in the United States of America by Sheridan Books, Inc.
A catalog record for this publication is available from the British Library.
ISBN 978-1-107-06579-6 Hardback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
..............................................................................................................................

Every effort has been made in preparing this book to provide accurate and
up-to-date information that is in accord with accepted standards and
practice at the time of publication. Although case histories are drawn from
actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors, and publishers can
make no warranties that the information contained herein is totally free
from error, not least because clinical standards are constantly changing
through research and regulation. The authors, editors, and publishers
therefore disclaim all liability for direct or consequential damages resulting
from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.

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Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
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Contents
List of Contributors vii

Part I–Plain Radiography 16 Deep Venous Thrombosis 239

Eitan Dickman, David Blehar, and Romolo Gaspari
1 Plain Radiography of the Upper Extremity in
Adults 1 17 Cardiac Ultrasound 247
Kenny Banh and Gregory W. Hendey Chris Moore and James Hwang

2 Lower Extremity Plain Radiography 11 18 Emergency Ultrasonography of the Kidneys and

Anthony J. Medak, Tudor H. Hughes, and Stephen Urinary Tract 261
R. Hayden Anthony J. Dean and Ross Kessler

3 Chest Radiograph 41 19 Ultrasonography of the Abdominal Aorta 276

Peter DeBlieux and Lisa Mills Deepak Chandwani

4 Plain Film Evaluation of the Abdomen 55 20 Ultrasound-Guided Procedures 284

Anthony J. Dean and Ross Kessler Daniel D. Price and Sharon R. Wilson

5 Plain Radiography of the C-spine 79 21 Abdominal–Pelvic Ultrasound 313

Eric Fox Silman Mike Lambert

6 Thoracic and Lumbar Spine 96 22 Ocular Ultrasound 324

Olusola Balogun, Natalie Kmetuk, and Christine Viet Tran and Zareth Irwin
Kulstad 23 Testicular Ultrasound 331
7 Plain Radiography of the Pediatric Extremity 107 Paul R. Sierzenski and Gillian Baty
Kenneth T. Kwon and Lauren M. Pellman 24 Abdominal Ultrasound 338
8 Plain Radiographs of the Pediatric Chest 120 Shane Arishenkoff
Loren G. Yamamoto 25 Emergency Musculoskeletal Ultrasound 346
9 Plain Film Radiographs of the Pediatric Tala Elia and JoAnne McDonough
Abdomen 144 26 Soft Tissue Ultrasound 359
Loren G. Yamamoto Seric S. Cusick and Katrina Dean
10 Plain Radiography in Child Abuse 174 27 Ultrasound in Resuscitation 368
Kenneth T. Kwon and Lauren M. Pellman Anthony J. Weekes and Resa E. Lewiss
11 Plain Radiography in the Elderly 178
Ross Kessler and Anthony J. Dean
Part III–Computed Tomography
28 CT in the ED: Special Considerations 401
Part II–Ultrasound Tarina Kang and Melissa Joseph
12 Introduction to Bedside Ultrasound 195 29 CT of the Spine 407
Michael Peterson and Zahir Basrai Michael E. R. Habicht and Samantha Costantini
13 Physics of Ultrasound 201 30 CT Imaging of the Head 422
Seric S. Cusick and Theodore J. Nielsen Marlowe Majoewsky and Stuart Swadron
14 Biliary Ultrasound 211 31 CT Imaging of the Face 439
William Scruggs and Laleh Gharahbaghian Monica Kathleen Wattana and Tareg Bey
15 Trauma Ultrasound 227 32 CT of the Chest 456
Bret Nelson Jonathan Patane and Megan Boysen-Osborn
v

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Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
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Contents

33 CT of the Abdomen and Pelvis 469 39 MRI of the Brain 519

Nichole S. Meissner and Matthew O. Dolich Asmita Patel, Colleen Crowe, and Brian Sayger
34 CT Angiography of the Chest 479 40 MRI of the Spine 538
Swaminatha V. Gurudevan and Reza Arsanjani Aaron J. Harries, Andrew V. Bokarius, Armando
S. Garza, and J. Christian Fox
35 CT Angiography of the Abdominal Vasculature 484
Kathleen Latouf, Steve Nanini, and Martha Villalba 41 MRI of the Heart and Chest 559
Jonathan Patane, Bryan Sloane, and Mark Langdorf
36 CT Angiography of the Head and Neck 495
Saud Siddiqui and Monica Wattana 42 MRI of the Abdomen 568
Lance Beier, Nilasha Ghosh, Andrew Berg, and
37 CT Angiography of the Extremities 505
Andrew Wong
Nilasha Ghosh, Chanel Fischetti, Andrew Berg,
and Bharath Chakravarthy 43 MRI of the Extremities 583
Kathryn J. Stevens and Shaun V. Mohan

Part IV–Magnetic Resonance Imaging

38 The Physics of MRI 515
Joseph L. Dinglasan, Jr., and J. Christian Fox Index 630

vi

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Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
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More Information

Contributors

Kenny Banh Laleh Gharahbaghian

University of California, San Francisco – Fresno Stanford University

Gregory Hendey Bret Nelson

University of California Los Angeles Mount Sinai University

Peter DeBlieux Eitan Dickman

Louisiana State University Maimonides Medical Center
Lisa Mills David Blehar
University of California, Davis University of Massachussets

Anthony J. Dean Romolo Gaspari

University of Pennsylvania University of Massachussets

Ross Kessler Chris Moore

University of Michigan Yale University
Eric Fox Silman James Hwang
University of California, San Francisco Scripps Memorial Hospital, La Jolla, California

Olusola Balogun Deepak Chandwani

University of Illinois, Chicago Christ Hospital University of California, Riverside

Natalie Kmetuk Daniel D. Price

University of Illinois, Chicago Christ Hospital Alameda County Medical Center, Highland Hospital
Christine Kulstad Sharon R. Wilson
University of Illinois, Chicago Christ Hospital University of California, Davis

Kenneth T. Kwon Michael Lambert

Mission Hospital, Mission Viejo, California University of Illinois, Chicago Christ Hospital

Lauren Pellman Viet Tran

University of Nevada, Las Vegas Garden Grove Medical Center, California
Loren G. Yamamoto Zareth Irwin
University of Hawaii Legacy Emanuel Medical Center, Portland, Oregon

Michael Peterson Paul R. Sierzenski

University of California, Los Angeles Christiana Care Health System, Delaware

Seric S. Cusick Gillian Baty

Hoag Hospital University of New Mexico
Theodore Nielsen Shane Arishenkoff
FujiFilm SonoSite, Inc University of British Columbia

William Scruggs Tala Elia

University of Hawaii Tufts University vii

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Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

List of Contributors

JoAnne McDonough Martha Villalba

Ellis Medicine, Schenectady, New York Jesse Brown Veterans Affairs Medical Center, Chicago,
Illinois
Katrina Dean
University of California, Irvine Saud Siddiqui
George Washington Univeristy Hospital
Anthony J. Weeks
Carolinas Medical Center, Charlotte, North Carolina Nilasha Ghosh
Northwestern University
Resa E. Lewiss
University of Colorado Chanel Fischetti
Duke University
Tarina Kang
University of Southern California Andrew Berg
Northwestern University
Melissa Joseph
University of Southern California Bharath Chakravarthy
University of California, Irvine
Michael E. R. Habicht
Barton Memorial Hospital, South Lake Tahoe, California Joseph Dinglasan
St. Judes Hospital, Fullerton California
Samantha Costantini
University of California, Irvine Asmita Patel
University of Illinois, Chicago Christ Hospital
Marlowe Majoewsky
University of Southern California Colleen Crowe
Medical College of Wisconsin
Stuart Swadron
University of Southern California Brian Sayger
University of Illinois, Chicago Christ Hospital
Monica Wattana
University of Texas, Houston Aaron Harries
Alameda County Medical Center, Highland
Tareg Bey Hospital
Saudi Arabia
Andrew V. Bokarius
Jonathan Patane University of Chicago
University of California, Irvine
Armando S. Garza
Megan Osborn Orange Coast Memorial Medical Center, Fountain Valley,
University of California, Irvine California
Nichole Meissner Bryan Sloane
Kaweah Delta Medical Center, Visalia, California University of California, Los Angeles
Matthew Dolich Mark Langdorf
University of California, Irvine University of California, Irvine
Swaminatha V. Gurudevan Lancelot Beier
Healthcare Partners Medical Group, Glendale, California Virginia Commonwealth University
Reza Arsanjani Andrew Wong
Cedars-Sinai Medical Center, Los Angeles, California University of California, Irvine
Kathleen Latouf Kathryn J. Stevens
Canonsburg Hospital, Pennsylvania Stanford University
Steve Nanini Shaun V. Mohan
University of Illinois, Chicago Christ Hospital Stanford University
viii

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 Part I Plain Radiography
Chapter
Plain Radiography of the Upper Extremity

1 in Adults
Kenny Banh and Gregory W. Hendey

Plain radiography remains the imaging study of choice for

most applications in the upper extremity. Far and away the
most common indication for plain radiography in the upper B
extremity is acute trauma. The shoulder, humerus, elbow, A
forearm, wrist, and hand are common radiographic series
that are useful in diagnosing an acute fracture. Other imaging C
modalities such as CT, ultrasound, and MRI are not generally E
indicated in acute trauma but have an important role in
F
diagnosing soft tissue pathology. G
Another common indication for plain radiography of the D
upper extremity is the search for a foreign body in a wound.
Plain films are an excellent modality for detecting common,
dense foreign bodies in wounds, such as glass and rock, but
they are much less sensitive in detecting plastic or organic
materials (1). Other imaging modalities such as CT, ultra- H
sound, and MRI are superior for detecting organic and plastic
foreign bodies (2). The principles of using plain films for
foreign body detection are similar regardless of the location
in the body and are not discussed in further detail here.
S.JOHNSON, M.D.

In this chapter, discussion of the upper extremity is divided

into three sections: 1) the shoulder, 2) the elbow and forearm,
and 3) the wrist and hand. Within each section, the indications,
diagnostic capabilities, and pitfalls are discussed, followed by
images of important pathological findings.

The shoulder Anterior shoulder. A = acromion, B = clavicle, C = coracoid process, D = neck of

scapula, E = scapular notch, F = greater tuberosity, G = anatomical neck, H =
surgical neck
Indications
The main indication for plain radiography of the shoulder is
acute trauma. There are a number of acute injuries that may time dislocations and those with a blunt traumatic mechan-
be discovered on plain radiography after acute trauma, ism of injury, and postreduction films for those with
including fractures of the clavicle, scapula, and humerus, as a fracture-dislocation. It is also important to order radio-
well as shoulder (glenohumeral) dislocation or acromioclavi- graphs whenever the physician is uncertain of joint posi-
cular (AC) separation. Although many patients may present tion, whether dislocated or reduced. Therefore, it may be
with subacute or chronic, nontraumatic pain, the utility of appropriate to manage a patient with a recurrent disloca-
plain films in that setting is extremely low. For chronic, tion by an atraumatic mechanism without any radiographs
nontraumatic shoulder pain, plain films may reveal changes when the physician is clinically certain of the dislocation
consistent with calcific tendonitis or degenerative arthritis, and the reduction.
but it is not necessary to diagnose such conditions in the
emergency setting. Diagnostic capabilities
Several studies have focused on whether all patients with In most settings, if the plain films do not reveal a pathological
shoulder dislocation require both prereduction and postre- finding, no further imaging is necessary. MRI is an important
duction radiographs (3). Some support an approach of modality in diagnosing ligamentous injury (e.g., rotator cuff
selective radiography, ordering prereduction films for first- 1
tear), but it is rarely indicated in the emergency setting.

09:49:57
01
 Kenny Banh and Gregory W. Hendey

With the possible exception of the scapula, most fractures

of the shoulder girdle are readily apparent on standard plain
Clinical images
Following are examples of common and important findings in
films, without the need for specialized views or advanced
plain radiography of the shoulder:
imaging. The shoulder is no exception to the general rule of
plain films that at least two views are necessary for adequate 1. Clavicle fracture (fx)
evaluation. The two most common views in a shoulder series 2. AC separation
include the anteroposterior (AP) and the lateral, or “Y,” 3. Anterior shoulder dislocation
scapula view. Other views that are sometimes helpful include 4. Posterior dislocation (AP)
the axillary and apical oblique views. The point of the addi- 5. Posterior dislocation (lateral scapula)
tional views is to enhance the visualization of the glenoid and 6. Luxatio erecta
its articulation with the humeral head. These views may be 7. Bankart fx
particularly helpful in diagnosing a posterior shoulder dislo- 8. Hill–Sachs deformity
cation or subtle glenoid fracture. 9. Humeral head fracture
Another radiographic series that is sometimes used is the
AC view with and without weights. Although the purpose of
these views is to help the physician diagnose an AC separa- The elbow and forearm
tion, they are not recommended for the following reasons: 1)
the views might occasionally distinguish a second-degree Indications
separation from a first-degree one, but that difference has Similar to the shoulder, the most common use of elbow and
little clinical relevance because both are treated conserva- forearm plain radiography is with acute trauma. There are
tively, and 2) third-degree AC separations are usually obvious numerous fractures and dislocations that can be easily visua-
clinically and radiographically, without the need for weights lized with plain films. Chronic pain in these areas is often
or additional views. secondary to subacute repetitive injuries of the soft tissue such
as epicondylitis or bursitis. Many of these soft tissue diseases
Imaging pitfalls and limitations such as lateral “tennis elbow” and medial “golfer’s elbow”
epicondylitis are easily diagnosed on clinical exam and gen-
Although most acute shoulder injuries may be adequately
erally require no imaging at all. Plain films may reveal such
evaluated using a standard two-view shoulder series, posterior
soft tissue pathologies as foreign bodies and subcutaneous air.
shoulder dislocation can be surprisingly subtle and is notor-
No well-established clinical decision rules exist for ima-
iously difficult to diagnose. When posterior dislocation is
ging elbows and forearms in acute trauma. Patients with full
suspected based on the history, physical, or standard radio-
range of flexion-extension and supination-pronation of the
graphic views, additional specialized views such as the axillary
and apical oblique can be very helpful. Most radiographic
views of the shoulder may be obtained even when the injured
patient has limited mobility, but the axillary view does require
some degree of abduction and may be difficult.

Figure 1.2. AC separation is commonly referred to as a “separated

shoulder” and can be classified as grade 1 (AC ligament and coracoclavicular
[CC] ligaments intact, radiographically normal), grade 2 (AC ligament
Figure 1.1. Clavicle fractures (A) are often described by location, with the disrupted, CC ligament intact), or grade 3 (both ligaments disrupted,
2 clavicle divided into thirds: proximal, middle, or distal. Note the scapular resulting in a separation of the acromion and clavicle greater than half the
fracture (B) as well. width of the clavicle).

09:49:57
01
 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.4. Posterior shoulder dislocation is uncommon and is difficult to

diagnose on a single AP radiograph. Although it is not obvious in this single
view, there are some hints that suggest posterior dislocation. The humeral
head is abnormally rounded due to internal rotation (light bulb sign), and
Figure 1.3. The large majority of shoulder dislocations are anterior, and the the normal overlap between the humeral head and glenoid is absent.
large majority of anterior dislocations are subcoracoid, as demonstrated in
this AP view.

Figure 1.5. Posterior shoulder dislocation is clearly evident on this lateral Figure 1.6. Luxatio erecta is the rarest of shoulder dislocations in which
scapula view, while it was much more subtle on the preceding AP view (see the humeral head is displaced inferiorly while the arm is in an abducted or
Fig. 1.4). This illustrates the importance of obtaining a second view such overhead position.
as the lateral scapula view or axillary view.

09:49:57
01
 Kenny Banh and Gregory W. Hendey

Figure 1.7. Although radiographically subtle, the Bankart fracture is a small

avulsion of the inferior rim of the glenoid. The loss of the glenoid labrum
destabilizes the glenohumeral joint and nearly ensures recurrent
dislocations.

Figure 1.8. The Hill–Sachs deformity is a compression fracture of the

superolateral aspect of the humeral head and is commonly noted in
recurrent shoulder dislocations. It is believed to occur when the humeral
head is resting against the inferior rim of the glenoid while dislocated.

visualized on plain films, but a traumatic joint effusion may

elevate the posterior fat pad enough to be visualized on a 90-
degree lateral radiograph. The anterior fat pad is normally
visualized as a thin stripe on lateral radiographs, but joint
effusions may cause it to bulge out to form a “sail sign” (6).
Traumatic joint effusions are sensitive signs of an intra-
articular elbow fracture (7). In an adult with fat pads and no
obvious fracture, an occult radial head fracture is the usual
culprit.
Figure 1.9. Humeral head fracture often occurs across the surgical neck (A)
but may also occur at the anatomical neck (B). Imaging pitfalls and limitations
The two standard views of the elbow are the AP view and the
elbow and no bony point tenderness rarely have a fracture, lateral view with the elbow flexed 90 degrees. The majority of
and they generally do not require imaging (4). Midshaft fore- fractures can be identified with these two views, but occasion-
arm fractures are usually clinically apparent, and deformity, ally supplementary views may be obtained to identify certain
swelling, and limited range of motion are all indications for parts of the elbow and forearm. The lateral and medial obli-
obtaining radiographs. Some suggest ultrasonography may que views allow easier identification of their respective epi-
reduce the need for elbow radiography (5). condylar fractures. The capitellum view is a cephalad-
oriented lateral view that exposes the radial head and radio-
capitellar articulation. The axial olecranon is shot with
Diagnostic capabilities a supinated and flexed forearm and isolates the olecranon in
In most cases, if no pathology is found in the plain films of the a longitudinal plane.
forearm or elbow, no further imaging is required. Although
obvious fractures are easily visualized on plain film, some
fractures leave more subtle findings. Radiographs of the
Clinical images
elbow in particular may yield important indirect findings. Following are examples of common and important findings in
The elbow joint is surrounded by two fat pads, an anterior plain radiography of the elbow and forearm:
one lying within the coronoid fossa and a slightly larger 10. Posterior fat pad
posterior fat pad located within the olecranon fossa. 11. Radiocapitellar line
4
In normal circumstances, the posterior fat pad cannot be 12. Elbow dislocation, posterior

09:49:57
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 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.10. Subtle soft tissue findings such as this posterior fat pad (A)
and sail sign (B) are markers for fractures that should not be dismissed.

Figure 1.11. A radiocapitellar line is drawn through the radius and should
bisect the capitellum regardless of the position of the elbow.

Figure 1.12. Elbow dislocation is a common joint dislocation,

outnumbered only by shoulder and interphalangeal dislocations. Most
elbow dislocations occur during hyperextension. The majority are posterior
and are obvious clinically and radiographically.

Figure 1.13. Monteggia fractures or dislocations are fractures of the

13. Monteggia fracture proximal ulna with an anterior dislocation of the proximal radius. These injuries
14. Galeazzi fracture (AP) are usually caused by rotational forces, and the dislocation may not be
15. Galeazzi fracture (lateral) obvious. Drawing a radiocapitellar line aids in diagnosis as it demonstrates the
misalignment.

The wrist and hand

tissue and skeletal injury on history and physical examination
Indications alone. Imaging is necessary even with obvious fractures
As with the rest of the upper extremity, the major indication because the extent of the fracture, displacement, angulation,
for imaging of the wrist and hand is with acute trauma. It is and articular involvement are important to determine if
one of the most difficult areas to differentiate between soft the patient needs closed reduction in the ED or immediate 5

09:49:57
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 Kenny Banh and Gregory W. Hendey

Figure 1.15. Often mistaken for a simple distal radius fracture on AP

Figure 1.14. A Galeazzi fracture, or Piedmont fracture, is a fracture of the
radiograph, the dislocation is clearly evident on a lateral forearm or wrist.
distal third of the radius with dislocation of the distal ulna from the carpal
joints. This is the exact opposite of a Monteggia fracture and is also caused
by rotational forces in the forearm, although more distal.
The minimum standard views of the hand and wrist involve
a posterior-anterior, lateral, and pronated oblique. This third
orthopedic referral for possible open reduction and surgical view helps assess angulated metacarpal fractures that would
fixation. normally superimpose on a true lateral. Accessory views of
There are still settings where imaging of the hand and the hand such as the supination oblique or ball catcher’s view
wrist is not indicated. Carpal tunnel disease and rheumatolo- can help view fractures at the base of the ring and little finger,
gic and gouty disorders are chronic diseases that usually do while a Brewerton view allows better visualization of the
not involve acute trauma and can be diagnosed based on metacarpal bases. The wrist accessory films include
a good history and physical exam alone. a scaphoid view, a carpal tunnel view that looks at the hook
of the hamate and trapezium ridge, and a supination oblique
Diagnostic capabilities view that isolates the pisiform. These accessory films should
be ordered whenever there is localized tenderness or swelling
Besides searching for acute bony fractures and dislocations, in these areas.
plain films can reveal other important pathology. With high- Unlike the proximal upper extremity, fractures in the
pressure injection injuries to the hand, subcutaneous air is wrist and hand may not always be readily apparent on plain
a marker for significant soft tissue injury and is often an films. Scaphoid fractures often result from a FOOSH injury.
indication for surgical exploration. Many carpal dislocations About 10% to 20% of scaphoid fractures have normal radio-
and ligamentous injuries are readily visualized on radio- graphs on initial presentation to the ED (8). Therefore, it is
graphs of the wrist and hand. Perilunate and lunate disloca- extremely important not to disregard these clinical signs of
tions usually result from hyperextension of the wrist and fall scaphoid fracture: “anatomical snuff box” tenderness, pain
on an outstretched hand (FOOSH) injury. They may be with supination against resistance, and pain with axial com-
poorly localized on physical exam and films, and a good pression of the thumb. These signs merit immobilization of
neurovascular exam, especially of the median nerve, is the wrist in a thumb spica splint and follow-up in one to two
indicated. weeks.
More advanced imaging modalities of the wrist and
Imaging pitfalls and limitations hand such as CT, MRI, and high-resolution ultrasound
Because of the size and number of bones, complete radio- are much more sensitive for identifying fractures, bone
graphic sets of hand and wrist films are often acquired. contusions, and ligamentous injury that would be missed
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 Chapter 1: Plain Radiography of the Upper Extremity in Adults

E G
F

H
D
C
A
B
M.D.
S.JOHNSON,

Figure 1.16. A Colles’ fracture occurs at the distal metaphysis of the radius
with dorsal displacement and radial length shortening. An extremely
common injury pattern also seen in FOOSH injuries, the radial head is
Bones of the wrist: palmar view. A = scaphoid, B = lunate, C = triquetrum, D = shortened, creating a disruption of the normally almost linear continuation
pisiform, E = hamate, F = capitate, G = trapezoid, H = trapezium of the radial and ulnar carpal surfaces.

on plain radiography (9). Whether advanced imaging is

indicated in the emergency department may depend on
local resources.

Clinical images
Following are examples of common and important findings in
plain radiography of the wrist and hand:
16. Colles’ fracture (AP)
17. Colles’ fracture (lateral)
18. Smith’s fracture (AP)
19. Smith’s fracture (lateral)
20. Scaphoid fracture
21. Scapholunate dissociation
22. Lunate dislocation (AP)
23. Lunate dislocation (lateral)
24. Perilunate dislocation (AP)
25. Perilunate dislocation (lateral)
26. Boxer’s fracture (AP)
27. Boxer’s fracture (lateral) Figure 1.17. The dorsal displacement is evident on the lateral radiograph,
and proper reduction is needed to restore this alignment.
28. Tuft fracture

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 Kenny Banh and Gregory W. Hendey

Figure 1.18. A Smith’s fracture, also known as a reverse Colles’ fracture, is

a distal radius fracture with volar instead of dorsal displacement of the hand. Figure 1.19. Sometimes referred to as a “garden spade” deformity, the
Usually caused by direct blows to the dorsum of the hand, these fractures lateral view differentiates this type of fracture from the more common Colles’
often need eventual surgical reduction. fracture.

Figure 1.21. A tight relationship between adjacent carpal bones and the
Figure 1.20. Because of the size and number of hand and wrist bones, many
distal radius and ulna should be observed as well. The loss of this alignment
subtle fractures are missed on cursory views of plain radiographs. All AP hand
or widening of the space, as seen here between the scaphoid and lunate
views should be checked for smooth carpal arches formed by the distal and
bones, is a sign of joint disruption from fracture, dislocation, or joint
proximal bones of the wrist. Evidence of avascular necrosis in scaphoid
instability. A widening of greater than 4 mm is abnormal and known as the
fractures occurs in the proximal body of the fracture because the blood supply
“Terry-Thomas sign” or rotary subluxation of the scaphoid. The scaphoid
of the scaphoid comes distally from a branch of the radial artery. The arrow
8 denotes a scaphoid fracture.
rotates away and has a “signet ring” appearance at times.

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 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.22. Lunate dislocations are the most common dislocations of the Figure 1.23. The lateral view shows the obviously dislocated and tilted
wrist and often occur from FOOSH injuries. They are significant injuries “spilled teacup” lunate. Observe how the capitate and other wrist bones are in
involving a volar displacement and angulation of the lunate bone. Notice how relative alignment with the distal radius.
the carpal arches are no longer clearly seen.

Figure 1.24. Perilunate dislocations are dorsal dislocations of the capitate Figure 1.25. The lateral view of a perilunate dislocation shows the lunate in
and distal wrist bones. Once again, there is a loss of the carpal arcs with alignment with radial head. It is the distal capitate that is obviously displaced,
significant crowding and overlap of the proximal and distal carpal bones. in contrast to the lunate dislocation.
Neurovascular exams for potential median nerve injuries are extremely
important in these injuries. 9

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 Kenny Banh and Gregory W. Hendey

Figure 1.27. The lateral view reveals the degree of angulation. The amount
of angulation that requires reduction or impairs function of the hand is
controversial, but many believe greater than 30 degrees of angulation requires
reduction (8).

Figure 1.26. Metacarpal neck fracture of the fifth metacarpal, commonly

referred to as a boxer’s fracture, typically occurs from a closed fist striking
a hard object such as a mandible or wall.
References
1. Manthey DE, Storrow AB, Milbourn J, Wagner BJ: Ultrasound
versus radiography in the detection of soft-tissue foreign bodies.
Ann Emerg Med 1996;287–9.
2. Peterson JJ, Bancroft LW, Kransdorf MJ: Wooden foreign
bodies: imaging appearance. AJR Am J Roentgenol 2002;178(3):
557–62.
3. Hendey G, Chally M, Stewart V: Selective radiography in 100
patients with suspected shoulder dislocation. J Emerg Med
2006;31(1):23–8.
4. Hawksworth CR, Freeland P: Inability to fully extend the injured
elbow: an indicator of significant injury. Arch Emerg Med 1991;
8:253.
5. Rabiner JE, Khine H, Avner JR, et al.: Accuracy of point-of-care
ultrasonography for diagnosis of elbow fractures in children.
Ann Emerg Med 2013;61(1):9–17.
6. Hall-Craggs MA, Shorvon PJ: Assessment of the radial
head-capitellum view and the dorsal fat-pad sign in acute elbow
trauma. AJR Am J Roentgenol 1985;145:607.
7. Murphy WA, Siegel MJ: Elbow fat pads with new signs and
extended differential diagnosis. Radiology 1977;124:659.
8. Byrdie A, Raby N: Early MRI in the management of clinical
scaphoid fracture. Brit J Rad 2003;76:296–300.
9. Waeckerle JF: A prospective study identifying the sensitivity of
Figure 1.28. A crush injury to the distal phalanx often causes a tuft
fracture. It is important to evaluate for open fractures, subungual radiographic findings and the efficacy of clinical findings in
hematomas, and concomitant nail bed injury. carpal navicular fractures. Ann Emerg Med 1987;16:733.
10

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 Lower Extremity Plain Radiography
Chapter

2 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Indications calcaneal views as opposed to imaging the entire foot, as this

allows for better visualization of subtle pathology.
Lower extremity injuries are common in ED and urgent care
settings. As part of the workup of these patients, healthcare
providers typically use some type of imaging modality. Plain Imaging pitfalls and limitations
radiography is frequently a starting point, as it is readily
Information obtained from plain radiographs may be limited
available, is inexpensive, and has few contraindications.
by several factors. Most notable is the quality of the technique
In addition, plain radiography involves much lower levels
employed. Penetration of the image and proper patient posi-
of ionizing radiation than CT, for example. The medical
tioning are crucial to obtaining useful images. Improper posi-
literature has discussed at length the long-term risks and
tioning can mask findings of subtle hip, tibial plateau, or foot
effects from ionizing radiation (1). As such, healthcare
and ankle fractures.
providers should give strong consideration to using addi-
Additionally, postoperative patients sometimes pose
tional plain radiograph views (gravity stress, weight bearing,
a challenge. If a patient has had prior surgeries or has an
etc.) rather than automatically opting for other modalities
internal fixation device in place, interpretation of the films
such as CT.
may be difficult. Also, plain radiography itself has inherent
Plain radiography is useful in a number of clinical situa-
limitations, regardless of patient or technique. For example,
tions, including diagnosing fractures and dislocations and
many foreign bodies, including organic material, plastics, and
evaluating the end result after closed reductions performed
some types of glass, are radiolucent and, therefore, not well
in the ED. In addition, it is helpful in evaluating for radio-
visualized with plain radiography. Ultrasound and MRI are
paque foreign bodies and assessing joint spaces for evidence
other imaging options in these cases.
of autoimmune or degenerative processes such as rheumatoid
Plain radiography is very good for evaluating most bony
arthritis or avascular necrosis. Finally, plain films are also
pathology; however, there are exceptions. In the case of osteo-
helpful in evaluating possible infections, including those
myelitis, for example, there is often a delay of 2 to 3 weeks
involving the bone, as in osteomyelitis, or the adjacent soft
between onset of symptoms (pain, fever, swelling) and onset
tissues, as in necrotizing soft tissue infections.
of radiographic findings. As a result, plain radiography alone
is relatively insensitive in diagnosing acute osteomyelitis (2).
Other modalities, including MRI and bone scan, are often
Diagnostic capabilities used in these cases.
Lower extremity radiography is useful for diagnosing frac- Other limitations of plain radiography include failure to
tures and dislocations of the hip, knee, foot, and ankle, as well detect fractures with subtle radiographic findings, such as
as demonstrating pathology of the femur, tibia, and fibula. acetabular, tibial plateau, or midfoot (Lisfranc’s) fractures.
Plain radiography is helpful in evaluating fractures of the In many such instances, CT or MRI is necessary if clinical
lower extremity bones, as well as masses and malignancies, suspicion is high, even in the setting of negative plain films.
including pathological fractures. In some cases, these films It is well reported that, in patients with complex foot and
will be supplemented with CT or MRI of the affected area to ankle fractures, the sensitivity and negative predictive
provide additional information. In addition to bony pathol- value of plain radiography alone are inadequate (3).
ogy, lower extremity radiography is helpful in assessing the In these cases, multidetector CT is the modality of choice.
soft tissues, as in the setting of joint effusions, inflammation of Another area where plain radiography alone yields insuffi-
bursae, soft tissue calcifications, or soft tissue infections. cient anatomical detail is the proximal tibia. Many authors
Finally, plain radiography is also useful for visualizing radio- support supplemental imaging with CT to better delineate
paque foreign bodies of the lower extremity. the anatomy and allow for preoperative planning and frac-
When ordering radiographs of the lower extremity, one ture management (4, 5).
must give careful consideration to selecting the optimal views. Despite these limitations of lower extremity radiography,
Obtaining the proper radiographic views will significantly some simple measures may be taken to improve overall diag-
affect the utility of the study. For example, when looking for nostic accuracy. As noted previously, proper image penetra- 11
calcaneal pathology, it is advisable to obtain dedicated tion and patient positioning are imperative. Beyond this, the

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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.2. Open anterior fracture-dislocation of hip. An AP radiograph

shows the left hip to be dislocated with the femoral head inferior, compatible
with anterior dislocation. The leg is abducted and externally rotated, which is
commonly the leg position that predisposes to anterior dislocation.
In addition, note the acetabular fracture on the right.

Figure 2.1. Anterior hip fracture-dislocation. The initial AP radiograph (A)

shows the right leg to be externally rotated and the superior acetabulum to
have a discontinuous margin due to an accompanying acetabular fracture.
The CT scans, both axial (B) and 3D reconstructions (C), show the anterior
dislocation of the femur, with both acetabular fracture and impaction fracture
of the femoral head.

use of stress imaging, whether it be weight bearing (to

enhance Lisfranc injury) or gravity stress (to enhance ankle
instability), can be very useful (6, 7). Stress views can reveal
much more about the function of ligaments and as such are
often superior and complementary to MRI.
Finally, as with any radiographic imaging, one must have
sufficient knowledge of the normal anatomy to be able to
recognize pathology. This includes the ability to distinguish
normal variants from true pathology. For example, bipartite Figure 2.3. Posterior hip dislocation. AP (A) and lateral (B) radiographs of
a 15-year-old male with a posterior left hip dislocation. Note the high position
patella, presence of a growth plate, or sesamoid bone may all of the left femoral head on the AP view and the posterior position on the
be mistaken for abnormalities if a basic understanding of lateral view, which is projecting supine with the ischium (a posterior structure)
normal anatomy is lacking. at the bottom of the image (arrow).
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 Chapter 2: Lower Extremity Plain Radiography

Figure 2.4. Acetabular fracture not well visualized on CT. This 19-year-old male sustained a horizontal fracture of the right acetabulum in a motor vehicle
collision. The AP view (A) shows the fracture line over the medial acetabulum, and the Judet views (B, C), RPO (right posterior oblique), and LPO (left posterior
oblique) show the involvement of the posterior column and anterior column, respectively (arrows). This fracture was very difficult to see on CT due to the fracture
plane being the same as that of the axial CT images. This underscores the importance, in some cases, of multiple imaging modalities to properly characterize the
injury.

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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.5. Posttraumatic avascular necrosis (AVN). This 17-year-old male sustained a femoral neck fracture (A). Four years later following decompression, the
subsequent radiograph (B), as well as the coronal plane T1-weighted MRI (C), show sclerosis and lucencies on the radiograph (arrows) and well-defined margins of
AVN on the MRI (arrow).

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 Chapter 2: Lower Extremity Plain Radiography

Figure 2.6. Impacted fracture of right femoral neck. An AP radiograph shows Figure 2.8. Horizontal intertrochanteric fracture. The left posterior oblique
impaction of the lateral femoral neck as well as a band of sclerosis (arrows) in radiograph of the pelvis shows a relatively horizontal intertrochanteric
this 46-year-old male. fracture. Most fractures in this region are more oblique from superolateral to
inferomedial.

Figure 2.7. Greater trochanter fracture. This 68-year-old female sustained a greater trochanter fracture, difficult to appreciate with plain radiography (A).
The subsequent coronal T2-weighted MRI (B) shows the edema in the greater trochanter and adjacent hip abductors (arrows). MRI is useful in the differentiation of
surgical and nonsurgical management.

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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.9. Pathological fracture of the left subtrochanteric femur. AP radiograph of the left hip in this
70-year-old male with Paget disease shows abnormal architecture of the proximal femur with a coarse
trabecular pattern and cortical thickening typical of the sclerotic phase of this disease. A pathological
fracture has occurred through the weakened abnormal bone.

Figure 2.10. Dislocated total hip arthroplasty. AP and lateral views of the right hip with anterior dislocation (A, B) (the ring represents the femoral head) and
following reduction (C, D). Note the femoral head must be concentric with the acetabulum on both views for it to be correctly located.

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Figure 2.12. Subluxed patella. A bilateral Merchant view of the patellae

shows the right patella to be laterally subluxed. Axial views of the patella are
taken with the knees flexed 40 degrees and with the film either on the shins
(Merchant projection) or on the thighs (Inferosuperior projection).

Figure 2.13. Bipartite patella. AP (A) and axial (B) views of the left knee in
Figure 2.11. Giant cell tumor of bone involving the right distal femur. a 16-year-old male. Note that the accessory bone fragment is always
AP (A) and lateral (B) radiographs in a 37-year-old male show a lytic lesion superolateral. The margins are rounded and sclerotic, excluding an acute
involving the metaphysis and extending to the epiphysis (arrows). It has fracture.
a mixed benign and aggressive appearance, with the lateral margin being
well defined and the proximal margin more ill defined.

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Figure 2.14. Patella alta. AP (A) and lateral (B) radiographs in a 55-year-old male show the patella to be in a higher location than is normal. The distance from the
inferior articular surface of the patella to the tibial tubercle should be between 1.5 and 2 times the length of the articular surface of the patella.

18 Figure 2.15. Femoral condyle fracture. AP (A) and lateral (B) radiographs of the left knee in a 37-year-old male show a coronal oblique fracture of the lateral
femoral condyle. Sagittal plane condylar fractures are more common than coronal. Coronal fractures tend to occur on the lateral side and are called Hoffa fractures.

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Figure 2.16. Knee dislocation. AP (A) and lateral (B) radiographs in a 77-year-old female show a knee dislocation. The subsequent postreduction angiogram (C)
shows abrupt disruption of flow in the popliteal artery (arrow). Arterial injury is one of the major concerns in a patient with knee dislocation.

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Figure 2.17. Tibial plateau fracture. AP (A) and lateral (B) radiographs in a 24-year-old female following trauma show irregularity of the lateral tibial plateau
with a band of sclerosis between the subchondral bone plate and the epiphyseal scar (arrows). The oblique view (C) confirms this finding (arrows) and is often
helpful in equivocal cases in the absence of CT. The CT images with coronal (D) and axial (E) reformations also confirm the impacted lateral tibial plateau fracture
(arrows). CT is much more sensitive in detecting tibial plateau fractures than is plain radiography, and it is often used for preoperative planning and management
decisions.

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Figure 2.18. Tibial spine avulsion. AP (A) and lateral (B) radiographs in a 58-year-old male show avulsion of the tibial spines by the anterior cruciate ligament
(arrow). The subsequent coronal T1-weighted MRI (C) confirms this finding (arrow). Due to the comparative strengths of ligaments and bones, this injury is more
common in children, whereas ACL tears are more common in adults.

Figure 2.19. Knee lipohemarthrosis. AP (A)

and lateral (B) radiographs in a 51-year-old
female show a vertical split fracture of the
lateral tibial plateau. In addition, the lateral
recumbent view (C) shows a large joint
effusion/hemarthrosis. The cross-table lateral
view taken with a horizontal beam (C) shows
a fat fluid level (lipohemarthrosis) within the
knee (arrows). The fat is released from the
bone marrow, confirming the intra-articular
fracture. In some cases, this may be the only
finding on plain radiography to suggest
a fracture.

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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

A B

Figure 2.20. AP close-up radiograph of the lateral aspect of the left knee (A) in a 34-year-old man following trauma, shows a small bone fragment projecting over
the lateral aspect of the proximal tibia and fibula (arrowheads). This represents a Segond fracture avulsion by the lateral capsular ligamentous complex and is
a strong indicator of an ACL tear. The ACL injury (arrow) is shown in the accompanying sagittal proton density fat saturated MRI through the midline of the
intercondylar notch of the same knee (B). Note that the rounded bone more superiorly overlying the lateral margin of the distal femur on the radiograph (arrow) is
a normal variant, the fabella.

Figure 2.21. Large knee joint effusion. Lateral radiograph of the knee shows
a bulging soft tissue density arising from the superior aspect of the patellofemoral
joint due to an effusion. If the lateral knee radiograph is obtained flexed more than
30 degrees, an effusion may be pushed posteriorly so that it is no longer visible.

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Figure 2.22. Osteoarthrosis of the knee. AP (A) and lateral (B) radiographs of the right knee in a 52-year-old male show the four cardinal signs of osteoarthrosis:
1) focal joint space narrowing, 2) subchondral sclerosis, 3) subchondral cysts, and 4) osteophytes. In addition, a large intra-articular body is seen in the popliteal recess
(arrow).

A B

Figure 2.23. AP radiographs of the right knee in a 71-year-old female with severe osteoarthrosis. Although the non-weight-bearing view (A) shows severe
medial compartment joint space narrowing, it is only with weight bearing (B) that the full extent of the accompanying genu varum deformity becomes apparent.
This will likely affect the arthroplasty technique selected for definitive treatment.
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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.24. Fabella. AP (A) and lateral (B) radiographs of the knee of a 35-year-old male demonstrate a fabella, a sesamoid bone within the lateral head of the
gastrocnemius muscle (arrows). The fabella is sometimes mistaken for an intra-articular ossified fragment. Note that the fabella is always lateral. In AP projection,
the fabella is round. In the lateral view, the anterior margin should be flat or concave.

Figure 2.25. Metal synovitis of the knee. Lateral oblique radiograph (A), with coned down view (B), in a 69-year-old female who has extensive
microfragmentation of a total knee arthroplasty. Metal has collected in the synovium, producing a synovitis.

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 Figure 2.26. Acute osteomyelitis. AP radiograph of the proximal tibia shows an ill-defined
lucency with periosteal reaction, compatible with an aggressive process – in this case,
osteomyelitis.

Figure 2.27. Osteosarcoma. AP (A) and lateral (B)

radiographs of the right proximal tibia in a 16-year-
old male show an ill-defined but dense area of
sclerosis in the lateral proximal tibia. Coronal (C) and
axial (D) T1-weighted MRI show low signal centrally,
compatible with bone formation, and high signal
peripherally, compatible with gadolinium uptake by
growing tumor.

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 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.28. Tibial fracture. AP (A) and lateral (B) radiographs of a 16-year-old Figure 2.29. Toddler fracture. AP radiograph of a 22-month-old boy, whose
male following trauma. The AP view clearly shows the steep oblique fracture of leg became trapped beneath his mother while descending a slide, shows
the midtibial shaft. Note the difficulty of seeing the fracture on the lateral view, a spiral fracture of the distal tibia (arrows). These nondisplaced toddler
emphasizing the need for more than one view to assess trauma. fractures are often difficult to see on radiographs acutely.

Figure 2.30. Fibular shaft fracture. AP (A) and lateral (B) radiographs of the Figure 2.31. Ankle effusion. Lateral radiograph of the ankle in a 25-year-old
26 tibia and fibula in a 45-year-old male following pedestrian versus auto male with chronic renal failure. Anterior to the ankle joint is a moderate-size
accident. The fracture of the midshaft of the fibula has a butterfly fragment, effusion. When such a dense effusion is noted, presence of hemarthrosis must
which is strongly associated with direct trauma. be considered.

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 Chapter 2: Lower Extremity Plain Radiography

Figure 2.32. Maisonneuve fracture. Mortise (A) and lateral (B) projections of the left ankle in a 54-year-old male show a transverse fracture of medial malleolus
(arrow in Fig. 2.32A), extending to involve the posterior malleolus (arrow in Fig. 2.32B). In this situation, especially if the distal tibiofibular space is widened, views of
the proximal tibia and fibula (C) are recommended to look for a proximal Maisonneuve fracture of the fibula (arrow in Fig. 2.32C).

Figure 2.33. Lateral malleolus fracture. Mortise (A) and lateral (B) views of the Figure 2.34. Wide medial and syndesmotic clear spaces. AP (A) and mortise
left ankle show a fracture line passing from superoposterior to anteroinferior (B) views of the left ankle in a 34-year-old male following a twisting injury.
on the lateral view (arrow), which is difficult to see on the mortise view. This is The ankle is incongruent, with the medial aspect of the joint wider than the
a very common pattern of ankle fracture and emphasizes the need to look superior joint space (arrow), indicating a medial ligament injury. In addition, the
carefully at the lateral view. distal tibiofibular clear space is too wide. In this setting, views of the proximal
fibula are recommended to evaluate for a Maisonneuve fracture (see Fig. 2.32).
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Figure 2.35. Medial and posterior malleolar fractures. AP (A), mortise (B), and lateral (C) views of the right ankle in an 18-year-old male show a medial malleolar
fracture (arrow in Fig. 2.35B) that extends around to the posterior malleolus (arrow in Fig. 2.35C). Posterior malleolar fractures appear on the AP and mortise views as
an inverted V–shaped lucent line. On the lateral view, it is important to discern whether the fracture is of the lateral malleolus or posterior malleolus.

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Other documents randomly have
different content
reside, and commence his journey to it immediately after leaving the
castle. At the same time, the commission would seriously warn him,
under threats of the royal displeasure, not to speak or to write about
public affairs, as his Majesty, through special clemency, granted him
a pension of 500 dollars, and the same to his wife.
The commission would demand of Colonel von Falckenskjold the
chamberlain's key and the Russian order, and announce to him that,
in consequence of his audacious and detrimental behaviour, he
would be conveyed to the fortress of Munkholm, and be imprisoned
there for life, half a dollar a day being allowed him from the treasury
for his support.
Lastly, the commission would announce to Justiz-rath Struensee
that, as he had caused his arrest by his own suspicious behaviour, he
was now released from it, but he must leave the country at once,
after making a promise, on oath, to reveal neither in writing nor
verbally anything he knew about the Danish state affairs, and
neither to write nor to speak about the events which had lately
occurred in Copenhagen, and he would also begin his journey
immediately he was released from the castle.
The fate of the three men was very different. Poor Von Gähler died
in exile; Justiz-rath Struensee became Minister of State in Prussia,
where he acquired a considerable fortune; he was ennobled in 1789
by the same court of Copenhagen which had his brother's
escutcheon broken by the executioner.[31]
As for the third person, he shall tell us his story himself, as it throws
such an extraordinary light on the treatment of state prisoners at a
period within a hundred years of our own.

FALCKENSKJOLD'S ABODE AT MUNKHOLM.

On June 12, 1772, Sevel, accompanied by the commandant of the
marines and several officers, entered my prison and told me that the
king stripped me of all my offices and the military order of Russia,
and that I should be transported to a rock and be detained there for
the rest of my days.
The crowd of people who entered with Sevel had so deafened me,
that a portion of what he said escaped me.
I begged him to repeat how long I was to remain in detention.
For your whole life, he replied, with a grin which I fancy I can still
see.
The commission had doubtless made a report. I requested the
communication of it—it was refused me. I was promised a copy of
my examination, but was unable to obtain it.
Thus I was deprived of every document that might one day be
useful in proving my innocence.
On June 26, I was taken on board a merchant vessel the Admiralty
had freighted in order to go to Munkholm, my place of destination; a
sergeant and four grenadiers of Prince Frederick's regiment, chosen
by Eickstedt, were ordered to guard me on board the vessel; two
grenadiers with drawn sabres were to watch me and prevent me
from speaking.
I have since learned that the sergeant commanding this guard, had
a promise of being made lieutenant if he could induce me to take
any step which would cause me to be landed at Munkholm in chains.
But the skipper had declared to the Admiralty that he would not
allow any one but himself to give orders, and that if he required the
guard, he would summon it.
This worthy man contrived to make himself respected, and to
protect me from ill treatment.
The vessel touched at Christiansund, where a part of its cargo was
to be delivered. A custom-house clerk came on board and wanted to
speak with me. He wished to insult me, as he had been dismissed in
1763 from his rank of lieutenant; observe, that I had no part in
military affairs till 1771. I heard his conversation on this subject with
the master, who saved me this annoyance.
The vessel arrived at Munkholm on August 4th, and I parted, not
without regret, from this honest skipper, who had so generously
protected me.
The fort of Munkholm is situated on a barren rock four hundred
paces in circumference, in the middle of the sea, half a league from
Trondhjem,[32] toward the 64° of northern latitude. During the
winter it is covered with an almost continual fog; the snow hardly
remains there eight days in succession; but it freezes there from the
beginning of September, and snow falls in the month of June.
The only inhabitants of this place consisted of a detachment of the
garrison of Trondhjem, the fort commandant, the officers under him,
and the prisoners guarded there.
I was lodged in a low room a little above the ground-floor. Its planks
and walls were damp, and the snow fell into it in a fine rain when it
thawed. Under the window was a cistern of stagnant water; this
lodging, which was also surrounded by the quarters of the soldiers
and the prisoners, whose cries stunned me, was assuredly not good;
but I was alone in it, had plenty of books, enjoyed the liberty of
walking on the ramparts when I pleased, and I felt much less
unhappy than in Copenhagen; everything is relative.
I had been warned that the water of the fort was unhealthy, and
produced gravel. I asked if I could have any other, and they offered
me spirits, the beverage par excellence at this spot, but it was worse
for me than bad water.
I could not procure good bread; old bread, partly spoiled, was
purchased for the prisoners, which cost 12 per cent. less than the
ordinary bread. Though the government had confiscated 8,000
crowns belonging to me, it only allowed me half-a-crown a day for
my subsistence.
A battalion of the Delmenhorst regiment was in garrison at
Trondhjem; I had served in this regiment, and found at Munkholm
soldiers of a company I had formerly commanded. They formed a
plan for carrying me off and deserting, but not having been able to
communicate their plan to me, they deserted without me, and tried
to reach Sweden overland; a detachment, sent in pursuit, caught
them and brought them back.
The solders, generally, were in a profound state of wretchedness and
demoralisation; the spirits and herrings on which they lived diffused
a frightful stench, and I had a difficulty in protecting myself against
their uncleanliness.
Everything here depended on Lieut.-General von der Osten, grand
bailiff and governor of Trondhjem: he was said to be fond of
presents, and did not hesitate to ask them, and I had none to offer
him. The commandant of Munkholm, on my arrival, had been a
servant and woodcutter to a Copenhagen tradesman. He was first a
gunner, then non-commissioned officer in the militia, afterwards a
spy, captain of a company of guides, inspector of an hospital, and,
lastly, commandant of Munkholm. This man, who was extremely
brutal and coarse, was frequently intoxicated; he called himself an
atheist, believed himself an engineer, astronomer, tactician, and
decided on everything without allowing an answer; he declaimed a
great deal, though I could not learn why, against Counts von
Bernstorff and St. Germain.
A poor author, a very pious man, who was placed here because he
had the simplicity to believe in the freedom of the press, had
become, on account of his devotion, odious to the commandant,
who used to beat him. He also treated very badly another person
who had held a post at court, although the latter made him
presents.
The other officers were given up to the most disgusting intoxication.
I took great care to avoid these gentlemen, and only spoke to them
when I could not help it. I do not believe it would have been very
difficult for me to escape from this fortress, and, perhaps, Guldberg
offered me the means by proposing to me a retreat at Vardohuus,
[33] under the polar circle. But, I said to myself, what should I go so
far to seek? more injustice and persecution!
What had been done to me gave me a sort of disgust for human
society. I had wished to render myself illustrious by arms—the
perusal of the lives of celebrated warriors had inflamed my
imagination at an early age. I aspired to become one day the rival of
the Löwendahls and the Münnichs. My studies, my reflections, were
all directed to this object. On emerging from childhood I took up
arms and sought combats—I followed this career successfully. I was
summoned to aid in the reformation of my country and the
amelioration of its condition. I quit with regret the mode of life I had
chosen and loved; I arrive, I consecrate my efforts, all my thoughts
to this new task, and persecution, exile and contumely are my
reward! No, I will not take a single step to return to society; I was
never a man of pleasures, though not at all insensible to the
enjoyments designated by that name; I shall, doubtless, learn to
forget them. Society has rejected me; they refuse to allow me any
part in its joys and honours, and I have been relegated to this rock.
Well, then, let us perform our task apart, let us work to render this
state supportable, and to depend on others as little as possible.
I daily confirmed myself in these thoughts—a favourite and habitual
subject of my reveries—and this has decided the rest of my life.
I should be satisfied if I had a healthy lodging, good water, and if I
were not obliged to speak to the people who surround me.
The taste for study is a great resource for me. I read a great deal
with a pen in my hand; on the margin of my books I note my
souvenirs, my reflections, and trace the details of the campaigns I
have been through, and develope the considerations I had sketched
about the military condition of Denmark. I still like to occupy myself
with society as a simple spectator, though I have no desire to act a
part in it. I like to dream awake while walking. The ramparts are the
ordinary scene of my promenades.
Thence, when the weather is fine, I perceive the mountainous coasts
of the mainland, the rocks, the valleys, the forests, the habitations,
which form varied scenes, the islets and shoals with which the coast
is studded. Sometimes I discern in the distance a vessel which is,
perhaps, bringing me books; more frequently I watch the departure
of the fishermen's boats, or else see them return, uttering shouts of
joy and triumph, with the booty they have gained by so much
fatigue and boldness in the dangerous Northern Seas.
I also take pleasure in contemplating the fury of the waves raised by
storms, and which break against the rock on which I am a captive.
In the months of July and August the coast of Norway offers an
aspect of magnificent vegetation; the navigation is active; clouds of
birds appear to animate the rocks that border the shore; the sky is
pure, and the view enjoyed from Munkholm is enchanting. The
nights, especially, have a peculiar charm; the air has something
unctuous and suave, which seems to soften my melancholy reveries;
the nights at this period are a species of twilight, for at midnight it is
clear enough to read even the finest type.
I have found in an external staircase a spot which has grown my
favourite asylum, even when winter has commenced. There I am
sheltered against the north winds; there, and in the company of my
books, wrapped up in an old bearskin coat, I feel less a prisoner
than elsewhere; though the eyes of the sentry plunge into the spot,
my presence in it could not be suspected.
Since the commencement of my stay on the island, I have regulated
the employment of my time. I rise in summer at daybreak, and in
winter at eight o'clock. I employ the first hour of the day in pious
meditations; I then occupy myself with readings that require some
mental effort; a short walk precedes my dinner; I take a longer walk
after the meal. Reading the newspapers, romances, or theatrical
pieces, generally ends my evenings. The days on which the public
papers arrive are holidays with me. The fort chaplain pays me a visit
now and then: the one who held this office on my arrival has been
removed to Bergen. His conversation caused me pleasure, and that
of his successor pleases me no less; I have found them both
enlightened, charitable, disposed to relieve me by consolatory
discourses, and by procuring me books. The Danish clergy, generally,
are distinguished from the rest of the nation by their virtues and
information.
When the weather is bad, I walk in a large room in the tower of the
fortress; this room served as a lodging for Count von Griffenfeldt. He
was the son of a wine-merchant, and rose by his merit to the place
of grand chancellor of the kingdom and the dignity of count. He
governed the state wisely; if he had retained the power, he would
have prevented the wars that ruined Denmark under Christian V. His
enemies had him condemned to the punishment which the unhappy
Struensee underwent; but on the scaffold itself the penalty of death,
which had been too hasty, was commuted, as if by mercy, into a
confinement on this rock, where he prolonged his wretchedness for
nineteen years, and died of the gravel.
"Such," I said to myself, "is the fate which menaces me; but I shall
not wait so long for it, for I believe that I can already feel the same
malady."
In October, 1774, the marriage festival of Prince Frederick was
celebrated, and at this very period a despatch arrived for the
commandant of Munkholm. He was recommended greater severity
with his prisoners, and especially with me. This letter of General
Hauch's was certainly not written with the intention of my seeing it,
but it was shown me by the commandant. His attentions to me did
not escape my notice; he, doubtless, wished to make me feel them;
what did he expect from me?
On March 1, 1775, a lodging was assigned me in another house,
which had just been finished. I was given two rooms, but did not
gain by the change. The other buildings of the fort, and in particular
the one I had inhabited, were sheltered by the ramparts, while the
new house, built in the angle of a lofty rock, was exposed to the
north, east, and west winds. The beams that formed the walls did
not join, any more than the planks of the floor; under my lodging a
cellar seemed to breathe an icy blast through the openings in the
flooring. The stove intended to heat the room could not protect me
from the cold; yet its effect was sufficient when the snow fell to
dissolve it into rain in the apartment; and it is in such a habitation,
under the 64° of northern latitude, that I write this description,
which is not exaggerated.
In November, 1775, I was attacked by an hemorrhoidal colic, which
caused me such pain as to draw shrieks from me. The surgeon who
attended me evidently thought my condition desperate. The pain
grew less, however; I needed rest, and begged the sentry not to let
any one enter. I was beginning to sleep, when the commandant
arrived; he entered in defiance of my orders, woke me, and said that
as I was on the point of death, I ought to make haste, and leave a
will in his favour; I evaded this by answering him that I did not
intend dying yet. He assured me again that I must believe him,
because he was commandant: I made no answer, and he went off
growling, and soon after made a frightful disturbance, alleging that
an attempt was going to be made to carry me off, and that a boat
had been noticed in the neighbourhood.
Early in 1776, the commandant of Munkholm was removed, and
Major Colin took his place.
This new commandant, two days after his arrival, sent me a bottle of
good water, bread, and fresh butter; this procured me the best meal
I had yet had. Under this commandant I enjoyed great tranquility
and greater ease. I relieved myself by writing these memoirs, and I
fancied that I felt less resentment at the evil that had been done
me, in proportion as I wrote the narrative of it.
It is certain that fate has been very contrary to me. I joined to the
passion of arms a taste for meditation, study, and retirement. I
eagerly desired to acquire glory, but an independence would have
been sufficient for me: I could not hope for either now.
Some one once said to Count de St. Germain, that it was surprising
he should resolve to quit the service of France, when he had 60,000
livres a year from the king's bounty; he answered, that 100 crowns a
year composed his whole patrimony, but he would sooner live on
that than endure affronts.
This answer struck me, and I resolved to save all I could, so as to
acquire an independence. I possessed, in 1771, 8,000 crowns, which
I had entrusted to Schimmelmann, while awaiting the opportunity to
sink them in an annuity. If I did not succeed in a military career, I
hoped with this resource to procure a retreat in an agreeable
country, and in a warm climate.
Now, my money is lost, I have no longer a career to follow, and I am
a prisoner for life on a rock in 64° of northern latitude: but how
great was my folly in leaving the service of Russia to come to
Denmark!
I was making these sad reflections when, on September 25, 1776, I
was informed by a note from Lieutenant-General von der Osten,
grand bailiff and commandant of Trondhjem, that I should receive a
visit from him. I had not recovered from the surprise this note
caused me, when Von der Osten himself appeared, followed by the
commandant, a surgeon, and his valet. He hurriedly entered my
room, shouting, Pardon, pardon, in the king's name! He held in his
hand a portfolio full of papers, among which were—
1. An order for my release, addressed to General Hauch, in his
quality of first deputy of the College of War: this order was signed by
the king, and countersigned by Guldberg, under date, Frederiksborg,
August 21, 1776.
2. An order to the same effect, addressed to the commandant of
Munkholm.
3. An instruction referring to the engagement I was to sign and seal
before obtaining my release.
These three documents were to the effect that his Majesty, on the
intercession of his Royal Highness Prince Frederick, his beloved
brother, consented to pardon me by liberating me from the captivity
in which I was at Munkholm, upon the following conditions:—
I. That I should leave Trondhjem by sea, to proceed to the northern
coast of France, and thence directly and immediately either to
Provence or Languedoc, at my choice.
II. That I would pledge myself never to return to Copenhagen, or
the king's states.
III. That I would not leave the country to which I was sent without
the king's permission, and that I would not make frequent journeys.
IV. That I would not approach the town of Orange (where Rantzau
had taken up his abode).
V. That I would not enter the service of any foreign power.
VI. That I would not act, write, or speak in any way against the king
or the royal family.
VII. That I would take no part in affairs of state.
If there was no vessel ready for me to embark, I was allowed to
remain at Trondhjem; but I must not leave the town without the
governor's permission, or go further than a league from it. The king
granted me for my journey 800 crowns of the money which had
belonged to me, and hopes were held out of a pension.
The instruction concerning my engagement was very long. Guldberg,
who had drawn it up, had interlarded it with a good many religious
motives: he even alluded to the efficaciousness of Christ's blood;
but, after all, it was probably to him that I owed the amelioration in
my fate.
General von der Osten added to the conditions various articles, by
which he hoped to pay court to the minister.
I signed what was asked, and though I felt perfectly well the value
of an engagement imposed on a man who had not been legally
convicted of any crime, I resolved to observe it. When this act was
regularly drawn up, the general, in order to give the circumstance
greater éclat, had me bled by his surgeon-major, after which he
proposed to me a bottle of red wine to restore my senses.
I excused myself by observing that I did not drink, and offered him a
liqueur, of which I possessed two bottles.
"I could carry them off," he said, after examining them; "but this
commission must be worth more than that."
This was giving me to understand that he reckoned on a goodly
portion of my 800 crowns. It may be supposed that my intentions on
this point did not at all accord with his.
There was no vessel at Trondhjem destined for France, and I could
not expect one for a long time, as from the beginning of September
till the end of April the sea is very stormy in these latitudes, and
hence I should have to wait eight full months before I could depart.
In this situation I wrote to the court to offer my thanks for the
mercy shown me, and to obtain permission to proceed to my
destination by land. In the meanwhile I remained at Munkholm,
hoping to be less exposed there to the importunities of the general.
The court of Copenhagen rejected my request, but allowed me to
take ship for Holland.
Three vessels were preparing to sail for Amsterdam, one of which
belonged to Trondhjem, and General von der Osten wished me to
take passage in it; but I gave the preference to a Danish ship.
The general offered me the services of his valet, to prepare a gold-
laced coat; but this offer did not tempt me. I set out with my
bearskin pelisse, which composed my wardrobe. I also carried off my
800 crowns, without leaving one for the general.
The three vessels bound for Amsterdam set sail from Trondhjem on
October 16; two perished: the one I was on board reached
Christiansund, where we remained till February 16. After a stormy
navigation, we reached Amsterdam on March 10.
On April 12, 1777, I arrived at Montpellier, where I fixed my domicile.

In 1780, Falckenskjold received permission to retire to the Pays de

Vaud, where his friend Reverdil invited him, and he established his
home at Lausanne. In 1787, the court of Petersburg proposed to him
to re-enter its service; he was offered the post of chief of the staff in
the army intended to act against the Turks. But, finding himself
bound by the engagements he had made, he replied, that he could
not accept the offer without the formal consent of the court of
Copenhagen; and this court refused its assent, under the pretext
that it needed his services. At the same time, it permitted
Falckenskjold to return to Copenhagen, and seemed disposed to
revoke his order of banishment.
In the spring of 1788 he went to Copenhagen, but his reception
there was such that he longed to return to his retreat at Lausanne.
He obtained permission to go back, and, having recovered a portion
of his property, which the state had seized, he invested it in
annuities in the French funds. In the same year, war having broken
out between Denmark and Sweden, the Danish government recalled
Falckenskjold, conferring on him the rank and pay of a major-
general; but when he was going to set out he learned that peace
was signed, and he was saved the journey.
His pay and savings enabled him to live comfortably, with such
friends as Gibbon and Reverdil; and he kept his health till the last
two years of his life, when he was attacked by a gouty rheumatism,
the seeds of which he had contracted in his Munkholm prison. He
died on September 30, 1820, at the age of eighty-two years and a
few months.
 CHAPTER V.
DEPARTURE OF THE QUEEN.

THE BRITISH FLEET—SPIRITED CONDUCT OF KEITH—THE ORDER OF

RELEASE—THE PRINCESS LOUISA AUGUSTA—THE DEPARTURE—THE
LANDING AT STADE—THE STAY AT GOHRDE—ARRIVAL IN CELLE—THE
QUEEN'S COURT—A HAPPY FAMILY—KEITH'S MISSION—LITERARY PIRATES
—REVERDIL TO THE RESCUE.

We have seen that the sentence of the court, decreeing a dissolution

of the marriage, was announced to Caroline Matilda. From this
moment she was no longer regarded as queen, and all her ties with
Denmark were broken off with her marriage. After her
condemnation, the ambassadors of the foreign powers were
convoked at the Christiansborg Palace. They proceeded thither in
mourning, and heard from the grand-master that, as the king no
longer had a consort, there was no longer a queen. The name of
Caroline Matilda was from this moment effaced from the public
prayers. She became a stranger to the country over which she had
reigned.[34]
As was the case with the other prisoners, whose position was
considerably mitigated so soon as they had made satisfactory
confessions in their examination before the Commission of Inquiry,
the queen, after the separation, was granted better apartments in
the first-floor of the fortress, and was allowed to take the air on the
ramparts. That Colonel Keith was permitted to visit the queen was
looked on as a further concession, and that the envoy frequently
took advantage of this permission, may surely be regarded as a
further and important proof how greatly he was convinced of her
innocence.
When her Majesty was informed of the circumstances connected
with the tragical death of the two prisoners, she said to Fräulein
Mösting, her maid of honour,
"Unhappy men! they have paid dearly for their attachment to the
king, and their zeal for my service."
No thought of self, it will be noticed: Caroline Matilda entirely forgot
the humiliation to which she had been exposed by Struensee's
dastardly confession, and only evinced sincere compassion for his
undeserved and barbarous fate. But she was ever thus: from the
first moment to the last, she sacrificed herself for others. Of this, the
following anecdote will serve as an affecting proof:—
The queen, having so fatally experienced the vicissitudes of human
grandeur, was not so deeply affected by her own disasters as to
overlook the sufferings and misery of some state prisoners, doomed
to perpetual exile in the Castle of Kronborg. Her Majesty's liberal
beneficence was never more conspicuous than in this period of
affliction and distress. She sent daily from her table two dishes to
these forsaken objects of compassion, and out of a scanty
allowance, she sent, weekly, a small sum to be distributed among
them. The governor having requested her Majesty to withdraw her
bounty from an officer who had been closely confined for some
years past in a remote turret, debarred from all human intercourse,
on suspicion of a treasonable correspondence with the agent of a
northern power, who had enlisted, with the assistance of the
prisoner, several Danish subjects for his master's service, the queen
merely replied with the following line of Voltaire:—
"Il suffit qu'il soit homme et qu'il soit malheureux."[35]
On one occasion, Caroline Matilda, conversing on the early
commencement of her misfortunes, observed that, since she was
born to suffer, she found some consolation in being marked out so
soon by the hand of adversity. "I may possibly live," said her
Majesty, "to see Denmark disabused with respect to my conduct:
whereas my poor mother, one of the best women that ever existed,
died while the load of obloquy lay heavy upon her, and went to the
grave without the pleasure of a vindicated character."[36]
Early in March, the charges against Caroline Matilda had been
forwarded to London, and were there submitted to the opinions of
the first lawyers, who, though consulted separately, all declared that
the evidence brought forward was so far from being legal conviction,
that it scarce amounted to a bare presumption of guilt: and they
affirmed that they did not give credit to any of the facts as lawyers,
but even found themselves obliged to disbelieve them as men. Upon
this the court of St. James insisted that no sentence should be
passed on her Danish Majesty, as the evidence against her was only
presumptive, and very inconclusive.
A strong fleet was now fitted out, and universally supposed to be
destined for the Baltic; still the most prudent thought, or at least
hoped, that the fleet was only intended to intimidate the Danes, but
would not sail, as the king of Prussia would certainly march an army
immediately to Hanover, and then a new war would be kindled in the
north. On the 22nd, counter orders, for suspending the preparations,
were sent to Portsmouth. Horace Walpole, the omniscient, shall tell
us what was the generally accepted version of the affair:—
"The king, as Lord Hertford told me, had certainly ordered the fleet
to sail; and a near relation of Lord North told me that the latter had
not been acquainted with that intention. Lord Mansfield, therefore,
who had now got the king's ear, or Lord Sandwich, First Lord of the
Admiralty, must have been consulted. The latter, though I should
think he would not approve it, was capable of flattering the king's
wishes: Lord Mansfield assuredly would. The destination was
changed on the arrival of a courier from Denmark, who brought
word that the queen was repudiated, and, I suppose, a promise that
her life should be spared: for, though the Danes had thirty ships and
the best seamen, next to ours, and though we were sending but ten
against them, the governing party were alarmed, probably from not
being sure their nation was with them. The queen had confessed her
intrigue with Struensee, and signed that confession. When the
counsellor, who was to defend her, went to receive her orders, she
laughed, and told him the story was true."
In this we have a favourable specimen of Walpole's talent as an
embroiderer of history. It is very evident that he had heard the facts
floating about society; but his additions to them were evidently pure
inventions. He shall give us one bit more of gossip, which may or
may not have been true, although there appears to be evidence in
its favour in the strange conduct of George III. toward his sister:—
"They gave her (Caroline Matilda) the title of Countess of Aalborg,
and condemned her to be shut up in the castle of that name. The
King of England had certainly known her story two years before. A
clerk in the secretary's office having opened a letter that came with
the account, told me that he had seen it before the secretaries gave
it to the king. It was now believed that this intelligence had
occasioned the Princess of Wales to make her extraordinary journey
to Germany, where she saw her daughter, though to no purpose.
Princess Amelia told Lord Hertford, on the 26th, that when the King
of Denmark was in England, observing how coldly he spoke of his
wife, she asked him why he did not like her. He answered, 'Mais elle
est si blonde!' The princess added, that Queen Matilda had a very
high spirit, and that she believed the Danes would consent to let her
go to Hanover. 'But she will not be let go thither,' added the princess,
meaning that the queen's brother, Prince Charles of Mecklenburg,
commanded there, 'or to Zell, but she will not go thither (another of
the queen's brothers was there); perhaps she may go to Lüneburg."
[37]

It is very probable, too, that the temper of the British nation, which
had undergone a complete revulsion on the announcement of the
fleet sailing, had something to do with its suspension. At any rate,
we read in the General Evening Post for April 30, the following
painful account:—
"Nothing, surely, is a greater impeachment of our laws, and more, of
our lawgivers and magistrates, than the unrestrained licentiousness
daily exhibited by the common people in this metropolis. Yesterday,
in some parts of the city, men were crying about printed papers
containing the most scandalous, ruinous, and impudent reflections
on the Queen of Denmark. The worst prostitute that ever Covent
Garden produced could not have had more gross abuse bestowed on
her."
But Sir R. M. Keith had been working hard in the meanwhile, and on
the receipt of his letters of recall and news of the menaces of
England in equipping a fleet, the regency gave in at once, promised
to repay the queen's dowry, allow her five thousand a-year, and let
her go to Hanover, beyond Jordan, anywhere, so long as they could
only be rid of her. In reply to the despatch in which Sir R. M. Keith
announced his success, he received the following official letter:—
LORD SUFFOLK TO SIR R. M. KEITH.
St. James's, May 1, 1772.
SIR,
Your despatches by King the messenger have been already
acknowledged; those by Pearson were received on Wednesday
afternoon, and I now answer both together.
His Majesty's entire approbation of your conduct continues to the
last moment of your success, and his satisfaction has in no part of it
been more complete than in the manner in which you have stated,
urged, and obtained the liberty of his sister. The care you have taken
to distinguish between a claim of right and the subjects of
negotiation, and to prevent the mixture of stipulations with a
demand, is perfectly agreeable to your instructions.
The national object of procuring the liberty of a daughter of England
confined in Denmark, after her connection with Denmark was
dissolved, is now obtained. For this alone an armament was
prepared, and therefore, as soon as the acquiescence of the court of
Copenhagen was known, the preparations were suspended, that the
mercantile and marine interests of this kingdom might be affected
no longer than was necessary by the expectation of a war.
Instead of a hostile armament, two frigates and a sloop of war are
now ordered to Elsinore. One of these is already in the Downs—the
others will repair thither immediately; and, so soon as the wind
permits, they will proceed to their destination. I enclose to you an
account of them, which you may transmit to Monsieur Ostein (Von
der Osten) ministerially, referring at the same time to the assurance
of these pacific proceedings.
The compliance of the Danish court with his Majesty's demand is still
a compliance. Their continuing, unasked, the title of queen, and
other concessions, and the attainment of the national object
accompanying each other, his Majesty would think it improper to
interrupt the national intercourse from any personal or domestic
consideration. You will therefore inform Mr. Ostein that his Majesty
intends to leave a minister at the court of Copenhagen, the
explanation you may give of this suspension of former directions,
and his determination, being left to your own discretion.[38]
It was with feelings of pride that the British envoy passed through
the vaulted entrance of "Hamlet's Castle," to carry to an afflicted and
injured princess the welcome proofs of fraternal affection and liberty
restored. The feeling was reciprocal, for when Keith brought the
order for Caroline Matilda's enlargement, which he had obtained by
his spirited conduct, she was so surprised by the unexpected
intelligence, that she burst into a flood of tears, embraced him in a
transport of joy, and called him her deliverer.[39]
The queen from this time forth was more constantly than ever on
the ramparts watching for the arrival of the British flotilla. The
squadron, consisting of the Southampton, Captain McBride, the
Seaford, Captain Davis, and the Cruizer, Captain Cummings, left
England on May 22, and anchored off Elsinore on the 27th. In the
meanwhile Caroline Matilda wrote her brother a most affecting letter,
asserting her innocence of all the criminal accusations against her in
the strongest manner, and declaring that the strictness of her future
life should fully refute the slander of her enemies. She at the same
time expressed a wish to be allowed to return to England, but left
her fate in his Majesty's hands. A consultation had been held at
Buckingham House on the subject, but it was found too expensive,
and it was finally settled that Caroline Matilda was to take up her
residence at Celle, in Hanover, George III. allowing her £8,000 a
year for the support of her dignity.
Very touching, too, is it to read that the queen at this time wore
nothing but deep mourning; and one of her ladies asking her why
she affected such a semblance of sorrow, she replied—
"It is a debt I owe to my murdered reputation."
Sir Robert Murray Keith supplies an interesting anecdote of the
queen in a letter to his sister:—
"Here I am, thank my stars, upon the utmost verge of Denmark. My
ships are not yet arrived, but a few days may conclude the whole
affair; and the weather is mild and agreeable. I return to
Copenhagen this evening, but only for a day or two, to wind up my
affairs, and give my parting advice to the little secretary, in whose
success as chargé d'affaires I take a particular interest. I am just
returned from her Majesty, who is, Heaven be praised, in perfect
health, notwithstanding the danger she has run of catching the
measles from the young princess, whom she never quitted during
her illness. A more tender mother than this queen has never been
born in the world."
Caroline Matilda was at dinner when the imperial salute of the
English frigate and the castle guns informed her Majesty of Captain
McBride's arrival. This gallant officer met Sir R. Keith on shore, who,
after a mutual exchange of compliments, introduced the captain to
her Majesty, by whom he was most graciously received as a man
destined to convey her safe to her brother's electoral dominions; far
from the reach of the personal shafts of her enemies, and that land
which had been the dismal scene of her unparalleled misfortunes
and humiliations. When the captain had notified his commission, and
said that he should await her Majesty's time and pleasure, she
exclaimed in the anguish of her heart, "Ah! my dear children," and
immediately retired. It was not for an insensible monarch on a
throne, on which she seemed to have been seated merely to be the
butt of envy, malice, and perfidy, that her Majesty grieved: the
excruciating idea of being parted from her dear children, and the
uncertainty of their fate, summoned up all the feelings of a tender
mother. She begged to see her son before he was torn for ever from
her bosom: but all her Majesty's entreaties were unsuccessful.
Juliana Maria envied her the comfort of the most wretched—that of
a parent sympathising in mutual grief and fondness with children
snatched from her embrace by unnatural authority.
A deputation of noblemen having been appointed by the queen
dowager to observe the queen after her enlargement till her
departure, under the fallacious show of respect for the royal
personage so lately injured and degraded—when they were admitted
to Caroline Matilda's presence, and wished her in her Majesty's name
a happy voyage, she answered—
"The time will come when the king will know that he has been
deceived and betrayed; calumny may impose for a time on weak and
credulous minds, but truth always prevails in the end. All my care
and anxiety are now for the royal infants, my children."[40]
On May 30, a lady belonging to the court went to Kronborg in one of
the king's coaches to remove the young Princess Louisa Augusta,
and conduct her royal highness to Christiansborg Palace. Hence the
last moments which the feeling queen spent in Denmark were the
most painful of all: she was obliged to part from her only
consolation, her only blessing, her beloved daughter: she was forced
to leave her dear child among her enemies. For a long time she
bedewed the infant with hot tears—for a long time she pressed it to
her heart. She strove to tear herself away; but the looks, the smiles,
the endearing movements of the infant, were so many fetters to
hold the affectionate mother back. At last she called up all her
resolution, took her once more in her arms, with the impetuous
ardour of distracted love imprinted on the lips of the child the
farewell kiss, and, delivering it to the lady-in-waiting, shrieked,
"Away, away, I now possess nothing here!"[41]
As the governor had behaved to the queen so as to merit her
Majesty's confidence and esteem, she entrusted him with a letter for
the king, which he promised faithfully to deliver into his Majesty's
own hands. It must have been very moving, as the king was
observed to shed tears on reading it.[42]
At six in the evening of May 30, Caroline Matilda proceeded in a
royal Danish boat on board the English frigate. Her suite consisted of
Colonel Keith, who would accompany her to Göhrde, and of Count
Holstein zu Ledreborg, his wife, Lady-in-waiting von Mösting, and
Page of the Chamber von Raben, who were ordered to convey her
Majesty as far as Stade, and then return by land. When the anchor
was apeak, the fortress, and the Danish guardship in the Sound,
gave a salute of twenty-seven guns.
The queen remained on deck, her eyes immovably directed toward
the fortress of Kronborg, which contained her child, who had so long
been her only source of comfort, until darkness intercepted the view.
The vessel having made but little way during the night, at daybreak
she observed with fond satisfaction that the fortress was still visible,
and could not be persuaded to enter the cabin so long as she could
obtain the faintest glimpse of the battlements.
Among Sir R. M. Keith's papers was found the following copy of
verses, whose title speaks for itself. Unfortunately, there is no
positive proof that they were written by the queen herself, beyond
the care that Sir Robert took of them:—

WRITTEN AT SEA BY THE QUEEN OF

DENMARK,
ON HER PASSAGE TO STADE, 1772.
At length, from sceptred care and deadly state,
From galling censure and ill-omened hate,
From the vain grandeur where I lately shone,
From Cronsberg's prison and from Denmark's throne,
I go!
Here, fatal greatness! thy delusion ends!
A humbler lot thy closing scene attends.
Denmark, farewell! a long, a last adieu!
Thy lessening prospect now recedes from view;
No lingering look an ill-starred crown deplores,
Well pleased, I quit thy sanguinary shores!
Thy shores, where victims doomed to state and me,
Fell helpless Brandt and murdered Struensee!
Thy shores where—ah! in adverse hour I came,
To me the grave of happiness and fame!
Alas! how different then my vessel lay;
What crowds of flatterers hastened to obey!
What numbers flew to hail the rising sun,
How few now bend to that whose course is run!
By fate deprived of fortune's fleeting train,
Now, "all the oblig'd desert and all the vain."
But conscious worth, that censure can control,
Shall 'gainst the charges arm my steady soul—
Shall teach the guiltless mind alike to bear
The smiles of pleasure or the frowns of care.
Denmark, farewell; for thee no sighs depart,
But love maternal rends my bleeding heart.
Oh! Cronsberg's tower, where my poor infant lies,
Why, why, so soon recede you from my eyes?
Yet, stay—ah! me, nor hope nor prayer prevails—
For ever exiled hence, Matilda sails.
Keith! formed to smooth the path affection treads,
And dry the tears that friendless sorrow sheds,
Oh! generous Keith, protect their helpless state,
And save my infants from impending fate!
 Far, far from deadly pomp each thought remove,
And, as to me, their guardian angel prove!
Yes, Julia, now superior force prevails,
And all my boasted resolution fails!

Before taking leave of Kronborg, I may be permitted to insert an

anecdote related by my grandfather in his "Travels in the North."
When he visited Kronborg, in 1774, a poor fettered slave came up
and addressed him in French. Mr. Wraxall then commenced a
conversation with him, and asked him if he were here when Queen
Matilda was in confinement.
"Ah! Monsieur," the prisoner replied, "I saw her every day. I had the
honour to turn the spit for her Majesty's dinner. She even promised
to endeavour to obtain me my liberty. I assure you," he added
warmly, "that she was the most amiable princess in the world."
Whether the man said this because he believed it would please an
Englishman, or whether it was the genuine effusion of respectful
gratitude, my grandfather was unable to say, but could not resist the
compliment to an English and injured queen.
By a royal resolution of March 18, 1773, all the documents
connected with the dissolution of the marriage of Queen Caroline
Matilda were made into four separate packets, and one of them,
which contained the orders, protocols, and examinations, was
deposited in the secret archives: the second, containing the perfect
acts with the votes of all the commissioners, and a copy of the
examination of the witnesses, was entrusted for safe keeping to the
governor of Glückstadt: the third, consisting of a copy of the original
articles and the examinations, was kept at the Norwegian fortress of
Bergenhuus, in an iron chest, in a room the keys of which were held
by the commandant and the viceroy: and the fourth packet, which
only contained a copy of the articles, but not of the depositions, was
placed in the archives of the Danish Chancery. This division of the
documents also serves as a proof, how every possible care was
taken that the queen's posterity should not hereafter find the whole
of the documents at any one place.
The queen did not reach Stade till June 5, where she was received
with all the respect due to crowned heads. The Hanoverian Privy
Councillor von Bodenhausen, and the Land Marshal Chamberlain von
Bülow, pulled on board the flag-ship to welcome the queen. At the
landing-place, where the ladies and gentlemen selected to attend on
her Majesty were awaiting her, the Danish escort took leave. The
queen gave Count Holstein a diamond solitaire as a souvenir, and
entrusted him with a gold snuff-box for the wife of General von
Hauch, commandant of Kronborg.
The new suite of the queen was composed of a grand lady, two
ladies-in-waiting, one chief chamberlain, a chamberlain, one page of
the bed-chamber, two pages and a number of servants. After
remaining for two days at Stade, she travelled with her suite, viâ
Harburg, to the Château of Göhrde, thirty miles from Stade, where
she intended to remain till the palace at Celle was restored for her
reception. At Göhrde, Sir R. Keith took leave of her, and she received
a visit from her eldest sister, the Hereditary Princess of Brunswick
Wolfenbüttel and her husband.[43] These near relations, however,
also belonged to the princely family from which Juliana Maria was
descended, and in consequence, were rather suspicious friends for
Caroline Matilda.
On October 20, the queen made her entrance into Celle, and took up
her abode in the royal château. This old residence of the former
Dukes of Lüneburg was at this time a fortified castle surrounded by
moats and walls. Although the apartments were spacious and
habitable, and well furnished, the exterior of the castle resembled a
prison rather than a palace. But the queen soon gained the hearts of
all the inhabitants by her amiability and resignation, and thus
converted the unfriendly asylum into an abode of peace and
consolation. She frequently attended at church, was fond of
conversing on religious topics, and gave rich gifts to the poor, both
with her own hands and through the clergy of the town. Treating all
gracefully who approached her presence, she more especially gave
children an opportunity of telling their parents, with delight, that
they had been spoken to by the queen. If, at night, she fancied she
had not been so friendly as usual to any one during the day, she
reproached herself for it. Judging all persons indulgently, she could
not endure that absent persons should be harshly condemned in her
presence, and, in truth, she ruled her court, not alone by her rank,
but even more through the lovingness of her noble heart. But,
whenever she was obliged to act the queen, she did so, on the other
hand, with a dignified demeanour and with majesty.
Although Caroline Matilda excelled in all the exercises befitting her
sex, birth, and station, and danced the first minuet in the Danish
court, she never again indulged in this polite amusement, of which
she had been extremely fond, after the masked ball the conclusion
of which had been so fatal and disgraceful to her Majesty. As one of
her pretended crimes had been the delight she took in riding, and
the uncommon address and spirit with which she managed her
horse, she also renounced this innocent recreation, for fear of giving
the least occasion to the blame and malice of the censorious and the
ignorant. Her Majesty had an exquisite taste for music, and devoted
much of her time to the harpsichord, accompanied by the melodious
voice of a lady of her court.
There was in the queen's dress a noble simplicity which exhibited
more taste than magnificence. As her mind had been cultivated by
reading the most eminent writers of modern times, she read
regularly for two hours before dinner with Fräulein Schülenburg,
whatever her Majesty thought most conducive to her instruction or
entertainment, in poetry and history, the ladies communicating their
observations to each other with equal freedom and ingenuity. The
queen improved the knowledge she had acquired of the German
language, and had a selection of the best authors of that learned
nation. As her manners were the most polished, graceful, and
endearing, her court became the resort of persons of both sexes,
celebrated for their love of the fine arts. The contracted state of her
finances could not restrain the princely magnificence and liberal
disposition which made her purse ever open to indigent merit and
distressed virtue. Naturally cheerful and happy in the consciousness
of her innocence, adored and revered by the circle of a court free
from cabals and intrigues, even the dark cloud of adversity could not
alter the sweetness and serenity of her temper. She was surrounded
by faithful servants, who attended her, not from sordid motives of
ambition, but from attachment and unfeigned regard.
Peace, content, and harmony dwelt under her Majesty's auspices,
and her household was like a well-regulated family, superintended by
a mistress who made her happiness consist in doing good to all
those who implored her Majesty's compassion and benevolence.
Banished with every circumstance of indignity from the throne of
Denmark, her noble soul retained no sentiment of revenge or
resentment against the wicked authors of her fall, or against the
Danish people. Ambition, a passion from which she was singularly
exempt, never disturbed her peace of mind; and she looked back to
the diadem which had been torn from her brow with wondrous
calmness and magnanimity.
It was not the crown Caroline Matilda regretted, for her children
alone occupied all her care and solicitude; the feelings of the queen
were absorbed in those of the mother; and if she ever manifested by
tears her inward grief and perplexity, maternal fondness caused all
these fears and agitations.[44]
In October of this year Sir R. Keith was requested by Lord Suffolk to
visit Caroline Matilda, and send in a minute account of her position
and feelings. How well the ambassador performed his task will be
seen from his letter.
SIR R. M. KEITH TO LORD SUFFOLK.
Zell, November 2, 1772.
MY LORD,—
I arrived here on the 31st October, late in the evening, and the next
day had the honour of delivering the king's letter to her Danish
Majesty, whom I found in perfect health, and without any remains of
pain from her late accident. In two very long audiences, which her
Majesty was pleased to grant me, I endeavoured to execute, with
the utmost punctuality, his Majesty's command, and shall now lay
before your lordship all the lights those audiences afforded me,
relative to the queen's wishes and intentions. I cannot enter upon
that subject without previously assuring your lordship that the queen
received those repeated proofs of his Majesty's fraternal affection
and friendship, which my orders contained, with the warmest
expressions of gratitude and sensibility; and that nothing could be
more frank or explicit than her answers to a great number of
questions, which she permitted me to ask upon any subject that
arose.
In regard to Denmark, the queen declares that, in the present
situation of the court, she has not a wish for any correspondence or
connection there, beyond what immediately concerns the welfare
and education of her children. That she has never written a single
letter to Denmark since she left it, or received one thence. That the
only person belonging to that kingdom from whom she hears lives in
Holstein, and is not connected with the court.
The queen having expressed great anxiety with respect to the false
impressions which may be instilled into the minds of her children,
particularly regarding herself, I thought it my duty to say that such
impressions, however cruelly intended, could not, at the tender age
of her Majesty's children, nor for some years to come, take so deep
a root as not to be entirely effaced by more candid instructions, and
the dictates of filial duty, when reason and reflection shall break in
upon their minds. The queen seemed willing to lay hold of that
hope, yet could not help bursting into tears, when she mentioned
the danger of losing the affections of her children.
Her Majesty appears very desirous to communicate directly to her
royal brother all her views and wishes in the most confidential
manner, hoping to obtain in return his Majesty's advice and
directions, which she intends implicitly to follow. She said that, in
matters of so private and domestic a nature, it would give her much
greater pleasure to learn his Majesty's intentions upon every point
from his own pen, than through the channel of any of his electoral
servants.
It gave me great satisfaction to find her Majesty in very good spirits,
and so much pleased with the palace at Zell, the apartments of
which are very spacious, and handsomely furnished. She wishes to
have an apartment fitted up in the palace for her sister, the Princess
of Brunswick, as she thinks that the etiquette of this country does
not permit that princess, in her visits to Zell, to be lodged out of the
palace, without great impropriety. Her Majesty said that she
intended to write herself to the king on this head.
The queen told me that the very enterprising and dangerous part
which Queen Juliana has acted in Denmark, has created greater
astonishment in Brunswick (where the abilities and character of that
princess are known) than, perhaps, in any other city of Europe.
Her Majesty talked to me of several late incidents at the court of
Denmark, but without appearing to take much concern in them. She
mentioned, with a smile, some of the paltry things which had been
sent as a part of her baggage from Denmark, adding, that this new
instance of their meanness had not surprised her. But the Princess of
Brunswick, who happened to be present when the baggage was
opened, expressed her indignation at the treatment in such strong
terms, that she (the queen) could not help taking notice of it in her
letters to the king.
She let me understand that a small collection of English books would
be very agreeable to her, leaving the choice of them entirely to his
Majesty.
Her Majesty more than once expressed how much she considered
herself obliged to the king's ministers, for the zeal they had shown in
the whole of the late unhappy transactions relating to Denmark and
to herself. She is particularly sensible to the great share your
lordship had in all those affairs, and has commanded me to convey
to your lordship her acknowledgments for that constant attention to
her honour and interests, which she is persuaded the king will look
upon as an additional mark of your lordship's dutiful attachment to
his royal person and family.
It only remains that I should beg your forgiveness for the great
length to which I have swelled this letter. The only excuse I can offer
arises from my ardent desire to excuse the king's orders with the
utmost possible precision.
I am, &c., &c.,
R. M. KEITH.[45]

At home, Caroline Matilda appeared to have dropped out of memory

with her landing at Stade. Her name is never found in the journals of
the time. Grub-street alone took possession of her memory. In those
days many literary scoundrels earned a precarious livelihood by
deliberately forging pamphlets on topics of interest at the moment,
and thought nothing of trying to enhance their veracity by assuming
names and titles to which they had not the slightest claim. One of
these hungry gentry received a severe discomfiture, and must have
felt ashamed, if he could feel shame, from honest Reverdil, in the
July number of the Monthly Review. Reverdil's letter, written in
English, is tremendously to the point. The lie, with a circumstance,
bore the title of—"The real Views and Political System of the late
Revolution of Copenhagen. By Christian Adolphus Rothes, formerly
Councillor of Conference, Secretary of the Cabinet to his Majesty
Christiern (sic) VII., and Great Assessor of the Supreme Council at
Altona."
To which Reverdil quietly makes answer:—
1. As I am pretty well acquainted with the Danish service, I can
assure you that there is not in Denmark, Norway, or any of the
Danish dominions, such a man as Mr. Christian Adolphus Rothes, in
any employment whatever.
2. The dignity of Councillor of Conference being merely titular, there
is no formerly Councillor.
3. The present king, Christian VII., has had three secretaries of the
cabinet: the first is now in London (himself); the second, who
followed his master on his voyage, is in the Court of Chancery at
Copenhagen; the third was beheaded on April 28.
4. There is no supreme council at Altona; that town, being no
capital, hath but a corporation, and no other council. In that
corporation there is no assessor, great or little.
To this crushing reply Reverdil adds that every circumstance in the
book is absolutely false, and grounded on facts and a state of things
that never existed. For instance, the conduct of the queen dowager
in the king's council is very circumstantially described; but she never
sat in the king's council.[46]
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