DUKE UNIVERSITY LIBRARY Treasure %oom GIPT OP . .law // - ■+%• % V ^*- . ■*/^* w ,.:'., MANUAL MILITARY SURGERY, FOR THE USE OF SURGEONS IN THE CONFEDERATE STATES ARMY ; WITH AN APPENDIX <>F Till'. JtoUs and geplations of the vftlcdiral Department CONFEDERATE STATES ARMY. J. JULIAN ( IIISOLM. M. D.. (. I Mi's : \ THE MEHMW I i ,.i I \ |\ 7 111 CO.VKEDl I. \ i I'. STATE8 \RM V. i:1 PUOFESSOn "F sn;CKCV in the MEDICAL I OLL1 '-i "I SOI TH CAROLINA, 137549 SECO.Mi ElMTkl.\-l!EUNELl AMI IMI'RU\EI>. i;i< EMOND, VA .1 QRVBTQ N. Mo MAIN BTB I L862. ;i^ \\ i the year l Si .1 J. OHISOLH, m . D. . In the i „rt of the CoufWIoi ito State* bl lli«. ' Cliiirl.Hlon. - int. . CaAauwroa • #42.' In putting t'orth tliis Manual of Militan Surgery for the use of Surgeons in tin- Confederate service, 1 have been led by the desire to mitigate, it' possible, the horrors of war as Been in ii- most frightful phase in military hospitals. A.s our entire army is made up of volunteer* from every walk of lite, ag we find the surgical staff of the army composed of physicians without surgical experience* Mosl of tlm-e who now compose the surgical staff were genera] praciitioneis, whose country circuit gave tliein hut little surgery, and xrvy seldom pre- sented a gunshot wound. As our country had been enjoying an uninterrupted Btate of peace, the collecting of large bodies of men. and retaining them in health, or the hygiene of armies, had been a study without an object, and. therefore, without interest When the war suddenly broke upon us. fol- lowed immediately by the blockading of our ports, all commu- nication was cut off with Europe, which was the expected source of our surgical informatiofj As there had been no pre- vious demand for works on military surgery, there were none to be had in the stores, and our physician- were compelled to follow the army to battle without instruction! X ■ work on military surgery eouhl be purchased in the Confederate State-. As military surgery, which is one of expediency, differs so much from civil practice, the want of proper information has already made itself seriously frit. In times of war. where invasion threatens, every citizen is expected to do his duty to his I m» no better means of showing mj willingness td eq the cause than by preparing a Manual of instruction for thi the army, which might be the means of saving the lives and preventing the mutilation of many friends and country- The present volume contains the fruit of Eur experience, as dearly purchased in recent campaigning. Be- sides embodying the experieq in military 137549 urn nt of wounds, I have incorporated ■ upon tli' ing anil hygiene <>i' troops; with « how the health <>t' an arm) i* i" be preserved, and I,,.-, i be sustained ; also, Che duties •■-. both in the cainp and in the 6eld. In •iii'l the regulations - lor the .,1 the M' 'ii -il il<-|i-irtm< lit of the Con irmy. In in'-. 1 have n"t hesitated t" add u< my own treatment of surgical injuries anj useful I ould obtain from the most recent Ger- man, French and English works on military surgery : and in mani instances, where the language used by them expressed t.> tli- point the subjeat under discussion, I have not hesitated t i transfer entire sentences directly to these pages. I make t!ii> acknowledgment en >mi-.« of the very liberal use of the follow- ing works, as quotation mark- were sometimes overlooked: men der Kriegshcilkunst. >"ii I.. Stromyer, Hanover, 18*5; Supplement tier Maximeri Hit Kriegsheilkunst, TOfl L. myer, Hanover, I860; Leeffler BehancHung der Schnss- wande, Berlin, 1869; Histoire Me*dico-Chirurgicale de la Guerre de t'liiiK-.-. par le docteur Adohphe Annaml. Paris, 1858; La Guerre de (rimer, par I.. Baodens, Paris, 1858; Des Plaies ■ i'Arme- a leu : Couiuiunit-ation- l-'aite- a 1 " . \ < • ; i ■ I < • i n i < • Nation- ale de Medicine, Paris, 1849; Notes of the Wounded, from the Muiiin in Imlia. I>\ Cn-u^r \\'iili,uii-i)ii. Londooj UJ59 ; l "!<•>' Military Surgery, with Experience "t' Field Practice in India, Load - Gunshot Wounds of the Ghcst, by Patrick • I l». London, L859; Guthrie's Commentaries on Mil- London, 1855; MeLeod*a Notes on the Surgery el" the Crimean War, London, 1858; Hcnnen's Principles "i ft Militan Surgery; Ballingall's Out- i jj SJui •.,-, j ; Ij-ieli- \ r S - 1 kson on the PormatioB, I unotnj of ( 9 lillot, Mi dicinc ( >pera» \ l' I "ii Military Surgery, bj I" II Hamilton, M l» Won Jfork, 1861; Report M.di- i 1 nt (Army) ordered by the House of Commons to : avia on Feigned Diseases, Lon- don, i ; h 4 ^ INDEX PASS Abdominal wonnds 343 Acclimation of soldiers 2 Advice bo surgeons left with the enemy 162 Ape necessary to make a soldier 8 Ambulance corps 107 A in 1 >u la n. :e cjprpe in French army lt>'.i % Ambulance wagons W A in bu la n cc wagons, < Iqnfcderate 93 Amputation of arm 396 Amputation, after-treatment of 131 A in i >n i :n i< 'ii. when required 122 ■\iii]«uiM!'ons. rules for 121 Amputation, primary and secondary 12". A in (tii t a t i. >n of tliijrli, for compound fractures M A in n sem cuts of soli Hers 63 An i-scorbutics 11 Appearances of gunshot wounds 163 . compound frai ture of 37? Arteries, escape injury 166 Arteries, injury ol 137 Arteries, ligation of I vs Articles necessarj i d the field 134 'Assistant srfrgcon, duties of 127 adants in s rag mental hospital 70 i general hospital 72 Halls, how to extra* t t In in * LiM MU • "''•"■ Hall.-, u In n . io\ -ti .1 alwa\ - danger< .- I BO net wiiiiol- );e.| of soldier Brvonack Bladder wounds •••'>» *2 I \ w \ rv.r • ' - ' •*" ■ •■ '■'" l;; - ' lira ii '• ■■ ■ - '-' I < |,; 52 ''•'" - " ( - W4 1 1 W5 ihijrl •''•' 1 IM > '•'" » 1f uiorpbinc 223 English army, medical department of 195 Enlistment, rules for 14 Entrance and exit of balls 185 Epidemics in hospitals 16 Equipment of a soldier 80 Erysipelas 228 Examination of wounds LM Expo sure to camp diseases 3 Exposure in the field, how borne by different classes 7 Extraction of balls I* 4 Face wounds 309 Feeding aid clothing of troops 16 Reigning disease 138 ►Female nurses in hospitals 83 Field infirmary 140 Field surgery, art teles used in 133 Field surgery proper 1 19 Field surgery with the t ran sports 1 15 Food of soldiers in the Confederate army ■"••> Fording a ri\ ulet 40 d bodies to be removed 375 Foreign bodies in brain 304 Foreign bodies, removal of 177 Fract ure, compound 365 Fracture of bones of the face 312 Fracture of ribs 340 Fracture of skull 205 Fracture of tlii-b 399 French medical siaff 10(6 French organization of an ambulance corps IW Fresh meat for i roops •"■ii Frost-bite 415 Fund, hospital 120 I • in' - Q .1 lei. -pita! 71 * IM IBS 1 ''•'■' 98 I St i I 70 Ml H I i . - i 1 Ml 1 ii.! ir- I ft H II '■ 7 V. 7 • ! v '» 117 J I 7 n "1 77 II 248 mis I Ml batllefleld 1 Hi •_':' I I -> 7 :: 1 1 3 In S 1 1 1 ::s \ i l. •.(■■ 41 ii i HI 86 I 3Qf] I ss I 132 TNPV.X. IX Litter carriers 107 Litters, horse 96 Litters, hand 93 Local i reatmenl of wounds 195 Lower jaw, fracture of 8 1 - Lit n _r wounds 823 Malingering, i r feigning disease l.'!S March, net inn of troops during 17 Materia] of armies 5 Medical department of Confederate army HH Medical department of SngKsh army 105 Medic 'a! cic partoraeut of French army 106 Medical department of Prussian- army 106 Mc , lion I Supplies "11 the field I ,".:; Mc-i Skull, fracture of rior splint* 108 • li'-c J Soup foi 37 Mali-- 1 ■ i Mexican war '•' Stumps, li<>« dressed I-'.' Supplies necessary on the field i ■ • as, duties of in earn] 121 ; on battlefield 130 u's haversack 187 i.-, hospital duties of I » • 7" ft with the ironnded Ifil i infirmary 149 ry with the ti 149 Rents for bospitah 67 Ti hi I. 8 INUKX. PA0I Thirst, how relieved 40 Thigh-joint, resection of 400 Thorax, wounds of 317 Tourniquet 171 Transports on the battlefield 158 Transportation of sick and wounded 90 Transportation of the wounded l.">7 Treatment of abdominal wounds 346 Treatment of chest wounds 330 Treatment of compound fractures .",711 Treatment of concussions 281 Treatment of erysipelas 236 Treatment of head injuries 288 Treatment of hospital gangrene 256 Treatment of intestinal injuries :', 1 I Treatment of joint wounds 385 Treatment of gunshot wound- 169 Treatment of pyaemia 245 Treatment of secondary hemorrhage 209 Trephining not required 301 Troops, when on march i7 Typhus, care necessary to prevent spreading 81 Ides, as food for troops 40 Ventilation of hospitals 77 escape injury Dm', Volunteers — of what material composed b Wagons, ambulance BY Water dressings for wound- 197 Water — how used when on march r.i Winter quarter.- for troops 54 Wire splints for leg 106 Women in hospitals Woorars in tetanus 269 Wounded, transportation of 91 Wounds, appearances of 163 Wonndi on the field 159 Wounds, examination of L50 Wounds, first treatment of 145 Wonnds, general treatment of 2 16 Woands, local treatment of In Wounds, punctured 214 wounds of abdomen xn IHMM PAOI I |« tl« r H BH 360 of g \ I \ . ' • ml •'(" Ith lnu- from i C IF A P T E R I. Susceptibilities of Soldiers — Material of Armies — !!• - ermting — Gfathmg — Food — Encampments — AnvUse- menfe, etc. As the strength of an army depends more upon the health and physical development of the soldier than in mere numbers, the hygiene of camps and the susceptibility of soldiers to disease, has long been a worthy study for mili- tary leaders. Wlien men are taken from civil life, where they are accustomed to think and act for themselves, and arc gathered together as sol- dier.*, the very ftel of acknowledgment or mus- tering in. deprives them of all liberty of action, and makes them dependent upon their superior officers. They must now live after a formula — with it< drills, labors, fatigues, privations, expos- ares, guard duties, aigbl watchings and rigid discipline. This new life, which is so different from his former habits, establishes a new era. similar to acclimation, and which is as marked 1 SI SCKPTIR] r SOLDI Kl in its effects upon the constitution of the bo!- dier. This sudden change from civil t«> military life, like accliniation, constitutes ft physiological and moral «risi -. wliieli is evident in an in- ascd mortality, ae an initiation for the t i i - 1 eding \ ears <>t service. The physical and organic revolution which this change engenders, establishes a special pa- thology for Boldiers, which differs in many re- spects from the negular forms which are observed in the routine of civil practice. The dis( i camps are few, and exhibit :i striking uniformity of character, dependent upon numerous depressing causes, to which all soldiers are equally liable, and Which belong in common to every army, irrespective of nation- ality and climate. Continued exposure and fatigue, bad and insufficient food, suit meat. in differ on 1 clothing, want of cleanliness, pdor shelter, exposure at night to sudden chairg of temperature, infected tents and ctimps, fiwrm a combination of causes which explains the fatal- ity .>t' an army in the field. I- ;n ■■ usually draw n from the rural dis- tricts, wher< thej have never been expofecd 60 those morbific causes which are incidental t<> NECESSITY OF HYlilKM B the atmosphere of cities, and which entail a series of infantile diseases upon the growing generation. The unavoidable exposure and the general liability to these causes whilst in transit, to which city troops are exempt, make such dis- eases a fearful scourge in armies. The measles. a mild disease, which excites no alarm under ordinary conditions of protection from the wea- ther, strikes terror in a camp, where its sequela* of pneumonia and phthisis are truly fearful. This disease alone has laid a heavy percentage upon the effective strength of our army. Add t<> this and kindred eruptive diseases, glandular affections, tuberculosis, capillary bronchitis, ty- phoid and malarial fevers, with diarrleea ami dy-ciitery. and we have already summed up the chief causes of army mortality and deterioration of Strength. All of these diseases can, to a cer- tain extent, he avoided by recourse to a proper hygiene, which 1ms not been valued by com- manding officers, and in many instances has neither been recognized nor urged by the health officers of the command. Until the claims of hygiene are duly considered, and its necessity acknowledged, the mortality will continue from causes which can readily he counteracted* Prudence and forethought, which should be SKCKSSm OF IIY',11 M' leading traits in the character of a military man. seldom enter into the composition ef officers \\1k». in times of war. join the army to fight, and oas> aider all those details so necessary to preserve an effidtent force to light w'uli. as derogatory t<> their imaginary official «luti«-s. 0«r army will always be burdened irith heavy mortuary lists. extensive hospital organisations, a Large pay roll, and comparatively few efficient troops. /< 'Unless officers take more interest in the general wel- fare of their men, and cease to consider profes- sional advice offensive and intrusive. As it takes tine and a considerable outlay to make a Boldier, it behooves the Government to keep them in a useful condition, which can only be effected 1 » \ the unceasing labors of the medical stall" and the rigid enforcement of all sanitary regula- tions bj the commanding officers. Among volun- teer troops, where the regulations of a regular army cannot be enforced, it should be the duty <>l' the officer in command to appeal to the good sense of the soldier through the orders of the day. and gradually to instil such wholesome rules of eue as will make them individually careful lor the general good. The sick list will offer a fair criterion of the military status of an officer ami his capacity for taking care of liis men. MATERIAL OF ARMIES. 9 which is one of the first rules in military sci- ence. RsOKl its. — In times of peace an army is formed of recruits, who are enlisted with much care. Eaeh individual before he is received un- dergoes a critical examination by the recruiting medieal officer, who rejects all blemishes as well as those conditions showing a predisposition to disease; the object gained being the selection of a body of men who, from physical and vital perfection o\' organization, will best resist exter- nal morbid influences. Besides, they are men whose inclinations lead them to pursue a life to which they are in a measure fitted, by the rough, exposed lives which such applieants have previously led. Volixti i.iis. — In times of war. especially be- tween contiguous countries, where national ani- mosity rages high, entire communities rush to arms, and with one accord adopt eamp life with its exposures and trials. Among those who take up arms in defence of their rights, or for the protection of their homes and families, are found men from ever) positm m Life — from those en- joying the most refined and cultivated social ' iMAI. <>t aio: privileges to tl i laborer — all having • common cause to Bupporl ; men i>t" every vari- ety of constitution, temperament and idiosyn- orasy, in whom even form of disease is found Lurking^ an show itself apon the slightest provocation. Those who have 1 * ' < 1 lives -■■ and luxury are suddenly called upon to in 1 1n* stern and laborious duties of the soldier, to share in the common t"il and to buf- fet with tin- element-. The irregular mode <>t' living, to which the majority are totally uuac-i customed, te more injurious than other hard- ships which they daily undergo, and to the san- itary influence of which they owe unwittingly much of the health which soldiers enjoy. Exer- oiw in the open air counteracts many of the would-be injurious effects of exposure. The physical improvement is surprising which the gloved members of high life exhibit, after even a few weeks campaign, although followed under tin- most disadvantageous circumstances of in- elelliellt Weather. This was well shown among the troops protect- ing the batteries in the neighborhood of Charles* ton harbor, prior fco the taking of Korl Sumter. When the cftll i«> arms waa tuo of cit'l/.clis. go through campaigns of greal exposure, with many priva- * u ■ ; MM M. OF \RMTF.S. tioM; much better than tlie lieavily-buill manry: whicli >> of 1. '•'•"> pe* ceut In ilic ten new regiiueuts, using the sawn' basis, tin- total loss was 3,£39 in an aggregate strength of 11,186 ; being 34.22 per cent. Ebr the whole ser- vice ol fifteen months, or a mouthly loss oJ |.rr coat In the regiments ami corps of volun- teer.-, the total loss was 20,38o in an aggregate force of 73,260, being 27.82 per ceut. for the aver- age period of service of ten months, or a monthly boss of ~2.~s per cent. When it is remembered that the old annv stood the hriiut of all the early engagements, and that ninny of the volun- teer regiments were never in battle, the dangers of camp life to volunteers and raw recruits become more conspicuously evident. The old army sus- tained a Lost of o. ,,:> > per cent, from killed in battle or dying from wounds — a loss of T'.'i! men from 15,736.. The ten new regime uts met with a loss of 148 from 11,186, or 1,27 pet cent. The volunteer corps, numbering 73,260, lost in M ii.-:il St»tistici U. s. Annv, I 139 to 1854 HF.ATHS FROM SICKNKsS AND WiMNhS. 11 battle and from wounds only Gbk Of 0.88 per cent., whilst the actual sick list, carefully com- piled, and le&ving out all losses to tlie armv cx.'e|»t from sickness, amount to 1~>,i>17, or 20.8-3 per cent. These statistics, collected with -Teat care hy the late surgoo.i-general of the Inked Stales. portray, in vivid colors, the effect of the exposures and hardships of an active campaign upon those who, for the first time, adopt the life of a soldier. As not only the valuahle lives of citizen soldiery, forming morally, socially, pecuniarily, our very hest people, should he to the utmost protected, but also, from the enormous expense and troiihle incurred hy a nation in training and in transport- ing an army for distant service, it is imperative that the medical staff labor to disseminate among the troops those rules of hygiene which, when considered in its widest sense, are so profitable in sustaining an ell'cctive military strength. We have jufit seen that in our own wars, as in all that have ever occurred. ;in army is rwrely deci- mated hy the tire of an enemy. Tln»e killed in battle are hut a handful when compared to the vic- tims of disease. In Mexico, our army of HUljSiJ men, in an average campaign of seventeen months, ( . V |„.-c,l |0 the continued tin- of an enemy who I _' lltiiM SK'KNKSS AXIl WOl ND8. y inch of around from the i«» their capital, making ■ linn stand ;ii every point, Prom which they had to be driven under a murderous fire, lost. l"it l,54il men in bat- rom wounds, all told; whilst 10,086 died in M i\i<> » from disease, besides the hundreds, or I would be well within bounds when 1 -ay thou- sands, who returned home t<> die among their friends from the effects of diseases contracted in camp. For some time after the war, volunteers formed a noted proportion of the inmates of civil hospitals, and the chronic diseases under which they were laboring were with great difficulty coo* trolled. In the Crimean Bervice, the statistics collected by Lord Panmure, minister of war. show the Kng- li-h loss to have been 22,457, of which number ■ were killed in battle, or died from the eftecta of wounds received. Whilst the French loss, as reported to his (Government by \l. Scribe, inspec- eueral of the French medical service in the ('rim. -a. exhibits the frightful loss by death of 68,000 ; whilst the admission into hospital num- bered 1 1 I. <■'•-. Could the statistics of our armies from the 1st of July, 1861, to Lsl January, isii-j, be eotteoted, it would be found even more striking than those RECRUITING SERVICE. 13 already mentioned. Our list of killed and -wounded has been very small, our mortuary and sick list enormous. One to thirty would not be an exag- erated proportion of sick to wounded in the army of llio Potomac alone, which, of all others, has been most exposed to the fire of the enemy. The above statistics arc sufficient to show that the efficiency of an army does not consist in its great numbers, but in the sanitary condition of the troops. The duties of the medical staff* arc paramount, as tin- nation should look to them as much as to the military leaders, for the successful termination of a campaign. Let us now see how this health, which is so valuable to an army, can be preserved* Recruiting Service. — The first protection which an army has is in the recruiting service, which is a thorough sifting of applicants for admission. The duty of deciding on the efficiency of a recruit de- pends upon an examination made by a recruiting officer and a military surgeon. The service de- mands that this examination be thorough, both in regard to moral and physical disabilities. The regulations, therefore, enjoin, that, "in passing ruit. the medical officer is in examine him stripped, to see that he has the free use of all hit! 11 RKi IUTITINO KKR\ II i limbs; thai his chest is amjilo: thai his hearing, >n ;iiul speech is perfect; that he has no tu- mors, ulcerated or extensively cicatrized legs: no rapture or chronic cutaneous attection ; tlmt he }i;i> ii..t received any contusion or wound of the head thai may impair his faculties ; that he fa nm a drunkard, is not subject to convulsions, and lias in. infectious or other disorder that may unlit him for military service. The surgeon ts alio r«< juir.*! to certify <»ii honor, that the recruit passed by him •• i- free from all bodily defects and mental infirm- ity, which would in any way disqualify him from performing the duties of a soldier; and Bhonld it appear that the recruit was, at the time paaooMj physically unfit t<> perforin all the duties i<»r which he was mastered into the service,; the surgeon who recommeuded his acceptance be- oomes pecuniarily liable for the pay of the sol- dim- during the time which he has been attached to the army. A- tie recruit must be between the age of eighteen and thirty-five years, at lea-t live feet lour inches in height" and able-bodied, we ean understand why an army selected by l rigid observance of the above regulations, cm- required in tbo French army, is five t' '•) one inch; in t!>. Ii.it. - 1 Slat.-.- arm;. Ore feel four and B half imlic- ; in •li.-li -■ r\ i ■ In i- ami a half Inchei . RECRUITING SKRVICE. 15 posed of healthy, robust men, in the vigor of manhood, when brought under thorough disci- pline, is in the best condition to preserve a high standard of health. To show with what stringency the laws on this subject are usually observed, we gfive the recruit- ing list of the United States Army for 1852. The total number examined were 16.0(54, of these 13,338 were rejected ; 2,276 were alone received into the service. Among the causes of rejection arc found the following: Not robust, too Blender, unsound, broken-down constitutions, general Un- fitness, imbecility, unsound mind, epilepsy, intem- perance and bad habits, hernia and lax abdominal rings, varicose veins and variocele. hemorrhoids, syphilis, gonorrhoea, loss of teeth, unequal length of limbs, general and local malformation, con- tracted chest, spinal curvature, old injuries, frac- fures, etc. ; cicatrices, tumors ; diseases of bones. joints, skin, heart, testis and tunica vaginalis; also of arms. eyes. ettTS, glands, chest, throat and abdomen : defective hearing, speech and vision ; ulcers, goitre, ascetes and anasarca, obesity, etc When wo take into consideration the little dis- parity of age with the absence of so many pre* disposing causes of disease, we can readily why the soldier, by profession, has so great an 1' M.oTIIINU AN'1» FOOD FOH TRoops. advantage over the volunteer force, into which any one ca]iahk> of performing duty is received, however untitteo! he may be phvsicallv for the toil ami privations of camp life. To "i -.tain Tin: i FM0ST < \r\een well taken care of are capable of opposing success- ful doubk the force badly provided. To PRESERVE HEALTH ANT) EFFICIENCY, TROOPS MUST re wet. i, CLOTHED. — This is one of the weighty questions in the economy of an army, and lias been the subject of much study and experiment by military leaders. *The object ^\' clothing is to protect the skin from diurnal variations or annual perturbation? of the atmosphere, whilst it absorbs excretions, and thus becomes the means which allows man to enlarge his native sphere, and successfully resist extremes of temperature in the torrid or frigid zones, The caloric properties of clothing ■MlflA be considered under the triple relation of absorption, reflection, and conduction. Every body, whatever be its temperature^ is continu- ally throwing oft' heat from every portion of its surface, the amount of radiation depending upon its temperature and extent of surface. The hu y mi Bygiei o, 1858. station, Discipline ami Economy <■)' Armies. 1 - CLOTHING Of TffJ man body, having a Buperior temperature to that of the surrounding atmosphere, reflects 1 1 « - r 1 1 bo Buch :i degree as would be incompatible with Life, were it nol controled) t<> :i great extent, bj the nonqpnduction of living tissue and the pn tective influence of clothing. The first retards the transmission of heal from the centre of the body, whilst the second acts as a Boreen. [f two bodies unequaltv heated be placed in proximity to each other, there exists a tendency t<> produce an equilibrium of temperature. A third body interposed would intercept entirely the heal until it be also heated, >«> that it may emii from the Bide corresponding to the <-"ld body thai which it absorbs from the warm body. Clothing placed between man and the atmosphere, exercises this protective influence in proportion t<> its power of reflection and conduction; and as clothing is a bad conductor of heat, the outer surface of the dress >«•!< I< >i n acquires the temperature of the person which it covers. The incarceration of a layer of air between the person and the cloth- ing, and also that which enters into the meshes of the cloth, Btill further retards the transmis- sion of caloric — heat passing to and through the clothing very Blowly, and the layer of incarcerated air being a very poor conductor. On a quiet, 9 CLOTHING OF TROOPS. 19 cold day, when we arc surrounded by a little at- mosphere of our own warming, we feel much more comfortable than when this nonconducting layer is constantly displaced, as on a windy day, when, although the thermometer indicates a much higher temperature, the cold is severely felt. It is the action of these causes which explains why the exterior of the clothing of a soldier, bivouacked without shelter under the clear sky, is colder than the surrounding air. As had con- ductors, the heat which escapes from the skin traverses slowly the thickness of clothing; hut, as soon as it reaches the external surface, it is radiated or emitted rapidly. The protection of a tent, or even a cloak, counteracts this radiation. The inverse protection which the blanket gives the Spaniard or Arab in hot weather, is similar- • -oinited for. The radiating properties oi wool exceeds its conducting or absorbing powers, and throws off the greal heat of the Bun before it can penetrate the thickness of clothing and reach the wearer's -kin. Besides the property jusl enumerated, the by- grometric powers of different fabrics, condensing moisture from the air and absorbing perspira- tion, are of much importance in the sanitary economy of clothing. In either case, their power 10 CLOTHlNti Of TK> of contacting heat is increased; and, therefore, the more moisture they contain in their meshes • 1 « 1 < - 1- they are as appafel. The fluid which Loth imbibes takes the place of air, and be- coinos a eausc of refrigeration by evaporation, robbing the neighboring skin of its heal t<> form aqueous vapor. Linen, for instance, imbib< once moisture from any source, and chills the body by the evaporation of this moisture; fchis material for articles <>f clothing exposes the bodj asations of *•« »1< 1 and dampness, and n< . rily to the diseases which arc brought >>n by such exposure. Cotton fabrics, although not so attractive to moisture, permil absorption and evaporation to a considerable extent; whilst woollen goods condense moisture as badly as they conduct heat. from them evaporation goes on so very gradually as scarcely to chill the external surface of the clothing. The hygrometric properties of clothing are in- timately connected with their action upon the skin, when considered as an organ of absorption and excretion. Cutaneous perspiration varies in quantity, according to the power- of conduction, radiation, and heat-absorbing properties of cloth- ing, which cannot modify the exhalation, ab- sorption ;md sensibility of the skin, without CLOTHINO OF TROOPS. 21 reacting npmi its functions. The energy of cu- taneous elimination regulates in a measure the march of other excretions. Anything which im- presses tin- nerves oi" the skin excites equally fche origin of these nerves, and causes exaltation or depression of the system. Clothing deter- mines the antagonism which exists between ani- mal heat and external temperature* The source of animal heat increases or diminishes its activ- ity according to changes in the atmosphere; but the unequal production <>i* beat causes corres- ponding oscillations, in the movements of res- piration and circulation, in the action of the muscles, and the hrain. Clothing affects, then, all the functions of the economy, and may clearly represent the question of health. A.8 the object of clothing is usefulness and convenience, the best uniform is that which will protect the body from the inclemencies of the weather* and whicb least impedes the move- ments wind] are connected with military duties. Experience in the field teaches what can be dis- pensed with or what can be added with advan- The clothing -elected depends much upon the habits of a people and the country in which 1 1 1< ■ war is carried on. We , ' : " 1 readily nnder- 1 how absurd ii would he in the English m\<; 01 TltOOPS. Government sending their home troops in their thick red coats, leathered neoks and ahakoed heads to <\>< field duty on the scorching plains of India. There are certain portions of the clothing which experience shows conducive he health, in all countries and under every cireum- stai '/'/,, clothing for troops should bi mad* of whether the material hi heavy ur liyht, to suit the climate. The soldier's coot should be a frock fitting \. easy over the shoulders, -with full play for tli*' arms, without binding in any way. and \\it to impede the ex- pansion of the chest when closely buttoned. The tail of a coat gives much protection to the body an life. In the French service, where flannel under- clothing is not in such conMant use as in the English and American service, every soldier car- ries a band of llannel, with which he envelopes bis abdomen, as a safeguard from abdominal af- fections. Baudens, one of the surgeons-in-chief of the Crimean service, speaks of this band ae (Essentia 1 to the health of the troops, and. at the samg time, refers to the much better and more convenient protection which the English flannel shirt gives to toe men. The liability of losing •_' I OLOTHIWO "F TR-- the flannel gircHe, and it- very partial protection, i- :i serious objection to it- use. For similar Bhould always be given to soldiers. They are much more durable than ••■•t- t"n. and much more healthy, preserving an equal temperature ami retaining warmth to the feel which, being at the greatest distance from tlie centre of the circulation, are leas! capable of ting cold. and. therefore, require most pro- tection against injury. They also afford ■ i"t- ter protection against the chance of blistering than aoeks of Other material. Tin' feet are pari of the person of h soldi* essential for the performance of military duty. that their condition should be particularly attend- ed to by the officers. Tfo shoes, boots, or half- boots Bhould be well made, of good, {durable material, and well fitted to the loot, so as to be easy to the wearer. The soles should he hroad. thick and firm, high quartered bo as to exclude mud or sand, and closely fitting around the instep, 90 thai teiiaeioii- (day eaniiot easily drag it from the foot. A good shoe or hoot add. Often tS much to the efficiency of the Boldier as a good weapon. Marching is as necessary a quaUlv as lighting, ami is made one of the requisites in ! miiig i member of the [mperial Board of CLOTHING OF TROOPS. lio the present French emperor. "When the shoe docs urn tit the wearer, "who is compelled to use them, sore feet, a very tronhlesome complaint in the army, is brought on. On the march men arc found lagging behind from lameness, and, as these are exposed to he cut off by maraud- ing parties of the enemy, it heeomes the duty of those in authority to prevent this, hy never de- livering to a soldier a pair oi' shoes which have not been tried on with care. The leather should lie Well smeared with grease, oil, wax, tallow or other composition to make them water-proof, soft and more durahle. This should be done daily in wot weather. One pound of tallow and half pound oi' rosin melted together, and applied hot with a painter's brush, and renewed until neither sole nor upper leather Will take up any more, is found an admirable leather preservative. The grease alone would, in time, rot the feather, hut the addition of rosin gives the compound anti- septic properties. In the Crimean service the Russian half-hoot was found so superior an article over the hoots or sho,- of the Allies, that they were sought for with avidity upon the dead, as soon as ihey Were shot down, and were more prised than any other article of wearing apparel, so conducive J<» PLOT til Mi »>K TROOl'S. they to tin- comfort of the wearer. Tliey protected the feel perfectly from the mud in which ilif troops lived for months. The /•'/-/"■/' gaiter used in tin- Crimea, ww made <>r heavy white *-l < »t 1 1 . covering two-thirds of the foot :iinl extending some distance up the leg. usually over the knee. It facilitates walk- ing, and prevents enlargement of the veins, whilst it protects the limb from cold and wet Experience in the field and upon the anarch lias proved them bo serviceable, thai the entire French army i> provided with them. They, a- a substitute for the boot, might be added with advantage to the equipment of the soldier. When made of leather, they beeome bard after getting wfi. and. Wy pressure) excoriate the ankle.-, l'.e- udee which, the leather is cold in winter and very hoi in summer. The only advantage in the leather gaiter, is durability; the cloth wears out much sooner, and also becomes saturated with moisture in rery wet weather. In addition, to the gaiter, many of the French troops wear greaves, made of heavy patent leather, which cover the leg to the knee, shutting in the botr toni of the pants. This gives them groat facil- ities in walking, as it protects the leg of the pantaloon from becoming foul with mud, which CLOTHING OF TROOPS. 27 is an endless annoyance to troops marching in bad weather. Every soldier should have an overcoat of stout cloth, reaching below his knees*, with a cape covering the shoulders. This, like all other ar- ticles of clothing, should be made easy, to per- mit of any movements without binding. The French have added a hood, to protect the head and neck in bad weather from cold, wind and rain, which diminishes the frequency oi^ catarrhal affections. When on guard duty in bad weather they are of great utility, and also to protect the head and neck from the damp ground when sleeping. Crimean soldiers found this addition ;i great improvement. In selecting a color for a uniform, it should be remembered that light colors aljeorb less than dark; and, also, that odoriferous exhalations ad- here with much greater pertinacity to dark than to light clothing, which is an item of no small importance when the deleterious emanations ac- companying large bodies of men are considered. Besides which, experience in battle shows that certain colors make much better marks to lire at than others; and, according to calculations, a soldier dressed in light cloth is much less liable to be hit than in dark. The following percent- I LOTH1NU OF in- age i- tin- relative liability: red, twelve; rifle green, seven; brown, six; Austrian bluish gray, five. Reel, which is the mosl attractive and fa- tal Color, 18 dlOre than twice a> 1 1 1 1 1 • - 1 1 SO a- gray, wnich is tin- least. Tin beat military liai in use is a light, bqA felt, with a sufficiently high crown to allow space for air over the brain. The rim can be fastened up' in fair weather; and, when turned down, pro- tects, in a measure, from the rain or from the rays of the sun. In a warm climate, the light Color of the hat adds much to the Comfort of the wearer. The small. French, jauntily-lit! in-' kepi IS light, hut does not protect the lace; and, when made of dark materials, concentrates the solar rays upon the head. This can he obviated by adding a ETaveloek. It consists of a cap- cover with a long cape attached, which, hanging down upon tin' shoulders, protects the neck from the -mi in the day and draughts at night. It is made of lighl cloth, of a Light color, for reflect- ing leal. Those who have wmn 1 1 n 1 11 on a march, or when exposed to the sun's rays, -peak in extravagant term- of the comfort ami protec- tion whicii ill. \ give. The advantage of wear- ing a light and high-crowned hal is that, under exposure t<> the sun, a.- during a march, a -mall, CT.OTUINc; or TROOPS. 20 wet handkerchief placed in tin- crown will not only preveut sun-stroke, but will add much to the comfort of the soldier. According to the army regulations of the Con- federate service, a soldier is allowed the (inform and clothing slated in the following table, or arti- cles thereof of equal value: CLOTHING. Cap. complete " rover !,.;,( Trousers Flannel sliirt Flafrinel drawers es,* pairs Stockings ],■ al 1m r stock Great ooat Stable frock (For mounted men ) Fatigue overall (for engineers and ordnance) Blankei FOR THREE TEARS. 1st. 2.1. a*. i i l 2 3 2 1 4 2 1 2 3 3 3 1 4 1 1 1 1 1 1 1 1 2 3 2 4 4 1 1 1 Total for three \ ears. In the field, there should be always a supply of clothing at hand, to replace the loss by unavoid- able accident. During the Crimean service. Dr. McLeod informs us that the deficiency of cloth- ing, which was so much complained of, was one of the nio8l prolific Bourcee of subsequent disease 'Mounted men maj raoerve am ]>:iir of* boots," and f«o | "boob ad of four pair of book I LOTHTXO OF TROOPS. among the finglish troops. The truth of this statement was corroborated by experience in the Confederate campaign of 1861, where a great amount of Bickness could be traced to insuffi- cient clothing. ('He of tin' universally admitted maxima for preserving health in a campaign, irrespective rff climate or Locality, is. that soldiers must j>,-<<>t,-i themselves m summer from nigfd air by warm cloth- ing. A heavy blanket, not in name but in weight, ami dp' and a half yards of india-rubber cloth, complete the equipment of a soldier. The india- rubber cloth is a waterproof covering for him during exposure, and will always make for him a dry bed, upon which he can find health as well as comfort. We make the following extract, on the extent oi a soldier's equipment, from Jackson*s Formation, Discipline ami Economy <>f Armies. In the form ami fashion of a soldier's equipment, "the aajnst- ment of the kind and quantity of articles termed necessaries is a matter of importance, and as such requires to he well considered. It is demonstra- bly proved, to the conviction of all persons who haw served with armies, that superfluous bag- gage, that is. baggage beyond the narrowest mca- CLOTHINf! OF TROOPS. 31 sure of utility, instead <>f bringing comfort to the possessor, js a cause of *>:ro:i 1 annoyance ami vex- ation. A complete change of the smaller parts of dress, in the event of being wet with rain, together with a cloak as a covering for the night. is all that a soldier requires for his comfort and the preservation of his health: and. as such, it is all that he ought to he permitted to possess. Where persons have not more than one change of raiment, the strong impression of necessity Obliges them to prepare for the return of want. Whore there is a superfluity, the necessity does not present itself so Forcibly, and hence the dirty clothes are crammed into the knapsack, where they accumulate in quantity without obliging the individual to recollect that they are not tit for use until they are Washed: It thus often happens that a soldier who has four or more shirt:- in his possession, has not one til for use. while a soldier Who possesses no more than two, has generally one in his knapsack ready for the contingent occasion." * The following is considered to D€ a full equip- ment for a soldier on service, namely: two flannel shirts; two pair of woollen socks: two pair of • Jackson's Formation, Dia iplinc and Economy "f Armies. :;_• i i.m ni i \«, i.i i aoops el drawers; two pair of shoes, or one pair of shoes and one of half boota : one pair of gait- & 'small case ol needles, thread and Imtt for mending ». - 1 < > 1 1 1 « ■ - : one small shoe-brush, with blacking; comb and. hair-brnsh: tooth-brush; one piece of soap; a sponge for washing the body, ami a towel for drying it: two i »* >«k*t handker- chiefs; an overcoat of heavy material, besides his uniform. He should also lave a heavy blanket — better if lined with stout osnaburgs to increase durability and warmth — and two yards of india-rubber cloth to protect him from the wepr ther. lie should also carry a knife, fork ami spoon, a canteen for water, and a haversack for carrying dressed provisions, If those articl clothing not in use be put up in a neat and compact manner, ami enveloped in oiled silk so as to be secure from wet, and deposited in the knapsack for easy carriage, the soldier will not be incommoded by the bulk or encumbered by the weight; ami possessing withiu himself everything actually necessary for use, will be independent of tLc accidents so common to the baggage wagons. In the above list we have purposely omitted shaving apparatu >cry Boldier in the held should allow his heard to grow. It protects his throat, ami often prevents lung diseases, catarrhal PERSONAL CLEANLINESS. 33 affections, etc. A heavy moustache is known to protect the wearer, to a certain extent, from mala- rial influences, acting as a. sieve to the lungs. It also purities from dust the atmosphere inhaled during marches, and thereby prevents many troublesome diseases. Cleanliness dictates that tlu- hair he cut close to the head, and although the heard he allowed to grow, it should also he kepi within hounds. Cleanliness. — Nothing contributes more to pre- serve health than personal cleanliness: and as the t>ee use df soap is a pro] ihvlactic as well as a civili/cr. it should he regularly distributed to the men. Daily ablutions should never he omitted: and, if possible, the chest and arms, as well as the face and neck, should he well sponged. Bathe should he used whenever opportunity permits. Keeping the skin clean prevents fevers and bowel com- plaints in warm climates, Baudens, in insisting upon cleanliness, says, "that the contrast in the sickness and mortality of the Euglish and French camp in the Crimea, can he in a measure attrib- uted to the frequent ablutions of the English, who washed their clothes in hot water, and changed their underclothes twice a week. It is easy to understand how carelessness in this respect will impair the functions of the skin, and induce dis- 31 PKRSONAL < I. i:\M.l\i SS. ease. At review, our French soldiers show new clothes. and on the whole an unquestionable mil- itary equipment, yet these beautiful battalions leave in their _«• m strong smell of barracks not to 1"- mistaken/' "\<>t only the bents, bul the persons of soldiers as well us their clothing should be daily inspected. However particular men may be in civil life, afe soon as they are pul into the field not only are all habits of cleanliness neglected, which we would have supposed had been incorporated with their very nature, but men actually take a pleasure in being careless, and comment upon the little need of corporeal ablutions, hays pass without the use of water, and tilth and vermin soon reign triumphant. One of the strongest reasons why regulars enjoy better health than volunteers, te that the <>nc arc daily inspected by their officers, who insist upon their faces being washed, head combed, etc.; whilst the volunteers, with whom the regulations of a Btrict discipline are not en- forced, are allowed t<> abuse Che privilege of fol- lowing the heiit of their own inclinations. It h deplorable to Bee the condition of our best society in camp. In the Confederate hospitals it was not rate to administer the first hath to volunteers who had been >i\ months in service, without ever hav- FOOD OF THE SOI.WF.R. 35 fog used water beytJnfl their laces. It would 1)0 a saiutary regulation of groat value if general ablu- tions could be made a portion of &e daily drill. A heavy penalty of extra fatigue duty should be imposed upon those who did not daily moot the requirements of hygiene" and cleanliness. It should t>e tho duty of the nietftcal officer to fequesl the commanding officer to insist that tin — hvgicnie regulations be rigidly enforced. Ho is not only tho best, hut also will become tlio iflOSt popular officer, who attends himself to these de- tailed comforts of his men. Food of tho soldier should be plain, nutritious tare, well cooked, which, with exercise as an appe- tizer, he will tind no difficulty in enjoying, how- over monotonous his daily ration may he. For a workingman (and where do men lahor more than the Boldiet in the field?) the diet should he of a mixed character, and rood should he «,t the va- riety easily COofeed. The character of the diet, however, nrasl depend, to a certain extent, upon the seasons and the ahility of the commissary i«» nreei the demands of the army. The fundamen- tal mlo in the culinary art is. boil slowly and raw! quiekly. Highly seasoned dishes arc neither possible nor desirable forf ihc sofflier. Toil, fa- ■ ■'• roOD Of Tin: SOLDI] tigue, and often hunger, will make any whole- some food savory. "The plain repast is sufii- cienl for sustenance : and ;i plain repast gives all ilif gratification t<> the palate of a hungry and thirsty man that a soldier ought to permit himself to receive,"* For the English there ua n<> beverage Like fcea; and a military writer remarks, that a breakfast of tea with bread, enables a person to sustain the fatigues of war with more energy and endur- ance than a breakfast of beeksteak and porter. The French prefer coffee, t<> which they give the highest prophylactic virtue. This is the stimu- latiug drink of the troops, and its free use makes the men much more healthy and cheerful. It is at ail times an excellent substitute for aleoholic beverages, which disorganize an army by tempt- ing to drunkenness. Whiskey should only he given out to men on very exposed duty, or in very had weather, and it is a question whether a cup of hot coffee is not preferable even under these circumstances. The common abuse of spir- its, and thf doubts of the necessity of using liquors in thf Bervice, are strong reasons for dis- carding intoxicating drinks from the army. The J> Ill V of Allllii 8. FOOD OF THE SOLDIER. 37 health of an army is always better, accidents al- wiys fewer, and insubordination at a minimum when spirits cannot be procured. Military com- manders generally denounce whiskey as the bane of the service. The Confederate loss by fetal accidents from the discharge of pistols, carelessly handled by drunken men, has been nearly as great as from" the halls of the Federalists. The Turks place great reliance on coffee as a preservative against dysentery; and McLeod states as a result of his Crimean experience: li I have no doubt that, if the precaution had been taken to supply the tfOOps every morning with hot cof- fee, as they went on or returned from duty, much of our mortality might have been avoided." A> roasted and ground coffee has become a fixed article of trade, it would be much better for the troops if it could be served out in this form, mixed with a due proportion of sugar, par- ticularly when they arc upon extra duty, as it not only saxes them much time, but insures the proper preparation of a BUpporting beverage. If coffee cannot he obtained, the best substitute is a pint of hot soup, which might be prepared from fresh beef when this article is abundant: hut, what is still bettef tor army purpose-, from a spiced soup-cake, which i- made of choice portions :'.S FOOD OF THE SOLDI Kit. of beef, farinaceous ingredients and spices — the whole cooked, compressed and desiccated. These cakes occupy but a small Bpace, can be easily carried; will keep for mouths, and. by cutting them up in the proportion of a pint oi boiling water for each cake, and allowed to boil (pr ten or fifteen minutes, pint of excellent, well ila- yored soup can be made. It requires no longer to make a pint of good soup, with one of Jones' soup cakes, than would be require^] to make a cup of coffee, with the coffee already paxche^ and ground. It may be needless to say that good water is even more necessary than good food, and should be obtained at any cos! for the use of the troops. There is no one item bo prolific in disease as drinking bad water. Should troops be so unfor- tunate as to be in a place where stagnant it ditch-water bas to be used, it can be purified by boiling with a lump "1 charCoal : alter which it should be freely agitated in the air. to restore to it the vivifying properties which the heai had driven oil'. Should tin- water be turbid, :i piece of alum thrown into a bucketful will quickly settle the de]io>'n ;iml restore its crystalline char- acter. Ii more time be allowed, the better plan would be to filter the water by sinking a barrel FOOD OF THE SOLDI KR. with holes bared in the side ; into this n much smaller barrel with the bottom knocked out is placed, and the intervening spaee between the barrels filled with straw. The water which passes through the holes leaves all impurities upon the straw, and springs up as clear, potable water in the smaller barrel. Fresh meat and vegetables should he served out to troops whenever they can he had, and the best mode of cooking them is in soup. A French military proverb says that "soup makes the soldier." The free use of fresh vegetables is the only mode of preventing the appearance ni' scurvy among the troops. "When these can- not lie obtained, the free use of dried vegeta- bles, a- rice, potatoes, cornmeal, etc., will tend to sustain health and vigor. One of the worst articles which can he issued t<> troops in the Geld, without conveniences for cooking, is wheat Hour. Fresh bread all will ■ acknowledge to be good Cane, and is always hailed with satisfaction; hut to issue raw Hour as the vegetable element of a ration, with no means of cooking it into an edible bread, is an act of cruelty to troops who have no means of ebtaining other food than that which the commis- sary allows. In our corn country, where corn- OF THE SOLDIKR. meal or grist ie a common article o"f food, a staple liked by nil. and the mode of cooking it easy and familiar, the article it-elf abundant, cheap, ami forming the very best food for man, why this article should not In- generally issued instead of unwholesome Sour, which fan only be made into die most indigestible of dough cakes, in!,, which the teeth Btiok in vain attempts ;it mastication, cannot be satisfactorily explained. Economy, the health of the troops, and general satisfaction in the army, Would he the result oi' the change from wheat to eornmeal. If orders were issued io carry portable ovens with the troops, so that good bread could he daily pre- pared, which can very easily hi' done: or if ovens were built wherever troops locate, then would flour he a useful issue, hut under no other con- dition. A distinguished military surgeon has remarked that 100,000 francs spent in fresh vegetables, will save 500,000 francs from the expenses <>f sick soldier,- entering the hospital, besides the nse of the men lor active service. Of the diied vegetables, rice is among the best for feeding troops. It is easily carried, easily cooked, easily -ted. and is one of the mottl wholesome of the farinaceous articles — correcting, as it often does, the tendency to intestinal ilu F001> OF TIIK SOLDIKK. 41 Tu the Crimea, where the temporary absence of fresh vegetables was a great and serious pri- vation, lime-juice, citric acid and BOUr-crout were extensively used to prevent and to stop scurvy. Acid frtfits arc anti-scorlnitic, and very good for soldiers. The English, in the Crimea, gave out a ration o\' lenion-jnice three times a week, which, when mixed with mm and sngar, made a very nice, healthy drink. This corrective protected, to a certain extent, the English soldiers from scur- vy, whilst with the French it was widely epidemic and very fatal. Vinegar, when freely distributed, also assists in preventing this scourge among troops. Vinegar, molasses and water, when mixed in proper proportions, make a very refreshing and palatable drink, not unlike lemonade, and pos- sessing similar anti-scorhntic properties to lemon- juice. Biscuits, or hard bread, is a common article of diet in camp life, because it is easily preserved and transported. When eaten as dry biscuit, it acts like a sponge in the month, exhausting sali- vary secretion, ami, tiring the jaws, it produces surfeit. When possible, and rarely is it incon- venient, soak it in tea. coffee or goup ; il then makes a very nutritious meal. Even water, with a little salt, makes it much more palatable and I 4_' nun. ub tiik soi.ini k nourishing. Fresh bread is always preferable when it c;ui be obtained. Bacou ia, par excellence, the laborer*' and sol- dier-' meat in Aineriea, and goes further, l>v weight, than any other. Ii never produces >nr- feit, is always acceptable, very easily cooked, ami with its rich juice will make tire dryest farina- ceous diet savory. It has the very great advan- tage, when properly cured, <>f keeping for a length of time, under any condition, which makt it far preferable to any other meal for troeps. In the Confederate service, the ration consists "f three-quarters of a pound of pork or haeon, or one and one-quarter poinds >»i fresh <>r .-alt beef; eighteen ounces of bread or flour, or twelve ounces of biscuit, or one and one-quarter pounds corn meal; and at the rate, to one hundred ra- tions, of eight quarts of peas <>r beans, or in lieu thereof, ten pounds 4 of rice, six pounds of coflee, twelve pounds <>f sugar; also, four quarts <>f vinegar. The rati. in is completed by adding one and one-half pounds of tallow, one and oiie- quarter pounds of adamantine, or one pound of sperm candles, four pounds of soap, and tun quarts <>f sail to one hundred rations. <>n a campaign, or on marches, or «>n hoard transports, the ration of hard bread is one pound. EOOD OF THK SOLDI KK. 4o Extra issues ©f soap, caudles and vinegar, are permitted lo the hospital when the surgeon docs not avail himself of the commutation oY the hospital rations, or when there is no hospital fund. Desiccated vegetables may be issued once per week, in lieu of beans or ricej and should a tendency to scurvy appear among the troops, the commanding officer may. by advice of the medical officer, direct their more frequent issue. Two "issues" per week of '•desiccated vegeta- bles" may be made in lieu of beans or rice. Potatoes and onions, when used, will always he in lieu of rice or bean a. 1'olatoes at the rale of one pound per ration; onions at the rate of three pecks per hundred ration-. When fresh beef can be provided bo as to co.-t not mere than six and a quarter cents pei- pound, net weight, or not more than an equiva- lent proportion of salt pork, it will he issued to the troops five times per week. \\ In-ii. from excessive fatigue or exposure, the commanding officer may deem it necessary, be may direct the issue of whiskey to the enlisted men of his command, no; bo exceed a e-in p,.p man for each day. Tea may be issued in lieu of coffee, at the 4 J FOOD OF THK SOLDIER. refe "t' "lie and a half pounds per hundred rations. When the- officers of the medical department Mm! anti-scorbutics necessary for tlie health of the troops, the commanding officer may order issues of rVesb vegetables, pickled onions, sour- crout or molasses, with an extra quantity of rice and vinegar; potatoes ire usually issued at the rate of our pound per ration, and onions at the rate of three bushels in lieu <>t' one of beanB. Occasional issues (extra) o1 molasses are mad< — two quarts to one hundred rations; and of dried apples, of from one to one and a half bushels to one hundred rations. When anti-scorbutics are issued, the medical officer will certify the necessity and the circum- stances which cause it. upon the abstract of extra issues. Daily issues of rations should bt made to the troops; for when, from the laziness of cow missaries, two or three days rations are given out at a time, through the proverbial careless- ness or improvidence of soldiers, the provisions are either wasted or all arc eaten in one day, and two days starvation, it' not sickness from jji >rmandizin£r, t'< illows. A.s Boldiera are expected to cook their own FOOD OF THK SOLDIER. 40 provisions, and as all are familiar with the fact that as much depends upon the mode of cook- ing as upon the articled cooked, it would be better to have one of the mess appointed special oook than to allow the Boldiers to cook in turn. A division of labor is clearly the preferable plan. It would be economical and beneficial if Gov- ernment would allow too professed cooks for eneli company, as the health of the army would be improved materially by having good fare. Firewood, of course, must be liberally provided, as it is one-half of a soldier's existence. The entire health of troops depends upon the quality, quantity, variety, and the regularity with which the provisions are supplied. The effect- ive condition and strength of the army, with a diminution of the sick, and consequently a dimi- nution in the hospital expenses, will depend in a great measure upon the commissary depart- ment. In 1847, the high price of provisions doubled the number of siek in the Freneh army, sending one-fifth of the effective regiments into the hospitals. The better paid, Beleel corps, who could increase their supply <»f nourishment, • - caped those diseases which ravaged the common soldier. Experience show- that, in a besieged city, when scarcity prevails, pestilence follows in the wake of famine. 4 not only much mora agreeable, but also profitable for ;ill <-.ui- cerued. The following appears to have been compiled bv an experieueed soldier: "Officers' messes should consist of the com- pauy omceri — four persona. The colonel, lieu* tenant-colonel, major, adjutant and sergeaut- niajor, with the commissary, quartermaster, Mir- geon, assistant Burgeon :ui<1 chaplain, oould eaajw lv arrange two mess< i. " Meases of privates Biid non-commissioned officers should number six persons, for obvious reasons, so that the details for guard dutj would always leave four in charge of the tent. "Articles wanted for a mess of six: Two champagne baskets, covered with coarse canvas, with two leather straps with truckles, six tin plates, six tin cups, >ix knives and forks, six bags for sugar, ooffee, salt, etc., to ln>|»l from half a gallon t<» one gallon, one large size camp kettle, one iron pot, one bake-oven, one fryiug- ]»;tn. one water-bucket, one lantern, one coffee- mill, six spoous, one tin salt- box, one tin pepper- box, two butcher-knives, two kitchen-spoons, two tin dippers, one tea-pot, one coffee-kettle." It is always a good rule t<> accustom an army SUGGESTIONS FOR A MARCH. 4 7 to adopt tlie modes of living common to the inhabitants of the country in which the army is found, as certain peculiarities of living naturally adapt themselves to certain climates. Although war brings with it privations and irregular living, which it is impossible to pre- vent the mode y)\' Living of a soldier, to a cer- tain extent, should follow a fixed standard. His meals should be equally distributed through the day, and he should never be put to work with- out having broken his fast, however light the meal be. If this lie neglected faintness some- times ensues, and exertion fails from mere crav- ing of the stomach. In camp soldiers should live with regularity, and the breakfast and din- ner hour should he respected; and as three meaU a dav i> the custom of our people, this regula- tion should hi' adopted. It is on the march that circumstances prevent the carrying out of rules. The following is the order which experience has proved t'» he most useful in the French service. A soldier should never commence a march with- out having partaken of a repast. A cup of hot coffee with bread soaked in it will sustain a march of tome duration. A little meat, which is always saved by the prudent soldier from the previous meal, would he an improvement! for night M SI i..,KV1! canteen wiili good water, or, whal is much more refresh- ing, weak coffee of tea. The start, especially in summer, should always be at the break of day. After marching three-fourths of an hour, the col- umn stops tor twenty minutes. In resuming the march, a halt is made for a few minutes in each hoar. Fifteen miles a day is considered gooo" marching tor an army, ami may Ik- divided in the following order. Nearly three miles may be made during the first hour of marching; then a hall is ordered for fifteen minutes, during which the men should remove their knapsacks and recline upon tin- ground, as standing e-ives but little relief. After marching for three or four hours, a halt should be ordered, especially in summer, until the heat of the day passes, when the march may he resumed. During the midday rest, whilsl dinner is being prepared, if any opportunity e\i>ts, the shoes and Btoclrings should he removed and the feet bathed, which, by removing din and acid secretions, will prevent excoriations. It may also he advantageous, at such times, to change socks from one foot to the other, so thai the seams may come at different portions ^i' the foot, SUOOESTION8 FOR A MARCH. 49 which will prevent continued and injurious pres- sure. Soaping the sock will also prevent excori- ations, and add much to the comfort of a soldier whilst on a march. In crossing a ford, the men take oft' their pantaloons, keeping on their shoes. A sentinel guards any fresh-water spring which is met in the march, to prevent soldiers from gorging themselves — a very wise measure, which pre- vents much sickness. An aphorism worthy of remembrance is — Drink always before marching, and whilst mi the match meisten the mouth often, hut drink seldom. Water should always be taken in reserve, and with precaution. When taken in great quantities, it weakens and fatigues' the organs of digestion, increases perspiration, and enervates the entire system. It is particularly injurious to drink rapidly and freely when heated m exercise, as sudden death sometimes follows this imprudence. The soldier should accustom him&elf, when thirsty, to drink slowly and in small mouth- futs, keeping the water in the mouth and throat . a< long as possible. The cravings of thirsl are often produced \>y a parched condition of the lining membrane of the mouth; and by rins- ing the mouth frequently, thirst can be allayed w 5 -I UG1 ST10NS FOR A MAI',' II to such a degree thai l>ut little water will be required, whilst much, hurriedly drunk, will not satisfy the urgent call. In marching, thirst can. in a measure, be prevented by keeping the mouth closed, and iii speaking as seldom as possible; otherwise, the dry air. often Loaded with dust, will parch the lining membrane of the mouth — a very distressing sensation when it cannol be relieved by drinking. Arabs, in crossing Bandy deserts, where hut little water can be found to allay the intense thirst of their hot climate, adept the wise precaution of tying a handkerchief over the mouth, which keeps out dust, and. by pre* venting conversation, prevent.- to a great extent thirst. It would be well for troop- upon a march to profit by their experience. When, during a march or halt, the fatigued and thirsty soldier finds water, instead of rushing to it at once, he should first try and repose himself before drinking; then, having washed out his mouth several times, drink slowly so a> to make the smallest possible quantity of water supply his -iii.-. Washing the face slackens thirst. When water cannot be obtained, a bullet or peb- ble in the mouth, or chewing a green leaf, will cause a secretion of saliva, and, by keeping the oiith moist, will temporarily allay thirst. As SUGGESTIONS COR A MARCH. 91 good water is not always to be obtained on a march, a soldier should never lose an opportunity to till his canteen with fresh water. If the can- beena be covered with a light colored woollen cloth, the water will keep cooler than in bright (in. which absorbs heal more rapidly, and ex- tends it to the contents of the canteen. Wften troops have had an early stai't. they should bivouac about ten o'clock in the morn- ing, and lie over during the heat of the day, as loldiers on a march should, if possible, be protected from the midday sun. Here they will have time to eook their midday meal, wash their clothes, and refresh themselves from their fatigue. This meal consists of coffee and bread, with meat cooked and saved from the preced- ing davs repast. 'The experienced soldier never forgets t<> keep in reserve a certain proportion of meal or other food, against a detieieiit distri- bution or the want of time for properly preparing il. The want of this precaution, which old sol- diers adopt, is severely felt by l'ccrnits. The meal should be taken iii the shade, under sonic protection from the son. A few branches prop- erly arranged, will form a comfortable shelter. 'flic main meal of meat, vegetables, etc. should he taken after the evening halt, at the end of the days march. Bfl DAMPING OF TROOPS. The officer in charge of the troops Bhould always know the road over which li«' is to travel the next day, and when he is compelled to bivouac in places where the prospect for getting wood fa bad, each soldier should carry on hi< knapsack a small quantity to cook his midday meal with. When troops are ordered on :i forced march, or on scoutiiiir service, their food should be pre- pared in advance, for two or three days rations, or they Bhould be furnished with such as can be rapidly cooked ; sausage or meat cakes with bis- cuit, would be an excellent i — lie at SUCH tunes. In the evening halt, the site selected tor the camp, when possible, Bhould be on rising ground, tree from low places, and in proximity to water and wood. These rules become of special im- portance in establishing a camp for even a few days stay. It is prudent to avoid the immediate vicinitj of swamp- and rivers: the emanations from such are noxious, often pestilential, Inn for- tunately do not extend to a great distance. In- terposing a piece of rising ground or wood i>. as neral rule, sufficient to turn <>r break Cur- rents from these low places, and protect from their hurtful influence. It would lie preferable to camp in the direction of the regular wind cur- rents, so that emanations may he wafted in the contrary direction. CAMPING OP TROOPS. f>3 When the halt is only for the night, and the camp wagons with the teats have not come up, the men bivouac under the clear sky, Or seek shelter under a few branches, with which they form a rojagh shed that will protect them from dew. If possible, dry grass or leaves form their bed. and. lyin,g in their great coats ami upon their india-rubber cloths, they can enjoy peaceful slum- ber. If there is no cover for the men, then they build tires, and sleep around these — lying as 80 many radii of a circle, the feet o\' the sleepers being nearest to the tire. Singular to say, this kind of rough life <]oc^ not bring with it disease, as one would suppose. If the men are warmly clad, they enjoy more health when bivouacked than when under tents. Xo troops should ever bivouac upon damp, marshy soil, where a single nights exposure in summer would poison num- bers with malaria, or in winter would be the fruitful cause of pneumonia or rheumatic affec- tions. The site of a permanent camp should be dry, with good drainage, the dryness of the wJ being •1 l>v digging thai a stratum oi water not immediately underlie the crust. In cold. damp countries, the material for tents should be close, ami. as nearly as possible, waterproof; when pitched, a good ditch should be dug wound them, with the earth banked up against the tent to keep <>ut the CoH ;mr fire-place in the centre of tin' tent. The dirt from within should he hanked up against the outer side of the tent, to keep out cold and moisture. Communicating ditches should bepro- vided, to facilitate drainage. Of tents, the cir- cular oil', i- the best protection against the wind. is least liable to he blown down, ami is most useful for winter. The light Bhelter-tent of the French troops, as introduced by Marshal Bugeaud, will he found CAMPING OF TROOPS. 55 most convenient for the summer months for an army in the field. The tent is made of the knapsack of the soldier, which, instead of being sewed up, lias its sides buttoned together. When unbuttoned, it is a square piece of cloth. When two or four sacks thus spread open are buttoned together, and the (Jentre supported by two sticks three feet long, and the angles staked to the ground by small camp-pins, the two or four persons to whom the sacks belong, by thus joining property, have a tent that will keep them from exposure to the sun. and also protect them from rain or dew. This tent is not more than three feet high at its ridge. In hot and dry weather, instead of pin- ning the two cuds to the ground, one of them can be hung horizontally to branches of tree-. leaving one side open for thorough ventilation. whilst the horizontal portion protects the sleeper from undue exposure. The size of this tenl can he increased t<> any extent by joining stock, as all sinh sacks are of the same size, with but- tons and button holes arranged equidistant. By employing this excellent suggestion, you avoid loading the shoulder.- of the soldier, or transporting tents for the army, which is often impracticable. In a few minutes after fl ball tents 56 camping of raoops. are pitched, and the camp has assumed its regu- lar appearance, without waiting for the baggage train. These tents, bo convenient and always at hand, were of great service in the Crimea, but particularly in Italy in 1859, whore they were the sole protection for the troops. Rider's tent knapsack is made as follows: It is composed of a piece of gutta-percha cloth, li\e feel three inches lone by three feel eight inches wide. Two of the borders are pierced with 1 >ut- ton holes for brass studs, a third border has a doubl between which may be inserted and buttoned a second knapsack, whilst the fourth edge would have the straps and buckles neces- sary to close the kuapsack. The weight of the gutta-percha sheet when prepared, is three pounds. The additional accoutrements carried by the soldier are two sticks, three feel eight inches long and one and a quarter thick, which may he divided in the middle, with the pieces securely attached to each other by a ferule; and also a small cord. When \\>v(\ a> a knap- sack, the clothing is packed in a bag, and the gutta-percha is folded around it, lapping al the ends, so that the clothing is protected \>y two or three thicknesses of gutta-percha. Four knapsacks buttoned together, will form a SOLDIEa's BKD. •"'" sheet ten feet six inches long by seven feet four inches wide, and when pitched on a rope three feet four indies above the ground, covers an area of six feet six inches wide by seven feet fonr inches long, which will accommodate five men. and may be made to give shelter to seven. The slieet can also be used upon the ground, and is a great protection against damp- ness. The soldier's bed should never be directly upon the ground: as the earth always contains mois- ture enough to permeate the clothing, and rheu- matism, pleurisy, pneumonia, and such kindred affections may be the consequence. It' beds can- not be obtained, branches or dried leaves or straw should be used, upon which the blankets are spread. This answers the double purpose of keeping the body from the damp ground and of elevating it into a layer of purer air. When the tent is filled, as is usually the case, the ex- haled air, loaded with carbonic acid and other impurities, settles to the ground, which persons Bleeping upon the soil would be continually in- haling, to their injury. The solder's bed should be always dry. All moi.-i, decomposing materials, such as greeu grass or leaves, are more injurious than sleep- I'll H's MED. ing upon the soil, owing to the gases escaping from their decomposition. True economy would dictate n painted cloth for the floor of the tent, which rs useful in preventing the exhalation of moisture from the earth's Burface, is convenient, always ready, and less expensive than straw. Ii can be cleaned every day with little trouble, without cost, and requires to be freshly painted only once a year. When straw or liav is used for bedding, it should be renewed as frequently as possible, and the straw should be turned, well beaten, and thoroughly aired daily, with exposure to the sun when possible. In the French camp, straw is given out every fifteen "clays; in our army regula- tions twelve pounds is allowed per month in bar- racks. As a soldier always sleeps in his clothes, if he has a thick bed of dry straw to lie on. he can cover himself with his blanket: but if otherwise, lie should lie on his blanket, well doubled, i<> protect him from the damp soil, and cover with his overcoat. If he has an india-rubber cloth, lie should always lie upon it. ;is the \i'\-y I >«-| Use he .-an make of it to protect him from dis- ease. It is an excellent substitute tor straw in field lite, more cleanly, and protects better from dampness; it i- always at Land and always ready ni'- prisiug that disease and death followed in the wake of sucb indifference to all laws of decency and hygiene. CLKANMNESS OF CAMPS. '*» I The privies should be placed at least one hundred yards from the tents, and in an oppo- site direction to the wind currents, so that offen- sive odors will be blown away. The slaughter pens should also be placed at a similar distance. Every evening the oftal of the day should be covered with three or four inches of earth, or a sufficient layer to prevent any smell arising from the davs deposit. When the trench is two-thirds full, it should be closed and another of similar dimensions opened. Where proximi- ty to the water permits, these privies should be established over the water. This will remove a greai and common source of infection, which is very difficult to counteract. In permanent camps, dead animals, horse dung, and all animal refuse, should also be bur- ied, otherwise the stench from them would be wvy injurious to the health of the troops. Bu1 ;.-. notwithstanding the utmost care, in the most salubrious situations, diseases will in time show themselves — from the inevitable accumulation of poisonous materials, resulting from the growing infection of the soil, with it- poisonous emana- tion-, from the prolonged sojourn of a Large number of men ami animals — the camp, anless occupying a position of marked military impor- AM ,; -«.|.!.IKli>. y tauce, should be changed for u new situation at >« »inc «i'n\ iii'n'iit distance. For i permanent camp, board huts are much more comfortable and healthy for troops, whilst for transient halts a shelter composed of brauch- i n mli more desirable than tents. Troops bivouacked are always more healthy than those regularly under shelter. It is well known that irregular troops, which ad in the advance lino of armies, and which have no other shelter from the weather than a tree, rarely experience sick- ; — never at least the sickness which proceeds from contagion, an evil contingent to camps. One great advantage of using huts is. that they an- left behind with the infectious air which might have been generated within them, whilst the same contagion is often transported with the tents. A- the daily drills do not suffice to develop the physical organization of the soldier, he might i>e usefully employed upon public work.-, which may revert to his individual benefit, as the mak- ing of military roads, draining the sites <<\ camps, etc. For months the roads in the vicinity of Manassas, where the army of the Potomac were stationed, were nearly impassable, and transpor- tation was so exceedingly difficult, that the army AMI SKMKNTS FOB SOUUKRs. G3 suffered severely for properfoed. Had the troops been ordered to work the roads instead of loit- ering tor months in camp, the service would have been materially advanced. To enliven and relieve the toil and tedium of camp lite, amusements are a very necessary por- tion of the davs duties; and it is found that lively music from the military Viands every af- ternoon, will elate the men and remove monoto- ny. Singing and music should be a portion ^\' the military education, as offering an agreeable mode of passing the many idle hours of camp life which usually hang so heavily upon the sol- dier. Temporary gymnasia might be established, and gymnastic exercises should be encouraged as conducive to health, strength, agility and address. Playing hall, rolling ten pins, shooting marbles, throwing quoits, racing, wrestling, are all pre- ferable to oard-playing, which in camp is Lnsep- erable from gambling. In the summer of 1869, during the Italian campaign, I was at Milan, when a large body of French troops, returning from the bloody field of Sol&rino, arrived. In a tew minutes their shelter-tents were pitched, under the shade of the tires on the broad bou- levard which surrounds the city, and the sol- diers were allowed to follow the bent of their 04 \Mi -kmi:\ n Lilt SOLDIERS. own inclination. Card-playing, dominoes, for- tune-telling, wrestling, and dancing to the dis- cordanf tunes of :t band organ, or the sharp notes of an accordeon^ appeared t<> Ik- the order of the v the regimenl as comrades, who have been associated together through many a hard-fought field and toilsome inareli. In the military hos- pital- of Milan — which were filled with the wounded, from its very near proximity to the battle field and railroad facilities lor transporta- tion — it was not unusual to see a Boldier, nearly exhausted from the tedious dressing of a fright- ful wound, when he had passed from the hands of the surgeon, take from his boso/n a Tittle spar- row, and from the cheerful chirp of this little bird appear to derive much consolation. Not the least attractive incident connected with the triumphal march of Napoleon's Italian army through Paris, in August, 1859, was the pet- accompanying these brave heroes. Here would he seen a -oat. evidently proud of its po- sition, marching with military Step at the head of a column of ferocious Zouave-: going through AMUSEMKNTS FOR SOLDIERS. 65 the halt and advance by word of command, look- ing neither to the rigid or left, as if the success of the day depended upon its military deport- ment. Here, a regimental dog would show the pleasure with which he participated in this great occasion, whilst the caresses of the company and the pleasant faces with which his presence would always be recognized, show the appreciation of his companionship. These little incidents are introduced to show the longing of all men for Objects of affection, and also how many a tedi- ous and otherwise unbearable hour in camp life is pleasantly spent in fostering those fine feel- ings of the human heart, which keep soldiers accustomed to hlood, from becoming degraded and brutal. c II A PT E R 11. Hospitals, Regimental -ir,il — ( ',!,•• necessary in preventing Infection — Vahm a/ Fumigation — FemaJk Attendants — Hospital Db The accommodations for the Bick form a very important departmenl in the economy ef an army, and, as a rule, are never sufficiently am- ple* With even bodj Of trOOpS, ill the field, there are two kinds of hospitals — the regimental and the general. With regular armies, there should always he a third — the convalescent hos- pital — situated in BOme BalubrioUB, rural location, where convalescents, by inhaling pure air. and enjoying the pleasures of country life, ran rap- idly rebuild their shattered constitutions. For the army in Virginia during the slimmer and autumn of 1861, convalescent hospitals were established at points well adapted for the | »ur- pose, and wviv of essential benefit. The Vir- ginia springs are known to all the world; at such places <>\' resort, every convenience exists for accommodating large numbers of visitors. At some of these watering places, the hotels and REGIMKNTAL HOSPITALS. 67 numerous cottages were converted into extensive hospitals, where convalescents from the measles ami typhoid fever could use the mineral waters, enjoy the fine scenery, and recruit rapidly. The REGIMENTAL hospital is usually under tents when in the field, if a suitable building in the immediate vicinity of the encampment cannot be obtained. The tents used as hospitals in the Confederate service are fourteen feet in length, fifteen feet wide, and eleven feet high in the centre, with a wall four and a half feet, and a kk fly " of appropriate size. The ridge pole is made in two sections, measuring fourteen feet when joined. On one end of the tent is a lapel, which admits of two or more tents being joined or thrown into one. with a continuous covering or roof; such a tent accommodates, comfortably, From eight to ten patients. The following is the allowance of tents lor the sick, their attendants and hospital supplies — being accommodation for ten per cent, of the command : ■ospn \i ii m i. COM WO* III V . . . Fur three companies . i . • n compani< - . i 2 :: 1 1 1 l 1 1 1 1 1 1 r acute diseases are retained for treatment in the regimental hospitals. Thcv are temporary structures, to be moved with the army and M be broken up at an hours notice. They should never, therefore, be encumbered with chronic cases, nor should they ever be per-, niitted to be crowded. As soon as a case threat- ens to remain longer than a few days in hos- pital, it Bhould he transferred to tin- general hospital for treatment. To ensure a comfortable abode lor the sick, the site of the regimental hospital Bhould be selected with much care — the driest spot in the Camp should he chosen, and the tent well ditched to give thorough drainage. The floor of the tent should he carpeted with oil floor- cloth or painted canvas, which will protect the sick from the emanations from the soil, and will prevent the soil from imbibing animal efflu- via. It also keeps out all moisture, which is 9Q deleterious to those lying upon the ground. This painted cloth strictly belongs to the hos- pital tent, and. as an essential part, should never be overlooked. A certain number of bed-sacks also belong to the hospital. When these are filled with straw, they make a much more com- REGIMENTAL HOSPITALS. 69 Portable bed than straw thrown in heaps, Which is the common mode of treating the sick in the field. There is much comfort in appearances, and these beds add nincli to the neatness as well as cleanliness of the tent. The beds fere arranged on either side of the tent, with the heads turned toward the wall. Could the beds !>■' elevated upon hoards tor six or twelve inches, they would place the sick in a purer atmos- phere than when lying on the floor, where the heavy, deleterious <^ases of expiration collect. In Lr<>od weather, ventilation of these tents should always he insisted upon. When the painted * floor-cloth is not at hand, the earthen floor should he well rammed, and should be daily Watered with a milkv lime-water as a purifier. The straw should hi' changed as often as pos- sihle. even twice a week, if it can be procured J whilst, if the patient can get up, the bed should be well beaten and thoroughly aired daily. /' r- snicil eleanUness of the "patient is as important as thai of the tent. Ablutions must be freely used, and under-clothing frequently changed. When- ever the patients permit, the tent Bnould he moved once a week, if it be only a few yards from it- former position, so as to enclose a fresh pier.- of rM.il not con t a mi ii afed with animal exha- 70 UKOIMIMAI, HOSPITALS. lations. This change c€ location is particularly required whenever any of the low grades of con- tagious diseases appear within it- wail>. or em under treatment take OB an astha-nic characfc t. The hospital is allowed a pertain number of attendant-, to attend to tne commissary ami medical duties of the establishment. Each com- pany has one steward, one nurse, and one cook; for eaeh additional company, one inn is added ; and, for commands of over live com- panies, one additional cook. The surgeon is general superintendent of the hospital, rnilcr his direction the steward takes care of the hos- pital stores and supplies, and sees that the » nurses ami cooks perform properly their respec- tive duties; and often he al-o acts as medical dispenser and apothecary to the regimental hos- pital, li' intelligent, he can readily he instructed in the preparation of prescriptions for the sick, and relieve the surgeon of this trouble. Not the least important personage in the hos- pital organization is the sentinel, who guards the door and sees that neither ingress nor egros if permitted except upon orders from the surgeon. It is onlv in this way that patients can he pre- vented from committing imprudences which may cost them their lives. This guard should be GENERAL HOSPITALS. * L constantly furnished to the hospital, and the sur- geon is to signify to the commanding officer 0$ the regiment the particular orders which he wishes to he given to the non-commissioned officer commanding it and to the sentries. Those treated in a tent hospital always conva- lesce much more rapidly than those collected together in a large hospital building, where, in proportion to the magnitude of the establish- ment and number of patients, we find the con- valeseence of the siek prolonged, the nnmher of deaths increased, and the germs of contagious diseases developed. In concentrating a number * of sick under one roof, the laws of hygiene will he violated — it cannot he avoided. Yet, from the very transient nature of regimental hospitals, more permanent institutions for the siek must he established. The general hospital, for the use of a division of the army, is usually located in some town or city contiguous to the army ; or, should these be too distant, without facilities of transporta- tion, some building.- are take possession of near tbe lines and converted into a hospital. Tbe organization of tbis, with its surgical staff, its steward, ward-master and nurses, is upon a much larger scale. Ordinarily, tlic following hospital fA 01 M B \1. HO8MTAL8. attendants are allowed: A Rteward, a ward-mas- ter, an orderly (taken from the ranks) to act as rttrree for every ten sick, a laundress for every twenty, and one cook to every thirty patients'. -Each nurse is made responsible for cleaning and taking care of ten beds, with the floor and utensils included in the spac< cupied by the ten beds. His duty includes bringing t«> the ward and distributing to the patients the daily rations, and also the medicines prescribed at tbe visit. The cooks and nurses are taken from tlie rank'-, and are returned when no longer re- quired in the hospital. In a general hospital,, there is always a dispensing officer or apothe- cary, who prepares the (prescriptions of the sur- ui. and delivers the same to the nurses upon application at the dispensary. In regimental hospitals, the surgeon, or Ins assistant, when present, perforate this duty, if an intelligent -teward has Bo1 been instructed by the Burgeon in preparing medical prescriptions. In a large general hospital, the steward represents the com- missary department. Wnoever attends to the pharmaceutical department should be careful to keep all poisonous drugs under key. so that no accident mighl occur to the inmates of the hospital, whether by design or through mistake. ( I.KANSINC UF IIOSI'ITAI.S. 73 In his general 1 n > ^ [ » i t ; 1 1 we have (tegular wards, whicb are always objectionable from the numhcr of s'u-k crowded into these compart- DH'iits. Every bed for a patient should liave a certain number of cubic feet, or, as height docs not compensate for area — as all the dangerous gases stagnate in the lower strata — it would be better to allow each patient so many square feet — say fifty square feet for each bed. For those who are severely wounded, or sick with typhus, twice this area, or one hundred square feet, will not be too much space, if it be de- sirable to prevent pyaemia, hospital pina'mii'. erysipelas, and other fatal complications, from showing themselves* Rooms with less than ten feet ceiling, are not fit accommodation for the sick. With the constant tendency to a poisoning of the atmosphere from imperfect ventilation, all precautions of cleanliness cannot be too rigidly enforced. In the cleansing of hospitals, too frequent scouring is prejudicial to the sick and is found to induce low forms of disease. In Fiviieh bo* jiitals. the wooden floors are waxed and rubbed daily, which avoids the excess of moisture in the atmosphere of a ward. In military hospitals it would be better to sand the floors daily, wash- 7 (4 rxEANsixn of hospitals. ing only tin' very dirty spots. Spittoons should he furnished to every bed, and the nek should he prohibited 1V« nn spitting upon the floors. The-e spittoons -hould be cleansed daily, and newly sanded; and when much used, the sand should be changed twice daily, or they become offensive and injurious. All urinals, bed-pans, or chamber-pots should he emptied as soon at used, and never be allowed to remain soiled in the ward. The hunks in the hospital after being in use for three or four weeks, should he taken out of the wards, well scoured, and exposed to the weather, before they are returned. As soon as a bed is vacated, if it has been in use more than ten or fifteen days, the straw should he burnt and the sac washed and refilled. Blankets should also he frequently efeanged and washed. Personal cleanliness is essential in a general hos- pital. If conveniences are at hand the patient, upon admission, should he bathed, and placed in clean clothes, and in a clean bed. The heds should always he kept in order, whether occu- pied or not, and should a patient leave it only tor a few minutes, it should he put in order whilst he is out of it. Such a general hospital should, among other things, be liberally furnished with hospital cloth- CLPANS1NO OP HOSPITALS. 75 ing. In European general military hospitals, the patient leaves everything behind him when lie enters its wards. lie receives a bath, and is dressed up in the hospital elothes; his own are washed and stowed away, properly lahelled by the ward-master. Should lie lie suffering under any contagions disease, as the itch, typhus fever*, etc., his clothing, alter being well beaten and washed in boiling water, are fumigated for twen- ty-four hours in a closed chamber or tent with chlorine gas. With itch patients, sulphur fumi- gations are substituted for chlorine. The ward-master should never allow the wards of a hospital to lie encumbered with the pack- ages or accoutrements of the inmates, but all such should he stored away in a store-room, where a series of pigeon holes, two feet square, are arranged, and numbered as are the beds, so that each inmate of the hospital has a square allotted to him, wherein to deposit his private stores. Where the hospital is well organised, every article which the patient brings in is de- posited in the storr-room. as he is expected to be supplied from the hospital wardrobe. Whenever an intentions or contagious epidemic threatens to Invade an hospital, the sanitary po- lice of the institution should redouble their vigil- , PI HIIK'AI ION 01 llnsl'll Al ,8. Alice to eemove <>r counteract those aausee which might assiei in produciug or disseminating such disease. A thorough examination of the build* in-- >]icul^ for purifying the same at intervals. Such rooms, ii ia said, should he thrown out of use for two weeks after every two months occupation. This is laid down as an important hospital regulation by Stromyer, in his Maxims of Military Surgery, based upon experience and observation during the Schleswig-Holstein war. Chemical disinfect- ants were not found useful by him when the rooms were occupied; the rooms must he empty. F<,r weeuepied rooms, draughts of fresh air arc the enly good disinfectants, and to obtain this end. without detriment to tin- sick:, the windowe should open mar the ceiling, and the sashe* 7^ PlTfclFICATJOW •'»' HOSPITALS. sin >ul< >ti the si<-k. The slight exposure t<> catarrhal affections i> n<>t to be considered, when compared to the danger of introducing infectious diseases, by permitting a foal and unrenewed atmosphere t<> be inhaled by the wounded. It is owing to the advantages of ventilation, that tents are so much better for typhus and severely wounded patients than wards. Pure air, continually renewed, is essential for the curt' of typhus. Abundance of fresh air covers a multitude of inconveniences. In the Crimean service, the French attached great importance be the fumigation <>l' their wards. The surgeons of their immense military hospitals thought thai they derived decided benefit from adopting the Turkish custom of fumigating with dried sage 1 which was Inirnt in the wards three times u day, besides the use of chlorine fumigations morning and evening. loudens states that, by using chlorine fumi- gations al 6, \. .M.. and at 7, P. M., the dried sage at 7.'.. \. M., 1. i\ m.. and 8$, p. ML, lie succeeded in preventing as well as stopping in- fectious disorders. A saucer of chloride of lime was also placed under the bed of each typhus PURIFICATION Of HOSPITALS. ft patient. It is a question whether these fu mi sta- tions act from the medicinal virtues which they possess, or upon hygienic principles. The Eu- ropean nations have such a dread of draughts, that a door or window is never left open* ^Y<• would judge that they were intended to give light, and nol air. The only way in whirl) such herb fumigations can be of use. is to make the atmosphere so disagreeable thai all the windows must he thrown ope* to s;-et rid of it. As it escapes from these openings, fresh air equally rushes in to purity the room. This difficulty of ventilation through the win- dows, which are the proper media for it. is the common subject of complaint aniono- the medi- cal staff* of the hospitals. Stromyer had to enter into a regular compact with his German pa- tients, lie would only allow them to smoke pro- vided they would keep the windows open, using this subterfuge to ventilate the wards. A cele- brated English medical lecturer placed the value of fumigations in their true light, when he said "fumigations are of essential importances they mf llic nurse, without in any way benefiting the patient. It must never be forgotten thai many Bymp- totns which are said to belong to a disease, de- pend upon tin* cirenm8tances under which it is treated, and many of these can with truth be accredited to bad ventilation ; hence the dif- ferent phases Which diseases assume when treat- ed in hospitals or in private practice. If Buch causes will produce disease (a fact with which every one is familiar), how much more likely are they to modify those already existing. Every physician of experience and observation has seen serious cases of fever, threatening a fatal issue, commence to improve from the moment that the patient was changed from the room in which he had long heen lying, with its closed windows and otnsty smell, to a light, cheerful, well-ven- tilated chamber. This is always attributed to change of Beene, whilst the true cause, change of air, is overlooked. Typhus cases particularly, should, if possible, be isolated in tents, and ample room be given to eaeh. Over-crowding is certain to produce such a condition of the atmosphere as to height- PURIFICATION OF HOSPITALS. < s i (mi the mortality. It also becomes hnperativta upon those taking care of such infectious pa* dents to breathe the air as little as they can-: live out o\' the room or tent as much as possible, compatible with the proper attendance upon the sick, and take exercise freely in the open air. Surgeons placed under such circumstances must take additional care of themselves. Personal cleanliness becomes a necessity; the liberal use of the hath, and the frequent changing of their clothing, will he found a wise sanitary precau- tion. Their diet should consist of simple and easily digested food, with wine in moderation. They should avoid all excesses, hoth in eating and drinking, as those addicted to intoxication and gormandizing are placed in the same cate- gory with the weak and poor, from which classes the mortuary tables of epidemics are chiefly made. The surgeon should live out of the hos- pital, and should not enter the hospital in the morning until the wards have been well aired. In taking exercise in the open air. fatigue must- be avoided. His mind musi he tree from all anxiety or personal fear of the disease. lie should take a full proportion of Rlocp, and in the general care of his person should watch every indisposition, and correel derangements of v _' PI BtlFICATlON OF HOSPITALS. the digestive syateni before they lead to more serious conditions. Tin- nuedieal attendants upon typhus hospitals, or in such as arc infested with pysemia, gangrene, <'t<\. should frequently change placet with those in charge of more healthy in- stitution-: otherwise, the permanent medical at- tendant, inhaling daily this poisoned atmosphere, will be sacrificed to an absence of a regular in- terchaage of stations and duties. In the best regulated hospitals, each typhus ease has two beds. Every twelve hours he is changed, and the bedding upon which he has been Lying fumigated and well aired. The bed and body linen of Bucb is also changed daily. As typhus is known by its infecting nature and it- easy transmission, the hospital wards cannot be protected by too many hygienic regulations. When a hospital has become infected with ty- phus, pyaemia or hospital gangrene, it is best to close it and turn out all patients. It would he much safer lor the sick and wounded to stay in the streets or lie in the field, than he sent to such an infected establishment Hi* permit for admission is his death-warrant : whilst combat- ing tin- elements would give him at least a chance of coming off conqueror. Any tempo- rary, well-ventilated structure — a hut rudely FEMALE NURSES IN UOS1MTAI.S. made of rough boards— would be Irfach health- ier than gorgeous palaces with gilded chambers, in Which Death sits in state to WCfrive his vic- tims. In general hospitals, the blessings of a wo- man's care, her ewwatehful eye and soothing words, her gentleness and patience, have recently been felt Florence Nightingale, when she made her disinterested offer to nurse the sick in the Crimea, could have little foreseen the new era dawning for suffering humanity, and the bene- fits which she was bestowing upon future gene- rations. It is woman's peculiar prerogative, as it is her earthly mission, to give comtort to thosfl in distress ; and when the EngKsh adopted the custom long prevalent in France, to allow female nurses to minister to the wants ni fefeoee suffering in military hospitals, the wounded felt that half their solicitude was removed. Xow a Sisters care will bathe the sufferer's aching head. or offer him the cooling draught to allay his putted thirst: will sympathize with his pains, and --ive sweet consolation to his dejected spirit; ami, by removing that overpowering weight of Loneliness, by which the sick in a foreign laud far from home ami friends are oppres>ed. will pave the r«.ad to speedy convalescence. A cheer- •I I KM \l.l M R -I - IN I. MTA1 t'ul look. :i kind word, r pleasanl smile from one of these self-denying Sisters, has Bent many a Thrill of pleasure through :i stricken soul. The surgeon sec-, at Ins next visit, the fruil of thin pleasantly-administered draught, whieh, perhaps, In- attributes to his own nauseous drug The experience of the Crimean hospitals, recog- nizing the vast amount of good which the female nurses accomplished, and the incalculable servie* which they are capable of performing, when judi- ciously selected and properly organized, is a suffi- cient reason why they should be attached to every hospital, and especially in times of war, when their many and peculiar services cannot be dis- hrihnl with. To tin- surgeon, a good, kind, re- liable nurse constitutes more than half the treat- ment of the sick. It is with the most serious cases tlwit their advantages in nursing are beat displayed. McLeod, who studied carefully Wo- man's services iii the Crimean hospitals, says: ■• A woman's services in a hospital are invaluahle. if they were of ih> further use than to attend to the cooking and the linen departments; to sup* l>lv 'extras' in the way of little comforts to ihe worst cases; to see thai the medicines and wine Ordered are administered at the appointed peri- ods, and to prepare and provide suitable drinks. FEMAJM NlltsKS IN HOSPITALS. 85 As to the employment of 'ladies,' I think they arc altogether out of place in military hospitals, except as superintendents. As heads of depart- ments, as organizers, as overlookers. ' otlmers' of tin' female corps, it* yon will, they rannot he dispensed with ; bat for interior posts, strong, aetivr, respectable paid nurses, who have under- gone a preliminary training in eivi] hospitals, should alone be employed. In camp hospitals, Which, with an army in the field, are merely the temporary resting-places of the sick, men should alone he employed as nurses: but in the more fixed hospitals in the rear, the lady superintend- ents and under«nurses should, in my opinion, always he added to the regular staff. Their attention should be limited to the had cases, and they should have the entire control of the linen, medical eomforts, and cooking. ! cleaning should he done hymen. There should be a lady superintendent over each divis- ion of the hospital, responsible to the surgeon as well as to her own lady chief. Then there should he a store of -extras' under her charge, distribu- table on requisition from the medical attendant, and which depot should he tilled up to a certain quantity weekly, the Sister being held accounta- ble for the contents. Wine and all extras should v " m if i\ ROftprr \i i pass through her hands. She shook! be responsi- ble for the due performance, by her female >ul>- ordiuatea, <>t' their duties, and have a rigfcl t<> interfere with the ward-maater it' the cleaning', •4c., is not properly attended to by his male corps." '/'/-< dieting of patients wi a hospital is alwaya ;i natter of oouaiderable moment, and one which reqoirea much attention. The Burgeon haa die- cretionary powers to order any extras which the patients may need and which the iaaoe of rations not include. To l»c enabled to supply these extra articles at the time when they arc wanted, and not depend Upon the doubts and uncertain- ties of the regular form through which all such orders now pass — n kind of circumlocution office, where, in time, the articles may be forthcom- ing — the medical director should be supplied with funds, for the judicious outlay of which he be- eomea personally reaponaible. From this fund the wants of the patients can he supplied with- out delay. Another mode of supporting tin- commissariat of a hospital, is by commuting the number of weekly rations which the inmates are entitled to draw. As the sick cannot consume the full ration allowed them, the difference not used, TUKT I\ HO8PITAL8. ST wbieb is considerable, would, in time, establish an hospital fund, which Would not only be suf- ficient to meet all of the necessary demands of the sick, lmt would also supply them with many luxuries. When the patient can Consume his entire ration, lie should be discharged from the hospital and returned for dUty. This hospital fund is in the keeping of the Burgeon, who has the right to expend it tor the benefit and eoiu- fort Of the patients — the articles purchased not being restricted to articles of subsistence. For the very sick, the dietary orders being indi- vidual, no difficulty exists in prescribing for them. It is tor those drawing ordinary fare, and who require to he guided by some fixed rule, that diet tables are found so useful in diminishing the daily routine duties of the surgeon^ This diet li-l i- carefully compiled by the medical directors of th«' hospital, and contains those articles of diet which would be besl suited to the many. As this i.> a 811H >/"" UOfl in a hospital, and gives much trouble in its preparation, I have here in- troduced, as a guide^ a diet table, which mighl he useful as a basis in preparing one for indi- vidual hospital service. sa MM IN HOSPITALS. .1 Schenu !■ '■ Patients in tin \IUit< II II l.l DIKT. II M I H1KT. 1 »\\ I'll T. I !!• Breaa 1 II.. Brea.l >. II,. Beef or M.iii ,u. . . or Matto | lb. Tea Potatoes, or ] .... 1 lb. Potatoes, or "\ 1 lb. 'Snjrar Beans, or. I ■■ . B an?, or I ■ •• Milk for tea f • .L^i-. !:• • i I to Corn Mi :.l 1 H>. •n|i. . I oz. \ pt'es for soup . . 4 oz. Milk I ok Bnfi l ,,/.. m'i l oj o . Tea 1 >,/. i 1 oz. Sujfar l' ,,/ 2 "/.. Milk for tea I os r ten i oz. MolasPe* | ,,• I ua.lCoro Meal I I i> Cora Meal 1 lb Sou] ' .Snip I pt i -sucb quantities, in lieu of beef and mutton, as !h'.' in 'lh-.il officer may prescribe. \\ i: ■ , Whiskey j Porter or \\<-. :>' the surgeon's discretion. Two drachma of tea or tour of coffee, with one ounce i'f sugar and one-eighth pint of milk, to lit- allowed to each patient for one pint of tea or coffee morning and evening. The beef or mutton for full or half diet is to lie made into soup, with vegetables, ami one pint of the soup given to each patient, with his pro- portion of the boiled meat. The vegetables, as lire, potatoes or beans, arc frequently changed to give variety to the meal. DIET IN HOSPITALS. 89 The diel Mould be distributed in the following order : I Bread * lb, BHBAKFA.8T. Tea or ooffee..l pt. ( Iliuniiiv & molasses. 1>i\ \ in. Supper, i Beef or mutfon.j lb. 1 Soup 1 pt, 1 Bread \ lb. ( Bi : « 1 1 .-- . potat's or ruse I Bread ^ lb - Tea or coffee . • I pt. Bread a lb. Tea 1 pt, II mnir, v & mo Beef or mutton.j lb. Snap 1 ).t. Bread 1 lb. Bcans,p»tal 'a or riee Bread. Tea . . . Q-ruel . Gruel Milk., • 1 lb. .1 pt. •ipt. .lpt. .1 pt. Bread } lb. Br a ! . fea 1 pt. Tea. . ■ Q-ruel. • j lb. .lpt. .A pt. The attending surgeon adds what he wishes to the above diet, to suit any individual case in the hospital. For regimental or post hospitals, where diffi- culty exists in obtainiug proper ihgrediehts for furnishing a good soup to the sick-, the medical department issues "Jones' soup or meat cakes," which contain all the necessary elements for its preparation. These cakes, which are composed of meat and vegetables, when boiled lor ten or fifteen minutes, wifb ;i sufficient quantity of water, will make a nutritious diet for convales- cents. CHAPT E l; MI. .1/ al ServUn of the Arm;/— Tin means of Trans- porting //><■ si,-/,- and wounded — II" ml Litters — Horse Utters — Ambulance Waggons, f even a lew hours oyer bad roads, and in unsuitable vehicles, is incalcu- lable. Wounds which laid been doing well prior (o the move, take; on at once an unhealthy appear- ance : some slough : erysipelas or mortification shows itself in others, whilst all feel more or less its malignant, injurious influence, even with the besl transports, and under the most favorable cir- cumstances. 'Idie jolting of a broken limb for three or tour hours over a rough road, is inde- scribable torture. The prostration and exhaust- ion depicted upon the laces of the wounded after such a transfer, explains ;tt ^wrr the problem why such numbers die during their transportation, and TRANSPORTATION OF SICK AND WOTTNPKD. 91 makes us wonder bow so many escape with life. after undergoing such unutterable hardships. The transportation of the sick should also be a source of anxious solicitude on the part of a quar- termaster whose humanity has not been berefl of every spark of sympathy. It is said that, in the service, the privation and the usual demoralizing agents, always at work and so widely diffused, destroy all the finer feelings of a man, making him not only careless of self, but callous to the wants of others. It is only similarity of suffering that can produce sympathy in feeling. Could ihose in the Quartermaster department undergo ihe same treatment which falls to the lot of the sick during transportation, there would be a few more comforts extended to those who are risking their lives for their country. Who can describe the agony of that fearful ride, which so many thousand sick were forced to take, from Manassas to the provincial and metropolitan hospitals, where a six hours ride by railroad was often extended to two days, the sick lying in box and cattle ears, without food. and often without water. Should it rain, which it diil nearly every day, these poor, brave fel- low-, who had left every comfort, if not luxury, at their country- call, soaked to the skin, with- '~ * u TRANSPORTATION OF SH'K AM) WOUNDED. <>ui ;i change of clothing, would remain in this plight until they arrived at a hospital, whieh, in iurn. wan often ban or twelve hours after their arrival in the city. Human nature could not en- dure such trial.-, ami many succumbed in tran-it i>r reached the hospital to die a few hours after admission. If the proper care had been taken, ami car.- had been judiciously arranged i'<>r the comfortable and rapid transportation of the sick, many a valuable life would have been saved* The following arc the usual modes of transport- ing those wounded during a battle: Lirb&s. — The common and best means o€ moving wounded men. for short distance-, i- ii)ioii Litters, which may be prepared in advance, or be an impromptu manufacture. In case of necessity, a Litter can al once be made from the blanket of a soldier. This is doubled upon itself, a slit being made through the end corners suffi- ciently Large to admit the barrel of a musket: one musket is passed through the fold of the blanket, another through the slits in the ends, ami a litter i> ready lor use. Soldiers blankets arc at times prepared lor this service, by having Strong loop- sewed to the corners, so that when the blanket is doubled the lour loops will come TRANSPORTATION OF SICK AND WOUNDED. 9$ on one straight side : one musket is passed through the four loops, the second through the folded blanket. Whert comrades from the ranks are expected to carry off llio wounded, this is the only litter which is of service, as any two sol- diers are prepared to act as transports, without hampering themselves during the tight with extra baggage. Such a litter is. however, very defect- ive, as the weight of the patient sags the yielding blanket until it nearly reaches the ground, whilst the muskets are pressed in upon the haunches or the bearers, which renders it impossible for them to proceed with ease or celerity. A more useful and equally simple litter or stretcher is made of strong sacking or canvas, six feet i«»ur indies long and two feet wide. A broad hem is taken up on either side, through which readily pusses a stout pole eight feet hmg. <>n either side of the litter is an iron or -tec] rod two (ret ]oug. with rings at the ends, which slip over the cuds of the poles and form the stretcher, to keep the poles separate, and prevent any sagging of the litter. A shoulder strap, with a loop ou either end to receive the poles, completes an apparatus which is capable of carrying oil" a wounded man with all the •mfort with which his situation admits. A 94 ^NSPORTATION f»F SICK ANP WOrVT>KT>. pike head attached to the pol - it a P midable wea] of defence. Each of those who I to transport (he wounded, is armed with such a pike, and 1ms one iron I o¥ Btretcher and canvas bottom Btrapped upon his knapsack. Any tw<> of tl i«i 1 1 meeting tos^ethef will be enabled in :i few minutes to equip an efficient litter. When placed in the litter, the soldier's knapsack is placed under his 1i«:h1 as a pillow, and Lis musket lies alongside of him, or may be hung from the side of the litter by loops placed there for thai purp< A framed litter is one of very questionable utility, as it is a very bulky article, and 6ne easily broken, so thai usually, after a long trans- portation, very few of them are tit for BervTce. The litters 1 1 - » • « 1 in the Confederate service are composed of canvas, twenty-four indies wide. securely tacked to two horizontal bars ei-ht feet long; the stretchers which slip over the han- dles, and to which the canvas is temporarily ired by strap-, being a square bar of wood, with a loop of band iron over the r]\i}<. forming the eyes through which pass the handles. These :iiv convenient, as they fold in ;i small compass for transportation. A.s the stretching apparatus^ which is loose, is sometimes losl or misplaced; TRANSPORTATION OF SICK AND WOUNDED. 95 which venders the litter useless, it may be se- cured to the side bars by hinges. Short fold- ing legs, working upon an iron pivot, and kept in place by a stop-block or an iron hook, per- fect the apparatus. In the Confederate service, ten of these arc issued to each regiment in the field. Williamson, in his Notes on the "Wounded from the Mutiny in India, published in 1850, lias, in the appendix, a plate and description of a fooley — a kind of litter used for the convey- ance of the sick and wounded in India. In the field service it forms the patient's bed as well as means of conveyance, from the time of bis being wounded until be is either cured or dies. It consists of a frame-WOrk, resembling a bed- stead in miniature, six and a half by two feet, with light posts, which run below the bed six inches. This is slung by two ropes placed on either side from the head and foot, and running up triangularly; the pule upon which the litter i- supported passing through the apex of these two triangle.-. A tarpaulin cover, with side curtain-, excludes tic sunlight and gives privacy to the wounded. When the bearers arrive at the encampment, they run the dooley into the hospital tent, take out the pole with the tar- paulih covering and curtains, with which they make their tent, leaving the patient comforta- bly in his bed. These were found t<» answer admirably in the Crimea, where they were used to a limited extent* This is the raosl comforta- ble conveyau#6 for a Bick or wounded person, nii introduction generally into the English service has been Btrongly recommended. Horse Litters. — Next to hand litters for the transportation of Wounded men are horse litters, made three feel wide, with poles sixteen feet long, folding in the middle for convenience 6t transportation. Elorsea <>r mules take the place of men — the poles acting as shafts, and su|i- ported by back-straps or by a saddle with tugs, as in ordinary harness. Each horse litter carries two persons. When the mules are led by men well trained for this duty, transportation by tins means is well suited to the comfort of the wounded; bu1 if the muleteers are raw hands. who, holding the mule by the head, attempt to lead it. instead of allowing it to pick its own way. the joltings and sudden jars make this litter anything but a bed of down. The French use what is called a cacolet, a kind of arm-chair, which is suspended on either AMBULANCE WAGONS. 97 side of a pack-saddle upon a mule. The me- chanism of this chair is so arranged, that, it can be unfolded, so as to he converted into a bed or a litter. It offers either a comfortable seat for the trivially wounded, or a bed for the more serious; and each mule can thus carry two men comfortably, from the held to the in- firmary. In hilly countries, over had, rough roads, this is found a much better conveyance than vehicles. The two and four wheel carriage <>r ambulance wago7is, which have been adopted in every civilized army, are considered indispensable for held service, and for the transportation of the wounded. The two-wheeled vehicle is the most comfortable. Both two and four are so ar- ranged as to allow of the wounded being car- ried lying, reclining, or sitting. The omnibus i> the most expeditious means of removing those slightly wounded, who are not able to walk from the field. Where 1 lie roads are good, in an open country, this vehicle should not he overlooked. The two-wheeled spring ambulance wagon is the most comfortable for the wounded, hut not the most useful for tin- In the Confederate & the four-wheel t A.MBI I.AM'K WAOON8. Bprillg WagOU M the one ill general Use. it consists of a square body, three and a hall' feel wide and seven and a hall' feet long, placed upon three springe. Two stuffed seats run the entire length < •!' i 1m- wagon; and the drop from this, which is attached to the seal by hinges, and is equally cushioned, can lie elevated hori- zontally, and supported by feet, which, with the seat* will form a continuous bed over the entire wagon. Such wagons will transport two men lying, or from ten to twelve Bitting — the in- mates being protected from the sun and rain hv a doth cover ami side curtains, supported upon a frame. Two five-gallon kegs, secured under the bottom of the wagon, will carry water for the sick and wounded. The Coolidge* two-wheel ambulance wagon, which is in use in the Federal army, is a wvy ingenious hut complicated arrangment, which is liable to he broken by the ordinary abuse of the service. In these, instead of seat<. there are two frames, which can he used as litters. These run upou rollers on the bottom of the wagon. The frames have folding legs and sliding handles. which occupy no available room. Upon the top of the litter i- a frame, divided into three por- AMBULANCE WAGONS. M tions, folding in such a way that the head of a wounded man can he elevated nearly to a sit- t i 1 1 iz: posture, or the leg equally elevated, should the peculiarity of the wound require it. A par- tition through the body of the wagon sepa- ratee the two patients which the wagon carries. Under the driver's scat is a box. which can be used as a medicine-chest. This vehicle is in- tended for one horse in shafts, or two in tandem. The Confederate service, based upon the army regulations of the United States, allows for every command of less than three companies one two-wheeled transport cart for hospital sup- plies, and to each company one two-wheeled ambulance carriage. For commands of more than three or less than five companies, two two- wheeled transport carts, and to each company one two-wheeled ambulance carriage. For a battalion of five companies, one four-wheeled ambulance carriage, five two-wheeled and two two-wheeled transport carts: and for each addi- tional company, less than ten, one two-wheeled transport cart. For a regiment, two four-wheeled ambulance wagons, ten two-wheeled ambulance wagons, and tour two-wheeled transport carts. Where there ire manj sick to be moved from TOO AMBULANCE WAGONS. camp to a general hospital, Bhould the transpor* tation in ambulance wagons be deficient, ad- vantage is taken of the return of empty com mis- « sarv wagons t«> the rear to send off the sick, and vehicles « > t " every description may l>e impressed for this special service. CTT A P T K R TV. Medical and Surgical Staff of Armies — 7%< Medical organization hi the Confederate service; English service; French service; Prussian servici — Sani- tary Corps, "/• litter carriers for transporting ile wounded from H<< ti/ the Hospital Surgeon — Duties of tfo "Regimental Surgeons and Assistants in camp "ml on the batth field — Pre- parations needed <>n the eve of a batth — Positions occupied by tin Medical Staff during the figftt. Medical Service of the Army. — The medical staff of an army i> selected with care by an ex- amining board, whose rigid inquiries into the literary and professional attainments, as well as into the moral and physical condition <>t' the ap- plicant, keeps the start' purged of inferior men. ami forma a body of scientific investigators whose efficiency will compare favorably with the profession of any country. During war. the Medical department increases puri passu with the army. These appointments 102 M K I • I « • \ I . STAMP. ghoald be made with ;i lull knowledge of the weighty responsibilities attached t<» the medical -t:itl'. without whose constant solicitude for the health and well-being of tin- troops committed to their care, the effective strength of an army will he materially reduced. With a view to en- sure, at nil times, the most active and efficient treatment for the -irk in the army, ami particu- larly during active service, it is not only essen- tial that the medical officers should he men of ability and of high professional qualifications, hut that they .-houhl possess physical energy adequate to the more arduous duties. It is ;i common impression that Burgeons alone me wanted in the army, under the erroneous be- lief that the only risks to which troops arc ex- posed are the bullets of the enemy. A- we have elsewhere shown that tor one killed by tin- enemy sixteen die of disease contracted in camp, this will he sufficient proof thai the phy- sician iii » i — 1 he even more important than the surgeon. Long before the first shot ia fired there are disi • contend against. Whether in camp or on the march, diseases are constant- ly developing themselves. Surgery has its peri- ods, and although hospitals niav he tilled imme- diately alter a fight, beds are soon vacated to MK1UCAL STAFF. Ltift the ever coming siek. Some of the wounded die, a large proportion rapidly get well and are discharged, and the protracted cases ace sent home to recruit; but these leave no vacancies, as their places are immediately tilled by the sick. The advantages of having an experienced sur- gica] Btaff in the field, and the influence which it can exert on tlic vicissitudes of war, must be acknowledged by every thinking man. Yet, medical advice is seldom asked or listened to by those in command, so long as Buffering and deatli are not cruelly felt. The proper under- standing between the surgical and military staff' of an army, with concert of action, will save many a soldier who would otherwise Lose or com promise his life, so valuable to the country in time of need. In the Confederate service, but two grades in the medical staff arc recognized — surgeons and assistant suru r vons. with the respective assimila- tive rank of major and captain. The head "f the Medical depart incut is presided over hv a Surgeon-General, with the rank of Lieutenant- Colonel, which i> the higheal grade in the mt- viee. and which position is n promotion by sen- iority <>f commission. There are two other meritorious positions of medical directors and medical purveyors of the array, which are ap- pointments from tlic Surgeon-General, and are considered high offices, although without in- i 'I rank. In the Confederate service, each regiment of thousand men has one surireon and '>n<- as- Bistanl surgeon. Where Beveral regiments are united into brigades and divisions, the Surgeon- ral usually assigns the oldest surgeons in the service, acting in Buch a division <>f the army, to th of Medical Director t<> superintend the medical affairs for Buch a division, unless In- make- a special appointment, irrespective of l<>r;il medical staff. In times of peace, these two tental officers are found scarcely sufficient t<. attend t<> tin- sick; whilst in times <>f epi- demics or war, they are Incompetent to offer that assistance which the sick and wounded re- quire. Many a life lias been sacrificed bo pro- crastination. Upon the first and immediate atten- tion to the wounded <>n the battle iielf a battle, the wounded must necessarily be nee <•ur sparse medical corps* Kuro- IN<;i.ls li SURGICAL STAFF. 1"~> pean experience confirms the observation, that two medical men are no< sufficient to takse etwe of the health of a regiment. This was the sub- ject of general comment in the Crimea, where the medical staff were unanimous in the de- mand for additional medical assistance. In active service, every regiment should have at least one surgeon and two assistant surgeons, these differ- ing only in rank, their duties being similar. Besides the regular regimental sure-cms. there is in the Confederate service a medical corps to take charge of military hospitals, whilst regi- mental officers accompany their commands. In the English service, the medical department is composed of regimental sure-cons, with their assistants, staff sure-eons of the first and second class, and medical inspectors. The staff sur- geons of the firsl class rank the regimental sur- geons, and. with their assistants, either take charge of military hospitals or a< I as medical supervisors lor a brigade, composed of three or nore regiments. The assistant stall* Burgeon holds the same rank as the regimental SUl'- geon. When many brigades are collected into a division, a staff surgeon of lone- service is ap- pointed to direct the medical and surgical af- fairs of the division : and when a large force, 10<» 1KK.MII AND I'KTNSIAN SlUiiK'AI. STAFF. consisting of several divisions, with their respec- tive generals and physicians, i- brought into the l'nld for actual service, and placed under a gene- r;il-in-i]iiet'. ;i medical staff officer, bearing the title of Inspector-General, is appointed t«> super- intend and concentrate nil the niovementi «'t the medical department of tie- army. The medical department take- the military, therefore, a- its model. In the French army, a somewhat similar or- ganization i- found. Besides surgeons and as- si>t;iut surgeons attached t«> regiments, the mili- tary hospital -lath which is a rery numerous « > i j * -. consists <>f medical inspectors or head sur- geons «>!' infirmaries, stall' Burgeons of the first • •las-, with senior and junior assistants — the num- ber detailed for special hospital duty depending npon the size of the institution ami the num- ber of it- inmate.-. The mosl thorough medical organization in Europe belongs to the Prussian service, ami is composed as follow Kaeh battalion of one thousand men has a sur- geon and assistaiil surgeon, who are thoroughly instructed in the duties which they are expected to perform. Besides these, there is to every <<s d'armSt of thirty thousand men. a -tali' of forty LITTER CARRIERS. 1(17 surgeons, who, in time of war, take eharge of the genera] military hospitals opened for the re- ception of the sick and wounded. This division li;is also attached to its medical department three infirmary stalls for light field service, composed of eleven surgeons each. These act as a reserve on tlio battle field, opening field infirmaries which follow the troops, and give the first aid and dress- ing in the wounded. This gives a proportion of nine surgeons to every two thousand men ; and, notwithstanding this large number, there are periods when even a larger number of sur- geons would not he sufficiently numerous to give proper and immediate assistance to the wounded. In most European armies the dispensing of medicines is performed by apothecaries, who com- plete the medical organization. In the English and American service, the assistant surgeon or hospital steward acts as apothecary. In recent European campaigns, a very impor- tant addition has been made to the surgical ser- vice It is the semtiary <-<>r/>s, or carriers of the wounded. Heretofore, when men were shot down from the ranks, they were borne t<> the back by their comrades in alius, who transported them to the tield infirmaries, where the Burgeons attended to iheir wounds. Although a most praiseworthy L< - LITTER CARRIERS. act of devotion to a fallen friend, it was often called for when help could least be Bpared, as tlir taking away <>i' so many fighting-men from the ranks enfeebles the strength of the command, ami diverts the attention of the soldiers, if its demoralizing effeel docs not break u]> the corps. It is also well known, that if any from the ranks are drawn from the fight to carry off the wounded, they never return until the fight is over, and thus three are lost to the company instead of the one wounded. Besides, with the very best intentions. these comrades are not instructed how to carry the wounded so that thev should suffer least det- riment, and the final result cannot he hut inju- rious to the wounded. The sanitary corps, which now forms a very essential part of continental armies, and has been Strongly recommended to the English service by the surgical staff of the army, is a regularly organized body, who are taught how to carry wounded men. These prac- ticed hands are under military discipline, with officers whose duty it is i<> s,.,. that the wounded are promptly and carefully removed from the places where they fall to tin- infirmaries. There are surgeons connected with the salu- tary corps to attend to the judicious transpor- tation. They only offer temporary assistance. LITTER. CARRIERS. 109 Should there be fearful hemorrhage, they may apply a tourniquet, or show tlie assistants how to Compress, effectually, the bleeding vessel: if a chest wound, they may ;i! once open a vein to prevent the soldier dying in transit. They ar- range broken Limbs so as to he conveyed with most comfort, and give a dose of morphine when ranch suffering is felt, hut beyond this tempo- rary assistance they never go. This sanitary corps, with litters, ambulance wagons, pack- horses, ami all other facilities for transporting wounded men, should he in the advance, imme- diately behind the troops, when the battle is going on. Their post is one of risk as well as of responsibility; for, not unfrequently, they lose their lives in accomplishing their benevolent tasks. Both humanity, civilization and economy dictate that a similar corps should he appended to every army in the held. When not wanted on the hat- tie field, experience makes them careful nurses for the sick and wounded. The French organization,* which may serve as a model for the formation of a hospital corps, is as follows: One captain, one subaltern, one ser- geant-major, one pay sergeant, five sergeants, or * Article Ambulance Costello's Cyclopedia of Practical Snrgery. Hi 4 i upper ward-masters when in hospital, ten corpo- rals or tractor ward-masters, two buglers (indis- pensable for Bounding halts and advance in the transport <>f tin* wounded i. ninctv->i\ | » i i \ ;i! . orderlies, one tailor, one shoemaker, one cutler (a Tii* ► — i lawful artisan t<> keep surgical instruments in repair), < >n« ■ carpenter, four cooks. \Vheu earn* ployed in hospital, these are distributed in tin- proportion of one ward-master for every hundred patient-, ami one orderly for every twelve. The wagons and cars will alse be trader the command of their proper officers; noncommissioned officers, with wheelwright, farriers, saddlers, etc., arc also to be attached to the corps. When on a march, should there be ■ deficiency of transport wagons, the ambulance wagons carry the hospital stores^ also the packs a€ weak men not requiring trans- portation; they also pick np such men as arc not able to proceed with their companies, or those uh<> are compelled bo fall out of the ranks from indisposition. When troops on ■ march arrive at i place where good water can be obtained, the hospital corps should till their canteens for the use of the sick. When the troops arc bivou- acked, the bospttaJ corps should be employed in throwing up huts, or in establishing tempo- rary hospitals in an\ adjoining buildings, and in PRT'SSIAX MKIUCAL OROANI/ATION. Ill preparing some light food for the sick -which they have brought in. The following is the course pursued />// t/<< Hussion medfcal corps of <> division of thirty thousand nun when going into battle: The reserve corps of forty surgeons establish a general hospital at sonic sale and convenient point, four or five miles from the battle field. Here all the appliances are 'concen- trated for giving proper attention to the injured, and most of the serious and tedious operations are to be performed, under judicious consultation. As this is the resting-place from the field, accom- modations must he ample: every facility for t resting successfully the seriously wounded must, therefore, he found, and all hospital stores should be concentrated at this hospital. Directly behind the line of battle, and mov- able with it, are placed the light field infirm- aries, with their special staff's. They are the way stations for medical service, as all the wounded pass through these on their way to the general hospital. At these field infirmaries, the wounded receive the first thorough examination. and many operations deemed imperative are here performed. All wounds are here cleansed, for- eign bodies Oi every kind extracted, hemorrhage controlled, and the first proper dressing applied. 1 U HUM. ORGANIZATION. ne wounded are brought bo this point as they are shot down, their wounds have undergone bo1 Little change; the system is -till Buffering tr.Hii m eertain amount of nervoua Bhock, which makes it the proper time for effecting ;i thorough examination without giving pain. In these, as in the general hospital, there is always s division of labor, and each surgeon, knowing his duty, accomplishes the greatest amount of work in his special department The division always recognized, is the txammir y the operator, and the dresser. Those who are most skilled in these various departments are expected v.- ill.- benefit of their *kill and experience to the wounded. More importance is placed upon these subdivisions of labor than we would, at lir>i sight, recognize. It is well known that many hands can be efficiently worked by one head, and that when a Burgeon of much expe- rience .uid mature judgment determines what course should !»<• pursued, then' arc many com- petent to carry out bis suggestions, who were not sufficiently prepared t»> establish a thorough diagnosis ami foresee the probable i>>uc. The importance of examining a wound as sel- dom a- possible being acknowledged, it is easy to understand why tin- most proficient Buxgeoua BRD&SfAK MEDICAL ORGANIZATION. 113 in the service should be appointed, as diagnos- ticians, to examine, thoroughly, the wounded, and determine upon a course of treatment. In gunshot wounds, above all others, the necessity for accurate diagnosis becomes imperative, and this first examination should never be slurred over, however urgent the demands upon the sur- geon's time. Except m very obscure cases, a second examination should never be made, as it always gives pain, increases irritability, heightens inflammation and permits air to gain access to the very depth of the wound, which is sure to promote the de- composition of the exudates around the wound, with its suppurative and sloughing sequelae. Many a Unib and Ufe would in' preserved wen it possible to initti the examination of thu wounded to //>< field in- jbrmary. Let it be remembered, that the first examination is always less painful and dangerous than any subsequent one. All surgeons agree upon the success of primary operations, when compared to secondary, after inflammation has set in. How lo proceed or what wounds to con- demn requires nice discrimination, hence the necessity of devoting the talent and experience <>i the staff to this very important duty. In the Prussian service, tie' regimental surgeons oncentrated in groups' with their, assistants, lo 1U I'KI ssiAN MKDIC'AL OROANIZAXIOMj rather than follow their respective regiments into i 1m- tin-. Thus, much time Lb saved ami the wounded receive more attention; and keeping tlicin together in this way, renders it easy to command medical service wheu it may be needed for any special extra doty. This, of course, does not prevent Burgeous being sent to various points of the line, to assist the medical portion of the sanitary corps in the proper transportation of the wounded.* In tin smu, service, the primary dressings fur ikt wounded an carried bg each soldier, so thai all -arv bandages are on the spot, and no time is lo.-t waiting for the bandage boxes or boa* pita! stores. The general plan adopted by the • •utile army is as follows: Every soldier oath rifs a small package, three inches Long and one inch thick, which contains the following articles, vi«: two pieces of old, soft, clean linen, nine inches Bquare; a piece of oiled silk or india- rubber tissue, nine inches Long by five inches wide; a small ball of lint; a t)andage two and a half yards long and two inches in width. One piece of ih,. linen i> folded double and rolled tightlj over the lint, and over this the piees o£ oiled silk is rolled, the bandage rolled around * I,c The surgeon makes requisitions in dupli- cate upon the medical purveyor for all medical and hospital supplies, and receipts in duplicate for the same t<» the Surgeon -General. When soldiers are discharged, as cured, from the hos- pital, or die, or are furloughcd or discharged 1J(I i.l'i IK- ... \ H"r which require consultation or arc seriously threatened. As the sick in all hospitals arc uol able to consume the ample BUppl-J of food which the (iovern- mciit recognizes as a ration, and which is is- sued to all soldiers, whether well or sick, the surgeon should direct the steward to draw from the commissary only such quantities as are v^- quired for the hospital, and to commute in money for the stores nol drawn. 'This surplus forma a Hospital Kami, an account of which the on keeps, and which can I xpeuded for comforts for the sick, botli as regards subsist- ('AMI- DUTIES OF A REGIMENTAL SIKOF.OX. 121 ence of hospital furniture. The condition of this fond is transmitted, quarterly, to the Sur- evon-tJeneral. ("amp Duties of a Regimental 8tjiw*e0W. — We have already shown that the tiro of an enemy never decimates an opposing arm v. Disease is the fell destroyer of armies, and stalks at all times through encampments: Whore shot has destroyed ils hundreds, insidious diseases, with their lone; train of symptoms, and quiet, noise- less progress, sweep away their ten thousands. To keep an army in health is, then, even more important than to enre wounds from the battle fields. But, as surgeons in the service are ex- pected to he skilled in both departments, so that, in either case, the troops under their care miirht suiter no detriment, they should he thor- oughly prepared for the very responsible posi- tions which they till. Conservative surgery re- quires much more at the hands of the surgeon than the destructive practice of former times. Every surgeon should now prepare himself for the field, by familiarizing himself with opera- tive Borgery. Halt' knowledge leads into med- dling, which is far worse than no surgical as- sistance. Many a wounded soldier has felt heavily 11 . \\ii' hi I IK« <>y A KKUJ Mh.\ i \l. -1 RUJ I8y luuid of tl<< willing surgeon who lacked il-> g head. 1 'In- surgeon has charge of a num- ber of very valuable lives, aud the necessity im- posed — by th>- absence <»i consulting :ii»l — o£ deciding the most serious ami critical upon uia own unaided judgment demands, upon part, self-reliance, which ran oulv be baaed upon previous preparation. Camp life gives a ..ii much food for thought ami ample per* -.■mil experience, 1 m t gives him no time to con- sult authors and improve himself with books, 1 1, does not i great a variety of disease - ati are uiet with iu civil practice, but he has a wider tield for observing the influences <>i ex- ternal modifying circumstances — as exposure, im- proper food, imperfect clothing, irregular work, want of cleanliness, and depressing or exhilarat- ing mental influences. Tim diseases of a soU dier, Like those of most trades, are peculiar — each trade begetting its own, whilst it gives immunity to others, The greater unilbrmity in constitution, modes of living, exposure t<> similar external influences, and strut discipline, modify, to a considerable extent, the diseases of camp. Ii i> especially the crowding together, with the animal emanations from such a num- • >t' living hciugs, that gives character t<> the ph.i •• -t 'Ii c'AMI' T»I [IKS OF A RKOIMKXTAI, SURGEON. 123 The preservation of the heaUh of the soldier being ih, sale (hit;/ <>f the imUkiry surgeon^ he will he expected to nee every means within his reach to attain this desirable end. and more especially by a rigid observance of those forms of discipline and economy which arc under the direction and surveillance of the military officers. As diseases will arise among troops, and. as very few of these cannot he arrested by means of art when skil- fuily applied at an early period, care should he taken that medical skill he promptly resorted to at the very first sign of indisposition. Hygiene must first claim his attention: under the adage, "prevention is better than cure." W the troops are about going into eamp, lie must examine the ground and see whether any causes exist for rendering the place insalubrious. When in a friendly country, he should seek information from the local physicians, which will not only give him a better insight into the sanitary condition of the point selected, but will also instruct him upon the diseases prevalent in the locality, and the means which local experience and observa- tion have proved most effective in controlling such diseases. He must see that the troops in camp are supplied with ^\vy straw tor beds, and that the? air the same with their tent dailv. so 1 I CAMP Dl - A RKUIMENTAL SUROEON. ensure ;i healthy place for repose, and re- port any iHLfl«t' good water, and, from time to time should BUggest to tin' commanding officer such changes in the diet as will In- conducive to the health of the command. It' the water is bad, lie should study how it can be improved, so as not to act injuriously upon the men. Cleanliness id" the encampment and of the tent, with frequent ablutions of the body and clothing of soldiers, should never he absent from his thoughts. He should point out to the commanding officer all nuisances which promise to he detrimental to the health of the corps, and xirgt their removal — suggesting how they can best he disposed of. Much of the sickness in the army eai be attributed to a dereliction of this duty upon the part of the medical officer. The hospital tents will he pitched upon a dry. well-drained spot, if a building cannot he ob- taincd for the same, and it is the duly of the regimental surgeon to attend to the proper fur- nishing of the same with all possible conveni- ences for the STck. lie will enforce all proper hospital regulations to promote health and \ \a\ to the hospital. Convalescents, <>n coming oat <>t' the hospital, •re not to be put on duty till the surgeon certt- tie< i.i the commanding officer that they have perfectly recovered : tor which purpose it i> tin' duty of the surgeon to make, daily, a particular inspection <»!' these men, at morning parades '" prevent any remaining longer exempt from duty than ilif state of their health renders absolutely necessary. Alter the Burgeon's call, he will make a morning report of all the BJck and disabled to the commanding officer. lie also recommends that leave of absence he granted, on furlough, to those convalescents who will recover more rapidly by change of scene and life; or discharges for those whom experience has proved physically unlit ldr the arduous duties of camp lite. The senior medical officer of a post, hospital, regiment, or detachment, will make monthly to the medical director, and quarterly to the sear* 'ii-^eiieral. a report of the sick and wounded, of deaths, and certificates granted for discharge from disability, and transmit to him the same, with n statement of the hospital fund. lie will ;d-o keep the following records, from which the condensed report to the superior medical officer CAMP DUTIES OF A REGIMENTAL SURGEON. ll'T is drawn, viz : a register of patients ; a proscrip- tion book; a diet book; a case book: copies of his requisitions-; annual returns, and reports of sick and wounded, and an order and letter book, in which will he transcribed all orders and let- ters relating to his duties. All requisitions for hospital and medical stores must come from the senior Burgeon, with the approval of tlie com- manding officer, certifying that the same are ne- cessary for the sick, and that the requisition conforms strictly to the supply table tor field service. These requisitions are drawn out by the surgeon in the proper form, always in dupli- cate, stating what medicines are on hand, and are sent to the Medical Director, or, should there be no one acting in his district, to the Burgeon-General. All stores received from the medical purveyor must be receipted for in dupli- cate to the Surgeon-General, by the senior siir- u'con, who also notifies the medical purveyor of their reception. The duties of //>< assistant sturgeon are very simi- lar, in many respects, to those of the surgeon. If he has the confidence <>f the regimental surgeon, the patients arc equally divided between them: be treating a certain number of sick ordinarily f'AMP II TIK> OF A HKiiniCNTAI. STROKOX. without interference from the senior Burgeon, ex- cept they be serious cases, when be seeks advice from the regimental surgeon. Although this is the common course pursued, it is not so from right, 1-ut by suffierance of the senior surgeon. In the army regulations the senior surgeon being the superior officer, the assistant surgeon is under liis control. lie is supposed to do merely the medical duties when the surgeon is present — that is to say, making up medicines, seeing that the patients get them at the proper time, apply dress- ings, bandage fractured limbs, keep the register, diet and prescription hooks, and assist in com- piling the monthly and quarterly returns* When a Attachment is sent oil' upon special service, the assistant surgeon accompanies it as medical officer. When epidemics occur in camp, then the du- ties of the medical officers become very arduous ; the daily and nightly toil which they are com- pelled to undergo, the fatigue of body and anxiety of mind which is their daily routine, soon breaks 1 hem down, and many an over-zealous surgeon becomes a prey to the diseases which his con- stunt efforts are trying to subdue in others. This is particularly the case when typhus is raging in camp: when a neglect of those hygienic precau- CAMP DUTIES (IF A I!K(!1MI'NTAI, SURfiEONF. 12fl tions which the medical officers are instilling into the men, causes many a victim in the medi- cal ranks. Under such conditions, it becomes as imperatively the duty oY the surgeons to take care of themselves as to attend to the sick: for, should they needlessly sacrifice their lives, they entail severe suffering on their regiments. The Crimean surgeons were severely censured, after spending all day in the typhus and cholera hos- pitals, with their tainted atmospheres, for re- maining there during the night also, when there was no necessity tor it. It was a useless and dangerous imprudence, an exaggeration of duty, which deprives the army of well-informed men, and impairs the utility of the service. In the Crimea, the surgeons would frequently meet together lor scientific conference and for mutual instruction. Hate each gave his expe- rience, and compared the results o\' different methods of treatment. Their meetings always terminated in practicing amputations, resections, and the ligation of arteries on the dead subject. 'flic object of this was not Only to gain dexterity in the operative manual, hut also to find out who were the most skilled, and. therefore, most worthy of being intrusted with important du- ties. It is said that the mortality of the armv 1"0 DUTI is. N P. A TTI.i. I! Ill' amounted t-> two hundred per day, which wave ample materia) for such practice. These meet- ing, vi ere presided over by one of the highest -i.iil' surgeons or medical directors, who would often deliver to the society practical lectures upon the treatment <>f gunshot wounds. This plan might be carried out in all armies, as it musl redound to the benefit of both surge and patients. I > ; ! I i : - if the tight. The early booming of cannon braces all for ac- tion; all thoughts of fear <>r self are now dis- carded, the demon of war rules triumphantly ^ over the assembled host, aud suppresses, through for blood and desire for victory, all de- DUTIES OF SURGEON ON BATTLE FIELD. 131 pressing influences. There is something in the smell dt" gunpowder which makes men forget their origin; by its magic spell women are made brave, and cowards heroes. In the eagerness of the fray, an intoxication guides all to acts of daring. Who, in his sober moments, would walk no to the mouth of a loaded cannon to which a torch is being applied ': Yet, on* the battle field find the man who, at the word of command, ami whilst under the stimulating in- toxication from gunpowder, would not face cer- tain destruction ! Fortunate it is that nature has so constituted us, or the terror of pursuing what duty dictates would be agonizing indeed. The surgeon on the battle field must participate in the dangers, without the stimulation of the con- flict: he requires, therefore, a double proportion of courage to sustain him in the trying part which he has to perform. Upon the eve of a battle, the regimental sur- geon has much to do to prepare facilities for the treatment of the wounded. lie must see that the hospital stores are brought up with the ammunition wagons — as the articles for treating ihc wounded and saving the life of comrades, are fully as important as those for the destruc- tion of the euemy, lb' examines his store-, and 132 DUTIES OF SURGEON ON HAITI. I FIELD. himself thai nothing which will be iv- quired for the wounded has been omitted or for- gotten, lie examines his instruments, his supply of bandages, lint,* india-i'ubber cloth, or oiled or • I -ilk, etc: the rale m 1 « »] >t *•< 1 in European armies being to haw ready dressings for one- tilth of ihf command going into action. Ho thai chloroform and opium, the main sup- of the wounded, are at hand in sufficient ijuantitv. Water he has nol overlooked, M abundant supply will be needed to meet the incessant, ii 1 1 1 ii i t i gat ed thirst <'t' the wounded. lie ihonld be well sup]. lied with astringent baa been used in military surgery, Crimea i- I substitute for lint l>y as, with whom an abundance of lint it «••» in tin' rands. \- ii can be .-" easily obtained m .lu\ pari oj i li> Confedera and al bo trifling a cost, it promisee Bpecdily t" usurp the place of the officinal preparation. .\"« thai tents and meehea are scarcely aeed, and receptacles lb» I in d .1 surgical practice, wo reason why carded cotton, with its pi would i :: ih in lint, whi< mi med ard Lb roads, whioh would leave their mark- upon a .-v\>- a flamed surface, and, therefore, must be the unrecognized cause 'in. , in bis work, "Bandagea i appareil k pansoment," after thai the a i ha 1 been I with- in atmei t "i woun -i 1*1 lie tor, thai fur from being lnutful, t, loft, to clean, bo t infple, bo abundant, sd, is the roi for protecting part's from pressure, and oalittag the | re- in.- of tin apparatus, tliis is the preferable DUTIES <>F SURGEON ON BATTLE FIELD. 133 which the per chloride or per sulphate of iron is the best to control annoying hemorrhage. He should also have a moderate supply of brandy to revive those exhausted from hemor- rhage, oil to grease their wounds; and a little tea. sugar, ami such medical comforts as will refresh and support the wounded. Having selected from the general stock those articles which he will need, such as all articles for dressing, as cotton, lint, cloth, bandages, oiled silk, sponges, ligatures, adhesive plaster, splints tor treating all varieties of fractures, am- putating and dressing instruments, with medi- article for many reasons. Now for the dressing wounds lint is used; ii is thought soft and soothing to the raw surface — how much better, on this very account, is ootton over the Buesl lint. If cotton is used, ami its claims recognized as an Application to the raw, inflamed, sensitive surface of a barn, with how much more reason could ii be applied to the comparatively healthy surface of a wound. The best lint i< obtained by scratching doth until it yields a sofl down, which, when obtained, is nothing but raw ootton, viz: reducing the oloth to its primitive element. Hereafter, there ■will not be that demand for lint as heretofore; ami in limos of war, the female population of a country will not be called upon to use all of their exertions in scraping lint from rags, many of which :iiv :i .1 v contain the germs of disease, when :niy number of bales ■ i lint i : 1 1 1 be obtained al ence, and at little expense, and without trouble. Female labor can l>o more profitably employed. Much can also he said of new cloth versus the old linen, of timp- d reputation. Suffice it to say, in this connection, that an army should •ever clog its movements bj an excess of baggage, and that the old linen (which ean be osed but onoe) required for an army is no Bmall item. New cloth can be washed a doccn time«, if repaired, wliieli in Itself i recommendation. ]:: | pan mi oines and stimuli, and a fall Bupply of good water, they are carefully put upon ;i pack-mule in two strong, iron-bound boxes, catted panniers. oiH- hanging on either side of the saddle One i- usually devoted to medicines, the other is used for dressing apparatus. 'Phis distribution Lrivoa the surgeon greal facility in moving about the field to where his services may be moel re- quired, whilst it dispenses with the hospital store wagon, which is altogether too cumbersome to follow light troops in their varied and active movements. In European armies every regiment has such a pannier, w 1 1 i . 1 1 is continually resup- plied from the medical store wagons. The com- manding general may sometimes have good rea- sons, under particular circumstances, for orderiug ihe medical wagons to remain behind with the baggage : then the conveyance of all needful medical supplies for the wounded on packvhorses, becomes imperatn e. panniers are sometimes objected to on ac- count of their >i/e. and as modern surgery re- cognises bul few medicines as really necessary on the field, lighl leather wat erproof eases, which are earried by an orderly, are found preferable. A LTeat convenience to the surgeon^ is the mod- ern addition of a hospital knapsack to his equip- HOSPITAL KNAPSACK. 131 meats, which enables hw orderly to carry con* venientiy, tor immediate nsi\ the 1 mm v articles -which attendance upon the sick require. The hospital knapsack in use in the Federal army is made of basket-work, about three times the size of an ordinary army knapsack. The divis- ions in its interior, which are entered from the side, contain tin cans for drugs. The knapsack when empty weighs six pounds, and when filled with the following ingredients, eighteen pounds* The contents are as follows: Castor oil, 1 <{t.; simple cerate, 1 11).: chloroform, 4 oz.: fluid extract of ipecac, 4 oz.; conip. cathartic pills, 4 doz.: blue pills (5 grains each), 2 doz.: opium pills (I grain each), 2 doz.: comp. opium pills (opium 1 grain, camphor - grains), 4 doz.: .: sponge. 2 pieces; fandages, 4 doz.; Ilannel, 2 yt\*.; hinders' hoards, No. 4.; field tourniquet, 1; lead pencils, 2 ; note paper, 1 qr.; paper pins, 1 : tape, I piece. In making the daily rounds of the sick in camp, wh&U they are scattered in their tents and HOSPITAL KJ qoI concentrated within an kospital enclosure, fcbis knapsack with contents, carried by an orderly or the hospital steward of the regiment, will sarve mack delay and trouble in the dispensing of drugs. When carried on the battle field many articles may be dispensed with, and in their stead the knapsack should contain lint, bandages, adhesive plaster, sponges, and a bottle of sweet oil, with pins and tape, for the dressing of wounds, a bottle of the per chloride of iron for controlling hemorrhage, field tourinquets, ■ hot- tic of morphine for allaying pain, chloroform, should an urgent case demand an immediate operation to save lite, and a quart br more of brandy; — also eandles and matches, which are in- disp< nsable, as no efficient aid can be given to the wounded upon the field after darkness Bete in. without them. The orderly, who carries the knapsack, also carries suspended to his person a large canteen, three times the ordinary size, tilled with water, and also a tin cup. The knap- sack should he so arranged that all the contents will he exposed to view without unpacking. The mi.' which has hecn issued to the Confed- erate army is framed similarly to ihe ordinary knap-ack. hut larger, being sixteen inches hum - , fourteen inches wide, and six inches deep. The DUTIES OF SURC.EON ON » ATT LB FIELD. 1H7 interior is divided by wooden partitions, into four compartments, with a broad band of leather lacked across the lower portion of the enclosure to prevent the contents from dropping out. A leather apron, similar to that of an ordinary knapsack, covers the front of the knapsack. The frame is surmounted by a horseman's valise, which is convenient for carrying large bottles, dressings, and instruments. Assistant surgeons should carry a small leather haversack, with a Hap cover, to button for security. This will contain his pocket instruments, torsion forcepts, light dressings, pins, sponges, etc. If the krmy would adopt those regulations of the Prussian service, which compel every soldier going into battle to carry in his knapsack a small bundle of dressings, prepared according to a formula, then the hospital stores could in a great measure be dispensed with, and with few additions to the individual stock, the wound- ed could receive careful dressing. The instru- ments and few medicines which the infirmary would require, could then be readily moved troiii place to place, following the line as the din of battle recedes from the points where the tight had commenced. The surgeon should examine the means of 12 138 amiii i.am'k ooaPi transporting the wounded from where they tall t" the field infirmary. These should consist of at least two stretchers for every one hundred men engaged, although in European armies four are allowed to each company, besides light am- bulance wagons, spring carts, or any other con- veyance of transportation, bo accommodate in the proportion of forty persons for every one thousand troops. The allowance of ambulaucea in the Confederate service, is for twenty lying and twenty Bitting per our thousand men. As there is no distinct organization <>t' an ambu- lance corps, but ten litters are issued to each regiment, the carriers being taken from the rank-. The character of the transport service will de- pend upon the character of the country in which the war is carried on. In a level country, wag- ons are the most serviceable, whilst in hilly localities, litters carried by mules would lie the most comfortable transportation for the wounded. In European armies, a distinct body of men are employed for conveying the wounded, so that practiced hands may soothe the agonies of trans- portation. This is by far the most humane course, ami a< a mark of civilized warfare should he of universal adoption. It is highly important DUTIES OF SURGEON ON BATTLE FIELD. 139 that a similar body be instructed to act as nurses as well as attend immediately upon tlic wounded, as this timely assistance may save many lives on the field. In those armies in which this amlm- lanee corps has not yet heeii introduced, the regimental quartermaster in charge of the pio- neers and musicians, form a temporary body o\' earners. Besides the litters, each bearer carries a canteen full of water, and the assistant sur- geon, who follows the litters and directs the transportation, is accompanied by two men as orderlies. One of these orderlies who habitually follows the medical officer, whether in hattle or on the march, carries the hospital knapsack. One of the orderlies is armed to protect the party against stragglers and marauders. The surgeon, for a similar reason, should he also armed with a revolver. The orderlies assist the surgeon in niacins the wounded carefully in the wagons; and also following them, are at hand to assist in unloading the wagons at the field infirmary. When the troops deploy or form for action, the surgeons, with their assistants and pack- horses, move a short distance to the rear out o|' the range of the shot, and they establish there the tield infirmary. It would he convenient if 140 DUTIES OF SURGEON ON BATTLE FIEI.D. some house could be used for this temporary hospital. WTiere this cannot be had, the shade of trees or the shelter of :i bill-side, will answer the temporary wants of the Burgeon. If the body of troops about entering into battle is a large one, with an extended line, several of these points should he selected and marked l>v a suitahle yel- low Sag, which designates the spot where those slightly wounded ean seek surgical aid. These Locations should he selected as near as possible to the line of battle, so that they may he easily reached by the wounded. They should he readi- ly recognized, protected from the enemy's tire, well supplied with water, and, if possible, straw and shelter for the wounded. These sites should he known to the commanding officer, so that he mi-lit extend his orders to the infirmary, should it he necessary, daring the fight. Before the medical army stall' was properly Organized, and their plan of work studied so as to render the stall' most efficient, surgeons ac- companied the troops into the lire and took po- sition along the line of hatt'ic where they could give immediate succor to the wounded. Expe- rience Bhowed them that, thus isolated from each other, and taring no means of Dairying DUTIES OF SURGEON ON BATTLE FIELD. 141 ■with them the various instruments which they would require^ it was impossible to perform any but the most trivial operations, hence the neces- sity of assembling surgeons together at the va- rious field infirmaries, where, by assisting each other, all the necessary operations may be suc- cessfully undertaken. Instead of each regimen- tal surgeon establishing such for his regiment, it would be much better if they would concen- trate for individual assistance, when the wound- ed would receive more attention, and the work of dressing would be much expedited. When surgeons combine at the field infirma- ries, the usual course is to be operator and as- sistant in turn — relieving each other when fa- tigued. It would be far better, however, to es- tablish at once, if possible, a division of labor; let there be an understanding that those best adapted by experience to undertake certain du- ties, should confine themselves strictly to the same. When each one knows what roll he is to play, and does not interfere with others, a great deal more work can be accomplished than where each one acts independently for himself. The force of this will appear, when it is remem- bered that all experience shows the medical siatf of an army, however numerous, to be al- 142 ourres op buroeon on battlk field. ways boo few on battle days. Remember, thai nil tin wounded must undergo a thorough eramina- and ,ill needful operations must Ik -performed within twenty-four hours, or the wounded suffer from neglect. Now. take into consideration the very sinnll surgical staff of dot army and the accuracy of fire of the contestants, with the most approved and destructive anus with very long range, and we will immediately see the neces- sity of economizing time and labor. The movements and position of the troops and the character of the ground, must establish the necessity for the greater or less concentra- tion of surgeons at the field infirmaries. As the troops advance, they are followed by the hands- men or hearers, and. it' the country permits it, the ambulance wagons, under charge <>f the quartermaster and assistant Burgeon with his or- derlies. They station themselves in the rear of the advancing line, where they can distinctly see what happens, and remove immediately, with- out the range of the shot, those who may fall wounded. It is imperatively demanded, on the SCOre of humanity, that the wounded he re- moved from the field of battle, with as little d< ia\ ;.- possible, for early treatment. In gun- shot wounds, above all others, to obtain success, DUTIES OF SURGEON ON BATTLE FIELD. 14:} early surgical assistance is of the greatest mo- ment: ami in many, as in chest wounds, the omis- sions on the battle field immediately after the injurv is received are never made up, with what- soever diligence and skill the after-treatment is pursued. Therein is the great advantage of having a special transport corps, otherwise the excitement of battle or the eagerness of pursuit carries the line to a distance from the ground where the battle first commenced; and it is only after the victory is achieved that the wounded arc thought of by their comrades, who in scour- ing the held, find many a dear friend whose life has paid the forfeit o\' delay. The practice too frequent in our service of taking off" the surgeon of a regiment with a wounded officer, and leaving the remaining eight hundred or one thousand men exposed to fire without surgical aid. is an abuse of authority which cannot he too severely denounced ; and any officer should be severely censured who, from selfish motives, would allow his command to he thus exposed. Another act for censure, which should render a surgeon liable to court-martial for dereliction of duty, is in so \';n forgetting his position a- n> s/ssume the offensive, and enter pell niell into the fight. The temptation i< strong. 144 DUTIKS HI' SI K<;K<>N < • N liAlil.l llKI.n. bul among the ftrst lessons "I" :i military sm ■_ U that of self-restraint, and rigid attention to those duties which are connected with lii> posi* tion. His duties lie with the wounded, and no4 in the charge; the comfort, if n«>t the lives of many arc in his keeping, and all unnecessary exposure which be voluntarily incurs can but be detrimental t<> the service. When our troops remain in possession of the field, the enemy having fallen back, the surgeons should proceed to the front of the line, with all possible means of transportation, t<> collect the wounded; and n- most frequently night bat in before the enemy has yielded, torches should nrricd by the hospital or ambulance corps* to facilitate this important and humane search which i- tnn frequently neglected. When our army retreats and our wounded have i«> be left, soma of our surgeons should be left in attendance, and supplied with sufficient dress- ings, as no dependence should be placed upon the medical stores of the enemy, which may be exhausted <»r of an inferior quality. CHAPTER V. Tret ' tment of guftshot wounds — What should be done on the field by the assistant surgeon in command of the Utters — '/'/<< treatment at the field infirmary — Jffow wounds should be examined — Tht character of gunshot wounds — Orifices of entrance and exit — Primary fa morrhage — Qfatural ha matosis — Tourni- quets but seldom required in surgery — Jlmr hemor- rhage controlled — Examination of wound for foreign bodies should only be done inter, but that thoroughly a ad as soon as possible after the accident — The, his- tory of the case important — Lodging foreign bodies always give trouble, even years afh r injury — Gunshot wounds do not require dilation — Necessity of ex- amining the pulsation* of tJtc main artery below ihi wound for suspected injury — Ligation, of the, open mouths of the artery the rule of practice — Water-dressing tfa only rationed treatment of gun- shot wounds; its advantages over all other applica- tions — Secondary hemorrhage, how treated — General or constitutional treatment of gunshot wounds. As a soldier tails or is wounded in battle, lie is nt once approached by the assistanl surgeon, who looks at liis wounds, applies the hast} 146 Kll.il> BURGRRY WITH TllK TRANSPORTS. sing which they reqiiire, then piecing him comfortably on the Litter, attends to his trans- portation. 1I«' can d<> us iiukIi for the wounded in this way as if he were actively engaged in operating. Should liis injury permit him to walk, a compress ami bandage is placed upon liis wounds, it' they be severe, and he is directed to the field infirmary. In those with fractured limbs, a rapid glance, quick intelligence, and an inventive turn, at once tells the Burgeon what '- required, and suggests the means of effecting it. Witli a sword-blade, a ramrod, or a bayonet, with a handkerchief or Btrip <>f cloth, a fracture apparatus is at once improvised, and the thanks el' tin- wounded, pow in comparative comfort, are freely bestowed during his transportation to the infirmary or gene nil hospital. If he has a mangled limb, which hangs by a very small por- ti i' the Bofl parts, the separation should be at once effected by separating the dangling parts in the mangled tissues. Should he be suffering much pain, which is not usually the case, the eon gives him a powder of morphine, with wbicn his pockets are well stored, and at once transports him to the infirmary, where the proper amputation is performed. If the wound be an abdominal one, with protrusion of the intestines, FIELD SUROERY WITn THE TRANSPORTS. 14" lie sees whether the bowel is injured or not. If not injured, returns it. carefully within the abdo- men, and gives a Large (\o por- t i < > 1 1 of his duties. His province is solely to prepare the wonnded for successful transport* lion, and beyond tliis In- should not intrude hi- attentions. The grea( perfection <>i rifled weapens have their influence upon the duties of the field Burgeon) as the rapid and frequent changes of the battle held tin-eaten to control, within very narrow limits, field surgery proper, ami necessitate very hasty dressing. An eminent military surgeon — Mr. Guthrie — states that bandages, applied on the field of battle, are, in general, so many things feasted, as they become dirty and still', and are usually cut away and destroyed without having heen really useful. There is much truth in this statement. Much of the hasty dressing by the transport surgeon can very well he dispensed with. As he has neither the time, nor is it his duty to examine carefully the wounds, nio-t of tin' wounded mig&1 he sent directly on to the field infirmary without dressing. The dressings, when removed at the Held infirmary, are so soiled that they are thrown away. Time, which is so valuable, and also material, which is never in excess, hui most frequently deficient, can he Saved by adopting this course. Only in cases Fir.i.rt sri;/>< r probe, and is used on all oeca- 1.". I EXAMINATION OF WOUWD8. sions, with but rare exceptions'. It is an intelli- gent instrument, and, appreciating what it feels, it will not onlv discover the character of foreign bodies complicating the canal, but will avoid increasing the dangers by making new lesions in the depth of the wound. In fresh gunshot wounds, the apertures which the balls now used IB warfare make, are large enough to admit the linger when introduced with Cftre. \"erv rarely is it necessary to dilate a wound with the probe- pointed bistoury, to assist in its exploration. The .silfn- proh is a dangerous "ml deceptive vnMm- menl, and should be discarded, from the battie Jtetok Its use on such occasions, For exploring recent wounds, marks the novice. Halls are readily detected in a fresh wound, by placing the patient in the position in which he received the injury, if the direction from which the ball came be known. Portions of clothing and wadding are detected with greater difficulty!. Before, however, probing the wound for the de- tection of foreign bodies, be quite sure that the clothing of the soldier has been perforated. Often, a single orifice is seen leading into a limb without exit, which would at once BUggSsI an embedded ball ; when an examination of the clothing would show that the ball had driven EXAMINATION OF WOUNDS. 151 these into the wound, without sufficient force to transfix them, :ms Wound before the Wall. Tlie cap had been .-light- ly nit by the .-harp edge of bone from tin- pn ure of the ball. bu1 there was no openiug -ulli- cieiitly Large 1m permit ;i ball to pass. An earlier examination of the cap would nave robbed the ease <>l' much of its interest. When the shirt or drawers arc not Torn, no foreign body could have been Lodged in the flesh which they were covering. From the nature of fresh wounds, the examination and removal of all foreign bodies will l»e more easily accom- plished at an early period, and with less pain and danger to the wounded ; it should he done carefully, thoroughly, and without delay. A regular report is kept of all the cases dressed at the held infirmary, and a brief description of each ease is sent on with the patient to the gen- eral hospital ; so thai if proper, officers, in whose judgment the hospital stall' can confide, had pre- viously examined thoroughly the wound, and sent on their report, no further examination is needed. The pinning a card to the coat of the wounded, upon which is written the history of the wound, saves, time, pain ami trouble at the regular hos- pital. //' tht surgeon &< trustworthy, his diagnosis slniiihl h, respected, adopting this simple expedient. In many cases, this is the only examination which the wound will need. The neglect or insufficiency of the first examination is often the after-cause of the loss of a limb and even life. .After-examinations heighten irritation and inflammation in the wonnd, and, as they permit air (which ought to be rigorously excluded) to pass to the bottom of the wound, this promotes the decomposition of the extravasaled fluids and exudations, induees suppuration and sloughing, and predisposes to pyaemia, with its fatal sequelae. Many a limb and life would he preserved, if the examination of gunshot wounds could he limited to the hattle field : and military surgery will have attained great perfection, when a thorough diagnosis is obtained by tins first examination. The extent and nature of gunshot wounds are often ascertained at a glance. Touching a limb may lie sufficient to indicate to the experienced surgeon the extent and character of the wound and the appropriate treatment ; whilst other wounds, which appear trivial, as those in the neighborhood of, joints, may require all the skill and scrutiny of the most experienced to obtain a satisfactory diagnosis. >u> haste shonld he permitted in this examination, to the injury of l.".| imKSSINCI OF WOUNDS nN TIIK FIKLH. th<- wounded, through carelessness "t' diagnosis. Should large arteritis be injured, they should be ligated always in situ above and In-low the point injured, and fer this purpose the wound must be enlarged. As a general rale, torn tissues will reunite, whilst bruised, crushed tissues slough. All wounds in which a probability exists of union by the first intention, should be nicely adjusted by adhesive plaster. The great inconvenience of the ordinary diachylon plaster, which requires heat to make it adhere, must exclude it from field service. The Husband's, or isinglass plas- ter, is much more easily applied, requires no heat, a little moisture being all that is needed, is not injured by hot weather, and when closing a wound, gives as much support as the diachylon. It also excludes, completely, the air, with its injurious influences, which is not its least ad- vantage. Diachylon piaster is rather required for hospital practice, where it is used to dress suppurating wounds, from which the continued discharge of pus would loosen strips of isinglass plaster. Should a limb be so injured that joints are largely opened into, main blood-vessels and nerves torn through, soft parts extensively lacerated, or NERVOUS SHOCK. 165 a limli Hayed, then amputation should follow im- mediately the condemnation of the limit: field surgery here proves itself the only successful sur- gery, ;is all statistics dearly show. If the limh is simply fractured, even if comminuted, without injury to the main blood-vessels and nerves, and without complications with joint injuries, they should he considered simple fractures, and dressed as such at the tield infirmary. If, in eonneetion with a condemned limh, other mortal injuries exist, the impropriety of performing the amputa- tion is clearly seen. When joints are crushed, or the heads of hones perforated, resections are urgently demanded, and should he performed he- fore reaction takes place. It is, of course, understood that, although wounds might he examined, foreign bodies re- moved, and the wound, if simple, dressed whilst a soldier is suffering under shock, no serious Operation, which would still furlher depress the nervous powers or cause a further loss of hlood, should be performed until extreme depletion suhsides. Although the nervous shock accom- panies the most serious wounds, it may often he met with in the most trivial injuries. It is re- cognized by the sutferer becoming cold, taint and pale, with the surface hedewed with a cold MKVers SHOCK. sweat; the pulaM i> small and flickering; there is anxiety, mental depression, with, at times, in- coherence of speech. Often, this shock is rery transient when accompanying simple wounds. A drink of water and a few Bneonraging words may be sufficient to dispel it. When it persists, even where the injury appears trivial, it fane- bodes trouble; and a more careful examination may detect a fatal injury. It is the duration. more than the degree of shock, which marks the Mrioofi character of the wound; and when this oenstitutiona] alarm persists, there it greart tear that hidden mischief is lurking, and the surgeon should be very guarded in his opinion of the ease. Keeping the patient warm, ill the recumbent posture, with blankets and hot bot- tle-, administering wine, brandy, ammonia, harts* horn to the nostrils, frictions and eataplasms to the extremities, is the course pursued to restore nervous energy. In all painful operations, chloroform should be freely administered l<> produce the desired anaesthesia. Like nil valuable medicinal agents, whicli when taken in overdoses are poisons, it can remove suffering or destroy life according to dminislration. The dangers can he avoided l>\ never pushing its inhalation to stertorous REMOVAL TO TTIK GENERAL HOSPITAL. 157 breathing, but fey rtopping its xmrt as soon as insensibility is attained. The recent Crimean and Italian wars, in recording the advantages of chloroform in field surgery, show it to be now one of the indis|tensal»les for successful practice. It saves the lives o\' many wounded, who would perish from the shock of a second operation ; and also many who would have heen considered as without the pale of surgical art, can now, thanks to this invaluable remedy, he benefitted by surgery. In our country, railroads traverse everv por- tion of the states, and as battles usually occur in the immediate neighborhood of thoroughfares between large cities, it is not improbable that they will be found in the immediate vicinity of battle fields. If such be the case, a suflicient number of cars should be kept in readme* for the use ot the wounded. Transport wagons are in constant communication with the tield infir- maries. As the wounded are attended to, thev should not be allowed to accumulate around the infirmary, but be scut oft' at once to the nearest railroad station, from whence ihey will be dis- tributed in the towns nearest to the scene of action. General hospitals should have been pre- viously prepared in these localities for the iv- IJS REMOVAL TO THE GENERAL HOSPITAL. caption of the wounded: and here the regular treatment commenc 1 > u r i 1 1 u* : i general engagement, each field infir- mary should be in constant communication with t!ii- general temporary hospital which Hie med- ical director has located, and as soon as the. wounded are examined and dressed;, they should be sent without delay to this point This allows the field infirmary to change its position, and t<> follow the division to which it is attached. W this transportation of the wounded be property attended to, no wounded should he left by night at the field in tinnaries. Another advantage in not allowing an accu- mulation of wounded at field infirmaries, is in avoiding confusion, should there he a reverse of our arms, and an advance of the enemy upon the site of our field hospitals. Should the ambu- lance wagons not he sufficient to transport the wounded. wagons, carts, carriages, and, in fact, every species of vehicle, should be impressed from the neighboring inhabitants, so as to insure for the wounded a place of safety and comfort. If i; he convenient for the wounded to reach the genera] hospital within twenty-four hours from tie- reception Of their injuries, many serious Cases i'^r operation. Mich as the resections, might DKKSSINCJ OF WOUNDS ON THE FIELD. 159 well l>e deferred from the field infirmaries until the wounded have arrived at the station where that quiet and rest, with medical comforts, which arc so necessary for a successful resulf, can he obtained, "When the wounded are brought to the field infirmary, they are not attended to in the order in which they arrive. Those most seriously injured always receive the earliest at- tention, officers and soldiers awaiting their turn. If the trivial accidents had heen dressed upon the field, they could pass directly on toward the railroad or the general hospital, without stop- ping at the field infirmary. The common dressings which all wounds re- ceive is a wet cloth, covered with a piece of oiled silk or waxed cloth, and secured with a single turn of the roll of handage. This keeps the wound moist, and is the most soothing, comfortable, efficient and simple dressing which can he devised. By wetting the outer bandage, the cold produced by evaporation is transmitted through to the wound, whilst the oiled silk keeps the parts moist. When oiled or india- iuhhei- cloth cannot he obtained, and no facili- ties exist for keeping the wound constantly wet. whilst the patient is being transported to the gen- eral hospital, a eloto well greased with olive oil lOO REMOVAL To THE (IKNKKAl. HOSPITAL. is the best substitute for the wot dressings. Many ragged wounds may have their edges pared off and then brought together, with every prospect of a speedy uni<»n. provided tin- after-t '"''at nn'iit with cold dressings La judiciously followed. It is understood that all those who can he conveniently moved, should he transported at the earliest possible moment to general hospi- tals, established in contiguous towns. Should there be no facilities for this transportation, then any house, in the neighborhood contigu- ous to the battle held, must he used as a tem- porary hospital for the treatment of those se- riously wounded, whose safety depends upon absolute opiiet, rest and careful nurs'ino, or tents can he pitched for the temporary aeeommoda- tion of the wounded. Should the army advance, the regimental sur- geons must follow their commands, leaving either an assistant or an extra medical attendant for the wounded, it being presumed that a reserve medi- cal corps had been attached to the army for extra or reserved duty, when it was known at headquarters that a battle was expected. These Reserve surgeons will make every preparation for ihc comfort and aeeomniodation of the wound- ed. Should the army unfortunately meet with SIKiiKOXS LEFT WITH THF. WMTWnKTV ICil a reverse, all available means of transportation must lie pressed into the service for the re- moval of the wounded to the roar, and they must be sent off as Bpeedily as possible. If tins had been attended to from the commencement of the engagement, there would be fewer to move later in the day, when a retreat was compulsory. No wounded soldier, whose injuries are so slight that he can walk, should ever he carried, as he lakes up a place in the transport wagon which excludes one who cannot assist himself. There are many cases of injury to which long transportation would he certain death. If the general hospital cannot he conveniently reached, such cases must be treated at some farm-house .contiguous to the field of battle: and if troops are compelled to retreat, humanity dictates that the severely wounded should always be left to the enemy, with a sufficient number of competent surgeons to look after their wants. AVhcn left without surgeons, they are always neglected, and many lives may be sacrificed for want of that immediate attention which the enemy's surge, his musl first give to their own wounded, and which precious time can never be recovered. This becomes especially urgent where the nations at war speak different Languages. The rule uow 1 1 162 SURGEONS LEFT WITH Til!. \V(U NHKH. recognized in civilised warfare is, always to Leave competenl Burgeons witb the wounded who arc left to be cared for by the enemy. The following excellenl advice is offered by Dr. Millengen to Burgeons who may be placed in Buch trying conditions: " When surgeons are thus placed on duly with an euemy, they must bear in mind thai the welfare of our wounded will, in a great degree, depend upon the pro- priety of their conduct. No irritation <>i' mind from disappointment, no national feeling, should induct.' them t<> enter into unpleasant discussions. They should especially endeavor to cultivate a friendly intercourse with their medical brethren, carefully avoiding altercations on professional points, in which most probably they may differ. A deviation from this prudential course lias often proved the source of jealousies and ani- mosities, from which the wounded ultimately suffered. When the enemy's wounded are nu- merous, and their surgeons are not in siillicient numbers to attend to them, we should invariahly volunteer our assistance, should our duties afford us leisure. Such a line of conduct is ever ap- preciated, and cannot fail to lead to ultimate reciprocal advantages and good feeling."* \ , imbalance, in Costello't Cyclopoedia of Practical Surgery. APPEARANCE OF GUNSHOT WOUNDS. K>3 Al'PEARANCE OF GUNSHOT WOUNDS. — We have already stated that the more perfect and de- structive arms now in use in modern warfare, and the variety, form and size of missiles, have modified materially the symptoms and march of gunshot wounds. The conical shot, with its ex- cessive momentum, transfixes the tissues with great rapidity, and when only soft parts are in- volved, the crushing and bruising is by no means so extensive as with round ball. The entrance made by a conical hall in the skin is oval, and sometimes even linear, as if made by the point of a sabre. Usually, they pass directly through the soft parts, rarely burying themselves, and, when not impeded in their transit, there is but little difference between the two orifices of en- trance and exit. When the conical ball, enter- ing point foremost, and meeting some resistance in its course through the tissues, is either changed in form or is turned upon its side, the. orifice of exit is found very large, and irregularly torn, with the surrounding tissues much bruised. Round balls usually give an irregularly rounded entrance, surrounded by discolored, depressed tis- sues: these having been evidently mashed or crushed by the ball prior to its entrance. The ti.-sues around the orifice of cxil are usually more 164 Al'PEARAM'K SI Cl'NSlInT Worses. or less protruding and lacerated. These two orifices are, however, modified in appearance by s<> many circumstance* — the form, size, velocity and Dumber of the missiles; changes in the mis- sile after its entrance into the body and prior to its escape; the distance of the wounded person, his position, bis clothing, foreign bodies which may have been about his person, and driven before the hall, etc. — that in some cast's, without the history of the accident from the patient or Obese who saw the occurence, it would be diffi- cult to determine which opening was first made. The effects produced hv the action o[' the hall upon the two orifices can be easily understood when it is remembered that, in entering, the tissues, which arc being perforated, are support- ed by the entire thickness of the limh, so that often the hall carries before it a piece of flesh which it has cut out as hv a die, and hence the more or less rounded appearance of this open- ing. After traversing the limh, in making its exit, the tissues through which it is now pushing have no support, they are stretched inordinately before they are torn, hence the flap-like lacera- tions of this exit, with sometimes nothing more than a rent or split in the skin. All who are familiar with the driving of a nail through a APPEARANCE OF GUNSHOT WOUNDS. 166 beard, or firing at tlic sumo with a pistol, will see a rough working of this principle. These peculiarities are said to be so stamped upon the clothing, that often, by an examination of them alone, a diagnosis can be established. It is often of con sequence to determine the character of these apertures, so as to distin- guish between a traversed hall, with its two orifices, or two halls embedded. At the same time, it mnst not he forgotten that one hall may make several openings, by the hall being divided in the limb upon a sharp crest of bone. Such eases are not unusual where the round musket hall strikes. A half of the ball may pass out, a portion remaining behind. A single hall, by splitting in this way against some obstacle in the llesh. has been known to break into six pieces. each in exit making a corresponding wound. Conical balls show much less deviation than round halls. They usually take a straight course, ploughing through all opposing structures: noth- ing resists the penetrating force of these projec- tiles. They seldom follow the contour of bones, as the round often do. but at once crush them; their double weight and increased velocity mak- ing many more fractures than the round hall of former wars. lilt", \i;.\mi: Of i.i CT8H0X WOl NDS. In spite "t' 1 1 j * - rapid passage of evea conical balls, some of the tissues, through their toughness ami elasticity, escape direcl injury from them. Arteries come under this head. Owing to their peculiar structure, cylindrical form, and loose connections, Lying in a bed <>f very loose, cellu- lar tissue, which permits of considerable move- ment, they often escape transfixion, when their positiou lies evidently in the direct course of the ball. In 1859, during the Italian difficulties, and after the battles of Magenta and Soiferino, I saw several of the wounded in the hospitals at Milan, who had rec< ived such injuries aboul the rool of the neck, where balls had traversed in some cases antero-posteriorily, in others later- ally, going deeply through the soft parts, yef picking their way, as it were, with such care as to avoid the great vessels among which the mis- sile had channeled its course. So great is this power of avoiding perforation in the huge arte* , thai carely does death take place on the battle field from division of the huge vessels ^i' the extremities by bullets. When a ball strikes a limb fairly, at right angles, it produces the least injury to the tissue which it traverses; it forms a simple canal, which may heal with vcvy little suppuration or HEMORRHAOK IN CitfNSHOT WOUNDS. 1<>7 sloughing ; but when it strikes at an angle, particularly when the ball lias lost a part of ils momentum, it ploughs up the tissues frightfully, and extensive destruction follows. Although numerous cases are met with in which gunshot wounds have healed by the first intention, the surgeon must not look for such a happy result. With hut rare exceptions, suppu- ration w the rule, and he must he prepared to control its action, and the excessive reaction which, in most cases, would accompany it. A certain amount of hemorrhage always ac- companies gunshot wounds; hut, owing to the irregularity and the asperities of the sides of the wound favoring the clotting of blood, we usually find that the external flow soon ceases, whilst internal hemorrhage, to a limited extent, extravasatcs into the surrounding tissues. When the divided blood-yessels are so closed that the blood-cells can no longer escape, serous oozing still goes on infiltrating the tissues. These are the causes of the rapid swelling which follows gunshot wounds. Those arteries which are di- vided by a ball in rapid motion will bleed more than those injured by a slow or spent ball. The pain which accompanies the reception of gun-dint injuries is often so trivial, thai the HW IS \ i i i: \i. \i>\ \vr \<.i S it siimck. attention of the wounded is only called bo the fact by blood streaming down his legs. The majority liken the striking of a ball to a smart blow willi a sopple walking-cane, wnilsl with a few the pain is very Bevere, and simulates the feeling which would be produced by running a red-ho1 wire through the flesh. McLeod men- tions the case of an officer who had both of his lega carried away, and wlm only became aware of the injury which he had received when he attempted to rise. It appears thai every gunshot wound is ac- companied by a certain anionnt <>\' shock, or a partial paralysis of sensation, which is nature's preparation, permitting a thorough examination, with little or ho pain. The unusual quiel of a hospital the nighi following a battle has been repeatedly noticed, and is accounted for by this DervOUS shock. When this condition passes off, then reaction brings with it much suffering. In this nervOUfl shock, with the suspension of activity in the circulatory function, lies the safety of many a wounded soldier. Its influence is im- mediately felt in the injured tissues, and the in- filtration and engorgement of these are prevented. When nervous depression exists, hut little Mood escapes from the injured vessels, and as there is AVOID HASTY DRESSINGS. 169 no force from behind, owing to the diminished action of the heart, to drive on and keep in mo- tion this blood, its dotting is favored. When reaction ensues, the ciot is already so firmly established that it cannot be displaced; the in- jured vessels remain thoroughly and permanently plugged up, and the dangers from immediate hemorrhage arc prevented. Shock ma}* accom- pany a very slight injury, and may exhibit itself in the most courageous and intelligent, so thai it cannot always Ik' attributed to alarm. On the oilier hand, a very severe wound may be unac- companied by any perceptible agitation. As the wounded soldier is always clamorous of having his injuries attended to as early as pos- sible, and as experience teaches that all wounds, and above all others, gunshot wounds, are beuc- titrd by immediate dressing, they should be at- tended to mi the field of battle; then they give Lata trouble to the surgeon, less pain to the sol- dier, and much better iinal results in treatment. All hasty dressings or examinations are to be deprecated, and a methodical course pursued. The indications of treatment, in all gunshot wounds, arc, 1st. To control hemorrhage; 2d. To cleanse the wound by removing all foreign bodies. and, -"id. To apply BUcli dressings and pursue such L5 IT" 1 ARREST OF HEMORRHAGE. a rational course of treatment, as will establish rapid cicatrisation. Hemorrhage, which produce* such terror in tin' bystanders and anxiety iii the patient, should never unnerve the surgeon, who requires all <>f self-possession ami Bnrgical tad to cope suc- cessfully with this ebbing away of life. Fortun- ately, in gunshot wounds, serious hemorrhage is Ot' rare occurrence; and when the largest arteries are injured, as a rule they either cease bleedirig Spontaneously, or the patient dies so rapidly that art is of little avail. It' the case is not injuriously interfered with, the natural hemostatics will often control the bleeding. The ragged character of the wound, and ilie nervous Bhock accompanying the injury, or brought <>n by the loss of blood, r< acting upon the circulatory organs, so diminish the heart's impulse, and drives so little blood to the extremities, as to favor a stagnation of Mood in the wound. The formation of a clot plugs Up the orilice in a bleeding vessel, and stops any Further loss of blood. This sp&ntaneous arrest of hemorrhage is ustiaUy permanent; and, if the ordinary prophylactic course is pursued, of absolute rest and quiet. with the limb elevated and bandaged, no return shows itself. Should, on the contrary, meddle- ARREST OF HEMORRHAGE. 171 some surgery suggest the use of a tourniquet, which cuts off the circulation, and especially the venous return, the limb soon swells, tissues be- come engorged, excessive extravasation in the wound follows, and a train is laid for future mis- chief. The Held tourniquet, in former days, was so much in vogue that it was considered indis- pensable on the battle field, and was. therefor.', carried in large numbers, to be applied to every limb from which blood was trickling, or from which hemorrhage was feared. JSTow they are nearly discarded from field service, and recent experience recommends their abolition from the field, as doing more harm than good to the wounded. Unless very tightly applied, it is of no service, as it does not control the bleeding, and if firmly applied it acts as a general ligature around the extremity, and can be used but for a short time without injury to the limb. Kecent writers warn surgeons of the too hastv use of hemostatics, and suggest that it is better for the wounded to lose a little blood, which will diminish the heart's propulsive force, than have the wounded tissues tilled with extravasated blood. If the hemorrhage be free, immediately after the receipt of injury, the best mode of con- trolling it would be the application of a ball of 17"_' AKKKST <>F HKMORRII lint, a compress, Of sponge over tho wound, at- on red by a bandage, which, in clewing the outer orifice, favors ihe formation of a clot. It' the hemorrhage is at nil active, as from some large artery, in addition to the compress on the wound, tli.- entire limb should be carefully enveloped in :i bandage, to some distance above the injury, go that the pressure made upon the soft parts would diminish the amount of circulating fluid in the !iuil>. and prevent the ingress of blood into the tissues. The hemostatic properties of tlii- dressing can be increased by soaking the sponge, or compress covering the wound, with the per chloride or per sulphate of iron, which, a- a powerful astringent, when brought in contact with fresh blood, will immediately form a clot. The injection of a solution of the per chloride of iron into the wound, not asing force enough to infiltrate the tissues, is an excellent method of establishing a solid dot up to the very bleed- ing mouth of the injured vessel. A lump of ice placed upon the compress, will act with equal efficiency. A Bponge or compress, tied on the bleeding wound, with or without the iron styptic, is all thai the surgeon superintending the trans- portation of the Wounded is expected to i\n. Unless the hemorrhage is very violent, threat- ARREST OF HEMORRHAGE. 1 7^> on'nig immediate destruction of life, the tourni- quet is rarely required. All recent writers on military surgery recommend that field tourniquets be dispensed with, as they are generally a useless, and often, when carelessly used, a dangerous in- strument. The linger pressure of an intelligent assistant is better than any tourniquet ever made, and is a far preferable means of controlling ex- cessive hemorrhage, which the compress and bandage may tail to check. The femoral artery, for any injury to its trunk or large branches, should he compressed in the groin where it runs over the pubic bone ; the brachial, where it pul- sates against the head of the humerus, as at this point, its course is nearly subcutaneous. When the position of these main trunks are shown to any intelligent assistant, and he is made to recog- nize the throbbing oi' the artery, he will have no difficulty in keeping the vessel compressed dur- ing the transportation. A- soon as the wounded arrive at the tempo- rary resting-place, where the surgeons are assem- bled, all bandages are removed, and the wounds carefully examined. A glance at the wound. when the clothing bus been previously examined) will often tell, when there are two orifices differ- ing in appearance and in a direct line with each 17 1 use tiii: ri.NMiKR as: a im: other, whether foreign bodies haw lodged Of not. A> the patient is now taint from !<• l>lood and from nervous depression, the wound not yet liciiiL r painful or swollen, the his finger \ which is the only admissible /'/■<•/), <>,, suck thai the military surgeon of experient cognizes, examinee the entire extenl <>t' the wound. searching for foreign bodies, This examination is made without fear of re- producing hemorrhage, as the finger cannot dis- place ilie clots which hold firmly to the open- lag! in the resseh Every surgeon haa noticed haw rudely a etump might be ponged, and what force it requires to wipe away dots which have formed over the face of a smooth, incised, open wound. The adhesions are increased a hundred-fold by the irregularities of a concealed bullet track. The finger finds no difficulty in entering a hole through which a bullet has passed, if examined, as every wound should be, hei'ore Bwelli&g has taken place. In examining fresh wounds, a silver probe will travel in (he direction given bo it l>v the sur- geon.; and as most persons guide the probe -'//- stood <>f (iliniriiKj the -probe to guide them, the true course of a ball can only be determined by it with great difficulty. It is bul recently that I 1 SE THE F1NOER AS A PROBE. 175 saw a physician of experience, in seeking the course of a ball which had lodged in the thigh, apparently without effort, pass the probe among the muscles quite across the limb, so that, the bullet wound being on the outer side of the thigh, the end of the probe could be felt under the skin on its inner side. When the finger was introduced, it followed the track of the ball at a very oblique course from the one which the probe had taken. This example is suincieut to show why military surgeons denounce the silver probe, and distinguish by its use the tyro in surgical practice. In those cases only in which, from the small size of the orifice, the finger cannot .be introduced, is a bougie, a female catheter, or lastly, a silver probe used. The wound is examined from both sides, with the double object of finding foreign bodies which may have lodged, and seeing the proximity of the course of the ball to the main arteries of the limb. It is ;i matter ^l' great importance to de- termine the condition of large vessels, whether they be injured or not. by examining the degree of pulsation which they possess; as an injury would necessitate a very careful after-treatment to avoid secondary hemorrhage. In some cases the linger introduced into the 17'' r.SK THE KINfiKU As \ PR' opening, after pausing through the skin and cellular tissue, finds no further \>: This would indicate either that the ball had been drawn out with the removal of tin- clothing, or that tlir deep tissues, muscles and uponcui have changed their relations from the move- ments of the limb. The track of the ball can- not be discovered until the former relations of the parts be resumed by placing the limit in tin 1 same position in which it hat] received the shot, when the entire route of the hall will he perceived. The inexperienced, readily deceived by the little resistance met with in probing recent wounds, mistaking muscular interstices lor the traek of the ball, make several Raise passages in their search for the foreign body, and by their isolation or denudation of the parts, cause inflammation and add to the difficulties of fur- ther examination. When the finger, huried in the wound, shows that it is continued beyond reach, a bougie or silver catheter introduced carefully and without force, will often reach and delect 1 1 m • foreign body. Should hut one opening exist, and the cloth- ing of the soldier covering the wound be fcoru, the probability is, thai foreign bodies oompli- REMOVE ALL FOREIGN ROUTES. 177 cate 1 1 10 wound. It must be remembered that the bail, as a bard body, can usually be readily reeognized, but that portions of wadding or clothing may be easily mistaken for a clot of blood or the ragged lining of the wound. This is particularly die case when they become satu- rated with the secretions. Forewarned being forearmed, the surgeon, remembering these diffi- culties, will examine with special care for these soft, foreign complications. Wheta found they should he extracted, as their presence is certain to establish a high degree of inflammatory ex- citement, with profuse subsequent suppuration. This effect was well shown in the case of a private of the "2d Regiment of South Carolina Volunteers, who, during the attack on Fort Sumter, was shot by the accidental discharge of a musket. The ball entered the chest at the anteriof fold of the armpit, fractured the clavi- cle, and. after a course of nearly six inches, was stopped by the tough skin over the posterior portion of the shoulder. The ball was readily detected by the regimental surgeon, and, by an incision through the skin, was easily removed. Inflammation <>t a high grade followed. He was sent up to a city hospital one week after the accident, when he was losing from three to I7J III8Tni:\ OK CASK 1M1 four ounces of pus daily from the wound. * Mi the day after his admission, in examining the wound. I detected in the shoulder wound some substance resembling a slough, and upon extract- ing it. found a mas* of wadding over two incites long and as thick as the finger, which tent-like mass had been driven into the tissues by the hall. Kxamiiiatioii of his clothing now. for the oral time, showed the deficiency in .the liuiug of his coat, from which this mass had been torn. The removal of this irritant diminished the discharge immediately, so that, in the sue* ceeding twenty-tour hours, tin- discharge dimin- ished to .one-sixth it> former quantity, and in fottr dayi was hardly sullieieiii to soil the sing. The history of the case is of much import- ance in examining wounds. Often, the course of tlic hall cannot he discovered without it. What surgeon, however e-reat his experience* seeing a wound made in the arm by a hall, would think of looking in the opposite thigh for i t > place of lodgment, did he not learn that the injury was received from above, whilst mounting a scaling-ladder, with arms raised above the patient's head? The hall, entering the back of the arm near the elhow, pa HISTORY OF CASE IMPORTANT. 179 down the arm under the shoulder-blade, across the loin, and. traversing the buttock, lodged under the skin of the outer part of the op- posite thigh, where it was found, and removed Knowing- the direction from whence the ball came, and the position in which the soldier was placedj you know at once the course which the ball most probably took ; and .your examinations in that direction will not only save much time, l>ut sare the patient n. icfi suffering and annoy- ance. Often the play of a muscle will shut off the track of the hall. The relations of the soft p*fl£ vary with every position of the limb, and a passage made when a limb was tlexed, could not be followed when the same limit is extended. Hence the necessity of placing the limb in the same position in which it was when the injury was received. The -"(Mind having been carefully examined by the linger within and careful manipulations without, and the foreign body detected, it should be at once removed. This rule may nearly be considered absolute, as all military surgeons place great weight upon its accomplishment. 'Idie question is not so much whether balls can remain innocuous in the flesh, but do th<;j.' Those who have had experience in gunshot 180 I.MBKDTiED BALLS ALWAYS liAMiKltm - wounds iu tlio tit-Id, know how c\ccs.- ; \ -«• is the irritability caused by the presence of a ball in a wound: how restless ninl irritable the patient is until it is removed; how profuse the suppura- tion and prolonged the period of treatment in n which it has been left : and how frequently the after-consequences are so distress- in;r. the pain so permanent, and discharg constant, as to demand ftiture interference or make life a burden. If such be the case with a ball, liow much more urgently is the extrac- tion of other foreign bodies indicated, especial- ly fragments ol shell, portions of clothing, tte. It is only by carrying out this mosl urgent in- dication in the ciiiniiiciicciiicnt of the treatment, that a number of consecutive dangers, such as pain, inflammation, suppuration, gangrene, am* putations, and even death, can he avoided. Balls may, in time, become encysted, but the8e are exceptional cases; and even when such occur, their presence in after years may set n|i inflammation, which will mat together and 1 • i 1 1 < 1 down important parts, whose useful- depends upon freedom of motion. bte- peated a) may form, pressure upon hones may give rise to ulceration and a tedious exfo- liation, blood-vessels may ulcerate, nerves be EMBEDDED HALLS ALWAYS DANGEROUS. 181 painfully compressed, and life rendered misera- ble, it' not jeoparded. Notwithstanding what lias been written upon the innoeuons character of balls embedded in the flesh, for every in- stance in which halls have thus remained, with- out giving trouble, one hundred can be exhibited showing the great danger of foreign bodies in the living tissues. Bacon Larrey's experience showed that, as a rule, amputations are eventu- ally necessary, after years of suffering, in those eases in which balls have been left embedded in boues. These remarks are equally applicable to all foreign bodies, including spicuhe. In McLeod's Surgery of the Crimea, the re- port of M. Hutin, chief surgeon of the Hotel des Invalides, is given, which is a striking com- mentary in favor of the removal of all foreign bodies. He reports that, of four thousand cases examined by him, in which halls had remained embedded, only twelve men suffered no incon- venience; and the wounds of two hundred con- tinued to open and close, continually, till the foreign body was extracted. When no doubt exists that a foreign body complicates the wound, the surgeon should ne- ■ •li'ct no precaution to discover it. As a general rule, he will find the examination facilitated by exposing the entire limb. 1 V L' HOW n I \ lltACT HA II - [f the ball be fell loo*.- in fhe soft parte, a bullet forceps can be 1 * » : i< 1 « * to Beize it ; and it c:mi be extracted without difficulty, provided tfu hnn'l <>/ >he nurgvon support the titnb on tfu npp it i<> that "f which tl-< forceps ia u>- in,ihif t ,i : otherwise, the ball glides in front of the forceps and cannot be seised. The ordinary ballet forceps, simulating the dressing forceps of tli" poeket caee, was the instrument pre- ferred by Larrey, and is still, deservedly, in ueral use. Many changes have been made in these, without advancing to any extend the mcr- :t> of the instrument. A rery good bullet for- oepi is one terminating with a sharp prong on either blade, at right angles to the blades ao that when closed tin- points are protected by the blades. These act as an axis upon which the ball may be rolled out of the wound, in- stead of being drawn out as with the dressing forceps. Should the site of the foreign body be not at once evident after the examination of the wound, the limb should be carefully manipulated for some distance from the wound. As the object of the examination is to detect abnormal projec- tions, the slightest elevation should attract atten- tion. When no projection is visible, pulsation now TO EXTRACT BALLS. 183 -will detect a hard body at a great depth in the tissues. 'Plic hand should lie run lightly over flic surface, as light pressure would expose the indurated spot, the site of a hall; when well de- fined pressure would move the object, push the ball back into its track, and cause its disappear- ance. If the tissues are soft, the foreign body can be seized between the fingers. If this be impossible, palpation over the region, as for de- tecting fluctuation, will discover the hard, resist- ing, circumscribed body. Experience soon makes perfect in this kind of research, and mistake's are rarely made. When a ball is firmly embedded in bone, it can be removed by boring into it with a gimlet, which holds it securely, and permits sufficient force being used for dislodging it. or it may be cut out by using a trephine. Should a ball have traversed a limb, as it often does, and its escape be resisted by the tough, elastic skin which very Often successfully impedes the further progress of the ball, it should be removed by making an incision over its position, and not be sought for, and drawn through, the entire length of the track which it had traversed. In removing subcutaneous foreign bodies, do not cut down directly upon them, as it will de- 184 MOW TO EXTRACT UALLs stroy the edge of the knife — n sail accident in field practice, where no conveniences exist for puttiug instruments in order; bat, after exposing a point of the foreign body, make the incision to one side, or pass in a grooved director ami cut outwards, when there will be no tear of doing harm to the blade. Baudens, in noting the difficulty of extracting these siihcntaneoiis halls, ascribes it to a layer of cellular tissue, whieh firmly and completely caps the hall. It is thin enough to he diapha- nous ami yet tough enough to clasp and hold firmly the ballet. Gruthrie Bpeaks of the diffi- culties o!' extfaetion depending upon the Bur- geon being too fearful of increasing the incision. I Jails can he extracted with the least pain and with great rapidity by making a hold incision. This course marks the difference betweftn civil and military surgeons; half an inch added to the incision does not increase its dangers, and expedites the extraction. Be quite sure, how- ever, that you are cutting upon a hall and not upon some bony proinineuce, which comparison with the opposite limb should warn you from. It is sufficient to mention that such mistakes have happened to military surgeons. By foreign bodies we mean halls, pieces of DILATATION OF WOUNDS. 185 elothinj?, spicuhe of bone which have been bro- ken off and arc loose in the wound, and any articles about the person which may nave been driven before the ball. These should all be re- moved immediately after tlie injury lias been received, and before swelling or infiltration ren- ders the task difficult. "When done early, the wound will be found sufficiently large to allow ot* easy extraction, without dilating. It is only when this early attention is neglected, and the wound has closed by inflammatory effusions, that the removal is painful and difficult, requiring, in some instances, the use of the Knife to enlarge the passage. The dilatation of gunshot wounds, which was formerly the constant rule of practice, m now altogether rejected from military surgery, unless it be for the special purpose of ligating a bleed- ing artery, or extracting a foreign body, which, from changes in the wound, cannot he rea lily extracted without injury to the soft parts. This old medical dogma was based neither upon ex- perience nor observation, and is now vei-y prop- erly considered useless, injurious and barbarous. When a ball alone complicates a wound, if it be lot readily found, alter a careful and intelligent Rearch, rather than continue the examination Hi l v ») l.N.l I HV TO LARGE ARTERIES. from day to 'lav, which ran only be prejudicial t<> the case, from the irritation and inflam- mation which will be excited, it would save the surgeoi] much anxiety and the patient much anuoyauce, if the ball or < » 1 1 1 * • i- foreign body be left until suppuration be well established. Theu it will gradually expose it- situation, and can 1m- much more readily removed than during the height of reaction, when the parts are very much swollen and very painful. The surgeou will as- si-t nature in the expulsion a- gOOU as the swell- ing lias subsided to such an extent that the finger or the forceps can again be introduced into the wound. The above rules apply chiefly to gunshot wounds of the extremities \ those of the trunk and head offer so many exceptions to the altove, ami require, in a measure, such special treat- ment, that the course to he pursued in such wounds, complicated with foreign bodies, will he specially dealt with in discussiug special in- juries. We have already stated that fatal hemorrhage, from the large vessels of the extremities, does. not often occur on the battle Held : and that when such arteries are wounded, the hemor- rhage is either so immediately fatal that no INJURY TO LARUK ARTKRIES. IS, assistance can be rendered, or it ceases sponta- neously. The nervous depression so common to shot wounds, with its tendency to syncope, and its control oyer the circulatory organs, ehecke the impulse and supply of blood through the injured vessel, and promotes the formation of clots. Openings in arteries may be temporarily closed by foreign Itodies. and in such cases hem- orrhage would recur when these are extracted. The largest arteries may, however, be wounded, and may cease bleeding spontaneously. The only means of detecting the injury of the Large arteries <>f a Limb would he in examining carefully the strength of pulsation in the vessel, beyond the point of injury. A diminution ol its force, when compared to that of the cor- responding vessej in the opposite limb, shows conclusively some hindrance to the circulation. When m> external hemorrhage exists, an ab- aence of pulsation in the course of the artery below the wound is the only means of detect- ing serious injury to tin' vessel, and it often decides whether the limb should be at once amputated. The presence of the pulse is, of course, no indication that injury has not been received. Although, from the course of the ball and Is* Lin \ I i i;i\.. Ol \i: i m:ii - tin- flow of blood, we know that the main v< of the limli has been injured, it' the bleeding ■ 1 -j niiit:iiM-«»u-l\ . <»r by the pressure <»t' tin- sponge, or compress, which was tied over the wound, the artery sliould not be interfered wiili. Iii by for the majority of cases, if proper precautions be taken, there will he no recur- rence of the hemorrhage. The patient should be kepi perfectly quiet, free from all caus< excitement, at perfect rest, and, fco ensure that the limb shall not be moved, a bandage Bhould be carefully applied from the extremity of the liiuli upward, ami a long splint secured. The flannel bandage being the in< >st elastic, is fee beat material for such methodical pressure and support. Elevation of the limh will :i control the bleeding from b recerrt wound, In'. •Mine- ;i very dangerous one to the safety of the limb or life of the individual. In of < I i — « : » - « • . nature, always <>n the alert, lia- enlarged contiguous blood-vessels, which arc read\ to assume all the ftmctiona of tin' one LIGATURING OF ARTERIES. 185) requiring obliteration. In a wound in a healthy person no sucb preparation has been made; and in eutting off the main supply of blodd through ji limit ii becomes a very serious question, often answered by the loss of the limb, and even life, whether the circulation will he -re-established in time to save the member from mortifying. When a ligature is placed upon the main artery of a limb for disease, previous developments in the collateral circulation have been made to sueh an extent, that the extremity may not even lose temperature after the ligation, and as there is no diminution of the nutrient supply there is no fear of mortification, [f placed on a healthy vessel for an injury, the limb at once becomes pale and cold, requiring the applicatidn of arti- ficial warmth ami enveloping in flannels to sup- port life in it until the circulation be* re-estab- lished, when the limb becomes actually warmer than it> colleague. The arterial supply is now disseminated in vessels much nearer to the SUV- fa>e than before, where its chief channel was deeply embedded in the tissues. The rapidity of this collateral development in the limb is well exhibited in primary and see- ondary amputation-. When a thigh is amputat- ed in a healthy portion, very seldom are there li)0 LIOATI KIM. OF AKTER1I - more thau three or four Ligatures required, to ■top all oozing ami render the stomp quite dry. If the amputation he necessary :it the same point three or four days after an injury to the main i baa been received, the number is greatly increased: as. many a> twenty-eight arteries have ligated by Langenbjeck after amputating ;i thigh under similar ciroumstani Should active hemorrhage continue, and show no disposition to cease, the wound thould bi dilated, the bleeding mouths of the artery found, ami a lU/atim applied both r, ,/,, ,r //,, injury. This has become the fixed practice, and the only safe one, taking its place among the aphorisms <>r iurgery. The universal adoption of this prac- tice is not onlv based upon experience and ob- servation, Imt could be determined a priori from the physiology ami anatomical distribution of arteries. All surgeons arc tarn i liar with the anastomosis or collateral circulation in Mood vessels. When the current of blood is stopped at any otic point, it will soon find its way, through many cirouit- oii> routes, back to the very point at which its direct course had been checked. When an ar- tery Is divided, it is well known that, owing to its niii>cnlar and elastic structure, that portion IJOATIUJINU OF ARTERIES. IW above the wound at once contracts and retracts, so that the tube which was before cylindrical. now resembles a claret bottle with a much con- stricted neck. A dot of blood soon forms in this mouth and neck, and the passage of the hlood is intercepted. Jn the lower portion of tin' divided vessel similar changes are going on, hut not to so great an extent. The contraction (owing to the severing of the nerves which give tone to the arterial walls) is only partial, the walls being to a certain extent paralyzed, and so little hlood remains in the tube that a very small and indifferent clot is formed. When the upper portion of the artery is firm- ly closed, preventing all egress to hlood, the lower portion remains patulous, inviting hemor- rhage. As soon as the Mood-currents find their way by circuitous channels, it wells up from the wound in a continuous purplish stream, all im- pulse having heen lost, and also most of the oxygen contained in the hlood, by the long, roundabout way which the circulation now takes. The darkness of the hlood will depend upon the difficulties of the circuitous passage; the rule, however, is: .-carle: or arterial blood from the upper end ^l' the vessel, dark colored or venous blood from its lower end. 10*2 LTGATURTNO or ARTKH Guthrie lays down tin- two following rul< the great principles "t" surgery, to be observed in the cases of wounded arteries, and which ought never to be absent from the mind of the surgeon : 1. That no operation ought to bt performed upon a irnii nil, il artery unless it bleeds. -_!. Tfrnt no operation is to I" performed for <> wovvded artery, in the jirst instance, but 'if thi spot injured, unless sttch operation not only appears to be, hut really is, impracticable. W 1km it is necessary to ligate an artery, the Burgeon musl be guided by his anatomical knowledge, and also by the pulsation, in find- htg it. In dilating the wound so as to expose the bleeding mouths, the incisions should be made parallel to the course of the vessel, and sufficiently free to facilitate the search. The dissection is carefully conducted, dividing layer liy layer", and avoiding the nerves and veins which always accompany the large arteries. Wlic-n the bleeding mouth is so exposed that the origin <>f the jet of blood is seen, the vessel i- transfixed by a tenaculum, drawn out, and secured as it would be in a stump after ampu- tation. When- it is impossible t<> ligate the bleeding LIGATURING OF ARTERIES. 193 vessel at tlic point wounded, a point should be selected, at which the vessel is comparatively isolated, easily diseovered, and lire from large collateral branched. Tn exposing it, make a free incision. The common mistake that most sur- geons make is in a small incision, which ham- pers the search. When we approach the artery, use the grooved director to isolate those cellular layers in which the vessel is always found. The point of the knife should never he used for this purpose. The lips of the wound should be drawn asunder by an assistant, so as to give to the operator the light necessary for accomplish- ing speedily, and successfully, the ligation. In all cases requiring such an operation, it is de- sirable to have the patient completely under control, and, therefore, chloroform should be ad- ministered. When tin 1 artery is found, ami the ligature passed under it. before tying it be quite sure that it is the vessel, and it alone, and not the nerve that has been seized. To be satisfied on this point, it is only necessary to draw slightly upon the thread, and examine above and below it to see whether the pulsaliou has altogether d below the ligature. Having determined that the thread is property placed, it is then 11*4 I.K.All U1M, OF AUTKKIKs. firmly tied, the endi arc brought out pf tlie wound and secured under a strip of adhesive plaster, attached to i 1m • immediate neighborhood of the wound. This node of disposing of it will protect it from becoming entangled in the ordi- nary dressing, and from being drawn upon when these are dairy removed. Water dressings form the proper after-treatment. The thread will come away spontaneously, by the eighth, twelfth or six- teenth day, according to the size of the vessel ligated. When ii is necessary to ligate the artery in its course above the seat of hemorrhage, I wop Id prefer using a fine silver wire ligature. This is well twisted upon the artery, and then v:emia. or secondary hemorrhage from the ligated point. In the treatment of reducible inguinal hernia, where I have obtained permanent cures by sew- in", the columns of the ring together by silver LOCAL TREATMENT OF WOUNDS. 195 wire sutures passed subcutaneousry, the small loo]) of wire remains permanently in the ingui- nal region under the skin, and gives no trouble. From experience, in limited periods, I have re* son to believe that it will remain innocuous for a lifetime. The silver wire shonld not be applied to arte- ries in ;i suppurating wound, or where suppura- tion and sloughing must ensue, as in eleansing the wound it would be liable to be disturbed, and mav be the cause of bleeding. Should the liga- tion of the large arteries at the root of the neck ever prove successful, it must be by the adoption ^i' the silver wire ligature, which can be twisted sufficiently to cause a certain degree of irritation iu the outer coats of the artery, and induce a copioui deposit of lymph for incarcerating the wire and thickening these coats, without caus- ing sloughing of the inner coats or opening the vessel. Local tr<c of the sim- plest description. It is known that gunshot wounds, belouing t<> the contused variety, show a constant disposition to suppurate, and often to LOCAL Tin \TMK\T pf WOUH ' slough. This pr partition sort/ to the heeding of 0<< wound, and should In kept in subjection "s much us possible. This i- effected by iDtinued application of cold crater, which, by keeping down excessive reaction, and keeping <>ut ;ui excess of blood, diminishes the source of the purulent supply, and thus hastens the cure. Tn former times, suppuration was considered essen- tial in the healing of all wounds, by permitting the escape of so much poisonous matter, which had accumulated in the system, and which moat either now find a vent, or, it' retained, would he considered the satisfactory cause of any sickness which the wounded man mav ever sutler I'rom hereafter. The wound was. therefore, plugged with a lint tent, piles of greasy lint in cushions were applied, and, after covering with a sufficient number of compresses and bandages, a forcing bed was formed, which supplied pus to the sat- isfaction of all interested; and it was common enough to see life drain away from this opening. This smothering Of wounds in hot poultices, and the smearing on of greasy ointments, which the wouuded formerly encountered, was a second enemy, far more fatal than the enemy on the battle field; as in its ranks were found exhaust- ing suppuration, with its hectic: pya?mia, with WATER DRESSING ALWAYS TO BE PREFERRED. 107 its rapid pot&enisg ; hospital gangrene, with its sudden collapse, and erysipelas, with its thou- sands of victims, broken-down constitutions, te- dious convalescence, very protracted cures, and endless pain and annoyance. How much more rational is the present prac- tice. Keep outer eloth, which will keep dp the low tempe- rature; or, adopt the much more convenient and Less Laborious plan, of suspending a bucket, er une vessel containing water, in the neighbor- hood of the w.nind. having ■ narrow slip of cloth, or, what m better; a lamp wick passing through a hole in the bottom of the suspended vessel to t Ik- bandage upon the wounded liml>. ISv ca- pillary attraction, a constant stream of water is carried from the vessel to the dressing, and. by lie evaporation, robbing the skin o€ its animal temperature to get a sufficient quantity of heat to convert the water into aqueous vapor, it re- frigerates the Limb* The wick must run freely through the hole, but not boo Loosely, « tlio water will flow out too rapidly. If ir pau s es through Bnugly, so as to Mock up the orifice, capillary action will not draw oil" the water, and the parts will not he irrigated. The advantage of using oiled silk, waxed cloth, or india-rubber tissue is, that, should tin- supply of water acci- dentally rr'wv out in the suspended vessel, the piece of cloth beneath it remains moist upon the wound. The wet eloth absorbs the discharges, and should he changed two or three times a day, it being well understood that they he disturbed Idoin as possible, compatible with cleanliness. WATER DRESSTXi; ALWAYS TO BE PREFERRED. 10!* The surgeon should never be m haste to change the cold for warm applications. Should the vir- tue* of a poultice be called into requisition, a soft, wet compress, covered with oiled silk and secured by a tlannel roller or outer compresfe, is always at hand, and will be found to combine, in a simple form, all the properties of a poultice. It is light, moist, soi't, and is kept warm by ab- sorbing animal beat, which the oiled silk and outer compress retain. If we add to these, cleanliness, facility of medication, and the readi- ness with which an impromptu dressing can be made, we find an array of advantages which ex- clude all substitutes. A more effectual mode of keeping down reac- tion is, by using- ice bladders, which are placed upon the india-rubber, waxed or oiled silk cover- ing. These are of very general application, and make the least call upon the personal attention of nurses. Whenever ice ie used, never apply it directly io tli< : skin, /'i/t always il'ii' lead, sulphate of zinc, tan- nin, muriate of ammonia or laudanum, spirits of COLD WATER THE 1'RnT'l SB APPLICATION. 201 camphor, and, especially' tincture of arnica, would be useful adjuvants. Borne surgeons consider any addition as detrimental to the efjicacy of simple water; but, unfortunately, simplicity is but little in accordance with the popular taste. Whilst the irrigation is going on, the com- presses next the skin may be moistened every tluve or four hours with any of the above prep- arations. Should the wounded p;itient feel chilly, the cold dressings will not be used until reaction lias taken place. There are a few per- sons to whom the application of cold water is inadmissible. In all eases the feelings of the pa- tient will be our guide as to the applicability of the remedy. When not grateful and refreshing to the patient, but, on the contrary, the c;mse of complaints, the irrigation must be superseded by a wet compress, covered with oiled silk or a waxed tloth. This will soon attain the temperature of the body, and wijl keep the parts moist and soft. The dressing requires to be changed twice in twenty-four hours; not that the compress would get dry, for the perspiration from the part, which is kepi in by the oiled silk, would bathe it in a. continual and permanent moisture. The object in ehanging is to gel rid of this secretion, which, in decomposing, would irritate the wound. 2<>2 POLD watii: Till-. PROPM Al'l'l.e VTTOy. A qnestim of great moment is, when should m desist from water applications and <■/. angt for sotm men "<, t',i I or appropriatt dressing? According to the present rational views of Burgeons, no other ling is ever required, however serious tin- wound may be. As long as inflammation threat- ens, so long is it necessary to prevenl engorge- ments. As long as Buppuratidn is kepi up, so long will the efftcacy of cold be required to con- Btringe the blood-vessels and control the source of the purulent supply. Pus. which we <-all a healthy fluid, is m heavy drain upon the By stem. It is made from the richest ingredients of the blood, which were id- tended for the repair of tissues. Once converted into pus, it is unlit for any further useful purpose, and is, therefore, a waste of precious material. This discharge is not more necessary to the heal- ing of wounds than to the nutrition of the body. Extensive wounds, healing by the first intention. So very well without its intervention. Large subcutaneous wounds, when eveu their sides are not kept in apposition, heal with rapidity with- out the formation of pus. Under a scab we find tissues form, by what has been called the re- modeling process, without it; and it should he our constant effort to heal all wound-, and I DISTURBING INFLUENCES or W0UND8. 20o would say. especially gunshot wounds, with the least possible discharge. Hence the water dress- rag can be continued beneficially for -weeks, or as long as the wound remains unhealed. The most recent writers on gunshot wounds state that the wet cloth should he kept on until cicatrization is completed ; and that no other application so protects and promotes the formation of new skin. There are a long list of ointments which have heretofore held universal sway in the treatment o!' wounds. All oi' these can he dispensed with for the more simple dressing. Should the wound require stimulation, the nitrate <,)[' silver wash, irrs. xx to the ounce, when brushed over the part, will suffice; or tincture of iodine, or iron, or some stimulating astringent, might be equally applied in addition to the water dressing, so that any imaginary condition of the wound might be successfully met by the medicated we* doth. The disturbing influences in the healing pro- cess of wounds are numerous, and most of them arc capable ^\' correction without much trouble. Among these are found imperfect transportation orer rough roads in improper vehicles: had at- tendance, Buch as rough or too frequent examina- tions; useless bandaging, which promotes infil- tration; too frequent dreseiug ; improper food: 2(»4 SU OOND U'.Y Hl'MulMUl I scorbutic, syphilitic, and other diseases ; the moral depression of defeat, and, above all, the imper- fect ventilation and insufficient regard to clean- Linese in the wards of military hospitals. W e have already said thai a surgeon is never warranted in cutting down upon an artery and tying it upon suspicion — he must be an eye-wit- of t!i<' hemorrhage, and see that it cannot be controlled by other means. The ligation of an artery is always a troublesome operation, and from the fear of subsequent mortification, always jeopards the limb, and necessarily with it the lite of the patient. This is specially the ease in recent wounds, before nature has prepared a col- lateral circulation, bo that the rule which we have laid down is imperative — never ligate an artery, however large, in which hemorrhage has spontane- ously ceased j and, moreover, that a good com- press is usually sufficient, when applied imme- diately after the Receipt of injury on the battle field, to stop the bleeding even from the Largest vessels, &nd that position, quiet, rest, and other prophylactics will prevent its return. In the ordinary course of u'tinshot wounds, suppuration is established about the fifth or sixth day. when the track of the wound commences in be cleansed of all those tissues which have SECONDARY HEMORRHAGE. 205 been crushed, and so much injured as to be no longer preserved among the living tissues; Dur- ing the elimination of these destroyed parte, where the precaution of rest and absolute <[uiet lias not been enforced, hemorrhage, called sec- ondary, appears. All injuries to large arteries threaten, sooner or later, to produce secondary hemorrhage. However large the artery reopened by tins process, the escape of blood seldom oc- curs with an impulse, but flows away in a- con- tinuous stream, which marks its escape from the lower end of the vessel. When hemorrhage, even from the femoral ar- tery, has been arrested for twelve hours, the efforts of nature are usually sufficient to prevent it> return from the upper portion of the artery, although not from the lower end of the vessel ; so that when the main vessel of a limb is divided by a ball, should primary hemorrhage be control- led, the great fear is from bleeding through the lower end of the artery, and from mortification of the extremity. Any hemorrhage, after twenty-four hours. w<>uld be considered secondary, and would require special treatment. As long as the wound remains open, hemorrhage may make its appear- ance; and il is not until a cure is effected and the parti are ewartrt#eu\ that the patient is posi- / 206 HEMORRHAGE FROM LOWRR HMD Of ART] RY. tivclv safe from this dangerous complication. Cases are recorded where it haa occurred ninety <1m\ - after the vessel bad received injury. Unless the causes of this hemorrhage be perfectly un- derstood, the rules laid down for treatment will not be duly appreciated. In speaking of the action of the two ends of a divided artery, we have already stated that the upper end contracts vigorously, diminishes its calibre at the mouth, and Got some distance up the tube, until it simulates in its proportions the neck and body of a claret bottle. The hlood, impeded in its outward course, allows a dot to form, which, acting a- a Stopper, shuts up the open mouth. The plug is continued in the con- tracted artery to the first collateral branch as a clot of blood, which nearly tills its cylinder. The lower portion of the vessel, having been in a measure paralyzed by tin- division of its coats, which had cut oil" its supply of nerves, acta with much Less energy. The diminution of its calihre depends more upon the removal of distension from its elastic walls than from the contraction of its muscular fibres, The result is. that it re- mains more or less patulous ; and as the supply of blood from above is cut otf. there is hut Little arterial Mood in it to clot and plug it up. iikmoiuwiack from lower end of artery. 20< As soon as tliis barrier or clot is placed uppu tlie main thoroughfare, at the upper wound. pre- venting the blood from following its accustomed channel, nature is at once busy, opening and en- larging the circuitous by-ways and alleys of the circulation, so as to restore the supply to the ex- tremity threatened with starvation, or, in surgical parlance, mortification. As when upon a high- road a bridge spanning a stream is destroyed, travellers seek a lord higher up by which they may return to the thoroughfare beyond the im- pediment, so the blood, taking the nearest by- roads above, soon gets around the obstacle, and empties itself into the main channel below it. The blood here changed! in its direction, and not opposed by valves, passes up as well as down the limb, and finding an open gate at the lower torn mouth of the vessel, escapes. This fluid, moreover, in its roundabout course, lias lost much of its vivifying properties; much of its oxygen is gone, and carbonic acid, ammoniacal gases and the like, having taken its place, mars its brilliant color, and diminishes its clotting properties. No proper material exists for stopping up the vessel, as in tin' upper end of the divided artery, and the result i>. that secondary hemorrhage nearly always occurs from the Lower end. TRKATMKNT OF BECONDARY 11 I M"i: !< M \. . K This befog well understood, we can now eoc- jilaiii why a ligature placed on the upper orifice alone, or on the course of the artery above the injury, should not stop hut only temporarily con- trol the hemorrhage. A- Boon aa the collateral circulation above the ligated poinl is re-estab- lished, the lower opening in the vessel remaining as before, hemorrhage musl recur, or, if this cir- culation is not re-established, mortification must follow. The rale, thkn, is w/vpetatbn : Hyatt both ends of fin vessel at th point woutoded; this is thx ovtttj saf< coursi tb pursue. Another Btroflg reason why the Kgature should be applied to the wounded ends of the artery is, that there is always BOme uncertainty as to the vessel injured. The very >erious and often fatal operation of ligating the femoral artery has been performed for an injury to one o\' its branches, which had not been suspected— a post- mortem examination revealiiig the source of hemorrhage. When the ligature is applied to the bleeding mouths, this accident cannot happen. The course which should be adopted in il<< cast of hemorrhage from "n injured artery, is as follows: After the hemorrhage lias once been controlled, and through either eafelesshess on the part of the BUrgeOIl or restlessness on the pkri of the TREATMENT OF SKCONDARY HEMORRHAGE. 209 patient, getting up to help himself when he had strict orders to the contrary, etc.j or per- 1ki}is from rough transportation over bad roads, or the sloughing of the wound, hemorrhage re- appears, the limb should be at once bandaged from the extremity upward, making careful, negu- lar pressure, so as to diminish the quantity of circulating fluid. Over the course of the main artery, and for some little distance above and below the wound, a compress, saturated or not with some of the styptic preparations of iron, should he firmly secured: the bandaging of the limb extending to one or two inches above the injury. The patient is then to he placed upon his bock, the limb elevated, and an ice bladder applied over tin 1 wound. Absolute quiet should be enjoined, and secured by administering a, Large dose of Opium; Tn many cases, this dressing will bring about the desired object, when assisted by those in. ternal remedies which control the force of the circulation, as veratrurd viride, digitalis, etc. By the use of compresses saturated with the per chloride of iron, in connection with absolute rest. I have succeeded in checking secondary hemorrhage from the carotid artery after the e cape of the ligature. is L'l<' TREATMENT OF SECONDARY HEMORRHAGE. "Rut should the parts be bo situated that this pressure cannot be applied for ;i suftcientiy long time, or should it n<>i control the bleeding, then the proper course If to ligate the mouth- of the artery in the wound without farther delay. No case of secondary hemorrhage should de- stroy life by repeated recurrence; a surgeon is very culpable who permits lift to ehfe away from his grasp. Physicians cannot be too guarded against the delusive attempts at stopping the bleeding after the recurrence of secondary hemorrhage: it is certain to return and Certain to destroy lite, as experience has repeatedly proved. Every fresh hemorrhage increases the dangers and multiplies the risks; therefore^ never neglect /i;/>//in> artery after the second hemorrhage. You must not be deterred from placing n liga- ture on the open mouths of an artery in a sup- purating wound, on the deeply grounded, but erroneous idea, that the artery has had its coats softened by this process. Practical surgery shows conclusively, that the coats are tough enough to sustain a ligature in a suppurating wound, and. therefore, the rule should have no exception. Tjidah in the wound under >nt>/ cfrcitmst^nces, n-jun it is 'possible. The swelling and infiltration of TREATMENT OF SECONDARY HEMORRHAGE. 21 1 tissues, renders the search after the injured ar- tery difficult; but the surgeon, who, looking to the side of humanity, considers it a sacred duty to do everything for the interest of the wound- ed, must not allow difficulties to interfere with Ins proper course. Safety lies alone in this operation. The difficulties must be met and overcome. The following appearances will he observed in the wound, and will assist in the search : After dividing the infiltrated tissues, should the in- jury have heen received over forty-eight hours, particularly if five or six days have intervened, the ends of the vessel will he found incarcerated in a mass of greenish yellow fihrine, which indi- cates, in a remarkable manner, their situation. That which conceals the lower mouth of the vessel is always in smaller quantity. Where post-mortem examinations are made, a probe in- troduced into the artery from below would make its appearance at a point under the yellow patch, raising a thin portion as it protrudes; and should the patient have been destroyed by secondary hemorrhage, an opening will usually he found in tliis pellicle. Through the upper portion of the artery the probe would pass down with much more difficulty, owing to a con- 212 THKATMl.NT Of BBOOMDAET RMOBftKAOS. | tracted tube plugged with coagula — conditions which do not exist in the lower portion. These lymphy, yellowish green spots are, then, mh guides after the wound baa beeu freely diluted. In a surgical operation, especially in ligating arteries, never eramp onesself from the Gear of making t < ►< » large an opening; the error is al- ways on the other side. Having found and ligated the orifices, the water dressing should be continued as before — care being taken not to apply it should the Kmh become cool and pale. This is not usually the ease after second- ary hemorrhage, for the return of the bleed* ing indicates a re-estahlished circulation, which the ligature at the bleeding mouths cannot now influence to the injury of the Limb. Should it be impossible to find the bleeding mouths, after a long and careful search, then wo will he reluctantly compelled to adopt the Leu satisfactory operation of ligating the artery ahove tli'- wound — hoping it may obviate any further operation, often, however, when this last plan has been adopted, a return of the hemorrhage necessitates a second ligature upon some higher point: and should this fail, as is often the case, amputatiqp of the limit will he the only resort to save life. Amputation must he equally re- TREATMENT OF SECONDARY HEMORRHAGE. 2b> sorted to if, after the application of a ligature, the circulation not being re-established, morti- fication of the limb ensues. In either case am- putate above the seat of the ligature, so as to ensure a supply ©f blood to the stump for its nutrition. These are some of the dangers incurred when the surgeon does not adopt the only proper course to stop the trouble at its eommeuce- ment. Military hospital statistics show heavy mortuary lists where this rule is not recognized and followed. As the ligature acts as a for* eign body, and must come away, it is of little importance what is used for that purpose, a strong cotton, flax or silk thread, fulfils all the indications required. When applied, it should not be interfered with, until it has either come away of its own accord, or ten to fifteen days have elapsed, when cautious tractions might be attempted to hasten its removal. Silver wire has been spoken of as ligatures for arteries. However well it may answer in fresh pounds, where union by the first inten- tion can be obtained, it is quite out of place in suppurating wounds, as when ligatures are ap- plied for controlling secondary hemorrhage. 214 PI Hi M K Kit \\ nl \ PlJlfOTUmED WOUNDS MADE Bl TUT BATONBT OR babeb, require similar treatment a< in gunshot wounds, [f 1 1n- hietory and appearances clearly indicate the character of the wound, there will be no need of probing for imaginary foreign bodies. Such wounds usually bleed more freely than gunshot wounds, but the hemorrhage is susceptible of control by similar means; press- ure being preferred to ligation of arteries. The treatment should be cold wain- dressings — irri- gation preferred. Protect the wound from air, if possible, by covering it with adhesive plaster, or collodion, and dress it as seldom as possible, compatibli with cleanliness. Onci probing of Buch a wound should satisfy the curiosity of any sur- geon. A frequent repetition of this meddlesome snrgery, besides the needless pain inflicted upon id.' wounded man, must end in mischief. Should ;i bayonet <>r sabre wound transfix one of the natural cavities, the internal injury mav be rapidly fatal from hemorrhage, qt the injury iuflicted ii] ><>n the contained organs may, sooner or later, lead to the destruction of the wounded by viscera] inflammation. Under ordinary con- dition-, when such wounds exist ill the extrem- where no large vessels are implicated, they require no special treatment. Ii is a class rUNCTUREP WOT'NDS. 215 of wounds not as frequently met with in mili- tary surgery as one would suppose. The newly introduced sabre-bayonet, when plunged into the body, leaves l>ut little work for the surgeon. Siidi eases seldom leave the battle field alive. WTien the ordinary bayonet lias buried itself deeply in a limb, suppuration may appeal- in the march of the wound. Should pus be sus- pected, and fears exist that it may be pent up under a fascia, to permit of its tree escape, it would be necessary to dilate the -wound. Under no other condition, except Ibr serious hemor- rhage, where it is necessary to Kgattt the open mouths of the bleeding vessel, should a punc- tured wound made by either sword or bayonet be dilated. Simple incised wounds, as sabre cuts, will be closed by adhesive plaster (or sutures, which arc preferable, should there be any tendency to gap- ing), to be followed by the cold water dressing. Sbould the wound be not of a serious charac- ter, it may be left even without after-dressing — the little oozing from its edges, when drawn together by straps or sutures, dries into a scab along tin' line of wound, and excludes air with its pernicious influences. This permits of the remodelling process, and cicatrization i< effected without suppuration. 218 GENERAL TIO.ATM K.NT 8f W0UND8. In gunshot wounds, the swelling which shows itself a few horns after the injury has been re- ceived, continues increasing until the comple- tion of the third day, when it has attained its acme with commencing suppuration. Should sloughing occur, it will show itself by the >i\th or seventh. (>n the eighth or ninth day, the slough has in most cases separated itself from tlw edges of the track of the ball, and in a few • lavs more will have been disengaged. With the cleansing of the wound, the inflammation gradually subsides, the swelling diminishes, puru- lent discharge lessens in quantity, and the wound commences contracting. The middle portion of the track tirst closes, and with it the opening of exit, leaving a funnel-shaped canal, which di- minishes from day to day, becoming more -n- perficial, until no depth is left to the orifice of entrance, which cicatrizes with a depression, marking distinctly the nature of the injury which has been received. This is the ordinary course which gunshot wounds take when judi- ciously treated in good constitutions. In th< general treatmeni of such <-a-cs. interfere with the general health as little as possible. 'I 'he commonly prescribed antiphlogistic reme- dies are. with hut few exceptions, not required. OENERAL TREATMENT OF WOUNDS. 217 The endless list of emetics, purgatives, diuretics and diaphoretics, to which sonic European writers still cling with wonderful tenacity, can be bene- ficially dispensed with. Guthrie, who represents this class, in speaking of the inflamed stage of gunshot wounds. Bays, that the treatment for subduing this should be active: "the patient, if robust, ought to he bled (if no endemic disease prevails), vomited, purged, k<'pt in tlic recumbent position, and cold applied as long as it shall be found agreeable to his feelings; when that ceases to be the case, warm fomentations ought to be resorted to,, but they are to be abandoned the instant the inflammation is subdued and suppuration well established." We believe active purgation and vomiting to be incompatible with that degreee of quiet which is laid down as a fundamental rule in the treat- ment of gunshot wounds. As suppuration is usually long continued, and debility, with a cer- tain degree of emaciation, usually accompanies the march of gunshot wounds, the disposition should rather be to harbor strength to support this drain than to despoil the system. The mod- ern practice of support rather than depletion hastens convalesce. noe, and is the only rational praei L' 1 x GENERAL TREATMENT Of WOUNDS. General and local bloodletting are oal) per quired in ■ t'<'\\ special injuries of particular organs, which will be hereafter mentioned. Emetics, a> such, arc never required in the genera] treatment of wounds. When very small doses of the emetic preparations are given* to induce relaxation and for generalizing the circu- lation, in this way deriving the excess of Mood from the wound, they may be useful. Small doses of tartar emetic may, with other remedies, form a good prescription in cases of excessive reaction. Mild purgatives are in constant ie<|iii- sition, hoth for their detergent as well as deriv- ator^- effects. The granulations of a wound are said to be a better index of the condition of the intestinal • •anal than the tongue, as they arc much more readily influenced by any cause which induces an irritable condition of the system. Keeping watch aver the digestive organs; preventing, by prop- er diet, any indigestible fond from getting into them, whilst the excretions which empty into this great sewer are not allowed to remain and disturb the system, will he at all times judi- cious practice. Diaphoretics and diuretics are the milder antiphlogistic and derivative reme- GENERAL TREATMENT OP WOUNDS. 219 • lies, which may frequently be called upon to quiet the pulse and equalize the circulation. The ordinary febrile reaction, which so fre- quently follows the receipt of severe injury, should give the surgeon no annoyance />< r se, It is only a symptom; an indication of the ex- tent of sympathy between the local irritation and the system at large. When, by judicious local treatment, the nervous excitement near the wound subsides, the pulse will pari passu lose its frequency and irritability. It is not a disease within itself, requiring to be especially attacked. In the general treatment of wounds, diet ami rest are the two great remedies, which, in by far the majority of wounds, even the most serious, ace all that is required for successful treatment. Should there be an excess of general excite- ment, which a purge with a diaphoretic or diu- retic is not able to quiet, we would administer to such, some one of that class of medicines which are known to control the excitement of the circulation, quiet the brain, and act as M& utives upon the nervous system generally, viz: opium, hyoseyamus. coniuni, belladonna, digi- tals, veratrum viride, etc. When local reaction is excessive, with great swelling and heat, there is a class of medicines 122U UKNKRAL TRKATMF.NT OF WOIN which might be given with advantage. They act by increasing the tone of blood-vessels, ami thereby cause a contraction in their walls and diminution of their calibre. Upon such reme- dies much reliance might be placed. Among these are found the mar. tinct. bf iron, tinct. of belladonna, wine of ergot, and others, which play ;i conspicuous part. It is by contracting ilie blood-vessels to such an extent that a suffi- cient supply of blood cannot be transmitted for the nourishment of distant tissues, that mortifi- cation follows the too libera] and long-continued nse of ergot. By tins property of producing contraction in blood-vessels, uterine hemorrhages are checked, or the action of the gravid womb, with its immensely developed blood-vessels, ex- cited. The entire profession have adopted ilu v mnr. tinct. of iron as nearly a specific, against the fearful inflammatory reaction of erysipelas^ for stronger reasons, it is equally efficacious in simple inflammatory engorgements. Belladonna shows its general action by dilating the pupil — an effect explained by the change in the circu- lation of the blood-ve8Sels of the iris. Its ad- vantages i n relieving injection of the blood-ves- sels of the eye are well known and largely used. It is spoken of as the remedy for the rapid re- GENERAL TREATMENT OF WOUNDS* 221 lief of congestion of the spina] cord. Although these are the individual effects of such remedies, ilu'v are not the specific action i)\' these medi- cines. Their influence belongs to the economy; and in affecting all the tissues, those feel their influence most which are offending, as there would he the widest field for the remedy to show its common effects. Inflammation is a perverted condition of the blood and blood-vessels of a part, which means a modified state of nutrition. There are two diametrically opposed means of correcting this condition and restoring health. One is, by re- ducing the amount of blood carried to the part which threatens to overwhelm the vital functions of such an inflamed portion of the body. This is effected by bloodletting, vomiting, purgation, abstemious diet, and the entire list of depletory or spoliative remedies, which weaken the enemy to such an extent as to allow of the part at- tacked successfully coping with the disease. I'>ut when the disease is conquered, the victory may he as disastrous as a defeat, a Long convalescence being required to restore the patient to Ins former stale of health. The other method is, by increasing the tone, both of part and system. !>y supporting agents which strengthen the garrison, 222 GENERAL TREATMENT OF WOUNDS. increase the vital powers residing within the tissues for resisting the encroachments of disease, and thus are enabled to drive out the enemy, however violently the attack may be made. These successes are attained with but little loss Oil the part Of the system, which comes out of the tire unscathed. Our object, then, should al- ways be to cure disease by using such remedies as will cause the least possible loss to the economy. In all injuries, were it not for an exquisitely sensitive nervous system, we would have hut little systemic sympathy, and. therefore, but little personal annoyance. In the inferior animals, whose sensibilities are of a low description, limbs can he torn off without deleterious effect, and without producing inflammation. These inflam- matory tendencies are only observed as we ad- vance in the scale of animal life, until we find in man a perfection of a nervous system, with its corresponding susceptibilities to physiological as well as pathological impressions. If we could, by some metamorphosis in man, temporarily revert to the more primitive developments, we would diminish the dangers of local trouble : Of if we could take possession, as it were, of the nervous functions, and reduce them to their BNDBRMIC ISK OF MORPHINE. '22'-) lowest stage tor extending sympathies, we could equally keep down irritation, and to a great ex- tent jugulate the tendency to congestion, and, subsequently, inflammation. Opium, by which we can effect this subjec- tion, will ever he the greatest hoon to the mili- tary surgeon ; it is a remedy which should never he ahsent from his reach, doing on the held, he should have his pockets well stored with it for immediate use; and in the entire treatment of the wounded it will ever hold a conspicuous place. Morphine is, perhaps, the hest article for wounded men, as it has lost in preparation some of those astringent properties which, as opium or laudanum, would produce too great a tendency to constipation. The endermic method of using this remedy would prevent endless suffering on the battle tield, or in hospital practice. When morphine is taken into the stomach, it b dissolved in the fluids there found, and then undergoes absorp- tion. This takes place with greater or less ra- pidity, according to the nervous excitement miller which the system is laboring. At times, it- absorption is very slow, and its effects upon the system, from the small quantity found in the circulation, very indifferent. Under other cir- >>\ RNDRKMIC USE OF MOBPHIM cunistances, very large dosei arc administered in vain, to produce the — « » « • 1 1 » 1 1 > lt effects oi' the drug. h remains, perhaps, unchanged in the stoniackj whilst, under the same condition, if a nnn-h smaller dose, in solution, be injected under, the skin of anj portion of the body, its full effects are obtained in a few minutes. The following cases will show the marked efficacy of tin- remedy when used bypodernueally : Mrs. C. had been operated upon for cataract l>y division of the lni>. Violent inflammation ensued, ending in the destruction of the eye, and for tliree days she suffered ugouj ; day ami night she was rolling about the bed in spite of repeated doses of morphiue. Finding that one-half grain every two or three hours produced no alleviation of her suffering, 1 tried the experiment <<( inject- iii>'" one-third of a tn*aiu under tin' skin covering the sternum. A Wood's eudermic syringe was used; absorbtiou was immediate; in two minutes she was relieved; in five, all pain had disappeared, and in ten minutes from tlie injection, she was sleeping soundly for the first time in seventy hours. Mr. M. was accidentally shol in the neck with a., polt's pocket revolver. His head being turned* the ball entered the skin over the larynx, coursed KNPKRMIC USK OF MORPHINE. 225 downward and backward through the posterior triangle of the nock, and was found under the skin of the shoulder over the spine of the scap- ula, and removed. Considerable swelling and extravasation followed, which, diffusing itself, discolored that side of the neck. Some of the brachial plexus of nerves must have been injured, as the patient was soon seized with violent pains, shooting down toward the fingers, which, al- though never altogether absent, would increase to torture as evening advanced. Toward morn- ing they would remit and allow of sleep, after a restless and painful night. Guni opium and morphine in Large doses gave him no relief. The arm was so sensitive that lie would not permit it- being handled. One-fourth of a grain of mor- phine, in three or tour drops of water, was in- jected under the skin of the shoulder; in five minutes all pain had left him, and his arm could lie examined rudely, without the slightest suffer- ing. Mr. T. had been suffering with articular in- flammation of the righl elbow joint, and for three weeks had suffered so severely as to he robbed ot all rest. He visited Charleston, tour hundred miles from his home, to seek relict'. An injec- tion of one-third grain relieved him of all pain 'J2<» KRMir \']>iiim. Xarcot- ising the patient immediately before the opera* tion, and keeping him under its influence for some hours, is among the best means of prevent" ing an excess of reaction. The rapidity of action when morphine is ased endermically is a very great advantage on the field, where every moment is of value. For complete narcotism, when- a sufficient quantity of morphine is used. ii\<- min- utes are all that is required : whilsl with ehloro- ENDEHMK' USE OF TVTOKPTIINE. 227 form we all know that, when under excitement, its inhalation is often extended to from thirty to sixty minutes, ami even longer — time which the field surgeon cannot well spare. Judging from analogy, I should say that, under the nareotising influence of morphine, operations should he much more successful than under chloroform : as the impression is more Lasting, and the inflammatory sequelae ought to be in abeyance. c II A 1' T E R V I . Complications which arisi during the treatment of gun- shot wounds — Erysipelas, contagious r>i <>f wafti/>li<. MWKied :i! ;i wry early day. Often by tin- fourth day the hardened (Bdematoua tissue already feels boggy, indicating the extensive formation of pin and sloughs under the akin. The wound usually gives outlel t<» these at an early day. .\~ the disposition <>t" the disease is not be localize itself, the effusion actively tin-own om in the extent of tissuee undergoes a conversion into pu», which Leaves this matter disseminated in all the tissues where the effusion had been poured out. It is in this manner that the aft tensfre purulent dissection of limbs takes place; by which muscles arc isolated, blood-vessela wp- arated from the surrounding connections, bones, exposed from their periosteum, joints opened* and a general destruction of cellular tissue takes place, shreds, or layers of these tissues, re- sembling strips of wet chamois Leather, may be pulled out from the wound. The extensive loss of support to the skin causes it to break down into gloughs, which make a vent tor the esn cape of this accumulating fluid. Nature in its weakened condition, cannot stand this drain of its best nutrient material: and prost ration, fce- ble, irregular pulse, dry tongue, diarrhoea, deli- rium, and finally coma, ends the scene. ()r, should judicious treatment check its inroads, a CONTAGIOUS CHARACTER OF ERYSIPELAS. 231 tedious convalescence and a shattered constitu- tion remain to the patient. Erysipelas can always he recognized by its distinctive characters of widely extended local inflammation, with tendency to the rapid sup- puration and sloughing of the wound. The prognosis of this complication, in mili- tary surgery, is always serious, when it occurs after gunshot wounds, because the constitutions of the patients have hecn undermined, to a certain degree, hy the hardships and irregular- ities which all soldiers in time of war must suhmit to. In the treatment of gunshot wounds it must he rememhered that erysipelas, which is a very fatal complication, is often produced hy a care- ■ — disregard of those hygienic regulations which are so essential in the proper organiza- tion of a hospital. Over-crowding, had ventila- tion, and want of cleanliness, are constant causes for its production and propagation. As the dis- ease is dearly contagious as well as infectious, the directors of military hospitals must he \'ery careful how they permit a case of erysipelas to he Introduced into a ward with wounded men: Got inoculation will at once ensue, and when erysipelas has taken possession of a ward, it i- 282 CONTAGIOUS rnARACTF.R OF ERY8IPE1 L8. with great difficulty eradicated. tts effects can be traced first upon contiguous patients, whose wounds, healing kindly prior to the introduc- tion of this focus <>f contamination, now lake <>ii erysipelas. The system soon shows the ie- on under which the patient is laboring. Some furthei complication, with low visceral inflammation of either the membranes of the brain or lungs or intestinal surface ensues, and life is overwhelmed by this combination. Erichsen, in liis Science and An of Surgery, mentions the following ease in proof of the con- tagion of erysipelas, as haying occurred in one of his wards at University College Hospital: "The hospital had been \)\'r from any cases of this kind for ;i considerable time, whim, on the loth January, L851, at about noon, a man was admitted under my care, with gangrenous erysipelas of the legs, and placed in the ward. On my visit two hours after his admission, I ordered him removed to a separate room, and directed the chlorides to he freely used in the ward from which he had been taken. Not- withstanding these precautions, however* two days after this, a patient, from whom a portion of necrosed ilium had been removed a tew weeks previously, and who was lying in the ERYSIPELAS A DISEASE OF DEBILITY. 233 adjoining bed to that in which the patient with the erysipelas had been temporarily placed, was seized with erysipelas, of which lie speedily died. The disease then spread to' almost every case in the ward, and proved fatal to several patients who had been recently operated upon." If such be its tendency in civil hospitals, how frightful will its march be among the wounded in military hospitals. Such cases should be kept exclusively to themselves, or they entail incal- culable loss upon the wounded. The antiphlogistic treatment of erysipelas, es- pecially the phlegmonous variety which we are now considering, has W^v many years been aban- doned ; and he who attempts to cure erysipelas in military surgery by depressing agents, will pay heavily for his rashness. However violent are its symptoms, the surgeon must not be de- ceived. Ti is ,1 discus,- qf marked debility: its vio- lent attack is only a mask to be thrown oft' in a few days, and often in a few hours. When tlu' plan of attack is so well known, as it is in erysipelas, where a study of the natural history of the disease has invariably shown, in its march, certain and speedy prostration, the surgeon i> highly culpable who doea not commence with the earlie-t treatment io build up and support TRKATMXNT Of B&l BIPXLAfl the system, ;m«l thus prepare it to withstand the depression which is bo Bure t.» ensae, and which, if overlooked, will be so fatal. Prevention is always more judicious khan cure, and, therefore, oar first care should be — by the stricl observance of those hygienic regulations for ventilation and cleanliness, ana against over- crowding — to keep the wards of an hospital with so pure an atmosphere as to give qo encourage- ment for this low class of diseases to intrude themselves. WTien a case appears, Isolate it at once, and use every precaution against contagion. The sponges, bandages, etc., used bj such a pa- tient, should be confined exclusively to himself; for it' the same sponge !»»■ used for a dozen, they would all be as surely inoculated. Freeh air is indispensable in the successful treatment of this disease. Leave all the windows open for thor- ough ventilation, running the risk of catarrhal affections, which are trivial when compared to the serious character of the disease under dis- cussion. The treatment, ever having in view the steady, onward march of the disease to suppuration, sloughing, and prostration, unless a barrier is thrown across its path, should be, from the com- mencement, stimulating and supporting. This TREATMENT OF ERYSIPELAS. 235 tonic course is prefaced by sonic mild cathartic, to cleanse the bowels of impurities which rapidly accumulate in them, and excite healthy secre- tions troni the digestive organs. For this pur- pose, the compound eoloeynth pill would be a good prescription, although a dose of castor oil or sulphate <)i' magnesia, would, in the majority of cases, fill every indication. t possible results follow the free adminis- 'J'.t'. SUPPORTING TRKATvr\r NSCK86ABY. (ration of t 1 1 « - 1. randy and egg mixture, to which I am in the habit of trusting in the ma- jority of these oases." Its Liberal use will restore strength, soften the tongue, and remove delirium. When tin- skiii is dry ami harsh, mild diapho- - should be used, and as anodynes are al- ways required in the treatment to allay pain and to give sleep, Dovers' powders would be a valu- alilc airent. By adopting this course of attend- ing to the secretions, keeping the bowels Boluble, and supporting the system, even from the very commencement, againsl thai prostration which is certain, sooner or later, to show itself, this scourge in military hospitals will be most suc- cessfully controlled. Considering the disease as one of marked de- bility, most reliam-e should be placed upon the general treatment. All local applications should tend to relieve engorgement. In the early in- flammatory stage, before suppuration is estab- lished, painting the limb with the per chloride of iron, or the tincture of iodine, or using com- presses soaked With tincture of arnica, etc., would tend to promote healthy action. Cold water, by irrigation, or iced applications, would be as useful here as in any other engorgements. All of these applications may be accompanied V LOCAL TREATMENT OF ERYSTT-ELAS. 237 with the methodically applied roller, which will compress the limb, and, by its mechanical sup- port, prevent infiltration and congestion, and re- lieve tension and swelling. Sugar of lead lotions are highly landed. Free incisions arc recom- mended by many surgeons to relieve the en- gorged vessels. They give great relief to the patient, but it is a question whether they do not increase the irritation and hasten the suppura- tive Stage — an effect not to he desired, as the entire armamentarium of the surgeon is directed against the formation of pus. When pus has formed, which will he recog- nized by the doughy condition of the parts, into which the fingers sink when pressure is made, and, a little later, by fluctuation, incisions, suffi- ciently free to admit of the ready escape of pus, should be made, and stimulating water dressings continued, to hasten the elimination of the sloughs and diminish the amount of secretion. The tinct- ure of arnica, or spirits of camphor, or Labar- raque's chloride of soda, diluted with from six i<> ten parts of water, or diluted tincture of iodine, make an excellent stimulating applica- tion. Wherever pus shows a disposition t<> bag, it should he let < >m by incisioas. As the skin, largely undermined, is disposed i<> slough extcn- •J. sively, it should be supported by properly ap- plied baudages, which, by diminishing the cavity within, will prevenl burrowing of pus, and cause the skin to adhere to the deeper parte as soon as adhesive actios can be excited. Pyjzmia, a disease very common in Europe, and a scourge of their military hospitals, 18 a disease hut little known among us, and, there- fore, not likely to attack our wounded, unless we neglecl necessary hygienic precautions. When it -how- itself in a hospital, like its kindred disease erysipelas, it is not satisfied until it has swept oil" its hundreds, and is a pest difficult to be gol rid of. The great similarity in causes, symptoms and effects, are sufficient grounds for iating this with the large class of asthenic diseases, among which erysipelas and hospital gangrene are prominent. It is impossible to con- trol the symptoms and prevent a tatal issue, when, as acute pyaemia, it seizes upon the wounded in military hospitals; it is, therefore, much more to be feared than its kindred disease JUSI mentioned. Although this disease is always associated with wounds, no wound, however trivial, or however well advanced toward cicatrization, is sale from Its attack Until completely healed. The di>ea>e SYMPTOMS OF PYEMIA. 289 is supposed to be caused by the absorption of the ichorous fluids decomposing in the wound, which produces a general poisoning of the blood, rendering it unfit for sustaining the economy. It lias been called an acute decomposition of the blood. The phenomena which accompany tins affec- tion are, great depression of the powers of the system, and the formation of abscesses in various parts of the body. In the incubative stage, which may precede the explosion of the disease by twenty-four or thirty-six hours, the patient is restless, anxious, ill at ease, with forebodings of impending trouble. He looks pale and sallow, has l,.ss of appetite, and generally deranged se- cretions. The disease commences by severe chills, which, in the acute cases, are repeated with much irregularity. In the subacute varie- ty, these chills appear at such regular intervals, followed by high lever and terminating in pro- fuse sweats, as to induce the belief of malarial fever. In many cases the skin is hot, with a pungent feel, irrespective of the chills; in oth- ers, the chilly ami feverish sensations alternate. The pulse is feeble: face pale, with anxiety of countenance and tendency to delirium: tongue foul: a tendency for sordea to collect on the 2I<» 81MPTOM8 OP 1'V EMI A. teeth, and the tongue to become dry; Btoraach uneasy, with bilious vomiting, and thirst con- stant. The suspension of secretions gives a f organs. These Form rapidly and without much inconvenience. Often, the swelling alone — which lias appeared (Star- ing ilir night, unaccompanied with pain, redness or heat — indicates that a large collection of pus lias alreadv taken place. Whilst these Bymptoms progress, the wound usually becomes foul and Bloughy, ceasing to se- crete pus. This is not the invariable rule, as surgeons have noticed cases in which the ap- pearance <>f the wound was n<> indication of the destructive disease which had laid its relentless hand upon the injured. The disease may even run its fatal course without material changes in the wound. (Vrtain injuries are more likely to he followed by pyaemia, and those of hone are TIIEOUY OF PURULENT FORMATIONS. S41 said to be peculiarly exposed to it. As in all such low diseases, typhoid symptoms ensue at an early day, and usually carry off the patient at the end of tlie first week. Often stupor eonies on as early as the fourth day. An examination after death will reveal a rapidly advancing de- composition, with gas in the blood-vessels, and purulent collections in many organs, as the Lungs, liver, spleen, kidneys, heart and brain. Similar collections are. found in most of the large joints, beside the multiplied abscesses of the cellular tissue. The theory of the metastatic character of the abscesses, or the sudden change of place of such deposits, by absorption and redepoeit, has long been abandoned. Pus, we now know to be a modified nutrient fluid, which, from an impair- ment of its vitalizing principle, falls short of its object of repairing tissues. This exudation leaves the blood-vessels under ordinary acute inflamma- tion, and is drawn out by the excited tissues which are not able to consume the excess which they have demanded from the circulation. This llnid, now ai rest without the blood-vessels, at- tempts a formation of it.-- own. developing cells of this plasma, which simulate closely the white • ells in tin- progressive development of the blood. 242 THEORY Of iTi:n.i:\T FORMATIONS. and are supposed by Borne pathologists t.> bi identical with them. Tlii> is pus. WTien the entire circulating fluid bas become poisoned, its entire plasma or liquor sanguinis is impaired. It is from tins plasma thai the blood-cells are to be generated. The usual process of development is commenced, white cells form as colorless blood corpuscles, and when the continued development into the red or perfect cell is attempted, many failures occur. There are, besides, many which had exhausted their formative powers in attain- ing the degree of development necessary to peiv feet the white cell. These remaining as such. continue in the circulation. When the blood of a pyflemic patient is examined, a very large number of such colorless cells are found in the blood, sufficient to modify its color, and it is in autopsies that the separation of these white cells from the generating fluid shows the deceptive appearance of pus in the blood, or emboli in the large vessels at the heart. Blood in this condition, with an impaired liquor sanguinis, is unfit for its duties as a life-supporting fluid. The various tissues of the body, not receiving the kind of nourish- ment appropriate 1 for their healthy function, he- come irritated. Nature tries to make up the IMPORTANCE OP HYGIENE. 243 deficiency in quality by quantity. The irritated parts are supplied witb as excess of the im- paired nutritive fluid, which, escaping from the capillaries, is received into the loose tissues. This is rapidly converted into pus, by the devel- opment of white or colorless cells in it, which is the height of vitality in such an exudate Experience, which sustains this view, shows the disease to be purely a blood poisoning; a general disease with its local manifestations. When the blood has been thus thoroughly deteriorated, no remedy which art possesses can restore it to its former healthy condition, and the patient dies. Our great remedy lies in prevention. The hy- gienic precautions of rigid cleanliness, thorough ventilation, good food, and proper shelter, with- out over-crowding, will, if properly insisted upon by the medical superintendent, go fur to keep away, if they do not altogether prevent, the oc- currence of pyaemia. Too much attention can- not be paid to the detail of cleanliness in the ward. The slop buckets, which are such a com- mon nuisance, should be examined with care, frequently emptied, scoured daily with lime, and always kept covered, that the emanations arising from decomposing urine, which is very deleteri- ous in hospital ward-, cannot escape: The bed 24 1 IMPORTANCE 01 HYGIENE. and body linen of the patients should be daily changed, doors and windows mnsl be kept open. [£ any difficulty exists in this respect, from the inattention of nurses or Fears of patients, it would be better to take out the sashes so as t<> en- sure continued renewal of the atmosphere, day and Bight. There is a popular dread of nighl air which should 1)0 exploded. The purest air we have in cities is the night air, and is the very article which is so much needed in hospitals. It' the patienl is properly covered in bed, there is no Tear of his taking cold, or contracting other in- jury from the continued renewal <>f pure air. These precautions must nut he commenced when pyaemia has already shown itself, but are those necessary to he taken wherever the seriously wounded are treated, or some low form of dis- ease will soon break out. Any one who will visit, during the night, a ward filled with sop- purating wounds, will perceive tin' degree of vitiated air, and see the necessity for five ven- tilation. It is a had principle to concentrate the seri- ously wounded; always scatter them over the building, mixing them in with inmates from other diseases. This increases the available space for TREATMENT OP PY.KMIA. 245 the seriously wounded, and prevents the de- pressing ctlect of the concentrated emanations from so many extensively suppurating wounds. It is for a similar reason that we have already recommended that rooms should not be kept too long in use when occupied by the severely wounded. As the air becomes poisoned, the ward requires to be unoccupied two weeks of every two months, for cleansing, whitewashing and purification. When pviemia threatens to become general in a military hospital, the seriously wounded should be put, if possible, in tents, or allowed double space in a constantly ventilated room, and an additional quantity of nourishing food should be given out to the sick. Feeding the wounded on broths ami other slops, is paving the way to the debility which is a precursor of pyfemia. All small operations should be avoid- ed, and even the nasty opening of abscesses guarded against. The best protection against this disease is a whole skin. When the acute form of the disease shows itself, surgery can do but little to assist the patient If it be possible, more benefit will be derived from changing the patient into fresh air than from any other remedy. Our entire reliance 2 I I TKKATMI \ l 01 l'V i:MI.\. should be placed apon the stimulating tonics. Strong, nutritious, easily digested food, and opium to allay pain and restlessness, are the means re- quired. The tendency to delirium should not prevent the free use of this last remedy, for although it would increase the difficulty if it be given in inflammation of the brain or meninges, it allays pain, removes restlessness, stops mut- tering, and induces quiet Bleep, when given in cases of debility accompanied by delirium. As in erysipelas, the arid preparations of iron, as a blood tonic, may be administered. Although bo little is to be expected in the acute form of Mood poisoning, in the subacute or chronic pyaemia, much benefit will be derived from rigidly pursuing the course of treatment just marked out. By the stimulating and sap- porting plan, with change of air, many patients, after a long struggle, may be saved. The important indication for local treatment in pyaemia is to prevent the accumulation of pu- trescent fluids in the wound by cleanliness — and tin- frequent application of chlorinated washes, which also remove factor and Btimuhtte the granu- lating surface. The abscesses which form during the march of the disease, should not he too HOSPITAL GANGRENE. 247 fegstily opened, as this course, pursued with the many collections, will induce rapid prostration. Hospital Gangrene. — Still another fatal com- plication, to which gunshot wounds arc liable, is hospital gangrene, the name being significant of _ the cause of this pest, as it is never seen as an isolated disease without the crowded wards of a hospital. It is highly probable that, like the former diseases which we have jnst con- sidered, it. is a blood poisoning, depending upon a foul, infected atmosphere, operating upon a depraved and enfeebled constitution. It seldom attacks the strong and robust, but most fre- quently those who have become debilitated by exposure, disease, want of proper food, intern" perance, etc.; so that in a crowded hospital, when gangrene threatens to devastate the wards, you might select, in advance, the cases which will most probably be first attacked. Many sur- geons consider it a constitutional disease, occur- ring from a strictly local cause, which is found within the walls of the hospital. All surgeons recognize its contagions as well as infections character, and the facility of transmitting it by sponges or dressings used in common in a ward. The facility with which the air of a ward, or 248 CONTAGION OP HOSPITAl evea of a hospital, becomes impregnated with this poison, \\<»iilkin always precedes the advance of the gray slough. The edg< the nicer arc abruptly cut, undermined and everted, gradually assuming a circular outline, irrespective of the form of the wound prior to its invasion. The gray, tenacious mass, being formed of the mortified tissue, holds its place and cannot be wiped oil', although it sways to and fro when any attempt is made to cleanse the wound. The Liquefaction of these mortified tissues soon commences, and a dirty, thick, highly offensive, irritating fluid, produced from the putrefaction of the slough, escapes from the wound, diffusing a peculiar odor which, when once smelt, will always he recognized. This is the poison which possesses such powers of infection when brought in contact with healthy wounds. (Mice the disease lias fairly rooted itself, its ravages are extensive and rapid. One can nearly >ce the extending line of slough, and often in twenty-four hours large portions of the skin, cellular tissue, and muscles will have mortified. SVMI'TOMS OF HOSPITAL GANGRENK. 251 These changes in the wound are accompanied by a severe burning, stinging, lancinating pain. Pari passu with tins local destruction, the sys- tem is gradually or rapidly showing the influ- ence • of the poison. Although the symptoms may he at first of an inflammatory character, accompanied by a high fever, the pulse soon loses its strength, the mind is peevish, fretful and desponding, and the tongue becomes dry and brown. The pain accompanying these changes is so severe as to deprive the patient of sleep. As the febrile accompaniments of the disease rapidly assume a typhoid cast, delirium ensues, and, with a tendency to coma, becomes a promi- nent symptom. Should the case not terminate before the elim- ination of the sloughs commences, the separa- tion of these may open large vessels, from which the hemorrhage will rapidly destroy life. The great nerves and arteries appear to resist the gangrenous destruction longer than the muscu- lar or cutaneous structures. These yield in the end, and repeated hemorrhages close the scene. J witnessed an epidemic of hospital gangrene, in Milan, during the summer ^\' L859. A large number of Austrian wounded had been put in a barrack prepared for their reception. They _•>_ SYMPTOMS OF B08PITAL QANGRENK. had undergone many hardships, retreating daily before a victorious enemy, and had, prior to the battle of Solferino, tasted no food for forty- eight hours. They had been deceived by their Leaders, who had taught them that certain death awaited them should they tall into the hands of the Italians. With these impressidns, the wound- ed hid themselves in the ditches and undeiorush of the extended battle field, where many per- ished. Some were not discovered for two or three days, when they were sent to the hospi- tals. The previous hardships which the A.ustri- ans had undergone, their Lymphatic tendencies, their irregular living, with the moral depression of repeated defeat, exposed them to the ravages of the lowest forms of disease. Eospital gan- grene raged fearfully among them, destroying numbers. Many of their wounds were frightful from the extended Bloughing, and their worn frames and gaunt visages indicated a fearful combat with disease. I was particularly struck with the mental depression under which many of them were suffering — amounting to despond- ency. This was further increased by the atten- dants and surgeons not Bpeaking the Ghsrmah language, so that neither could their wants lie known nor could sympathy he extended to them. SYMPTOMS OF HOSPITAL GANGRENE. 253 From the combination of these depressing causes, an epidemic of sloughing phagadosna appeared, which was appalling even to those accustomed to see disease in its most fearful form. McLeod tells us that, iii the Crimea, during the heat of the summer of 1855, not a few of those operated upon were lost by a gangrene of a most rapid and fatal form. All of those attacked by it were carried off. In the ease of a few, who lived long enough for the full de- velopment of the disease, gangrene in its mosd marked features became established; but most of them expired previous to any sphacelus of the part, overwhelmed by the violent poison which seemed to pervade and destroy the whole economy. "The cases of all those who died in my wards seemed to be doing perfectly well up to sixteen hours, at the furthest, before death. During the night previous to death, the patient was restless, but did not complain of any par- ticular uneasiness. At the morning visit, the expression seemed unaccountably anxious, and the pulse very slightly raised, the skin moist, and the tongue clean. By this time the stump felt, as the patient expressed it. heavy, like lead, and a burning, stinging pain had begun to shool through it. < >n removing the dressing, the 254 THKAIMKNT 01 HOSPITAL ■. A M.U1 N I stamp waa found slightly swollen and hard, and the discharges thin and gleety, colored with blood, and having masses of matter, like gruel, uonally mixed with it. A few hours afteis ward, the limb would be greatly Bwollen, the skin tense and white and marked along its sur- face by prominent bine reins. The cut edges of the stump looked tike pork. Acute pain was felt. The constitution by this time had begun to sympathize. A cold sweat covered the body* the stomach was irritable, and the pulse weak and frequent. The respiration became short and hurried, giving evidence of tin' great oppression of which the patient so much complained. The heart's action gradually ami surely go( weaker, till, from fourteen to sixteen hours from the first Itad symptom, death relieved his sufferings." In the treatment <>/ hospital gangrene, we must consider it frequently a local disease, with rapid tendency to constitutional poisoning. One of our early duties would be to destroy the accumulat- ing poisonous ichor in the wound to prevent further infection, whilst, at the same time, we correct those depressing causes which predisposed to the disease, Guthrie says, that constitutional treatment, and every kind of simple, mild, deter- gent applications, always failed unless accoiiipan- TREATMENT OF nOSPITAL GANGRENE. 255 ied by absolute separation, the utmost possible extent of ventilation, and the greatest possible attention to cleanliness: and not even then with- out great loss of tissue in many instances. The local remedies act as caustics, and com- pose the most energetic of the pharmacopoeia. The French and German military surgeons pre- fer the actual cautery to all other applications to check the encroachments of the disease, al- though Armaml even speaks of this remedy, upon which much reliance was placed, as exception- ally checking tlie progress of mortification. "Af- ter a thorough cauterization, the eschar separates rapidly, and often exposes a second infected sur- face ol' greater extent."' His individual experi- ence gives the preference to tincture of iodine as a local application. The best results were obtained when a compress saturated witli it was applied to the wound. Guthrie recommends the liberal use of the concentrated mineral acids, es- pecially the fuming nitric acid. McLeod refers to the nitric acid :is the most efficacious means ct' stopping the sloughing process. Labarraque's chloride of soda, pyroligneous acid, creasote. peT chloride of iron, lemon juice, etc.. are frequently nsed with benefit : but general experience in mil- itary surgery givei the preference to the mineral •J.V. TRK\i\!i:vr 01 BOSP1TAL I \ VI 1 1; i.sr. acid preparations. These are to be followed by irrigation, which washes away the ichorous dis- charges as rapidly as they form, and prevents further infection. Powdered charcoal, camphor, and bark poultices, are useful applications. The Local treatment alone, without the consti- tuti6nal, would be followed by no good results. ']'!■< most important of all //>< constitutional remedies is charuji of air. W the patient could be removed from the atmospheric influences of the infected ward. Lis chances for recovery would be greatly increased. Baudens states that without isolation all treatment will Bhow itselt powerless. Carry- ing ilif patient from the ward to a tenl would be followed by immediate amelioration — fresh air being the great remedy. Keeping the intestinal action free by a little Mtu- mass, or compound extract of colocynth, and the liberal use of tonics and stimulating diet, with wine or brandy and opium, will complete the treatment. Opium is required in every stage of the dis- and is administered in large and repeated a to allay tin- pain, irritability and sleep- lessness, which so generally attend the severe cases oi gangrene. The diet t^hroughoul Bhould lie highly nutritious, and should be liberally pre- scribed. McLeod, in Id.-- experience in the Eng- TREATMENT OF HOSPITAL GANGRENE. 2f)7 lish service, states " that nitric acid, applied lo- cally, and the exhibition of the tincture of the muriate of iron internally in half drachm doses, three times a day, proved to be the most effica- cious means of stopping it, as it appeared in our hospitals." It is thus seen that the three most fatal com- plications to gunshot wounds are the three kin- dred diseases, erysipelas, pyaemia, and hospital gangrene, all recognizing a common origin, viz: imperfect ventilation and want of proper atten- tion to cleanliness, with the absence of those. hygienic regulations necessary for the health of an army. \Yith propel- care from the medical corps, these diseases, which are the chief scourges to the wounded, and the causes of nearly all the deaths, can be in a measure, if not altogether, prevented. Once they have made their appearance in a hospital, they will never be got rid of until the building is closed, and the proper measures for purification resorted to. Prevention, in this in- stance as in all others, will be found better than attempts ;i1 cure, as many of these diseases, once they appear, are quite unmanageable, and tend naturally to a fatal issue. All of these diseases are benefited by the isolation of the patient in :i 258 TKTAM B. pare atmosphere, when the infectious character of the disease ia counteracted, and 1 1 1 * - patient is in the besl condition For successful treatment. In all of them the antiphlogistic treatment cannot be too severely condemned. However doubtful Buch :i course may be in a civil hospital, or in private practice, with patients unexposed to hard- ships, who are robust, and have not been influ- enced by depressing agents, in a military hospital, with the material which compose the inmates, an antiphlogistic course should not be thought o£ Tin' supporting plan, with stimulating tonics, is the only rational course that promises su< and should be followed throughout the treatment. Attending to the Becretiona with mild remedies, allaying pain, and inducing refreshing sleep l>y means of opium, good diet, and due regard to hygienic regulations, will be the course of prac- tice to be pursued. Tetanus. — Another fatal complication of wounds, depending, however, apon very differ- ent circumstances from those recently consid- ered, is tetanus, or lockjaw — a disease fearfully malignant Qnder any circumstances, and with scarcely an exception in military Burgery. For- tunately, this is never an epidemic, nor can it TETANUS. 259 infect a hospital, although pathologists have recently attempted to prove its origit) traceable to an animal poison. This disease is much more frequent with ua than it is in Europe, where it is rarely met with. In the Crimean service, MeLeod mentions but thirteen eases as occuring in camp and in the hospitals. This disease, which does not depend upon the size of the wound from which the patient is suffering, appears to he caused frequently by sudden atmospheric changes in connection with dampness. Larrey, in his experience hoth in Germany and Egypt, found it in those wounded who, after sustaining great exertions during the fight on a very hot day, were exposed to the cold, damp night air on the field, without shel- ter. Alter the battle of Bautzen, where the wounded were left on the field during the night, exposed to severe cold, Larrey found on the fol- lowing morning that more than one hundred were affected by tetanus. In very hot climatei it requires hut little excitement to produce it — a trifling puncture or scratch is at times sutH- cienl to cause an attack, and it has been noticed by military surgeons that the scraping of the skin by a hall, with bruising of the nerves, is more liahle to this complication than the more severe wound- • 260 causi a o* rv\ am •-. The proximate cause appears to be Bome in- jury to tin- nerves, ool necessarily connected with an open wound, as it haa been known to follow the blow of n whip or a spraiu. Wounds, in certain situations, are thoughl t<> favor its ap- pearance, viz : injury td the hands, feet, joints. etc. It may occur very Bpeedily — a few hours after the injury has been received, or it may pot occur For days. Rarely does it attack chronic wound- after the twentieth day: [ts common period for appearing is between the lii'tli and fifteenth day, when, perhaps, the simple wound haa completely cicatrized. The premonition of uneasiness on the pari of the patient, with vague fears of impending trouble, disturbed digestion, etc, are nol often observed. The first symptom which we usually recognize is a complaint of soreness of the throat, which, in ordinary cases precedes, by some hours, the contraction of the muscles 6f the jaw and pinch- in-' of the features. The spasm, instead of com- mencing in the injured part, always -hows itself lirst in those muscles supplied by the fifth pair of nerves; and although in sudden and violent the spasmodic contraction of the muscles generally may rapidly follow the locking of the jaw.-, or appear to be even simultaneous with it. SYMPTOMS OF TETANUS. 261 they are never found to precede it. The locking of the jaws; the contraction of the muscles of the neck, especially the sterno-cleido-mastoid, which, by bounding under the skin, accurately defines the triangles of the neck ; the hardened condition of the abdominal muscles, the knots formed over the region o\' the recti muscles dur- ing the paroxysm; the stiffening of the muscles of the legs, whilst those (A' the arms remain free ; the sardonic expression of the face ; clear brain; sleeplessness: profuse sweating; incessant desire to drink, and difficulty in accomplishing i) ; the occurrence of paroxysms of violent mus- cular contraction every few minutes, with loss of strength in the pulse, and rapid prostration, de- tine the disease so accurately that it becomes one of those most easily recognized. Any one who has ever felt a cramp of the calf muscles, may have a faint appreciation of the intense pain which a permanent and violent cramp of all the muscles must produce — a pain sufficient to destroy life promptly, through ner- vous exhaustion. The prognosis of this disease is so serious, and the treatment, however conducted, so unsat- i factory, thai many surgeons of large experi- ence have never cured a ease of traumatic 262 IIM'.ATMKNT 01 TKTAM S. tetanus. That fruitful source of information, pathology, gives as no instruction iu this dis- ease. An autopsy reveals nothing commensusata with ill*- intensity of symptoms. A alight eon- ■ m m)' the spinal eord and medulla oblon- gata, is all thai can be discerned. From the symptoms, we judge of the disease as one of intense nervous irritation. Recognizing the ex- haustion which so soon >lio\\s itself, the treat- ment as laid down by the most recent authors, and the <>nc now generally adopted, is one of support to both the nervous and muscular sys- tems. Larrey has cut short the disease in its inci- pient stage by amputating the limb, or dividing the nerve which is supposed to he at fault. Other surgeons, by isolating the irritation, have been equally successful. Such results are. how- ever, rarities in practice, the operation often tailing when performed at the very commence- ment of the symptoms, and always when the disease shows confirmed general spasms. At times, patients Buffering from tetanus get well under the most varied treatment. Nearly every powerful remedy in the pharmacopoeia has been recommended as a sovereign cure hv those who mav have derived some benefit from such in the TREATMENT OF TETANUS. 263 treatment of tetanus. Disappointment is sure to follow the confidence placed in any of these arti- cles. The most judicious course is to disclaim all specific remedies, and be guided by the symp- toms; allay, if possible, the intense nervous ex- citement, and the local cause of irritation by which the disease is occasioned, and support the system against the ensuing exhaustion, both by sustaining the patient's strength by strong, easily digested food, and, by procuring sleep, to allow the nervous system the opportunity of regaining its wasted powers. The local treatment should consist in examin- ing the wound for foreign bodies, and removing them, if possible, as they are frequently the ex- citing cause of nervous irritation, under the pre- sumption that unless the local cause be removed we can expect but little abatement of the general tetanic excitement. Should no foreign body be found, if it be possible, an incision may be made on the cardiac side of the wound, to divide the nerves implicated, and paralyze their sensibility. The powerful acids and the actual cautery have been recommended for the similar purpose of destroying the excited nerves at (lie seat of injury; and although they may be at times d, T have seen fatal tetanus occur in ulcers '-'til TKKATMKNT OF TKTAM - under the cauterizing treatment, and I have re- cently lost a ease, after amputation of the leg, from gunshot fracture of the tibia, in which mor- tification attacked the stump. After arresting the slougTfing by the liberal use of Fuming nitric acid, and having a line of demarcation estab- lished, tetanic symptoms appeared and destroyed the patient in thirty-six hours. A solution of morphine, atropine or kindred preparations, may be instilled into the wound, for their sedative action, and the simple water dressing continued. If it be a small member wounded, such as a finger or toe, an early amputation may stop the spasm by removing the irritating cause.. This amputation should be performed irrespective of the local condition of the wound. Should the injured extremity be in a sloughy slate, so as to render its recovery doubtful, amputation should be performed at any stage of the disease. When tetanus supervenes upon an amputation, it would he better to perform a second amputation upon the early establishment of the symptoms, as good results mighl follow such a course. The constitutional treatment will have for its object to remove all general and internal causes which may keep up excitement. We should con- stantly bear in mind th< its offects can 1"' speedily and with certainty obtained. In one case, in which I injected one-tenth grain of atropine under the skin of the arm. the effect upon the pulse vgas so immediate that, in five minute-, it had increased from eighty to one hundred and fifty heats. It rapidly all'eeled (he TREATMENT 01 TETANUS. 267 salivary and mucous glands of the mouth — diminishing their secretions, without, however, producing dilatation of the pupils or causing re- laxation of the muscles. As no beneficial effect followed tne atropine injection, morphine had to be used, when relaxation to a certain extent was immediately obtained. The libera] use of belladonna has been recom- mended, and, from its great utility in relieving congestions of the lower portion of the spinal cord, we might naturally infer similar good effects for the medulla oblongata. The tincture of cannabis indica has been highly extolled. Some i lasea have recovered under its use. hut a very much larger number have died in spite of its ad- ministration. Stimulating and nourishing fluids must he Liberally administered at regular inter- \als. and, notwithstanding the difficulty in swal- lowing, the nurse should insist upon its being taken. Many a fatal ease can he laid to the charge of carelessness in nursifig, where the wishes of the patient are permitted to regulate ihe nurse 'a duties. Beef tea, eggs, milk, cus- tards, egg-nog and similar articles of concen- trated fluid nourishment, with wine, must he frequently poured down the throat of the un- willing patient, and, if the mouth cannot he ->'>- TKKATMF.NT 01 TKTANIS. sufficiently opened, the inhalation of chloroform, or the etdermic nee of morphine should be used to effect it. I have Been excellent results with either of these relaxing agents, I have t '« • 1 1 1 1 « 1 porter an cxcellcnl tonic in such cases, as it combines both sedative, nourishing, and stimu- lating or supporting properties. Dnder the fre- quent inhalation of chloroform, the spasms can often he kept under control. By pursuing the above course of keeping the patient quiet, using sedatives with forced nour- ishment, iii i < 1 relieving the Loaded intestines by crotou oil. I have had the good fortune of ing three tetanic patients out of six cases which have coin. • under my personal observation. As tin' three first cases which I treated were all restored to health, although they were very severe, 1 imagined that I hail found a success- ful mode of treating tetanus, and published the same in the Charleston Medical Journal for 1857. Since that time, I have had three cases under observation and lost them all. notwith- standing the same course was pursued as in the BUCCeSflful cases. When the patient is able, constant smoking of strong scgars may he useful in quieting the excited nervous system. The impression among W00RARA AS A IIEMKDY FOR TETANUS. 269 many observing surgeons is. thai the patient is destroyed by exhaustion — called by some starva- tion. It is known that, if the patient can be kept alive to the sixth day after the attack. there is a likelihood of his recovery, and that by the tenth day he may even he considered convalescent. If the debilitating effects of the disease can he counteracted by the free admin- istration of very nutritions food, such as brandy and eggs, etc., many surgeons believe that the nervous irritation will wear itself out. It is based upon this belief, and the known failures of the spoliative plan of treatment, that the ahove plan is now recommended. Wborara poison has been recommended as an antidote, from its known powerful sedative ner- vous action and its marked influence in counter- acting the effects of strychnia. When poisonous doses of these substances are given conjointly, nn poisonous effects are observed. The strik- ing similarity between the spasm- produced by strychnine and those of lockjaw, suggested the f woorara in tlii> latter disease. As experi- ments proved it efficacious in the tetanus of animals, its field of usefulness was enlarged to the human Bubject. Several cases <•!' it- success- ful use in chronic tetanus are reported. Tli sre L'7<> EfSCTTC n:vKR. is much difficulty in obtaining g I specimens of ilii> remedy. A- no two possess similar properties, each musl be tested by experiment before it can 1»<' tried upon the human subject. I are reported where its use hastened the death of the patient. It was first used by inoc- ulation, now it is administered in the form of a mixture: ten grains of the wdbrara to a six ounce mixture — a taBlespoonful everj half hour until perfect relaxation is produced. Should tnous effects, with death-like symptoms, show themselves from an over-dose, artificial respiration will aupport life and sustain the ac- tion of the heart until the poison j s eliminated from the circulation by the kidneys. The ra- tionale of the remedy is to keep the spasms from killing the patient by their violence, until the morbid state calling them into play has ex- hausted itself. Prom the known influence of quinine in di- minishing the pulse, and its tendency to mitigate spasms, many consider it a nse&l drug in teta- ny . and Bpeak of it as a remedy well worthy of trial. Ebctio Pbtbe. — The not a&frequent sequela of severe gunshot wounds is Long-continued dis- EBECTio fever. 271 charge, producing emaciation and hectic, with its gradual dissolution of body and soul. It is not at all surprising that the daily discharge of a wound, when at all profuse, should cause de- bility, as we have already characterized pus as the nutritive 1 essence of the circulating fluid. If the surgeon, who has many suppurating wounds under his care, overlooks the fact that lie must make allowance for this drain and feed the wound as well as the patient, the wound being more imperious in its demands than t]\e econo- my, deprives the latter of its due supply of nourishment, and progressive starvation must follow. It is on this account that what is called the antiphlogistic treatment, when fully carried out in the treatment of suppurating wounds, is injurious, and that the supporting plan is required. With diet, we have a powerful weapon for weal or woe in surgical practice. Soon after injuries have been received, when reaction runs high, by abstemiousness we can do much to quiel excessive irritability. But as soon as this stage has passed, and suppuration has become established, then the course of diet should be modified : now, liberal diet is necessary to pre- vent the febrile coin] .licat ion, which, in the 272 in < tic ikvi:k. early stage of the wound, abstemiousness con- trolled. The use of an abundance of strong, nutritious food, by enriching the blood, will increase the vital properties of the plasma, improve the tone of the ti op tin- excessive demands of the irritated wounded parts, and diminish the drain. This treatment, with Ifce Libera] use of the astrin- gent tonics, and the injectiou of stimulating astringents into the wound (as nitrate of silver, tun grains to one ounce of water, or tincture of iodine, or the acid tinetures of Iron diluted, one part to five of water), will gradually diminish a discharge, which, ander less supporting treat- ment, would continue lor a much Longer period. The economy cannot withstand this constant drain : it becomes irritable in its weakness. In its efforts t<> throw off tie' yoke, it still further enfeebles itself. Daily fevers, with their profuse sweats, reappear with fearful regularity. Finally, the blood heroines so poor, that it deteriorates rapidly, and the useless material which is ejected from the circulation, irritating the organs through which it passes, causes diarrhea, and also copious deposits in the urine. The quadruple drain from wound, -kin. bowels and kidneys, cannot long he resisted. Debility gradually increase.-, the pa- PERIODIC' PAINS. 373 tient rapidly wastes to a living skeleton, having literally melted ;nvav. and at last dies from sheer exhaustion — the conjoined result of malnutrition and wasting discharges. Such is hectic fever. Periodic Pains. — Another sequela ^i' gunshot wounds is more or less permanent or periodic pom in the injured limb, connected or not with par- alysis of certain muscles — the nervous supply to which has been impaired by the hall in its passage. When a nerve has been completely divided, permanent paralysis, with atrophy of the muscles, ensues — the limb gradually dwindling, if the muscles, indirectly destroyed, be important to the common movements of the extremity. A bruising of the nerves, without division, is also followed by a paralysis more or less persistent, which time, however, and stimulating embroca- tions will, to a great extent, remedy. This is not so much the case in sabre wounds. Where a nerve is divided by a sharp, cutting instrument, when the tissues are not displaced and the wound heals without suppuration, both experiments upon animals and experience in man show that a reunion of the ends of the nerves is effected, and nervous action restored to its former integrity. L'7 I raftlODIG PAINS When nerves are pricked, or in any other way injured withoul eomplete division, very Bevere neuralgic pains, with spasmodic action of the muscles of the limb, arc occasioned. These pains extend ap and down the injured Limb, and. as in oases reported by Guthrie, have, with irregu- lar intermissions, annoyed the patient for years. In one case, although the severity o\' the symp- toms subsided after six or seven years, annoy- ance was, at times, experienced forty years after the injury had been received. A coldness of the parts supplied by she injured nerve is not an uncommon effect, and is more or Less persist- ent. Sudden changes in the temperature, cold weather, or mental excitement, are among the exciting causes of such attacks. The best means of mitigating the suffering, independently of the application of warm flannels, is the free use of stimulating narcotic embrocations. Any combi- nation from the many articles of the materia medica, of stimulating and narcotic, or anesthetic ingredients, would fulfil the indications of treat- ment. The internal use- of quinine, aconite. hyoseyamus, belladonna or opium, will blunt sensibility. The endermic use of morphine in one-fourth grain doses, or aconitine, one-sixteenth of a PERTOmr PATNS. 275 grain dissolved in two or three drops of water. will give immediate relief — in some instances a permanent cure lias followed the firet injection. Great reliance will hereafter be placed upon this new method of treatment. A Complete division of the nerve at fault has been recommended, and practiced with some good results: but the divided nerve is liable to become diseased, or its cut ends swell into a neuroma, which, incorpor- ating itself with the cicatricial tissue. Would, from the amount of pressure exercised by the new formations, allow of only temporary relief. I MATT K R VII. Treatment of wounds of th different parts of the body, or topical surgery — Wounds of th head — Concus- sion; Us characters and treatment — Compression; Us symptoms — Variety of wounds of the head; their prognostic ruin, — Simple wow/id of the scalp ; treatment — Vracture without depression; course to be pursued when mftammaium of the brain threat- ens — Uracture, with depression, to be treated with- out an operation — Trephining very rarely called for — Compound fracture, with depression and pression ; trephining even here of doubtful propriety — Perforating wounds of the cranium complicated with foreign bodu s. Wounds of the head, when received in battle, require ;i special treatment, which cannol be engrossed in the routine' practice fdr wounds. Owing to the proximity <>f the brain and mem* branes, and the facility with which Bhocks or direcl injury can be transmitted through the pro- tective envelopes, injuries of the head possess a peculiar significance. All wounds of the head CONCUSSION. 277 are more or loss serious, as the Burgeon can never know in advance whether the brain be injured, and what amount of irritation or inflammation will ensue upon such an occurrence. Hence the necessity of caution in prognosis and treatment, which the experienced surgeon will always ex- hibit, however trivial the wonnd may appear. Injuries of the head wonld divide themselves into those produced from shot, those from the bayonet or clubbed musket, and those caused by the blow of a sabre. Wounds are found of every grade of intensity, from a simple scratch to ex- tensive destruction of the soft and hard parts, with or without those phenomena recognised as concussion and compression. As these terms will be continually referred to in speaking of the treatment of head injuries, we will, in brief, define the meaning which the surgeon attaches to them. ( 'minis*;, ,n. or stunning, appears to be a shock to the brain, by which its substance is more or leai shaken, with interference of its circulation, and often injury to its structure — its functions bring suspended for a certain period. Immediately as an injury upon the head has been received, if at all severe, the patient is knocked senseless He lie- perfectly insensible •J7^ SYMPTOJM "I OOMC1 B8ION. motionless, ami all but pulseless. Hi- face ami surface becomes pale ami cool; tin- breathiug, althougb feeble, i> regular ami easily peroi the pupils Irregularly contracted or dilated*; sphincters arc relaxed, in common with tin- en- tire voluntary muscular Bystem, so iliat the con- teuta "I' the bladder and bowels often escape involuntarily. After continuing in this condition for a few minutes, hours or days, he gradually recover- consciousness. The heart first regains it- accustomed action, tin' pulse gradually under* goei development, and the skin becomes wanner. At this period vomiting usually comes on, which arouses the action of the heart. This organ un- der the excitemenl of emesis, drives blood i<> the brain, ami with this free supply <•!' stimulus to the general controlling organ, the patient rapidly rallies. This is the common picture of concussion as .-ecu in surgical practice, and the combination of its symptoms will he more familiarly recognized as those ft' ordinary fainting or Byncope. The extremes would he those Cases in which the pa- tient staggers, hut. after supporting himself for an instanl against some house, fence or tree, recovers himself, and without further annoyance continues bis employment; or those in which tin- TATnOLOGY OF CONCUSSION. 279 patient is picked u]> apparently (load, with re- laxed muscles, pale surface, glassy eve, scarcely perceptible pulse, and very feeble and irregular respiration. The death-like appearance becomes more and more continued, the breathing gradu- ally ceases, and the pulse imperceptibly tlitters away, without any sign of consciousness from the moment of injury. In fatal cases, where concussion bad been present, the brain has been found more or less injured, and so highly congested as to exhibit a dusky hue. Fissures have been found in its sub- stance, or extravasations of blood in numerous or concentrated spots. Tn certain instances, the brain has apparently shrunk from the excessive skaking or vibrations to which it has been sub- jected, so that it no longer tills the cavity of the skull. In some fatal eases, where the brain bad been fissured, the commotion among its particles had at once annihilated its functions, so that the heart's action had instantly ceased, and no blood had been driven to the mangled brain to be ex- taavasated into it- substance. In cases oi nearly instantaneous death from concussion or stunning, the brain, on examination, appeared in every respeel bealthy. <>n the other hand, in eases of perfed recovery after concussion, where llie pa- PATHOLOGY "T CO NCI SSION liciit had lived some time (weeks or month the lull enjoyment of all his faculties, and had died from some disease totally foreign t<> the former head injury, extensive lesions have l>*«n fonnd in tli<- brain, and traces of large and ex- tended extravasations of blood covering the hem- ispheres as well as in the cerebral substance. The irritable condition <>f the brain in which the patient is often left, after concussion of limited duration, with the impairment <>!' memory, Of ©f boh ue of the special senses, or even partial paralysis, would be physiological proof of cere- bral injury. Although its symptoms are usually transient, we may. doubtless, consider it a con- tusion or interstitial laceratiou of brain >ul>- stance. As this is an alarming condition, t>> those not lamiliar with the march of Buch lesions, those interested in the injured man art- always clamor- ous for active interference, and it is with diffi- culty that th<' Burgeon can free himself from the argent solicitations of friends who believe that, unless prompt means arc used, the accident must terminate fatally. The surgeon, under such cir- cumstances, requires all of his p of mind, and with firmness should strictly pursue the non- interference plan of treatment TKKATMi'.vr of CONCUSSION. 281 The course which rational surgery now recom* mends is to lay tin 1 patient horizontally, with hie head, perhaps, a little lower than his body, so that the brain may have the benefit of gravi- tation to assist in its supply of blood. lie is wrapped in warm blankets, hot bottles are placed around his body, and dry frictions may be used to excite the re-establishment of the circulation in the extremities; hut beyond this the surgeon should not interfere. The safest practice consists in doing as I<'f/ft as possible. The use of stimuli on // !( om hand <i< lh<' other, are to be espe- cially "in/ studiously avoided. Only a few years since bleeding was the prac- tice in stunning, and the amount of mischief done by this universal mania for bloodletting was often irreparable. We might as well bleed in a faint- ing tit and expect good results. We find, as in syncope, that the heart scarcely pulsates; SO little blood is driven to the surface 1 1 1 ;i t it is pale and cold. The same for the brain, where so little flood circulates that, from want <>f its proper stimulus, its functions are temporarily suspended. Were it ] . < » r- - j 1 • I < ■ t,» draw away much flood, the tion of the nervous functions would become permanent. Modern Burgcry, in studying the natural history L'l 282 TUK ATM1N I 01 0ON< I 38T0N. of < 1 i s < ■ : i - « ■ s mid Injuries, perceives now. what it should long Binoe have recoguized, thai nature, in her desire to harbor the circulating fluid, tries to pin ;i safeguard agaiust the rashness of Bur- geons, 1'v shutting up the bulls of this living fluid in the inner red ee of the body, when it cannot be easily despoiled. On accounl of this change in practice, we now seldom hear of deaths from concussion, which was comparatively of com- mon occurrence a few years hack. As regards stimulation, we must also desisl as long as it is possible, and, when its administra- tion is compulsory, give it with a most cautious. Bparing hand. Remember that the degree ami duration of shock depends upon the extent of injury which the brain lias received, ami that nature always the most skilful physician, adopts this concussion as a safeguard to prevent further mischief. I low are we to know that the brain has not sustained severe injury, extensive bruising or laceration, and that this extreme depression of the system, with consecutive control of the heart's action, is not especially indicated to prevent hem- orrhage within the brain substance, and rapid death from compression by extravasated blood? We know this, that after severe injury to the brain, when, through officious meddling and the TREATMENT OF CONCUSSION. 283 five use of brandy, the symptoms of concussion early disappear, violent reaction is induced, and internal hemorrhage or violent inflammation soon shows itself; and that, for the doubtful gratifica- tion of seeing the patient rapidly revive, we have the mortification of seeing him as rapidly de- stroyed. Oases of concussion, absolutely requiring stimulants, are* but very, very seldom met with in practice. Even when of a very severe form, all that is necessary, in the vast majority of cases, is to apply warmth to the surface, and carefully to watch the case. Should it so happen — hut this occurs very rare- ly — that the patient is manifestly in danger of sinking from depression of the circulation, then stimulants must he resorted to. As long as the pulse does not lose its strength under concussion of the brain, desist from active interference, al- though the insensibility last for hours or even days. After-trouble will he avoided by allowing nature to take its own course unmolested. When from the great and long-continued depression stimuli are called for to prevent threatening dis- solution, their effects should he carefully watched, ami. as Boon as reaction is apparent, with an im- proving pulee, :it once desist from rurthei inter- ference. As is the state of depression, so will 284 OOHPRSSSION. be the state of reaction. WheD the depreeeioa is extreme, 1 1 1 « • reaction will be correspondingly re, and especially bo, if stimuli have been freely administered. When the patient has recovered from the state of insensibility, be Bhoald be kept perfectly quiet; excitement of every kind should be carefully avoided, the diet Bhould be abstemious, Ehe head kept cool, and tendency to constipation cor- rected. Beyond thia no treatment is required until expressly called for by excessive reaction, with Bymptoms of congestion or inflammation ef the brain. The precautionary bleeding, with re- peated scs of calomel, to keep off Bymptoms which, in the majority of Oases, would not have occurred, was the routine practice of the <>ld school, and cannot be too severely criticised. The complications which might arise in injuries of the head, after more or less serious concus- sion, will be hereafter considered. Compression. — Concussion is always simulta- neous with the blow, and gradually decreases, it' death does not carry oil' the patient at an early period. Compression, the condition with which it is often allied, usually comes on some little time after the reception of injury, although it SYMPTOMS OF COMPRESSION. 285 may appear either at the moment, or may not show itself for days, or even weeks, after the in- jury. The name explains the lesion. Compres- sion is pressure made upon the brain, either by a portion of the skull or some foreign body driven into or upon the cerebral mass; or by an escape of blood from some torn vessel, which, by forc- ing itself into the unyielding skull, compresses its contents, or by an effusion of lymph or pus, which inflammation causes to be deposited within the cavity of the skull. The symptoms by which this condition would be recognized, are as follows: The patient lies in a state of coma, stupor, or lethargy — being paralyzed more or less completely, both as re- gards motion and sensation, lie is heavy, insen- sible, and drowsy; at times answers mutteringly when rudely shaken or loudly spoken to, but immediately afterward is again breathing slowly, heavily and laboriously, as if in deep Bleep. Should his t'aee be examined, the lips and cheek on one side will be found to flap during expi- ration, with a blowing sound, as if smoke was being blown from the mouth as in smoking. There is paralysis of that side of the body op- posite to the seal of injury, and. as a necessary B86 SYMPTOMS Off OOMffKBSSION consequence, both in expiration or in attempts :ii speaking, the corner of tin- month is drawn over t" the sound side. The counteuan< usually pale, cold, ;ui<1 ghastly, although it may be flushed, with a 1 * « » t and perspiring skin: the eyelids ;uv partly or completely opened, with the pupils dilated and insensible t<> light; the pulse is slow, the heart acting under greal oppression ; there is constipation from torpidity of the bowels, with involuntary discharge of the faeces. From want of action in the bladder the urine is re- tained, and, unless drawn oil*, will decompose within the organ, when, from accumulation, either the bladder will rupture with poisonous infiltra- tion, or the blood becomes poisoned from absorp- tion. These symptoms are not always equally marked — the degree depending upon the cause. Unless the causes of compression be removed, the ease usually terminates fatally, although ease- are not rare in which, after weeks of uncon- sciousness, reason has gradually been restored — the accompanying paralysis slowly disappearing. Having now explained the two conditions of concussion ami compression, which so commonly accompany Bevere wounds of the head, we are heiier prepared to study this special class iA' in- juries. DISEASES OF HEAD INJURIES. 287 The divisions which experience lias proved of practical utility, are : 1. Injury to the soft parts alone, uncompli- cated "WITH INJURY TO SKILL OB BRAIN. -. Wound op soft parts, with simple frac- ture OF THE SKULL. 3. Wound with depressed fracture of the SKULL, RUT WITHOUT SYMPTOMS OF COMPRESSION. 4. Compound depressed fracture of the skirl. WITH SYMPTOMS OF COMPRESSION OF Till; RRAIX. 5. Perforating woi ni>s of the skull, compli- cated WITH FOREIGN BODIES. From the peculiar formation of the skull, and the resistance which it offers to Mows, unless a shot strikes it fairly at right angles, it does not perforate; but whether it be a grape, musket, or pistol ball, it Hies off at a tangent, and running beneath the skin upward, downward, or laterally, escapea The head may even be struck with a round shot without serious injury. The patient may, or may not be knocked down by the blow; severe pain is felt, and a puffing up of the part instantly follows. When the hair is remove], although there may be uo discoloration of the skin, there is abundant evi- dence of subcutaneous Lesion, which, unless ooun- 288 TRKATMKNT Off SIMIM,K IH'.Ah I VI I RIBS. tcracted, will soon develop inflammation and extensive suppuration. The severity of the blow upon the head may have knocked the patient senseless; ami in this condition, he La found hy the litter earners. The transportation of head injuries requires great care, and the best transports should be devoted to this service. When the patient ar- rives at the Held infirmary, be is laid down, with the head low, until lie recovers himself. The nation is left to nature: cold water may he dashed into the face, hut all stimulation should be avoided unless the pulse is found to flag, when a little brandy may he cautiously given. The surgeon takes advantage ^\ the insensibility of the patient, shaves the head at the point of injury, and gives the wound a thorough exam- ination. When reaction has taken place, and the patient is restored to consciousness, should the wound have been a simple one of the sofH parts, the cold water dressings is all that will he required, and should he applied according to general principles. The thin, wet compress, with oiled or waxed cloth, should cover the wound and head \'<>v some distance around the injury; and instead of tying these in place by the roll yi\' bandage, the better plan i.> to adopt the bead TREATMENT OP SIMPLE HEAD IN.MH1ES. 281* net of the Prussian medical service. It is a round piece of coarse netting, made of cotton yarn: a string tics under the chin to keep the dressing on, and a drawing-string running around the net, Like a purse string, attaches it securely to the head around the temples. This is an admiral )le dressing for all head injuries, Which require light, cool, and efficient applications. Should the soft parte have been much bruised, the ice bladder will he required to keep down excessive suppuration. To prevent mischief, all injuries of the head demand rest and quiet, avoidance of stimulants, and abstemious diet. By adopting this course in uncomplicated wounds, whether gunshot or sahre, a speedy cure is usu- ally obtained. Effusions of blood under the skin should not he interfered with; incisions are -not required. If the effusions are allowed to remain excluded from air. tlic cold water dressings, with arnica, will cause their rapid absorption; if the skin is punctured and air admitted, suppuration will surely ensue. Should suppuration occur, as soon as pUS can he clearly detected, let it out by a small incision. If this operation he not attended to at the pp. .per time, the pent-up pus will sepa- rate the periosteum from the skull, and cause, 29U TRKATMKNT > the brain or its meninges, should be managed according to the ordinary principles of surgery^ remembering always, how- ever, that the braitt is in rtear proximity, and may have hern injured, although no symptoms arc present for detecting such a lesion. If the patient is iinVnsihle, Ave adopt the means already recommended for removing shock, viz: place the btidy in a horizontal posture, and leave the ease pretty much' to nature — avoiding everything tend- ing to internal stimulation. Whilst Insensible, we examine the wound thoroughly, usin£ the finger as a probe; and if any loose Spiculte Of bone be felt (pule five in the wound and uncon- nected with the soft parts, they should he re- TRKATMKNT OF FRACTUUK OF SKULL. 291 moved. If attacked, they must be left to escape spontaneously after Suppuration is established. Gunshot fractures are usually distinctly limit- ed to the portion struck, and seldom ramify as do fractures from diffused blows. It is this con- centration of the force within a small compass, and the extended injury to the inner tablet of the skull, which render irunshot injuries of the head so serious. When we are satisfied, from a careful exami- nation of the condition of the bones, that they remain in their normal position without depres- sion, the head is shaved, and the wound care- fully closed with a strip of adhesive plaster so as to exclude air. As soon as the patient has revived, the cold water or ice treatment is at once instituted. Should there have been but little shock from the injury, these wet applica- tions should be commenced with on the battle field. When the patient is put to bed (which should be as soon as possible, for early treatment is all-imp<>rtant), his head and shoulders should be elevated : quiet and absolute rest should be strictly enjoined : the room should be darkened ; all .-tiniuli, including light and noise, should be avoided : the bowels should he freely opened by 292 TRKATMKM OK FRACTIRK Of BK1 II. a saline, mercurial, or Bloetic cathartic; ami l'<>r a few days. abstemious diet prescribed. These precautions are necessary t<> prevent irritation of tli.' brain, willi subsequent < - « n i ir » ■ ^- 1 i « » 1 1 , intlamma- tion and effusion. It* the patient appears irrita- ble and peevish, without heat of head or fulness of pulse, give <>]»iuni to quiet him. Tin- rase should be watched with care, and if symptoms of congestion of the brain threaten, with injection of the face, red eves, hot skin, forcible throbbing of the carotids, increasing headache, with an early tendency to delirium, the patient should be at once bled, the head should be shaved, and an ire bladder be assidu- ously applied over the entire scalp; the intes- tines should be freely acted upon for the revul- sive effect upon the brain, and. for a similar reason, sinapisms should be applied to the legs and thighs. Should relief not be promptly ob- tained, leeches or cups might be applied to the mastoid processes. Calomel was formerly the universal prescription for threatening cerebral in- flammation. Salivation was induced as early as possible, and when the system was brought under its influence, the patient was considered compar- atively sate In modern BUrgery, calomel has lost its hi^h position, and the, dependence upon TREATMENT OF FRACTURE OF SKULL. 293 its salivating powers is annually diminishing. Many still administer it, but not with the con- fidence of former times. Should this threatened inflammation not sub- side under this course of treatment, but, after a period of high febrile excitement, the delirium becomes merged into stupor, with noisy breath- ing, dilated pupils, slow, labored pulse, relaxed Sphincters and paralysis, the case indicates com- pression from effusion, within or upon the brain, and chances tor life become very doubtful. Per- haps a thick layer of lymph may have formed upon the cerebral surface, or a quantity of serous fluid collected in the ventricles, or a circum- scribed or diffused abscess in or upon the brain. This lymphy effusion sometimes covers the entire surface of one or both hemispheres. The arach- noidal membrane appears to be the one chiefly inflamed. It is thickened, semi opaque, adherent t<> the brain surface, and reddened in patches. The pit mater and brain substance is highly injected. It', with the occurrence of these symptoms, the patient lie seized with chills, the scalp wound becoming dry. and the tissues puffy, or a col- lection forms under the periosteum, lifting this membrane from the bones which appear dry and 294 TREATMENT OS 9BAC1VB1 Of I R 1 I I yellow, it would indicate, in many instances, a circumscribed collection <>i' pus within 1 1 1 * - skull. These symptoms might be> bnl very rarely arc relieved by the nae uf the trephine. As a gen- eral rule, tlif operation hastens the fatal catas- trophy. Unless an external Sbscead, with the characteristic puffy scalp, defines the collection of effusions' within, the trephine should not be used. It often happens, after trephining, that these supposed collections have not been found, and it is only alter tin- operation that tin- seem* tion of pos has been established. When air is admitted, suppuration is certain ; whilst without the operation the effusions are known, in many instances, to have been absorbed — the patient re- covering alter remaining insensible, in one as loug as twenty-one days. Cole, in his Military Surgery, mentions eases of fracture of the skull from hall, without the skin being torn. Unless the hones arc much detached, as they were in one of his cases, the condition can only he BUSpected. Such injuries must he treated under the antiphlogistic expect- ant plan. An nil symptoms before n- tbrferenci is instituted, M u vv€ thai we will ftnd the point where hemorrhage bee taken place, of thai the Mood i- still fluid ami cau be nsmoved — both very improbable re- sults. Blood-vessels may bave given way ai any other portion of the brain than at the portion corresponding to the point where the skull is injured. The. recoil of the contents <>f the skull may have raptured vessels diametrically opposite to the injured point. Autopsies not unusually reveal such conditions. The operation "t* trephining is always very Berious /"/• at, and is sufficient of i t >•*■ 1 1" to cause cerebral or meningeal inflammation, which will nearly always terminate fatally. The operation is often more serious thai the condition for which it is used, and, although the patient might recover from cither, he succumbs under the combination. Experience and autopsies have shown us many oases of extensive intra-craniaJ hemorrhage, which have been unaccompanied by symptoms denoting such an accident ; and the traces of such have been found when the pa- tient, recovering from his head injury, had, at some subsequent period, fallen a victim to a totally foreign disease. Had such a condition been inspected, and the surgeon used his instru* ments, an autopsy at a much earlier day would have revealed the condition. TKKATMKNT 00 FRACTURE OF SKCT.l,. L".l7 7 he third variety <>/ mjvry oj the head, with de~ prossion of the skull, belongs to a more serious <-l:iss of woui^ls. The complication is detected at once by examining the wound with the tin- ker, when the sinking of the boties is felt, tlic extent of injury is detected, and the condition of the depressed portion, whether en masse or spicu- lated, determined. The broken fragments, if quite loose, should be removed within the first twenty- four hours after the injury and before reaction ,sets in. When concussion lias passed off, and no symptoms exist indicating injurious pressure upon the brain, the case should be treated in even- respect as if no depressed fragments existed. Un- less we see clearly that the bone is very much -piculated, and that sharp fragments are pierc- ing the meninges, avoid all instrumental interfer- ence, even to dilating the wound, for the pur- pose <>f facilitating a more accurate diagnosis. We should never be anxious to set' the symp- toms of concussion rapidly disappear: let nature abide her time: watch the case, and ^<'<. that the patient sutlers no detriment. Examim frequently t/u pulse, but i")i flu head, and as long as it sustains its, if. everything is working to tin ul congestion bj rest, quiet, cold, revulsives and venesection, rather than by the trephine, which experience hat Bhowii t<» be unprofitable. Opium is now seed with much greater freedom in the treatment of injuries of the head than formerly; and, when administered with discre- tion, will, to a certain extent, take the place <>t" trephining. Whenever the patient is restless, .sleepless, and irritable with delirium, should the face not he red. nor head hot. it can lie used with safety and benefit. When suppuration is established in the wound, and granulations commence to form, those por- tions of bone which cannot he saved, will gra- dually become detached and will escape. A tendency to bleeding in the granulations of the WOUnd is an indication that the fragments of bone have become loose, and are ready to lie removed. This symptom, which is a valuable one, must he noted. 7'A. fourth variety of injury to >/" /■<>> compound fracture, with depressed fragments, is <■<,sues to injurious atmospheric influences, and hasten on a violent, and usually fatal, inflam- mation. If the brain and membranes lie not injured, then ii i> said that the brain will soon become accustomed to the pressure; and, although in- sensibility may continue for hours, days, or, as in many instances of ultimate recovery, for weeks, the symptoms of compression will gradually pass off. By not using instruments, the surgeon has the satisfaction of knowing that he has not increased the local trouble by a serious opera- tion. Th< removal of the symptoms of com- 302 TREPHINING NOT REQUIRED IN lll.\l> IN.IfHlKS pression being very gradual, excessive reaction is not likely to follow; and as m> air lias been admitted t<» the effusions beneath the skull, the probability <>f suppuration will he much dimin- ished. When effusions have taken place, the depressed bone acta as a covering, excluding air with its injurious chemical influences. Fluids, uncontaminated by decomposition, can In- ab- sorbed. When the skull is opened, and the free admission of air is permitted, suppuration, with, perhaps, pyaemia, is prone t<> occur. Stromyer, who is one of the highesl authori- ties on gunshot wounds of the head, and who? as sargeon»in-chief of the Scbleswig-IIolstein army. bad every facility for studying his favorite branch of Burgery, gives us as the resull <>r Ms experience, observation and study, thai the tre- phine can be abandoned in military surgery. In a supplement to his work on Military Surgery, recently published, he states: " that in military surgery, trephining is never needed. — When the ease i« §e severe as to require the trephine in gun- shot wound-, the patient will die in spite of it." In the last two campaigns, in which he had charge of tfie army, he has not trephined. Loeffler, a distinguished Burgeon in the Prus- sian Service, who has published one of the hest TREPHINING NOT REQUIRED IN HEAD INJURIES. 303 books of instruction for military burgeons, after acknowledging Stromyer as the master in all relating to the treatment of gunshot wounds of the head, endorses His views in opposition to trephining. McLeod gives the following as the Crimean experience: vk .\s to the use of the trephine — the oases and time for its application — less differ- ence of opinion, I believe, exists among the experienced army surgeons than among civil- inns: and T think the decided tendency aiflong them is to endorse the modern 'treatment by expectancy.' and to avoid operating except in rare eases. In this, T believe they judge wisely: for when we examine the question carefully, we find that there is not one single indication for Having recourse to operations; which cannot, by the adduction <>f pertinent cases, be shown to be often fallacious." HeWCtt, in a series of lectures on injuries of the head, published in the Medi- cal Times and Gazette for 1859, which form the moet complete treatise extant on the subject, is equally adverse to the trephine. Guthrie, Cole, and Williamson, in their reports, equally confirm the dangers of the trephine; and the great fatality accompanying its use. The entire records of the science mav be ,,n 1 FOREIGN BODIES IN BRAIN. searched in vain, to tind a duplicate series of successful cases to that reported by Stromyer. of forty-one cases of fracture, with depression from gunshot wounds, in many of which it was probable that the brain and membranes were injured, only seven died — all the rest recovered. In only one case was there any operative inter- ference, although signs of secondary compression ap- peared in several. The antiphlogistic treatment, carefully carried out, was alone adhered to. No surgeon dan doubt that the operation of trephining has cost many a man his life, and although many cases have recovered after the operation, it is a question whether, in the ma- jority of cases, more rapid recovery would not have been obtained without it. When symptoms of compression ensue in the course of treatment, continue the steady, onward use of antiphlogistic remedies. At this junc- ture, many surgeons recommend calomel pushed to salivation, which sonic state to he synonymous with salvation. There is no unanimity, however, on this head ; the modern tendency is to treat such cases without the use of mercury. When bails penetrate or perforate the cra- nium, the detached pieces <>f bone are driven before the hall into the substance of the brain. FORKIGN BODIES IN BR A IX. 305 The resistance which the ball meets changes its course, and glancing from the depressed fragt- ment, it takes a different direction — burying itself in the brain at some distance from tin; piece ot bone. In by far the majority of cases, deatli is instantaneous, or soon follows the re- ceipt of injury. There are, nevertheless, a lew- exceptions to this rule, in which the patient, recovering from the shock and sequelae, lias carried the ball or other missile in his brain for rears; and, eventually dying of some disease unconnected with the head, an autopsy revealed the ball embedded in the brain, and surrounded by a mass of lymph. Of ninety-one cases of penetrating and perforating gunshot wounds of the head which were admitted into hospital in the Crimea, all. without exception, proved fatal. When the openings are examined, it will be found that the ho].' made in the outer tablet is more or less smooth, whilst the orifice in the inner tablet is much more extensively fractured, and usually much spiculated. This condition of the orifices is owing more to the direction of the blow than from any supposed brittleness in the inner tablet ; i'o\\ should the ball traverse from within outward, the reversed condition is found. It would be folly to attempt tin' search rO&l I'.N DOBXl I IN HRAIN. after such foreign bodies for r 1 1 « - purpose of re- Eooving them, as inch :i piece af meddlesome iv would ensure a fatal issue, whatever bopi of recovery might have been entertained.* Cole, in hi> [ndian Reports, mentions "that there are many soldiers now doing duty in ear ranks, for whom (having been wounded in their heads during the late war) the medical officers had not the smallest hope; and every military Burgeon, who has had inndi practice in the field, has learned not to despair so long as lite remains." The thorough probing <>t' Buch i t" satisfy the curiosity of a Burgeon, would -nun have destroyed all hope, with tin- lite of the patient The genera] treatment of such cases should in nowise differ from that laid down for the treat- ment of lu-ad injuries in general. The concus- sion and compression, which arc well marked and alwavs present, must l>c combated by using all tin' precautions which have been already pointed out. we might now sum op, in a few words, the • On one occasion, by thi bougie, K:ir.>n Larrev red ball wlii.-li had penetrated ili< forehead, and, trarel- mg the dura mater, had lodged al and under the occipital protuberance, whence ii was Buocessfullj removed bj trephining. — • lot IfedietUi 0) tain . /'■• SUMMARY OF INJURIES IN HEAP. 307 rational and successful treatment of gunshot wounds of the head. In concussion, unless there is evident sinking, leave the case to nature, and avoid, studiously, both stimulation and venesec- tion. When the patient is restored to con- sciousness, should imiiammation of the brain threaten, if there be no congestion of the face, give opium to allay irritation. Should conges- tion be evident, use the antiphlogistic treat- ment, locally and generally, commencing with venesection, and with ice applications to the head. In every ease, absolute quiet and rest are essential. For the want of a proper sen- tinel at the door of the ward in which head injuries are being treated, many cases have been tagfc All gunshot injuries of the head are seri- ous, however trivial they may seem, inasmuch as violent inflammation often follows slight wounds; all. therefore, should be carefully watched. Chronui ostitis or periostitis, resulting from gun- shot wounds, possesses no peculiarity, and should be combated by iodide of potassium. OH A P T E R VIII. Wounds of (hi Fan — Fractures of the I "/'/"'• >/■< neck "ft divided, th> necessity of ligatmg the bleeding mouths. Wot NDfi -I i ill. I 1 ' H i:. when they »1<> not im- plicate the brain, are not usually of a ^«.i i« >uh character. The Bevere cute about the face, made by tin' Bab re or by pieces of shell, should be treated bo as to obtain adhesion by the first in- tention. The lips should be brought together by sutures, and eoid water dressings will com- plete tin 1 cure. The excessive swelling, which accompanies many injuries of the face, impe- rially gunshot wounds and bums from explosion • '!' powder, is readily controlled by cold water dressings. It inns its harmless course, mod- erated by the cold applications, and subsides at the end of a lew days. In the Italian cam- paign. I Baw cases in which Minnie halls had traversed the full breadth of the face, passing WOUNDS OF THE FACE. o09 through each malar bone, without leaving any injurious sequelae. The rapidity with which all wounds of the face heal lias often boon re- marked. The most common injuries to the face from gunshot wounds are fractures of the upper and lower jaws. Balls often become embedded in i lie soft, spongy bones of the thee, and. if not discovered, are in time discharged spontaneously When the bones of the face are struck by a grapeshot, or a flattened conical ball, there may be great destruction of the features, followed by shocking deformity. The senses are not (infrequently destroyed — sight or smell being often impaired, it' not com- pletely lost, after gunshot injuries. Where the wound has been Deceived in the orbit, the loss of vision is not only very probable, but there is great fear that the cause producing the injurv, whether it be a ball, bayonet, or a sword point, may have perforated the thin plate of tin- skull, and, entering the brain, may induce cerebral in- flammation. Many cases of apparently trivial wounds of the eyelids have terminated fatally, and an autopsy revealed serious injury to the anterior lobes of the brain and its enveloping membranes. Such eases should be carefully 310 WOUNDS OF TOE FACK. watched, and any cerebral symptoms which may arise should be actively met by the antiphlogistic treatment, headed by venesection. From tbe great vascularity of all the struct- ures composing tbe face, we would expect to have serious hemorrhage accompanying all inju- ries — for controlling which, the astringent pee* parations <>\' iron will be frequently required. The vessels are BO numerous that the direct application of ligatures cannot be made. In fractures of the upper jaw, the hones are always more or less spiculated, with one or more teeth loosened or completely detached. As all por- tions are freely Bupp'lied with blood-vessels, union will take place among the fragments, even after considerable shattering of the hones. Unless the fragments are either completely detached or hut slightly adherent, they should not be taken away, hut should he replaced with care, as, in time, consolidation may lake place, and very little permanent deformity will he left. Should some of these fragments die, they will be found loose, often as early as the sixth or eighth day, and should be removed. The cold water dressings, to relieve the excessive swelling, with an eeesM sional dose of salts, is the only medication re- quired. The wound in the face should he closed FRACTURES OF BONES OF TflE FACE. 311 with adhesive plaster, and. after careful adjust- ment of the movable fragments, and the use of cold water dressings for a few days, the case is left pretty much to nature. When the soft parts, as well as the hones, are crushed, secondary hemorrhage frequently recurs, as the sloughing tissues come away. Formerly, the difficulty of restraining this loss of hlood was so great as to require, in many cases, the ligation of the main vessels in the neck. AVe now find the local application of the per-chlo- ride or per-snlphate of iron an efficient remedy. Should necrosis follow injuries to the hones of the face, the dead pieces of hone should he re- moved as they become loosened, or a special operation may he undertaken for ridding the face of the local cause of trouble. Fractures of the lower jaw are not a rare accident on the battle field, whether caused by shot wounds or other casualties. At times, the entire jaw may he swept off by a round shot, leaving the mouth and throa*t exposed. One of the most fearful cases on record of such an in- jury i> one in which the entire face was carried away l>v a cannon ball, leaving nothing but the skull proper appended to the vertebral column. The opened gullet marked the former >ite of 312 FRACTl RES OF BONES OF THE FACE. the features. The patient lived ten hours, aud from tin' frequent change of positiou, and the squeezing of.the hand when his was taken, it was thought that consciousness remained up to the time of death. The surgeon accompanying the transport usu- ally sends injuries of the face to the Held in- firmary uutouched, or, should the lower jaw be broken, applies a folded handkerchief, or hand, under it to support it. This fracture is perma- nently put up at the field infirmary in a paste- hoard splint, well padded with carded cotton, and secured by a folded cloth or double-tailed band- One hand passes over the vertex, support- ing the .jaws, whilst the other passes from the front of the chin behind the head, and then around the forehead, where it is secured by pins. Before the dressings are applied, the wounds should have been examined carefully with the finger, and all perfect ly-detached spiciilaa of hone should have been removed. The surgeon must be prepared to meet* much swelling and profuse salivatiou. All gunshot injuries to the hones of the face being compound, suppuration is soon established, and the secretion of pus is copious. It will add much to the comfort of the patient, if his mouth be swabbed out daily with a piece WOUNDS OF THE NKCK. 313 of soft rag or sponge attached to a thin piece of wood. From the difficulty in swallowing, fluid nourishment must be prescribed. "Flu 1 con- stant thirst of those wounded will be relieved by small doses of morphine, or by acidulated drinks, made either with diluted nitric acid or Vinegar. Injuries about the face are very liable to erysipelatous attacks. The treatment by the tincture of the muriate of iron, locally and gen- rally, will stop its progress. Wounds of iht me/,-, with injury to the numer- ous Large vessels which course through this con- stricted region, arc among the serious accidents in battle. From the anatomy of this region, we would suppose that a missile could not traverse tin' neck in any direction without destroying some important part. We find, after every great bat- tle, the neck perforated by balls in every direc- tion, accompanied by violent bemorrhages ; yet, with the first fainting brought on from shock and loss of blood, we find a spontaneous cessa- tion of the bleeding, and the onward progress of tin' case becomes one of continued convalescence, to perfect cicatrization. 1 have seen conical balls perforate the neck antero-posteriorly, entering just above the sterno-clavieular junction, and passing in the mid.-i. it not through, the largest vessels of 27 ;; | | WOUNDS OP THE NECK. the body, without producing a fatal hemorrhage. I have also seen them perforate the throat tateN ally, on a level with and just hehind the angle of the lower jaw. Mid a cure equally follow. Ii n wonderful how the great vessels escape-, <»r the rapidity with which clots form and the wounds of such vessels etose. McLeod reports one hundred and twenty-etght cases, more or less severely in- jured in the neck, with but four deaths. Many, to be sure, die on the battle field in a few mo- ments after receiving a serious injury to the large arteries; but, Undoubtedly, many also recover. The powerful iron styptics, with methodically applied compresses and bandages, arc the only local remedies applicable on the battle field, as thi' assistant surgeon, following the troops, has neither the time nor conveniences for ligating the bleeding mouths of the divided vessel, how- ever urgently it may he needed. The preeau- tions which were urged in discussing the means of arresting hemorrhage in wounds generally, must here he carefully applied ; ami should sec- ondary hemorrhage occur, notwithstanding the pareful application of the iron styptic, the safety of the patient will then He only in the ligation of both bleeding orifices : the anastomosis of the blood-vessels in the neck being so free that all WOUNDS OF THE NECK. 315 other operations will be futile, and the patient will perish. A ligature upon the carotid artery, at a short distance both above and below the wound, has been reported a failure in control- ling a hemorrhage, whieh was only checked by dilating the wound and lighting the artery at the point injured. In enlarging the wound, the in- cision will always be made parallel with the axis of the neck, so as to avoid injuring important nerves or blood-vessels. CJJ A 1'T ]•; !i IX. Wounds of ihi < 'lust— Plesh wounds — Effusions within //,, cavity when the pleura is injured — Wounds of th( heart or lung — A transfixed Chest does riot necessarily imply a />< rforated Lung — Diagnostic value of the various symptoms — Haemoptysis, Dysp- noea, Collapse, Emphysema — Treatment of Chest wounds — How inflammatory complications are to be combated — The treatment of a Fractured Bib. Wounds of tii:: Chest, when taken as a class, are, perhaps, the most fatal of gunshot wounds. Many are shot down, and die more or less rapidly on the hattle held from internal hemorrhage, with its accompanying suffocation, and are returned among the killed. Fraser, in an excellent trea- tise on chest wounds, based upon data obtained in the Crimea, states the mortality to have been twenty-eight per cent, of all chest wounds, and seventy-nine per cent, of those in which the lung had been injured. The Russian Crimean reports give as their mortality in chest wounds ninety- eight per cent., which is sufficient proof of the FLESH WOUNDS OK TI1K Clll'.ST. :>17 serious character bf this lesion. The danger in wounds of the thorax is from visceral complica- tions. Should the lung be severely injured, the case usually terminates fatally. From the peculiar formation oi' the thoracic box and the curve of the ribs, halls, in striking, are often deflected from the straight line, and, after a longer or shorter course, escape without having penetrated the chest. Often, the two openings correspond so accurately in direction as to establish a strong conviction of a direct pas- sage through or across the thorax, when the wound has been but a subcutaneous one through- out: I have seen an instance similar to reported cases, iu which a ball, which had entered the chest just below the left armpit, was removed from a similar position in the right side, and although it had apparently traversed the thorax, no inconvenience was experienced ; its entire course had been subcutaneous. This tortuous track can only be made by a ball striking at a considerable obliquity. Its direction is generally indicated by a reddish or purplish line under the skiu. which, when followed by the finger pressed on the surface, imparts a crackling sensation, caused by sir in ilie cellular tissue. Such inju- ries arc usually simple, and require but little Slfl -lloCK l\ CHEST INJURIES. treatment. The cold water dressing Jills every indication, and it- application for a few days usually effects a owe. A great amount of nervous shock often accom- panies \< ry trivial injuries of the chest. Many instances are mentioned by military surgeons, in which balls had struck articles about ilic person of the soldier — tlic breast-plate of a cuirassier, or, perhaps, a book in the breast-pocket of a soldier's coat — and had fallen to the ground with- out even touching the skin, yet the soldier had been knocked down breathless, and, in boom eases, did not recover completely from the shock for dnys. Wlien the ball has penetrated the chest, it may course for some distance between the ribs and the pleura, when it may either escape from the cavity, and be found under the skin, or remain capped by the pleura. Such cases may give no trouble, or pleuritis may ensue, which the rational signs, with auscultation, will detect, and an antiphlogistic course, accompanied with the i'vvc ii.-e of opium, will readily subdue. Opium, when u-ed in large and frequently repeated doses, possesses oiher virtues than merely allaying pain and quietiug nervous symptoms. It combats, directly, intlammat ion, and, by the greal control PKRFORATlXi: WOUNDS OF THE CIIKNT. 310 which it exercises over the brain and circulation, becomes, in the treat meal pf the serious sequelae of wounds, one of the most, if not the most valu- able remedy of the materia niedica. When given in combination with nitrate or carb. of soda, its nauseating effects are counteracted. The evil which the surgeon fears from perfo- rating wounds, followed by inflammation, is that a serous, or sero-purulent effusion may rapidly accumulate in the thoracic cavity, and destroy the patient So rapidly is this fluid formed, in many cases, that the chest has been known to fill in twenty-four pr forty-eight hours — the fluid compressing and condensing the lung against the vertebral column. In expanding the chest, it will lie found that as soon as a thin layer of fluid is effused into the cavity, separating the lung from the thoracic wall, the respiratory murmur becomes very feeble, and will altogether disappear when the <;i\ity ie filled. At the same time, respiration becomes much embarrassed, with marked dysp- noea* Percussing the side, will now give a dull, heavy sound, instead pf the ordinary clear, sonor- ous one of health; and the position of the pa- tient, unless the cavity is filled with fluid, must vary the sound by the gravitation ,,1' the serous collection. The lung is condensed and flattened PERFORATING WOUNDS <»F TFIE C1TV.ST. -t the vertebral column, and is temporarily impervious to air; trader n long continuan* the pressure, \\ will become permanently consoli- i. The increase in the circumference of the chest, and the rulness of the intercostal B] with the absence, to a greal extent, of respiratory movements upon the affected side, are conspicu- ous svin|it(iiiis of a distended cavity. The quantity of fluid thrown out varies from I few ounces to several pints. When the natural dimensions of the cavity are not sufficiently ex- tensive to accommodate it. it forces the medias- tinum over to the sound side, interfering with the action of the healthy lung, whilst an encroach- rrienl may be equally made upon the abdomen. When the surgeon has recognized such collec- tions as rapidly forming in the chest after gunshot wounds", accompanied by distressing Bymptoms of dyspnoea, an early evacuation will be required: Should the collection be purulent, and show a disposition to point, an opening for the escape of the fluid should be made at the point which nature indicates; but, in cases of excessive effu- sion, any broad Intercostal space, between the sixth and eighth ribs on the right, or between the seventh and ninth on the left, might be the point selected. The instrument, usually a trocar LTJNO WOUND IN CUEST TN.TIU1KS. "21 and canula, should be introduced at right angles to the chest and near the upper edge of t lio 11 1 » . toward its angle, in a lino continuous with tlio posterior border of the armpit. As this punc- ture corresponds with the lowest portion of the cavity, the chest can be perfectly drained through it. In all gunshot injuries of the chest, the most serious complication is injury to the Lungs or heart, and it is often difficult to detect at first such lesions. Notwithstanding the many infalli- ble signs laid down by authors, military surgeons of experience inform us that no one symptom is sufficient for making a diagnosis. When the heart is injured, although instantaneous death (\m'> not take place as a general rule, the wounded man lives but a short period. The pericardium soon becomes tilled with blond; the action of the heart is mechanically impeded, and. sooner or later, depending upon the size of the wound and the facility for letting out blood, it ceases its pnlsation. Report* of eases are not very rare in which small, oblique incised wounds of the heart have been recovered from : and even gunshot wounds of this organ, perfo- rating it> cavities, have escaped with life. When the pericardium is perforated, and the heart not 32'J l.l N<; WOUND IN CHEST IN.II llll.s. i ii j u ihm I . a successful result might be obtained by a judicious course of antiphlogistic treatment, which will keep down inflammation, with ii- I I- fitsions ai lymph and serum. The Lung often escapes injury when, from the position of thr wounds of entrance and <>!' exit, with the certainty of the cavity beiug transfixed, the natural belief would lead t<> a perforation <«t" the organ. A straight line between tin- wounds is apparently through tin 1 substance of tin- Lung, but the ball, in perforating the rib. had been deflected from its straight course, had fol- lowed, perhaps, the inner curve of tin- chest, and. meeting with some resistance, had forced its way through the chest — either appearing un- der the tough, elastic skin, or cutting its way out without having touched the contained organs. The Lung may. on the other hand, be severely injured when no perforating wound exists. A blow by a spent ball, or a fragment oi' shell, may make a very superficial wound or bruise in ihe skin, and yet may shatter one or more ribs, driving the spicule into the lung, lacerating, to a greater or less extent, its substance. Kven without fracture of the ribs, the concussion or Mow may have been sufficiently great to have caused irreparable injury. LUNG WOUND IN CHEST INJURIES. 0--i The following eases, extract ed from 8 Memoir on Amputations, by Baron Larrey. will exhibit die extent of internal injury from a spent liall without external indications of mischief : "■At the siege of lioses. there were brought from the trenches to the amhulance that I had established at the Village of Palace, two gumnerB, having nearly tlie same kind of wound: they had heen struck by a hall oi' large calibre, which, when nearly spent, had grafted posteriorly their two shoulders. In the first, I discovered a slight ecchymosis over the whole posterior part of the trunk, without any apparent solution of continuity, lie was hardly ahle to hreathe, and spit up a great quantity of vermilion and frothy hlood. The pulse was small and intermitting, and the extremities cold ; in short, he died an hour after the accident, as I had prognosticated. I opened the body in the presence 'of M. Dubois, inspector of military hospitals. The skin was unhurt: the muscles, the aponeuroses, the nerves and vessels of the shoulder, were broken and torn, the ftoapuls fractured, the spinous pro- • of the corresponding vertebra of the hack and the posterior extremities of the neighboring rife* fractured; the spinal marrow was distended, the parenchyma of the lungs toward the COITBS- HEMORRHAGE IN CHEST WOUNUf ponding points « eratad, and :i considera- ble effusion bad taken plaee into both cavities of the thorax. The .—*•«-< > 1 1 « 1 gunner died, with the Banie Bymptoms, three-quarters of an hour after his etitranoe into thehospitaJ. < >n opening the body the same mischief was perceived as in the first." The severity of the Bymptoms will depend upon ili«' depth of the injury in the lung. The deeper the lung is perforated, the larger are the blood-vessels implicated and the more excessive and rapid tin- hemorrhage. It is on account of this loss thai the most conspicuous Bymptome arise, viz : hemorrhage, collapse and suffocation. The patient may Ik- at once suffocated by a large quantity ■>!' blood filling up tin- thorax, and preventing the ingress of air into the Uingflb Usually, Wl I |p;i->c> from both month and wound : that from the month is frothy and timid. and is brought it]> liy a short, tickling, harass- Qough. The size of the dark-colored stream, poa ring from the wound, depends upon tin- | ■< >~i - ii<>ii of the orifice. Wliere the orifice n situ* ated 1"\\ upon tin- cheat, and is large and direct, the effusion into the cavity escapes freely — the symptoms of ool lapse may soon appear, but suffocation is prevented; whilst from an injury HEMORRHAGE IN CHEST WOUNDS. 325 in Ike upper portion of the chest, particularly if small and oblique, the thorax may till with blood, and suffocation becomes imminent, with- out much external loss. The danger from hem* orrhage is greatest during the first twelve hours. and is pretty well over by the second day. It may. however, continue for eight or ten days, gradually diminishing in quantity. With the flow of blood from the wound, air often escapes, and the two symptoms are considered unequiv- ocal proof that the lungs have been injured — their absence does not prove the contrary. • The mere loss of blood from the lung is ao certain indication that the organ has been injured, as bloody expectoration is a common symptom of blows upon the chest, and may accompany the RIOS1 trivial injury. Fraser, in his recent work on gunshot wounds of the chest, places a less value on haemoptysis than do other military sur- geons. Guthrie considers it a proof of lung wound: so does Baudens, MeLeod, Btromyer, Ballingall and others. Eraser's experience in the Crimea gives, in nine fatal eases in which the lungs were wounded, but one instance of lacniop- tysis, ami in BCTetl fatal cases in which the lungs not injured, two h:id spitting of Wood. In t\\c|\ of recovery, three had hiemoptysis. .;_'». HYSI'VK.V IN ("HKST tie, therefore., infers, that the spitting of blood it ;i very deceptive diagnostic sitrn of lunsj wound. When it is rapidly brought up by mouthl'uls, it an important -\ mpi >m. The discharge from the wound is sometimes occasioned by injury to fche intercostal vessel; 1 »u t tliis is bo rarely the case, that sicLeod states tliat he neither saw nor heard of an instance' daring the Crimean war. The most distressing symptom is dt/xpncea, which may appear soon after the injury has »•»■ received* or, perhaps, not until some days have intervened ; in eertaia eases of undoubted fling injury, it may UOl have heeii present at any time. This symptom is sometimes very intense — from Etoral or otlier causes — when the lung is not wonmleil. sod it may he hut slightly marked, ,,y even altogether absent, when the lung is seri- ously implicated. This difficulty in breathing depends, in some instances, upon the direct press- ure and condensation of the lung by air or hy fluids. When the chot has heeli opened hy a hall, the ludsg does not collapse, as ia generally supposed, but, it' the opening u sufficiently large, can he veen moving lo and fro ae;ain-t the tho- racic walls >imullaiuoii>| v with respiration: and. as a proof i>( the continued action of the Lung, EMPHYSEMA IN CHEST WOUNDS. 3^7 and its inflation with air, it is sometimes found protruding from the orifice, forming a hernia of the organ. Even when the lung has been com- pletely perforated, it does not necessarily collapse, hnt as blood ©scapes into the pleural cavity, the lung may be driven hack and condensed against the vertebral column, with all the accompanying symptoms of dyspnoea. From injury to the lung and continued escape of air into the pleural sac, we sometimes find similar difficulties in respira- tion induced. Emphysema is a symptom of injury to the lung upon which much importance lias bees placed. It can occur under any circumstance by which air is admitted into the pleural cavity, where, being compressed by the action of the lnng and walls of the chest, it is forced ont through the wound: hut if a ready exit is ao1 offered for its escape, or should any obstacle exist in the form, size, or direction of the wound, it is forced into 1 1 !<• cellular tissue. Owing to the free commu- nication in the interstices of areolar tissues, it diffuses itself widely and rapidly. Should a perforated wound from a hall or other weapon allow air to enter the pleural cavity. Whether the luii- he injured of not. emphysema might appear. It is m.t m eMixma after gunshot :;_"* COLLAPSK IN en wounds, as :i free exit if offered to the cunteuts of i 1m- cavity, h ii :i much more common ac- companiment of oblique punctured wounds by sword poind or bayonet, and a l>» • in c a s e s ti fractured ribs, when sharp spieulse of bone have abraded the surface of the lung and allowed air to escape from tile Air tabes into the cavity. As it is found either with or without lung injury, il cannot be ol' much value in diagnosis. The injured Lung, in gunshot wouuds, does not often permit air to escape for any length of time from it> wounded surface, as an immediate extravasa- tion of blood into the bruised tissue closes up she air tubes, and shuts <>il commuuicstiou with the cavity. Another Bymptom <>( greal value i> collapse, depending upon Loss of blood. It is well known that all the blood of the body must continually pass through the Lungs; and should the vessels composing the parenchyma of this organ 1»<' ex- tensively opened, the loss in even a short period must he excessive. It is not surprising, there* fore, that the patient should soon become cold, pale, ami faint — with feeble, small and irregular pulse, and with rapid tendency to syncope. This is natures effort to check further Loss; and al- though sometimes successful, often c-ives but VALUE OF SYMPTOMS IN CHEST WOUND.\ 329 temporary security. The surgeon trios to induce this condition for a similar purpose. From consideration of the above symptoms, we are induced to believe that no one symptom is pathognomonic of injury to the lung, hut it is rather from a combination o'{ phenomena that any certainty in diagnosis is attained. The im- mediate danger and intensity of the symptoms will depend upon the depth of the penetration. Where the chest is only superiicially wounded, although the force of the blow may lie sufficient to produce an amount of shock oi~ shorter or longer duration, and blood may he expectorated, from the concussion of the lungs, the symptoms will be trivial. The pain of the bruised tissues will pass oil' in a lew days, and with it all the accompanying symptoms. When the chest has been opened without injury to the lung, heart, or intercostal vessels, the symptoms are also trivial; and unless inflammation of the pleura ami subsequent effusions of scrum <>r pus should ensue, the case will equally require but little treatment. "When the lung is implicated, and especially when severely wounded, other symp- toms arc niore or less conspicuously present. ;i after the reception of a severe wound, Mood pours from the injured vessels and escape* o.;n TRKATMENT OF CHEST INJURIES. both into the air tubes and into tin- pleural From the tir vessels ii is brought up and expectorated, in greater or lest quantity* as haemoptysis, whilst it flows from tha exto rnal wound in the aide. It' the openings in both luog and chest be free, the blood escaping is min- gled with air when the patieul coughs. With the loss of blood, the surface becomes cold ami bedewed with ;i eoW perspiration; the pulse ie weak ami tremulous, becoming more and mote enfeebled until syncope comes on, which tempo- can ly checks the. excessive bleeding. Should the orifice in the side oiler an imperfect escape to the blood, it collects in the pleural cavity, rap- idly encroaches upon the lung, which is forced back against the spinal column, and, by com- pressing the opposite side of the che6t through the mediastinum, threatens suffocation. The eyes protrude, nostrils expand to their utmost, the arms arc thrown about in every direction, and fright- ful struggles for breath appear in every feature- These arc the cases which, it' not immediately relieved, will in a few moments terminate fatally hv suffocation. Tha field Burgeon, in transporting those wound- ed in the chest, will give the most careful atten- tion to the severely wounded. The Bimple cases, TREATMENT OF CHEST INJURIES. 881 requiring no immediate attendance, will be sent on to the field infirmary. Although the wound has evidently transfixed the chest, if no urgent symptoms exist, the ease is also carefully con- veyed to the intiimarv, or even directly on to the general hospital ; hut should the distressing symptoms above mentioned follow soon after the injury has been received, then the life of the patient is in the hands of the ambulanee sur- geon, and should he ignore or neglect the ease, the soldier may not reach the. infirmary alive. Notwithstanding the hemorrhage, open a large vein and draw away blood, if possible, to syn- cope. The safety of the patient depends upon this being obtained; as in the interval, when the heart's action is at its minimum, but little blood will be driven t<> the Langs, and a dispo- sition to the formation of a dot may plug op the bleeding vessels. Tke dyspnwa, and not t),c pulse, will be the indication for bleeding in lung wounds. 'flic patient is not detained on the field to sec the effects of the venesection, but. with his vein open. i> seal on to the field infirmary, accompa- nied l.y the surgeon, or by an intelligent assistant. A- MOD .1 he faints, the surgeon at the field infirmary removes the rough field dressing, ex- ■IK 1 OK (Mil ST IN JUKI I amines the wound with the finger, and. if not sufficiently large to permit :i thorough search for foreign bodies, where such are suspected, he dilates it with ■ probe-pointed bistoury. In perforating chesl wounds, unless urgenl symptoms of dyspnea arc present, the general treatment Is of the expectanl plan. The wound having been carefnlly closed with diachylon, the patieut lies on the wounded side, so as to throw the lung against the ori&ce, hopiug tliai it may adhere to the ohest at that point, and so close the cavitgr; he also finds this the most comfortable position. He ii kept quiet, in ■ dark room ; all excitants are avoided, rigid diet is instituted; veratrum viride, or digitalis, is given to control the action of the heart: opium ia freely administered to quiet the constant hacking, tickling cough, and iced cloths or blad- ders are applied to the chest. With such treat- ment and careful watching, Beeing the patient, if possible, every hour, we await the develop- ment of symptoms. The accurate closure of the wound excludes the admission of air. and. to a certain extent, prevents emphysema, and also the rapid decomposition of the escaped Quids in the c;(\ it V. It' it be a shot wound, with a single orifice. TREATMENT OF CHEST INJURIES. 333 and the clothing 1 bo. found perforated, the wound should be examined for foreign bodies. II' found, extract them; if not detected, then close the wound carefully with a strip of diachylon, and apply the water or ice dressing. The search tor foreign bodies must always be made with the finger, and should never be pro- tracted. Should nothing be found after a mod- erate, intelligent search, close tin- wound, and await developments. This examination should he made before reaction comes on. Should we iim! see the patient until he is icYerish, all exam- inations must he absolutely forbidden for at least eight days, until the reaction has subsided and suppuration well established. It is well known that balls, etc., — even pieces of clothing — have been found encysted in the lungs years after they had been deposited; and, in -lime instances, these articles have been ex- pectorated, after long intervals, during a severe spell of coughing. Although always desirable that these he removed, a prolonged search may entail BUch an amounl of injury as to destroy all hope of saving the patient, when the pres- ence of the foreign body would not have been necessarily incompatible with life or even health. JJesides. when suppuration is veil established, :;.. I IBtATMt.M Oi 1'llt.Vr I.NJUU - \vr have a second and mucli hotter opportunity for a careful examination, without mud doing injury. S ouid the gradual accumulation of blood in the cavitj <>l ike chest « :* u^«- tlyspnaa, tin gee 1 1 1 : i \ require opening, i<> allow tin- fluid to escape and relieve the pressure upon tin- lung. J ii drawing oft' the contents of the chest, if syncope threatens, we close the opening, and await another opportunity. Tin- collection is retained in certain cases, when no dyspnu'a ex- for the purpose of retai'ding, and dually controlling the bleeding, by pressure upon the Lung and its injured blood-vessels. After the third or fourth day, the tendency to hemorrhage having ceased, and the wound having all commenced to suppurate, the adhesive plaster ia removed, aud the eftusion is allowed to escape. If air has been admitted into the cavity, the exuded blood has decomposed, and. mingled with serum and pus, makes, for the first few days, ;i copious and very offensive discharge Gradually the escaping lluid loses its dark color and oft- tensive uiell, and assumes the appearance of healthy pus. (formerly, much care was taken to favor the flow of fluids from the chest, and dilation of the wound was the recognized rule; TREATMENT OF CI}EST INJURIES. 335 now the opposite treatment is the one urged, to exclude air, and, if possible, retard decomposi- tion, as this deterioration of the effused iiuids is more injurious to the system than the advanta- ges obtained by their ready escape, From this time onward, simple water dressing will be the only loeal treatment required for the wound. If the orifice from a punctured wound has healed, with escaped blood remaining within the chest, the collection, if small, should be ig- nored, as it will gradually he absorbed; but if the extravasation be extensive, particularly if air had previously entered the cavity, it must be withdrawn through a puncture made at the most dependent portion of the chest. This operation, unless called for by urgent or distressing symp- toms, should in no ease he hastily performed, hut should, on the contrary, be delayed as long as possible. huring the treatment of perforating wounds of the chest, dyspmea, whenever urgent, should always be removed by the Lancet, the venesec- tion to he repeated as frequently as called tor hy threatened suffocation, unless this symptom he clearly traced to pent-up fluid, when opening the wound or enlarging it, to permit a ready escape, will remove the oppression of breathing. :;:;.; 1 Rl VI'VI NT OF -III -I INJl Prompt and repented venesection, followed by such remediei a^ will control the action of the heart, will also be required to cheek hemorrhage, which is a common cause of death in such in- juries, and will alone diminish the number of victims of chesl wounds. In collapse, we have alreadj recognized a valuable aid for cheeking hemorrhage, and its remediable advantages should be appreciated. A- a symptom, ii must be care- fully watched, and should it threaten t<> stop the action of the heart, external stimulation must be freely need; but the internal stimuli must be administered only in small quantity, and with ;it caution. WTien the immediate dangers have passed, tin' next in order is inflammation of the lung and pleura. Neither of these conditions differ in any very material respect from the idiopathic varieties of the disease. The traumatic pneu- monia is sometimes circumscribed to narrow limits, and its caU8e maw to a certain extent, modify the general symptoms. As the cause of pleuritis is a direct injury to the membrane, and. in the majority of instances, as air lias been admitted within the cavity, the efrusions which accompany the inflammation soon become purulent, and. in time, false membranes of con- INFLAMMATORY COMPLICATIONS. ' ;: >7 tiderable fthiokness line the inner surface of the ribs. The treatment for either pneumonia of pleu- risy, when occurring from a ganehol wound, does not differ from the treatment of the dis- ease from any other cause* MacLeod's experi- enee is in favor of early, active, and repeated bleedings, with cool drinks and abstemious diet, recognizing, at the same time, however, that many excellent recoveries have beet! made with- out recourse to the. lancet. Guthrie uses the lancet, which he designates the first and most essentia] remedy, and which he says should he resorted to in every case. The venesection, which he repeats whenever the inflammatory symptoms show an increase, is vigorously fol- lowed by large doses of tartar emetic in pneu- monia, and calomel in pleurisy — the object being to affect the ejums as soon as possible. This is the treatment of the old school, which recent experience does not uphold. Guthrie stum- "that in the Crime;) bloodletting had not been -o favorably viewed, nor found so serviceable, nor v,, uecessary." Fraser, from Crimean expe- rience, states thai, in the prevention" and re- duction ><\' inflammatory action, in perforating Wound- o| the c.]l6bt. venc.-.-t 1 ion j.. uol demand- I \ h I.AM MATiiRY COMPLICATION." ed. it Bhould only be used when the pa lull, strong, and labored — :» condition not often lui-i with. When the heart sud pulse are both weak, a comn condition alter severe wounds, the abstraction of blood will occasion a complete prostration of strength, and may be fatal. There is no reason for changing the plan of treatment, already discussed in detail, for com- bating inflammation following gunshot wounds, and which is equally applicable to chest wounds. Even when the lung is inflamed, we would p*a- fer the mild, expectant and antiphlogistic treat- ment to ill*' spoliative. Absolute rest, cooling beverages, moderate nourishment, avoiding over- stimulation, with small doses of tartar emetic, veratfura, of digitalis, with the liberal ase «'t' opium, and attention to the intestinal secretioiw, will be required in all cases, and in many will Compose the entire treatment. A certain degree of pleuritia ie expected and desired in penetrating lung wounds, to establish adhesions between the injured lung and thoracic wall, which will at oner isolate the injured part, and prevent inflammatory Bequelse. As gunshot wound- do not elose rapidly, but usually Buppu- rate, permitting the free access of air within the thorax, the suppuration will he profuse and long- PUS IN THORACIC CAVITY. 830 continued. We must remembeT this in the treat- ment, and not use depressing agents. When the pleoritis is excessive and general, both false mem- branes and the sapid accumulation of fluid are to be anticipated. If the external wound is still open, the position of the body, which is very important, will allow the ready escape of the effusion, which is, at first, serous, but soon be- comes purulent. Position and constitutional sup- port will form the basis of treatment. If the ]>u> could have a constant outlet for escape, and accumulation within the cavity could he pre- vented, the false ■ membranes would tie the lung to the thoracic wall at a much earlier period. and. by obliterating the pleural cavity, prevent further discharge. Should the wound be in the upper portion of the cheat, it would hasten the cure to establish a counter-opening from the Mod dependent portion of the cavity, through which the drain would be facilitated. The chapter on the treatment of suppurating wounds lays down general laws for counteracting the injurious influences of long-continued sup- puration. Penetrating wounds of the thorax oeeaiionallj remain fistulous lor an almost indefinite period— which i.-« caused by a failure of general adheaieu Silt VCTlRKIi between tin- costal mid pulmonary pleura;. A kind of poucb is found, lined b\ it false mem- brane, from which a purulent lymph is continu- ally secreted. Alter empyema, the cheat cott- bBacta, the wails link in, the diaphragm rises high on the affected side, the spine beenmes contorted, nir cntrrs indifferently into the lung, Little or bjo respiratory movements are seen in the chest, and a portion of the respiratory apparatus is rendered useless to the economy. Usually, the long train of symptoms terminate fatally in phthisis. Very Jew oases of injury to the lung, from gunshot wounds, are ever restored to perfect health. In eases of fractured ribs, from gunshot injuries, the hone is usually spieulated, and some of the fragments may accompany the ball in it- onward course. Upon examination with the finger — exe- cuted with great caution from the fear of push- ing the fragments iuto the chesl and converting a simple wound into a perforating wound, which, in itself, is always a serious accident — these irreg- ular fragments, if detected, should be removed, and. if accessary, the outer wound should be enlarged, to facilitate this importanl step. The danger is not so much from the breaking of the hone, hut from the displaced, sharp fragments, which ma) seriously injure the pleura and Lung. rHACTI nr.i> Kll> 3-11 When removed, and the sharp edges of the rib. which turn in toward the cavity, arc excised, the wound should be closed with a wide adhesive strap, and cold water dressings applied. If no symptoms indicate injury to the lung, a broad hand may surround the chest, to control the thoracic movements and allay the pain : hut, should any oppression in the breathing show itself, the bandage cannot he applied, as it will increase the suffocative feelings. Where the spicuhe are not displaced, a broad adhesive strap is the only local apparatus Required. Necrosis of the rib very commonly follows a gushot frac- ture, and may require a subsequent resection for its removal. When (w intercostal artery is divided, the bleed- ing point will he discovered by drawing out the lips of the wound with a tenaculum, when the i should be secured. All military surgeons agree that this is an operation more frequently spoken of than performed. Many of extensive experience have never seen a <-ase. When foreign bodies, as balls, pieces of hone. cloth, wadding, etc., are driven into the pleural cavity, unless removed, they produce fatal results by inflammation and exhausting discharges. A hall can he sometimes felt by the patient, '.)\2 FRACTTRF.n l: and ita movement* often detected i>\ the stethe- aoope. Through an opeuing, made :it tin- most dependent portion of tha obeat, the foreign body can lie removed sueeessfnllv. (IT AFTER X. Wounds of Abdomen — Flesh wounds — Never probe perforating wounds of the abdomen, and, especially, never attempt to search for foreign bodies which have passed beyond the abdominal waUs — Sew up intestinal wounds — Dilate wound in abdomen when necessary to relieve strangulation and to facilitate reduction — Where thx forget viscera arc injured, wry ui the en- track of the ball lies in the thickness of the wound is Bimply a flesh wound, and should be treated accordingly. The track of the ball is not always in a straight coarse, as the muscles, or their, tendinous portions, when in action, offer sufficient resistance to turn tin- bail. The fascia transversalis is said to >\\<>w a similar resistance t" oblique sli.it. A perforating wound <»!' the abdomen is equally dangerous as those of the chest, from the fear of peritonitis, which is apt to supervene. It' the perforation be made by a Bword or bayonet, or it' there Ik- anj prospect of healing by tin- first intention, tin 1 wound should 1"- accurately closed by adhesive straps or by sutures. In sewing op an abdominal wound, many recommend that the needle should not pass deeper than tli<' super- ficial cellular tissue — giving as q reason that when tin- muscles arc included in tin- suture*, fehey sometimes draw themselves out of the noose by their contraction, whilst, it' tin- peritoneum be aleo included, peritonitis is much more likely to occur. Although this may hold good tor the peritoneum, I can see no reason why attempts PROBING VBDOMINAL WiHNDS. 845 should not be made to cause union in the muscles, and, therefore, avoiding the peritoneum. T would include all the tissues — even to the transversalis fascia — in the suture. When this is done, the cicatrix will be tinner, and there will he less probability of secondary hernia — a very eommon accident alter injury to the abdominal walls. In probing abdominal wounds, the only object to he sought by the examination is. whether the wound has perforated the cavity or not ? From the direction of the track, this can nearly always be determined. As in any other gunshot wound, the use of the silver probe is very dangerous, as it may convert a simple into a perforating wound: whilst with the finder, or a lastrr. it' a gunshot wound. He then administers ;i dose of morphine, ;ui«l sees tliat the wounded man is properly trans- ported t<> tin.- held infirmary. To facilitate the return oi' the protrusion, whether it be intestinal or omental, tin- patient is placed upon his back, with tin- thighs drawn up and the abdominal muscles relaxed, when the ambulance surgeon makes steady pressure upon tin- protrusion in the direction of the wound. The bowel must la- handled \crv carefully — no force should be used, or so mueh injury might be inflicted as to cause tin- rupture, sloughing or inflammation of the protruding organ. The bet- ter plan would be to encircle tin 1 protrusion by tin- fingers clustered together as a funnel or cone, which will diminish the hulk at the opening in the abdomen, and facilitate its return. If it be found that tin- mass is so constrieted, bv tin' small size of tin' oiil'nc. thai the return TREATMENT OF WOUNDS OF THE ABDOMEN. -17 within the abdominal cavity is impossible with- out inflcting injury upon the bowel, the intestine should be drawn to one side, and, using ureal caution, the wound should be enlarged upward for a quarter or half an inch. As the constric- tion is rarely in the peritoneal wound, but usually in the muscles and fascia, the incision, if possi- ble, should not include the peritoneum. Cutting upon a grooved director, or using a probe-pointed bistoury, will diminish the dangers of wounding -nine important port within, whilst enlarging tic wound. The return o\' the bowel should always be effected by the ambulance surgeon before the ease is transported to the field infirmary, inas- much as the crowding of the wounded at the infirmary may be such that several hours might elapse between the receipt of injury and the hos- pital examination — quite long enough to cause strangulation of the intestine, and sufficient to excite either inflammation or mortification of the protrusion, usually a fata! complication in abdom- inal wounds. The early return of the protruding intestine makes the ease one for simple and successful treatment. Be satisfied thai the intestine has been returned within the abdominal cavity, and not forced under the sheaths of the abdominal :; to tki \ i mi. vi or in ii-i in m. oroi n mi. muscles, where it would strangulate, unci rapidly destroy life. Should the case not !"■ seen until several horn's had elapsed, the intestine should be equally re? iiinictl whether it boot il or inflamed: but when gangrenous, which Is recognize^ by its greenish ash oolor, Loss of polish, its flaccid con- dition,- with already a disposition to separation in its various coats, it should remaiu withouf the wound, and be laid open bo as to allow its fecal contents to 1"' evacuated. Adhesions rapidly form, uniting the protruded intestine to the peri- toneum at the inner orifice of the wound. This -lints off all connection with the peritonei cavity, and prevents extravasation of feeal mat- ter within it. It' the bowel be returned in ■ mortified condition, the contents of the bowel would be discharged into the peritoneal cavity, and fatal peritonitis would be excited. Should the intestine be injured, it is left in situ, covered with a wet or oiled cloth, until the wounded soldier reaches the field infirmary, when it i- closed with one, two. or more points of interrupted suture* according to the size of the openiii-- — a stitch being placed for every one- sixth o! an inch of intestinal wound. The ends of the suture arc cut oil' close to the knot, and TREATMENT OF INTESTINAL WOUNDS. o4t» the whole is returned with care into die abdo- men. A line cambric needle will be tin' best instrument for sewing up intestinal wounds, as tin' small puncture and tine thread produce but little irritation. In passing the sutures, do not include the lining mucus membrane in the noose, tor if this he allowed to pout between the Lips of the intestinal wound it might interfere with rapid healing c the serous or peritoneal layers should be brought in contact, wben union rap- idly follows. If a large dose of opium bad been admin- istered on the battle field, or as soon as the patient bad arrived at tbe infirmary wbilst await- ing his turn to be dressed, the peristaltic action of the bowels would have been suspended, and the wounded portion of the bowel, which should always be tbe last portion returned, when tbe hernia is extensive, remains within tbe abdomi- nal cavity, in immediate contact with the wound, and to this point it soon becomes attached through adhesive inflammation. Should the su- tures give way. or Ihe bowel sk)Ugfa from the injury which it had received, its contents, instead oi being thrown into tin' peritoneal cavity where it would produce fatal inflammation, on account of tli** adhesions of ihe bowel near an external 350 TREATMENT OF INTESTINAL WOl'NhS. outlet, will escape externally, which diminis materially the rie]s. and red iee the intestine by sutures, treating the case M if an incised wound of the bowel had alone ex- isted. t '■'>■'- I KI.A I Ml N I (»] I VI 1 -II sAI. \\ I Iii nil perforating w.-u mi- of tin- abdomen, as we cannot tell, in 1 1 » * - ab- s\ mptoms, whether the intestines have been injured or not. are two fundamental rules of treatment never to he forgotten, and which arc required in every instant 1. dive opium freely and frequently, with the double object, viz: of controlling the peris- taltic action, which alone ran prevent extrsi lion of the contents into the peritoneal cavity, and tor its antiphlogistic eftect, to equalize the circulation, allay pain, suspend nervous irritabil- ity, and prevenl inflammation. 2. A \ i >iil the use of purgatives. With the majority of physicians who have had lmt little experience in the treatment o\' abdominal wounds, the tir>t impulse is to see the bowels emptied, and hence the fatal purga- tive is eagerly administered. An evacuation ap- parently reassures them that all i- right: when, on the contrary, all is very wrong, as the march of the case will soon show them. This is a fatal error, which the utmost after-care cannot remedy. For three <»r lour days at leasl after COMPLICATIONS OP ABDOMINAL WOUNDS. 353 tin- receipt of injury, in which the intestines ore known or are supposed to be wounded, ali- solute rest, the most abstemious diet, and the libera] use of opium (one grain o€ gum opium, or its equivalent in laudanum, every five hours), in connection with cold water or iced dressing, will compose the entire treatment. If the patient t'ceU uneasy, an enema will relieve the large intestines and add much to his comfort. By the fourth day. the wound in the intestines will have elosed by lymphy effusion, and the dangers will, to a certain degree, have subsided. If re- quired, a doBe of Epsom salts, citrate of mag- nesia, or castor oil, may now he given, although it would he better to wait one or two days longer, when the risk of reopening or disturb- ing the wound would he hut Slight. If peritoneal inflammation he excited, with fe- brile reaction, pain greatly increased by pressure over the ahdoineii. and more particularly in the neighborhood of the wound, with tympanitis, vomiting, hiccup, small, quick pulse, and anxi- ety of countenance, the fears are that lymph and sero-purulent matter will he rapidly thrown out. gluing coils of intestines together and till- ing the cavity with fluid. To check this rap- idly fatal disorganization, leeches or cups should .'in 854 COMPLICATIONS OP ABDOMINA1 \r<>i \ be applied to the abdomen, to be followed by 1 arcotic or turpentine Btnpes, or by i<-.« blad- ders, which are bow preferred, or by blisters, whilst opium should be sriven in I a rare ■ and at short intervals, [f the patient be young and plethoric, and the inflammatory symptoms are early recognized, the lancet might be used; lu;t usually, in military surgery, this remedy is badly borne. Calomel was formerly used with tlif opium, and was considered the mam depend enoe, but is now being generally discarded, as all advantages gained are accredited t<> Ibe opium. Sometimes in a [few hours, usually at tin- end of the Becond or third day, collapse, with a cold, sweating skin, ami Feeble, irregular pulse, bbowb ilif ravages which the Bvstem lias experienced from the peritonea] inflammation, ami marks rapidly-approaching dissolution, h is rare thai the liberal use of brandy, with carbonate <<\' am- monia, external warmth ami synapisms, rescue the patient at this advanced stage; although, if given when debility commences to show itself, they may BUpport the patient, ami he the means of saving life. When the swelling of the ab- domen, and the dull sound which percussion elicits, shows extensive effusion, the abdominal COMPLICATIONS OF ABDOMINAL WOUNDS. 6t>0 wound should be reopened, and, by placing the patient in a proper position, the effusion be al- lowed to escape. It is a desperate operation, but has been known to save a tew eases, which, if let't alone, would have certainly perished as those do upon whom this operation is not per- formed. In gunshot wounds of the abdomen, if the missile has perforated, it would he madness to prohe the abdominal cavity. We must imagine the worst, give the patient the benefit of these doubts, and bv extreme care hope to counteract the baneful influences which foreign bodies, when remaining in tin' abdominal cavity, always exer- cise. The ball may have traversed the cavity and embedded itself in the fleshy walls, without having injured any organ of importance in its course; the absence of serious symptoms, as the progresses, can alone inform us on this head. from the physiological effects we might, at times, trace the resting-place of the ball. When par- alysis of the lower limbs follows an abdominal gunshot wound, we might infer the burying of the ball in the vertebral column, or an injury to the nerves of the extremity as they emerge from the spine, etc. Should the abdominal wound bleed profusely, HEMORRHAGE IN - tares of lil 1 may be from within the cavity from injured viscera, or may be caused by division of the epigastric artery in the abdomi- ual walls. If tli. ■ hitter, dilatation of the wound will expose it. and the vessel should be Ligated. When, from the former sourer, but little can be done, venesection to syncope miglil check the flow, and the formation of ■ ek>1 may plug up the injured vessel. Seme Burgeons, knowing the desperate condition brought on by internal hemorrhage, recommend dilating the wound, and shoiihl it he found that hemorrhage conies from one of the mesenteric vessels, the artery should be Ligated. The position of the external wound will as.-ist us in forming a diagnosis a> to the probable source of the hemorrhag i recovery are recorded where the wound was dilated, and the bleeding vessel iii the omentum SOUghl and secured. Where some of the large viscera or blood-ves- sels are injured in perforating abdominal wounds, the Bymptoma are much more marked than in intestinal wound.-; hemorrhage at once takes place, to ;i serious amj[ often fatal extent. Such wounded are often found dead upon the battle field; or should they he alive, they are pale ;ind cold, with anxious countenances and intense long- HEMORIUIAOK IN ABDOMINAL WOUNDS. oO I ing for water. This insatiable thirst is not pecu- liar to visceral wound or to nervous shock, but is an indication of serious hemorrhage. If the wound be extensive, they never rally from this collapse. In other cases, the shock may permit the clogging oi' injured blood-vessels, and stop internal bleeding. Should life be prolonged until reaction takes place, the violent inflammation which is lit up. either from direct injury to the peritoneum or from the quantity of blood in the cavity, usually carries off the patient after a period of intense suffering. On account of the hemorrhage and subsequent inflammation which accompany these injuries, all wounds of the larger abdominal viscera are con- sidered nearly necessarily mortal, as the excep- tional cures are very rare. When the external orifice is small, the position and direction of the wound will lead us to suspeel the special injury, and. in connection with persistenl vomiting, the ejection of blood by the mouth, by stool, or with the urine: the escape of special secretions. as bile, urine, or feecee by the wound: and the peculiar pain or sensations experienced by the patient, will be our chief indications in deter- mining the pari injured. The treatment of the-'' serious wounds, which um M's (MT Tin: BLADIN on tlio whole is >o unsatisfactory, is similar to that required for perforating wounds of the cheat, with injury to the Lungs. It wen Boon after the accident, before much blood baa been extrav- i. and it' nervous Bhock is not present, the patient should be bled pearly to syncope for its anti-hemorrhagic effect, and then opium internal- ly. ;iik1 cold locally, with absolute diet, should become the basis of treatment; a little water or small pieces of toe is all thai is required tor the first two or three days. In wounds of the kidney, frequent micturition, with bloody urine, marks the injury; whil.-t in injuries to ifu bladder, bloody mine, or rather the age of dots as well as pure blood through the penis, is the diagnostic sign — should urine escape from the wound, it is equally pathogno- monic. In addition to the course already laid down for internal abdominal injuries, the intro- duction of a large gum catheter into the bladder through the penis, through which urine is allowed bo drain away as fast as it is secreted, will prevent urinous infiltration, which is one of the most fatal complications connected with a wounded bladder. The catheter should be introduced on the Held of battle, and should be worn continuously for four or five days until adhesive iuuammatioa has WOUNDS OP THE BLADDER. 359 closed the torn cellular tissue, and shut up the avenues into which the urine would have escaped. The catheter will also be required when the sloughs are separating, as swelling ol' the pails often obstructs the readyflow of urine. The gum catheter may even he kept in from the com- mencement of the treatment until the wound is well advanced in healing, unless it excites nuieh irritation, when it may he temporarily with- drawn. This precaution will prevent many cases of urinous infiltration, and save many lives. When the nook of the bladder, or the prosta- tic part of the urethra has heen divided, if the catheter cannot he introduced, a free incision should he made through the perineum for the evacuation of urine and the discharges from the wound. Fortunate it is for men going into battle that the excitement under which the troops are at that time laboring, causes a continual dropping from the ranks to urinate, so that rarely doee a soldier go into battle with his bladder full. In this physiological fact lies the safety of many a man. as the contracted Madder concealed behind the puhis. in the cavity ^\' the pelvis, often es- capes injury from the passagi of a hall, which. wore tiic organ distended, would assuredly trav- erse it. i.NJl UU Of 1 1 1 h. I.AK..1 I N ! I - From the hattles mi' Ihill Hun and Mann several cases of vesical injury were collected in the hospitals, Borne of which were successfully cured. Among tliese was one of Bpecial inter- est, in which the ball, in traversing the pelvic i antero-posteriorly, transfixed bladder and rectum, anterior abdominal wall and sacrum, which was recognized by the escape of urine anteriorly, and urine with fecal matter through the sacral orifice, as well as urine running oft' by the rectum. Jn time these orifices closed, and the patient -was discharged cured. Injury to tin large intestines arc uo1 so serious as perforations of the small. As the large bowel is bound down iii the greater pan of its oourse, extravasations of their contents d<> not nec< rily take place into the peritoneal cavity; and although fecal matter escapes externally from the wound, and high inflammation, with profuse sup- puration, usually follows, many of the wounded eventually do well. Cases not unusually occur on the battle field in which the abdominal contents might be se- verely crushed without apparent external injury. it is the toughness and elasticity of the skin which gives rise to the exploded theory of the wind of a ball destroying life; and such cases INJURIES OF THE LARGE INTESTINES. SCI as those we are now considering were formerly brought forward as instances of the fatal effects of the vacuum following the wake of a cannon hall. Observation has shown that a knapsack might he torn from the hack, a hat strtick from the head, an epaulet from the shoulder, or a pipe from the mouth, without leaving a trace of in- jury, whilst, on the other hand, viscera might be reduced to a jelly, or bones crushed, •without a visible bruising of the skin. It is the hall itself, and not the wind, which produces these disor- ganizations. From the blow o\' a spent cannon hajl or fragment of a shell, the liver might he lacerated, intestines torn, hlood-vessels opened, spleen fissured, or kidney ruptured, without an external wound. Severe shock and collapse mark the extent of injury received; and should the patient rally from this condition, which is rare, violent inflammation will soon destroy lite. Al- though we follow vigorously the treatment laid down above, we very seldom have the satisfac- tion of saving a patient The amount of destruction effected by a spent hall is often surprising. The uninitiated on the battle held will attempt to stop, with the foot, a cannon hall rolling on the ground, and which is jnsl ahoiii exhausting its force, perhaps with only 862 ^ 1N.II HIK> "I Till'. I. AH". I INTK>riN»> momentum sufficient t<> carry it one or two farther, yet it crushes tin- limb pot out to op- it. Baudens, in warning persons to avoid cannon lulls, however plowh they may be roll- ing "ii tin- ground, mentions the case of a irifi i- adier of the guard, sleeping on his side on the ground, who was instantly killed hv ;i spent cannon ball, the blow from which luxated the vertebral column. The ball came with <<> little momentum that it rolled itself up in the hood of the soldier's overcoat, where it \v;is found. It was just about to Btop when it struck. One or two feet further, and it- entire force would have been exhausted. CHAPTER XI. Injuries of the Extremities — Compound Fractures — Differma of treatment in the upper and lower limbs — Importance of am early examination, and adoption of a course of treatment within twenty- four hours after tht receipt of accident — Compound fractures of th Arm from shot wounds, when not implicating joints, do not require amputation ; should the blood-vessels and nerves bt crushed with the bone, then amputation necessary — When gunshot fractures implicate joints, resection or amputation is the only means of saving life— How resections are to be per* formed — Special Resections of Shoulder, Elbow, Wrist — Resections and amputations of the inferior extremity — Primary and consecutive 'imputation — Frost JUti — When, and under what circumstances^ amputations should be performed — Modes of operat- ing, and of dressing stumps — Chloroform in >>// st ,-ious opt rations. As the major portion of the injuries of the extremities are merely flesh wounds, these will ii"i require to be again noticed. Those which •'!''>! 1NJIIUKS OK THE KXTHKMITI1 we will dow consider are such as involve the hones, joints, or important . ami whiefa may call f de- partment that conservative Burgery has made tin 1 greatesl advances, and has accomplished so much in diminishing mortality and mutilation. Not that amputations will ever be abolished, tor many can be saved in bo other way than by the sacrifice of limbs ^ but conservative Burgery has shown that the constant flourish of the ampu- tating knife is not the way to obtain the greatest number of surgical victories in times of war. imputations must, however, ever remain a sur- gical necessity; and he who removes crushed limbs with the greatest skill, and saves the pa- tienl by successful after-treatment, will ever de- serve the high position which humanity and philanthropy will bestow upon him. In gunshot wounds of the extremities, we ftnd a much greater vitality and resistance to injuries in the upper than in the lower limbs, which would modify the treatment <>\' similar injuries located in these two portions of the body. This depends upon the greater vascularity and freer anastomosis in the arm than in the leg. In the more liberal supply of blood-vessels and nerves, we find the source of sateh which enables us to COMPOUND FRACTURE OF THE EXTREMITIES. 805 save an arm. when, for a similar injury, a leg would be generally condemned. The most common accidents of the extremities which give surgeons the greatest annoyance and require the most careful diagnosis, prognosis and treatment, are <-<>iitj><»/itl\ and extensively accomplished by the coni- cal hall that, while only a small opening leads '■■''"'■ COMPOUND FRACTVRF. OP THE EXTRKMT1 to the seal of fracture, tbe whole shaft may be rent from end to end. Fortunate it is that this extensive splitting or Hssuring of the long bones iM'i - xtend into the joints, or ili<- i • e for operation would be much nn>rc numerous than they now are. The epiphysis of the bone ap- pears not to transmit the force of cleavage, as the injury most frequently Btops at the junction <>i' ilic head of the bone with its shaft. The successful treatment of such wounds requires much judgmenl and experience, with a thorough knowledge of those agencies antagonistic to the healing of wounds, and which belong to military surgery. When a bone is crushed by a ball, the patienl is conveyed very carefully to the field infirmary; or, if it can be done withoul delay, to the gen- eral hospital, where the treatmenl commences. On the field, the ambulance surgeon can do nothing bu1 administer a dose of morphine, and secure the limb to a rough splint to facilitate transportation. For a fractured clavicle, scapula or humerus, the arm is bandaged to the chest, which, on the battle field, answers the purpose of a temporary splint : for a crushing of the forearm or hand, the arm is laid upon a board splint, and slung from the neck. If the splint COMPOUND FRACTURE OF THE EXTREMITIES. 3G7 is not at hand, the sling made of a handker- chief must answer until the wounded man can be better attended to: it being understood that a wet or greased cloth is always put over the wound for its protection during the transpor- tation. When he arrives at the hospital, the limb is carefully examined. The external wound may give no indication o( the extent of internal in- jury. When ihe linger is introduced and the wound carefully explored, the degree of crush- ing will he ascertained, and the question at once proposes itself: what course shall we pursue? Shall we attempt to save the limb; or docs its condition, with the want of proper facilities for ii> successful treatment, necessitate its condem- nation? If we have had experience in the eare of guushol fractures, we should, with Sir Charles Bell, contemplate what will be the condition of the parts in twelve hours, in six days, or in three months. "In twelve hours the inflamma- tion, pain and tension of the whole limb, the inflamed countenance, the brilliant eye, the sleep- i< 9e and restless condition, declare the Lnipres- lioB the injury is making on the limb and on tic constitutional powers. In six days, the limb, from tic groin to the toe, or from the shoulder * N! POUND FRACTURE <>F TnE EXTRKMITII H to I ivolleii to half the siae oi I body; a violent phlegmonous inflammation per- vades the whole; serous effusion baa taken pli in the whole limb, and al are forming in the greal beds of cellular texture throughout the whole extent of the extremity. In three months, if the patienl hae labored through the my, tin' bones are carious; the abscesses ate interminable Bin uses; the limb is undermined and everywhere unsound, and the constitutional strength ebbs to the lowest degree." All these conditions must be rapidly considered, and with tin in the move immediate dangers of mortifi- cation, and the remote dangers of erysipelas, pyaemia and hectic, and the questionable utility of the limb, when, after Beveral months oi con- tinued trials, the wound has been healed. Business presses and time is valuable. Within twenty-four hours, or before reaction sets in, whilst the patient has his sensibilities depressed \>\ the shock, our conclusions musl be made and acted upon; success of treatmenl depends upon prompt action — the delay of a few days lias de- stroyed thousands of wounded. Should amputa- tion be required, there is no period in the progn oi' the case so favorable for the performance of this operation as the first four and twenty hours. COMPOUND FRACTURE OF THE EXTREMITIES. ol)9 Should ;in injudicious attempt be made to save the Limb, amputation cannot be resorted to with any hope of success until suppurative action has hem well established. Should erysipelas attack tlic wound, an amputation is impracticable ; and whan gangrene lias supervened, during the stage of reactionary excitement, we are driven to an operation under the most unfavorable circum- stances. There are numerous compound fractures upon which judgment can he immediately passed: with some, there is every probability that the limb ean be saved; whilst there are others in which the limh is condemned at a glance — our prognosis being based upon the following circumstances: A.s the Upper extremity ean sustain a much more serious injury than the lower, we may lay it down as a rule that a compound fracture of any of the Long hones of the arm, when not complicated with excessive crushing of the soft parts, or injury to hlood-vessels and nerves, ean and should be saved. An arm is rarely to he amputated except from the effects of a cannon shot, which, besides crushing the hones, makes Erightful Lacerations of the mi\ tissues, tearing away muscles, nerves, and blood-vessels, and of- ten amputating completely the limh, the surgeon * 370 TREATMENT OF 0OMPO1 M> VK.V I ! i: ! - being required only t<> give a better form to the stamp. For a gunshot wound from a musket or Minnie ball, which has fractured the bones of the arm without implicating a joint, the following is the course t<> In- pursued : At tin' field infirmary the wound is carefully probed with the linger, ami its spiculated condition noted. All Loose fragments are to he removed at this first examination before reaction ensues, I'm- it will be very injurious to the wound, as well as excessively painful to the boI- dier, to continue Buch examinations from day to day. The first examination should always he effectual. The patient is then Buffering from shock, with sensibility temporarily blunted, and is, therefore, in the besl condition to he operated upon. To render this first examination complete, should the shock have passed off and the patient complain of much pain, it would be better to give him large doses of opium, or administer chloro- form, rather than desist from this important por- tion of tlie treatment. Should we omit to bring away all spiciihe. the further removal should not he attempted during the Btage of excitement and febrile reaction which will come on after twenty- lour hours, and which wili run its course in six or eight days. When this sulfides, then and not and no TREATMENT OF COMPOUND FRACTURES. 371 before, we make the second examination, and by the use of instruments, remove any loose frag- ments which wo now detect. We will simply mention, in this connection, that as there is not the slightest probability, or even possibility, of the wound closing by the first intention, the in- sertion of tents and pieces of lint is a relic of barbarous surgery, which being useless, injuri- ous, and very painful, cannot be too severely con- demned. Modern surgery recommends that all spicuho, whether detached or not. should be removed: hut this practice is not upheld by surgeons generally. Experience and observation has in some instances shown, that although the larger fragments may he detached from the shaft of the hone, they may siill he adherent to the periosteum, which will effect a reunion and consolidation. On the other hand, experience and observation have shown that, from the force with which conical shot Strike a hone, the spicuho, which are very numerous, are driven in every direction, hut gen- erally toward the opening of escape of the ball. These Bharp splinters canuol but produce ex- e irritation in the soft parts, and may. by transfixing vessels, pricking nerves, or irritat- ing muscles, induce hemorrhage, mortification, or «i SJ72 IIU.ATMKNT OS OOMPOUMD lltAlTI l!l- lotaiiuo. N< • • 'ii doubts the prop moving all such on the Bpot, or :it tin- earliest p< -iMr moment. A.> the opening: of exit, around which iIm- larger Dumber of the fragments mv fouud, may be toe oontraeted to admit of a ihor- ongh exploration of the wound, it will not in- creaae the dangers but, on the contrary, materially diminish the risks of after-trouble, it the wound of exit, in compound fractures with crushing of the bone, be dilated, bo as to facilitate the oLsti tiuii and removal of every spicula. In enlarging this orifice, injury to the important blood' ami nerves will, of course, be avoided. On the subject of removing oil fragments, whether detached or not. there appears to be I diversity of opinion, which is based upon the changes introduced into modern warfare. Tbe older surgeons, who base their treatmeul on the effects of musket halls, know that often the ass* paction of tin- fragments to hhe Bofl parte and bo tlir periosteum will guarantee a consolidation of the fragments. The round bail simplj breaks tin' bone without scattering the fragments, and. therefore, their relations to the surrounding tis- Baee will not be so materially changed. Bnt, notwithstanding this impression, which may or may not be correct, what does actual experience TREATMENT OF COMPOUND FRACTURES. 373 prove, when brought down to tacts? Take the experience given by the inmates of the Hotel dee Invalides. as recorded by M. llutin. the surgeon of the institution. He states, that those spicules which had been attached to the soft parts, and which Mere allowed to remain in the hope of reunion, although they may not give trouble at the moment, invariably end by becoming seques- tra, and. after a long period of pain and sup- puration, demand removal. He reports several hundred cases in which the retained fragments, sooner or later, set up an eliminative action, which is always painful, often dangerous, and at times fatal. M. Hutin refers chiefly to the effects of round or musket halls. Baudens gives, as his Crimean experience, "that whether adherent or not, it is better to remove all spienhe. and thus simplify the wound. If these be retained, end- suppuration, continued Buffering, with exac- erbations of all the svmptoms at the escape of each fragment, will gradually exhaust the vital forces, and entail it- seqttelss of marasmus, diar- rheea and hectic." Suppuration will eventually bring all of the fragments to the surface, but at what a sacrifice! McLeod, after quoting the experience of Roux, l»aiid simplify the wound." Again, he says: "Tin' extensive comminution of tin- bone by a conical bail, makes the indi- cation.- with regard to tin' management of the sequestra more evident than it i> commonly <-on- sidered. 1 do oot think that we paid sufficient attention to their removal in the Bast It may he true as some tell as, that in fractures with the old hall, it was desirable t«> meddle as link- as possible with the fragments; hut this i> the teaching of only a few. However, to my mind, the question ;is>mncs a totally different light when viewed by the pathological results which we bad occasion to witness." Borne surgeons go further, and recommeud that not oniv should all spicule he removed, but that tin' sharp, irregular ends of the bones should be sawed oil'. This suggestion lias not met with general approval, and is spoken of by Stromyer TREATMENT OF COMPOUND FRACTURES. 375 and LoefBer as no improvement. Their experi- ence gave a larger mortuary list when this prac- tice w:is attempted. There is no doubt that the removal of all frag- nu'iiis. in which there is not a strong probability ci' reunion taking place, will expedite the cine. In surgery, whenever we are in doubt, we should always give the patient the benefit of it; and in the subject under consideration, knowing that the removal of s]>ieul;e. which niiuhl eventually become consolidated, can do no harm, whilst leav- ing theni in. should union not be obtained, would be followed by much danger, annoyance and Buf- fering, we give the patient the benefit of the doubt, and remove them at the first examination. Feeling now secure that we have removed every foreign body, and have left nothing in the wound which is likely to retard the cure, we should ignore the presence of the wound as much as pos- sible, and treat ihe case as one of simple fraetuiv. Inflammation and suppuration we expect ; they generally accompany compound fractures, and es- pecially those connected with gunshot wounds: and remembering the long continued ami profuse drain which will establish itself in four or live days, we should be careful how we make use of active antiphlogistic treatment. For the first 376 TKKATMKNT OF OOMPOl \'l» FRACTURES. week or tin davs. the arm may be stretched upon a pillow, or loosely secured to a broad, long splint, which will support the entire ex- tremity. We confine the treatment to cold water dressings, either l>v iced bladders, applied over compresses to remove the injurious effects of di- rect application* or by the process of irrigation — either of which is better than the continued renewal ot' wet cloths. The general treatment, during this period of inflammatory excitement, is diet, rest, quiet, and the use of mild diapho- retics, diuretics, and the liberal use of opium. Tain we do not consider, in any sense, n< sary to the healing of wounds, and. therefore. have always made it a rule in practice to reduce it t<> its minimum. The complete annihilation of pain will neither detract from the rapidity of healing, nor from the gratitude (A' patients. Tim impropriety of free catharsis, will he at once evi- dent from the movements made necessary by their action. Bloodletting, emetics, and the use of mercury we absolutely discard, as always use- less and injurious in the treatment of any stage of compound fracture-. As Boon as the period of inflammatory reaction has subsided, we then apply such splints to the arm as will secure quiet and rest to the liml». whilst a \v<-r vent i> COMPOUND FRACTURES OF THE ARM. o77 allowed in the apparatus for the escape of &W charges from the wound — this opening also per- mits water dressings being applied to the wound. Tt cannot be expected that an arm. after a serious gunshot injury to the bones, will lie cured without deformity. The arm will always be shortened, wliere many spieuhe have been re- moved. We acknowledge this feet in anticipa- tion, and never attempt, by traction and coun- ter-extension, to restore it to its former length; We simply place the arm in an easy position and allow the muscles to approach the broken ends. In the treatment of simple fractures, the main object is to prevent deformity, and, especially, shortening of the limb. As this ob- jert is discarded in compound fractures of the upper extremity, the treatment becomes much simplified, and the patient is saved its greatest annoyance. In fractures of the arm. the pasteboard spliiirs are to be preferred; whilst for the forearm, wooden splints, made of light material and wider than the diameter of the arm, will make the best application. The tumefaction bandage is not now insisted on, and by many Burgeons is altogether discarded. In gunshot injuries, where we have an open wound to dress daily, our 378 MI'<>1 Mi 11! \< II UB n( THK ARM. mechanical applications should be of such a character at to permit o£ easy inspection, and also the ready readjustment of the apparatus when disarranged, whilst, at the same time, the splints are kepi secure. Diachjlon plaster is now extensively used to secure splints t<> frac- tured limbs; 1 1 1 r* ■» • or four bands encircling the limb will always secure the supporting appa- ratus, while! the limb remains open to inspect tion. When the pasteboard is moistened, it moulds itself to the arm and makes a very sat- isfactory dressing. A- soou as the patient has passed the roae tive stage, he should no Longer be confined t<» his bed, 1'iit with his arm in a sling may obtain sufficient exercise to keep his Bystem in good order. The erect position will have the addi- tional advantage of permitting the ready dis- charge of i»us. and will prevenl the bagging of this liui I, and obviate the necessity for tin- estab- lishment <»f counter-openings. In all Bimple fraa- tures, tin' excess of callus depends upon the de- gree "i' mobility between the broken ends. In compound fractures the deposil for consolidation i- usually very great, which may he explained by tie amount of irritation from inflammatory action, ami also by the difficulty of keeping the COMPOUND FRACTURES OF THfl ARM. • >,!• fragments at rest. Fortunately, this docs not interfere with the final results, as false joints are not more frequently met with in compound than in simple fractures. Experience shows us that there is not that necessity, which many practice, of frequently tightening the apparatus, to the very great annoyance of the patient. If the constitution he strong, a considerable degree of relaxation may he permitted, and he found not incompatible with perfect consolidation. In animals with compound fractures, we sec contin- ual exemplifications of this fact; their broken hones becoming united, notwithstanding the con- tinued motions of the Limb, in the absence <>l" all retentive apparatus. The local and general treatment of the wound will, in no respect, he modified on account of the fracture. Water dressings, until cicatrization is completed, medicated with astringents to al- lay profuse discharges, or with antiseptics to remove fetor, or with stimuli to promote gran- ulations, will be the proper course, whilst the genera] health is watched, retarded secretions promoted, and debility guarded against. If frag- ments of hone have remained and have become necrosed, the Burgeon must assist nature in the expulsion ;i> soon as they have become detached, MPOUNTl FH \t' injury, when the swell- ing has Bubsided to such an extent that the finger can be introduced. From the passing off of tlic shock until the period of reaction has subsided, all examination of the wound must be absolutely interdicted. During the first week, no one should be permitted to probe the wound. A.a -"Mil as we conclude that all fragments have been removed, we desisl from all further prob- ing, as it cannot hut be injurious to the deli- cate granulations. Cleanliness is necessary to successful hospital practice in the treatment of suppurating wounds, btft, when excessive, becomes a Berioua obstacle to rapid cicatrization. It is a common error for surgeons to place a wounded limb over a basin <>f water, and sponge and nil» it at it they were cleansing a piece of porcelain I have -ei-n others cleanse gunshol wounds by the free use of a powerful syringe, with which they poured a stream of water into the wound until the granu- I'oMI'iU'XIi FRACTURES or THK ARM. -5 s I lntions were bleached and the water returned dis- colored with blood, and this repeated with greal regularity at the morning and evening visit. Tt was not surprising' that wounds, treated with this over-care, took a very long time to heal. This too liberal use of the syringe is a very common error with sum-eons, who overlook the protective influence of healthy pus in their over- estimate of excessive cleanliness. I have seen a surgeon, in a ease of resection of the shoulder joint, which promised a speedy and successful cure, put the heak of a syringe into one of two or three fistulous tracks through which the liga- tures had escaped, and distend the cavity until jets d'eau spouted from the opposite orifices, the perspiration streaming from the face of tin 1 pa- tient, and the distorted countenance indicating the unnecessary torture which tic surgeon was inflicting. AVas it singular that the ease retro- graded from the time this rude and ignorant practice was instituted ? and could any other reeuh have been reasonably expected ? if the wound he gangrenous, and the object In- to remove ichorous decomposing fluids, to di- minish or prevent absorption and general poison- ing, then the syringing i- desirable ; hut tinder no other conditions should the granulating sur- 388 Ml'i.l ND FRAC1 I HKS 01 TIIK ARM. face of a wmiiimI be washed. Wipe around the edges :ui«l remove any secretions which might have eolleeted upon the akin, but leave the put, as the best eovering which healthy granulations can have. Under its protection, the plasma, which is thrown out from the blood-vessels, will rapidly form tissues; but rub < »r wash away this covering, and the exposure to the baneful influ- ences of the atmosphere will rapidly destroy the granulations which had already formed. How- ever useful the local and general bath is to ad- vance the cicatrization of a suppurating wound, do not generalize too much, and expect equally good service from cleansing the granulations. Compound fractures, under the \ « • i \ besl condi- tions, arc tedious oases, and in gunshot injuries our patience will often be taxed to bhe utmost Despondency should not be an element in thi character of a military surgeon. We niusl ex- pect to have a compound fracture under treat- ment at least twice, if not three times as long as would be required to consolidate a simple fracture. Bhould the main vessel be injured, in connec- tion with the fractured bones, we have not suffi- cient cause to sacrifice the limb; but, ligating the arten at " s bleeding mouths, we treat the TREATMENT OF GUNSHOT INJURY OF JOINTS. 383 fracture as if this complication had not existed. Owing to the free anastomosis of the blood-ves* sels of the arm, mortification is not to be Seared when a ligation is applied even to the brachial artery; a circuitous route soon supplies the need- ful nourishment to the parts beyond. Should the nerves as well as the artery be injured, or the principal nerves alone with the bones, then the limit, even when saved, Mould be a useless. paralyzed extremity, and its immediate removal will save the patient a long, tedious, and danger- ous convalescence. In such eases, it is our duty to sacrifice the limb to diminish the risks to life. The most dangerous fractures of the extremi- ties are those involving the heads of the bones and extending into a joint. The synovial injury add- greatly to the danger of the case, ami in former times was considered nearly a fetal com- plication, as it necessitated an amputation, which, under the ordinary circumstances attending hos- pital treatment, was not far removed from a fatal termination. Nor have we now much to hoast <>f: for, when amputations near the trunk are required, notwithstanding all the improvements in modern seieii<-<>. we succeed but little better in checking the fearful mortality. *J£4 TRKATM1 NT "1 Ol N8HOT 1N.il l!V OF Joints. The -'•v.tiiv of the Bvmptoms of articular in- juries depend upon the size of the joint mid the character of the wound. The dangers mv serious enough with 1 1 u ■ smallest puncture, but when the wound is large and lacerated, exten- biyc local mischief and constitutional disturhance i> Bure to ensue, leading with certainty to the destruction of the joint, and usually destroying the patient. Hence - , in the days of John Bell, the united experience of surgeons considered wounds of joints mortal. Crimean experience corroborates John Bell's conclusions, as no seri- ous injury to the large joints recovered unless the limbs were amputated ar joints resected. TW great fear is not in the serious injuries, as these cases are at ontje operated upon. It is in the ap- parently trivial ease, where, from the very small size of the wound, we hope that no trouble will supervene, tliat violent inflammation shows itself and life is sacrificed. A wounded joint, under the ordinary hospital treatment, will exhibit the following Bymptoms: When a hall has perforated the joint, the pe- riod of reaction is not long absent. In exten- TitKATMiN: "i 0CN8H0T injoth op jon the joint, from which a constant discharge of purulent matter escapi [f the patieni is no1 destroyed in the early - of the disease by erysipelas, pytemia, etc., in connection with the irritative fever, he tails a prtey to hectic, caused by the continued drain from the disorganized joint: synovial mem* brane, cartilages, and bones forming one mass of disease. In gunshot wounds of joints, very rarely does tin- patient escape with life in mili- tary hospitals. In private practice he some- Times recovers, bu1 even under the most advan- tageous circumstances a successful case is rarely seen, and then usually with a destroyed and an- chvlosed joint. As the results in injured joints are so fatal, surgeons had, ai an early day, adopted amputations as giving the only chance for recovery. In recent years, conservative sur- srerv lias introduced the operation of resection as affording no1 only the means of preserving life, but also of saving a useful limb. The diagnosis of articular injury is usually evident from the direction of the wound, and from the escape of synovia: at times, however, when the orifice is small and the wound ciivui- bous, ;i successful diagnosis requires much expe- rience and close observation. When possible, a RESECTIONS PREFERABLE TO AMPUTATIONS. 387 consultation should always be had over these cases'. It is in these very cases of doubt, or erf apparently trivial injury, that the most violent reactionary Bymptoms are met. and that a fatal issue occurs. If left unoperated upon, the tri- fling wound, perforating the joint, might nearly be considered mortal ; whilst, if the joint be not implicated, the operation of resection is not only not called for, hut unnecessarily risks the lite of the individual. The urgent necessity for ah accurate diagnosis is evident. For injury to joints in the upper extremity resection is particularly applicable, and this op- eration is now the rule of practice, having su- perseded amputation in all eases where the blood-vessels and nerves around the joint are not involved in the injury. When a joint has in any way been injured by a gun-shot wound. whether the articulation has only been opened, or the heads of the hones forming it crushed, a- BOOB as the excessive shock under which the patient may he; suffering passes oil", we proceed at once to operate. A primary re- section is as essential as a primary amputation, and is followed by as successful results. It should he performed within twenty-four or thirty-six hours, or before reaction sets in. Such IONS J'UKKI KAlll.l. In A'.,IM CATIONS. cases would do much better if the patient could be transferred to the genera] hospital prior to an operation, as transportation is difficult and dan- gerous immediately after the resection, from the difficulty of securing the limb from movements. Should the case not come under observation un- til reaction lias come on, then, by general, mild, antiphlogistic treatment, and ice Madders or cold water dressings locally, we awarl the establish- ment of suppuration, when the operation might be attempted with good prospects of success. The results of the primary resection are more successful than the seoondary; and these arc in turn, much more likely to succeed than when the operation is performed during the stag febrile excitemeot. There arc three or four rules necessary in all cases of resection, and which should not be forgotten during the operation, viz: Make the incisions for exposing the heads of the bones in that portion of the extremity opposite to the main Mood-vessels and nerves, so that these may no1 he exposed to injury. If possible, make the existing wound lie in the line of one of the incisions, and place the incisions in such a way as to permit a continued drain from the joint. Make these iuci.-dons free, so as not RESECTION OP THE STTOT'LOER-.TOTXT 8SD to cramp the operator in turning oilt the heads of the bones. An ineli added to the incision does not increase its serious character, and hast- ens the operation. Remove most of the synovial membrane, and save as much periosteum as pos- sible: the one is prone to take on inflammation, the other makes, and Will, to a certain extent, reproduce the bone. In performing secondary resections, the removal of all the diseased syno- vial membrane becomes one of the first elements for success. More successes are obtained from resections of the shoulder-joint than from any other artic- ulation — the statistical tables of the final re- sults oi' operations in favor of resection being conclusive over amputations. The following is the course recommended for performing the op- eration of resection, a substitute for amputa- tion of the arm: a I" shaped flap, about three inches in length, is made of the deltoid mus- cle, on the upper and outer portion of the arm : if there be any wound on this portion ot* the extremity, make one branch of the in- cision include the wound. The knife passing directly to the bom 1 , from the clavicle or accro- mial process downward for three inches, makes B large flap of the deltoid, which is raised by :i [OR Off tiik. siioi I. in. is .hunt. few touches of the knife. The circumflex arte* are divided in tliis first incision, and Bhould be at once ligated, otherwise, aa the? are of con- f~ i ( 1 » ■ s : 1 1 > I « • size, tin- patient will lose mncfa Mood, and the steps of the operation 1"' obscured. Bj carrying the arm over the chest, the capsule oJ tin- joint La exposed and divided transversely, and with it the rotary muscles of the shoulder, when the head A\ill protrude from its position. Tin- Long head of the biceps is carefully removed from its bicepital groove and protected from in- jury. The In. no are now examined; a knife blade, or spatula, as a guard, is placed behind the bone so as to protect the soft parte and ves- sels from injury, and all of the injured portion is removed with the saw. When the hall has entered directly within the joint, only the surface may require excision ; Inn should the head of the hone he extensively speculated, we must cut hack to the sound hone, even if we arc compelled to remove four or live inches of the shaft of the hone, as was w»- cessfully done first by Stromyer lor a gunshot injury: should the glenoid cavity he equally in- jured, the fractured portion would he removed. The rule is. never to remove more of the hone than is absolutely called tor. and not to open RESECTION OF THE SHOULDER-JOINT. 391 the medullary cavity if it can in any way be avoided. When the wound has been cleansed of all foreign bodies, the flap is replaced and secured with one <>r two points oi suture. As adhesion by the first intention is not usually expected, and gives n<> advantage over the final result by granulation, nice adjustment is not necessary. The natient is then put to bed, and cold water dressings applied. Inflammation at first runs high, the parts around the joint are mueh swol- len, and a collection soon forms within the cav- ity from which the bones have been removed. The escape of this decomposed blood and pus from the wound gives great relief. When kept in by the too nice adjustment of the flap, the collection increases the swelling, u'dema. and pain which is diffused over the neighboring parts, involving the chest as well as arm. When sup- puration becomes established, the swelling ami pain subside, granulations spring up, and event- ually close the wound. Iii the meantime, the divided muscles have formed new relations: by means of the lymphy exudation, they become more or less incorporated with the surrounding tissues, aud by taking an insertion around the cut portion of the bone, form in time a closed .'I!' ■_' [ON OF THE SU01 I D1 R-JOIN I head bo the bo ometimea, in a measure, formed; in other cases, the end of the bone becomes attach. <1 i<» t In- cavity by fibrinous bauds. < >f the eases of resection of the Bhoulder performed in the Crimea bnl few died; ami all those saved regained a aseful limb, pos- sessing all the motions, with the exception af those oi tin- deltoid, which muscle is, to a cer- tain extent, paralyzed from the division of its nerves, whioh cannot, altogether, be avoided in exposing the head of the bone. A- Buppu ration will be excessive, and often long-continued, nourishment, and even stimuli, may be demanded during the treatment. When abscesses form in the Burronnding cellular tissue they should be opened. It i.- a matte]- of but little importunes in what position the limb is placed, and how it is secured, provided its pot* tion i- comfortable to the Bufferer. The uneaei* uese and irritation which the splints and bandages give, do much to prevenl Buceese. It matters little what length of limb the patient has, pro- vided his life be saved, and the convalesce nee In' speedy. A shortened arm does nol affeel its usefulness, and a slightly changed direction can be corrected in the after-stages of the treatment. The most effectual management is tin- simplest; RESECTION OF THE ELBOW-JOINT. '■W and tedious daily dressings are to be discouraged. Straightening the limb apon the bod, a pillow, or 8 long, broad splint, without bandaging, is tbe best and most comfortable dressing for any resection. The patient is kept in bed until tbe suppurative stage is established, when he will be permitted to get up. His arm is then placed in a sling, and the water dressings ate continued until a complete cure is effected. When the parts are nearly cicatrized, it will be time enough to apply the tumefaction bandage, for removing the (edema of the limb. Anchylosis rarefy follows this operation in the shoulder-joint. As a proof of the efficacy of resection, Stromyer excised nineteen shoulder-joints, with a loss of seven, chiefly from pysemia. Of eight eases in which tin' operation was required, but, from some miti- gating circumstances, was not performed, five died. Gunshot wounds in the neighborhood of the elbow-joint are much more readily recognized, by the escape of the synovia, etc.. than injuries of the shoulder. Inflammatory reaction runs high, as in all cases in which joints have been opened by a ball. Collections soon form, and the excessive swelling stretches the softeiud cap- sule, which, giving way. allows k\' the burrowing Kl SECTION O] i in. BLBOK 401 of pus and final discharge through open abso< Alter running ;i t « ■< i i » n 1 r~. painful, and dangerous course, it' the patient escapes with a shatl constitution aud an anchylosed limb, it much as he can expect. A primary resection offers a diminution of the risks to life, a rapid convalescence, and a movable joint, in the Schleswig-Holstein army, of fifty-four amputations of the arm niueteeu died; whilst of forty resections under similar circumstances only six died. The results of the operations were also modified by the period at which the resection was performed. Of eleven excised within twenty-four hours before reaction ensued, bat one died: of tweuty cases between the second and fourth day, or during the stage of irritation <>r excitement, four died; and of nine oases operated upon between the eighth and thirty-seventh day, only one died : an exemplification of ;i general rule laid down in the commencement of this chapter, that the wounded hear operations before the stag* reaction, or after the establishment of suppu- ration, much better than thej do whilst suffer- ing under high inflammatory excitement. This shows the necessity of deferring secondary op- erations until the proper time has arrived, which experience has determined. RESECTION OF THE ELBOW-.TOTNT. 895 The elbow-joiui, for gunshot wounds, transfix- ing its capsule and fracturing the bones, is best resected from the baek of the joint, the patient lying upon hie abdomen. An II. L, or T incis- ion, taking in the breadth of the articulation, when sufficiently long (from torn- to five inches), will expose perfectly the heads of the bones. There are no important vessels on this poste- rior portion of the arm, and only one nerve, the ulna, which must be sought on the inner side and avoided in the incision, or paralysis of all the muscles supplied by it will follow its section. When the posterior Ligaments are divided, and the joint exposed, only remove the fractured head and all foreign bodies, and do not interfere with that bone which has not been injured. The lips of the wound arc closed by sutures, and cold w;iicr dressings become the principal treatment. The limb is placed upon pillows, and no| dis- turbed, if possible, until suppuration is estab- lished. When the sofl parts are cicatrizing, and healing is nearly completed, passive motions in the joint will prevent anchylosis, and a tumefac- tion bandage will remove the oedema of the limb. [■stances of successful resections are recorded for injuries at the wrist-joint, where the Bpiculated 5-500 TIIF. ri'I'KH KXTKKMTTY HAltll.Y ends of both radius and ulna have been satisfac- torily removed; also, instances in which either of these bones have been removed entire, for chronic ostitis and necrosis brought on from gun- slioi injuries. Bimilar incisions to those recom- mended for the resection of the elbow-joint will expose the heads of the wrist bones, and permit of the ready removal of any injured portion. In this as in all other cases, we must save all ten. Ions passing over a joint to supply distant bonee; and in the wrist particularly, many of the muscles which supply the fingers can be drawn <>ut of the way and thus escape section. However frightful an injury involves the hand, it is very seldom that it is so mangled as to be beyond the pale of surgical skill, and unless it is. literally ground up it should not be amputated. In certain cases, fingers may have been already torn oiK or may be hanging by a fragment of skin, when they should be removed; but for ordinary gunshot lacerations of the hand, ampu- tation of the < utile hand is very rarely required. Different hones of the hand and wrist arc to ho removed when irrevocably injured, with or with- out the metacarpal hones of the fingers or the thumb. Any fingers which can be saved will he better than the best artificial limb. In cases REQUIRES TO BE AMPUTATED. 397 of lacerated hands in military surgery, when at- tempts are made to save the limb under cold water dressings, the inflammation which comes on makes a shocking limb to those unaccustomed to treat lacerations of this extremity; but at the end of eight or ten days, when suppuration has been well established and granulations are form- ing, the swelling subsides, the torn portions are drawn together, cicatrization advances rapidly, and often but little deformity remains; at least, the patient retains a useful limb. Some surgeons lav down the rule, that an amputation of the hand is never imperative, however frightful the injurv to it may appear; and there is much truth in the assertion. Lt the inferior extremity f we find the treatment of gunshot injuries somewhat ditlercnt from those of the upper limb, on account of the minor degree of vascularity, and the much greater tendency to mortification, so that the rule to which we called attention, of amputations being rarely required for the superior extremity, is reversed for the Leg, where it te often the only way of escape left to save the life of the wounded. We have elsewhere slated that when balls em- bedded themselves in the pelvic bones, and their position could be discovered, provided a serious 398 COMPOUND FRACTURES of THE operation is not needed. tli«\ should be removed, ;ts their presence will. Booner or later, give rise to trouble. All loose spicules should also he taken away, and as Bequestra frequently Bhow themselves from time to time during the treat- ment, they should l>e withdrawn. Wlien the ball strikes lower down, in the neighborhood of the trochanters, it usually splin- ters the bone, and frequently involves the ilio- femoral articulation. Such injuries are of the mos1 serious character, and are usually consid- ered fatal. It is a question <>t' much moment, to inquire how can modern Burgery, with all <»t its appliances, improvements and experience, as- sist in Baving the life and limb of such Beriously wounded'.'' Within a lew years the rule for all compound fractures of the lemur was amputa- tion of the limb; but the statistics from military hospitals in time of war are so frightful — hut few successes for the numbers treated — that it was naturally suggested that the risks could not he materially increased by letting the patierri take the chances with his limb <>n; when, it' his lite was Baved, it would he with and not with- out bis leg. 'This has settled down into a oon- vieiion lor fractures of the upper third of the lemur, which are now treated without ampuia- 1 N FF.RI OR KXTRF.M [TIES. -'!'• »'• I tion, inasmuch as nearly every amputation in the neighborhood of the trochanter, and all at the hip-joint, are fatal. If we arc assured that the ball lias crushed the head of the bone, then the operation of rc- section offers the beat prospects oi' stiecess for the patient; but it docs not always follow that this diagnosis can be clearly made out, if the signs of intra-capsular fracture be not present. Military surgical experience shows, that a frac- ture of the upper portion of the shaft of a bone does not necessarily extend into the head; and met verm. Unless the junction of the epiphysis with the shaft is struck, the fracture is more likely to be confined to a centre of ossification ; so that, in the thigh as in the arm, a blow just bel«>w the trochanter will not usually fracture the head of the femur. When the joint is opened and the head of the bone fractured, the wound should be enlarged, or an opening made into the joint from the outer side of ibe hip. by which the fractured head might be removed. If any success is hoped for. those cases alone should be selected in which neither blood-vessels or nerves are injured, nor the soft parts exten- sively torn. If all or any of such are injured, where experience teaches us that the chances Km QUNSHOI ivu im> OS Tin: BIP. from successful resection arc more than doubtful, do qoI have recourse to amputation, which is bo certainly fetal, bui lei the patient live his few remaining hours or days without being haunted by the ghost of a useless operation. Should he revive the reactionary Btage, and still retain a good pulse and comparatively unshattered consti- tution, then a secondary operation might give a chance <>l' success. In the Crimean service, n<> amputation in the vicinity of the hip-joint was BUCCessful — every individual case died. This only corroborates the experience of other campaigns, and also -hows the inutility of such mutilations. When death from a crushed thigh-joint is inevi- table, it is hardly humane to amputate under the plea of giving to the patient the benefit of the chances which experience teaches us are uugatory. As regards resections in suitable cases, the re- port is a little more satisfactory. Of bLx resec- tions performed by the English surgeons in the Crimea, one was Bucces&ful, and the condition of all operated upon was made more comfortable. Had the conveniences for treatment been greater and the general sanitary condition of the troops better, with less pyaamia, hospital gangrene, chol- era and scurvy, much better results mighl have been obtained. Some of the cases were doing GUNSHOT INJURIES OP THE HIT. 401 well, with every prospect of final success, when they were swept off by one of the above diseases. In amputations at the hip-joint, all the cases died speedily. In cases of resection, the greatest difficulty lies in the after-treatment. As it is not expected to restore a perfect limb, no good result can he ob- tained by using violent extension. The leg, how- ever, must be fixed to facilitate those movements in the changing of position, which are necessary to the patient's comfort. A long, straight splint is used for this purpose by some surgeons, whilst the incline-plane, or Smith's anterior splint, which I would much prefer, is depended upon by others. Some have bandaged the limb to the sound one, and speak of it as a good mode of support. Water dressings compose the local treatment. Baudens succeeded in saving both Kmb and life in eases in which compound fractures of the upper half of the thigh were treated without operation. Consolidated and useful limbs, with hut little deformity, are reported as having been saved. By the use of the fracture-box and incline-plane, he succeeded in curing a compound fracture on a level with the trochanter: saving a useful limb, although he had extracted two inches of the shaft of the femur. His experience proves that om- 84 4u_' on of Tin: hip-joint. ■ pound comminuted fractures of the upper half of the thigh are not so fatal when attempts are made to save the Itmh as when the thigh is ampu> The experience of Burgeons derived from the wounded of the army of the Potomac would establish a similar course of treatment, as excel- lent limbs were saved where fractures had <><•- curred in the upper third of the femur, whilst amputations in the neighbor! d of the trochan- ters met with the usual fatality. As the resection of the hip is so much more successful when performed for disease than for injury, it has been suggested by surgeons of expe- rience that an exception t<> the rule of immediate tions be made I'M' tin- hip-joint, and that such cases, even the most suitable for the opera- tion, be deferred until suppuration is well estab- lished. For hip-joint resections, it is said that nothing is lost by this delay, whilst, on the con* trary, there may be a chance of saving the limb without an operation. Larrey, in 1812, reported six cases of gunshot fractures of the neck of the femur, with three cures: showing that the pros* peets are not altogether hopeless. When the patient is in a measure placed in a similar condi- tion to those affected with diseases of the bones, his prospect for a successful resection appears to RESECTION OP THE HIP-JOINT. 4U3 be improved. Bandens says, that as the resection of i lie hip-joint only succeeds as a secondary operation, attempts should first be made to save the limb. We preface the following table, taken from Ar- mand's Histoire Medico- Chirurgicale de la Guerre de ( rimee. with the suggestion that any surgeon who lias ever had a successful case of resection at the hip-joint lias always been eager to publish it; whilst many have been disposed to hide their misfortunes from the public, so that the tables, showing tlu- relative advantages of primary and secondary resections, appear in their very best light PRIMARY RESECTIONS AFTER GUNSHOT W0TTNDS. < Iperat* >1 Upon. Deal be. Larrey. ( Volume '■'>. Clinique) .1. Cooper. (Dictionary i (Relatione 'In Siege d'Anvurs i>;ir M. H. Larrej I Hotin. (Memoirea de Medicine el de Chi- rurgie Militaires) Sedillot. i \ 11 n :ilc- de In Chimrgie Francaise Ghiyon. (Expedition do Churchill, i Journees de Juin, 1848) Gtabiot. (These d< MontpelHer, 1840) French Crimean Service McLcnd. (Crimean War > Stromjei I * Tlii- - joint, but •■•niflned without the cwpsnlo; and we are. therefore, Justified in the belief that the caae irould have done equally well without lb -40-4 ! 0UNI1 FRACT1 RES. N'DARY RESECTIONS VFTER 01 SSHOT WOUNDS. iniqua, volume 5) (lutliric. (Clinic rolume 5) ( Bull< tin 'I' - rolame 3 i ri..'«- de Jain. 1848) 9 Juin. I • I' Vidal. (Traite de Chirorgi Uounii r. (I 1. '"II antinople, 1854) (Ci imean War) upon. 1 1 1 1 1 1 1 1 1 1 3 1 1 •■ 12 i Deaths. It has been suggested, thai it' the patient who baa been operated apoti could have facilities fbi slinging the whole body, ii would afford many advantaged in the management of excisions of the hip-joint. A compound fracture in the upper third of the thigh should be t rented in every respect as it' in the arm. Unless the leg is so mangled tliat an amputation is an net of necessity, it should not be thought of. We have already said that, in field military Burgery, amputation near the trunk is Bynonymoua with death. The treatment must commence on the battle field by proper transport tation; the judicious removal of fractured limbs important as an operation, and any neglect in this department will deprive the wounded man of all hope of retaining his limb, or of having hid COMPOUND FRACTURES. 405 life saved; We will carefully remove all loose and movable spieujse, dilating the wounds if ne- cessary to i'aeilitate the thorough removal of all foreign bodies. Until suppuration is well estab- lished, the limb is kept in an easy position and surrounded witb cold applications. All tight, re- tentive bandages are to be rejected, as they inter* fere, with topical antiphlogistic applications. Dis- pense with bandages. On the eighth or tenth dav. when tin 1 reactionary Btage has passed, the wound is again to be examined for foreign bodies, and all portions of bone which may have become separated by the inflammatory process must lie removed; or, as sequestra, they will become in- corporated in the new osseous formations, and be the cause of much trouble and suffering. In all compound fractures, with much loss of bone, it is always injurious to attempt to obtain a limb of equal length with the bound one. It cannot be done and the chafing and annoyance of splints and tight bandaging may react wry seriously, if not fatally, upon the constitution. The drst thing to be attended to is to prepare the facilities for treating such a fracture. If we are striving foi successful results, we must not expeel to obtain them if a patient, with a coin- pound fracture of the thigh, i> being treated upon J' ; '■ COMPOUND PRAC1 round or is lying upon a little straw. !!<• must have a proper bed :m< 1 ;i good firm mat- tress, prepared with :i bed-pan hole for facilitat- ing nature's daily wants without the necessity of moving him. I pon this the patient ia placed, lying on his back, with the l%g extended. Two long straps of diachylon plaster are attached to the Bid hia leg from the knee bo the ankle; tbey form a loop under the foot, and a weight is Bwung from this over the Soot of the bed. This will be >u\Y\- eient to tire the muscles and make the necessary degree of extension; or the limb might be loosely attached to a long thigh-splint. The tumefaction roller is inadmissible, and strips of adhesive plas- ter, or strips of bandage, will secure the limb t<> the splint, and at the same time leave the wound open for inspection and dressing. For the first week oi- ten days, this will Ik- ;ill the apparatus aeeded. A- tin' case advances, splints may be more methodically applied by using long inner and outer >[ilints of light hoard, well padded with loose cotton, and secured in position by bands of adhesive plaster <>r with tapes. The «osH«Sar- extending hands an' made by adhesive strips, attached to the sides of the leg and carried under the too,, where they are secured to the end of the COMPOUND FRACTURKs. 407 splint. Allow the ends of the bones to fill up the void made by the extraction of the spicules, as this hastens consolidation. A better method of treating fractures of the thigh is in the use of Smith's anterior splint, by which the limb is suspended. This splint is formed of a strong iron wire (three-sixteenths of an inch) bent in the form of a parallel logramj as long as the limb, and five inches wide Cross- pieces of the iron prevent the sides from collapsJ ing, and are also used for suspending the limb. This wire splint is placed upon the anterior sur- face (^' the limb. Whilst traction is being made upon the loot by an assistant, which removes ail shortening, the splint is secured by enveloping the entire limb in a roll of bandage, omitting the bandage at the point where the ball lias pene- trated. The limb is then suspended two or three inches above the bed, by passing cords from the upper and lower cross-wires of the splint, which, uniting in a single cord, is attached to the ceil- ing or top of the bedstead. With the limb thus suspended, the patient may move about in the bed at pleasure, without tear of disturbing the adjustment or giving himself pain. A- the roll of bandage has been omitted at the site of the wound. loc;d applications can he daily made and the parts duly inspected. i nv oohpound PBAorvmn ^^^ i 1 1 1 the exception of the mechanical appli- ances Por tlic broken bone, the case is treated as for :i long-continued Buppurating wound, by avoid- ing, in iill cases, depletion and by giving liberal diet. Manv of these cases will die; bul if we have facilities in a well-ventilated and well-organ- ised hospital, we will have the satisfaction of Bar- ing Bome of the patients submitted to our care. In fractures of the middle and lower third o( the thigh, not implicating the knee-joint, the question will again occur: whal course is to be pursued with them? These arc still very serious cases, ami arc classed wiili those of the Qpper third. Where attempts are made to gave them, ;i~ recommended by Guthrie, the fatality will not he very dissimilar to fractures nearer the trunk, and the moderate success which, under the very beat circumstances, we will obtain, will depend upon the State of health of the suH'erer and the conveniences for treatment. There arc cases which often appear so trivial — only a small bullet hole leading to the crushed hom — that it seems barbarous surgery to con- demn the limb without an attempt ;:t saving it. The young military surgeon expects much from conservative surgery in such cases. We are in- formed by the experienced, that this striving AMPUTATE COMPOUND FRACTURES. 40 ( .> after conservatism is the main cause of the heavy mortality. Surgeons generally are not prepared to believe how hopeless compound fractures of the thigh are, until the unwelcome truth is forced upon them by an ever-recurring experience, that mauy lives are sacrificed to attempts at Baving these broken limbs. In civil surgery, or with every facility in military hospitals, we should attempt to save the limb — it is the proper course to pur- sue : hut on the battle field, with the deteriorated material upon which we are operating, and the poisoned atmosphere of the wards into which tin 1 patient is to be carried, it is a fatal error. Mil- itary surgeons must abandon their conservative intentions to expediency. It is for such eases that primary amputation offers the best chances tor life. In rejecting amputations, we lose more Lives than we save limbs. As a rule, amputa- tions are less hazardous the greater distance we Operate from the trunk: and the reason why am- putation-, are urged for compound fractures of the lower and not upper portions of the femur i<. thai the ehances being similar withoul it. amputations are ninth lc~< fatal in the lower than in the upper half of the thigh. Attempts at saving limbs, after the battles on the 1'" 41 U AMPUTATE C0MP01 M» RBAOXI RE8. tomac, confirm the above experience. Too few primary amputations were performed upon the lower portion of the thigh, and the result was a heavy mortality among this class of wounded. Resection of the shaft of the femur foe a crushing of the bone has been often recom- mended, and as often practiced: but the experi- ence of tatter years discourages its performance, as the operation is more serious than the con- cfttion for which the remedy is used. When the splinters of bono are removed, there is con- siderable space tor the play of the rough edges remaining, which, therefore, give but little trouble. Should we attempt to save a fractured thigh in its lower third, we may use either the straight splint or the double incline-plane. The latter is much the more comfortable position for the patient, but has the disadvantage of promoting the burrowing of pas, which, in working its way down the limb, may dissect passages for itself as far as the buttock, and, by its multiplied openings, cause much annoyance us well as much destruction to bones and muscles. The anterior, wire splint of Smith is found most suitable in these fractures. Surgeons in the Crimea often had cause to regret attempts at savin-- fractured thighs, but never regretted an early amputation. KNEE-JOINT INJURIES. 411 When the knee-joint is implicated in a shot wound, or cut open by a shell, with injury to the head of the tibia or femur, experience has shown that, however trivial the wound may ap- pear, if the synovial sae be entered, and air be admitted, or a foreign body lie within the joint, violent synovitis, with great pain, swelling and heat, and with excessive inflammatory fever, will come on alter twenty-four or thirty-six hours. Should the patient survive the inflammatory stage, erysipelas, pyaemia or hectic will ultimately destroy life: and although, on the other hand, the effusions may he absorbed, and an anehylosed hut useful limb saved, it is a very rare occur- rence. If the soft parts are not much lacerated, or the flood-vessels and nerves behind the joint injured, such cases are well adapted for resection, and excellent results are obtained in practice. A straight or elliptical incision over the an- terior portion of the joint, across its entire diameter, will expose the interior, and enahle the surgeon to remove (he foreign bodies, what- ever they may he. and with them the head of the injured hones, 'flic section of the hones should he made in such a way that the surfaces will adapl themselves to each other — usually the patella is removed. When the externa] wound KM ,i:-.l.ii\ ( I.N.I I R i> closed by Botures, anion by the tirsl intention may, to a < «n :ii n extent, be obtained. In the successful cases, the b entually become firmly united, and, with an anchylosed joint, the patient retains a useful Limb. Ai'i.t the resection, a 1 < > 1 1 ^r splint upon the back of the leg, reaching from the buttock to the heel, is all the apparatus required, whilst oold water dressings alone are applied around the joint. In cases of resection, the sui must ii"i expect quick union in the wound, as that does not often occur in military surgery. A tedious suppuration, the formation of nume- rous absc< and often the exfoliation of por- tions of bone, is the rule, requiring care and judicious management to obtain a final success ; many of those operated upon being lost by the action of those deleterious causes which act in- juriously upon all wounds in military hospitals. When attempts are made to save the limb in what we Buppose to be a trivial or doubtful case of knee-joint injury, we shduld follow the routine of the antiphlogistic treatment. In a Bingle puncture of the capsule, even when Byno- via has escaped, the orifice may heal \<\ quick union. When local inflammation ensues, and run.- such an acute course that the free applies- COMPOUND FRACTURE OP THE T,KC 4T3 tion of leeches — twenty to fortj to a limb — does not quell the inflammation, and we are led to infer that pus lias formed within the joint, the articulation should be largely opened, and the joint thoroughly cleansed, whether wo resed the heads of the bones or not. There is no longer injury from the admission of air, whilst there is serious fear of destruction of the carti- lages should the colleetion of pus he retained'. This tret- opening- of the articulation may, in some cases, obviate the necessity lor secondary ions, as excellent results have been obtained by this apparently hold surgery — the patient liv- ing his life and limb, with an anehylosed joint. The effect of this incision in allaying the general irritation is said to he marked. The course which -will he pursued with a frac- ture of the bones of the leg must depend upon the extent of injury to the soft parts, and also the facilities at hand for treating Fractures. Our main object is always to save life. and. it' possi- ble, the limb also: hut. in our too-grasping dis- position, we must be very guarded how we jeopard the one to save the other. It is in this respect that military surgery is so very differ* at from civil practice. We are continually com- pelled to sacrifice limbs lo expediency, when, Ill COMPOUND rRACTTTRfi OF THE LEO under more favorable conditions, we would not hesitate to practice conservative surgery. To introduce ;i Bingle example: where ;i long and tedious transportation becomes i ry utter :i battle, ii would be expedient to amputate mncti more freely than we would do were there hos- pitals in the immediate neighborhood of the battlefield where the wounded could be treated. I low. for instance, could we transport with any chance of Buccess n resected joint, such as the shoulder, or a gunshot-fractured thigh or leg? I'udt'i- Midi circumstances, an amputation would give the patient a much better chance for lite, which should always be the main object. When facilities offer for attempting the pres- ervation of a fractured leg, the same precautions are taken as iu other fractures for removing immediately all loose or very movable fragments of hone. The limb is placed in a fracture-box, or upon the double incline-plane, and by the constant application of cold water, whilst we use those remedies already suggested for keeping down an excessive reaction, we watch the march of the case, and meet the various complications as they arise, hy the rule- of practice which have he. mi already frequently discussed. Should mor- tification appear in the wound a few days after FROST-BITE. 4 1 5 tho injury, wo will find the only moans of safety in early amputation. Resections of the ankle-joint have not been followed by that success which has characterized operations upon the larger joints, especially the knee and the elbow; It is recommended as a conservative measure, but is seldom practiced. When gunshot injuries occur about the ankle. crushing the bones, excision offers but a meagre resource. Mortification often follows such inju- ries, and amputation holds out stronger induce- ments for immediate and subsequent benefit. Fr.usr-I'.rn:. — Anions the affections of the ex- tremities which surgeons in the field are called upon to treat, during the inclemency of the winter's campaign, are those occasioned by ex- posure io cold and moisture. During the winter months, an army suffers from these accidents in proportion to the privations which they arc com- pelled to undergo — for well led and well clothed troops do not readily yield to the injurious influ- ences of exposure. During the Crimean war, the two winters which the allied army spent before Bebastopol very different in character. The winter of . was not \cry colli, hut was a season of 116 FROST-BITE. contiuued rain; the soldiers were literally Jiving in the mini, with wet clothes, which for weeks they had do means of drying; at the same time, the difficulty of procuring supplies was ao great that their means of subsistence kept them just above starvation. Bleeping in wet boots as long as the boots were whole enough to remain on, and the continued masceration of the feel in snow ami ice-water caused a gradual diminution of the circulation and vitality <>i" the toes and feet. Very short allowance, unusual exposure, and very indifferent shelter, more than counterbal- anced the absence of a very low temperature, and the result was that extremities, which could barely be kept alive, would be given over t<> disease under a temperature which would, undei other conditions, be innocuous. The feel and toes would become swollen and udeinatoiis, with a feeling of ten.- ion which gave much uneasiness during the day, with Buch an increase of pain toward oight as, in many instances, to prevent deep ; the parts would be discolored of a brown- isli red hue. In more serious cases, blisters would form upon the discolored surfaces, beneath which blood would extravasate. The dFying ami blackening of this would simulate mortification so closely as to he mistaken by the careless observer; FROST-RTTK. \ 1 l the peeling oft' of this blackened pellicle -would. however, expose either a new skin or an ulcer- ated surface. Tn feeble constitutions, the parts attacked by this low inflammation break down into sloughing ulcers, characterized in their future march by ehronicky, and an inactivity in the for- mation oi' healthy granulations; also an excessive secretion of a highly offensive, ichorous pus, with pale, greyish, exuberant, irritable, very painful and bleeding granulations. Like burns, the effects of cold show various degrees of gravity, from the redness and putiiness of a toe, through blistering of the surface, and the formation of superficial ulcers, to the com- plete mortification of extremities and putrescent liquefaction of the soft parts, with the usual systemic irritation, general depression, and intes- tinal complications. A second variety of Frost-bite was well exem- plified in the Crimea during the winter of 1 '")«'). At this period, the soldiers were better clothed and W'd, all the comforts of army life, at their disposal, and the hygiene of the camp was in every reaped good. The temperature of this winter was so extreme, that warm clothing could not retain the degree of heal necessary to support life in the extremi- 11^ PKOBT-BTTE. \\ li<» were mwli exposed first loal all sensation in their feet, bo thai ii" feeling would be imparted t<» the foot upon touching tit** ground, and then found some difficulty in walk- ing, or even in supporting the erect posture. The feet, upon examination, would be round cold, livid, mottled, slightly swollen, hard, oedematous, and without sensation. Tin- continued influence of cold would destroy the limb, causing it t<> shrivel and become dark. In time, a line <>t' de- markation would form, and the slow process of separation commence, leaving a chronic, fungus, sensative ulcer, from which a foetid pua would lie continuously discharged for months. As the fibrous tissues resist mortification, they retain dead, blackened bonea, which protrude from the face of tin' ulcer — a Bource of much annoyance, keeping up irritation, causing abscesses in the vicinity, and extending the mischief to contigu- ous bones. Should any attempt be made to re- move these protruding and hanging phalanges, constitutional irritation, with increased pain, and a fungus condition of the ulcer, if not gangrene, were sure to follow. The treatment, which is found most useful in of frost-bite, would be of a stimulating ■ character, avoiding studiously the application of KKOST-1UTE. 41i> heat in any Form. Where the parts are swollen, painful and discolored, frictions, with simw or ire water, is the popular mode of treatment, which indications we carry out by local applications of spirits of camphor, turpentine, or sugar of lead and laudanum, or by painting the parts with tincture of iodine or a solution of nitrate <>!' silver. Under Birch applications, the local symp- toms will gradually disappear. For the more serious grades, with ulceration, stimulating and narcotic applications will be found the most useful, although a tedious cicatrization Will ac- company the most judicious treatment. When mortification threatens, never use warm poultices, which I have seen applied in such cases — a certain means of insuring an extensive destruction — hut by frictions, with cold, stimu- lating substances, try bo excite new action in tiie parts, and should the genera] system have been much depressed, stimuli and nourishing food, with the tonic preparations of iron, should he administered. Until the line of separation between the dead and living parts is well es- tablished, and the neighboring tissues have lost their discoloration, swelling and induration, no amputation should he performed, as gangrene is likely to follow the irritation produced by the 4 J < » IHoST-lSITK. knife in such diseased tissues. A.s, however, these -lowly decomposing masses would poison the atmosphere of an hospital by putrefactive emanations, the course which was found most successful was to cut away the dead masses, and remove the sloughs, but without touching the Living Tissues. In the majority of cases, those Burgeons who cut off the bones at the face of the stump, leaving nature to complete the cure, had the most satisfactory results. Experience, howev< t. shows the process of cicatrization to be BO slow, and the cicatrix remains so Long sensative, that a preferable mode is to amputate in healthy tissues, a1 some tittle distance above the well- defined line of separation. When the patient is in good health, or his system has been prepared by good food and stimuli, and when no gastro- intestinal complications are engrafted upon the local injury, this secondary amputation hastens the cure. It may be necessary to modify the form of amputation in such cases. Where the toes have all been destroyed, the line of mortification is usually found as extensive in the sole as upon the hack of the foot, which prevents the usual Hap from being taken from the plantar surface. WIIKX AMPUTATIONS NB0ES8ART. 421 Iii such cases it is better to perform the circu- lar amputation, making perpendicular incisions on the sides of the foot to facilitate the section of the bones; and as the bones of the inner side of the foot are much more extensive than those of the outer side, the line of circular incision should he oblique to allow of a greater extent of soft parts on the inner side of the foot. It is not necessary to follow the contour of the joints in making these amputations. The much sim- pler plan is to use the saw rather than to dis- articulate — which is at all times a tedious and troublesome operation, especially when, with the mortification of the anterior portion of the foot, the lever is destroyed, which assists so materially in exposing the articular interspaces for the pas- sage of the knife. We have often referred to the fact that am- putations will ever he a necessity in military surgery; and, according- to McLeod, had they been more freely practised in the Crimea, a larger number of lives would have been saved. It was tor thai reason that, in the distribution of labor in the field infirmaries, it was recom- mended that the surgeon who had the exam- 422 WIIKN AMPUTATIONS NEC] SARY. in< r: and his decision 1"' carried out by t) who mav possess a greater facility for the oper- ative manual. A a general rule, the following conditions necessitate the Loss of a liml>. viz: When an entire limb ia carried off by a cannon ball, leav- ing a ragged stnnip; or when a limit is literally crushed up. although still attached to the body, it will be necessary to amputate bo form a good stump: also, if ihf principal vessels and nerves are torn, even without injury to the bone; of it' the soft parts are niiirli lacerated; or in cases of extensive destruction of the skin — as such cases offer very tedious cures if cicatrization is ever obtained. Au-ain. in severe compound tVae- tures, and often in apparently simple compound fractures, where experience teaches us thai al- though the wound may appear trifling to-day, in attempting to save it we will sacrifice a life a few days hence, imputation is compulsory when mortification of the limb rapidly follows upon an injury : also when, in compound fractures or perforated joints, the profuse discharge or the continued irritation threatens s fatal issue; again, where joints are crushed, and where resections are not admissible; or where a fracture of the shall of a hone extends into a joint : also in WHEN AMPfTATIONS NECESSARY. 42:; cases where secondary hemorrhage cannot he con- trolled by the Ligature, or by any other hemos- tatic. Knowing that in such cases, sooner <>r later, the linih and life will be jeoparded, we must anticipate these troubles by amputation, Military surgeons have long made the impor- tant division of amputations into primary and secondary — a division of great practical impor- tance, and which forces itself upon our notice by the relative mortality following the two oper- ations. Amputations for direct injury are styled primary: those required for cases of mortifica- tion, profuse suppuration, secondary hemorrhage, or lor necroses, are called secondary or mediate, mid comprise all amputations performed after the first twenty-four or thirty-six hours, when reaction has set in. The experience of every battlefield shows, that the mortality following the amputation of limbs which require imme- diate operation is always less than those per- formed some days after the infliction of the wound — although the milder cases wore those retained, and the most Bevere those selected for immediate operation. As all military surgeons recognise the propriety of amputating condemned limbs within twenty-four or thirty-six hours after injury, before inflammatory reaction has set in. 4-!l WIIKN AMl'l TA II ; Bfl \KY the aobjecl requires no discussion. The rule in military surgery is absolute, viz: that tfu ampu- intni'i knife should immediately follow tl>< co/ndemfttir- /,'■,,, of flu Umb. These are operations for toe battlefield, and Bhould be performed at the fieW infirmary. When this golden opportunity, be- fore reaction, is lost, it ran never be compen- sated for. The rule in performing primary amputations is. fee operate as far as possible from the trunk, as every inch diminishes the risk to life. This rule is so general, that when an amputation can be performed at a joint, never amputate higher Upj for instance, if an amputation cannot be performed upon the uppor pari of the leg, re- move the limb at the knee-joint rather than amputate the thigh. In secondary amputations it may not be expe- dient to follow this rule; necessity or the desire to save life, which is always paramount, may compel us to amputate al a distance from the injury, as in cases of mortification. Gangrene should seldom, however, require a secondary am- putation, if the rules for primary amputation be followed, viz: of removing, at once, all limbs in which the blood-vessels and nerves arc exten- MiVely injured in connection with the crushing of the bon< . WHEN AMPUTATIONS NECESSARY. 4'2o When mortification attacks a limit, it will bo known by change of color in the skin. When it occurs in the leg, which is its common scat, the foot changes from the natural fiesh color to a tallowy or mottled white; the tissues in a measure liquify, arc cold, and become offen- sive — breaking up into more or less extended sloughs, saturated with an ichorous fluid. This gangrenous condition may stop at the ankle, cither above or below 7 it, depending upon the seat of injury; or it may creep up to the knee, where it equally shows a disposition to limit its extension. When the ankle limits the mortifica- tion, we amputate below the knee; when other- wise, above it. These cases are usually unsatis- factory, as a general poisoning is soon effected, and the stump, wherever made, is attacked in a few days, as if by a continuation of the same gangrene. In mortification of the stump, unless it be in the vicinity of the ankle-joint, a second amputa- tion is not admissible. P>y the local use of pure nitric acid to the mortified surface, or the concen- trated Labarraque's chloride of soda, or pyrolig- ueoua acid, we Btrive to limit the extent of the slough: whilst, with carbonate of ammonia, qui- nine, brandy, and strong food, we support the HOW AMPTTTATIO? - PKBFORM1 - \- - 1 o 1 1 1 until some improvement makes its appear- ance in the stump. WTien all the sloughs have l n eliminated ;ui<1 the stamp has commi i1 will be time enough to remodel ill.' old amputation, by cutting off the protruding . which ie always better practice than per- forming a —«-«-< > 1 1 * 1 amputation. Having condemned a limb, we should wait un- til the nervous shock — from which most of the wounded Buffer — subsides, and then give chloro- form. Should we not have tin' time for it- proper inhalation, we may i i ij< <-t a half grain or more of morphine auder tin' skin, which will produce a rapid blunting of nervous sensibilities; and in five minutes, or even in less time, tin- patient will be in a fit condition t<» stand the operation with the leaal degree of constitutional Bhock. In th<> performance <>l" all serious operations, when possible, there should be three assistants. One aid gives the chloroform; a second com- pres i main artery, which is much better than nsing the tourniquet — an instrument which ie now, in a great measure, discarded from prac- tice — and a third holds the limb and supports the flap during the sectiop. The aid wli<> adminis- tered the chloroform during the incisions, can assist in ligating the arteries. Military surg HOW AMPUTATION'S PERFORMED. 4^7 prefer the circular operation to tlic flap, wliicli they onlv use in the exceptional cases. With the circular stump, covered onlv by skin, there is less soft tissue to suppurate and slouch, and a much more rapid cicatrization is effected. Ex- perience, which lias knag recognised the utility erf the circular operation for the leg, has now gener* alixed it as the most useful amputation tor the thigh or arm. Having assigned the aids their posts, and seen that all the necessary instruments which may 1><> needed are at hand — tor a surgeon should never commence an operation until he has satisfied him- self on tltis scon — the surgeon removes the limb, ligates the vessels, and when all oozing has ceased, secures the stump by points of suture placed at intervals of an inch or a little less along the entire line of wound. /// dividing ih<- skin, //<<■ surgeon cannot be t<«> care- ful to leave cover thi /<<>"/>• of the hems. This is the tirst and most important rule in amputation. You cannot well leave too much skill, and can \>-v\ easily commit the opposite error. Tin- surplus of skin will he absorbed; a deficiency can in no way be supplied. The rule is, i" have the flaps bo ample that no tension be :\V\ ill closing the Wound. due of the | HOW T<> DEI constant as well as one of the most frightful exhibitions in the military hospitals, whore the Burgeons have not yet gained experience, is the protrusion of the bones from the stamps of am- putated limbs, necessitating .1 second operation should the patient survive tin- tir>t. A little cure will obviate all this trouble, and save the >m. 1 1 1 iuIi mortification. Any omission in this respect must be corrected before tin- stump is dressed : :m cover it without traction, re- move a section of hone with the saw, and not attempt, through want of honesty, to conceal a badly-performed operation, and make the inno- cent patient the victim of our misplaced pride. In ligating the vessels, tie every one which bleeds or is likely to hlced. It i- not derogatory top a surgeon to apply ten. fifteen, or even twenty liga- tures to ;i st II 1 1 1 1 > ; it .-hows that he II lldel'sl amis his profession; experience has taught him the . trouble and annoyance of reopening a -tump to find a bleeding vessel, when he has hut little time to attend to the urgent demands of the wounded. 'J' In ful, is. neglect no small artery. adhesive straps for supporting ami sustain- ing the daps are antagonistic to water dressings, they are Useless in amputations, and arc not used, HOW TO DBMS STUMI's. 42!) except a small patch to secure the ligatures upon the limb at one angle of the wound. Sutures are recommended in all operations, as they keep the flaps in apposition — not being influ- enced by the water dressings; they also obviate much after-dressing. A Bingle layer of wet cloth is applied to the stump; this, in turn, is covered by a piece of waxed cloth, to keep in the moist- ure, and either an ice bladder <>r water by irriga- tion is continuously applied over this outer cloth. The case should now he looked upon as a wound, and should he treated accordingly. The course laid down for wounds is here strictly applicable, and should he closely followed. In certain cases of amputation, as in the cir- cular, where the skin alone forms the flap, the dressing may he changed, as follows: After ap- plying sutures to the entire Length of the wound, draw the intervening Bpaces accurately together by means of strips of isinglass-plaster, and cover, also, the length of the wound with a folded strip, only leaving uncovered the angle where the lig- atures escape, and where drainage from within i- permitted. The object of the dressing is to convert the wound into a subcutaneous one. ex- oludiug the air and hastening union. To the stump no other dressing i- applied, the wound 430 TREATMENT AFTER AMPUTATIONS. being exposed. No water dressing is to be used, and Tin- -lump is left unmolested, except in cleansing the effects of drainage. At the expi- ration <>f a week. the removal of the Btraps will show complete cicatrization along the lino of incision. In healthy patients, and in a pnre atmosphere, a rapid healing of stumps may in this way be obtained. The isinglass-plaster will alone answer fbr this dressing — the diachylon being too irritating, and not sufficiently pliant to eal, hermetically, the wound. We find but lit- tle use for ointments in dressing stumps, the wel • •loth being much simpler, not irritating, and. therefore, more efficient. During the treatment of all wounds in mili- tary hospitals, previous want and exposure, which belongs to every army, however well organized; will show their influence; and if the plan of abstemious or antiphlogistic diet be adopted for those operated upon, from misguided view the pathology of inflammation, the mortality will he heavy. Liberal feeding tells in the . treatmenl of amputations; and the great differ- ence in the surgical statistics of the French and English depends more, perhaps, upon the dirt in their hospital practice than 11)1011 any one other cause. Tisanes cannot support a person in or- TREATMENT AFTER AMPUTATIONS. 431 dihary health, and certainly cannot support him under the additional drain of an exhausting sup- puration. Tf patients are placed under identi- cally similar conditions, the successful treatment of amputations will be found to loan to the side of those who are the most Kberally supported. Slops arc out of place in a surgical hospital, and li'ood cooking will be found as useful as good nursing. Let nature be our guide. For the first one or two days after a serious operation, there is hut little disposition to eat. Under such conditions. T would not advise food to he forced; hut. as soon as the patient expresses a desire to cat. foster his appetite with good, strong, nour- ishing, easily-digested food, and lei his supply he liberal. Any attempt at starvation will be highly injurious. If the patient escapes the ordinary diseases incident to hospitals, viz: erysipelas, gangrene, pviemia. etc.. we must he extremely careful of him about the tenth or twelfth day. When the ligatures arc escaping from the arteries, absolute rest should he insisted upon, and the patient should not be allowed to exert himself in any way until this fear of secondary hemorrhag d. We have elsewhere stated how this com- plication is to be met. 432 OBLOftOJ^OBM. Whenever operation! arc to be performed in military surgery, chloroform should be adminis- tered. It is a remedy which the surgeon should never be without, and which might be need u|«|>! For ourselves, we place unlimited confidence in it- judicious administration, a>. with :i large experience, we have never had the slightest cause t<> douhl it- advantages under every, circumstance. We hope thai the humanizing tendencies of the aire, in introducing this invaluable comfort, has banished that dread of being cut as an item to be considered when operations are necessary ; and we hope to see anaesthetics used as liberally in allaying the pain of surgical affections a> cold water is now used for keeping down in flam ma- tiou. Wi do not hesitaU to say, thai it should be given t" every patient requiring a serious or painful operation. We may hear now and then of an accident from its administration, but who can tell us of the immense nuinher who would have sunk from operations, had it not been admin- istered ''. In its administration, we must USC the follow- ing precautions: The best apparatus is a folded cloth, in the form of a cone, in the apex of which a Bmall piece of sponge is placed. This is first held at some distance from the uose and month of the patient. 10 that the fust inhalation may be well diluted with air. A.- the exhilarating CHLOROFORM. 435 stage is readied, the cloth should be approached to the nose, so that a more concentrated ether inny ho inhaled, which will rapidly produce the desired insensibility. Noisy breathing is tin' sign that the anaesthetic effect is produced, when the inhalation should he suspended, and the opera* tion commenced. Unless the operation is very tedious, do not renew the inhalation. Ingenious inhalors are mere or loss compli- cated, and are. on that account, more or less inefficient. The great perfection of the above* mentioned apparatus is its simplicity* Finding that much chloroform is wasted by evaporation from the handkerchief, 1 have for some years usod a common funnel as my inhaler, which pro- tects the hands of the person administering the chloroform, and prevents the loss from general evaporation. If a piece of heavy wire, or a small har of tin. he attached across the interior of the funnel, about half-way toward its throat, the sponge containing the chloroform can be sup- ported between this har and the side of the funnel, leaving a space on one side for the air to rush over the surface of the sponge as it comes through the elongated end of the appara- tus, when the air. loaded with ether, is inhaled. The funnel should he large enough to cover the I ■lll.dlliiFollM. tower half of the face, including the nose and mouth, and the sponge Bhould nol come within two inches of the face, for Bhould it touch the skin it would blister it. The eyes, being exclud- ed from the apparatus, are not annoyed by the evaporation of chloroform. A.s the funnel does not in accurately to the lower outline of the face, there will be ample spaces on either side of the chin to admit air for diluting the vapor. Besides a great saving of chloroform, which is no small recommendation, the use of this instru- ment obviates the tear of suffocation, which is always present to my mind when I see chloro- form carelessly administered. When the cloth is used, should the patient struggle — ■ very com- mon occurrence — or should the assistant admin- istering the anaesthetic be at all interested in the operation, the cloth is thrust down upon the face of the patient, respiration is impeded, and suffocation is imminent. Suppose the patient lias already heen influenced to such an extent that he has l<»st the voluntary control of his muscles, and cannot pull away the cloth, he is in a very dangerous condition, and the continued thoughtlessness of the assistant might suffocate Hjm. I can readily understand, in this way. why deaths should sometimes occur from the care- CHLOR0F0BM 437 lessncss of administration, and am only surprised that it occurs so seldom. Were we as careless in the use of other potent remedies as we arc of chloroform, cases of poisoning would be largely increased. In times of hurry, contusion and ex- citement, as after a battle, we cannot surround the safety and well-being of the wounded with too many guards for their protection. MALIK G KlJlXn In closing this Manual, experience induce- me Id oflfef to army BiiT^eona a few suggestions re- garding the frauds daily practised upon Medi- cal officers by impostors, who feign disease i" escape military duly. Malingering, or the feign- ing of disease, lias ever been and will continue to be popular with soldiers, irrespective of the materia] of which the army is composed. Hon- esty "i' purpose and patriotic motives ate net, the only incentives i<» enlistment, even against such an invasion as our enemies are now carry- ing <>n for the destruction of all our most sacred and cherished rights. The odium heaped upon those who would re- main at home, lias forced many into the ranks who were hut little disposed to give up their comforts and their habitual idleness for the active and laborious duties of camp life. Such soldiers are always ready to use every subter- fuge tor escaping from what is irksome ami dis- tasteful t,. them: and as complaints of indisposi- tion oiler an easy release, it is the plan usually MALINGEKIXO. I-'. 1 adopted. Moreover, where large bounties are offered for enlistment, many are found who would enlist, obtain the bounty and a suit of clothes, and, by feigning disease, successfully im- pose upon their medical officers, be discharged from service, to re-enlist in a few days. In- stances are known in which this course has been successfully pursued several times in a short period. Hence it is that the study of feigned diseases heroines an important branch of mili- tary surgery, both for the protection of the ser- vice and the detection i){ fraud. Unless medical officers are aware of impostors, and are always on the alert to detect and punish such imposi- tions, the service gutters seriously, and the will- ing soldier is over-taxed with double duty. — Among the varieties of sickness classified as malingering, are slight indispositions, much ex- aggerated; or the symptoms of disease may be purely fictitious, whilst diseased conditions, such as ophthalmias, a leers, wounds, etc, etc., may be either intentionally produced or aggravated by the malingerer. General experience shows that, at times, one may feel more or Less depressed, with uneasy, ous feelings, foreboding sickness. These are transienl conditions, depending, perhaps, upon a disturbed digestion, aud will disappear spon- taneously ai the t'lnl of ■ few hours, leaving us in pur accustomed health, Ignorant or infatu- ated is that physician who believes medicine necessary for every such temporary indisposition, and who adopts the rule of prescribing drugs for every person who presents himself for treat- ment. This coustanl drugging is detrimental to the service, in making cases, and diminish- ing the effective strength of a command, whilst it squanders medicines which arc only replaced with trouble and expense. A little moral cour- "U the part of the medical officer t<> refuse the applicant as a patient, and a word to the commanding officer, to overlook his call for guard duty, will gain him the confidence and the respect of the soldier- The surgeon should not aet hastily in his diagnosis, hut should pa>s judgment only after a careful study of the ease: for it is hard to force a sick man to duty, hut feigned diseases, which escape detection, ate re- wards granted to fraud. Among the diseases most readily and frequent- ly feigned, are pain, rheumatism, deafness, Im- paired vision, etc.; all of these are as difficult of detection as their simulation is easy, ami hence the readiness with which such complaints are MAfilNOBftlNG. 411 feigned. When we arc called upon to investigate these suspected cases, we must carefully weigh the moral and physical condition of the patient — liis habits, his probable motives, with the pres- ence or absence of pathognomonic symptoms. During the examination we must mark the dispo- sition of such malingerers to overact their part, their anxiety to impress us with the reality and severity of their sufferings, and also the readiness with whieh they can lie led on to acknowledge the presence of incompatible and preposterous symptoms. When pain is feigned, as this may really exist as a disease without external manifestation, it is the most difficult of all symptoms to detect. By close observation and constant watching the fraud may he detected, although the malingerer may continue his complaints until he attains his ob- ject — a discharge from the service. In studying out this imposition, we must examine info the nature and cause of this pain — its duration and intensity — iis character, whether fixed or wan- dering, whether persistent, remitting, or inter- mitting, and whether increased or diminished by pressure: for no pari can be exquisitely sensitive under pr< ssure, which will not show other indi- cations of local trouble. If the patient com- 442 MAMNCKUlNt, plains of an internal pain, we Bhould examine whether it be accompanied by those Bymptome which it is impossible to :i — iiiii*-. and the absence of which would lead to suspicion. Much may also be learnt from the treatment pursued. In real diseases, painful remedies will not be objected to, whilst in the feigned a decided aversion is shown when the use of these remedies is threatened. 1 have cured a pain of six months standing in a malingerer by the use of the actual cautery, and the promise that, if the first applica- tion did not remove all the pain, a second would most certainly effect it. Kven the prospect of a severe application on the following day. if the patient does not feel better, lias brought its fruit. r I 'his, however, does not always succeed, as malin- gerers have withstood the repeated application of the most powerful remedies, and have >'^\\- U'^r^cd their imposition only after exhausting the resources of the snspectiug surgeon, or after obtaining their dismissal; A simple mode of testing the sensitiveness of what tin' patient complains of as an intense pain, is by niaking pressure upon the part when the patient sleeps. sleep, in itself, may lead to detection, as quiet, placid Bleep at night, with intense pain during the day. without los< of flesh or general impair- mai,in have difficulty in hearing. The oon must exercise his ingenuity in devising means for exposing the imposition. A.mong would he making, suddenly, loud noiseo, such as discharging a pistol near the ear of the unsuspecting person. Very few have such eon* trol <»\cr themselves as to withstand this trial, although instance- are known where impostors remained unmoved, notwithstanding this tout Relating a conversation in which tin- patient is deeply interested, ami watching clandestinely the play »>f liis features, will, at times, lead t<> de- tection. Like impairment in hearing, so is impaired Bight a very common complaint among those who desire to escape duly. Night or day blind- ness i^ a complaint which may have foundation under oertain circumstances, Inn i- rarely met with. When suspicion is aroused, compulsory duty is the best remedy. Under the plea that, for sentinel duly, ami especially lor night duty, hearing is even more important than and as four fars arc always loiter than two. a double guard, of which the malingerer is one, should he placed at the post. At the same MALrNOERINO. 445 time, a low diet will show the impostor that his complaint does not moot with much sym- pathy. A soldier may appear before the medi- cal officer with an excessively dilated pupil, and with a complaint of impaired vision. It must ho remembered that, as a disease, this symptom seldein appears alone, and that a drop of a solu- tion of belladonna will at any time induce it. Where such a ease excites suspicion, searching the patient and locking him up, under guard, will in a few days solve the douhts by the re- turn of the pupil to its normal dimensions. Epilepsy is another disease often attempted. To have fits is thought by the public to be the acme of an incurable condition, deserving the commisseration of a community, and the soldier necessarily infers that a man who can have a tit whilst in camp, surrounded by his compan- ions, may have a similar one whilst on guard duty, and is. therefore, not a proper person to he entrusted with the protection of a camp. This disease has been so frequently feigned, both in civil as well as military life, and the symptoms Of the disease have been so carefully studied. that ni<»st surgeons will he en their guard against such impostors. A dTOp of turpentine or alcohol in ii. U4 li an one will, without d 44ti MALINGERING. harm, bring his acting to a speedy close. Vety few impostors can stand tliis innoceut test. It is, perhaps, as well to state thai during the epileptic lit all insensibility is for the time sus- pended. A feverish skin may also be simulated by the liberal use of a ftesh brush, whilst the foulest '-"at upon the tongue can he manufactured at will by a local application of chalk, day, ashes, brick- dust, Hon)-, soap, etc. Deformities and contrac- tions of the limbs, which are never drawn up during sleep, or under the influence of chloro- form, arc also feigned l>y malingerers, and will require the most careful scrutiny. In order i>> deceive, the mouth is scarified to permit the spit- ting of blood, ulcerations on the legs are made by the pressure of hard substances, and swollen arms and legs by ligating the extremities near the trunk. Frequent micturition or diarrh.ea may easily be complained of, and dysenteric stools have been actually stolen from neighboring pa- tients to assist in carrying out the deception. It is only necessary for surgeons to know to what extent diseases may he feigned, to be pre- pared to meet the impostors.; and by using all the means, both morally and medically, which their ingenuity/ would suggest, to detect and punish the malingerer. APPENDIX. Appendix No. 1. REGULATIONS FOR THE MEDICAL DEPARTMENT OF TIIK CONFEDERATE STATES. 1160. .The Surgeon-General is charged with the administra- tive details of the medical department, the government, of hos- pitals, the regulation of the duties of surgeons and assistant surgeons, and the appointment of acting medical officers, when needed, for local or detached service. He will issue orders and instructions relating to the professional duties of medical officers; and all communications from ^theni, which require his action, will be made directly to him. 1151.. The Medical Director of an army corps will have the general control of the medical officers. 1152. .The Medical Director will inspect the hospitals under bis control, and see that the rules and regulations with regard to them and the duties of the surgeons and assistant surgeons arc enforced. 1153. .He will examine the case books, prescription and diet hooks, and ascertain the nature of disease's which may hare prevailed, and their probable causes: recommend the best method of prevention, and also make such Aiggestionfl rela- 4f>') APPENDIX. tivo to the -it 'in inn. construction and economy of the hospi- tals, and to the police of the camps, as may appear ne ■ for the benefit and comfort of the sick, and the good of the sen i 1154. .From the monthly reports of the m« -< Ti< -nl offici the command (Form 1), he will make to the Surgeon-General a consolidated monthly report of the sick and wounded. 1155. .He will make t<> the Surgeon-General a monthly re- turn (Form •-' ) of the medical officers of the command. 1156.. The Medical Purveyor will, under the direction of the Surgeon-General, purchase all medical and hospital supplies required tin - the medical department <>t' tin- army. 1157. .Medical Purveyors will make to the Surgeon-General, at the end dt' eacjh fiscal quarter, returns in duplicate (Form •'> ) of medical supplies received, issued, ami remaining on hand — stating to whom, or from whom, ami when ami where issued or received. Other medical*officers in charge of medical supplies trill make similar returns semi-annually, on the SOth of June and the SI si of December; ami all medical officers "ill make tin in when relieved from tin- dutv to which their returns relate. The returns will show the condition of the stores, and particu- larly of the instruments, bedding and furniture. Medical pur- veyors "ill furnish abstracts of receipts and issues, with their returns ( Form 4). LI 58. .Medical disbursing officers will, at the end of one* tic.il quarter, render to the Surgeon-General, in duplicate, a quarterly account currtfil of moneys received and expended, with tin- proper vouchers for the payments, and certificates that the scr\iei-< have been rendered and the supplies purchased and received for the median! service, and transmit to him an esti- of the funds required for the m-xt quarter. 1159. .The medical supplies for the arm} are prescribed in the Standard Supply Tali]cs*for Hospitals and Field Service. i n;o. .Medical and hospital supplies will be obtained by mak- ing requisitions, in duplicate ( Form 5), on the Surgeon-General, forwarding them through the Medical Director of the command. If an army he in the Held, aifd there he a Medical Purveyor in charge of supplies, requisitions will he made on him. after receiv- APPENDIX. 4"'l inp the approval of the Medical Director. The quantities on hand, of the articles wanted, must be stated in all requisitions. L161..When it is necessary to purchase medical supplies, those which are indispensable may be procured by the quar- termaster, if recourse cannot be had to a medical disburs- ing officer, on a special requisition (Form 6), and account ( Form 7). m>2. .In every case of special requisition, a duplicate of the requisition shall, at the same time. In' transmitted to the Surgeon- (ieneral tor his inl'ormation. il<).».. An officer transferring medical Bupplies will furnish a certified invoice to the officer who is to receive them, and transmit a duplicate of it to the Surgeon-General. The receiv- ing officer will transmit duplicate receipts (specifying an ides and quantities) to the Surgeon-General, with a report of the quality and condition of the supplies, and report the same to the issuing officer. A medical officer who turns over medical supplies to a Quartermaster tin- storage or transportation, will forward to the Surgeon-General, with the invoice, the Quarter- master's receipts for the packages. IL64. .Medical officers will take up and account tor all medi- cal supplies of- the army that come into their possession, and report, when they know it. to whose account they are to be credited. 1165. .Medical supplies are not to he detained or diverted from their destination, except in cases of absolute necessity, by commanding Generals, who will promptly report the circum- stances to the Adjutant-General, that orders ma} he given tor supplying the deficiency; and the medical officer receiving them will immediately report the tact to the Surgeon-General; and, ako, when practicable, notify the officer tin' whom they were intended. inn;. .In all official lists of medical supplies, (he articles will he entered in the order of the supply tables. 1167. .The senior medical officer of each post, regiment, or detachment, will, with the approbation of the commanding officer, select a suitable site for the erection of a hospital, or of hospital tents. -!.">_' AI'l'KM'IX. 1168. .'I'h'' senior medical officer of a hospital will distribute the patients, according t<> convenience ami the nature of their complaint*, into wards or divisions, nnder the particular charge of tlif several assistant surgeons, and will \i-it then himself each k. with the name <>t' the patient and the number of has bed ; the assistants will till np the diet table for the day, and direct the administration of the pre- scribed medicinea He will detail an assistant Burgeon to re- main at the hospital day and night, when the state of the >\< k requires it. ii7o. .In distributing the duties of his assistants, he will or- dinarily require the aid of one in the oare and preparation of the hospital reports, registers and records, the rolls and descriptive bats; and of another, in the charge of the dispensary, instru- ments, medicines, hospital expenditures, and the preparation of the requisitions and annual returns. 1171.. He will enforce the proper hospital regulations to promote health and prevent contagion, by ventilated and not crowded rooms, scrupulous cleanliness, frequent changes of bad- ding .and linen, occasional refilling of the bed Backs and pillow ticks with fresh straw, regularity in meals, attention to cook- ing, etc. 1172. .He will cause to be printed, or written in ;i legible hand, and bung up in a conspicuous place in each ward, such rules and regulations as he ma] deem necessary for tin- guidance ol the attendants, and the order, cleanliness, and convenience of the patients. u::;..IIc will require the steward to take due care of the hospital Btores and supplies; to enter in a book, daily (Form s). the issues to the wardmasters, cooks and nurses; to prepare the provision returns, and receive and distribute the rations. 1171.. He will require the wardmaster to take charge of the effects of the patients; to register them in a book (Form 9); to luive them numbered, and labeled with the patient's name, rank and company ; to receive from the Bteward the furniture-, bed- AJ'l'ilMUX. 45o ding, coding utensils, etc., for use. and keep a record of them ( Form 10), and how distributed to the wards and kitchens, and. oni'c a week, to lake an inventory of the articles in use, and report to him any loss or damage to them, and to return to the steward such as are UOl required for use. 1175. .Assistant Surgeons will obey the orders of 'their senior Surgeon, see that subordinate officers do their duty, and aid in enforcing the regulations of the hospital. 1176. .The cooks and nurses are under the orders of the steward. He is responsible for the cleanliness of the wards and kitchens, patients and attendants, ami all articles in use. He will ascertain who are present at sunrise and sunset, and tattoo. ami report absentees. 1177. .At surgeon's call tin' sick then in the companies will he conducted to the hospital by the first sergeants, who will each hand to the Surgeon, in hi- company hook, a list of all tin' sick ot the company, on which the surgeon shall state who are to re- main or go into the hospital; who are to return to quarters as -iek or convalescent ; what duties the convalescents in quarters are capable of; what cases are feigned; and any other informa- tion in regard to the sick of the company he may have to eom- munieate to the company commander. LI 78. .Soldiers in hospital, patients or attendant-, excepl stewards, shall he mustered on the rolls of their company, it' it he present at the post 117:t. , When a soldier in hospital is detached from his com pam so as not to In- mustered with it tin- pay. his company com- mander -hall certify and semi to the hospital hi- descriptive li-t. and account ot pay and clothing, containing all necessary infor- mation relating to his accounts with the Confederate States, on which the Surgeon shall enter all payments, stoppage^ and i-ie ■- of clothing to him in hospital When he leaves the hos- pital, the medical officer shall certify and remit his descriptive li-t. showing the state of hi- accounts. It he is discharged from the service in hospital, the surgeon shall make mil hi- final statc- menta tin- pay and clothing. It he die- in hospital, the surgeon -hall take charge of hi- effects, and make the r ep ort s required I 4 \ITK.\1H\ iii the peaeral regulations concerning soldiers who die aWut in. in their companies. 1 180. . Patients in hospital are, it' possible, to leave their anus ■ ii. "1 accoutrements with their companies, and in no case i" take ammunition into the hospital 1181. .When i patient i> transferred from one hospital i>> another, I he medical officer .-hall send with him an account of hi- case, and the treatment. 1182. .The regulations for the service of hospitals apply, as far as practicable, t<> the medical service in the field. 1188. .In the field, the -i -i i it n- medical officer will inspect camps, and urge the enforcement of stringent rules of police. 1184. .The senior medical officer of each hospital, post, regi» meat or detachment, will keep the follow ing records, and deliver theni to his successor : A register of patients (Form il): a pre- scription ami dirt book (Form 12); a case l>o<>k : copies of i.i- requisitions, returns of property, and reports of sick and wounded, and an order and Inter lunik, ill which will lie tran- scribed all orders and letters relating to hi- dutiea 1185. lie will make the muster and paj rolls of the hospital steward and laundresses, and of all soldiers in hospital, sick or on duty, detached from their companies, on the forms furnished from tin- Adjutant and inspector-General's oilier, and according to the directions expressed on them. 1186. .The extra pay allowed to soldiers acting as cooks and Durees in hospitals will lie paid bj the Quartermaster Depart- ment — the extra service being noted QB the hospital innsler rolls. 1 lis?. .The senior medical officer will select the cooks, nurses, and laundresses, with the approval of the commanding officer. Cooks ami nurse-, taken from the privates, will be exempt from other duty, I'Ut shall attend llie parades for muster and weekly inspection of their companies at the post, unless specially ex- cused l>\ the commanding officer. They will not In- removed excepl tor misdemeanor, ami at the request of the medical offi- cer, mil'- in cases of Urgent necessity, ami then only by the order ot the commanding officer. 1188. .Cooks ami nurses, other than enlisted man or volun- teers, an- subject to military control. Tiny will lie paid on the APPENDIX. 455 hospital muster rolls, by the Quartermaster Department, at the rates at which they have been engaged, which, in do case, will exceed $18 50 per month, being the pay proper of an enlisted man. together with the extra pay allowed in paragraph lf86. They should not be employed for a less period than a calendar month. I [89. .Ordinarily, hospital attendants are allowed as follows : To a genera] hospital, one steward, one nurse as wardmaster, one nurse to ten patients, one laundress to twenty, and one cook to thirty; to a hospital where the command exceeds live compa- nies, one steward ami wardmaster. one cook, two laundresses and four nurses: to a posl or garrison of one company, one steward and wanlmaster. one nurse, one cook, and one laun- dress; ami for every two companies more, one nurse; at arsenals, where the number of enlisted men is not less than fourteen, one laundress is allowed. The allowance of hospital attendants in the field will he. for command- of one company and not exceed- ing five, one steward, one cook. and. lor each company, one nurse ; for regiments, or other commands of over five companies, one steward, two cooks, and. tor each company, one nurse. 1 190. .Medical oliicers. where on duty, will attend the officers and enlisted men. and the laundresses authorized by law: ami at stations where other medical attendance cannot lie procured, and on marches, the hired men of the army. Medicines will lie dispensed to the families of officers and soldiers, and to all per- sons entitled to medical attendance: hospital stores to enlisted men. 1 191 . .Medical oliicers, in giving certificates of disability (Form 18), are to take particular care in all cases that have not bees under their charvv : and. especially, in epilepsy, convul- sion-, chronic rheumatism, derangement of the urinary organs ophthalmia, ulcer-, or any obscure disease, liable to be feigned or purposely produced: and in no caw shall such certificate be given until after Btffficienl time and examination to detect an\ atti nipt at deception. 1192. .In passing a recruit, the medical officer is to examine him stripped; to see that he has free use of his liml i> : that his r (round of the head, th.it may impair hi? faculties; thai he is not ;i drunkard; is not subject to con- vulsions, and has no infectious disorder, n«>r any <>t!icr that may unfit him for militar;. 1198. .Medical officers attending recruiting rendezvous, will keep a record ( Form i i) of all tin- recruits examined by them. Books for this purpose will In- procured by application to the Surgeon-General, to whom they will be returned when filled. L194. .As -""ii a- a recruit joins any regiment or station, he shall In- examined by the medical officer, and vaccinated when it is required. i ]!•."). .Tin- senior medical officer of each hospital, post, regi- ment or detachment, will make monthly to the Medical Director, and quarterly to the Surgeon-General, a report of sick and wounded, and of deaths, and of discharges for disability ( Form l ) : and transmit t<> the Surgeon-General a copy of the Monthly Statement of the Hospital /•''/»•/ ( Form 19). 1196. .After surgeon's '-all. he will make a morning report of t he sick t>i the commanding officer ( Form 1 5 >. nit:. .Every medical officer will report to tin- Surgeon-Gen- eral and to the Medical Director, the date when he arrive- at a Btation, or when he leaves it, And his orders in the case, and at the end of each month, whenever not at his Mation. whether on service or on leave of absence; and when on leave of absence, hi- post-office address for the next month. 1198. .They will promptly acknowledge the receipt of all orders relating to their movements; and in all official communi- cations, when at stations the positions of which are not well known, they will state the nearest post-office. i 199. .Win n it i^ necessary to employ a private physician as medical officer, tic Medical Director, or if circumstances pre- clude reference to him. the commanding officer may execute a written contract (notifying the Medical Director), c litioned a- in Form 16, at a stated compensation, not to exceed nth when the number of officers and men. with authorized APPENDIX. 457 laundresses, is LOO or more ; $40 when it is from ."><> to LOO, and $30 when it is under 50, 1200. .Bui when he is required to abandon his own business, and give his whole time to the public service, the contract may he not to exceed $80 a month; and not to exceed ^i<» n , besides transportation in kind, to he furnished by the Quartermaster's Department, where he is required to accompany troops on marches or transports, But a private physician will not he employed to accompany troops on marches or transports, except by orders from the War Department, or. in particular and urgent eases, by the order of the officer directing the movement. 1201.. And when a private physician is required to furnish medicines, he will he paid, in addition, from twenty-live to fifty per cent., to he determined by the Surgeon-General, on the amount allowed hv contract. 1202. .In all cases, a duplicate of the contract, with a par- ticular statement of the circumstances which make it accessary, appended, will he transmitted forthwith to the Surgeon-General lor approval; ami the commanding officer tor the time being will at once discontinue it, whenever the necessity tor it ceases, or the Surgeon-General may so direct. 1203.. The physician's account of pay due must he sent to the Surgeon-General tor payment, vouched by the certificate of the commanding officer, that it is correct and agreeable to con- tract, and that the services have been duly rendered, lint on the frontier or in the field, when it cannot conveniently he sub- mitted to the Surgeon-General, the contract having already received his approval, tie- account may lie paid on the order of the commanding ollicer, not to exceed 'he regulated amount, by a Quartermaster or a medical disbursing officer. 1204. .Private physicians, employed by contract, will conform to the regulations, and, accordingly, will keep all the records, and make tin' reports, requisitions and returns required from medical officers. L205. .When medical attendance is required by ollicer- or enlisted men on service, and the attendance of a medical officer cannot he had. the officer, or if there he no ollicer. then the i.> APPENDIX. enlisted man. may employ a pr irate physician, and a jus! ac- eount therefor will be paid by the Medical Boreas. 1906. .The account will set nut the name of tin- patient, tlie date nt' and charge for each \i~it. and for medicines. The phy- sician will make a certificate t" tlif acoouat in case ofaa officer, Or affidavit in ease of an enlisted man. that the account is cor- rect, and the charges are the customary charges of the place. 1807. .The officer will make his certificate, or the enlisted man hi- affidavit, to the correctness Of the account, that he was on service at the place, and stating the circa mstauoc s pre ve nt - inL r him from receiving the services of a medical offieen 1208. .When the charge is against an officer, he will pay the aecount, if practicable, and transmit it to the Medical Bureau for reimbursement. In all other cas e s, the account will he transmitted to the Medical Bureau for settlement. 1209. .If the charge is against a deceased officer or enlisted man. the physician will make the affidavit, before required, to the account, ami that he has been paid no part of it. L210. .No charges tor consultation tecs will he paid by the .Medical Bureau; DOT will an\ account for medical attendance or medicines he paid, it' the officer or enlisted man he not on service. 1211. .A board of not less than three medical officers will he appointed from time to time, by the Secretary of War. to exam- ine applicants for appointment of assistant surgeons in the reg- ular army, and assistant g u asj C O n s tor promotion. And no one shall he so appointed or promoted until so examined and found qualified. 121 -.'..The board will scrutinize rigidly the moral habits, professional acquirements, and physical qualifications of the candidates, ami report favorably, either for appointment or promotion— ho no case admitting of a reasonable doubt. 1218. . The Secretary of War will designate the applicants to bi> examined tin- appointment of assistant Burgeon. They must he between twenty-one and t\vent\-li\e years of age. The hoard will report their respective merits in the several branches of the examination, and their relative merit from the whole; agreeably whereto, if vacancies happen within two years there- ArrENDix. 48i after, thev will receive appointments and take rank in the medi- cal corps. 1214. .When HO assistant Burgeon lias served five years, he is subject to be examined for promotion. It' he declines the exam- ination, or be found not qualified by moral habits or professional acquirements, he ceases to be a medical oflicer of the army. 1215. .An applicant for appointment foiling at one examina- tion, may be allowed a second after two years; but never a third. 1216. .The Secretary of War will appoint, on the recom- mendation of the Surgeon-General, from the enlisted men of the army, or cause to be enlisted, as many competent hospital stewards as the service may require* 121 7.. The senior medical oflicer of a command requiring a steward, may recommend a competent non-commissioned officer or soldier to be appointed, which recommendation the com- manding officer shall forward to the Adjutant and Inspector- general of the Army, with his remarks thereon, and with the remarks of the company commander. L 218. • When no competent enlisted man can be procured) the medical officer will report the fact to the Surgeen-General. Applications and testimonials of competency, from persons seek- ing to be enlisted for hospital stewards, may be addressed to the Surgeon-General. 1219. .The commanding oflicer may re-enlist a hospital stew- ard at the expiration of his term of service, on the recommenda- tion of the medical officer. 1220. .No soldier, or citizen, will be recommended for ap- pointment who is nod known to be temperate, honest, and in every way reliable, as well as sufficiently intelligent, and -killed in pharmacy, for the proper discharge of the responsible duties likely to he devolved upon him. Until this is known, he will be appointed an acting steward by the medical oflicer, with the approval of tin- commanding officer, ami will be entitled to the pay and allowances of hospital steward. 1221. .Hospital steward-, appointed by the Secretary of War, whenever stationed in places whence noposl return i> made to the Adim-ant-General's office, or when on furlough, will, at tl,. 460 APPENDIX. end of every month, report tbemselvee, 1>\ letter, bo the Adju- tanl General and Snrgeon-( Jeiieral. a- well as to the Medical Director of the military department in which they ma\ l>e serv- i : i lt : i" each of whom they will ako report each new assign- ment to duty, or ehange of Btation, ordered in their case, noting carefully the amnber, date, ami sowrea <>f the order directing tie' same. They will likewise report monthly, when on fur- lough, to the medical officer in charge of the hospital to which they arc attached. 1 222 . . The jurisdiction and authority of courts martial arc the same with reference to hospital steward- as in the eases of other enlisted men. When, however, a hospital steward is sen- tenced by an inferior court to be reduced to the ranks, such sen- tence, though it may he approved by the reviewing officer, will not be Carried mto effect until the ease has been referred to the Secretary of War for final action. In these eases of reduction, the application of the man for discharge from service, though not recognized as of right, will generally be regarded with fewer, if bis offence has not been of too serious a nature, and especially When he has not been recently promoted from the ranks. 1 22S . . As the hospital stewards, appointed by the Secretary of War, are permanently attached to the Medical Department, their accounts of pay, clothing, fitC., must be kept b\ the medi- cal officers under whose immediate direction they are serving, who are also responsible for certified statements of such accounts, and correct descriptive lists of such stewards, to accompany them in case of transfer; as, also, that their final statements and certificates of discharge are accurately made out, when they are at length discharged from service. APPFAIUX. 463 Standard Supply Table for General and Post Hospitals. [In General Hospitals detached from troops. Hie supplies for every LOO sirk will correspond with the allowance u> commands at 600 men. ARTICLES. Quantities for one year fur commands of From 100 to U0, From 200 to 300. From 300 to 4110. 600 men. 1,000 men. MEDICINKS. Acacise 11>. Acidi acctici ll>. arseniosi >z. benzoic] . Sulphurici lb. aromatiei. ..lb. tannici oz. i;u tarici lb. - ralphurici loti lb. Alcoholis bott. Aliuninis lb. Ammoniaeia . . .* lh. Ammonite carbonal is oz. miiriiif is Hi. AnthemidSs lb. Antimoniiet potass, tartratis.oz. Argenti nitratia i crystals). ■ .oi. {fused e. \ rnicae lb. .\ ssafcel idm >■/.. Bismuthi bu bnitral is z. Camphors ll>. Cardamomi z . Catechu 11,. Cera alb»« Lb. Ccrati resinse lb. sitoplicis lb. zim-i carbon atis lb. Chloroform! 11>. Collodii oz. Copaibas lb. i OB. Cretse preparatm lb. Capri Bulpbatis >z. ri ad ha; ivi vis. 2 4 6 8 1 1 2 2i i 1 2 -!■ 1 2 3 4 1 2 3 4 4 1 2 2i l 2 3 i l a I l 2 3 4 2 4 6 8 2 4 6 8 2 4 6 8 24 48 72 96 1 o 3 4 J 1 2 2i 8 16 21 32 i 1 2 2i 1 2 :: 1 3 6 9 12 1 •2 3 4 1 2 3 4 1 o 3 1 4 8 12 16 4 8 12 M 2 4 6 s 8 16 24 32 J 1 2 2\ 2 4 6 8 2 4 6 8 8 ie 21 32 2 4 6 8 1 2 3 1 2 4 6 - 5 lu 15 20 2 4 6 8 1 2 3 4 2 1 6 8 5 10 15 20 L6 5 5 8 16 16 16 lit 2 8 5 64 5 8 24 8 8 8 32 38 16 U 5 16 16 u 16 8 16 in 16 8 16 hi • To be Issued t.. posts where slmpli cerate i inuol i • nenl without b< raw ill. 462 APPENH1.V SUPPLY TAI'.I.K KUi: IIOHPH \l - Continued. AHTK l.i:>. quantities for one year f.>r commandi "f LOO to no. From 900 to Prom 800 to too. nun. Euiplastri c&ntharadia lb. ferri lb. " hydrargyri U>. " ictbyooollae yds« Extracti belladonna oz. " bacha Qaidi 1 1 > - " oolocyntbidis, comp.oz. " oolombse fluidi lb. " couii ox. " qnbebse fluidi lb. " gentians? fluidi lb. " glycyrrhizse lb« " hyosoyami ob. " ipecacuanha Quidi. . 1 1 > - piperia fluidi z< " pruni rirg. fluidi. . .lb. rhei fluidi lb. •' Barsaparillse fluidi. .ll>. s i ■ H i ■ lT : t ■ lluidi lb. seuuae lluidi lb. "' tara.xai-i llui'li lb. " Valerianae lluidi. . . .oz. zingiberis fluidi . . . .lb. Ferri iodidi «/.. " et quinia>citratis oz. " Buipbatia >■'■■ Gambogia oz • Glycerine >/.. (luaiari reeina lb. Hydrargyri cbloridi oorr. . . .oz. " " miiis .. .lb. " cuni oreta lb. iodidi oz. oxidi rubri /.. [odinii n • Lini lb. Li(|iioris A m 1 1 1 ' . i > i^i- lb. " ferri iodidi lb. " potass : araenil is /.. •' Bodse cblorinatflB • • I " zinoi chloridi . . • .bo( I ■ Magnesia lb. Bulpbatie ll>. 3 6 9 12 1 9 3 4 i 1 2 2i 3 G 9 12 2 4 6 8 1 I . 3 I 8 16 24 32 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 •1 6 12 18 24 2 4 6 8 i 1 2 H 1 •> 3 4 1 ■1 3 4 1 3 • 4 2 4 8 1 1 2 n 1 2 3 4 1 2 3 4 1 8 lti 24 32 1 1 2 2i 2 4 6 8 4 8 12 16 2 4 6 8 A 1 2 2i 4 6 s A 1 2 l\ i 1 2 2i 1 2 3 4 J 1 2 2i 1 2 3 1 1 2 8 4 2 4 6 8 I 8 12 Hi ■1 8 12 16 1 2 3 -1 2 A 6 8 8 6 g 12 8 6 9 12 a 1 2 2i 25 50 75 Kin * ,\PPKNIHX. SUPPLY TABLE FOR HOSPITALS Omtnnu-d. 463 Quantities t"ir one year for commands of From Kin to aoo. Prom I Prom aoo to j a > 300. 400. .,iiii men. 1,000 men. M:i--;r ]iil : hydrargi oz Mollis despumati lb Morphite snlpbatis 7. •■ cajupoti oc " oaryepbylli <>/. " cinnamomi om> " menthse piperita <•/. •• motrhusa botl " olivae botl " origami Ir •• ricial (Jt. bott •• terebintbinse it. botl •' tiiilii dr Opii .'. Lb Pieia abietia . .lb Plnmbi aeetatia lb Potasse aeetatia lb biearbonal is lb " bitartratia lb '• ckloratia lb nitratis lb " talpbatia lb Potassii i-VMiiureti dr iodidi 07. Pruni virginiana* lb Ptilveris acaciae lb " aloes 07. " eantharidia >z •' oapaici lb " Binohonee lb " forri oz per sulphatia. .oz " glycyrrhizae »/. ipecaeoatihsB lb " " et opii. .lb " lalapae i 'lini lb Opii Hi " rbci lb ■abioa .... i Pulvoris siiiajii.- aigTC lb s 16 24 32 2 4 6 8 2 4 I) 8 1 1 2 24 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 3 4 e 8 Hi 24 32 8 Hi 21 32 4 8 12 10 12 24 36 4* 4 8 12 16 2 4 6 8 1 1 2 24 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 2 4 6 8 1 <) 3 4 1 2 3 4 4 1 2 24 l 2 3 4 8 li; 2 1 32 4 l 2 24 2 4 li 8 4 8 12 16 2 4 C 8 1 2 :; 4 1 2 3 4 2 4 6 s 1 2 8 4 4 8 12 16 4 1 2 24 J 1 2 24 t 3 12 H 8 in 24 32 1 2 1 4 i 1 1 2 i 4 I 6 12 L8 94 4i;t APPENDIX. si IMM.V TABLE FOP HOSPITALS- Continued. Quantities f..r rme jr«ur for commandi of Prom 300. from 4(Mi. 500 men. 1 ooo nun. I'uh eria nlmi Il>. Qnassise Hi. Qaiuise rolphatia /• Rhci oz . Saccbari lb. Saponia Lb. Si-illa- * oz. Barpentarisa lb« Sodae bicarbonatk lb. boratia Hi. h potaaa ; tartratia ... Hi. Spigelian Hi. Spiritua ami : aromal i'i. .oz. " aatheria compoaiti ... Hi. " " nilrici Hi. " liiviiniliil;i com p. . . .Hi. " villi g&llici bott. Strychnia Ir« Balpharis loti lb. B| rapi Boillae lb. Tinctures aconiti radicie lb. " digitalis oz. " ergotaa (Dublin) . .oz. " I'crri chloridi lb. " \ eratri veridia >/. . CTnguenti hydrargyri lb. " •' nil nitis. . lli. Vera! rise lr« Vini colchici aeminia Lb. Zinci acetatia "/. . " clilnriil ii/.. " aulphatia iz. i\s I i:i mi m B. A mputating Beta . Ball foraepa no. 1 : ■ i n ^ i i ■ > . u. 1 1 1 1 1 elastic (1 to 12) no. metallic (assorted I. no. I * in K " - apbn i holder for the throal n<>. Catheters* gum ela I Lc (2 i" I") in,. 2 4 6 8 I 1 2 10-20 20-10 30-60 in SO • 8 12 16 20 •10 60 Ml < 8 12 16 1 s ll' 16 4 1 •1 1". 2 4 6 8 4 1 2 24 3 '.i IL- 4 1 2 24 •1 4 6 B 4 1 2 n 2 1 6 8 4 1 J 12 24 36 US 1 2 :; -1 1 2 :'. -l 3 ii 9 12 1 _' :i 4 4 8 12 Hi ■1 8 12 Hi A 1 2 a 4 8 12 16 1 2 3 4 i 1 2 24 I 2 3 4 4 1 2 2j i 2 3 1 4 1 1 2 l i 2 3 1 i 1 1 1 i 1 1 1 6 B '•■ I 6 ii 6 fi 1 I I 1 (i ii i B In 5 BO 100 32 1 60 32 32 I 16 5 L'l 5 in E M j «J6 8 i L'l 8 32 82 5 32 B 5 3 j 8 3 8 APPKNDTX. 465 SUPPLY TABLE FOR HOSPITALS— Continued. Quantities for one year for commands of Prom 100 to 200. Prom 200 to 800. < lathetera, silver I 3, 6, 9 I. • • .no. . " eases no. . Capping glasses, or tina • . . .no. . Dissecting ?eis. . Lancets, spring 4 no. . y tfaumbf no. . Needle?,surgeons', with cast s.no. . Obstetrical sets. . Pocket seta.. Probangs no. . Pulleys seta. . Scarificators no. . Splints (assorted) sets. . Stethesoopes no. . Stomach pump and ease . . . .no. . Syringe, enema} no. . junis. glass no. . metallic no. . '' vagina|| no. . Teeth extracting sets. . 'I ongue depn ssor (hinge I. . .no. • Tourniquets, field no. . spiral no. . Trepanning set-. . Trocars | I small) no. . Trusses, hernia no. . Anatomy cop. Chemistry oop.. I lispensatory p. Medical Dictionary cop. Formulary sop. Jurisprudence and Toxicology oop. Practice cop; Obstetrics oop. I;, gulationt for Med. Dapl .cop. V 3 3 3 3 1 1 1 1 12 12 is IS 1 1 1 1 1 1 1 1 2 2 3 t 6 6 . <; Lnger, gronnd | Jamaica). ■ -lb. N atmege oz. Tea li>. Whiskey, bottles of 1 15 - 6-10 1L' L'O !< 30 21 10 •j so 75 loo in 20 30 in so 120 L'iio 1 8 ]■: 16 1 6 s 12 12 24 36 w 1 1 ■J 2 10 160 5 32 BO 10 5 ::_• 100 10 16 80 ;- 50 bo ieo so 10 16 I- so 200 v,| 400 32 16 90 | 18 Inches »j 4. APPENDIX. 467 SUPPLY TABLE FOR HOSPITALS— Continue). Quantities for one year for commands of From 200 to 300. Prom 800 to 4(10. 500 men. Cotton batting lb. . " wadding lb. . Flannel, red v. Is. . Funnels, glass no. . tin no. . Hatchets no. . Hones (in wood )• no. . Ink powder papers* . Inkstands no. . Lini n yds. . Lint .lb.. Measures, graduated no.. " tin sols. . Medicine cups and glasses^ .no. . Mills, coffee no. . Mortars and pestles, glaas ..no.. " '• " iron . . . no. . " " " wedge- wood no. . Muslin yds. . Needles, sew in g no. . Oiled silk, or gutta pcnlia tissue. Or India rubber I is- sue yds. Pans, bed no. Paper envelopes} no-. Paper, filtering quires. wrapping qnires. " writing! [uirea. Pencils, hair no. " lead no. Pencils, steel doe. Pill boxes papers. mach|ne no. Pins, assorted papers. .Quills no. Rain guagei no. Razors no. Elaior strops no. Scabs and Weights, aputbe- eary's sets. . sir p . .sets. 1 1 5 1 1 1 1 2 1 5 4 9 1 3 2 1 1 1 25 25 4 2 Inn i 10 12 12 6 2 3 1 2 25 1 1 1 10 1 1 1 1 2 1 10 6 3 1 e 2 1 1 2 50 25 125 1 12 20 18 g f. 1 I 25 1 1 1 3 1 4 1 4 15 20 2 2 2 2 2 2 1 1 3 :; 2 • 2 15 20 s HI 4 6 1 1 9 12 2 3 2 2 1 1 2 3 75 Kill 25 26 6 8 s 4 150 200 2 2 15 Li 20 20 24 30 111 12 3 4 9 12 1 1 9 s 50 1 1 1 1 1 1 2 2 1 1 *4 inches by 1. +_ cupa to l trin~- . {Assorted, 8 sizes — '-iiiiirijii business" printed on each. , Foolscap, letter and note — white; bine ruled. hl\ 81 ITI.\ T \r.l i: FOB HOSPIT kL8 DO. DO. Silk, surgeons' /•• •' (CM" . v,1> - Spatulas ii". Sponge lb. Thermometers and hydre- Mi' tei ii". Thermonu ters no. Thread, line /. • In i. T..W lb. Towels ii"- Tn ine 1 • » - Urinals to. iMorted 'l<>/.. DO. W i e, sealing sticks. •J 1 i . 4 l 3 1 i l i 2 ■ 1 i ' •• 3 i 2 -ii 30 i 1 2 3 6 13 1 1 3 3 8 i •l 12 2 l a 2 jit '! 5 18 2 i 10 6 I 16 2 1 S 3 I l i 13 I l." 1 2 I ! 1J0 III 8 c i toe quarter, woolli n ; thn e qua if the following artiok o( B pital Furniture cannot be o witli the hospital fond, they may be procured from ;i qnssrsn master "t- medical disbursing officer, by special requisition: Basins, trash. Bowls. Box« -. i"r i" pper Buckets. Cloth ; Dippi ii rati 1 1. AKTM I I 9. Gridirons. Kettli -. tea. and K ni\ es and Forki I r 1 1 - . Locks add K ej -. Mo. Pans, i>; ing. •• Pitchi s. Plates. Pots, i and ti •• iron. Sadiron -. . lire Skillet, » Itb Snuffers. Spoons. i n I ] Tumblers. i« s. shambor X chair.l AIMT.NDIX. 469 Standard Supply Table for Field Service. Ql im mi IS. Iteg't Bat. Comp. :; urns. :; mos. 3 inos. M l.l'K IM>. Acidi nitrici lb. sul ph. aromatici lb. bantiioi oz. Aleoholia bott. A him In i- Hi. A in in "II i;>' ciili'iiiMlis iz . Aiitiiii'iini *■: potass, tartratria <>z- i aitratis (fused) ■■ < Dill ]'ll IM' lb. Ceral i resrnae lb. si in pli' i.- II). Chloroformi 11>. Copaibae lb- I ' 1 i B .- " , i OZ . Capri Bulphatis oz. Emplastri adhoesivi j da . cantharidia Lb. " irhtl iv ncil he yds. Extract i eolocynihidia comp oz. glycyrrhisse lb. Bydrargyri chloridi oorrosivi • • niitis lb. i lud in ii m . Liquoru ammonite lb. . potass, arson itis ■/. ■ Magnesias sulphatu Lb. . pil. bydrargyri Morphia Bulphatic dr. . Olei menthae piperita ....«/... " olivu In. II.. ricini |i. berebinthinse |t. bott.. ti^'lii ilr. . Pil nl : cathartic : comp: (U. 8.) doe. . opii (U.S.) Plnmbi aeetatu lb. . i 11... chlorati Lb. . oitratii lb. . P 'l.i --ii i.i'li ii ../. . Palreria acacia lb. . " <• « l > s i e i lb. . • i i 1 4 2 1 6 4 1 i 16 8 2 1 -1 2 4 2 2 1 8 4 2 1 2 1 2 1 4 2 15 8 4 2 2 1 16 8 2 1 i i 2 1 4 2 4 2 4 2 25 1* Hi s 4 2 2 1 - 4 12 6 - 4 2 1 S 4 8 4 2 1 2 1 2 1 1 I 8 4 1 9 ! 1 « 470 APPENDIX. SUPPLY TABLE FOR FIELD SERXICE -Continued. Ijl \N :; mas. Bat. .", mas. C imp 3 mow. Pulveris ferri per sulphatis 01 '• ipi- :i'U;inh;>' Lb et opii II) lini 11. " opii Hi rkei lb " sinapis aigrsB lb Qui nia- sulphatie oz Saoehari lb Saj urn is lb Bo4n bicartonatis lb Spiritus ammonia aromaaioi oi BBtheria adtrici 11) \ini gallici butt Syrupi actUse lb Tinctures einchonm oomp lb " columbat lb fcrri chbnridi lb " pentianae comp lb '• opii oz veratri reridis an Unguonti bydrargyri lb " nitratis lb Vini oolbhioi Beminia lb Zinci aoetatis oi •' sulphatis oz INSTIll MI'NTS. Amputating Beta Bail forceps do I dugii t, "inn elastic | l to 12) do imTallic (assort i'il) no Catheters, gum elastic (2 to 10) no silver Ci, C. tl) no eases do Cuppin v ti do i -. spring do thumbs (with cases) no NTeedlot, Burgeons | with cases) no •1 2 1 4 1 i 16 8 2 1 A i 12 6 24 12 in 5 8 4 i i 4 2 1 1 12 6 :; 2 4 •i 4 2 1 i 4 2 16 8 8 4 1 1 A 1 1 ■v 2 1 2 1 2 1 2 1 ti 6 6 6 C :; 3 1 I 12 B 1 l 4 2 | 12 <3 i Hall' glass, half tin. APPENDIX. 471 SUPPLY TABLE FOll FIELD SERVICE— Continued. ARTICLES. IJl ANTITir.S. Pocket Bets Prob&ngs ". mi Scarificator! no Splints (assorted) sets Syringes, enens (assorted |* no ■' penis, glass no " " India rubber no Teeth extracting sets Tongue depressor (hinge) no Tourniquets, field no " spiral no Trepanning sets Trocars (1 small) no Trasses, hernia no A i hi in my ( surgical) cop. Medical practice »p. Regulations for medical department cop. Surgery ( operative) cop. Thompson's Conspectus cup. Blank no. HOSTITAI. STORES. Arrow root lb. Candles (sperm )f lb. Farina lb. Ginger (fluid extract) lb. Nutmegs oz. Tea*. lb. Whiskey, bottles of doz. Bed -acks no. Blanket! (woolen) no. Reg'l .". inns. 3 mos 2 1 f. I 2 1 1 1 4 2 8 4 8 4 1 1 1 1 12 r. 2 i 1 i 2 i 6 3 1 1 1 1 1 5 5 10 5 2 1 10 5 1 1 8 4 30 I.". 3 2 20 10 30 15 i * 1 Davidson's ; 1 bard rubber, 6 oz. f To bi For use in surgical operations in the night. 472 APPENDIX. SUPPLY TABLE FOR FIELD BERVK E » intoned. ARTICLES i Dump. 8 mo*. 3 ni"-. ■"• nii-. Quits perdha cloth Mosquito ban lo. Pillow ticks ao. I I I : N I I i Ki; A.HD DRESSINGS. Bandages,* roller, assorted loi. suspensory, a ssorted no. Binder's boards (18 inches by f i no. Corks, assorted Uti. Corkscrews no. Cotton batting lb. wadding lb. Flannel | rod i yds. Hatch* ts • -ii"- Hones (4 inches by l , in sroed) no. Ink, 2-ouane bottles no. Knapsacks, hospital^ no. Lanterns no. I.inl U>. Litters ami stretchers, hand no. '• horse;}; no. 20 in 20 10 20 11' U 7 12 6 1> 9 L2 6 2 1 :• 1 ■2 1 5 :: ■2 1 1 1 IL' •J 1 1 ■> 8 I 10 ■i •• :; •2\ •• a :t •• I :;'. •• :, i •• (i ■ 1 dozen. 1 inch wi.lc, 1 yur i pieces constructed i" acl as stretchers to kocp tin- poles apsu U AJt'l'E.NJJlX. 473 SUPPLY TART.E FOR FIELD SERVICE— Continued. Qi INT1TIES. But. '■'• mos. 3 mos. Comp. 3 mos. Measures, graduated, assorted* no. Medicine chests no. " cups and glassesf no. panniers no« Moss chests i see Bete] no. M ills See no. Mortars and pestles, wedgewood (.small) ...no. Muslin yds. Needles, sewing [assorted, in a case) no. Oiled Bilk, or gutta-percha tissue, or India rubber tissue yds. Pans; bed I no. Paper envelopes, assorted no. Paper, wrapping mires. writing! quires. Pencils, hair no. " lead (of Faber's make, No. 2 no. Pens, steel '■ doz ■ Pill boxes, wood papers . " tin no. Tins, assorted | large and i Lium) papers. Razors no. Razor strops no. Scales and weights, apothecary's sets. ScissoW no. Slicc]i skins, dressed no. Silk, surgeons' ox. •' green yds. Spatulas no. Sponge (washed) lb. Store chest no. 20 100 12 21 12 1 2 ii 4 1 1 1 I I 1 3 1 1 1 10 25 4 1 50 3 Ii 12 6 2 1 6 2 1 1 1 2 2 i i :; I 1 2 1 2 i i i 5 25 2 1 26 1 3 6 3 1 I 6 2 1 1 1 2 1 i 4 2 i I ■ 6 ox., 2 os., minim. t 2 cu|ps to I glass. J of hard India rubber or oilier material. Shovel. ."■0 letter, 2o note, 26 lai " printed on each. >/2 foolscap, o letter, 4 note, white: blue ruled. in 474 APPENDIX. SUPPLI TU5I.E FOB FIELD SERVICE Continued. AKTICI.KS. qi \s :t moa. Bnt. Tape piece! Thread, limn .,• Tiles bo Towels no II. Viols, assorted (1 os. and 2 ot.) los Wafers, i \ oanee boxes) tio Wax, Beating Btleks 4 ■J •J 1 2 1 in N 1 1 1 i 1 1 2 1 NOTE TO F'KK<'I-;it[NG T Ull.K. m i:niti"rr ok mkss cni:5T. 8 I !;i si n s, tin. i Boxes, pepper and salt. ii ( laps, tin. ■I Canist< rs (for tea, coffee, sugar and batter). 2 Dippers and ladles. I Qrati r. 1 gridiron. 1 Kettle, tea, iron. I L' Kni\ B8 find forks. Kugi i Hi itannia, half pint I. I Pan, fry ing. 1 Pan, aaaea. 8 Plates | 1) and diski - 1 Pot, ir.m. '_' Pete, eoffee ami tea, tin. 12 Spoon 8, iron: table if>) and tea (•). I BkiHet, with .-over. I Tray, tin. t'i Tumblers, tin. The Standard Si I in -ill the articles to be purchased by medical pan ej ors, axoepl on the orders of the Surgeon General : but any l< 98 i nanfjty may bo required or any article omitted at the disare-i tion ol RXTRACTS FROM THE REGULATIONS CONFEDERATE STATES AE^IY. " Before an action, the Quartermaster of the division makes all the necessary arrangements for the transportation of the wounded. He establishes the ambulance depots in the rear, and gives his assistants the necessary instruction for tike service of she ambulance wagons, and other Beans of removing the wounded." " The ambulance depot, to which the wounded are carried or directed for immediate treatment, is generally established at the most convenient building nearest the field of battle. A red flag marks its place, or the way to it, to the conductors of the ambu- lance, and to the wounded who can walk." " The active ambulance follows the troops engaged, to succor the wounded anil remove them to the depot. For this purpose, the conductor should always have the accessary assistants, that the soldiers may have no excuse for leaving the ranks for that object." The medical director of the division, after consultation with the Quartermaster-General, distributes the medical officers and hospital attendants, at his disposal, to the dep6ts and active ambulances. He will send officers and attendants, when prac- ticable to the active ambulances, to relieve the wounded who require treatment before being removed from the ground. He will see t lint the depots and ambulances are provided with the ary apparatus, medicines and stores. He will tak ami render his profesMonal Services at the principal depot. 176 APPENDIX. It' the enemy endangers the depdt, the QuarteraMater takei the orders of the General to remove it. or i" strengthen its guard. The wounded in the depots, and the >i«k . are removi -,,.,1, ,i- poasible, to the bospitahi thai have been established by Quartermaster-General of the Ann\. on the flanks or rear lit" the arm} . In Beiges, the field officer nt' the trenches Bees thai men and litters are always ready to bring off the wounded No officer making returns of property shall drop from his return any public property as worn out or unserviceabre until it has 1 >< i it condemned, after proper inspection, and ordered t>> be bo dropped. Every officer having pnbtie money to account for, and failing to render his account thereof quarter-yearly, with the Touchers necessary ti> its correcl and prompt settlement, within throe months after the expiration of the quarter, if resident in the Confederate States, and within abt months if resident in a foreign country, will be promptly dismissed bj the President, he shall explain the default to the satisfaction of the President. Every officer entrusted with public monej or property shall render 5 all prescaibed r e t u rns and account- to the bureau of the department in which he is Berving, where all such returns and accounts shall j>am letter paper (quarts post) whenever practicable, am) not on not*/ or foolscap paper. The letter must be folded i" 1 1 1 r*-« ■ equal folds', parallel with the writing, and t*n« 1. >r--. -. 1 across that fold which corresponds with the top of the sheet, thus : [Name and rank nf writer.] [Poal Of station and data of letter.] [Analysis If ( ontente, ] SMJ153U •S'OSU^) ■Bq»«9Q •sas«o *m«aa 'B9&BQ •blHB9(J •S88«0 ■Bq^voa •S9SV3 GO o < < w .J CO y •-" -i— - - B'53t = - r * = -.-■= beg - - n-r-c-c^: v. - S — t *- • ■- 1, . .. is ;i:r- <— - i ' -. ,ti ^.™~ •_' T! H .-* i— — — — - " j :Ci::;;-:;: g ••• ** * APPENDIX. 481 Form 1 — Contihued. DISCHARGES 01 BUlQBOmS CERTIF 19 1TE, A.ND DEATHS. N \MF. Rnnk. e — 1 Date of ih- Date of sin name. Christian aame. 1 service. death, • « REMARK: • hi Surgeon's certificate, and deaths occurring .uiMiig those of the command not on ?-i< K report, will b I. bul separate 1 I others b> a double line drawn screes i!m. page. TIip remarks will in i b I > • ■ < - i l \ ihe manner in which tin natod. when it is known In every case r.f the ileatli "I an officer, whethei "ii duty "i ii"t. a special report i* t,. he ina ie to the Surgeon -General 41 182 AI'l'KMUX. Form 1 — Continued. iltNT. ELEPOfiT OF sick ANH WOUNDED. F'i|{ THK QitmrU r ending St Remarks . ■ a. o s < > = s gg £ < ■ M f- c H I - « * • 7. 5 £ i- S S 2 « ■ ---'-;- 6 S SbuS»jj — '. ~ - = .1 i - - s. 8 c g a a = _£ = -=^ I. !Oh joe g < s ~ - r : - : _ - -= £« - I - '- f 5 : i'/ - £ if r 1 -• B 5 -= 1 1 " * 1 1 ' - - — - — _ •i £ "B = — B-2 J" <- -- o - - - - - ~ £ M 4 i -- - - Irsq - H ■ *■ > - '£""■? = t i - a ojm = --f - r .J: x~ - « i- -. - - g S .= i 1M APPENDIX. « o ■ M 1 ■< s - tf •!"" !l l ■'<' > r- - - r •0}3 •p.ll.n.i'lx.. |i:i"l. 2 •9sn _ joj )i|iin Jo 'jn<> ujh^v - — PL, V •]uo|n.i.n: a^qvpioAvmi \.| |iJ.\OJ|-.>[> 10 J-"'| : - « •|. .ii-- 1 |z -- - 'W ''I 1 MH" p«pn«dxj| " '_ >- - u: •l«lox g fa ■U.IIU -oj ^s«j aonis i>8.\ia.>a}j * - H •|Un)JJ )>i:[ |l! 1>U«I| 11(1 M ■1 C£ ■^ f- - 4 - = E ■_ t. V c <: - 3f a* u H £ ■ - I ■ J| fl - ■ 1 -- : 'J a a '£ >■■* APPENDIX. 485 B g C 1 • 1**0 1 •g -o>j -no A 'I '°M ' no A c "9 *0JH '""A in •Q ^.M - n°A 1 OJH •"" 1 •;:-»\' -io A •-•0^ -no \ | ■f»JH "»«A •pn-'j. 6 a ''.' "X '""A j; •I t>jj -no A - . e ■::'"X '""A '.- ' V »"A 'I "K '""A * *r :; - j 2s ■ f ( - r- <^ 1 — - P- 1 " 4*6 APPENDIX. * l-o - - - = " _ - z I ■■■ E « - i N _ 5 N < - b | t - - - a o = - fe - — — o - - = z U i- ■a = "S.S i g ^ - — = APPENI>T\. 48" o d S « o S g .5 * - - ^ — s r - - £?£ — s »- APPENDIX. * g - IE : 8 - 3« .-. K ,.£ a c'£ W vr — - o u 3 « n a I - 1 £ o a JO z APPENDIX. o pel o I ■033 ■■''M ■«»a •00503 •ApuTiag 5 >!.U ■,.,,;| z 490 APPENDIX. 1 - < 3 *£*•*& • ■Si •- — _ ^ | r ; r 9 B J[ . - ~ <- - -- « ' - : - > -= . 7- s a> When delivered. •oia S||«J3A0 '-J 1 •-|l!o) ■ CiradiaoQ - 6 1 — a h s - a \ 1 1 AIM'KNIMX. 401 R F.MARKS. TIki r.Mti.irks will state how articles have '" en lost, and bj whom destroyed, oi t lie pereoni ii"l. etc. •p.I1!.«^J- ''1 ji.lll 'JOpJO Ai( p.lAiU|.-'.l( | ■Hi" "-i"AV ■l-o'l •^a , ■■ >a 1 MU\| "'-' •s.M'i'M ■M-^|U1:15| - '-"1 ,: - I' '11 -sjang ii.>ii.iji>i J" |Hi I" '"< 4U2 APPENDIX. ■ - PS l'".'l ll..|.lll| II(| •[i!;!>Ui.i| ptraaaS • •. • ioi \d.<< I.-. | ii.ir..n.'i].i»i([ ~ •ji.ii.i ,-..,i • \'i.. r n| p. >ii.ni).>i| •|'-Miu"]i\ ■ ■- - 9 ' Alllltllllii ,) 'ScUoo j" m 'in; S >;| •■[ ,li: :i - < y. APPENDIX. | u = i ^ Bi ■a u M ^' •I « < i • H 1 rz H P i— J= A H P fc — e? - •c _ ft w i ^ ■ — g i ■ ^ s K. — - « Q £ *, 31 . a .5 - b- -z -5 9 •£ J£ ■ ■ ~ 2 3 z — * ; ^ s .~ t- o *L,«*-i tea -" _ * •— O ik ^c -« -a fl . 5 ^ - c a 3&§v * V g «■» _>. g 5 £ ?i. 3 c s s - ■ B £ =5 ♦» !2 * - c lj 2 •- ± '~ " T - 5 8 ."• c't- * « * *■ 2 --- , SB f- -= £ - s - = a.Sja iiU- O P ^ • — - , ~ . r- -' * -2 •"" — Cj — -^ t^. ■" '"■ - O i) C c3 .2 '"— " •r - - -- - 2 - 5 = -z r- r _c P-i -z - ~ TZ - « £ ^£ : B.Sfa E a s £ ~ - = z 7Z t r - z >.>■£- r ~ Z tt - <- h a tn ^ f _ s: ■~ _ c ■a < p ft a . — : . - "r o > >, c — ■- -z ' *- T £i ^ '■--'- , - a a __. ___ •_. - M -^ r "^ "r. - ; •- *~ ^ ~ = r— - - : Z- = z o s — J il- X s :J1 •S £ - - >.-T • ~ *zl ■— • • - ■ _ ~-Z «. i '■= a ': " tt-!i S §• .5 2 ^ • •**£. 2 s3 £ 2 "" S a * jj S * S"J - — z\— z\.~ ~~ ■ ' ~ jz — -jl - r,, -t-~T a "" — z: - ~ Z >' •— Z - -zz - - -.t. ■- ~ r r c. > "r - . ■— t •• .— *s - < '~ ~ •_ — "~ - - '- E " a " ~- ; - — ^ -=•- = = i— ." = js - : - z = r * - ; 4 jiqi ~— -3 I*M Al'l'ENDIX. I" -.KM 1 3 . akmv <>r tiii: . "\n DM \ti: R \ i M [('<.«! .if Arm».] DisabUUif far Discharge. A I'.. ..f Captain — — *i coanpaarjr, ( ). of tin- — — rcja- iiH -in nt' Confederate States , was enliste d by , regiment of . at ■ — —.on the day of- yearaj he vras born in , in the State .>t' — yean of age; fret indie* hfgh, complexion, e\e-. liair. ami by occupation, wlien en- listed, ■. During the las( two months, said tieku&r hanbeen unlit for duty days. [The company commander will hen- a. 1.1 a statement >'t' all tlie facta known to liitn ejouteiuiug 'lie disease or wound, or cause nt disability "t" the soldier; the time, place, manner; ami all tin- circumstances under which tit*- injury occurred, or disease originated or appeared : the duty. 'if the tolditr decuos to W atidr'trnl may hf Uoi o iuld^ 1 T'tm- Chunty- fit5 * o fe is »! n-g — - > a as O - H ps o Q oi o H PS 496 API'KM.IX. C B en - i ■ •< 7 M OS Remain in 1 -'. •saajjBnb uj •pnulsoq uj •p a ?a ■[I!)lllsnl| •poSat;i|.i>i([ •^inp oi paaanio'jj Tm;,l. s.iojjiinb ut 1 1 •|i:|i(>)!« U05Jt.'X Remaining at last report. ■saojjitnl i uj •|i:inl>oq nj L*Y. ■ < APPENDIX. 497 Form 16. CONTRACT WITH A PRIVATE PHYSIC! AN. This contract, entered into this day of , IS — , at , State of . between ; of the C. S. Army, and Dr. — . of — . in the State of , witnesseth, that for the consideration hereafter mentioned, the said Dr. — — promises and agrees to perforin the duties of a medical officer, agreeably to the Aran Herniations, at (and to furnish the necessary medicines). And the said promises and agrees, oh behalf of die Confederate Stales, to pay, or cause to be paid, to the said Dr. . the sum of dollars for each and every month he shall continue to perform the services above stated, which shall be his full eom- pens at ion. and in lieu of all allowances and emoluments whatso- ever (excCpt thai /<»• medicines furnished, which shall he at the rate of per cent, on his monthly pay, to be deU rmint d by tin Sun;e>>it-
  • eing, or the Surgeon-General. [SKAL.] Signed, sealed, and delivered, > in presence ot ^ [ >l AL.] I certifV that the number of persons entitled in medical at- tendance, agreeably bo regulation*, at is , and that no competent physician can be obtained at a lower rate. . ( 'iiiiiiiKiiidiin: (Jjficer. 42 498 APPENDIX. Form 17. FORM OF A MEDICAL CERTIFICATE.. FOR LEAVE OF ABSENCE. of the regiment of , having applied for a certificate on which to ground an application for leave of ab- sence, I do hereby certify that I have carefully examined this officer, and find that . [Here the nature of the disease, wound, or disability, is to be fully stated, and the period during which the officer has suffered under its effect*.] And that, in consequence thereof, he is, in my opinion, unfit for duly. I further declare my belief that he will not be able to resume his duties in a period less than . [Here state, candidly and explicitly, the. opinion as to the period which will probably elapse before the officer will be able to resume his duties. When there is no reason to expect a recovery, or when the prospect of recov- ery is distant and uncertain, it must be so stated.] Dated , this day of . Signature of the ) Medical olficer. j APPENDIX. 4<>9 o 1*4 e c C3 ^ e of ■««s •dveg •>.i||nn:,) •jnJfoui y M«Sng ■ MOIH mveg 1 e — 1 - o» =: IM ■♦ '• — o — Q * -r O O 1 o •M e-i © T - I o O 1 o •M © IM ^ s h © C^ 0-1 r; -r o © 1 © tl s — -f o o © l~ rr. a :r !.in d -noiji:}| jd .i.Kjnmjj •Sjfljp JO .Ml|!IIIl\- 'I'-VVL 'owo \\ j" nqwt£ •torn jo jn«(tnn\ © s ! 3 H — s CI © 1 © "1 * ; - e 23 7 '"' — 9 E pj I 5(i0 APPENDIX. Form 19 .1 Montlily Statement of the Hi-spital Fund at month of , 186 — . -, for thf 1>K. To balance due hospital last month, - - 8 00 1,532 rations, being whole amount due this month, at 9j cents per ration, 145 5-4 Ck. 1881 ri>. By the following pro\ -isions. at contract ptiotHJ js.".} lbs. of ])ork, at 6 fonts per pound, 690 His. of fresh beef, at 4c. per pound, l.iii •_',",; lb* of (lour, at 2 cent-; per pound, 10 lbs, ef hard bread, ai 8£c. per 11>. JO Iba of rice, at 6 cents per pound, 56 His. of coffee, at 9 eta per pound, 193 J g lbs. of sugar, at 8 eta per pound, 17£ qrts. of vinegar, at 5c. per quart, 15,''; Iba of candles, at 12c. per pound, 6l4 Iba of soap, at 6 cents per pound. 16$ qrts. of salt, at 3 cents per quart, 12 galls, molasses, at 88c. per gallon. PURCHASED. 2 pra of chickens, at 87Ac per pair, - - - - SI 75 ■1 qrts. of milk, ai 7c. per quart, 28 :f do/., oranges, at 25c. per doz. (| 76 Total expended, - - Balance due this month, - Sill is-, 1 i 78 114 96? $30 57.; [Date] Surgeon. e- < •■IKS ONCCVeiBNiC^CSSO o O li>| [ tC a, I'tieNoonKeNecooc cc r c cc "SOOtllW) •N»i«N« I - — y. -. i -cc — . r. c> te — — — N c-c :c — '-c •-; cc c i cc cr. c n :: r. BQ •Spillluj M -l Ci cc cc -*• O © -* o — 03 H ►J s < 'BaounQ | -. X ~. 1 ccr w — X CI cc - - x ~ - - - - - — CI ^ !>■ Cc C-3 ^<4DO>H^00C4tDC t X N 'J O — 1 — •spnnoj - 1-H UTS ■< e K fc ■ > "SffiO N^tOCOpNTftDBOOOC cc r c cc cc — Cc- ci CC Cc tN >~ x :i -» c 7. CI — ■— <= — CI C-l C-l NICi h re cc — -+ •sj.n:ii(") I — ■— N ~i -i ■: sc •sunijur) | ~ 1 = a V.I.UI11(> Cs CC 1— cr CC >0 -* cc ci CT ■* — X CI — -c / h « io i^ - — o: >c — p: ffi cs N cc cr r. c i •spnno^j rtriti::t;i-i cc c c i ■— cc i— i— .>1I11(| - .IX-tOcCNCf — — cc — r x c. — ci — ■spvaoj - : I . - : c c i— o o 1-H O •J. to •>ll!!» — f ~i -~ — — CNECOOOC - c:c:c: x M c?. 'C CI 7 — — 1 - — /. ci cr — A Cl 'C o-r-Nnni'iOioe-tK- -r — cc — 'si-iun?, 1 T-Nw^^flei- •s|at IS n a | & e 'B90QIIO 1 N^KOHONi 1 «■*«« — x -< — at / / / / ■ H -spaaoj ^NrtiotDNacHMi.ci.c; ci- > c i .--.-. r i - y c — - _ — " ci sa.innn 1 2 °° "* ""^ r,r ' * I ._. „„„ .1 t— CI : • — " C .- i - - C-) o I- o CM O l- "CJ = O > l'" lll) cT — 'e-jcccc-c-occ-c: in a 1 c a i i 1 M O H •< s: ■ — ■ c - 1 - ' : c c c c; cc ; c - c : — e-i .-. — - - i - cc cr o o o HCC Appendix K<>. J. MEMORANDUM FOR THE INFORMATION OF MEDICAL OFFICERS IX TIIK KXCI.ISIl ARMY, o\ TAKING rrn: FIELD FOR active SKiivici:. 1. .The ambulance equipment for one division of tlie army, consisting of two brigades of tittle battalions cadi — tlic battal- ion- 1 »inur 600 strong — Tumid consist of two large stone wagons, to be under the care of a purveyor's clerk, at the head-quarters of tlie division. TblMS wagons to contain a reserve supply of medicines, materials, medical comforts, tents and beddrhg. Each battalion surgeon should have a pack-horse for the conveyance of his instruincnts. a few medical comforts for immediate Me, such as a bottle of brandy, half pound of tea. one pound of su- gar, and four ounce- of aiwwruet, a few tin- of essence of beef, sonic medicines, and a supply of surgical materials agreeably to tlie printed scale laid down in the regulations. A spring wagon should also be attached to each battalion tor the removal of the wounded off the field, and for the conveyance of the hospital ■'-. A and 1'.. with twelvi bedding, ten CBtbVSM bearers, and the hospital marquee on the line of man h ; or. "»i Burgeons of regime m« is complete in every respect, and it would be a neceasar} precaution \<r. Hall thinks medical officers will find f'hc\ can tem- porarily secure fractured limb- better and oracii more el dilioiish than In any olher manner. Ter, full of water, and a drinking eup. I ft ond man should pan k boarai ■ ;.h shoulder straps, and. like tlx- rantee, full of water. Z«e third nian. 1 think, should be armed, to pro- tect the patty against and marauders, and. like bis fellows, carry a canteen full of water. The afrnnd abstain - •i should receive the wounded from the i «re- lailv placed in »«. and lie 5U6 \1 I K.NDIX wapon to whore the surpeon and third assistant are stationed, ready to afford them the surgical aid they may require. For rvice the second assistant surpeon should be accompanied by two men to assist in placing the men carefully in the wagoa; these men should accompany the wapon, and assist in like man- ner in takinp tlie wounded out. These men should likewise carry canteens full of water, and then- should be a .-kin of water a- a reserve, in the wapon, with a drinkinp cii]>. 6. .The site selected by the staff-surpeon of brigade for the reception of the wounded from the held should be as sheltered M pOMiUe; and it' not easily distinguished, a flap should be put ii|> | and it' any houses be near, calculated for the reception of wounded men. the\ should lie taken posnMIM of at MM, and an aliundant supjdy of water, and. if possible, straw provided. 7.. Should the action prove decisive, tents can lie pitched lor the temporary accommodation of the wounded ; but should the army advance, the surgeon, and one assistant, at least, should accompany their repiments, leavinp one or two assistants, accord- ing to the number of wounded, to aid the divisional stall', who will piteh the reserve marquees, and make all necessary prepar- ation for the comfort and accommodation of the wounded by having tea. broth, or essence of beef (which is readilv made into broth by adding hot water), wine, and braud\, etc.. ready. Should (he army unfortunately meet with a reverse, all avail- able transport nm-l lie pressed for the removal of the wounded to the rear, and they must he sent off as speedily as possible ; but neither here, nor on the field of battle, should any one be carried wdiosc hurts are so slight as to admit of his walking. Nor should nommanding-ofticcrs of regiments, when wounded, be allowed to take medical officers of their own corps to the rear with them, or officers of any grade be permitted to appro- priate the sprinir wapons for the special coin e\ anee of thein- selves and their lupgage : and positive orders should be uiven to pn\cnl bandsmen, drummers, or pioneers, specially told olf to assist the wounded, from beinp left in charge of officers' horses and effects. 8.. Should the army have to effect a landinp on an enemy's coast, with an opposing force to meet it, the men should cat a APPENDIX. 5(fi pond meal before leaving the ships, and should cook whatever provisions it is necessary to serve oat to them before the start. Pork is better than beet' tor tin's purpose, as i( warms up more readily with any vegetable the men may find on shore. The medical officers should land with the last boats of their regi- ments, and should carry with them their haversacks, dressings, and canvas bearers, if the landing be opposed, so as to be able to bring the wounded at once to (he boats for conveyance to the ships set apart for their reception; care should be taken that each boat employed in this service contains a supply of water and a drinking-horn. !>.. Should a landing be effected, and any horses lie disem- barked, the surgeon's pack-horse and panniers should be amongst the tnt. lo. ,Afl soon after an action as possible, medical officers in charge of corps will make out and transmit to the Inspector- General of hospitals, for the information of the General com- msnding-in-chief, returns of casualties made out agreeably to the following form : Return of Killed and Wounded in the of Regiment, in ihr action Danger ously. Total Ij \\ ounded. i ifficers. N OS-com- missioned officers :• in I pi i i officers Uill- i'il Mid wounded to be u»8( rted h 48* Atpendix No. 3. DIRECTIONS COOKING BY TROOPS IN CAMP AND HOSPITAL. PRSPARBB ruR Till'. AIDIV A\l> PUBLISHED BY o 111) Kit <>K 1 !! B SI RQRON-QBNERAL. DIRECTIONS FOR COOKING IN CAMP. COFFEE FOB ONE HUNDRED MEN, ONH TINT EACH. Put 12 gallons water into a suitable vessel (or divide if ne- cessary) on the fire : when boiling, add '■'> lbs. ground coffee : mix well will: a spoon; leave on the lire a few minutes longer; take it oil*, and pour in I a gallon cold water: let it stand till tin' dregs subside, sa] from 5 to 1 minutes ; then pour off, and add 6 lbs. sugar. IT milk is used, put in 12 pints, and diminish tin' water by that amount. FRESH BEEF SOUP FOB ONB HUNDRED MEN. Take 7") lbs. beef ; cui into pieces of about j lb. each; !•"» gallons water: 8 lbs. mixed vegetables; 10 -mall table-spoonfuls sail: 2 small table-spoonfuls ground peppery some cold bread, crackers, or .'! lbs. rice, to thicken : place on the lire ; let il come to a boil ; then simmer tor .'! hours. Skim off the t'at and APPENDIX. BOTERS - i ' w ! "i: OKE flXJNDRl i> Ml N. Cut 50 lbs. fresh beef in pieces of about j lb. each, and with water put int<> the boiler; add l" table-spoonfuls of Bait, iwu of pepper, 7 lbs. onions, cut in Blices, and 20 lbs. | toes, peeled and sliced; Btir well, and let it boil for 20 or SO minutes; then add I 1 lbs. Hour, previously mixed with water; mix well together, and with a moderate heat simmer for about l' hours. Mutton, veal or pork can be Btewed in a Bunilar man- ner, l>ut will take half an bour less cooking. A pound of rice, or plain dumplings, may be added with great advantage. i DUMPLINGS. Take 10 lbs. flour, 15 tea-spoonfuls of salt, 7 of ground pep- per, 7 lbs. chopped fat pork or suet, 6 pints water; mi well together: divide into about L50 pieces; which roll in flour, and boil with meat for 20 or 80 minutes, [f do fat or suel can lie obtained, take the same ingredients, adding a little more water, and boil about 10 minutes. v rve with the meat. Place your pan on the fire for a minute or so; wipe it clean ; when the pan is hot. put in either tat or butter (fa! from salt meat is preferable) ; then add the meat you are going to c turn it several i inn > to have it pound a small tea-spoonful of salt and a quarter of pepper. A few onions in the remaining b the addition of a little flour, a quarter pint of water, two table-s] nfuls of vinegar, or a few (diopped pickles, will be very relishing. TO COOK BA1 i in i i OB l'OKK. Put the meat, cut in pieces of from S to i lbs., to soak the night before ; in the morning, wash in fresh water, and squi well with the handi to ct the salt ; after which, put in your kettle, with a pint of water to each pound, and boil from two to three hours. APPKNTMX. 511 SALT BEEF OR PORE, WITH MASHED BEANS, FOB ONE HUN- DRED MEN. Put in two vessels 87£ His. meal each ; divide 24 lbs. bean* in four pudding-cloths, loosely tied; putting to boil ;it tin time as your meat, in sufficient water ; let all boil gently for two hours; take oul the meal and beans; put all t lie meat into one boiler, and remove the liquor from the other; into which turn out the beans; add to them two tea-spoonfuls of peppi pound of fat, and with the wooden spatula mash the beans serve with the meat. Six sliced onions, tried and added, im- proves the dish. [Note.— In cooking all kinds of meat, he careful to preserve the grease, which can he easily dune by putting the liquor in which it is boiled by till il cools: then skim oil' and place in a (dean covered vessel. It is an excellent substitute for butter; is useful lor cooking purposes, and will burn in a common lamp or tin plate, with a piece of old cotton twisted up for a wick.] DIRECTIONS FOR COOKING TN HOSPITAL. MUTTON STEWED, AM) SOUP FOR ONE R I U'V. Put in a convenient sized \ esse! 16 gallons water, 60 lbs. meat. \2 lbs. plain mixed vegetables, 9 lbs. pearl barley or rice ten), H lbs. salt, i .}- lbs. flour, I •• Ptrt all tlm ingredients, except the flour, into th ■ if on tfl and when beginning to boil diminish the heat, and si lv for two boars and a hah': take the meal out and keep warm ; add to the soup your flour, which you have mixed with i to form a light batter; stir well together with a spoon: boil another half hour; skim off the fat, ami serve the meat and soup separate. The soup should be stored occasion- ally while making, to prevent burning or sticking. 312 Al'l'K.MUX. i;i i I BOOT.* Proceed tin- same ;i> for mutton, only leave the meat in till serving, as it takes longer to cook thaa mutton. Xhe pieces are not to ba above i oc 5 ll>s. weight each. r.i i i 1 1 \. bi i ii n i a. Cut three pounds lean beef into pieces the size of walnuts, ami break up the bones (it* any) ; put it into a convenient Bused kettle, with J 11). mixed vegetables (onion-;, celery, turnips, car- rots, or one or two of these it' all arc not to be obtained), 1 OB. salt, a little pepper, 2 oz. butter, .', pint of water. Set ii on a sharp fire for 15 minutes. Btirring occasionally, till it tonus a rather thick gravy at the bottom, but not brown; then add 7 pints of hot water ; simmer gently for an hour. Skim off all the fat, strain through a sieve and serve. THICK BEEF TEA. Dissolve a tea-spoonful of arrowroot in a gill of water, and pour it into the beef tea twenty minute-; before passing through tin- sieve, or add ^ oz. gelatine to the above quantity of beef tea, w ben cooking. Mutton and veal will make good tea hy proceeding the same as above. KSSKXCK OF UKKF. Take l lb. lean beef; cut fine; put it into a porter bottle with a lea- cup of water, I tea-spoonful of Bait, a little pepper, and •' grains allspice; cork loosely, and place in a sauce-pan of cold water; then with a gentle Ileal let il .-iniiner till sullicient cpian- tii\ of the essence is obtained. Serve either warm or cold. CHICKEN BROTH. Put in a stew-pan a fowl. ."! pints of water. 2 tea-spoonfuls of rice, l of salt, a little pepper, and a small onion, or 2 oz. of mixed ,i, Issued to tin- hospitals wbm *n]i|iii.-< an- difficult to ba obtained. APPKNMX. vegetables ; boil the whole gently for one hour (if an aid fowl simmer for two hours, adding one pint more water}. Skim off the fat and Berve. A light mutton broth may be made in the same way, taking 1£ lbs. mutton — meek if convenient. PLAIN r.oll.KD KICK. Put two quarts water in a stew-pan, with a iea-sp<-onfnl of salt: when boiling, add to it ^ lb. rice, well washed: boil for ten minutes: drain oil' the water, and slightly grease the pan with butter; put the rice back and let it swell slowly lor about twenty minute-, near the lire. Each grain will ihen swell up. and be well separated. Flavor with nutmeg or cinnamon, and sweeten to i - \<<> .U.i.LY. Put in a pan, with :; pints water. :; oz. >ago. H 03. sugar, half a lemon peel cut very thin, ± tea-spoonlul of around einnanion, or a small stick of the same, and a little salt ; boil about fifteen minutes, stirring constantly; then add a little port, shorn or madeira wine, as the ease will admit AKKow-KooT milk. Put in a pan 4 oz. arrow-root, '■'< BA SOgBT, the peel of half a lemon. ] tea-spoonful of salt, •_' ', pints of milk; Be! it on the lire: stir gently: boil for ten minute-, and -rrve. If no lemons af€ at hand, a little essence of any kind will do. When Bhorl o£ milk, use half waters-half an (inner of batter i- an improvement. ARBOW-ROOT WATKR. Put in a pan 3 oz. arrow-root. 2 oz. white sugar, the peel of a, lemon, { tea-spoonful of -alt. and t pints water; mix well, set on the fire, and boil for ten minute* Serve h<>t or cold. Kii i w \ 1 1 i:. Put 7 pints water to boil ; aid 2 <z. - the pe.d of two-thirds of a lemon, boil gently Tnr thrce-qu •'>''4 \1-1T.MU \. of an lionr. or ti!! vedii"cd to live pints. Strain and m --\- as a beverage. UAKI.l. Y ■ AUK. Tut iii a iQuee-pan r pints water, 2 os. pearl barley; stir bow and then when boiling; add 2 oz. white Bugar, tin- rind <>t' half a lemon thinly peeled; boil genfly for two bohrs, and serve either -trained or willi the barley K It in. ( 'IMMi: \\ I.KMONADI'. Tut in a basin '1 table-spoonfuls of white, or brown sugar, \ a table-spoonful lime juice; mix well together, anil add one pint of water. CITRIC ACID I.I Mi'N U>K. Dissolve 1 oz. citric acid in 1 pint of cold water : add 1 lb. !• oz. white soger; mix well bo lorn, a thick syrup; then put in lit pints cold water, slowly mixing well. TOAST AM) WATEK. Cut a piece of crusty bread, about | lb.: toast gently and oni- tbrmly to a lijrht yellow color: then piece near the lire, and when of a good brown chocolate put in a pitcher; pour on it .'! jj its boiling water; cover the pitcher, and, when cold, strain. it is then read} for use. Never have the toast in, as it causes fermentation in a short time. A piece of apple, slowly toasted till it gets quite black, and added to the above, makes a wry refreshing drink.