ill €t)e Librarp of the Glntoeusitp of Jftortb Carolina (EnDotoeo bp TOc Dialectic anH P&ilant&ropic feocic tire £17.3*3 a *- . /oa pratensis) grows in the greatest perfection. A strong similarity exists between the diseases of this section, including Kentucky and those of the eastern portion of the State. Ma- larial fevers are of a mild type, and are found very amenable to treatment. It is chiefly where from freshets the rivers overflow their banks, leav- ing deposits to be acted upon by the hot sun of summer, that malaria is generated. In many low portions of Tennessee and Kentucky, in the neighborhood of the low banks of the rivers, the S TENNESSEE AND KENTUCKY. sources of malaria arc found producing virulent cases of fever. The western portions of Tennessee and Ken- tucky, with the southern part of Illinois, are low river bottoms of rich soil, covered with rank vegeta- tion. This portion of Illinois, skirting the Missis- sippi river for sixty miles in length and seven in width, is known as "the great American bottom/' The immediate banks of the river, from one-half to one mile in depth, are bordered by a heavy forest, behind which margin is a rich prairie country, cov- ered with luxuriant crops of grass. This prairie is dotted with numerous lakes, and as the evap- oration of the water during the latter part of summer exposes the surface of the subjacent soil, a fruitful source of disease is engendered. The influence of this poisoned atmosphere is so sensi- bly felt on the opposite side of the river, which is here one mile wide, that at Jefferson barracks — a beautifully located station in a rolling, thoroughly drained country, gradually rising into hills at an elevation of two hundred feet, and one mile dis- tance from the river bank — nearly all the garrison are affected by malarial fevers during the fall months. The medical statistics of the United States army give, as the annual average sickness DISEASES OP THIS REGION. 9 for twenty-one years at this post, eight hundred and eighty-four cases of malarial fevers per thou- sand men. These statistics are gathered from a mean strength of nine thousand six hundred and eighty-one men. At this station, intestinal diseases are very prev- alent during warm weather. The proportion of these, exclusive of Cholera Asiatica, amounting to eight hundred and nine per thousand. Asiatic Cholera has raged at this post as an epidemic for several consecutive summers, having appeared in 1849, '50, '51, '52, '54 and, '55. Among the common diseases of this entire range of country, extending through all the mid- dle States from the seahoard to the Mississippi, can now be classed Erysipelas. For the past ten or twelve years it has been found very prevalent, especially during the winter months, when the disease appears more severe. This, with Typhoid Fever, which, as a disease of the winter season, is also common to this entire belt of country, is of comparatively recent introduction. The former inflammatory character of diseases has given place to lower types, with increased irrita- bility of the system, with its accompanying intol- erance of antiphlogistic treatment and urgent de- mands for protection and stimulation. 10 DISEASES OF THIS REGION. The diseases which an army must encounter (luring the summer months, when encamped on the soil of Maryland, Virginia, Kentucky or Missouri, will depend altogether upon its location, whether on the low or high lands. If in the low country, in the vicinity of water courses, malarial fevers may be the most numerous, their frequency de- pending upon the degree of exposure. These are found to be amenable to treatment, and qui- nine is the great specific for this common disease. The majority of uncomplicated cases will, accord- ing to the experience of local physicians, yield to a single dose of ten to fifteen grains, given ten hours before the expected paroxysm. To those who are especially exposed in scouting parties or in, the swamps, the prophylactic influence of quinine should be extensively relied upon, and cannot be too strongly urged. Five grains, taken daily, has proved sufficient protection on the river swamps of South Carolina, where malaria in its most con- centrated and virulent forms infests the atmos- phere. When we leave the coast line and reach the hill}' countiy, we come to a genial climate and salubrious country, where general health can be preserved. No malarial influences are here felt except upon the alluvial banks of the rivers, where DISEASES OF THIS REGION. 11 it is sometimes met with in a mild form during the autumn months. Here Diarrhoea and Dysen- tery will be the prevailing affections, with gastric disturbances, and perhaps cholera morbus. These intestinal diseases often rage epidemicall} 7 over ex- tensive tracts, as found in Reports to the American Medical Association. All of the Middle States are common ground for these general diseases, which commence in June and continue until October, increasing in severity with the advance of hot weather. Even among the mountain ranges, with the most salubrious climate, diarrhoea shows itself the prevailing disease. From the medical reports of Carlisle barracks and Alleghany arsenal, ex- tending over a series of years, and which have been compiled by order of surgeon-general Law- son, we find the proportion of Diarrhoea in the garrison to number, annually, five hundred and sixty-two per thousand, and Intestinal affections, exclusive of Asiatic Cholera, to be one thousand and seven cases per thousand men. Exposure to atmospheric vicissitudes, eating crude and indigestible articles of food, unripe fruits and vegetables, intemperance in eating and drinking, irregularity in eating, improper clothing, with sudden check of perspiration, are the com- mon productive causes of intestinal disturbances. 12 DISEASES OF THIS REGION. These diseases show no peculiarity; they are rarely purely inflammatory, and seldom demand the strictly antiphlogistic plan of treatment. Opi- um forms the basis of treatment for most bowel complaints, in combination with a little calomel to excite secretions from the liver, and also ipecac in small doses to restore cutaneous action, and perhaps camphor, for its general stimulating- effect. By the judicious use of these remedies, intestinal fluxes are readily controlled. When, from the enervating effects of long-con- tinued heat, with its sedative influence upon the skin, these diseases assume a chronic form, a fur- lough for two or three weeks, with change of air, when assisted with mild astringent tonics, will be found the most successful treatment. The modern treatment of Dysentery by salines and opiates has called for many advocates, who use largely salts and laudanum as a prescription for it ; the object being to relieve the engorgement of the vessels with the saline laxative, whilst the opiate allays irritability and checks tormina and tenesmus. Judging from an analysis of the reports handed in from the various Middle States to the American Medical Association, there is no very great difference in the success of these two modes of treatment. External stimulation by dry heat; DISEASES OF THIS REGION. cataplasms of mustard or cayenne pepper; frictions, in connection with internal stimulation by admin- istering the aethers, Hofmann's anodyne, spirits of camphor, essence of peppermint, ginger or tincture of capsicum, become very necessary when exhaustion of the nervous powers and .collapse, with cold extremities, make their appearance. In western Tennessee and Kentucky during the summer months malarial fevers are found, assum- ing a bilious remittent or intermittent type. They are amenable to the judicious administration of the preparations of bark, of which quinine and cinchona are the most active. * During the winter months, the high region of these Middle States becomes the most unhealthy. Catarrhal affections prevail upon the coast, now and then, taking on pneumonic symptoms; but with these, when not neglected in the commence- ment, there is no fatal tendency. In the mountain lands, Typhoid Fever may be expected, sometimes raging extensively and fatally. It is often the leading disease of the season. It generally runs a uniform course, ending when skilfully treated, in convalescence in from fourteen to twenty-one daj-s. In its treatment, the intractable and de- pressing nature of the disease must be kept con- tinually in view; the aim of the physician being 14 DISEASES OF THIS REGION. » rather to brace up the system against the exhaust- ing effects of* the disease and allow it to run its course. All depressing agents, as the mercurial preparations, etc., are thought prejudicial when given for their peculiar effect. Quinine has not proved itself so useful in controlling the febrile paroxysms, as might have been supposed, unless the fever shows a marked remission. Opium in guarded doses is found invaluable in controlling the looseness of the bowels, in quieting delirium and inducing sleep. The bowels, when a tendency to constipation exists, are Ikept soluble by the mild cathartics, as rhubarb, magnesia or castor oil, with a little turpentine ; and, as debility soon makes its appearance, brandy, commenced with early and administered with judgment, becomes an invalua- ble remedy. Fluid nourishment, given at regular intervals whether the patient wishes it or not, is now recognized as a valuable adjunct in the treat- ment. The action of all the secretory and excre- tory organs must be inquired into from day to day, and any irregularity in their functions must be corrected by the use of mild remedies. Frequent sponging the body with vinegar and water cools the skin and adds much to bodily comfort. There is another disease which occurs sporadi- DISEASES OP THIS REGION. 15 cally in the cities of this middle region, and may even show itself in scattered localities when in- duced by specific local causes. I refer to Typhus Fever, which is the pest of armies, occurring wherever animal accumulations are found and known, from its constantly accompanying armies, as the Camp Fever. As its causes are chiefly local emanations which, in spite of rigid cleanli- ness, cannot be prevented in permanent camps, the difficulties to combat this disease without re- moval into a healthy region are nearly insurmount- able. Hence the frightful mortality which renders this the plague, when it appears among large col- lections of men. In civil practice debilitating remedies cannot be borne — the stronger reasons for rejecting them m camp medical service. All prostrating treatment must be sedulously avoided. Make stimulating tonics the chief dependence, and the best results will be obtained. Quinine may be given from the very commencement of the disease with benefit. Brandy will be constantly required, and when judiciously and regularly administered, will be found a valuable agent. Giving nourish- ing fluids throughout the attacks, and restoring or correcting secretion with mild medicinal agents will be the proper course to pursue. CHAPTER II. Material of Armies Recruiting, Clothing, Food, En- campments, etc. Recruits. — In times of peace an army is formed of recruits, who are enlisted with much care. Each individual before he is received undergoes a criti- cal examination by the recruiting medical officer, who rejects all blemishes as well as those condi- tions showing a predisposition to disease; the object gained being the selection of a body of men who, from physical and vital perfection of organization, will best resist external morbid in- fluences. Besides, they are men, whose inclina- tions lead them to pursue a life to which they are in a measure fitted, by the rough, exposed lives which such applicants have previously led. Volunteers. — 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 camp life with its exposures and trials. Among those who take up arms in defence of their rights or for the pro- MATERIAL OF ARMIES. 17 tection of their homes and families, are found men from every position in life, from those enjoying the most refined and cultivated social privileges, to the street laborer, all having a common cause to sup- port; men of every variety of constitution, tem- perament and idiosyncrasy, in whom every form of disease is found lurking, ready to show itself upon the slightest provocation. Those who have led lives of ease and luxury are suddenly called up to assist in the stern and laborious duties of the soldier, to share in the common toil and to buffet with the elements. The irregular mode of living to which the majority are totally unac- customed, is more injurious than other hardships which they daily undergo, to the sanitary influ- ence of which they owe unwittingly much of the health which soldiers enjoy. Exercise in the open air counteracts many of the would-be injurious effects of exposure. It is surprising the physi- cal improvement which the gloved members of high life exhibit, after even a few weeks' cam- paign, when followed under the most disadvan- tageous circumstances of inclement weather. This was well shown among the troops protecting the batteries in the neighborhood of Charleston har- bor, prior to the taking of Fort Sumter. When the call to arms was made, the militia — composed in a 2 18 MATERIAL OF ARMIES. large measure of clerks, merchants and professional men, most of whom were much more familiar with the duties of the desk than manual labor — with one common impulse rushed to meet the enemy. Many of them of delicate frames and frail constitutions, exposed themselves upon sandy islands, directly upon the sea beach, with little or no protection. They were badily housed, irregularly fed and mis- erably watered. Their daily duties were with pick and shovel to throw up redoubts, establish batteries and mount heavy ordnance during the day ; whilst their nights, when not spent in anxiously watching an expected invasion or performing tedious guard duty during a spell of continuous stormy weather, was forgotten in sweet oblivion upon the wet sand, at times without the shelter of a tent. jSTotwith- standing, the sanitary condition of the troops was excellent; and many, of delicate frame, returned to their homes, at the expiration of two months, sturdy, robust men, with an addition in some cases of twenty-five pounds weight. All, without excep- tion, were improved by the change of life, under the exhilarating influence of sea air and active exercise. It has been often noticed that soldiers, taken from the better classes of citizens, go through cam- paigns of great exposure, with many privations, MATERIAL OF ARMIES. 19 much better than the heavily-built yeomanry ; which can be accounted for in the personal care of the one and the known carelessness of the other. All armies confirm the well-established fact, that raw recruits, in the field, always suffer more than veterans. In the Crimea, thousands of recruits filled the hospitals, en route, before arriving at the seat of war. These troops had been selected, indis- criminately, under a pressure. Many of them were young, ill-conditioned, undeveloped in body, un- confirmed in constitution, and hence without stam- ina or powers of endurance. When compelled to undergo the hardships of a siege, where the strength of full-grown men soon failed, they were very quickly used up. Unaccustomed to either the work, food or exposure, to which they were compelled to submit, they were speedily seized with disease, and when severely attacked they usu- ally died ; or if they survived, their convalescence was painfully prolonged, and the least imprudence produced a relapse. An English Crimean surgeon, in speaking of the character of the troops sent to the East, and of the hardships which they sub- mitted to, mentioned to me, that old age, decrepi- tude, with feeble, bent frames, wrinkled faces and grizzly locks, were seen in youths of two or three and twenty, the effect of two winters' toil, want and misery. 20 STATISTICS OF KILLED IN MEXICO. In examining the statistics of the Mexican war, we find this well-established rule confirmed, al- though the material of which the volunteer force was composed was much superior to the average from conscriptions or forced enlistments. The troops sent out from the States were picked men, well developed in bodily frame and constitution, yet we find a fearful disparity when we compare the mortuary reports of the three arms of the service. The three classes of troops in the war with Mex- ico were : the old or standing army, composed of men accustomed to the fatigues and routine of a soldier's life ; ten regiments of enlisted men, care- fully selected b} T recruiting surgeons ; and 73,000 volunteers, taken at random from all walks of life.* The total loss in the old army, by deaths, discharges, resignations and desertions, exclusive of discharges by expiration of service, was 7,933, in an aggregate force of 15,736; being 50.79 per cent, for the whole service of twenty-six months, or a monthly loss of 1.95 per cent. In the ten new regiments, using the same basis, the total loss was 3,839, in an .aggregate strength of 11,186 ; being 34.22 per cent, for the whole service of fif- teen months, or a monthly loss of 2.28 per cent. * Medical Statistics U. S. Army, 1839 to 1S5L STATISTICS OF KILLED IN MEXICO. 21 In the regiments and corps of volunteers, the total loss was 20,385, in an aggregate force of 73,260, being 27.82 per cent, for the average pe- riod of service of ten months, or a monthly loss of 2.78 per cent. When it is remembered that the old army stood the brunt of all the early engagements, and that many of the volunteer 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 loss of 5.03 per cent, from killed in battle or dying from wounds — a loss of 792 men, from 15,736. The ten new regiments met with a loss of 143, from 11,186, or' 1.27 per cent. Whilst the volunteer corps, numbering 73,260, lost in battle and from wounds only 613, or 0.83 per cent., whilst the actual sick list, carefully compiled, and leaving out all losses to the army except from sickness, amount to 15,617, or 26.83 per cent. These statistics, collected with great care by the late surgeon-general of the United States, 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 valuable lives of citizen soldiery, form- ing morally, socially, pecuniarily, our very best people, should be to the utmost protected, but 22 STATISTICS OF KILLED IN MEXICO. also, from the enormous expense and trouble in- curred by a nation in training and in transporting an army for distant service, it is imperative that the medical staff labor to disseminate among the troops those rules of hygiene which, when consid- ered in its widest sense, are so profitable in sus- taining an effective military strength. We have just seen that in our own wars, as in all that have ever occurred, an army is rarely deci- mated by the fire of an enemy. Those killed in battle are but a handful when compared to the vic- tims of disease. In Mexico, our army of 100,182 men, in an average campaign of seventeen months, exposed to the continued fire of an enemy who contested every inch of ground from the seaboard to their capital, making a firm stand at every stra- tegic point, from which they had to be driven under a murderous fire, lost but 1,549 men in battle and from wounds, all told; whilst 10,986 died in Mex- ico from disease, besides the hundreds, or I would be well within bounds when I say thousands, who returned home to die among their friends from the effects of diseases contracted in camp. For some time after the war, volunteers formed a noted pro- portion of the inmates of civil hospitals, and the chronic diseases under which they were laboring were with great difficulty controlled. . RECRUITING SERVICE. 23 In the Crimean service, the statistics collected by Lord Panmnre, minister of war, show the Eng- lish loss to have been 22,457, of which number 3,448 were killed in battle, or died from the effects of wounds received. "Whilst the French loss, as reported to his Government by M. Scribe, inspec- tor-general of the French medical service in the Crimea, exhibits the frightful loss by death of 63,000 ; whilst the admission into hospital num- bered 114,668. The above statistics are 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 are paramount, as the 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 hj a recruiting- officer and a military surgeon. The service de- mands that this examination be thorough, both in 24 RECRUITING SERVICE. regard to moral and physical disabilities. The regulations, therefore, enjoin, that, " in passing a recruit, the medical officer is to examine him strip- ped, to see that he has free use of all his limbs ; that his chest is ample ; that his hearing, vision, and speech is perfect ; that he has no tumors, ul- cerated or extensively cicatrized legs ; no rupture or chronic cutaneous affection ; that he has not received any contusion or wound of the head that may impair his faculties ; that he is not a drunkard, is not subject to convulsions, and has no infectious or other disorder that may unfit him for military service. The surgeon is also recmired to certify on honor, that the recruit passed by him "is free from all bodily defects and mental infirmity, which would in any way discmalify him from performing the duties of a soldier." As the recruit must be between the age of eighteen and thirty-five years, at least five feet four inches in height, and able- bodied, we can understand why an army selected by a rigid observance of the above regulations, composed of healthy, robust men, in the vigor of manhood, when brought under thorough discip- line, is in the best condition to preserve a high standard of health. To show with what stringency the laws on this subject are observed, we give the recruiting list of CLOTHING AND FOOD FOR TROOPS. 25 the United States Army for 1852. The total num- ber examined were 16,064, of these 13,338 were rejected ; 2,726 were alone received into the ser- vice. Among the causes of rejection are found the following : jSTot robust, too slender, unsound, broken-down constitutions, general unfitness, im- becilit} T , unsound mind, epilepsy, intemperance and bad habits, hernia and lax abdominal rings, varicose veins and varicocele, hemorrhoids, syphilis, gonorrhoea, loss of teeth, unequal length of limbs, general and local malformation, contracted chest, spinal curvature, old injuries, fractures, etc.; cica- trices, tumors; diseases of bones, joints, skin, heart, testis, and tunica vaginalis ; of arms, eyes, ears, glands, chest, throat and abdomen; defective hear- ing, speech and vision ; ulcers, goitre, ascetes and anasarca, obesity, etc. "When we take into consideration the little dis- parity of age with the absence of so many predis- posing causes of disease, we can readily see why the soldier, by profession, has so great an advan- tage over the volunteer force, into which any one capable of performing duty is received, however unfitted he may be physically for the toil and pri- vations of camp life. To obtain the utmost capacity of labor from 3 26 CLOTHING AND FOOD FOR TROOPS. men, they must be properly clothed and well fed. These are the pre-requisites, without which their powers of resistance to exposure and excessive exertion are not developed. A soldier is com- pelled to familiarize himself with many occurren- ces which experience in actual war shows to he common. He is often called upon for laborious work, to expose himself to wind and rain, heat and cold, to suffer hunger and fatigue, to travel at night as well as during the day, to sleep dressed and accoutred in cloak or blanket. He must be taught when thus exposed" to secure his person from disease, and to ward off injurious conse- quences. In short, he ought to be put in possession of the best remedies for every contingency which may or can happen in military service. This is particularly the case with an armed body who may be called upon at any moment to exert great efforts in making forced niarches, and, under many privations, to meet a bold and determined enemy, and to repulse a superior force. The strength of an army is calculated rather by the physique of its men than by numbers, as experience shows that men who have been well taken care of are capable of opposing successfully double the force badly provided. To preserve health and efficiency, troops must be well clothed. This is one of the THE PHYSIOLOGY OF CLOTHING. 27 weight}' questions in the economy of an army, and has been the subject of much study and experi- ment by military leaders. The object of clothing is to protect the skin from diurnal variations or annual perturbations 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. As clothing is the septum placed be- tween the body and the circumambient air, it iso- lates by retarding the transmission of caloric, and thus protects in proportion to its powers of reflec- tion and conduction. These properties are- much modified by the layer of air which is shut in next to the skin, as also by that which permeates the cloth, filling up the meshes of the fabric, this layer of air being known to be a bad conductor. We are acquainted with a familiar application of this law in the bitter coldness of a windy day, when compared with the comfort of much colder but quiet weather. 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 bad conductors, the heat which escapes from the skin traverses slowly the thickness of clothing, but 28 THE PHYSIOLOGY OF CLOTHING. 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 similarly accounted for. The radiating properties of wool exceeds its conducting or absorbing powers, and throws off the great heat of the sun before it can penetrate the thickness of clothing and reach the wearer's skin. Besides the property just enumerated, the hy- grometric powers of different fabrics, condensing moisture from the air and absorbing perspiration, are of much importance in the sanitary economy of clothing. In either case their power of con- ducting heat is increased, and therefore the more moisture they contain in their meshes the colder they are as apparel. The fluid which the cloth imbibes takes the place of air, and becomes a cause of refrigeration by evaporation, robbing the neighboring skin of its heat to form aqueous vapor. Linen, for instance, imbibes at once mois- ture from any source, and chills the body by the evaporation of this moisture ; this material for articles of clothing exposes the body to sensa- tions of cold and dampness, and necessarily to the diseases which are brought on by such exposure. THE PHYSIOLOGY OF CLOTHING. 29 Cotton fabrics, although not so attractive to mois- ture, permits absorption and evaporation to a considerable extent. Whilst woollen goods con- denses moisture as badly as it conducts heat, from it evaporation goes on very gradually, so as scarcely to chill the external surface of the clothing. The hygrometric properties of clothing are inti- mately connected with their action upon the skin, when considered as an organ of absorption and excretion. Cutaneous perspiration varies in quan- tity, according to the powers of conduction, radia- tion, and heat-absorbing properties of clothing, which cannot modify the heat exhalation, absorp- tion and sensibility of the skin without reacting upon its functions. The energy of cutaneous elimination regulates in a measure the march of other excretions. Anything which impresses the nerves of the skin excites equally the origin of these nerves, and causes exaltation or depression of the system. Clothing determines the antago- nism which exists between animal heat and ex- ternal temperature. The source of animal heat increases or diminishes its activity according to changes in the atmosphere ; but the unequal pro- duction of heat causes corresponding oscillations in the movements of respiration and circulation in the action of the muscles and the brain. Clothing OU CLOTHING OF TROOPS. affects, then, all the functions of the economy, and may clearly represent the question of health. As the object of clothing is usefulness and con- venience, the best uniform is that which will pro- tect the body from the inclemencies of the weather, and which least impedes the movements which are connected with military duties. Experience in the field teaches what can be dispensed with or what can be added with advantage. The clothing se- lected depends much upon the habits of a people and the country in which the war is carried on. We can readily understand how absurd it would be in the English Government sending their home troops in their thick red coats, leathered necks and shakoed heads to do field duty on the scorching plains of India. There are certain portions of the clothing which experience shows conducive to health in all countries and under every circum- stance. The clothing for troops should be made of wool, whether the material be heavy or light, to suit the climate. The sold/'er'.s coat should be a frock fitting loosely, easy over the shoulders, with full play for the arms, without binding in any way, and wide in the body, so as not to impede the expansion of the chest when closely buttoned. The tail of a coat gives much protection to the body and abdomen CLOTHING OF TROOPS. 31 from damp, whilst a jacket — which is a very poor costame for soldiers — exposes the entire body to drafts and dampness, fruitful causes of bowel com- plaints. The trousers should be of good, heavy woollen material, made also free, for the easy play of the limbs. Flannel shirts, coming well down upon the thighs, and drawers of the same material, are of great hygienic utility. In winter they retain the animal heat and support the health} 7 function of the skin, whilst in summer they absorb more readily the excess of perspiration, which occurs under severe exercise ; and whilst agreeable to the wearer, they prevent sudden arrests of perspira- tion, and are thus a protection against diarrhoea and dysentery, which are so fatal to armies. These should be furnished in sufficient numbers to enable the soldier to change when he has been exposed to rain, as he may thus prevent pneu- monias and bronchial affections, so common to camp life. In the French service, where flannel under- clothing is not in that constant use as in the English and American service, every soldier carries a band of flannel, with which he envelops his abdomen, as a safeguard from abdominal affec- tions. Baudens, one of the surgeons-in-chief of the Crimean service, speaks of this band as 32 CLOTHING OF TKOOPS. essential to the health of the troops, and refers to the much better and more convenient pro- tection which the English flannel shirt gives to the men. The liability of losing the flan- nel girdle, and its very partial protection, is a serious objection to its use. For similar rea- sons woollen socks should always be given to sol- diers. They are much more durable than cotton, and much more healthy, preserving an equal tem- perature and retaining warmth to the feet which, being at the greatest distance from the centre of the circulation, are least capable of resisting cold, and, therefore, require most protection against in- jury. They also afford a better protection against the chance of blistering than socks of other mate- rial. The feet are part of the person of a soldier so essential for the performance of military duty, that their condition should be particularly attend- ed to by the oflicers. The shoes, boots or half-boots should be well made, of good, durable material, and well fitted to the foot, so as to be easy to the wearer. The soles should be broad, thick and firm, high quartered so as to exclude mud or sand? and closely fitting around the instep, so that tena- cious clay cannot easily drag it from the foot. A o-ood shoe or boot adds often as much to the effi- CLOTHING OF TROOPS. 33 ciency of the soldier as a good weapon. Marching is as necessary a quality as fighting, and is made one of the requisites in becoming a member of the Imperial Guard of the present French Emperor. When the shoe does not fit the wearer who is compelled to use them, sore feet, a very trouble- some complaint in the army, is brought on. In the march men are found lagging behind from lameness, and, as these are exposed to be cut off by marauders, it is the duty of those in authority never to deliver a pair of shoes which have not been tried with care. The leather should be well smeared with grease, oil, wax, tallow or other com- position to make them water-proof and soft. This should be done daily in wet weather. In the Crimean service the Russian half-boot was found so superior an article over the boots or shoes of the Allies, that they were sought for Avith avidity upon the dead as soon as they were shot down, and were more prized than any other article of wearing apparel, so conducive were they to the comfort of the wearer. They protected the feet perfectly from the mud in which the troops lived for months. The French gaiter used in the Crimea, was made of heavy white cloth, covering two-thirds of the foot and extending some distance up the d4 CLOTHING OF TROOPS. leg, usually over the knee. It facilitates walking, and prevents enlargement of the veins, whilst it protects the limb from cold and wet. Experience in the field and upon the march has proved them so serviceable that the entire French army is pro- vided with them. They, as a substitute for the boot, might be added with advantage to the equip- ment of the soldier. "When made of leather they become hard after getting wet and, by pressure, excoriate the ankles. Beside which, the leather is cold in winter and very hot in summer. The only advantage in the leather gaiter is durability; the cloth wears out much sooner, and also becomes saturated with moisture in very 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 bottom of the pants. This gives them great facilities in walking, as it protects the leg of the pantaloon from becoming foul with mud, which 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 cov- ering the shoulders. This, like all other articles of clothing, should be made eas}?-, to permit of any movements without binding. The French have added a hood, to protect the head and CLOTHING OP TROOPS. 35 neck in bad weather from cold, wind and rain, which diminishes the frequency of catarrhal affec- tions. When on guard' duty in bad weather they arc of great utility, and protect the head and neck from the damp ground when sleeping. Crimean soldiers found this addition a great improvement. In selecting a color for a uniform, it should be remembered that light colors absorb less than dark, and also that odoriferous exhalations adhere with much greater pertinacity to dark than to light clothing, which is an item of no small im- portance when the deleterious emanations- ac- companying large bodies of men are considered. Beside which, experience in battle shows that certain colors make much better marks to fire 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 is the pro- portion: red, twelve; rifle green, seven; brown, six ; Austrian bluish gray, five. Eed, which is the most attractive and fatal color, is more than twice as much so as gray, which is the least. The best military hat in use is a light, soft 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, protects, in a measure, from the rain or from the rays of the 36 CLOTHING OF TROOPS. sun. In a warm climate, the light color of the hat adds much to the comfort of the wearer. The small, jauntily-fitting kelpe is light, but does not protect the face; and, when made of dark mate- rials, concentrates the solar rays upon the head. This can be obviated by adding a Havelock, which consists of a cap cover with a long cape attached, and, hanging down upon the shoulders, protects the neck from the sun in the day and draughts at night. It is made of light cloth, of a light color, for reflecting heat. Those who have worn them on a march, or when exposed to the sun's rays, speak in extravagant terms of the comfort and protection which they give. The advantage of a light and high-crowned hat is, that when exposed to the sun, on a march, a small, wet handkerchief placed in the crown will not only prevent 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 uniform clothing stated in the following table, or articles thereof of equal value : CLOTHING OF TROOPS. 37 CLOTHING. Cap, complete, cover. . . . Coat Trousers Flannel shirt Flannel drawers Bootees,* pairs Stockings Leather stock Great coat Stable frock (for mounted men) Fatigue overall (for engineers and ordnance) Blanket FOR THREE TEARS. Total for three years. In the field, there should be always a supply of clothing at hand, to replace unavoidable accidents. During the Crimean service, Dr. McLeod informs us that the deficiency of clothing, which was so much complained of, was one of the most prolific sources of subsequent disease among the English troops. One of the maxims for preserving health in a campaign is, that soldiers must protect themselves in summer from night air by warm clothing. A heavy blanket, not in name, but in weight, and one and a half yards of india-rubber cloth, complete the furnishing 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. * Mounted men may receive one pair of "boots" and two pair of 'bootees," instead of four pair of bootees. db CLOTHING OF TROOPS. . We make the following extract, on the extent of a soldier's equipment, from Jackson's Formation, Discipline and Economy of Armies. In the form and fashion of a soldier's equipment, "the adjust- ment of the kind and quantity of articles termed necessaries is a matter of importance, and as such requires to be well considered. It is demonstrably proved to the conviction of all persons who have served with armies, that superfluous baggage, that is, baggage beyond the narrowest measure of util- ity, instead of bringing comfort to the possessor, is a cause of great annoyance and vexation. 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 sol- dier requires for his comfort and the preservation of his health; and, as such, it is all that he ought to be 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. Where there is a super- fluity, the necessity does not present itself so forci- bly, 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 fit for use until they are washed. It thus often happens that a soldier who has four or EQUIPMENT OF A SOLDIER FOR SERVICE. 39 more shirts in his possession, has not one fit 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 he a full equip- ment for a soldier on service, namely : two shirts, flannel preferable ; two pair of woollen socks; two pair of flannel drawers ; two pair of shoes, or one pair of shoes and one of half boots ; one pair of gaiters ; a small case of needles, thread and but- tons for mending clothes ; small shoe brush, with blacking ; comb and hair brush ; one piece of soap ; a sponge for washing the body, and a towel tor drying it ; two pocket handkerchiefs ; an over- coat of heavy materia], besides his uniform. He should also have a heavy blanket, better if lined with stout osnaburgs to increase its durability and warmth, and two yards of india-rubber cloth to protect him from the weather. He should also carry a knife, fork and spoon, a canteen for drink, and also a canteen or haversack for carrying dressed provisions. If those articles of clothing not in use be put up in a neat and compact man- ner and 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 ; and pos- 40 PERSONAL CLEANLINESS. sessing within himself everything actually neces- sary for use, will be independent of the accidents so common to the baggage wagons. In 'the above list we have purposely omitted shaving apparatus, as every soldier in the field should allow his beard to grow. It protects his throat, and often prevents lung diseases, catarrhal 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 purifies the atmosphere inhaled, of dust dur- ing marches, and thereby prevents many trouble- some diseases. Cleanliness dictates that the hair be cut close on the head, and although the beard be allowed to grow, it should also be kept within bounds. Cleanliness. — Nothing contributes more to pre- serve health than personal cleanliness ; and as the free use of soap is a prophylactic as well as a civilizer, it should be regularly distributed to the men. Daily ablutions should never be omitted ; and, if possible, the chest and arms, as well as the face and neck, should be well sponged. Baths should be 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 FOOD. 41 and mortality of the English and French camp in the Crimea, can be in a measure attributed 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 under- stand how carelessness in this respect will impair the functions of the skin and induce disease. At review, our French soldiers show new clothes, and on the whole an unquestionable military equip- ment, yet these beautiful battalions leave in their passage a strong smell of barracks not to be mis- taken." It should be the duty of the medical officer to suggest to the commanding officer to insist that these hygienic regulations be rigidly enforced. He is not only the best, but also the most popular officer, who attends himself to the detailed com- forts of his men. Food of the soldier should be plain, nutritious fare, well cooked, which, with exercise as an appe- tizer, he finds no difficulty in enjoying, however monotonous his daily ration may be. For a work- ing man (and where do men labor more than the soldier in the field?) the diet should be of a mixed character, and food should be of the variety easily cooked. The fundamental rule in the culinary art is boil slowly, and roast quickly. Highly seasoned 4 42 FOOD. dishes are neither possible nor desirable for the soldier. Toil, fatigue, and often hunger, will make any wholesome food savory. "The plain repast is sufficient for sustenance ; and a plain repast gives all the gratification to the palate of a hungry and thirsty man that a soldier ought to permit himself to receive."* For the English there is no beverage as tea; 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 endurance than a breakfast of beefsteak and porter. The French prefer coffee, to which they give the highest prophylactic virtue. This is the stimula- ting drink of the troops, and its free use makes the men much more healthy and cheerful. It is at all times an excellent substitute for alcoholic beverages, which disorganize an army by tempt- ing to drunkenness. Whiskey should only be given out to men on very exposed duty, or in very bad weather, and it is a question whether a cup of hot coffee is not preferable even under these circumstances. The Turks place great reliance on coflee as a preservative against dys- entery ; and McLeod states as a result of his Crimean experience : " I have no doubt that if the * Jackson, Economy of Armies. FOOD. 43 precaution had been taken to supply the troops every morning with hot coffee, as they went on or returned from duty, much of our mortality might have been avoided." As 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, par- ticularly when they are upon extra fatigue duty, as it not only saves them much time, but insures the proper preparation of a supporting beverage. It may be needless to say that good water is even more necessary than good food, and should be obtained at any cost for the use of the troops. There is no one item so prolific in disease as drinking bad water. Should troops be so unfor- tunate as to be in a place where stagnant or ditch- water has to be used, it can be purified by boiling with a lump of charcoal ; after which it should be freely agitated in the air to restore to it the vivify- ing properties which the heat had driven off. Fresh meat and vegetables should be served out to troops whenever they can be had, and the best mode of cooking them is in soup. A French mili- tary proverb says that " soup makes the soldier." The free use of fresh vegetables is the only mode of preventing the appearance of scurvy among the troops. When these cannot be obtained, the 44 FOOD. free use of dried vegetables, as rice, potatoes, corn- meal, etc., will tend to sustain health and vigor. In the Crimea, where the temporary absence of fresh vegetables was a great and serious privation, lime juice, citric acid and sour-crout, were exten- sively used to prevent and to stop scurvy. Acid fruits are anti-scorbutic, and very good for soldiers. The English, in the Crimea, gave out a ration of lemon juice three times a week, which, when mixed with rum and sugar, made a very nice and healthy drink. This corrective protected, comparatively, the English soldiers from scurvy, 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-scorbutic properties to lemon juice. A distinguished military surgeon has re- marked that 100,000 francs spent in fresh vegeta- bles, will save 500,000 francs from the expenses of sick soldiers entering the hospital, besides the use of the men for active service. Of the dried vege- tables, rice is the best for feeding troops. It is easily carried, easily cooked, easily digested, and is the most wholesome of the farinaceous articles, RATIONS. " 45 correcting intestinal fluxes. Biscuits, or hard bread, is a common article of diet in camp life, be- cause it is easily preserved and transported. When eaten as dry biscuit, it acts like a sponge in the mouth, exhausting salivary secretion, and, tiring the jaws, it produces surfeit. "When possible, and rarely is it not convenient, soak it in tea, coffee or sonp ; it then makes a very nutritious meal. Even water, with a little salt, makes it much more palatable and nourishing. Fresh bread is alwa} T s preferable when it can be obtained. Bacon is, par excellence, the laborers' and sol- diers' meat in America, and goes further, by weight, than any other. It never produces sur- feit, is always acceptable, very easily cooked, and with its rich juice will make the dryest farina- ceous diet savory. It has the very great advan- tage of keeping for any length of time, under any condition, which makes it far preferable to any other meat for troops. In the Confederate service the ration consists of three-quarters of a pound of pork or bacon, or one and one-quarter pounds of fresh or salt 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 rations, of eight quarts of peas or beans, or in lieu thereof, 46 THE MESS. ten pounds of rice, six pounds of coifee, twelve pounds sugar ; also, four quarts of vinegar. The ration is completed by adding one and one-half pounds of tallow, one and one-quarter pounds ada- mantine, or one pound sperm candles, four pounds soap, and two quarts salt to one hundred rations. On a campaign, or on marches, or on board trans- ports, the ration of hard bread is one pound. When the officers of the medical department find anti-scorbutics necessary for the health of the troops, the commanding officer may order issues of fresh vegetables, pickled onions, sour-crout or molasses, with an extra quantity of rice and vine- gar ; potatoes are usually issued at the rate of one pound per ration, and onions at the rate of three bushels in lieu of one of beans. Occasional'ssues (extra) of molasses are made — two quarts to one hundred rations; and of dried apples, of from one to one and a half bushels to one hundred rations. As soldiers are expected to cook their own pro- visions, and as all are familiar with the fact that as much depends upon the mode of cooking as upon the articles cooked, it would be better to have special cooks in each mess than to allow the soldiers to cook in turn. A division of labor is clearly the preferable plan. Firewood, of course, must be liberally provided, as it is one-half of a soldier's existence. THE MESS. 47 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 department. In 1847 the dearness of provisions doubled the number of sick in the French arary, sending one- fifth of the effective regiments into the hospitals. The better paid, select corps, who could increase their supply of nourishment, escaped those dis- eases which ravaged the common soldier. Officers and soldiers usually club together into messes, as this living together is not only much more" agreeable, but also profitable for all con- cerned. The following appears to have been compiled by an experienced soldier : " Officers' messes should consist of the company officers — four persons. The colonel, lieutenant- colonel, major, adjutant and sergeant-major, with the commissary, quartermaster, surgeon, assistant surgeon and chaplain, could easily arrange two messes. " Messes of privates and non-commissioned offi- cers should number six persons, for obvious rea- sons, so that the details for guard duty would always leave four in charge of the tent. 48 the mess; "Articles wanted for a mess of six: Two cham- pagne baskets, covered with coarse canvas, with two leather straps with buckles, six tin plates, six tin cups, six knives and forks, six bags for sugar, coffee, salt, etc., to hold from half a gallon to one gallon, one large size camp kettle, one iron pot, one bake oven, one frying pan, one water bucket, one lantern, one coffee mill, six spoons, one tin salt box, one tin pepper box, two butcher knives, tAVO kitchen spoons, two tin dippers, one tea pot, one coffee kettle." It is always a good rule to accustom an army to adopt the modes of living common to the inhabi- tants 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 prevent, the mode of living of a soldier, to a certain extent, should follow a fixed standard. His meals should be equally distributed through the day, and he should never be put to work without having broken his fast, however light the meal be. If this be neglected faintness sometimes ensues, and exertion fails from mere craving of the stomach. In camp soldiers should live with regularity, and the breakfast and dinner hour should be respected. SUGGESTIONS. 49 It is on the march that circumstances prevent the carrying out of rules. The following is the order which experience has proved to be most useful in the French service. A soldier should never commence a march without having partaken of a repast. A cup of hot coffee with bread soaked in it will sustain a march of some duration. A little, meat would be an im- provement, which is always saved by the pru- dent soldier from the previous day's meal. For night marching, an alcoholic drink after the meal will enable him to undergo much more fatigue. Preparatory to marching, the soldier tills his can- teen with good water, or what is much more re- freshing, weak coffee or 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 for twenty minutes. In resuming the march, a halt is made for a few minutes in each hour. In crossing a ford, the men take off their pantaloons, keeping on their shoes. A sentinel guards any fresh-water spring which is met in the march, to prevent soldiers from gorging them- selves — a very wise measure, which prevents much sickness. Water should be always taken in reserve and with precaution. When taken in great quanti- 5 50 SUGGESTIONS TO RELIEVE THE ties it weakens and fatigues the organs of di- gestion, increases perspiration and enervates the entire system. It is particularly injurious to drink rapidly and freely when heated from exercise, as sudden death is not very rare from this imprudence. The soldier should accustom himself, when thirsty, to drink slowly and in small mouthfuls, keeping the water in the mouth and throat as long as possible. The cravings of thirst are often produced by a parched condition of the lining membrane of the mouth; and by rinsing the mouth frequently, thirst can be allayed to such a degree that but little water will be re- quired, 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 in 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 cannot be relieved by drinking. 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 as to make the smallest possible quantitj^ of water supply his necessities. Washing the face ANNOYANCES OF THE MARCH. 51 slackens thirst. As good water is not always to be obtained on a march, a soldier should never lose an opportunity to fill his canteen with fresh water. If the canteens be covered with a light colored woollen cover, the water will keep cooler than in bright tin, which absorbs heat more rap- idly, and extends it to the contents of the canteen. When troops have had an early start, they should bivouac about ten o'clock in the morning, and lie over for the heat of the day, as soldiers on march should, if possible, be protected from the midday sun. Here they will have time to cook their mid- day meal, wash their clothes and refresh them- selves from their fatigue. This meal consists of coffee and bread, with meat cooked and saved from the preceding day's repast, The want of this precaution, which old soldiers adopt, is se- verely felt by recruits. The experienced soldier never forgets to keep in reserve a certain propor- tion of meat or other food, against a deficient dis- tribution or the want of time for properly prepar- ing it, The meal should be taken in the shade, under some protection from the sun. A few branches, properly arranged, will form a comfort- able shelter. The main meal of meat, vegetables, etc., should be taken after the evening halt, at the end of the dav's march. The officer in charsre of 0"J CAMP. the troops 'should always know the road over which he is to travel the next day, and when he is compelled to bivouac in places where the prospect for getting wood is bad, each soldier should carry on his knapsack a small quantity to cook his mid- day meal with. In the evening halt, the site selected for the camp, when possible, should be on rising ground, free from low places, and in proximity with water and wood. These rules become of special impor- tance in establishing a camp for even a few days stay. It is prudent to avoid the immediate vicinity of swamps and rivers ; the emanations from such are noxious, often pestilential, but fortunately do not extend to a great distance. Interposing a piece of rising ground or woods is, as a general rule, sufficient to turn or break currents from these low places, and protect from their hurtful influence. It would be preferable to camp in the direction of the regular wind currents, so that emanations may be wafted in the contrary direc- tion. When the halt is only for the night, and the camp wagons with the tents have not come up, the men bivouac under the clear sky, or seek shelter under a few branches, with which they form a rough shed that will protect them from CAMP. 53 dew. If possible, dry grass or leaves form their bed, and, lying in their great coats and upon their india-rubber cloth, they can enjoy peaceful slum- ber. If there is no cover for the men, then they build fires, and sleep around these as so many radii of a circle, the feet of the sleepers being nearest to the fire. Singular to say, this kind of rough life does not bring with it disease, as one would suppose. If the men are warmly clad, they enjoy more health when bivouacked than when in camp. The site of a permanent camp should be dry, with good drainage, the dryness of the soil being tested by digging, to see that a stratum of water does not immediately underlie the crust. In cold, damp countries, the material for tents should be close, and, as nearly as possible, water-proof; and when pitched, a good ditch should be dug around it, with the earth banked up against the tent to keep out the cold and rain, and also to prevent draughts. Communicating ditches should be pro- vided to facilitate drainage. The circular tent offers the best protection against the wind, is least liable to be blown down, and is most useful for winter. The light shelter tent of the French troops, as introduced by Marshal Bugeaud, will be found most convenient for the summer months 54 CAMP. for an army in the field. The tent is made of the knapsack of the soldier, which, instead of being sewed up, has 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 centre 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 angle. In hot and dry weather, instead of pinning the two ends to the ground, one of them can be hung hori- zontally to branches of trees, leaving one side open for thorough ventilation, whilst the hori- zontal portion protects the sleeper from undue exposure. The size of this tent can be increased to any extent by joining stock, as all such sacks are of the same size, with buttons and button holes arranged equidistant, By employing this excellent suggestion, you avoid loading the shoul- ders of the soldier, or transporting tents for the army, which is often impracticable. In a few minutes after a halt tents are pitched, and the camp has assumed its regular appearance, with- BED OF SOLDIER. 55 out waiting for the baggage train. These tents, so convenient and always at hand, were of great service in the Crimea, but particularly in Italy in 1859, where they were the sole protection for the 'troops. The soldier's bed should never be directly upon the ground ; but if beds cannot be obtained, branches or dried leaves or straw should be used, upon which the blankets are spread. This an- swers the double purpose of keeping the body from the damp ground and also elevating it into a layer of purer air. When the tent is filled, as is usually the case, the exhaled air. loaded with car- bonic acid and other impurities, settles to the ground, which persons sleeping upon the soil would be continually inhaling, to their injury. The soldier's bed should be always dry. All moist, decomposing materials, as green grass or leaves, are more injurious than sleeping upon the soil, owing to the gases escaping from their de- composition. True economy would dictate a painted cloth for the floor of the tent, which is useful in preventing the exhalation of moisture from the earth's surface, is convenient, always ready and less expensive than straw. It can be cleaned every day with little trouble, without cost, and requires to be freshly painted only once a 58 BED OF SOLDIER. with three or four inches of earth or a sufficient layer to prevent any smell arising from the day's deposit; and when the trench is two-thirds full it should be closed and another of similar dimensions opened. Where proximity to the water permits, these privies should be established over the water. This will remove a great 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 buried, other- wise the stench from them would be very injurious to the health of the troops. But as, notwithstand- ing the utmost care, in the most salubrious situa- tions, diseases will in time show themselves — from the inevitable accumulation of poisonous materials, resulting from the growing infection of the soil, with its poisonous emanations, from the prolonged sojourn of a large number of men and animals — the camp, unless occupying a position of marked military importance, should be changed for a new situation at some convenient distance. For a per- manent camp, board huts are much more com- fortable and healthy for troops, whilst for transient halts a shelter composed of branches is much more desirable than tents. Troops bivouacked are always more healthy than those regularly under shelter. It is well known that irregular troops, AMUSEMENTS. 59 which act iii the advance line of armies, and which have no other shelter from weather than a tree, rarely experience sickness, never at least the sick- ness which proceeds from contagion, an evil con- tingent to camps. One great advantage of using huts is, that they are left behind with the infec- tious air which might have been generated within them, whilst the same contagion is often trans- ported with the tents. To enliven and relieve the toil and tedium of camp life, amusements are a very neces- sary portion of the day's duties ; and it is found that lively music from the military bands every afternoon will elate the men and remove monoto- ny. In the summer of 1859, during the Italian campaign, I was at Milan when a large body of French troops, returning from the blood} 7 field of Solferino, arrived. In a few minutes their shelter tents were pitched under the shade of the trees on the broad Boulevard which sur- rounds the city, and the soldiers were allowed to follow the bent of their own inclination. Card- playing, dominoes, fortune-telling, wrestling, and dancing to the discordant tunes of a hand organ, or the sharp notes of an accordeon, appeared to be the order of the day. Pets in various forms were commonly found HO AMUSEMENTS, among the troops, and these were guarded with scrupulous care. Many appeared to be adopted by the regiment as comrades, who have been associated together through many a hard-fought field and toilsome march. In the military hospitals of Milan — which were filled with the wounded, from its very near proximity to the battle field and railroad facilities for transporta- tion — it was not unusual to see a soldier nearly exhausted from the tedious dressing of a frightful wound, when he had passed from the hands of the surgeon, take from his bosom a little sparrow, 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 pets accompanying these brave heroes. Here would be seen a goat, evidently proud of its position, marching with military step at the head of a column of ferocious Zouaves ; going through the halt and advance by word of com- mand, looking neither to the right or left, as if ! v success of the day depended upon its mili- tary deportment. Here, a regimental dog would show the pleasure with which he participated in this great occasion, whilst the caresses of the AMUSEMENTS. 61 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 lone'ins: of all men for objects of affection, and also how many a tedious 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 blood from becoming degraded and brutal. CHAPTER III. Hospitals, Regimental and General — Hospital Tents, with Equipment — Number of Attendants allowed — Care necessary in preventing Infection — Value of Fumigation — Female Attendants — Hospital Diet. The accommodations for the sick form a very important department in the economy of an army, and, as a rule, are never sufficiently am- ple. With every body of troops, in the field, there are two kinds of hospitals — the regimental and the general. With regular armies, there should always be a third — the convalescent hos- pital — situated in some salubrious, rural location, where convalescents, by inhaling pure air, and enjoying the pleasures of country life, can rapidly rebuild their shattered constitutions. The regi- mental hospital is usually under tents, when in the field, if a suitable building in the imme- diate vicinity of the encampment cannot be ob- tained. The tents used as hospitals in the Confederate service are fourteen feet in length, fifteen feet HOSPITAL TENTS. 63 wide, and eleven feet high in the centre, with a wall four-and-a-half feet, and a "fly'' of appro- priate size. The ridge pole is made in two sec- tions, measuring fourteen feet when joined. On one end of the tent is a lapel, so as to admit of two or more tents heing 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 for the sick, their attendants and hospital supplies — being accommodation for ten per cent, of the command: COMMANDS. HOSPITAL TENTS. SIBLEY TENTS. COMMON TEXTS. For three companies. . . For five companies. . . . For seven companies... 1 2 2 3 1 1 1 1 1 1 1 1 1 1 Only those cases which promise to be transient indispositions or acute diseases are retained for treatment in the regimental hospitals. They are temporary structures, to be moved with the army and to be broken up at an hour's notice. They should never, therefore, be encumbered with chronic cases, nor should they ever be permitted to be crowded. As soon as a case threatens to remain longer than eight or ten days in hospital, it 04 HOSPITAL TENTS. should be transferred to the general hospital for treatment. To ensure a comfortable abode for the sick, the site of the regimental hospital should be selected with much care — the driest spot in the camp should be chosen, and the tent well ditched" to give thorough drainage. The floor of the tent should be carpeted with oiled 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 so deleterious to those lying upon the ground. This painted cloth strictly belongs to the hospital 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 comfortable bed than straw thrown in heaps, which is the com- mon mode of treating the sick in the field. There is much comfort in appearances, and these beds add much to the neatness as well as cleanliness of the tent. The beds are arranged pn either side of the tent, with the heads turned toward the wall. Could the beds be elevated upon boards for six or twelve inches, they would place the sick in a purer atmosphere than when lying on the floor, where HOSPITAL TENTS. 65 the heavy deleterious gases of expiration collect. In good weather ventilation of these tents should always be insisted upon. When the painted floor- cloth is not at hand the earthen floor should be well rammed, and should be daily watered with a milky lime water, as a purifier. The straw should be changed as often as pos- sible, even twice a week, if it can be procured ; whilst, if the patient can get up, the bed should be well beaten and thoroughly aired daily. Per- sonal cleanliness of the patient is as important as that of the tent. Ablutions must be freely used, and under-clothing frequently changed. Whenever the patients permit, the tent should be moved once a week, if it be only a few yards from its former position, so as to enclose a fresh piece of soil not contaminated with animal exhalations. This change of location is particularly required whenever any of the low grades of contagious diseases appear within its walls, or cases under treatment take on an asthenic character. The hospital is allowed a certain number of attendants to attend to the commissary and medical duties of the establishment. Each com- pany has one steward, one nurse, and one cook; for each additional company one nurse is added; and, for commands of over five corii- G 66 HOSPITAL TENTS. panies, one additional cook, The surgeon is general superintendent of the hospital. Under his direction the steward takes care of the hospital stores and supplies, and sees that the nurses and cooks perform properly their respective duties. Often, he acts as medical dispenser and apothe- cary to the regimental hospital. If intelligent, he can readily be instructed in the preparation of prescriptions for the sick, and relieve the sur- geon 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 egress is permitted except upon orders from the surgeon. It is only in this way that patients can be pre- vented from committing imprudences which may cost them their lives. This guard should be con- stantly furnished to the hospital, and the surgeon is to signify to the commanding officer of the regiment the particular orders which he wisbes to be given to the non-commissioned officer com- manding 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 establishment and number of patients, we find the convalescence THE GENERAL HOSPITAL. 07 of the sick prolonged, the number of deaths increased, and the development of the germs of contagious diseases. In concentrating a number of sick under one roof, the laws of hygiene will be violated — it cannot be avoided. Yet, from the very transient nature of regimental hospitals, more permanent institutions for the sick must be established. The general Jiospital, 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 buildings are taken possession of near the lines and converted into a hospital. The organization of this, with its surgical staff, its steward, ward-master and nurses, is. upon a much grander scale. Ordinarily, the following hospital attendants are allowed : A steward, a ward-mas- ter, an orderly (taken from the ranks) to act as nurse for every ten sick, a matron 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 space occupied by the ten beds. His duty includes bringing to the ward and distributing to the patients the daily rations, and also the medi- 68 THE GENERAL HOSPITAL. cines prescribed at the visit. The cooks and nurses are taken from the ranks, and are returned when no longer required in the hospital. In a general hospital there is always a dispensing officer or apothecary, who prepares the prescriptions of the surgeon and delivers the same to the nurses upon application at the dispensary. In regimental hospitals the surgeon, or his assistant, when pres- ent, performs this duty, if an intelligent steward has not been instructed by the surgeon in pre- paring medical prescriptions. In a large general hospital the steward represents the commissary department." Whoever attends to the pharma- ceutical department should be careful to keep all poisonous drugs under key, so that no acci- dent might occur to the inmates of the hospital, whether by design or through mistake. In this general hospital we have regular wards, which are always objectionable from the number of sick crowded into these compartments. Every bed for a patient should have a certain number of cubic feet, or, as height does not compensate for area, as all the dangerous gases stagnate in the lower strata, it would be better to allow each pa- tient 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 PURIFICATION OF HOSPITALS. 69 square feet, will not be too much space, if it be desirable to prevent pysemia, hospital gangrene, erysipelas and other fatal complications from show- ing 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 pre- cautions of cleanliness cannot be too rigidly enforced. Such a general hospital should, among other things, be liberally furnished with hospital cloth- ing. In European general military hospitals the patient leaves everything behind him when he enters its wards. He receives a bath and is dressed up in the hospital clothes ; his own are washed and stowed away, properly labelled by the ward-master. Should he be suffering under any contagious disease, as the itch, typhus fever, etc., his clothing, after being well beaten and washed in boiling water, are fumigated for twenty-four hours in a closed chamber or tent with chlorine gas. With itch patients, sulphur fumigations are substituted for chlorine. When any low form of disease makes its ap- pearance in a ward, it would be better could it be temporarily abandoned. Then, let it undergo a thorough cleansing and whitewashing, with 70 PURIFICATION OF HOSPITALS, fumigations of chlorine. Heating the air con- tained within the closed room by means of stoves, so as to attain a high temperature, may destroy the fomites causing the disease and ren- der the ward again habitable. This course should also be adopted whenever a ward has been occu- pied by the seriousby injured, with extensively suppurating wounds. Should any one enter, at midnight, a ward thus inhabited, the insufferable smell, and the apparent weight of the atmosphere, would at once explain the danger of infective diseases and the necessity for not only constant cleanliness and continued ventilation, but also for purifying the same at intervals. Such rooms, it is said, should be thrown out of use for two weeks after every two months occupation. This is laid down as an important hospital regu- lation by Stromyer, in his Maxims of Military Surgery, based upon experience and observa- tion during the Schleswig-Holstein war. Chem- ical disinfectants were not found useful by him when the rooms were occupied ; the rooms must be empty. For occupied rooms, draughts of fresh air ore the only good disinfectants. The slight exposure to catarrhal affections is nothing, when compared to the danger of introducing infectious diseases, by permitting a foul and unrenewed at- PURIFICATION OF HOSPITALS. 71 mosphere to be inhaled by the wounded. It is owing to the advantages of ventilation, that tents are so much better for typhus and severely wound- ed patients than wards. Pure air, continually renewed, is essential for the cure of typhus. Abundance of fresh air covers a multitude of inconveniences. In the Crimean service, the French attached great importance to the fumi- gation of their wards. The surgeons of their immense military hospitals thought that they derived decided benefit from adopting the Turk- ish custom of fumigating with dried sage, which was burnt in the wards three times a day, be- side the use of chlorine fumigations morning and evening. Baudens states that, bj using chlorine fumiga- tions at 6, a. M., and at 7, p. m., the dried sage at 7J, a. m., 1, p. m. and 8|, p. m., he succeeded in preventing as well as stopping infectious disorders. A saucer of chloride of lime was also placed under the bed of each typhus patient. It is a question whether these fumigations act from the medi- cinal virtues which they possess, or upon hygienic principles. The European nations have such a dread of draughts, that a door or window is never left open. We would judge that they were intended to give light, and not air. The only <-S PURIFICATION OF HOSPITALS. way in which such herb fumigations can be of use is to make the atmosphere so disagreeable that all the windows must be thrown open to get rid of it. As it escapes from these openings, fresh air equally rushes in to purify the room. This difficulty of ventilation through the win- dows, which are the proper media for it, is the common subject of complaint among the medical staff of hospitals. Stromyer had to enter into a regular compact with his German patients. He would only allow them to smoke provided they would keep the windows open, using this subter- fuge to ventilate the wards. A celebrated English medical lecturer placed the value of fumigations in their true light when he said, "fumigations are of essential importance ; they make such an abomina- ble smell that they compel you to open the windows. " When these means are used, without affording the impure air means of escape the} 7 only act as masks, disguising, by their stronger odors, the offensive and injurious exhalations from the sick. It quiets the anxieties of the nurse without in any way benefiting the patient. It must never be for- gotten that many symptoms which are said to be- long to a disease, depend upon the circumstances under which it is treated,, and many of these can with truth be accredited to bad ventilation ; hence PURIFICATION OF HOSPITALS. 78 the different phases which diseases assume when treated in hospitals or in private practice. If such 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 been lying, with its closed windows and musty smell, to a light, cheerful, well-venti- lated chamber. This is always attributed to change of scene, 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 each. Over-crowding is certain to produce such a condition of the atmosphere as to heighten the mortality. It also becomes imperative upon those taking care of such infectious diseases to breathe the air as little as they can: live out of the room or tent as much as possible, compatible with the proper attendance upon the sick, and take exercise freely in the open air. The medical attendants upon typhus hospitals, or in such as are infested with pyaemia, gangrene, etc., should frequently change places with those in charge 74 PURIFICATION OF HOSPITALS. of more healthy institutions; otherwise the per- manent medical attendant, inhaling daily this poisoned atmosphere, will be sacrificed to an absence of a regular interchange of stations and duties. In the best regulated hospitals each typhus case 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 such is also changed daily. As typhus is known by its infecting nature and its easy trans- mission, the hospital wards cannot be protected by too many hygienic regulations. When a hos- pital has become infected with typhus, pypemia or hospital gangrene, it is best to close it and turn out all patients. It would be much safer for the sick and wounded to stay in the streets or lie in the fields, than be sent to such an infected estab- lishment. His permit for admission is his death- warrant; whilst combating the elements would give him at least a chance of coming off conqueror. Any temporary, well-ventilated structure — a hut rudely made of rough boards — would be much healthier than gorgeous palaces with gilded cham- bers, in which death sits in state to receive its victims. In general hospitals, the blessings of a wo- PURIFICATION OF HOSPITALS. I'O man's care, her ever-watchful 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 benefits which she was bestowing upon future genera- tions. It is woman's peculiar prerogative, as it is her earthly mission, to give comfort to those in distress ; and when the English adopted the custom long prevalent in France, to allow fe- male nurses to minister to the wants of those suffering in military hospitals, the wounded felt that half their solicitude was removed. Now, a sister's care will bathe the sufferer's aching head or offer him the cooling draught to allay his parched thirst ; will sympathize with his pains and give sweet consolation to his dejected spirit; and by removing that overpowering weight of loneliness, by which the sick in a foreign land far from home and friends are oppressed, will pave the road to speedy convalescence. A cheerful look, a kind word, a pleasant smile from one of these self-denying sisters, has sent many a thrill of pleasure through a stricken soul. The sur- geon sees, at his next visit, the fruit of this pleas- antly-administered draught, which perhaps he at- tributes to his own nauseous drugs. 76 PURIFICATION OF HOSPITALS. The experience of the Crimean hospitals, recog- nizing the vast amount of good which the female nurses accomplished, and the incalculable service 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 dispensed with. To the surgeon, a good, kind, reliable nurse constitutes more than half the treatment of the sick. It is with the most serious cases that their advantages in nursing are best displayed. McLeod, who studied carefully woman's services in the Crimean hospitals, says: "A woman's services in a hospital are invaluable if they were of no further use than to attend to the cooking and the linen departments; to supply 'extras' in the way of little comforts to the worst cases ; to see that the medicines and wine ordered are administered at the appointed periods, and to prepare and provide suitable drinks. As to the employment of 'ladies,' I think they are alto- gether out of place in military hospitals, except as superintendents. As heads of departments, as organizers, as overlookers, ' officers ' of the female corps, if you will, they cannot be dis- pensed with ; but for inferior posts, strong, ac- DIET TN HOSPITALS. 77 tive, respectable paid nurses, who have under- gone a preliminary training in civil hospitals, should alone be employed. In the camp hospitals, which, with an army in the field, are merely the temporary resting-places of the sick, men should alone be employed as nurses ; but in the more fixed hospitals in the rear, the lady superinten- dents and under-nurses should in my opinion always be added to the regular staff. Their atten- tion should be limited to the bad cases, and they should have the entire control of the linen, medi- cal comforts, and cooking. " All cleaning should be done by men. 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 be a store of ' extras ' under her charge, distribu- table on recprisition from the medical attendant, and which depot should be filled up to a certain quantity weekly, the sister being held accountable for the contents. "Wine and all extras should pass through her hands. She should be responsible for the due performance, by her female subordinates, of their duties, and have a right to interfere with the ward-master, if the cleaning, etc., were not properly attended to by his male corps." The dieting of patients in a hospital is always 78 DIET IN HOSPITALS. a matter of considerable moment, and one which requires much attention. The surgeon has dis- cretionary powers to order any extras which the patients may need and which the issue of rations does not include. To he enabled to supply these extra articles at the time when they are wanted, and not depend upon the doubts and uncertainties of the regular form through which all such orders now pass — a kind of circumlocution office, whore, in time, the articles may be forthcoming — the medical director should be supplied with funds, for the judicious outlay of which he becomes per- sonally responsible. From this fund the wants of the patients can be supplied without delay. For the very sick, the dietary orders being indi- vidual, no difficulty exists in prescribing for them. It is for those drawing ordinary fare, and who require to be guided by some fixed rule, that diet tables are found so useful in diminishing the daily routine duties of the surgeon. This diet list is carefully compiled by the medical directors of the hospital, and contains those articles of diet which would be best suited to the many. As this is a sine qua nan in a hospital, and gives much trouble in its preparation, I have here in- troduced, as a guide, a diet table, which might DIET IN HOSPITALS. 79 be useful as a basis in preparing one for indi- vidual hospital service. A Scheme of Diet for Patients in the Military Hospital. FULL DIET. Bread, 1 lb. Beef or Mutton,. .1 Potatoes, or*) ...1 lb, Beans, ur. . > . . . 4 oz. Rice, J . . .4 oz. Veget'es for soup, 4 oz. Salt 1 oz. Tea, or ] "j oz. Coffee, J 1 oz. Sugar, 2 Milk for tea, 4 Molasses, 1 Corn Meal, 1 Soup, 1 HALF DIET. Bread, £ lb. Tea, 4 oz. Sugar, 2 oz. Milk for tea, ...4 oz. Corn Meal, 1 lb. Milk 1 pt. Bread, 1 lb. Beef or Mutton,. . * lb. Potatoes, or") ...1 lb. Beans, or. . > . . .4 oz. Rice, j . . .4 oz. Veget'es for soup, 4 oz. Salt 1 oz. Tea, i oz. Sugar 2 oz. oz. | Milk for tea, 4 oz. oz. Molasses, 1 oz. oz.jCorn Meal, 1 lb. lb. [ Soup, i pt. l't Veal, Fowls, or Bacon — such quantities, in lieu of beef and mutton as the medical officer may prescribe. Wine, Whiskey, Porter or Ale, at the surgeon's discretion. Two drachms of tea or four of coffee, with one ounce of sugar and one-eighth pint of milk, to be 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 be made into soup, with vegetables, and one pint of the soup given to each patient, with his propor- tion of the boiled meat. The vegetables, as rice, potatoes or beans, are frequently changed to give variety to the meal. 80 DIET IN HOSPITALS. The diet would be distributed in the following order : Breakfast Dinner - Supper. Bread, J lb. Tea or coffee, . I pt. Hominy & molasses Beef or mut'n, I lb. .1 pt. ;oup. Bread i lb. Beaus, pot'es or rice Bread, J lb. Tea or coffee, . 1 pt. Bread, £ lb. ; Bread, i lb. Tea, 1 pt. Tea, ..1 pt. Hominy & molasses Gruel, i pt. Beef or mut'n, + lb. Soup 1 pt. Gruel. I Bread, J lb. Milk,..l Beans, pot'es or rice Bread, i lb. Tea, 1 pt. Bread, J lb. Tea, ..1 pt. Gruel, i pt. The attending surgeon adds what he wishes to the above diet, to suit any individual case in the hospital. CHAPTER IV. Medical Service of the Army — The means of trans- porting the 'wounded — Medical and Surgical Staff of Armies — The Medical organization in the Prussian service — Sanitary Corps, or litter carriers for trans- - porting the wounded from, the field — Duties of the Regimental Surgeons and Assistants in camv and* on the battle field — Preparations needed on the eve of a battle — Positions occupied by the Medical Staff during the fight. The transportation of the sick and wounded of an army is always a matter of difficulty, and is not uncommonly the indirect cause of an increased mortality. The injury inflicted upon a wounded man by a transportation of even a few hours, over bad roads, and in unsuitable vehicles, is incalcu- lable. Wounds which had been doing well prior to the move, take on at once an unhealthy appear- ance ; some slough, erysipelas or mortification shows itself in others, and all feel more or less its malignant, injurious influence, even with the best transports, and under the most favorable circum- stances. The jolting of a broken limb for three 82 HAND UTTERS. or four hours over a rough road is indescribable torture. The prostration and exhaustion depicted upon the faces of the wounded after such a trans- fer, explains at once the problem of why many should die during the transportation, and makes us wonder how so many escape with life, after undergoing such unutterable hardships. Litters. — The common and best means of moving wounded men for short distances is •upon litters, which may be prepared in advance, or be an impromptu manufacture. In case of necessity a litter can at once be made from the blanket of a soldier. This is doubled upon itself, a slit being made through the end cor- ners, sufficiently 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, and a litter is ready for use. Soldiers' blankets are at times prepared for this service, by having strong loops sewed to the corners, so that when the blanket is doubled the four loops will come on one straight side ; one musket is passed through the four loops, the second through the folded blanket. Where comrades from the ranks are expected to carry off the wounded, this is the onlv litter which is of service, as any two soldiers HAND LITTERS. 83 arc prepared to act as transports, without hamper- ing themselves during the fight with extra bag- ijaii'e. Such a litter is, however, very defective, as the weight of the patient sags the yielding blanket until it nearly reaches the ground, whilst the mus- kets are pressed in upon the haunches of the bearers, which renders it impossible for them to proceed with ease or celerity. The proper litter or stretcher is made of strong sacking or canvas, six feet four inches long and two feet wide. A broad hem is taken up on either side, through which passes readily a stout pole, ten feet long. On either side of the litter is an iron rod two feet wide, with rings at the ends, which slip over the poles and form the stretcher, to keep the poles separate, and prevent any sagging of the litter. Two iron projections from these rods, eight to twelve inches in length, will serve as feet for the litter, and will be found very useful in relieving the carriers, as they can then rest themselves when travelling over uneven ground, without the wounded man being annoyed by the irregularities of the surface. A shoulder strap, with a loop on either end to receive the poles, completes an appa- ratus which is capable of carrying off a wounded man with all the comfort with which his situation 84 FRAMED LITTERS. admits. A pike head attached to the pole makes it a formidable weapon of defence. Each of those who are expected to transport the wounded is armed with such a pike, and has one iron traverse or stretcher and canvas bottom strapped upon his knapsack. Any two of them meeting together will be enabled in a few minutes to equip an efficient litter. When placed in the litter, the soldier's knapsack is placed under his head as a pillow, and his musket lies alongside of him, or may be hung from the side of the litter by loops placed there for that purpose. A framed litter is one of very questionable utility, as it is a very bulky article, and one easily broken, so that usually, after a long transportation, very few of them are tit for service. Williamson, in his Notes on the Wounded from the Mutiny in India, published in 1859, has, in the appendix, a plate and description of a dooley — a kind of litter used for the conveyance of the sick and wounded in India. In the field service it forms the patient's bed as well as means of convey- ance from the time of his being wounded until he is either cured or dies. It consists of a frame- work resembling a bedstead in miniature, six and a half by two feet, with light posts, which run below the bed six inches. This is slung by two HORSE LITTERS. 85 ropes placed on either side from the head and foot, and running up triangularly, the pole upon which the litter is supported passing through the apex of these two triangles. A tarpaulin cover, with side curtains, excludes the 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 tarpaulin covering and curtains, with which they make their tent, leaving the patient comfortably in his bed. These were found to answer admirably in the Crimea, where they were used to a limited extent. This is the most com- fortable conveyance for a sick or wounded per- son, and its introduction generally into the Eng- lish service has been strongly recommended. Horse Litters. — Next to hand litters for the transportation of wounded men are horse litters, made three feet wide with poles sixteen feet long. Horses or mules take the place of men, the poles acting as shafts, and supported 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, trans- portation by this means is well suited to the comfort of the wounded; but if the muleteers < Q( 3 AMBULANCE CARRIAGES. 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 largely what is called a cacolet, a kind of arm chair, which is suspended on either side of the saddle upon a mule. It offers a com- fortable seat for the wounded, and each mule can carry comfortably two men from the field to the infirmary. In hilly countries, over bad, rough roads, this is found a much better conveyance than vehicles. The two and four wheel carriage or ambulance wagons, which have been adopted in every civil- ized army, are considered indispensable for field service, and for the transportation of the wounded. The two-wheeled vehicle is the most comfortable. Both two and four are so arranged as to allow of the wounded being carried lying, reclining, and sitting. The omnibus is the most expeditious means of removing those lightly wounded but not able to walk from the field. Where the roads are good, in an open country, this vehicle should not be neglected. The Confederate service, based upon the army regulations of the United States, allows for every command of less than three companies one two- MEDICAL SERVICE OF AN ARMY. S7 wheeled transport cart for hospital supplies, and to each company one two-wheeled ambulance car- riage. For commands of more than three or less than five companies, two two -wheeled transport carts, and to each company one two-wheeled am- bulance carriage. For a battalion of five compa- nies, one four-wheeled ambulance carriage, five two-wheeled and two two-wheeled transport carts; and for each additional company less than ten, one two-wheeled transport cart. For a regiment, two four-wheeled ambulance wagons, ten two-wheeled ambulance wagons, and four two-wheeled trans- port carts. Medical Service of the Army. — The medical service of an army in times of peace is selected with care by an examining board, whose rigid inquiries into the literary and professional attain- ments, as well as into the moral and physical con- dition of the applicant, keeps the staff purged of inferior men, and forms a body of scientific inves- tigators whose efficiency will compare favorably with the profession of any country. During war, the medical department increases ■pari passu with the army. These appointments should be made with a full knowledge of the weighty responsibilities attached to the medical OS CONFEDERATE .MEDICAL SERVICE. staff, without whose constant solicitude for the health and well-being of the troops committed to their care, the effective strength of an army will be materially reduced. With a view to ensure the most active and efficient treatment of the sick in the army at all times, and particularly during active service, it is not only essential that the medical officers should be men of ability and of high professional qualifications, but that they should possess physical energy adequate to the more arduous duties. The advantages of having an experienced surgi- cal staff in the field, and the influence which it can exert on the vicissitudes of war, must be acknowledged by every thinking man. Yet medi- cal advice is seldom asked or listened to by those in command, so long as suffering and death are not cruelly felt. The proper understanding be- tween the medical and military staff of an army, with concert of action, will save many a 8010110", who would otherwise lose or compromise his life, so valuable to the country in times of need. In the Confederate service, each regiment of one thousand men has one surgeon and one assist- ant surgeon. These in times of peace are found scarcely sufficient to attend to the sick, and in times of epidemics or war they are incompetent ENGLISH MEDICAL SERVICE. 89 to offer that assistance which sick and wounded require. Many a life has been sacrificed to pro- crastination. Upon the first and immediate atten- tion to the wounded on the battle field depends in a great measure the success of treatment; and in any encounter which deserves the name of a battle the wounded must necessarily be neglected by this deficient medical staff. Our experience in the Mexican war proved the inefficiency of our sparse medical corps. European experience confirms the observation that two medical men are not suffi- cient to take care of the health of a regiment. This was the subject of general comment in the Crimea, where the medical staff were unanimous in the demand for additional medical assistance. In active service, every regiment should have at least one surgeon and two assistant surgeons, these differing only in rank, their duties being similar. Besides the regular regimental surgeons, there should be a medical reserve corps to take charge of military hospitals, whilst regimental officers accompany their commands. In the English service, the medical department is composed of regimental surgeons, with their assist- ants, staff surgeons of the first and second class, and medical inspectors. The staff surgeons of the first class rank the regimental surgeons, and with S UU FRENCH MEDICAL SERVICE. their assistants either take charge of military hos- pitals or act as medical supervisors for a brigade, composed of three or more regiments. The assist- ant staff' surgeon holds the same rank as the regi- mental surgeon. When many brigades are collected into a division, a staff' surgeon of long service is appointed to direct the medical and surgical affairs of the division ; and when a large force, consisting of several divisions, with their respective generals and physicians, is brought into the field for actual service, and placed under a general in chief, a medical staff officer, bearing the title of inspector general, is appointed to superintend and concen- trate all the movements of the medical depart- ment of the army. The medical department takes the military therefore as its model. In the French army, a somewhat similar organi- zation is found. Besides surgeons and assistant surgeons attached to regiments, the military hos- pital staff, which is a very numerous one, consists of medical inspectors or head surgeons of infirma- ries, staff" surgeons of the first class, with senior and junior assistants, the number detailed for special hospital duty depending upon the size of the institution and the number of its inmates. The most thorough medical organization in PRUSSIAN MEDICAL SERVICE. ( J 1 Europe belongs to the Prussian service, and is composed as follows: Each battalion of one thousand men has a surgeon and a distant surgeon, who are thoroughly instructed in the duties which they are expected to perform. Besides these, there is to every coi-j's cfarmte of thirty thousand men, a staff of forty surgeons, who, in time of war, take charge of the general military hospitals opened for the reception of the sick and wounded. This division has also attached to its medical department- three infirmary staffs for light field service, composed of eleven surgeons each. These act as a reserve on the battle field, opening field infirmaries which follow the troops and give the first aid and dressing to the wounded. This gives a proportion of nine sur- geons to every two thousand men; and, notwith- standing this large number, there are periods when even a larger number of surgeons would not be sufficiently numerous to give proper and immediate assistance to the wounded. In most European armies the dispensing of medicines is performed by apothecaries, who complete the medical organization. In the English and Ameri- can service the assistant surgeon acts as apothe- cary. In recent European campaigns a very important 92 SANITARY CORPS OR CARRIERS. addition has been made to the surgical service. It is the sanitary corps or carriers of the 'wounded. Heretofore, when men were shot down from the ranks, they were borne to the back by their com- rades in arms, who transported them to the field infirmaries, where the surgeons attended to their wounds. Although a most praiseworthy act of devotion to a fallen friend, it was often called for when help could least be spared, as the taking away of so many fighting men from the ranks enfeebles the strength of the command, if it does not break up 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 com- pany instead of the one wounded. Besides, with the very best intentions, these comrades are not instructed how to carry the wounded so that they should suffer least detriment, and the final result cannot be but injurious 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 sur- gical staff of the army, is a regularly organized body, who are taught how to carry wounded men. These practiced hands are under military disci- pline, with officers whose duty it is to see that SANITARY CORPS OR CARRIERS. 9o the wounded are promptly and carefully removed from the places where they fall to the infirmaries. There are surgeons connected with this sanitary corps to attend to the judicious transportation. They only, offer temporary assistance. Should there be fearful hemorrhage they may apply a tourniquet, or show the assistants how to compress, effectually, the bleeding vessel; if a chest wound, they may at once open a vein to prevent the soldier dying in transit. They arrange broken limbs so as to be conveyed with most comfort, and give a dose of morphine when much suffering is felt, but beyond this temporary assistance they never go. This sanitary corps, with litters, ambu- lance wagons, pack horses, and all other facilities for transporting wounded men, should be in the advance, immediately behind the troops, when the battle is going on. Their post is one of risk as well as of responsibility. ISTot unfrequently they lose their lives in accomplishing their benevolent tasks. Both humanity, civilization and economy dictate that a similar corps should be appended to every army in the field. When not wanted on the battle field, experience makes them careful nurses upon the wounded. The folloiuing is the course pursued by the Prussian medical corps of a division of thirty thousand men 94 SANITARY COUPS Oil CARRIERS. xch.cn going into battle: The reserve corps of forty surgeons establish a general hospital at some safe 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. Here, 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 be ample, and every facility for treating successfully the seriously wounded must therefore be 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 staffs. They are the main 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. Many operations deemed imperative are here per- formed. All wounds are here cleansed, foreign bodies of every kind extracted, hemorrhage con- trolled, and the first proper dressing applied. As the wounded are brought to this point as they are shot down, their wounds have undergone but little change ; the system is still suffering from a certain amount of nervous shock, which makes it the SANITARY CORPS OR CARRIERS. 95 proper time for effecting a thorough, examination without giving pain. In these, as in the general hospital, there is always a 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 examiner, the operator, and the dresser. Those who are most skilled in these various departments are expected to give the benefit of their skill and experience to the wounded. More importance is placed upon these subdivisions of labor than we would, at first sight, recognize. It is well known that many hands can be efficiently worked by one head, and that when a surgeon of much experience and mature judgment determines what course should be pursued, there are many competent to carry out his suggestions, who were not sufficiently prepared to establish a thorough diagnosis and foresee the probable issue. The importance of examining a wound as sel- dom as possible being acknowledged, it is easy to understand why the most proficient surgeons 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 96 SANITARY CORPS OR CARRIERS. 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 in very obscure cases, an after- 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 limb and life would be preserved were it possible to limit the examination of the wounded to the battlefield. Let it be remembered that the first examination is always less painful and dangerous than any sub- sequent one. All surgeons agree upon the suc- cess of primary operations, when compared to secondary, after inflammation has set in. How to proceed or what wounds to condemn requires nice discrimination, hence the necessity of devoting the talent and experience of the staff to this very important duty. In the Prussian service, the regimental surgeons are concentrated in groups with their assistants, rather than follow their respective regiments into the fire. Thus much time is saved and the wounded receive more attention, and keeping them together in this way renders it easy to com- SANITARY CORPS OR CARRIERS. Vl mand medical service when it may be needed for any special, extra duty. This, of course, does not prevent surgeons being sent to various points of the line, to assist the medical portion of the sani- tary corps in the proper transportation of the wounded.* In the same service, the primary dressings for the wounded are carried by each soldier, so that all necessary bandages are on the spot, and no time is lost waiting for the bandage boxes or hos- pital stores. The general plan adopted by the entire army is as follows : Every soldier car- ries a small package three inches long and one inch thick, which contains the following articles, viz: two pieces of old, soft, clean linen, nine inches square; a piece of oiled silk or india- rubber tissue, nine inches long by five inches wide; a small ball of lint; a bandage two and a half yards long and two inches in width. One piece of the linen is folded double and rolled tightly over the lint, and over this the piece of oiled silk is rolled, the bandage rolled around this, and the whole enveloped in the second piece of linen and fastened with two pins. This should be put in a particular place in the knap- sack, where it can always be found. Should *Loeffler. Behaudlung der Scliusswuude; Berlin, 1859. 98 SURGICAL STAFF, there be two wounds, the oiled silk and cloth may be divided to make a double dressing, and one piece of cloth may be used by the sur- geon as a towel. In this small but very useful package is found the requisite dressings for every gunshot wound. It saves the surgeon the annoy- ances and delays incidental to the transportation of hospital stores. In the light field infirmaries, nearly all the dressings of the wounded are ob- tained from this individual package, the very few extra articles needed being furnished from the iufirmary supplies. Stromyer, in his surgical writings on the Schles- wig-Holstein war, speaks of the medical depart- ment of the army as modelled upon the military. Beside the regimental surgeons, each brigade had a brigade surgeon with three assistants. The larger divisions of the army were equally supplied with superior medical officers and staff. On the battle field the surgeons of the. army established infirmaries for the immediate care of the wound- ed, who were, after the first dressings, sent into the more permanent infirmaries. In the Confederate service, where so small a surgical staff is recognized, we will be compelled to take advantage of the railroad facilities of trans- CONFEDERATE SERVICE. 99 portation, and use the hospitals of those cities contiguous to the scene of encounter, with volun- teer surgical aid as our reserve corps. This will not diminish the arduous duties of the regimental surgeons and their assistants, who will find con- stant employment whilst in camp and on the battle field; in spite of their unceasing efforts, the wounded cannot but be wofully neglected. Modern warfare, in introducing arms of precision, of immensely increased range, and perfected in- struments of destruction, has created a new era in military surgery. The conical ball of double weight has become the common missile, and when discharged from a rifle it flies with fearful velocity. Such balls*, when traversing soft parts, produce extensive destruction, but seldom bury themselves. Comparatively few of these are to be extracted after a battle. Should they impinge upon a bone, the splitting and crushing is extensive ; large spicula? are driven in every direction, transfixing limbs and even impaling those standing in the neighborhood. In Crimean experience, a serious wound was sometimes inflicted by a large frag- ment of bone driven from a neighboring soldier. The extensive injury to bones necessitates more frequent amputations and resections. This coni- cal ball seldom fails to take the shortest cut 100 CAMP DUTIES OF SURGEON. through a cavity or limb, and it has at times been seen to pass through the bodies of two men and lodge in that of a third. Those who compare the dead on recent battle fields with those of former wars are painfully struck with the greater mutilation of the bodies from conical balls. Rarely are they deflected from their course, as is the round ball, which is turned by every little obsta- cle, and takes up a position at striking variance with any rule of propulsive forces. In steady hands, frightful wounds are produced by the Minie ball, which requires all the resources of surgery to successfully counteract. Let us now define the duties of a surgeon in the Confederate service, both in camp life and on the battle field. Camp Duties of a Regimental Surgeon. — We have already shown that the fire of an enemy never decimates an opposing army. Disease is the fell destroyer of armies, and stalks at all times through encampments. Where shot has destroyed its hundreds, insidious diseases, with their long train of symptoms and quiet, noiseless progress, sweep away their ten thousands. To keep an army in health is, then, even more important than to cure wounds from the battle fields. But, as CAMP DUTIES OP SURGEON. 101 surgeons in the service are expected to be skilled in both departments, so that, in either case, the troops under their care should suffer no detriment, they should be thoroughly prepared for the very responsible positions which they fill. Conserva- tive surgery requires 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 surgery. Half knowledge leads into meddling, which is far worse than no surgical assistance. Many a wounded soldier has felt heavily the busy hand of the willing surgeon who lacked the guiding head. The surgeon has charge of a number of very valuable lives, and the necessity imposed — by the absence of consulting aid — of deciding the most serious and critical cases upon his own unaided judgment demands, upon his part, self-reliance, which can only be based upon previous prepara- tion. Camp life gives a surgeon much food for thought and ample personal experience, but gives him no time to consult authors and improve him- self with books. He does not see so great a variety of diseases as are met with in civil prac- tice, but he has a wider field for observing the influences of external modifying circumstances, as exposure, improper food, imperfect clothing, 102 CAMP DUTIES OF SURGEON. irregular work, want of cleanliness, and depressing or exhilarating mental influences. The diseases of a soldier, like those of most trades, are pecu- liar, each trade begetting its own, whilst it gives immunity to others. The greater uniformity in age, constitution, modes of living, exposure to similar external influences, and strict discipline, modify to a considerable extent the diseases of camp. It is especially the crowding together, with the animal emanations from such a number of living beings, that gives character to the phases of disease. The preservation of the health of the soldier being the sole duty of the military surgeon, he will be expected to use every means within his reach to attain this desirable end, especially by a rigid ob- servance of those forms of discipline and economy which are under the direction and surveillance of the military officers. As diseases will arise among troops, and, as very few of these cannot be arrested by means of art when skilfully applied at an early period, care should be taken that medical skill be promptly resorted to at the very first sign of indisposition. Hygiene must first claim his attention; under the adage, prevention is better than cure. If the troops are about going into camp he must examine the ground and see CAMP DUTIES OF SURGEON. 103 whether any causes exist for rendering the place insalubrious. When in a friendly country he should seek information from the local physi- cians, 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 observation have proved most effective in controlling such dis- eases. He must see that the troops in camp are supplied with dry straw for beds, and that they air the same with their tent daily, so as to ensure a healthy place for repose, and report any neglect to the commanding officer. He must see that the soldiers are properly clothed and well fed with wholesome, nutritious food, and supplied with an abundance of good water, and, from time to time, should suggest to the com- manding officer such changes in the diet as will be conducive to the health of the command. If the water is bad, he should 'study how it can be improved, so as not to act injuriously upon the men. Cleanliness of the encampment and of the tent, with frequent ablutions of the body and clothing of soldiers, should never be absent from his thoughts. He should point out to the commanding officer all nuisances which promise 104 CAMP DUTIES OF SURGEON. to be detrimental to the health of the corps, and urge their removal, suggesting how they can best be disposed of. The hospital tents will be pitched upon a dry, well-drained spot, if a building cannot be obtained for the same, and it is the duty of the regimental surgeon to attend to the proper furnishing of the same with all possible conve- niences for the sick. He will enforce all proper hospital regulations to promote health and pre- vent contagion, by ventilation, scrupulous clean- liness, frequent changes of bedding, linen, etc. At the morning surgeon's call, the sick of the regiment will be conducted to the hospital by the first sergeants of the various companies, who will each hand to the surgeon a list of all the sick of the company, on which the surgeon will state who are to remain or go into hospital ; who are to return to quarters as sick or con- valescent ; what duties the convalescents in quar- ters are capable of performing; what cases are feigned, and any other information in regard to the sick of the company he may have to com- municate to the company commander. He will then distribute the patients in the hospital, see that they are properly provided w r ith com- fortable beds; enter in the proper register the CAMP DUTIES OF SURGEON. 105 name, the case, the disease; and in the diet and prescription book the medicines which the case requires. If his assistant is not present, he prepares the medicines and superintends their administration. He will visit the hospital each day as frequently as the state of the sick may require. Should any soldier be taken suddenly sick, his case is at once reported to the surgeon, who will visit and prescribe for him in his tent, unless the case threaten to be serious, when he should be removed without delay to the hospital. Convalescents, on coming- out of the hospital, are not to be put on duty till the surgeon certifies to the commanding officer that they have perfect- ly recovered ; for which purpose it is the duty of the surgeon to make (daily) a particular inspection of these men at morning parade, to prevent any remaining longer exempt from duty than the state of their health renders absolutely necessary. After the surgeon's call, he will make a morning report of all the sick and disabled to the commanding officer. He also recommends that leave of absence be granted on furlough to those convalescents who will recover more rapidly by change of scene and life. The senior medical officer of a post, hospital, regiment, or detachment, will make monthly, to 10G DUTIES OF ASSISTANT SURGEON. the medical director, and quarterly, to the surgeon- general, a report of the sick and wounded, of deaths, and certificates granted for discharge from disability, and transmit to him the same, with a statement of the hospital fund. He will also keep the following records, from which the condensed report to the superior medical officer is drawn, viz : a register of patients ; a prescription book ; a diet book ; a case book ; copies of his requisi- tions; annual returns, and reports of sick and wounded ; and an order and letter book, in which will be transcribed all orders and letters relating to his duties. All requisitions for hospital and medical stores must come from the senior surgeon, with the approval of the commanding officer, cer- tifying that the same are necessaiy for the sick. The duties of the assistant surgeon are very similar in many respects to those of the surgeon. If he has the confidence of the regimental surgeon, the patients are equally divided between them; he treating a certain number of sick ordinarily with- out interference from the senior surgeon, except they be serious cases, when he seeks advice from the regimental surgeon. Although this is the com- mon course pursued, it is not so from right, but by sufferance of the senior surgeon. In the army DUTIES OF ASSISTANT SURGEON. 107 regulations, the senior surgeon being the superior officer, the assistant surgeon is under his control. He 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 dressings, bandage fractured limbs, keep the register, diet and prescription books, and assist in compiling the monthly and quarterly returns. When a detachment is sent off on special service, the assistant surgeon accompa- nies it as medical officer. When epidemics occur in camp, then the duties of the medical officers become very arduous; the daily and nightly toil which they are compelled to undergo, the fatigue of body and anxiety of mind which is their daily routine, soon breaks them down, and many an over-zealous surgeon becomes a prey to the diseases which his constant efforts are trying to quell in others. This is particularly the case when typhus is raging in camp, when a neg- lect of those hygienic precautions which the medi- cal officers are instilling into the men causes many a victim in the medical ranks. Under such condi- tions it becomes as imperatively the duty of the suro-eons 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. 108 DUTIES OF ASSISTANT SURGEON. The Crimean surgeons were severely censured, after spending all day in the typhus and cholera hospi- tals, with tainted atmospheres, for remaining there during the night also, when there was no necessity for 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 for scientific conference and for mutual instruction. Here each gave his expe- rience and compared the results of different methods of treatment. Their meetings always terminated in practicing amputations, resections, and the ligation of arteries on the dead subject. The object of this was not only to gain dexterity in the operative manual, but also to find out who were the most skilled and therefore most worthy of being intrusted with important duties. It is said that the mortality of the army amounted to two hundred per day, Avhich gave ample material for such practice. These meetings were presided over by one of the highest staff surgeons or medi- cal directors, who would often deliver to the society practical lectures upon the treatment of gunshot wounds. This plan might be carried out in all armies, as it must redound to the benefit of both surgeons and patients. DUTIES OF SURGEON ON FIELD. 100 Duties of the Surgeon on the Battle Field. — The common fear which depresses the soldier on the eve of a battle more than any other is not so much death, but the dread of mutilation. Bullets are neither respecters of parts nor persons, and the prospect of losing an eye, an arm or leg makes many a brave man quail before the ordeal through which he is to pass. So that before a battle there is a vague, uneasy restlessness — a foreboding of coming evil, which takes possession of the bravest, and cannot be driven off except by the com- mencement of the fight. The early booming of cannon braces all for action, all thoughts of fear or self are now discarded, the demon of war rules triumphantly over the assembled host, and sup- presses, through thirst for blood and desire for victory, all depressing influences. There is some- thing in the smell of gunpowder which makes men forget their origin ; by its magic wand women are made brave, and cowards heroes. In the eager- ness of the fray, an intoxication guides all to acts of daring. Who, in his sober moments, would walk up 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, and whilst under the stimulating intoxication from gunpowder, would not face certain destruction ! 110 DUTIES OF SURGEON ON FIELD. 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 conflict ; 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 surgeon has much to do to prepare facilities for the treat- ment of the wounded. He must see that the hos- pital stores are brought up with the ammunition wagons, as the articles for treating the wounded and saving the life of comrades are fully as impor- tant as those for the destruction of the enemy. He examines his stores, and satisfies himself that nothing which will be required for the wounded has been omitted or forgotten. He examines his instruments, his supply of bandages, lint, india- rubber cloth or oiled or waxed silk, etc. ; sees that chloroform and opium, the main support of the wounded, are at hand in sufficient quantity. Water he has not overlooked, as an abundant supply will be needed to meet the incessant, unmitigated thirst of the wounded. He should be well supplied with astringents, of which the per chloride or per sul- phate of iron is the best, to control annoying hemorrhage. He should also have a moderate DUTIES OF SURGEON ON FIELD. Ill supply of brandy to revive those exhausted from hemorrhage, oil to grease their wounds, and a little tea, sugar, and 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 lint,* cloth, bandages, oiled silk, sponges, ligatures, adhesive plaster, splints for treating all varieties of fractures, amputating and dressing instruments, with medi- cines and stimuli, and a full supply of good water. These are carefully put upon a pack mule in two strong iron-bound boxes, called panniers, one hang- ing on either side of the saddle. One is usually devoted to medicines, the other is used for dressing- apparatus. This distribution gives the surgeon * Carded cutton has been extensively used in military surgery, and was found in the Crimea to be a good substitute for lint by the French surgeons, with whom an abundance of lint is a sine qua tion in the treatment of wounds. As it can be so easily obtained in any part of the Confederate States, and at so trifling a cost, it promises speedily to usurp the place of the officinal preparation. Now that tents and meshes are scarcely used, and receptacles for collecting pus are denounced in modern surgical practice, we see no reason why carded cotton, with its very soft, elastic fibre, would not make a more soothing dressing than lint, which is often formed of coarse, hard threads, which would leave their marks upon a sensitive, inflamed surface, and therefore must be the unrecognized cause of pain. Much can also be said of new cloth versus the old linen, of time- honored reputation. Suffice it to say, in this connection, that an army should never clog its movements by an excess of baggage, and that the old linen (which can be used but once) required for an army is no small item. New cloth can be washed a dozen times, if required, which in itself is no mean recommendation. ]12 DUTIES OF SURGEON ON FIELD. great facility in moving about the field where hi* services may be most required, 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, which is con- tinually resupplied from the medical store wagons. The commanding general may sometimes have good reasons, under particular circumstances, for ordering the medical wagons to remain behind with the baggage; then the conveyance of all needful medical supplies for the wounded on pack horses becomes imperative. If the army 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 for- mula, then the hospital stores could in a great measure be dispensed with, and with few addi- tions to the individual stock, the wounded could receive careful dressing. The instruments and few medicines which the infirmary would require, could then be readily moved from place to place, following the line as the din of battle recedes from the points where the fight had commenced. The surgeon should examine the means of trans- porting the wounded from where they fall to the DUTIES OF SURGEON ON FIELD. 113 field infirmary: These mould consist of at least two stretchers for every one hundred men en- gaged, although in European armies, four are al- lowed to each company, besides light ambulance wagons, spring carts, or any other conveyance of transportation, to accommodate in the proportion of forty persons for every one thousand troops. The character of the transport service will depend upon the character of the country in which the war is carried on. In a level country, wagons are the most serviceable, whilst in hilly localities, lit- ters carried b}* mules would be the most comforta- ble 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 transportation. This is by far the most humane course, and as a mark of civilized warfare should be of universal adop- tion. It is highly important that a similar body be instructed to act as nurses as well as attend immediately upon the wounded, as this timely assistance may save many lives on the field. In those armies in which this sanitary corps has not yet been introduced, the regimental quartermas- ter in charge of the pioneers and musicians, form a temporary body of carriers. Besides the litters, each bearer carries a canteen full of water, and 10 114 DUTIES OF SURGEON ON FIELD. the assistant surgeon, 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 battle or on the march, carries the hospital knapsack which contains instruments, ligatures, sponges, lint, oiled silk, bandages, tapes, pins, two field tourniquets, a bottle of brandy, and one of laudanum or morphine, or other medi- cines which may be needed in an emergency on the march or in the field. One of the order- lies is armed to protect the party against strag- glers and marauders. The surgeon, for a similar reason, should be also armed with a revolver. The orderlies assist the surgeon in placing the wounded carefully in the wagons;' and also fol- lowing 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 of the range of the shot, and they establish their field infirmary. It would be convenient if some house could be used for this temporary hospital. "Where this cannot be had, the shade of trees or the shelter of a hill-side will answer the tem- porary wants of the surgeon. If the body of DUTIES OF SURGEON ON FIELD. 115 troops about entering battle is a large one with an extended line, several of these points should be selected and marked by a suitable yellow flag which designates the spot where those slight- ly wounded can seek surgical aid. Instead of each regimental surgeon establishing such for his regiment, it would be much better if they would concentrate for individual assistance, when the wounded would receive more attention, and the work of dressing would be much expedited. When surgeons combine at the field infirmaries, establish at once, if possible, a division of labor ; let there be an understanding that those best adapted by experience to undertake certain duties should confine themselves strictly to the same. When each one knows what roll he has 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 remembered that all experience shows the medical staff of an army, however numerous, to be always too few on battle days. Remember that all the wounded must undergo a thorough examination, and all needful operations must be performed within twenty-four hours, or the wound- ed suffer from neglect. Now, take into considera- tion the very small surgical staff of our army and 116 DUTIES OF SURGEON ON FIELD. the accuracy of fire of the contestants, with the most approved and destructive arms with very long range, and we will immediately see the ne- cessity 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 concentration of surgeons at the field infirmaries. As the troops advance, they are followed by the bandsmen or bearers and, if the country permits it, the ambu- lance wagons, under charge of the quartermas- ter and assistant surgeon with his orderlies. They station themselves in the rear of the advancing line, where they can distinctly see what hap- pens, and remove immediately, without the range of the shot, those who may fall wounded. It is imperiousl}' demanded, on the score of humanity, that the wounded be removed from the field of battle with as little delay as possible, for early treatment. In gunshot wounds, above all others, early surgical assistance is of the greatest moment for success; and in many, as in chest wounds, what is omitted on the battle field immediately after the injury is received is never made up, with whatsoever diligence and skill the after-treatment is pursued. Therein is the great advantage of hav- ing a special transport corps, otherwise the excite- DUTIES OF SURGEON ON FIELD. 117 ment 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 are thought of by their comrades, who, in scouring the field, find many a dear friend whose life has paid the forfeit of delay. CHAPTER V. Treatment of gunshot wounds — What should be done on the field by the assistant surgeon in command of the litters — The treatment at 'the field infirmary — How wounds should be examined — The character of gunshot wounds — Orifices of entrance and exit — Primary hemorrhage — Natural hasmatosis — Tourni- quets but seldom required in surgery — How hemor- rhage controlled — Examination of wound for foreign bodies should only be done once, but that thoroughly and as soon as possible after the accident — The his- tory of the case important — Lodging foreign bodies always give trouble even years after injury — Gunshot wounds do not require dilatation — Necessity of ex- amining the pulsations of the main artery below the wound for suspected injury — Ligation of the open mouths of the artery the rule of practice — Water-dressing the only rational 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 falls or is wounded in battle, lie is at once approached by the assistant surgeon, FIELD SURGERY WITH THE TRANSPORTS. 119 who looks at his wounds, applies the hasty dressing which they require, then placing him comfortably on the litter, attends to his trans- portation. He can do as much for the wounded in [this way as if he were actively engaged in operating. Should his injury permit him to walk, a compress and bandage is placed upon his wounds, if they be severe, and he is direct- ed to the field infirmary. In those with frac- tured limbs, a rapid glance, quick intelligence, and an inventive turn, at once tells the surgeon what is required and suggests the means of effecting it. With a sword-blade, a ramrod or a bayonet, with a handkerchief or strip of cloth, a fracture apparatus is at once improvised, and the thanks of the wounded, now in comparative com- fort, are freely bestowed during his transportation to the infirmary or general hospital. If he has a mangled limb, which hangs by a very small por- tion of the soft 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 surgeon gives him a powder of morphine, with which his pockets are well stored, and at once transports him to the infirmary, where the proper amputation is performed. If the wound be an 120 FIELD SURGERY WITH THE TRANSPORTS. abdominal one, with protrusion of the intestines, he sees whether the bowel is injured or not. If not injured, returns it carefully within the abdo- men, and gives a large dose of morphine to ensure quiet. Should the intestine be cut by the ball, he warns the carriers and assistants from inter- fering until the wounded man be carefully trans- ported to the infirmary. In case of punctured chest wounds, with internal hemorrhage, cough- ing of bloody sputa and great oppression in the breathing, the treatment, to be ultimately suc- cessful, must commence at once. The surgeon, in placing the wounded man in the litter, will, if the symptoms be urgent, open a vein in his arm to save him from immediate death. To this timely bleeding, on the very spot where the acci- dent has occurred, and not wait until transported to a more convenient place, the life of the soldier often depends. Those wounded in the head, if insensible, require very careful transportation; they should be as little disturbed as possible. Chest w r ounds, head wounds, and fractured legs give the most trouble, as they require the greatest care in conveying them safely to the designated places for surgical treatment. It is seen from this rapid sketch that the sur- geon who follows the troops into action has WASTE OF BANDAGES. 1 21 nothing to do with amputations, resections, ex- tracting foreign bodies, etc.; these form no por- tion of his duties. His province is solely to prepare the -wounded for successful transportation, and beyond this he should not intrude his atten- tions. The great perfection of rifled weapons have their influence upon the duties of the field surgeon, as the rapid and frequent changes of the battle field threaten to control, within very narrow limits, field surgery proper and necessitate very hasty dressing. An emineut military surgeon — Air. Guthrie — states that bandages, applied on the field of battle, are, in general, so many things wasted, as they become dirty and stiff, and are usually cut away and destroyed without having been really useful. There is much truth in this statement Much of the hasty dressing by the transport surgeon can very well be dispensed with. As he has neither the time, nor is it his duty to examine carefully the wounds, most of the wounded might be sent directly on to the field infirmary without dressing. The dressings, when removed at the field in- firmary, are so soiled that they are thrown away. Time, which is so valuable, and also material, which is never in excess, but most frequently defi- cient, can be saved by adopting this course. Onlv 4 ' 11 122 EXAMINATION OF WOUNDS. in cases of sharp hemorrhage would it be neces- sary to apply compresses and the roller bandage, or what is very rarely required, the tourniquet. Should the soldier have a large artery wounded, and the hemorrhage be excessive, which is but eldom the case, the surgeon should instruct the orderly, who superintends his transportation, how to make judicious finger pressure. This is much better than the tourniquet, producing much less engorgement of the injured tissues. Field surgery, properly speaking, commences at the field infirmary. Here all wounds are thoroughly examined, and an accurate diagnosis established. The w T ouncls are here thoroughly cleansed; all foreign bodies which can be are here removed, and the first dressing made. If trivial, they are dressed and the men sent to rejoin their com- panies. When the wounds are quite recent, before the tissues become engorged, there is a temporary absence of pain and a relaxation of the injured parts, which favors an examination. The wound should now be examined to its very bottom, to detect the presence of foreign bodies, whether they be balls, wadding, portions of clothing, de- tached spiculse of bone, etc. For this purpose the finger is the proper probe, and is used on all occa- EXAMINATION OF WOUNDS. 123 sions, with rare exceptions. It is an intelligent instrument, and, appreciating what it feels, it will not only discover the character of foreign bodies complicating the canal, but w r ill 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 in warfare make, are large enough to admit the finger when introduced with care. Very rarely is it necessary to dilate a w T ound, with the probe-pointed bis- toury, to assist in its exploration. The silver probe is a dangerous and deceptive instrument, and should be discarded from the battle field. Its use on such occasions, for exploring recent wounds, marks the novice. Balls are readily detected in a fresh wound by placing the patient in the position in wdiich he received the injury, if the direction from wdiich the ball came be known. Portions of clothing and wadding are detected with greater difficulty. Before, how 7 ever, 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 su freest an embedded ball; when an examination of the clothing would show that the ball had driven 1-4 EXAMINATION OF WOUNDS. ■ these into the wound without sufficient force to transfix them, and, on removing, hastily, the clothing, the hall had heen extracted by this diverticulum pushed in before it. This ex- amination of the clothing will save much time to the surgeon, and painful, protracted, injuri- ous probing to the wounded. "When the shirt or drawers are 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 be more easily accomplished at an early period, and with less pain and danger to the wounded; it should be done carefully, thor- oughly, and without delay. A regular report is kept of all the cases dressed at the field infirmary, and a brief description of each case is sent on with the patient to the gen- eral hospital; so that if proper officers, in whose judgment the hospital staff can confide, had previ- ously 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 and trouble at the regular hos- pital. If the surgeon be trustworthy, his diagnosis should be respected, and no further investigation per- EXAMINATION OF WOUNDS. 125 mitted. Many serious cases can be protected by 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 limb and even life. After-examinations heighten irritation and inflammation in the wound, and, as they permit air (which ought to be rigorously excluded), to pass to the bottom of the w r ound, this promotes the decomposition of the extravasated fluids and exudations, induces suppuration and sloughing, and predisposes to pyaemia, with its fatal sequela?. Many a limb and life would be preserved if the examination of gunshot wounds could be limited to the battle field, and military surgery will have attained great perfection when a thorough diagnosis is obtained by this first examination. The extent and nature of many gunshot wounds are often ascertained at a glance. Touching a limb may be 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. JSTo haste should be permitted in this 126 TREATMENT OF GUNSHOT WOUNDS. examination to the injury of the wounded through carelessness of diagnosis. Should large arteries be injured, they should be ligated always in situ above and below the point injured, and for this purpose the wound must be enlarged. As a general rule, 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 plaster, 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 inju- rious influences, which is not its least advantage. Should a limb be so injured that joints are largely opened into, main blood-vessels and nerves torn through, soft parts extensively lacerated, or a limb flayed, then amputation should follow imme- diately the condemnation of the limb : field sur- gery here proves itself the only successful surgery, as all statistics clearly show. If the limb is simply fractured, even if comminuted without injury to NERVOUS SHOCK. 127 the main blood-vessels and nerves, and without complications with joint injuries, they should be considered simple fractures, and dressed as such at the field infirmary. If, in connection with a con- demned limb other mortal injuries exist, the im- propriety of performing the amputation is clearly seen. When joints are crushed, or the heads of bones perforated, resections are urgently demand- ed, and should be performed before reaction takes place. It is, of course, understood, that although wounds might be examined, foreign bodies re- moved, and the wound, if simple, dressed whilst a soldier is suffering under shock, no serious operation, which would still' further depress the nervous powers or cause a further loss of blood, should be performed until extreme depression subsides. Although the nervous shock accompa- nies the most serious wounds, it may often be met with in the most trivial injuries. It is recognized by the sufferer becoming cold, faint and pale, with the surface bedewed with a cold sweat; the pulse is small and flickering; there is anxiety, mental depression, with at times incoherence of speech. Often this shock is very transient when accompanying simple wounds. A drink of water and a few encouraging words may be sufficient to 128 CHLOROFORM TO ALLAY PAIN. dispel it. When it persists, even where the in- jury appears trivial, it forebodes trouble; and a more careful examination may detect a fatal inju- ry. It is the duration, more than the degree of shock, which marks the serious character of the wound; and when this constitutional alarm per- sists, there is a great fear that hidden mischief is lurking, and the surgeon should be very guarded in his opinion of the case. Keeping the patient warm, in the recumbent posture, with blankets and hot bottles, administering wine, brandy, am- monia, hartshorn to the nostrils, frictions, and cataplasms to the extremities is the course pur- sued to restore nervous energy. In all painful operations, chloroform should be freely administered to produce the desired anaes- thesia. Like all valuable medicinal agents, which when taken in overdoses are poisons, it can re- move suffering or destroy life according to its administration. The dangers can be avoided by never pushing its inhalation to stertorous breath- ing; stop 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 indispensables for successful practice. It saves the lives of many wounded, who would perish from the shock of a second TRANSPORTATION TO GENERAL HOSPITAL. 129 operation, and also many who would Lave been considered as without the pale of surgical art, can now, thanks to this invaluable remedy, be benefited by surgery. In our country, railroads traverse every portion of the States, and as battles usually occur in the immediate neighborhood of thoroughfares be- tween large cities, it is not improbable that they will be found in the immediate vicinity of battle fields. If such be the case, a sufficient number of cars should be kept in readiness for the use of the wounded. Transport wagons are in constant communication with the field infirmaries. As the wounded are attended to, they should not be allowed to accumulate around the infirmary, but be sent off at once to the nearest railroad station, from whence they will be distributed in the towns nearest to the scene of action. General hospitals should have been previously prepared in these localities for the reception of the wounded; and here the regular treatment commences. If it be convenient for the wounded to reach the general hospital within twenty-four hours from the re- ception of their injuries, many serious cases for operation, such as the resections, might well be deferred from the field infirmaries until the wounded have arrived at the station where that 130 COMMON DRESSINGS FOR WOUNDS. quiet and rest, with medical comforts, which are so necessary for a successful result, can be ob- tained. 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 attention, offi- cers and soldiers awaiting their turn. If the trivial accidents had been dressed upon the field, they could pass directly on toward the railroad or the general hospital, without stopping at the field infirmary. The common dressings which all wounds receive is a wet cloth covered with a piece of oiled silk or waxed cloth, and secured with a single turn of the roll of bandage. This keeps the wound moist, and is the most soothing, comfortable, efficient and simple dressing which can be devised. By wetting the outer bandage, the cold produced by evapora- tion is transmitted through to the wound, whilst the oiled silk keeps the parts moist. When oiled or india-rubber cloth cannot be obtained, and no facilities exist for keeping the wound constantly wet, whilst the patient is being transported to the general hospital, a cloth well greased with olive oil is the best substitute for the wet dressings. Many ragged wounds may have their edges paired off and then brought together, with every prospect TEMPORARY HOSPITALS. 131 of speech* union, provided the after treatment with cold dressings is judiciously followed. It is understood that all those who can be conve- niently moved, should be transported at the earliest possible moment to general hospitals, established in contiguous towns. Should there be no facilities for this transportation, then any house in the neighborhood, contiguous to the battle field, must be used as a temporary hospital for the treatment of those seriously wounded, whose safety depends upon absolute quiet, rest and careful nursing; or tents can be pitched for the temporary accommo- dation of the wounded. Should the army advance, the regimental surgeons must follow their com- mands, leaving either an assistant or an extra medical attendant for the wounded, it being pre- sumed that a reserve medical corps had been attached to the army for extra or reserved duty, when it was known at head-quarters that a battle was expected. These reserve surgeons will make every preparation for the comfort and accommoda- tion of the wounded. Should the army unfortu- nately meet with a reverse, all available transport must be pressed into the service for the removal of the wounded to the rear, and they must be sent off as speedily as possible. If this had been at- tended to from the commencement of the engage- 132 SEVERE WOUNDED LEFT TO ENEMY. ment, 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 be carried, as he takes 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 be certain death. If the general hospital cannot be 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 sur- geons to look after their wants. When left with- out surgeons, they are always neglected, and many lives may be sacrificed for want of that immediate attention which the enemy's surgeons must first give to their own wounded, and which precious time can never be recovered. This becomes espe- cially urgent where the nations at war speak dif- ferent languages. The rule now recognized in civilized warfare is, always to leave competent surgeons with the wounded who are left to be cared for by the enemy. Appearance of Gunshot Wounds. — We have APPEARANCE OF GUNSHOT WOUNDS. 133 already stated that the more perfect and destruc- tive 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 excessive momentum, transfixes the tissues with great ra- pidity, and when only soft parts are involved, the crushing and bruising is by no means so exten- sive as with round ball. The entrance made by a conical ball 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 be- tween the two orifices of entrance and exit. When the conical ball, entering 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, irregularly torn, with the surrounding tissues much bruised. Round balls usually give an entrance sur- rounded by blackened, inverted tissues; these having been evidently mashed or crushed by the ball prior to its entrance. The orifice of exit is usually more or less everted and lacerated. These two orifices are, however, modified in appearance 134 APPEARANCE OF GUNSHOT WOUNDS. by so many circumstances — the form, size, velocity and number of the missiles; changes in the missile after its entrance into the bod} T and prior to its escape ; the distance of the wounded party, his position, his clothing, foreign bodies which may have been about his person, and driven before the ball, etc. — that in some cases, without the history of the accident from the patient or those wdio saw the occurrence, it would be diffi- cult to determine which opening was first made. The effects produced by the action of the ball upon the tw r o orifices can he easily understood when it is remembered that in entering, the tissues, which are being perforated, are support- ed by the entire thickness of limb, so that often the ball carries before it a piece of flesh which it has cut out as by a die, and hence the more or less rounded appearance of this opening ; whilst after traversing the limb 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 lacerations 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 board or firing at the same with a pistol, will see a rough working of this principle. APPEARANCE OF GUNSHOT WOUNDS. 135 These peculiarities are said to be so stamped upon the clothing, that often, by an examina- tion of them alone, a diagnosis can be es- tablished. It is often of consequence to determine the character of these apertures, so as to distin- guish between a traversed ball, with its two orifices, or two balls embedded. At the same time it must not be forgotten that one ball may make several openings, by the ball being divided in the limb upon a sharp crest of bone. Such cases are not unusual where the round musket ball strikes. A half of the ball may pass out, a portion remaining behind. A single ball, by split- ting in this way against some obstacle in the fiesh, has been known to break into six pieces, each in exit making a corresponding wound. Conical balls show much less deviation than round balls. They usually follow 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 do often the round, but at once crush them; their double w T eight and increased velocity making many more fractures than the round ball of for- mer wars. In spite of the rapid passage of even conical 136 APPEARANCE OF GUNSHOT WOtJNDS. balls, some of the tissues, through their toughness and elasticity, escape direct injury from them. Arteries come under this head. Owing to their peculiar structure, cylindrical form and loose connections, lying on a bed of very loose cellu- lar tissue, which permits of considerable move- ment, they often escape transfixion, when their position lies evidently in the direct course of the ball. From the battle fields of Italy, I saw several of the wounded in the hospitals at Mi- lan, who had received such injuries about the root of the neck, where balls had traversed in some cases, antero-posteriorily, in others later- ally, going deeply through the soft parts, yet picking their wa} T , 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 large arte- ries, that rarely does death take place on the battle field from division bf the large ves- sels of 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 might heal with very little suppuration or sloughing: but when it strikes at an angle, particularly when the ball has lost a part of its momentum, it ploughs up NERVOUS SHOCK. 137 the tissues frightfully, and extensive destruction follows. Although cases are upon record where gun- shot wounds have healed by the first intention, the surgeon must not look for such a happy result. With but rare exceptions, suppuration is the rule, and he must be prepared to con- trol its action, and the excessive reaction which, in most cases, would accompany it. A certain amount of hemorrhage always ac- companies gunshot wounds; but owing to the irregularity and the asperities of the sides of the wound favoring the clotting of blood, we usually find that the external escape soon ceases, whilst internal hemorrhage, to a limited extent, extravasates into the surrounding tissues. When the divided blood-vessels 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. The pain which accompanies the reception of gunshot injuries is often so trivial, that the attention of the wounded is only called to the fact by blood streaming down his legs. The majority liken the striking of a ball to a smart blow with a supple walking cane, whilst with a 12 18S NERVOUS SHOCK. few the pain is very severe, and simulates the feeling which would be produced by running a red-hot wire through the flesh. McLeod mentions the case of an officer who had both of his legs carried away, and who only became aware of the injury which he had received when he attempted to rise. It appears as if every gunshot wound was accompanied by a certain amount of shock, or a partial paralysis of sensation, which is nature's preparation, permitting a thorough examination, with little or no pain. The unusual quiet of a hospital the night following a battle has been repeatedly noticed, and is accounted for by this nervous shock. When this condition passes off", then reaction brings with it much suffering. In this nervous shock, with the suspension of activity in the circulatory function, lies the safety of many a wounded soldier. Its influ- ence is immediately felt in the injured tissues, and the infiltration and engorgement of these are prevented. When nervous depression exists, but little blood escapes from the injured vessels, and as there is no force from behind, owing to the diminished action of the heart, to drive on and keep in motion this blood, its clotting is favored. When reaction ensues, the clot is al- HEMORRHAGE, HOW CHECKED. 130 ready so firmly established that it cannot be dis- placed; the injured vessels remain thoroughly and permanently plugged up, and the dangers from immediate hemorrhage are prevented. 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 benefited by immediate dressing, they should be attended to on the field of battle ; then they give less trouble to the surgeon, less pain to the soldier, and much better final results in treatment. Here all hasty dressings or examinations are to be deprecated, and a methodical course pursued. The indications of treatment, in all gunshot wounds, are, 1st, To control hemorrhage; 2d, To cleanse the wound by removing all foreign bodies, and, 3d, To apply such dressings and pursue such a rational course of treatment as will establish rapid cicatrization. Hemorrhage, which produces such terror in the bystanders and anxiety in the patient, should never unnerve the surgeon, who requires all of his self-possession and surgical tact to cope success- fully with this ebbing away of life. Fortunately, in gunshot wounds, serious hemorrhage is of rare occurrence; and when the largest arteries are in- 14:0 TOURNIQUETS DISCARDED. jnred, they either cease bleeding spontaneously, or the patient dies so rapidly, that art is of little ayail. If the case is not injuriously interfered with, the natural hemostatics soon controls the bleeding. The ragged character of the wound, and the nervous shock accompanying the injury, or brought on by the loss of blood, reacting upon the circulatory organs, so diminishes the heart's impulse and drives so little blood to the extremi- ties, as to favor a stagnation of blood in the wound. The formation of a clot plugs up the orifice in a bleeding vessel, and stops any further loss of blood. This spontaneous arrest of hemorrhage is usually 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- some surgery suggest the use of a tourniquet, which cuts off the circulation and especially the veinous return, the limb soon swells, tissues become engorged, excessive extravasation in the wound follows, and a train is laid for future mis- chief. The field tourniquet, in former days, was so much in vogue that it was considered indis- pensable on the battle field, and was therefore carried in large numbers, to be applied to every HEMORRHAGE, HOW CHECKED. 141 limb from which blood was trickling, or from which hemorrhage was feared. Now, 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. Recent writers warn surgeons of the too hasty 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 filled 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 lint, a compress, or sponge over the wound, secured by a bandage, which, in closing the outer orifice, favors the formation of a clot. If the hemor- rhage is at all active, as if from some large artery, in addition to the compress on the wound, the entire limb should be carefully enveloped in a bandage, to some distance above the injury, so that by compressing the soft parts it could dimin- ish the amount of circulating fluid in the limb, 142 HEMORRHAGE, HOW CHECKED. and prevent the ingress of blood into the tissues. The hemostatic properties of this dressing can be increased by soaking the sponge or compress covering the wound with the per chloride or per sulphate of iron, which, as a powerful astringent, when coming in contact with fresh blood, will immediately form a clot. A lump of ice placed upon the compress will act with equal efficiency. A sponge or compress, with or without the iron styptic, tied on the bleeding wound, is all that the surgeon superintending the transportation of the wounded is expected to do. Unless the hem- orrhage is very violent, threatening immediate destruction of life, the tourniquet is rarely re- quired. 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 instrument. The finger pressure of an intelligent, assistant is better than any tourniquet ever made, and is a far preferable means of controlling excessive hemor- rhage, which the compress and bandage may fail to check. The femoral artery, for any injury to its trunk or large branches, should be compressed in the groin where it runs over the pubic bone ; the brachial, where it pulsates against the head of the humerus, as here its course is nearly subcutaneous. PROBING WOUNDS. 143 When the position of these main trunks are shown to any intelligent assistant, and he is made to recognize the throbbing of the artery, he will have no difficulty in keeping the vessel com- pressed during the transportation. As soon as the wounded arrives at the tempo- rary resting place where the surgeons are assem- bled, all bandages are removed, and the wound carefully examined. A glance at the wound when the clothing has beeu previously examined, will often tell when there are two orifices differ- ing in appearance and in a direct line with each other, whether foreign bodies have lodged or not. As the patient is now faint from loss of blood and from nervous depression, the wound not yet being painful or swollen, the surgeon using his fin- ger, which is the only admissible probe on such occa- sions that the military surgeon of experience recognizes, examines the entire extent of the wound, search- ing for foreign bodies. This examination is made without fear of repro- ducing hemorrhage, as the finger cannot displace the clots which hold firmly to the openings in the vessels. Every surgeon has .noticed how rudely a stump might be sponged, and what force it requires to wipe away clots which have formed over the face of a smooth, incised, open wound. 144 PROBING WOUNDS. 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, before swelling has taken place. A silver probe will travel in the direction given to it by the surgeon, in examining fresh wounds, and as most jiwsons guide the ■probe in- stead of allowing the probe to guide them, the true course of a ball can only be determined by it with great difficulty. It is but recently that I 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 intro- duced it followed the track of the ball at a very oblique course from the one which the probe had taken. This example is sufficient to show why military surgeons denounce the silver probe, and distinguish by its use the tyro in surgical practice. 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 REMOVE FOREIGN BODIES. 145 course of the ball to the main arteries of the limb. It is a matter of great importance to deter- mine 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 secon dary hemorrhage. Should but one opening exist, and all the clothes of the soldier covering the wound be torn, the- probability is, that foreign bodies com- plicate the wound. It must be remembered that the ball as a hard body can usually be readily recognized, but that portions of wadding or clothing may be readily mistaken for a clot of blood or the ragged lining of the wound. This is particularly the case when they become satura- ted with the secretions. Forewarned being fore- armed, the surgeon, remembering these difficul- ties, will examine with special care for these soft, foreign complications. When found they should be extracted, as their presence is certain to estab- lish a high degree of inflammatory excitement, with profuse subsequent suppuration. This effect was well shown in the case of a pri- vate of the 2d Regiment of South Carolina Vol- unteers, who, during the attack on Fort Sumter, was shot by the accidental discharge of a musket. 13 146 HISTORY OF CASE IMPORTANT. The ball entered the chest at the anterior fold of the armpit, fractured the clavicle, 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 sur- geon, and, by an incision through the skin, was easily removed. Inflammation of a high grade followed. He was sent up to a city hospital one week after the accident, when he was losing from three to four ounces of pus daily from the wound. O.n 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 mass of wadding over two inches long and as thick as the finger, which tent-like mass had been driven into the tissues by the ball. Examination of his clothing now, for the first time, showed the deficiency in the lining of his coat from which this mass had been torn. The re- moval of this irritant diminished the discharge immediately, so that, in the succeeding twenty-four hours, the discharge diminished to one-sixth its former quantity, and in four days was hardly suffi- cient to soil the dressing. The history of the case is of much import- ance in examining wounds. Often, the course of the ball cannot be discovered without it. What HISTORY OF CASK IMPORTANT. 147 surgeon, however great his experience, seeing a wound made in the arm by a ball, would think of looking in the opposite thigh for its place of lodgment, did he not learn that the injury was received from above, whilst mount- ing a scaling-ladder, with arms raised above the patient's head? The ball entering the back of the arm near the elbow, passed down the arm under the shoulder-blade, across the loin and, traversing the buttock, lodged under the skin of the outer part of the opposite thigh, where it was found, and removed. Knowing the direc- tion from whence the ball came, and the position in which the soldier was placed, you know at once the course which the ball most probably took ; and your examinations in that direction will not only save much time, but save the pa- tient much suffering and annoyance. Often, the play of a muscle will shut off the track of the ball. The relations of the soft parts vary with every position of the limb, and a passage made when a limb was flexed, could not be followed when the same limb is extended. Hence the necessity of placing the limb in the same posi- tion in which it was when the injury was re- ceived. The wound having been carefully examined 148 REMOVAL OF FOREIGN BODIES. 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. The ques- tion is not so much whether balls can remain innocuous in the flesh, but do they ? Those who have had experience in gunshot wounds in the Held, know Iioav excessive is the irritability caused by the presence of a ball in a wound; how restless and irritable the patient is until it is removed; how profuse the suppuration and prolonged the period of treatment in those cases in which it has been left: and how frequently the after-conse- quences are so distressing, the pain so perma- nent, and discharge so constant, as to demand future interference or make life a burden. If such be the case with ball, how much the more urgent the extraction of the foreign bodies is indicated, especially fragments of shell, portions of clothing, etc. Balls may, in time, become encysted, but these are exceptional cases : and even when such occur, their presence in after years may set up inflammation, which will mat together and bind down important parts, whose usefulness depends upon freedom of motion. Repeated REMOVAL OF FOREIGN BODIES. 149 abscesses may form, pressure upon bones may give rise to ulceration and a tedious exfoliation, blood-vessels may ulcerate, nerves be painfully compressed, and life rendered miserable, if not jeopardized. In McLeod's Surgery of the Crimea, the report of M. Hutin, chief surgeon of the Hotel des Invalides, is given, which is a striking commen- tary in favor of the removal of all foreign bodies. He reports that of 4,000 cases examined by him, in which balls had remained unremoved, only twelve men suffered no inconvenience ; and the wounds of two hundred continued to open and close continually till the foreign body was re- moved. If the ball be felt loose in the soft parts, a bul- let forceps can be made to seize it; and it can be extracted without difficulty, provided the disengaged hand of the surgeon support the limb on the oppo- site side to that at which, the forceps is introduced. Otherwise the ball glides in front of the forceps and cannot be seized. The ordinary bullet forceps, as simulating the dressing forceps of the pocket case, was the instrument preferred by Larrey, and is still, deservedly, in general use. Many changes have been made in these, without ad- vancing to anv extent the merits of the instru- 150 REMOVAL OF FOREIGN BODIES. merit. A very good bullet forceps is one ter- minating with a sharp prong on either blade, at right angles to the blade, so that when closed the points are protected by the blades. These act as an axis upon which the ball may be rolled out of the wound, instead of being drawn out as with the dressing forceps. When a ball is firmly imbedded in bone, it is 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 trav- ersed 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 in- cision over its position, and not be sought and drawn through the entire length of track which it had traversed. Baudens, in noting the difficulty of extracting these subcutaneous balls, ascribes it to a layer of cellular tissue, which firmly and completely caps the ball. It is thin enough to be diaphinous, and yet tough enough to clasp and hold firmly the bullet. Guthrie speaks of the difficulties of ex- traction depending upon the surgeon being too fearful of increasing the incision. Balls can be ex- REMOVAL OF FOREIGN BODIES. 151 tracted with the least pain and with great rapidity by making a bold incision. This course marks the difference between civil and military surgery; half an inch added to the incision does not in- crease its dangers, and expedites the extraction. Be quite sure, however, that you are cutting upon a ball and not upon some bony prominence, which comparison with the opposite limb should warn you from. It is sufficient to mention that such mistakes have happened to military sur- geons. By foreign bodies we mean balls, pieces of clothing, spicule of bone, which have been bro- ken off and are loose in the wound, and any articles about the person which may have been driven before the hall. These should all be re- moved immediately after the injury has been re- ceived, and before swelling or infiltration renders the task difficult. When done early, the wound will be found sufficiently large to allow of the easv extraction without dilating. It is onlv 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 152 REMOVAL OF FOREIGN BODIES. formerly the constant rule of practice, is 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 be readily ex- tracted without injury to the soft parts. This old medical dogma was based neither upon ex- perience nor observation, and is now very prop- erly considered useless, injurious and barbarous. When a ball alone complicates a wound, if it be not readily found, after a careful and intelligent search, rather than continue the examination from day to day, which can only be prejudicial to the case, from the irritation and inflammation which will be excited, it would save the surgeon much anxiety and the patient much annoyance, if the ball or other foreign body be left until suppuration be well established. Then it will gradually ex- pose its situation, and can be much more readily removed than during the height of reaction when the parts are very much swollen and very painful. The surgeon will assist nature in the expulsion as" soon as the swelling has subsided to such an extent that the finger or instrument can again be introduced into the wound. The above rules apply chiefly to gunshot wounds of the extremities; those of the trunk and PRIMARY EEMORRHAGE. 153 liead offer so many exceptions to the above, and require, in a measure, such special treatment, that the course to he pursued in these wounds, complicated with foreign bodies, will be speci- ally dealt with in discussing special injuries. We have already stated that fatal hemor- rhage, from the large vessels of the extremities, rarely occurs on the battle field, and that when the large arteries are wounded, the hemorrhage is either so immediately fatal that no assistance can be rendered, or it ceases spontaneously. The nervous depression so common to shot wounds with its tendency to syncope, and its control over the circulatory organs, checks the impulse and supply of blood through the injured vessel, and promotes the formation of clots. Openings in arteries may be closed by foreign bodies, and in such cases hemorrhage would recur when these are extracted. The largest arteries may however, be wounded, and may cease bleeding spontaneously. The only means of detecting this injury would be in examining carefully the strength of pulsation in the vessel, beyond the course of injury. A diminution of its force, when compared to that of the corresponding vessel in the opposite limb, shows conclusivelv some hindrance to the circu- 154 LIGATION OF ARTERIES. lation. When no external hemorrhage exists, an absence of pulsation in the course of the artery below the wound is the only means of detecting serious injury to the vessel, and it often decides whether the limb should be at once amputated. The presence of the pulse is, of course, no indica- tion that no injury has been received. Although, from the course of the ball and the flow of blood, we know that the main vessel of the limb has been injured, if the bleeding has ceased sponta- neously, or by the pressure of the sponge, or compress, which was tied over the wound, the artery should not be interfered with. In by far the majority of cases, if proper precautions be taken, there will be no recurrence of the hemor- rhage. The patient should be kept perfectly quiet, free from all causes of excitement, at per- fect rest; and to ensure that the limb shall not be moved, a bandage should be carefully applied from the extremity of the limb upward, and a long splint secured. The flannel bandage being the most elastic, is the best material for such methodical pressure and support. Elevation of the. limb will add much to the efficacy of the preventive treatment. The ligation of an avtery, which is the only sure precaution against the return of hemorrhage, LIGATION OF ARTERIES. 155 is not only a difficult operation, requiring much skill for its successful performance, but when necessary to control the bleeding from a recent wound, becomes a very dangerous one to the safety of the limb or life of the individual. In cases of disease, nature, always on the alert, has enlarged contiguous blood-vessels, which are ready to assume all the functions of the one requir- ing obliteration. In a wound in a healthy person no such preparation has been made ; and in cut- ting off the main supply of blood through a limb it becomes a very serious question, often answered by the loss of the limb and even life, whether the circulation will be 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 such 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 mortifi- cation. If placed on a healthy vessel for an in- jury, the limb at once becomes pale and cold, requiring the application of artificial warmth and enveloping in flannels to support life in it until the circulation be re-established, when the limb becomes actually warmer than its colleague. The 156 LIGATION OF ARTERIES. arterial supply is now disseminated in vessels much nearer to the surface 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 secondary amputations. When a thigh is amputated in a healthy portion, very seldom are there more than three or four ligatures required to stop all oozing and render the stump quite dry. If the amputa- tion be necessary at the same point three or four days after an injury to the main vessel has been received, the number is greatly increased : as many as twenty-eight arteries have been ligated by Langenbeck after amputating a thigh under similar circumstances. Should active hemorrhage continue and show no disposition to cease, the wound should be dilated, the bleeding mouths of the artery found, and a ligature applied both r t ami heloir the injur;/. This has become the fixed practice and the only safe one, taking its place among the aphorisms of surgery. The universal adoption of this practice is not only based upon experience and observa- tion, but could be determined a priori from the physiology and anatomical distribution of arteries. All surgeons are familiar with the anastomosis or collateral circulation in blood-vessels. A\ nen LIGATION OF ARTERIES. 157 the current of blood, is stopped at any one point, it will soon find its way through many circuitous routes round to the very point through which its straight course had been checked. When an arte- ry is divided, it is well known that, owing to its muscular and elastic structure, that portion above the wound at once contracts and retracts, so that the tube which was before cylindrical, now resem- bles a claret bottle with a much constricted neck. A clot of blood soon forms in this mouth and neck, and the passage of the blood is intercepted. In the lower portion of the divided vessel similar changes are, going on, but 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 blood remains in the tube that a very small and indifferent clot is formed. "When the upper portion of the artery is firmly closed, preventing all egress to blood, the lower portion remains patulous, inviting discharge. As soon as the blood-currents find their way by cir- cuitous channels, it wells up from the wound in a continuous purplish stream, all impulse having been lost, and also most of the oxygen by the long roundabout way which the blood now takes. The darkness of the blood will depend upon the 158 LIGATION OF ARTERIES. difficulties of the circuitous passage; the rule, however, is scarlet or arterial blood from the upper end of the vessel, dark or veinous colored blood for its lower end. Guthrie lavs down the two following rules as the great principles of 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 be performed upon a wounded artery unless it bleeds. 2. That no operation is to be done for a wounded, artery in the first instance, but at the sp>ot injured, unless sack operation not only appears to be hit is impracticable. When it is necessary to ligate an artery, the surgeon must be guided by his anatomical knowl- edge, and by the pulsation in rinding it. In di- lating 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 by layer, and avoiding the nerves and veins which always accompany the large arteries. When the bleeding mouth is so exposed that the origin of the jet of blood is seen, the vessel is transfixed by a tenaculum drawn out and secured as it would be in a stump after amputation. LIGATION OF ARTERIES. 159 Where it is impossible to ligate the bleeding- vessel at the point wounded, a point should be selected, at which the vessel is comparatively isolated, easily discovered, and free from large collateral branches. In exposing it make a free incision. The common mistake that most sur- geons make is a small incision, which hampers 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 be 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 accomplishing speedily and successfully the ligation. In all cases requiring such an operation, it is desirable to have the patient completely under control, and, therefore, chloroform should be adminis- tered. When the artery is found, and 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 to see whether the pulsation has altogether ceased below the ligature. Having determined 160 LIGATION OF ARTERIES. that the thread is properly placed, it is then firm- ly tied, the ends are brought out of the wound and secured under a strip of adhesive plaster, attached to the immediate neighborhood of the wouud. This mode of disposing of it will pro- tect it from becoming entangled in the ordinary dressing, and be drawn upon when these are daily removed. Water dressings would he the proper after-treatment. The thread will have come away spontaneously, by the eighth, twelfth or sixteenth day, according to the size of the vessel ligated. When it is necessary to ligate the artery in its eourse above the seat of hemorrhage, I would prefer using a fine silver wire ligature. This is well twisted upon the artery, and then cut oft', leaving only the loop with one or two twists in the wound. The advantage is, that the foreign body being very small, not weighing more than one-third or one-half of a grain, creates but little irritation, and the wound can be healed in a few days by quick union. This will protect the patient from the dangers of sup- puration, pyaemia, or secondary hemorrhage from the ligated point. In the treatment of reducible inguinal hernia, where I have obtained permanent cures by sewing TREATMENT OF WOUNDS. 161 the columns of the ring together by silver wire sutures passed subcutaneously, the small loop of wire remains permanently in the inguinal region under the skin, and gives no trouble. From ex- perience, in limited periods, I have reason to believe that it will remain innocuous for a life- time. The silver wire should not be applied to arteries in a suppurating wound, or where sup- puration and sloughing must ensue, as in cleans- ing the wound it would be liable to be dis- turbed, and may be the cause of bleeding. Should the ligation of the large arteries at the root of the neck ever prove successful, it must be by the adoption of the silver wire ligature, which can be twisted sufficiently to cause a certain degree of irritation in the outer coats of the artery, and induce a copious deposit of lymph for incarcerating the wire and thicken these coats, without causing sloughing of the inner coats or opening the vessel. Local treatment of wounds. — Having removed all foreign bodies, and hemorrhage having ceas- ed, the dressing now required should be of the simplest description. It is known that gun- shot wounds, favoring the contused variety. 14 162 TREATMENT OF WOUNDS. show a constant disposition to suppurate and often to slough. This process of suppuration is not necessary to the healing of the wound, and should be kept in subjection as much as possible. This is effected by the continued application of cold, which, by keeping down excessive reaction, and keeping out an excess of blood, diminishes the source of the pus supply, and thus hastens the cure. In former times, suppuration was consi- dered essential in the healing of all wounds, by permitting the escape of so much poisonous matter, which had accumulated in the system, and Avhich must either now find a vent, or, if retained, would be considered the satisfactory cause of any sickness which the wounded man may ever suffer from 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 band- ages, a forcing bed was formed, which supplied pus to the satisfaction of all interested ; and it was common enough to see life drain away from. this opening. This smothering of wounds and smearing -on of greasy ointments, which the wounded formerly encountered, was a second enemy, far more fatal than the enemy on the battle field : as in its TREATMENT OF WOUNDS. 163 ranks ranged exhausting" suppuration, with its hectic ; pyaemia, with its rapid poisoning ; hos- pital gangrene, with its sudden collapse, and erysipelas, with its thousands of victims, broken- down constitutions, tedious convalesence, very protracted cures, and endless pain and annoy- ance. How much more rational is the present prac- tice. Keep away all hot dressings, which invite blood to the part. Vote poultices a curse, and eject the dirty, troublesome application. Guthrie says poultices should not be permitted in a mili- tary hospital ; they are generally cloaks for negli- gence, and sure precursors of amputation in all serious injuries. With more recent writers they even meet with less favor. The only dressing required for wounds, of whatever character, is the irate)' dressing, and it should be used as follows : apply a single thickness of wet linen or cotton cloth over the wound, allowing it to ex- tend over a considerable surface. If possible, cover this with a layer of oiled silk, waxed cloth, or india-rubber tissue. A second layer of cloth or a band secures the two former layers in position, so that they will not be displaced by the motions of the patient in sleeping. Then, either squeeze cold water frequently upon this outer cloth, which 164 TREATMENT OF WOUNDS. will keep up the low temperature ; or what is a much more convenient and less laborious plan, suspend a bucket or some vessel containing water in the neighborhood of the wound, having a narrow slip of cloth, or, what is better, a lamp wick from the suspended vessel to the bandage upon the wounded limb. By capillary attrac- tion, a constant stream of water is carried from the vessel to the dressing, and by its evaporation, robbing the skin of its animal temperature to .get a sufficient quantity of heat to convert the water into aqueous vapor, it refrigerates the limb. The advantage of using the oiled silk, waxed cloth, or india-rubber tissue is, that should the water supply accidentally give out in the suspended vessel, the piece of cloth be- neath it remains moist upon the wound. The wet cloth absorbs the discharges, and should be changed two or three times a day, it being well understood that they be disturbed as "seldom as possible, compatible with cleanliness. The surgeon should never be in haste to change the cold for warm applications. Should the vir- tues of a poultice be called into requisition, a soft wet compress covered with oiled silk and secured by a flannel roller or outer compress, is always at hand, and will be found to combine, in a simple TREATMENT OF WOUNDS. 105 form, all the properties of a poultice. It is light, moist, soft, and is kept warm by absorbing animal heat, which the oiled silk and outer compress retains. If we add to these, cleanliness, facility of medication, and the readiness with which an impromptu dressing can be made, we find an array of advantages which excludes all substi- tutes. 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 is used, never apply it directly to the skin, but always through the intervention of com- presses, which may be made sufficiently thick to accommodate the application to the sensitiveness of the patient. AYhen possible, these bladders should be of india-rubber or gutta-percha. A large supply of these should always be on hand. The animal bladder is a miserable substitute, as it is not only a very dirty application, allowing the water to ooze out and keep the patient con- stantly wet, but the bladders become very offen- sive, and are soon destroyed. Cold water is the only proper and universal antiphlo- gistic that can be applied to wounds. It has the con- 166 TREATMENT OF WOUNDS. venience of always being at hand, it keeps up a uniform action, is clean, simple, cheap, agreeable to the feelings of the patient, easily obtained, easily applied, demands least care from the nurses, who have their hands usually full, and is withal effectual. With the judicious application of cold the surgeon can defy inflammation. Cold acts by keeping down temperature, con stringing vessels, and keeping blood from the part injured; so that inflammation, which consists in the engorgement of blood-vessels and an excessive supply of blood, cannot get a foothold. Heat, redness, pain and swelling, all depend upon congestion ; control the supply of blood to a part, and inflammation is kept in abeyance. As the advantages of cold water dressings are obtained through the evaporating properties of water, this action may be increased by medi- cating it with saline substances or alcoholic tinctures. Sugar of lead, sulphate of zinc, tan- nin, muriate of ammonia or laudanum, spirits of camphor, and, especially, tincture of arnica would be useful adjuvants. Whilst the irrigation is going on, the compresses next the skin may be mois- tened every three or four hours with any of the above preparations. Should the wounded patient feel chilly, the cold dressings will not be used TREATMENT OF WOUNDS. 167 until reaction has taken place. There are a few- persons with whom cold water is not admissible. In all cases the feelings of the patient will he our guide as to the applicability of the remedy. When not grateful and refreshing to the patient, but, on the contrary, the cause of complaints, the irrigation must be superseded by a wet compress, covered with oiled silk or a waxed cloth. This will soon attain the temperature of the body, and will keep the parts moist and soft. The dress- ing requires to be changed twice in twenty-four hours; not that the compress w 7 ould get dry, for the perspiration from the part which is kept in by the oiled silk w/ould bathe it in a continual and permanent moisture. The object in changing is to get rid of this secretion, which, by decom- posing, would irritate the wound. A question of great moment is, when should we desist from water apjrtieations and change for some more useful or appropriate dressing? According to the present rational views of surgeons, no other dressing is ever required, however serious a wound may be. As long as inflammation threat- ens, so long is it necessary to prevent engorge- ments. As long as suppuration is kept up, so long will the efficacy of cold be required to con- stringe the blood-vessels and control the source of the purulent supply. 168 TREATMENT OF WOUNDS. Pus, which we call a healthy fluid, is a heavy drain upon the system. It is made from the richest ingredients of the blood, which were intended for the repair of tissues. Once converted into pus, it is unfit for any further useful purpose, and is therefore a w T aste 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, do very well without its intervention. Large sub- cutaneous wounds, when even their sides are not kept in apposition, heal w T ith rapidity without the formation of pus. Under a scab we find tissues form, by what has been called the remodeling process, without it; and it should be our constant effort to heal all wounds, and I would say espe- cially gunshot wounds, with the least possible discharge. Hence the water dressing can be con- tinued beneficially for weeks, or as long as the wound remains unhealed. The most recent writers on gunshot wounds state that the wet cloth should be kept on until cicatrization is completed; and that no other application so protects and pro- motes the formation of new skin. There are a long list of ointments which have heretofore held universal sway in the treatment of wounds. All of these can be dispensed with for the more simple SECONDARY HEMORRHAGE. 169 dressing. Should the wound require stimulation, the nitrate of silver wash, grs. xx to the ounce, when brushed over the part, will suffice ; or tinc- ture of iodine, or iron, or some stimulating astringent might be equally applied in addition to the water dressing, so that any imaginary con- dition of the wound might be successfully met by the medicated wet cloth. The disturbing influences in the healing pro- cess of wounds are numerous, and most of them are capable of correction without much trouble. Among these are found imperfect transportation over rough roads ya improper vehicles; bad at- tendance, such as rough or too frequent examina- tions ; useless bandaging, which promotes infil- tration ; too frequent dressing ; improper food ; scorbutic, syphilitic, and other diseases; the mor- al depression of defeat, and above all, the imper- fect ventilation and undue regard to cleanliness in the wards of military hospitals. We have already said that a surgeon is never warranted in cutting down upon an artery and tying it upon suspicion — he must be an eye-wit- ness of the 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 15 170 SECONDARY HEMORRHAGE. jeopards the limb, and necessarily with it the life of the patient. This is specially the case in recent wounds, before nature has prepared a collateral circulation, so that the rule which we have laid down is imperative, never ligate an artery, however large, in which hemorrhage has spontaneously ceased; and, moreover, that a good compress is usually sufficient, when applied immediately after the receipt of injury on the battle field, to stop the bleeding even from the largest vessels, when position, quiet, rest, and other prophylactics will prevent its return. In the ordinary course o£ gunshot wounds, suppuration is established about the fifth or sixth day, when the track of the wound commences to be organically cleansed of all those tissues which have been crushed and so much injured as to be no longer preserved among the living tissues. During the elimination of these destroyed parts, where the precaution of rest and absolute quiet has not been enforced, hemorrhage, called se- condary, appears. All injuries to large arteries threaten, sooner or later, to produce secondary hemorrhage. However large the artery reopened by this process, the escape of blood seldom occurs with an impulse, but flows away in a continuous stream, which marks its escape from the lower end of the vessel. SECONDARY HEMORRHAGE. 171 When hemorrhage, even from the femoral artery, has been arrested for twelve hours, the efforts of nature are usually sufficient to prevent its 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, once primary hemorrhage is controlled, the great fear is then from bleeding through the lower end of the artery, and from mortification of the extremity. Any hemorrhage, after twenty- four hours, would be considered secondary, and would require special treatment. As long as the wound remains open hemorrhage may make its appearance, and it is not until a cure is effected and the parts are cicatrized, that the patient is positively safe from this dangerous complication. Cases are recorded where it has occurred ninety days after the vessel had received injury. Unless the causes of this hemorrhage be perfectly under- stood, the rules laid down for treatment will not be duly appreciated. In speaking of the behavior 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 for some distance up the tube, until it simulates in its proportions the neck and body of a claret bottle. The blood, 172 SECONDARY HEMORRHAGE. impeded in its outward course, allows a clot to form, which, acting as a stopper, shuts up the open mouth. The plug is continued in the contracted artery to the first collateral branch as a clot of blood, which nearly fills its cylinder. The lower portion of the vessel, having been in a measure paralyzed by the division of its coats, which had cut off its supply of nerves, acts with much less energy. The diminution of its calibre depends more upon the removal of distension from its elastic walls than from the contraction of its muscular fibres. The result is, that it remains more or less patulous; and as the supply of blood from above is cut off, there is but little arterial blood in it to clot and plug it up. As soon as this barrier or clot is placed upon the main thoroughfare, at the upper wound, prevent- ing; the blood from following; its accustomed chan- nel, nature is at once busy, opening and enlarging the circuitous by-ways and alleys of the circulation, so as to restore the supply to the extremity threat- ened with starvation, or, in surgical parlance, mortification. As when upon a high road a bridge spanning a stream is destroyed, travellers seek a ford higher up by which they may return to the thoroughfare beyond the impediment, so the blood taking the nearest bv-roads above, soon TREATMENT OF SECONDARY HEMORRHAGE. 173 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 ves- sel, escapes. This fluid, moreover, in its round- about course, has lost much of its vivifying prop- erties ; much of its oxygen is gone, and carbonic acid, ammoniacal gases and the like, have taken its place, marred its brilliant color, and dimin- ished its clotting properties. No material then exists for stopping up the vessel, as in the upper end of the divided artery, and the result is, that secondary hemorrhage nearly always occurs from the lower ends. This being well understood, we can now ex- plain wlvy a ligature placed on the upper orifice alone, or on the course of the artery above the Injury, should not stop but only temporarily con- trol the hemorrhage. As soon as the collateral circulation above the ligated point is re-establish- ed, the lower opening in the vessel remaining as before, hemorrhage must recur, or, if this circu- lation is not re-established mortification must follow. The rule then is imperative, ligate both ends of the vessel at the point wounded; this is the only safe course to pursue. Another strong reason why the 174 TREATMENT OF SECONDARY HEMORRHAGE. ligature should be applied to the wounded ends of the artery is, that there is always some un- certainty as to the vessel injured. The very serious and often fatal operation of ligating the femoral artery has been performed for injury to one of its branches, which had not been suspected until a post-mortem examination revealed the source of bleeding. When the ligature is ap- plied to the bleeding mouths, this accident can- not happen. The course ivhich should be adopted in the case of an injured artery bleeding, is as follows: After the hemorrhage has once been controlled, through either some carelessness on the part of the sur- geon or restlessness on the part of the patient, getting up to help himself when he had strict orders to the contrary, etc., or perhaps from rough transportation over bad roads, or the sloughing of the wound, hemorrhage reappears, the limb should be at once bandaged from the extremity up- ward, making careful, regular pressure, so as to diminish the quantity of circulating fluid. Over the course of the main artery, and for some little distance below the wound, a compress saturated or not with some of the styptic preparations of iron should be firmly secured, the bandaging of the limb extending to one or two inches above TREATMENT OF SECONDARY HEMORRHAGE. 175 the injury. The patient is then to be placed upon his back, the limb elevated and an ice bladder applied over the wound. Absolute quiet should be enjoined, and secured by a large dose of opium. In many cases, this dressing will bring about the desired object, when assisted by those internal re- medies which control the force of the circulation, as veratrum viride, digitalis, etc. B3' the use of the compress saturated with per chloride of iron, in connection with absolute rest, I have succeeded in checking secondary hemorrhage from the caro- tid artery after the escape of the ligature. But should the parts be so situated that this pres- sure cannot be applied for a sufficient!}" long time, or should it not control the bleeding, then the proper course is to ligate the mouths of the artery in the wound without further delay. ISTo case of secondary hemorrhage should destroy life by repeated recurrence ; a surgeon is very culpable who permits life to ebb away from his grasp. Phy- sicians caunot be too guarded against the delusive attempts at stopping the bleeding after the recur- rence of secondary hemorrhage, it is certain to return and certain to destroy life, as experience repeatedly proves. Every fresh hemorrhage in- creases the dangers and doubles the risks, there- fore, never neglect ligating after the second hemorrhage. 176 TREATMENT OF SECONDARY HEMORRHAGE. You must not be deterred from placing a liga- ture on the open months of an artery in a suppur- ating wound, on the deeply grounded, but erro- neous idea, that the artery has had its coats soft- ened by this process. Practical surgery shows con- clusively, that the coats are tough enough to sus- tain a ligature in a suppurating wound, and there- fore the rule should have no exception. Li 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 subcutanoeus. This tor- tuous track can only be made by a ball striking at a considerable obliquity. Its direction is gen- erally indicated by a reddish or purplish line under the skin, which, when followed by the linger pressed on the surface, imparts a crackling sensation, caused by air in the cellular tissue. Such injuries are usually simple, and require but 278 PENETRATING WOUNDS OF CHEST. little treatment. The cold water dressing tills every indication, and its application for a few days usually effects a cure. A great amount of nervous shock often accom- panies very trivial injuries of the chest. Many instances are mentioned by militar}^ surgeons in which halls had struck articles about the person of the soldier — the breast-plate of a cuirassier, or, perhaps, a book in the breast-pocket of a sol- dier's coat — and had fallen to the ground without even touching the skin, yet the soldier had been knocked down breathless, and, in some cases, did not recover completely from the shock for days. When 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, winch the rational signs, with discultation, will detect, and an antiphlogistic course, accompanied with the free use of opium, will readily subdue. Opium, when used in large doses, frequently repeated, possesses other virtues than merely allaying pain and quieting nervous symptoms. It combats, directly, inflammation, and, by the great control which it exercises over the brain and circulation, INFLAMMATORY EFFUSIONS IN CAVITY. 279 becomes one of the most, if not the most valuable remedy of the materia medica in the treatment of the serious sequelre of wounds. 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 or forty-eight hours, the fluid compressing and condensing the lung against the vertebral column. In expanding the chest, it will be 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 dis- appear when the cavity is filled. At the same time respiration becomes much embarrassed with marked dyspnoea. Percussing the side, will now give a dull, heavy sound, instead of the ordinary clear, sonorous one of health ; and the position of the patient, unless the cavity is filled with fluid, must vary the sound by the gravitation of the serous collection. The lung is condensed and flattened against the vertebral column, and is 2S0 INFLAMMATORY EFFUSIONS IN CAVITY. temporarily impervious to air: under a long con- tinuance of the pressure, it will become per- manently consolidated. The increase in the circumference of the chest, and the fulness of the intercostal spaces, and the absence to a great extent of respiratory movements upon the affect- ed side, are conspicuous symptoms of a distended cavity. The quantity of fluid thrown out varies from a few ounces to several pints. When the na- tural dimensions of the cavity are not sufficient- ly extensive to accommodate it, it forces the mediastinum over to the sound side, interfering with the action of the healthy lung, whilst an encroachment 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 symptoms of dyspnoea, an early evacuation will be re- quired. 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 effusion, any broad intercostal space, between the sixth and eighth ribs on the right, or be- tween the seventh and ninth on the left, might INFLAMMATORY EFFUSIONS IN CAVITY. 281 be the point selected. The instrument, usually a trocar and canula, should be introduced at right angles to the chest and near the upper edge of the rib, toward its angle, in a line continuous with the posterior border of the arm- pit. As this puncture corresponds with the lowest portion of the cavity, the chest can be perfectly drained through it. In all gunshot injuries of the chest, the serious complication is injury to the lungs or heart, and it is often difficult to detect at first such lesions. Notwithstanding the many infallible 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 does not takes place as a general rule, the wounded man lives but a short period. The pericardium soon becomes filled with blood; 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 pulsation. Reports of cases 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 its cavities, have escaped with life. When 24 282 SYMPTOMS OF LUNG WOUNDS. the pericardium is perforated, and the heart not injured, a successful result might be obtained by a judicious course of antiphlogistic treatment, which will keep down inflammation, with its ef- fusions of lymph and serum. The lung often escapes injury when, from the position of the wounds of entrance and of exit, with the certainty of the cavity being transfix- ed, the natural belief would lead to a perfora- tion of the lung. A straight line between the wounds passes apparently through the substance of the lung, but the ball in perforating the rib had been deflected from its straight course, had followed, perhaps, the inner curve of the chest, and, meeting with some resistance, had forced its way through the chest, either appear- ing under the tough, elastic skin, or escaping without touching the contained organs. The lung may, on the other hand, be se- verely injured when no perforating Avound ex- ists. A blow by a spent ball, or a fragment of shell, may make a very superficial wound or bruise in the skin, and yet may shatter one or more ribs, driving the spicula? into the lung, lacerating to a greater or less extent its sub- stance. Even without fracture of the ribs, the concussion or blow may have been sufficiently SYMPTOMS OF LUNG WOUNDS. 283 great to have caused irreparable injury to the lung. The severity of the symptoms will de- pend upon the 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 the hemorrhage. It is on account of this loss that the most conspicuous symptoms arise, viz : hemorrhage, collapse and suffocation. The patient may be at once suffocated by a large quantity of blood filling up the thorax, and preventing the ingress of air into the lungs. Usually blood passes from both mouth and wound ; that from the mouth is frothy and florid, and is brought, up by a short, tickling, harass- ing cough. The size of the dark-colored stream, pouring from the wound, depends upon the po- sition of the orifice. Where the orifice is sit-* uated low upon the chest, and is large and direct, the effusion into the cavity escapes freely — the symptoms of collapse may soon appear, but suffocation is prevented; whilst from an injury in the upper portion of the chest, particularly if small and oblique, the thorax may fill with blood, and suffocation becomes imminent, with out much external loss. The danger from hemorrhage is greatest during the first twelve 284 SYMPTOMS OF LUNG WOUNDS. 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 unequivocal proof that the lungs have been injured, although their absence do not prove the contrary. The mere loss of blood from the lung is no certain indication that the organ has been injured, as bloody expectoration is a common symptom of blows upon the chest, and may accompany the most trivial injury. Eraser, 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, McLeod, Stromyer, Ballingall and others. Fraser's experience in the Crimea, gives, in nine fatal cases in which the lungs were wounded, but one instance of haemoptysis, and, in seven fatal cases in which the lungs were not injured, two had a spitting of blood. In twelve cases of recovery, three had haemoptysis. He, therefore, infers that spitting of blood is a very deceptive diagnostic sign of lung Avound. When it is rapidly brought up by mouthfuls it becomes an important symptom. SYMPTOMS OF LUNG WOUNDS. 285 The discharge from the wound is sometimes occasioned by injury to the intercostal vessel, but this is so rarely the case that McLeod states that he neither saw nor heard of an instance during the Crimean war. The most distressing symptom is dyspnoea, which may appear soon after the injury has been received, or, perhaps, not until some days have intervened; in certain cases of undoubted lung injury it may not have been present at any time. This symptom is sometimes very intense, from moral or other causes, when the lung is not wounded, and it may be but slightly marked, or even altogether absent, when the lung is seriously implicated. This difficulty in breathing depends in some instances upon the direct pressure and con- densation of the lung by air or by fluids. When the chest has been opened by a ball, the lung does not collapse as is generally supposed, but, if the opening is sufficiently large, can be seen moving to and fro against the thoracic walls simultaneously with respiration ; and, as a proof of the continued action of the lung, 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 completely perforated, it does not necessarily collapse, but as blood escapes into the 286 SYMPTOMS OF LUNG WOUNDS. pleural cavity, the lung may be driven back and condensed against the vertebral column, with the accompanying symptoms of dyspnoea. From in- jury to the lung and continued escape of air into the pleural sac, we sometimes find similar diffi- culties in respiration induced. Emphysema is a symptom of injury to the lung upon which much importance has been placed. It can occur under any circumstance by which air is admitted into the pleural cavity, where, being compressed by the action of the lung and walls of the chest, it is forced out through the wound; but if a ready exit is not offered for its escape, or should any obstacle exist in the form, size, or direction of the wound, it is forced into the cel- lular tissue. Owing to the free communication in the interstices of areolar tissues, it diffuses itself widely and rapidly. Should a perforated wound from ball or other weapon allow air to enter the pleural cavity, whether the lung be injured or not, emphysema might appear. It is not so common after gunshot wounds, as a free exit is offered to the contents of the cavity. It is a much more common accompaniment of oblique punctured wounds by sword point or bayonet, and also in cases of fractured ribs, when sharp spicule of bone have abraided the surface of the SYMPTOMS OF LUNG WOUNDS. 287 lung and allowed air to escape from the air tubes into the cavity: as it is found either with or without lung injury, it cannot be of much value in diagnosis. The injured lung, in gunshot wounds, does not often permit air to escape for any length of time from its wounded surface, as an immediate extravasation of blood into the bruised tissue closes up the air tubes and shuts oft" communication with the cavity. Another symptom of great value is 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 be ex- tensively opened, the loss in even a short period must be excessive. It is not surprising, therefore, that the patient should soon become cold, pale, and faint — with feeble, small and irregular pulse, and with rapid tendency to syncope. This is na- ture's effort to check further loss; and although sometimes successful, often gives but temporary security. The surgeon tries to induce this con- dition 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, but it is rather from a combination of phenomena that any 288 SYMPTOMS OF LUNG WOUNDS. certainty in diagnosis is attained. The imme- diate danger and intensity of the symptoms will depend upon the depth of penetration. Where the chest is only superficially wounded, although the force of the blow may be sufficient to produce an amount of shock of shorter or longer duration, and blood may be expectorated from the concus- sion of the lungs, the symptoms will be trivial. The pain of the bruised tissues will pass oft' in a few 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 and subsequent effu- sions of serum or pus should ensue, the case will equally require but little treatment. When the lung is implicated, and especially when se- verely wounded, other symptoms are more or less conspicuously present. Soon after the reception of a severe wound, blood pours from the injured vessels and escapes both into the air tubes and into the pleural cavity. From the air vessels it is brought up and expectorated, in greater or less quantity as haemoptysis, whilst it flows from the external wound in the side. If both openings in lung and chest be free, the blood escaping is min- TREATMENT OF LUNG WOUNDS. 289 gled with air when the patient coughs. With the loss of blood, the surface becomes cold and bedewed with a cold perspiration; the pulse is weak and tremulous, becoming more and more enfeebled until syncope comes on, which tempo- rarily checks the excessive bleeding. Should the orifice in the side offer an imperfect escape to the blood, it collects in the pleural cavity, rapidly encroaches upon the lung, which is forced back against the spinal column, and by compressing the opposite side of the chest through the medias- tinum, threatens suffocation. The eyes protrude, nostrils expand to their utmost, the arms are thrown about in every direction, and frightful struggles for breath appear in every feature; these are the cases which, if not immediately relieved, will in a few moments terminate fatally by suffocation. The field surgeon, in transporting those wounded in the chest, will give the most careful attention to the severely wounded. The simple cases, re- quiring no immediate attendance, will be sent on to the field infirmary. Although the wound has evidently transfixed the chest, if no urgent symp- toms exist, the case is also carefully conveyed to the infirmary, or even directly on to the general hospital; but should the distressing symptoms 25 290 TREATMENT OF LUNG WOUNDS. above mentioned follow soon after the injury has been received, then the life of the patient is in the hands of the ambulance surgeon, and should he ignore or neglect the case, the soldier may not reach the infirmary alive. Notwithstanding the hemorrhage, open a large vein and draw away blood, if possible, to syncope. 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 to the lungs, and a disposition to the formation of a clot may plug up the bleeding vessels. The dyspnoea, and not the pulse, will be the indication for bleeding in lung wounds. The patient is not detained on the field to see the effects of the venesection, but, with his vein open, is sent on to the field infirmary, accompanied by the surgeon himself, or by an intelligent assistant. As soon as he faints, the surgeon at the field infirmary removes the rough field dressing, examines the wound with the finger, and, if not sufficiently large to permit a thorough search for foreign bodies, w^here such are suspected, he dilates it with a probe-pointed bistoury. In perforating chest wounds, unless urgent symptoms of dyspnoea are present, the general treatment is the expectant plan. The wound TREATMENT OF LUNG WOUNDS. 291 having been carefully closed with diachylon, the patient lies on the wounded side, so as to throw the lung against the orifice, hoping that it may adhere to the chest at that point, and so close the cavity ; he also finds this the most comfortable position. He is kept quiet, in a dark room; all excitants are avoided, rigid diet is instituted; veratrum viride, or digitalis, is given to control the action of the heart; opium is freely administered to quiet the constant hack- ing, trickling cough, and iced cloths or bladders are applied to the chest. "With such treatment and careful watching, seeing the patient, if pos- sible, every hour, we await the development 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 fluids in the cavity. If it be a shot wound, with a single orifice, and the clothing be found perforated, the wound should be examined for foreign bodies. If 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 for foreign bodies must always be made with the finger, and should never be protracted. Should nothing be found after a moderate, intelligent 292 TREATMENT 0F~LTJNG WOUNDS. search, close the wound, and await developments. This examination should be made before reac- tion comes on. Should we not see the patient until he is feverish, all examinations must be ab- solutely 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 encyst- ed in the lungs years after they had been de- posited ; and, in some instances, these articles have been expectorated during a severe spell of coughing, after long intervals. Although always desirable that these be removed, a prolonged search may entail such an amount of injury as to destroy all hope of saving the patient, when the presence of the foreign body would not have been necessarily incompatible with life or even health. Besides, when suppuration is well estab- lished, we have a second and much better oppor- tunity for a careful examination, without much fear of doing injury. Should the gradual accumulation of blood in the cavity of the chest cause dyspnoea, the orifice may require opening, to allow the fluid to escape and relieve the pressure upon the lung. In drawing off the contents of the chest, if syncope threatens, we close the opening, and await anoth- TREATMENT OF LUNO WOUNDS. 293 er opportunity. The collection is retained in certain cases, when no dyspnoea exists, for the purpose of retarding, and finally controlling the bleeding, by pressure upon the lung and its in- jured blood-vessels. After the third or fourth day, the tendency to hemorrhage having ceased, and the wound having already commenced to suppurate, the adhesive plaster is removed, and the effusion is allowed to escape. If air has been admitted into the cavity, the exuded blood has decomposed and, mingled with serum and pus, makes a copious and very offensive discharge for the first few days. Gradually the escaping fluid loses its dark color and offensive smell, and assumes the appearance of healthy pus. Formerly much care was taken to favor the flow of fluids from the chest, and dilatation of the wound was the recognized rule ; now, the oppo- site treatment is the one urged to exclude air, and if possible, retard decomposition, as this de- terioration of the effused fluids is more injurious to the system than the advantages obtained by their ready escape. From this time onward, simple water dressing- will be the only local treat- ment required for the wound. If the orifice from a punctured wound has healed, with es- caped blood remaining within the chest, the 294 TREATMENT OF LUNG WOUNDS. collection, if small, should be ignored, as it will gradually be absorbed ; but if the extrava- sation be extensive, particularly if air had pre- viously entered the cavity, it must be withdrawn through a puncture made at the most dependant portion of the chest. This operation, unless call- ed for by urgent or distressing symptoms, should never be hastily performed, but should, on the contrary, be delayed as long as possible. During the treatment of perforating wounds of the chest, dyspnoea, whenever urgent, should always be removed by the lancet, the venesection to be repeated as frequently as called for by threatened suffocation, unless this symptom be clearly traced to pent-up fluid, when opening the wound or enlarging it, to permit a ready escape, will remove the oppression of breathing. Prompt and repeated venesection will also be required to control hemorrhage, which is a common cause of death in such injuries, and will alone diminish the •number of victims of chest wounds. In collapse, we have already recognized a valued aid for checking hemorrhage, and its remediable advan- tages should be appreciated. As a symptom, it must be carefully watched, and should it threaten to stop the action of the heart, external stim- ulation must be freely used, but the internal TREATMENT OP LUNG WOUNDS. 295 stimuli must be administered only in small quantity and with great caution. When the immediate dangers have passed, the next in or- der 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 pneumonia is some- times circumscribed to narrow limits, and its cause may, to a certain extent, modify the gen- eral symptoms. As the cause of pleuritis is a direct injury to the membrane, and, in the ma- jority of instances, as air has been admitted within the cavity, the effusions which accom- pany the inflammation soon become purulent, and in time false membranes of considerable thickness line the inner surface of the ribs. The treatment for either pneumonia or pleurisy, when occurring from a gunshot wound, does not differ from the treatment of the disease from any other cause. McLeod's experience is in favor of early, active, and repeated bleedings, with cool drink and abstemious diet, recognizing, at the same time, however, that many excellent recov- ries have been made without recourse to the lancet. Guthrie uses the lancet, w T hich he desig- nates the first and most essential remedy, and which he says should be resorted to in every 296 TREATMENT OP LUNG WOUNDS. case. The venesection, which he repeats when- ever the inflammatory symptoms show an increase, is vigorously followed by large doses of tartar emetic in pneumonia, and calomel in pleurisy, the object being to affect the gums as soon as possible. This is the treatment of the old school, which recent experience does not uphold. Guth- rie states "that in the Crimea bloodletting had not been so favorably viewed, nor found so ser- viceable, nor so necessary." Fraser, from Cri- mean experience, states that in the prevention and reduction of inflammatory action in perfora- ting wounds of the chest, venesection is not demanded. It should only be used when the pulse is full, strong, and labored — a condition not often met with. "When the heart and pulse are both weak, a common condition after 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 prefer the mild, expectant and antiphlogistic treatment to the spoliative. Absolute rest, cooling bever- TREATMENT OF LUNG WOUNDS. '± { .H ages, moderate nourishment, avoiding over-stimu- lation, with small doses of tart, emetic, veratrum or digitalis, with the liberal use of opium, and attention to the intestinal secretions, will be re- quired in all cases, and in many will compose .the entire treatment. A certain degree of pleuritis is expected and desired in penetrating lung wounds, to establish adhesions between the injured lung and thoracic wall, which will at once isolate the injured portion and prevent inflammatory sequela?. As gunshot w r ounds do not close rapidly but usually suppu- rate, permitting the free access of air within the thorax, the suppuration will be profuse and long- continued. We must remember this in the treat- ment, and not use depressing agents. When the pleuritis is excessive and general, both false mem- branes and the rapid 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 pus could have a constant outlet for escape, and accumulation within the cavity could be pre- vented, the false membranes would tie the lung 29S TREATMENT OF LUNG WOUNDS. 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 chest, it w r ould hasten the cure to establish a counter-opening from the most dependant portion of the cavity, from which the drain would never be interrupted. The chapter on the treatment of suppurating w T ounds lays down general law r s for counteract- ing the injurious influences of long-continued suppuration. Penetrating wounds of the thorax occasionally remain fistulous for an almost indefi- nite period, which is caused by a failure of gen- eral adhesion between the costal and pulmonary pleurae. A kind of pouch is found, lined by a false membrane, from which a purulent lymph is continually secreted. After empyema, the chest contracts, the walls sink in, the diaphragm rises high on the affected side, the spine becomes contorted, air enters indifferently into the lung, little or no respiratory movements are seen in the chest, and a portion of the respiratory appa- ratus is rendered useless to the economy. Usu- ally, the long train of symptoms terminate fatally in phthisis. Very few cases of injury to the lung, from gunshot wounds, are ever restored to health. TREATMENT OP LUNG WOUNDS. 299 In cases of fractured ribs, from gunshot injuries, the bone is usually spiculated, and some of the fragments may accompany the ball in its onward course. Upon examination with the finger — executed with great caution from the fear of pushing the fragments into the chest and con- verting a simple wound into a perforating wound, always a serious accident — these irregu- lar fragments, if detected, should be removed, and, if necessary, the outer wound should be enlarged to facilitate this important step. The danger is not so much from the breaking of the bone, but from the displaced, sharp frag- ments, which may seriously injure the pleura? and lung. When removed, and the sharp edges of the rib, which turn in toward the cavity, are 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 band may surround the chest, to control the thoracic movements and allay the pain ; but, should any oppression in the breath- ing show itself, the bandage cannot be applied, as it will increase the suffocative feelings. Where the spicule are not displaced, a broad adhesive strap is the only local apparatus required. Ne- crosis of the rib very commonly follows a gun- 300 TREATMENT OF LUNG WOUNDS. shot fracture, and may require a subsequent re- section for its removal. When an intercostal artery is divided, the bleed- ing point will be discovered by drawing out the lips of the wound with a tenaculum, when the vessel should be secured. All military surgeons agree that this operation is more frequently spoken of than performed. Many of extensive experience have never seen a case. When foreign bodies, as balls, pieces of bone, cloth, wadding, etc., are driven into the pleural cavity they produce fatal results, by inflamma- tion and exhausting discharges, unless removed. A loose ball can be sometimes felt by the patient, and its movements often detected by the stethe- scope. Through an opening, made at the most dependant portion -of the chest, the foreign body can be removed successfully. CHAPTER 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 walls — Sew up intestinal wounds — Dilate wound, in abdomen when necessary to relieve strangulation and facilitate re- duction — Where the larger viscera are injured, re- covery is rare — Avoid using purgatives when the intestine is wounded — Peritonitis a common cause of mortality — Where the intestine is much crushed, leave it out of the wound, or excise the crushed portion and, close the intestinal wound, by sutures — In wounds of the bladder, continued use of catheter essential. Sir Charles Bell has remarked that, although abdominal wounds hore a fair relative proportion to other wounds, immediately after a battle, a few days sufficed to remove them — so that, by the end of the first week, there was scarcely one to be seen. As a rule, all who have received 302 PERFORATING WOUND. wounds of the large abdominal viscera die — the exception, of restoration to health, being rarely met with. Like wounds of the chest, where the abdominal walls are not perforated, but the en- tire track of the ball lies in the thickness of the muscles, "the wound is simply a flesh wound and should be treated accordingly. The track of the ball is not always in a straight course,, as the muscles, or their tendinous portions, when in action, offer sufficient resistance to turn the ball. The fascia transversalis is said to show a similar resistance to oblique shot. A perforating wound of the abdomen is equally dangerous as those of the chest, from the fear of peritonitis, which is apt to supervene. If the perforation be made by a sword or bayonet, or if there be any prospect of healing by the first intention, the wound should be accurately closed by adhesive straps or by sutures. In sewing up an abdominal wound, many recommend that the needle should not pass deeper than the super- ficial cellular tissue, giving as a reason that when the muscles are included in the sutures, they sometimes draw themselves out of the noose by their contraction, whilst, if the peritoneum be also included, peritonitis is much more likely to occur. Although this may hold good for the PERFORATING WOUND. 303 peritoneum, I can see no reason why attempts should not be made to cause union in the muscles, and, therefore, avoiding the peritoneum, I would include all the tissues, even to the transversalis fascia, in the suture. When this is done, the cicatrix will be firmer, and there will be less probability of secondary hernia — a very common accident after injury to the abdominal w T alls. In probing abdominal wounds, the only object to be sought by the examination is whether the w.ound has perforated 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 w r ound; whilst with the finger, or a gum bougie, the course of the wound, should it be a flesh wound, can be traced, and also the existence of foreign bodies detected. Should we find that the opening transfixes the abdominal wall, our examination should go no further — it is a dangerous amusement to satisfy curiosity at the expense of such irreparable mis- chief as may destroy the life of the patient. If the wound be a large one, as when made by a sabre-bayonet, fragment of shell, or Minnie ball, a portion of the abdominal contents may protrude from the wound. When the ambulance 304 PERFORATING WOUND. surgeon finds such a case on the field, his first duty will be to examine the protrusion. If it be a portion of small intestine and be not injured, he cleanses it of dirt and all other extraneous sub- stances, by pouring water upon it, and carefully returning it within the abdomen, closes the wound by sutures, if it be an incised wound ; or a broad strip of diachylon plaster, if a gun- shot wound. He then administers a dose of mor- phine, and sees that the wounded man is properly transported to the field infirmary. To facilitate the return of the protrusion, whether it be intes- tinal or omental, the patient is placed upon his back with the thighs drawn up, and the ab- dominal muscles relaxed, when the ambulance surgeon makes steady pressure upon the protru- sion in the direction of the wound. The bowel must be handled very carefully — no force should be used, or so much injury might be inflicted as to cause the rupture, sloughing or inflammation of the protruding organ. The better plan would be to encircle the protrusion by the fingers clustered together as a funnel or cone, which will diminish the bulk at the opening in the abdomen, and facilitate its return. If it be found that the mass is so constricted by the small size of the orifice, that the return within the abdominal PERFORATING WOUND. 305 cavity is impossible without inflicting injury upon the bowel, the intestine should be drawn to one side, and, using great caution, the wound should he enlarged upward for a quarter or half an inch. As the constriction is rarely in the peritoneal wound but usually in the muscles and fascia, the incision, if possible, should not include the peritoneum. Cutting upon a grooved director, or using a probe-pointed bistoury, will diminish the dangers of wounding important parts wuthin whilst enlarging the wound. The return of the bowel should always be effected b} T the ambulance surgeon before the case is transported to the field infirmary, inasmuch as the crowding of the wounded at the infirmary may be such that several hours might elapse between the receipt of injury and the hospital examination — quite long enough to cause stran- gulation of the intestine, and either necessitate inflammation or mortification of the protrusion, usually a fatal complication in abdominal wounds. The early return of the protruding intestine makes the case one for simple and successful treatment. Be satisfied that the intestine has been returned w T ithin the abdominal cavity, and not forced under the sheaths of the abdominal 26 306 INTESTINAL INJURY. muscles, where it would strangulate and rapidly destroy life. Should the case not be seen until several hours had elapsed, the intestine should he equally re- turned whether it he congested or inflamed; hut when gangrenous, which is recognized by its greenish ash color, loss of polish, its flaccid condition, with already a disposition to separa- tion in its various coats, it should remain without the wound, and be laid open so as to allow its fecal contents to be evacuated. Adhesions rapidly form, uniting the protruded intestine to the peri- toneum at the inner orifice of the wound. This shuts off' all connection with the peritoneal cavity, and prevents extravasation of fecal mat- ter within it. If the bowel be returned in a 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 is closed with one, two, or more points of inter- rupted suture, according to the size of the open- ing — a stitch being placed for every one-sixth of an inch of intestinal wound. The ends of the suture are cut off* close to the knot, and INTESTINAL INJURY. 307 the whole is returned into the abdomen with care. A fine cambric needle will be the best instrument for sewing up intestinal wounds, as the small puncture and fine thread produce scarcely any irritation. In passing the sutures, do not include the lining mucus membrane in the noose, for if this be allowed to pout between the lips of the intestinal wound it might inter- fere with rapid healing ; the serous or perito- neal layers should be brought in contact, when union rapidly follows. If a large dose of opium had been admin- istered on the battle field, or as soon as the patient had arrived at the infirmary whilst 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 the last portion returned, when the hernia is extensive, remains within the 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 the bowel slough from the injury which it had received, its contents, instead of being thrown into the peritoneal cavity where it would produce fatal inflammation, on account of the adhesions of the bowel near au external 308 INTESTINAL INJURY. outlet, will escape externally, which diminishes materially the risk run by the patient. The threads used in closing the opening in the intes- tine either escape through the bowel by stool, or are discharged through the abdominal wound. When examining the external wound when no protrusion exist, should we find an escape of fecal matter — which proves that the bowel has been perforated — the abdominal wound must be en- larged, and the wound in the intestine closed by suture. This is the only expedient for saving life; for if the contents of the bowel are allowed to escape into the peritoneal cavity, a fatal issue must be expected. The dilatation of the wound diminishes the risks. Should the intestine be extensively injured beyond the possibility of saving it, rather than return a portion of bowel within the abdomen to mortify and destroy the patient, it should be left hanging out of the wound. All of the sound portion of the protrusion having been returned, the crushed portion is enveloped in a wet or oiled cloth. The peritoneal coat of the bowel will form adhesions to the peritoneal edge of the abdominal wound, the outer portion sloughs, and an artificial anus gives constant escape to the fecal contents. In time, this artificial outlet gradually INTESTINAL INJURY. 309 closes by a spontaneous effort of nature, the fteces seeking their normal passage, or an operation at some subsequent period removes the deformity. In examining the archives of surgery, we find cases in which portions of the intestines have been cut off, the cylinder of the bowel reunited by sutures, and excellent recoveries obtained. These experiments have been tried successfully upon animals, and instances are met with where the human subject has been saved by a similar operation. I have recently had under my care a lunatic, who, some months since, attempted suicide by opening his abdomen, drawing out his bowels, and cutting oft* two feet of intestine. Dr. Gaston, of Columbia, S. C, who had the case under charge, brought the two ends of the intes- tine together, and securing them by carefully arranged sutures, returned them within the cavity. The patient made a perfect recovery. This accident, which terminated so successfully for the lunatic, suggests an operation for a crushed intestine, which may offer better prospects than leaving the bowel to slough and form an artificial anus : — remove the injured portion, secure the bleeding vessels, and reclose the intestine by su- tures, treating the case as if an incised wound of the bowel had alone existed. 310 INTESTINAL INJURY. In all perforating wounds of the abdomen, as we cannot tell, in the absence of symptoms, whether the intestines have been injured or not, there are two fundamental rules of treatment never to be forgotten, and which are required in every instance. 1. Give opium freely and frequently, with a double object, viz: of controlling the peristaltic action, which alone can prevent extravasation of the contents into the peritoneal cavity, and for its antiphlogistic effect, to equalize the circula- tion, allay pain, suspend nervous irritability, and prevent inflammation. 2. Avoid the use of purgatives. With the majority of physicians who have had but little experience in the treatment of abdomi- nal wounds, the first impulse is to see the bowels emptied, and hence the fatal purgative is eagerly administered. An evacuation apparently reassures them that all is 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 or four days at least after the receipt of injury, in which the intestines are known or are supposed to be wounded, absolute rest, the most abstemi- ous diet, and the liberal use of opium (one grain INTESTINAL INJURY. 311 of gum opium, or its equivalent in laudanum, every five hours) in connection with cold water or iced dressing, will compose the entire treat- ment. If the patient feels 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 closed by lymphy effusion, and the dangers will, to a certain degree, have subsided. If required, a dose of Epsom salts, citrate of magnesia, or castor oil, may now be given, although it would be better to wait one or two days louger, when the risks of reopening or disturbing the wound would be but slight. If peritoneal inflammation be excited with fe- brile reaction, with pain greatly increased by pressure over the abdomen, more particularly in the neighborhood of the wound, with tympa- nitis, vomiting, hiccup, small, quick pulse, and anxiety of countenance, the fears are -that lymph and sero-purulent matter will be rapidly thrown out, gluing coils of intestines together, and filling the cavity with fluid. To check this rapidly fatal disorganization, leeches or cups should be applied to the abdomen, to be fol- lowed by ice bladders, which are now preferred, or by hot narcotic or turpentine stupes, or by blisters, whilst opium should be given in large 312 INTESTINAL INJURY. doses and at short intervals. If the patient he young and plethoric, and the inflammatory symp- toms are early recognized, the lancet might be used; hut usually in military surgery this reme- dy is badly borne. Calomel was formerly used with the opium, and was considered the main dependence, but is now being generally dis- carded, as all advantages gained are accredited to the opium. Sometimes, in a few hours, usually at the end of the second or third day, collapse, with a cold, sweating skin, and feeble, irregular pulse, shows the ravages which the system has experienced from the peritoneal inflammation, and marks rapidly-approaching dissolution. It is rare that the liberal use of brandy with carbonate of am- monia, external warmth and synapisms rescue the patient at this advanced stage; although, if given when debility commences to show itself, they may support the patient, and be the means of saving life. When the swelling of the ab- domen, and the dull sound which percussion elicits, shows extensive effusion, the abdominal wound should be reopened, and, by placing the patient in a proper position, the effusion be allow- ed to escape. It is a desperate operation, but lias been known to save a few cases, which, if INTESTINAL INJURY. 313 left alone, would have certainly perished as those do upon whom this operation is not performed. In gunshot wounds of the abdomen, if the missile has perforated, it would be madness to probe the abdominal cavity. We must imagine the worse, give the patient the benefit of these doubts, and by extreme care hope to counteract the baneful influences which foreign bodies, when remaining in the 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 case pro- gresses, can alone inform us on this head. From the physiological eifects we might, at times, trace the resting place of the ball. When paralysis 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, the source of blood may be from within the cavity from injured viscera, or may be caused by division of the epigastric artery in the abdomi- nal walls. If the latter, dilatation of the wound will expose it, and the vessel should be ligated. 27 314 HEMORRHAGE FROM ABDOMINAL INJURIES. When from the former source but little can be done, venesection to syncope might check the flow, and the formation of a clot may plug up the injured vessel. Some surgeons, knowing the desperate condition brought on by internal hemorrhage, recommend dilating the wound, and should it be found that hemorrhage comes from one of the mesenteric vessels, the artery should be ligated. The position of the external wound will assist us in forming a diagnosis as to the probable source of the hemorrhage. Cases of recovery are recorded where the wound was dilated, and the bleeding vessel in the omentum sought and secured. "Where some of the large viscera or blood- vessels are injured in perforating abdominal wounds, the symptoms are much more marked than in intestinal wounds; hemorrhage at once takes place to a serious and often fatal extent. Such wounded are often found dead upon the bat- tle field; or should they be alive, they are pale and cold, with anxious countenances and intense long- 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 col- lapse. In other cases, the shock may permit the HEMORRHAGE FROM ABDOMINAL INJURIES. 315 clogging of injured blood-vessels, and stop inter- nal 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 pe- riod of intense suffering. On account of the hemorrhage and subsequent inflammation which accompany these injuries, all wounds of the larger abdominal viscera are considered nearly neces- sarily mortal, as the exceptional cures are very rare. When the external orifice is small, the position and direction of the wound will lead us to suspect the special injury, and, in connec- tion with persistent vomiting, the ejection of blood by the mouth, by stool, or vrlth the urine ; the escape of special secretions, as bile, urine, or fa?ces by the wound ; and the peculiar pain or sensations experienced by the patient, will be our chief indications in determining the part in- jured. The treatment of these serious wounds, which on the whole is so unsatisfactory, is similar to that required for perforating wounds of the chest, with injury to the lungs. If seen soon' after the accident, before much blood has been extrava- sated, and if nervous shock is not present, the 316 INJURY TO. BLADDER. patient should be bled nearly to syncope for its anti-hemorrhagic effect, and then opium inter- nally, and cold locally, become the basis of treat- ment. In loounds of the kidney, frequent micturition with bloody urine marks the injury; whilst in injuries to the bladder, bloody urine, or rather, the passage of clots 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 to 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 field of battle, and should be worn continuously for four or five days until adhesive inflammation has 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 of the parte often obstructs the ready flow of urine. The gum catheter may even be kept in from the com- mencement of the treatment until the wound is CRUSHING OF ABDOMINAL VISCERA. 317 well advanced in healing, unless it excites much irritation, when it may be temporarily with- drawn. This precaution will prevent many cases of urinous infiltration and save many lives. When the neck of the bladder, or the prostatic part of the urethra has been divided, if the catheter cannot be introduced, a free incision should be made through the perineum for the evacuation of urine and the discharges from the wound. Injury to the large intestines are not so serious as perforations of the small. As the large bowel is bound down in the greater part of its course, extravasations of their contents do not necessarily take place into the peritoneal cavity; and although fecal matter escapes externally from the wound, and high inflammation, with profuse suppuration, usually follows, many of the wounded eventually do well. Cases not unusually occur on the battle field in which the abdominal contents might be severe- ly 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 as those we are now considering were formerly brought for- ward as instances of the fatal effects of the vacuum 318 THE EFFECT OF SPENT BALLS. following the wake of a cannon ball. Observa- tion has shown that a knapsack might be torn from the back, a hat struck from the head, an epaulet from the shoulder, or a pipe from the mouth, without leaving a trace of injury, whilst, on the other hand, viscera might be reduced to a jelly, or bones crushed, without visible bruising of the skin. It is the ball itself, and not the wind, which produces these disorganizations. From the blow of a spent cannon ball or frag- ment of shell, the liver might be lacerated, intestines torn, blood-vessels opened, spleen fis- sured, 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 life. Although we follow vigorously the treatment laid down above, we very seldom have the satisfaction of saving a patient. The amount of destruction effected by a spent ball is often surprising. The uninitiated on the battle field will attempt to stop, with the foot, a cannon ball rolling on the ground, and which is just about exhausting its force, perhaps with only momentum sufficient to carry it one or two feet further, } 7 et it crushes the limb put out to oppose THE EFFECT OF SPENT BALLS. 319 it. Baudens, in warning persons to avoid cannon balls, however slowly they may be rolling on the ground, mentions the case of a grenadier of the guard, sleeping on his side on the ground, who was instantly killed by a spent cannon ball, the blow from which luxated the vertebral column. The ball came with so little momentum that it rolled itself up in the hood of the soldier's over- coat, where it was found. It was just about to stop when it struck. One or two feet further, and its entire force would have been exhausted. CHAPTER XI. Injuries of the extremities; compound fractures; difference of treatment in the upper and lower limbs; importance of an early examination and adoption of a course of treatment within twenty- four hours after the receipt of accident — Compound fractures of the arm from shot wounds, when not implicating joints, do not require amputation; should the blood-vessels and nerves be 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 amputation; when, and under what circumstances should amputations be performed — Modes of operating and of dressing stumps — Chloroform in all serious operations. As the major portion of the injuries of the extremities are merely flesh wounds, these will not require to be again noticed. Those which we INJURIES OF THE EXTREMITIES. 321 will now consider are such as involve the bones, joints, or important vessels, and which may call for special treatment. It is in this department that conservative surgery has made the greatest advances, and has accomplished so much iu diminishing mortality and mutilation. ISTot that amputations will ever be abolished, for many lives can be saved in no other way than by the sacrifice of limbs; but conservative surgery 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. Amputations must, however, ever remain a surgi- cal necessity; and he who removes crushed limbs with the greatest skill, and saves the patient by successful after-treatment, will ever deserve the high position which humanity and philanthropy will bestow upon him. In gunshot wounds of the extremities, we find a much greater vitality and resistance to injuries in the upper than in the lower limbs, which would modify the treatment of 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 safety which enables us to 322 COMPOUND FRACTURES. 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 compound fractures. These have always been a numerous and important class in military surgery, but have become doubly so in modern warfare, from the substitution of coni- cal shot for the round musket ball. This projec- tile never impinges upon a bone without leaving frightful traces of devastation. Such a conical ball very rarely remains embedded, but acting on the principle of a wedge, it splits and comminutes the bone, driving the loose spiculse in every direction, and even detaching some of them from the body to impale neighboring soldiers. Crimean surgeons, who have had many opportu- nities of observing injuries, from every description of missile, in referring to the conical ball, speak of their effects as so dissimilar to those of round balls, as almost to justify a classification of injur- ies founded upon the kind of ball giving rise to them. They state that the longitudinal splitting of the bone is so dexterously and extensively accomplished by the conical ball, that while only a small opening leads to the seat of fracture, COMPOUND FRACTURES. 323 the whole shaft may be rent from end to end. Fortunate is it that this extensive splitting or Assuring of the long bones does not exteDd into the joints, or the cases for operation would be much more numerous than they now are. The epiphysis of the bone appears not to transmit the force of cleavage, as the injury most frequently stops at the junction of the head of the bone with its shaft. The successful treatment of such wounds requires much judgment 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 patient is conveyed very carefully to the field infirmary; or, if it can be done without delay, to the general hospital, where the treatment commences On the field, the ambulance surgeon can do nothing but administer a dose of morphine, and secure the limb to a rough splint to facilitate transpor- tation. For a fractured clavicle, scapula or hu- merus, 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 broad splint, and slung from the neck. If the splint is not at hand, the slins; made of a handkerchief must answer 324 SHOULD THE LIMB BE AMPUTATED ? 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 pro- tection during the transportation. When he arrives at the hospital, the limb is carefully examined. The external wound may give no indication of the extent of internal injury. When the finger is introduced and the wound carefully explored, the degree of crushing will be ascertained, and the question at once proposes itself, what course shall we pursue? Shall we attempt to save the limb; or does its condition, with the want of proper facilities for its successful treatment, necessitate its condemnation? If we have had experience in the care of gunshot frac- tures, we should, with Sir Charles Bell, contem- plate what will be the condition of the parts in twelve hours, in six days, or in three months. " In twelve hours the inflammation, pain and ten- sion of the whole limb, the inflamed countenance, the brilliant eye, the sleepless and restless condi- tion, declare the impression the injury is making on the limb and on the constitutional powers. In six days, the limb, from the groin to the toe, or from the shoulder to the linger, is swollen to half the size of the bod}'; a violent phlegmonous inflammation pervades the whole; serous effusion SHOULD THE LIMB BE AMPUTATED ? 325 has taken place in the whole limh, and abscesses are forming in the great beds of cellular texture throughout the whole extent of the extremity. In three months, if the patient has labored through the agony, the bones are carious; the abscesses are interminable sinuses; 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 them the more immediate dangers of mortification, and the remote dangers of erysipe- las, pyaemia and hectic, and the questionable utility of the limb, when, after several months of continued trials, the wound has been healed. Business presses and time is valuable. "Within twenty-four hours, or before reaction ensues, whilst the patient has his sensibilities depressed by the shock, our conclusions must be made and acted upon; success of treatment depends upon prompt action — the delay of a few days has destroyed thousands of wounded. Should ampu- tation be required, there is no period in the pro- gress of the case so favorable for the performance of this operation as the first four and twenty hours. Should an injudicious attempt be made to save the limb, amputation cannot be resorted to with any hope of success until suppurative 826 SHOULD THE LIMB BE AMPUTATED? action has been well established. Should ery- sipelas attack the wound, an amputation is im- practicable; and when gangrene has supervened, during the stage of reactionary excitement, we are driven to an operation under the most un- favorable circumstances. There are many compound fractures upon which judgment can be immediately passed: with some, there is every probability that the limb can be saved; whilst there are others in which the limb is condemned at a glance — our prog- nosis being based upon the following circum- stances : As the upper extremity can sustain a much more serious injury than the lower, we may lay it down as a rule that a simple compound frac- ture of any of the long bones of the arm, when not complicated 3vith excessive crushing of the soft parts, can, and should be saved. An arm is rarely to be amputated except from the effects of a cannon shot, which, beside crushing the bones, makes frightful lacerations of the soft tissues, tearing away muscles, nerves, and blood-vessels, and often amputating completely the limb — the surgeon being required only to give a better form to the stump. For a gunshot wound from a musket or Minnie REMOVE SPICULE. 327 ball, which has fractured the bones of the arm without implicating a joint, the following is the course to be pursued. At the field infirmary the wound is carefully probed with the finger, and its spiculated condition noted. All loose fragments are to be removed at this first ex- amination before reaction ensues, for it will be very injurious to the wound, as well as exces- sively painful to the soldier, to continue such examinations from day to day. The first exami- nation should always be effectual. The patient is then suffering from shock, with sensibility temporarily blunted, and is therefore in the best condition to be 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 chloroform, rather than desist from this important portion of the treat- ment. Should we omit to bring away all spiculse, the further removal should not be attempted during the stage of excitement and febrile reac- tion which will come on after twenty-four hours, and which will run its course in six or eight days. When this subsides, then and not before, we make the second examination, and by the use of instruments, remove any loose fragments 328 REMOVE SPICULE. which we now detect. We will simply men- tion, in this connection, that as there is not the slightest probability; or even possibility, of the wound closing by the first intention, the inser- tion of tents and pieces of lint is a relic of bar- barous surgery, which cannot be too severely condemned as useless, injurious, and very painful. Modern surgery recommends that all spicuhe, whether detached or not, should be removed; but this practice is not upheld by surgeons gene- rally. Experience and observation has, in some instances shown, that although the larger frag- ments may be detached from the shaft of the bone, they may still be adherent to the peri- osteum, which will effect a reunion and con- solidation. On the other hand, experience and observation have shown that, from the force with which conical shot strike a bone, the spi- cule, which are very numerous, are driven in every direction, but mostly toward the opening of escape of the ball. These sharp splinters can- not but produce excessive irritation in the soft parts, and may, by transfixing vessels, pricking nerves, or irritating muscles, induce hemorrhage, mortification, or tetanus. No surgeon doubts the propriety of removing all such on the spot, or at the earliest possible moment. As the open- REMOVE SPICULE. 329 ing of exit, around which the larger number of the fragments are found, may be too contract- ed to admit of a thorough exploration of the wound, it will not increase the dangers but, on the contrary, materially diminish the risks of after-trouble, if the wound of exit, in compound fractures with crushing of the bone, be dilated so as to facilitate the detection and removal of every spicula. In enlarging this orifice, injury to the important blood-vessels and nerves will, of course, be avoided. On the subject of removing all fragments, whether detached or not, there appears to be a diversity of opinion, which is based upon the changes introduced into modern warfare. The older surgeons, who base their treatment on the effects of the musket ball, know that often the connection of the fragments to the soft parts and to the periosteum will guarantee a consolida- tion of the fragments. The rouud ball simply breaks the bone without scattering the frag- ments, and therefore their relations to the sur- rounding tissues will not be so materially changed. But notwithstanding this impression, which may or may not be correct, what does actual experience prove, when brought down to facts ? Take the experience given by the inmates 28 330 REMOVE SPICULE. of the Hotel des Invalides, as recorded by M. H'utin, the surgeon of the institution. He states, that those spiculse which had been attached to the soft parts, and which were allowed to re- main in the hope of reunion, although they may not give trouble at the moment, invariably end by becoming sequestra, and after a long period of pain and suppuration, demand removal. He reports several hundred cases in which the non- extracted 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 balls. Baudens gives, as his Crimean experience, "that whether adherent or not, it is better to remove all spiculee, and thus simplify the wound. If these be retained, endless suppuration, continued suffer- • ing, with exacerbations of all the symptoms at the escape of each fragment, will gradually exhaust the vital forces, and entail its sequela? of maras- mus, diarrhoea and hectic." Suppuration will eventually bring all of the fragments to the sur- face, but at what a sacrifice! McLeod, after quoting the experience of Roux, Baudens, Guthrie, Hutin, Dupuytren, Curling, Begin, and others, on the dangers of allowing movable fragments to remain7 and the necessity REMOVE SPICULE. 831 of extracting every piece which is not extensively attached to the soft parts, gives his experience as decidedly in favor of the modern practice of re- moving all movable spiculce as the best mode of hastening a cure and diminishing mortality, "as the removal must tend immensely to simplify the wound." Again, he says: "The extensive comminution of the bone by a conical ball, makes the indica- tions with regard to the management of the sequestra more evident than it is commonly con- sidered. I do not think that we paid sufficient attention to their removal in the East. It may be true, as some tell us, that in fractures with the old ball, it was desirable to meddle as little as possible with the fragments; but this is the teaching of only a few. However, to my mind, the question assumes a totally different light when viewed by the pathological results which we had occasion to witness." Some surgeons go further, and recommend that not only should all spicule be removed, but that the sharp, irregular ends of the bones should be sawed off. This suggestion has not met with gen- eral approval, and is spoken of by Stromyer and Loeffler as no improvement. Their experience gave a larger mortuary list when this practice was attempted. 332 TREATMENT. There is no doubt that the removal of all frag- ments, in which there is not a strong probability of reunion taking place, will expedite the cure. 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 spicule, which might effect consolidation, can do no harm, whilst leaving them in, should union not be obtained, would be followed by much danger, annoyance, and suf- 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 possible, and treat the case as one of simple frac- ture. Inflammation and suppuration we expect; the}- are the portion of compound fractures gen- erally, and especially of those connected with gunshot wounds ; and remembering the long con- tinued and profuse drain which will establish itself in four or five days, we should be careful how we make use of the active antiphlogistic treatment. For the first week or ten days, the arm may be stretched upon a pillow, or loosely secured to a broad, long splint, which will support PAIN NOT NECESSARY FOR HEALING. 333 the entire extremity. "We confine the treatment to cold water dressings, either as iced bladders, applied over compresses to remove the injurious effects of direct application, or as by the process of irrigation — either of which is better than the continued renewal of wet cloths. The general treatment during this period of inflammatory excitement, is diet, rest, epiiet, and the use of mild diaphoretics, diuretics, and the liberal use of opium. Pain we do not consider, in any sense, neces- sary to the healing of wounds, and therefore have always made it a rule in practice to reduce it to its minimum. The complete annihilation of pain will neither detract from the rapidity of healing, nor from the gratitude of patients. The impropriety of free catharsis, will be at once evident 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 fractures. As soon as the period of inflammatory reaction has subsided, we then apply such splints to the arm as will secure quiet and rest to the limb, whilst a free vent is allowed in the apparatus for the escape of discharges from the wound; this opening also permits water dress- ings being applied to the wound. 334 TREATMENT OF COMPOUND FRACTURES. It cannot be expected that an arm, after a serious gunshot injury to the bones, will be cured without deformity. The arm will always be shortened, where many spiculse have been re- moved. We acknowledge this fact in anticipa- tion, and never attempt, by traction and counter- 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 ordinary fractures, the main object is to prevent deformity, and especially shortening of the limb. As this object is dis- carded in compound fractures of the upper ex- tremity, the treatment becomes much simplified, and the patient is saved its greatest annoyance. In fractures of the arm, the pasteboard splints 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 surgeons is nearly altogether discarded. In gunshot injuries, where we have an open wound to dress daily, our mechanical applications should be of such a character as to permit of easy inspection and also the ready re-adjustment of the apparatus when disarranged ; whilst, at the same time, the TREATMENT OF COMPOUND FRACTURES. 335 splints are kept secure. Diachylon plaster is now extensively used to secure splints to frac- tured limbs: three or four bands encircling the limb will always secure the supporting appa- ratus, whilst the limb is freely open to inspection. When the pasteboard is moistened, it moulds itself to the arm and makes a very satisfactory dressing. As soon as the patient has passed the reactive stage, he should no longer be confined to his bed, but with his arm in a sling may obtain sufficient exercise to keep his system in good order. The erect position will have the additional advantage of permitting the ready discharge of pus, and will prevent the bagging of this fluid, and obviate the necessity for the establishment of counter-open- ings. In all simple fractures the excess of callus depends upon the degree of mobility between the broken ends ; in compound fractures the deposit for consolidation is usually very great, which may be explained by the amount of irritation from inflammatory action, and also by the difficulty of keeping the fragments without motion. For- tunately, this does 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 neces- sity, which many practice, of frequently tightening 336 TREATMENT OF COMPOUND FRACTURES. the apparatus, to the very great annoyance of the patient. If the constitution be strong, a consid- erable degree of relaxation may be permitted, and be found not incompatible with perfect consoli- dation. In animals with compound fractures, we see continual exemplifications of this fact. The local and general treatment of the wound, will, in no respect, be modified on account of the fracture. Water dressings, until cicatrization is completed, medicated with astringents to allay profuse discharges, or with antiseptics to remove fnetor, or with stimuli to promote granulations, will be the proper course, whilst the general health is watched, retarded secretions promoted, and debility guarded against. If any fragments of bone have been left in, and have become necrosed, the surgeon must assist nature in the expulsion as soon as they have become detached, otherwise they will become surrounded by new formations, and as sequestra, incarcerated in an involucrum, will only be expelled after much time and trouble. From time to time, when spiculse are suspected, the wound should be examined, especially about the eighth or tenth day from the receipt of injury, when the stage of reaction has subsided to such an extent that the finger can again be introduced. From the passing off of the INJURIOUS CLEANSING. 337 shock, all examination must be absolutely inter- dicted until the period of reaction lias subsided. During the first week, no one should be per- mitted to probe the wound. As soon as we conclude that all fragments have been removed, we desist from all further probing, as it cannot but be injurious to the delicate granulations. Cleanliness is necessary to successful hospital practice in the treatment of suppurating wounds, but, when excessive, becomes a serious obstacle to rapid cicatrization. It is a common error for surgeons. to place a wounded limb over a basin of water, and sponge and rub it as if they were cleansing a piece of porcelain. I have seen others dress gunshot wounds by the free use of a power- ful syringe, with which they poured a stream of water into the wound until the granulations were bleached, and this repeated with great reg- ularity at the morning and evening visit. It was not surprising that wounds, treated with this over-care, took a very long time to heal. If the wound be gangrenous, and the object be to re- move ichorous decomposing fluids, to diminish or prevent absorption and general poisoning, then the syringing is desirable ; but under no other conditions wipe or wash the granulating surface of a wound. Wipe around the edges and remove 29 338 WHEN ARE AMPUTATIONS REQUIRED? any secretions which might have collected upon the skin, but leave the pus, as the best covering which healthy granulations can have. Under its protection, the plasma, which is thrown out from the blood-vessels, will rapidly form tissues ; but rub or wash away this covering, and the exposure to the baneful influences of the atmosphere will rapidly destroy the granulations which had already formed. However useful the local and general bath is to advance the cicatrization of a suppurating wound, do not generalize too much and expect equally good service from cleansing the granulations. Compound fractures, under the very best condi- tions, are tedious cases, and in gunshot injuries our patience w T ill often be taxed to the utmost. Despondency should not be an element in the character of a military surgeon. We must expect to have a compound fracture under treatment at least twice, if not^three times as long as would be required to consolidate a simple fracture. Should the main vessel be injured, in connec- tion with the fractured bones, we still have not sufficient cause to sacrifice the limb ; but, ligating the artery at its bleeding mouths, we treat the fracture as if this complication had not existed. Owing to the free anastomosis of the blood-vessels WHEN ARE AMPUTATIONS REQUIRED ? 339 of the arm, mortification is not to be feared when a ligation is applied even to the brachial artery ; a circuitous route soon supplies the needful nour- ishment to the parts beyond. Should the nerves as well as the artery be injured, or the principal nerves alone with the bones, then the limb, even when saved, would be a useless, paralyzed ex- tremity, and its immediate removal will save the patient a long, tedious, and dangerous convales- ence. In such cases, 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 adds greatly to the danger of the case, and in former times was considered nearly a fatal com- plication, as it necessitated an amputation, which, under the ordinary circumstances attending hos- pital treatment, was not far removed from an early dissolution. .Nor have we much to boast of: for, when amputations near the trunk are required, notwithstanding all the improvements in modern science, we succeed but little better in checking the fearful mortality. The severity of the symptoms of articular injuries depend upon the size of the joint and the character of the wound. The dangers are serious enough with 340 SYMPTOMS OF JOINT WOUNDS. the smallest puncture, but when the wound is large and lacerated, extensive local mischief and constitutional disturbance is sure to ensue, lead- ing wuth 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 con- clusions, as no serious injury to the large joints recovered unless the limbs were amputated or joints resected. The great fear is not in the serious injuries, as these cases are at once operated upon. It is in the apparently trivial cases, where, from the very small size of the wound, w T e hope that no trouble will supervene, that violent in- flammation shows itself and life is sacrificed. A wounded joint, under the ordinary hospital treatment, will pursue the following course: When a ball has perforated the joint, the peri- od of reaction is not long absent. In extensive wounds a great degree of nervous shock accom- panies the injury, the patient lying deadly pale, cold and faint. In from twelve to twenty-four hours, the tissues around the articulation become hot, swollen, and painful ; inflammation has already seized upon the synovial membrane, and will soon involve all the structures. All the SYMPTOMS OP JOINT WOUNDS. 341 symptoms rapidly increase until they become excessive. There is no rest for the weary suf- ferer, who, in spite of iced applications, and the free use of morphine, with the entire arcana of antiphlogistic remedies, writhes about in unmiti- gated agony. If the aperture leading into the joint be made by a ball or piece of shell, the synovia at first, and in two or three days pus freely escapes. Should the entrance into the joint be small or the passage oblique, the purulent synovia fills and distends the joint, adding much to the agony, which is again increased by the irregular spasmodic contractions of the surround- ing muscles. Accompanying these local symp- toms will be found a high grade of inflammatory fever, with rigors determined, great gastric dis- tress, intense thirst, excessive restlessness, and with such an amount of constitutional disturb- ance as sometimes to destroy life in a few days. As the disease advances, abscesses form in the surrounding tissues by extension of the inflam- matory process, and in a few days open con- tinuous passages to the joint, from which a constant discharge of purulent matter escapes. If the patient is not destroyed in the early stages of the disease by erysipelas, pyaemia, etc., in connection with the irritative fever, he falls 342 NECESSITY OP ACCURATE DIAGNOSIS. a prey to hectic, caused by the continued drain from the disorganized joint; synovial membrane, cartilages, and bones forming one mass of dis- ease. In gunshot wounds of joints, very rarely does the patient escape with life in military hos- pitals. In private practice he sometimes recovers, but even under the most advantageous circum- stances a successful case is rarely seen, and then usually with a destroyed anchylosed joint. As the results in injured joints are so fatal, sur- geons had, at an early day, adopted amputations as giving the only chance for recovery. In recent years, conservative surgery has introduced the operation of resection as affording not only the means of preserving life, but also of saving ' a useful limb. The diagnosis of articular injury is usually evi- dent from the direction of the wound, and from the escape of synovia; at times, however, when the orifice is small and the wound circuitous, a successful diagnosis requires much experience and close observation. When possible, a consultation should always be had over these cases. It is in these very cases of doubt, or of apparently trivial injury, that the most violent reactionary symp- toms are met, and that a fatal issue occurs. If left unoperated upon, the trifling wound, perfor- TREATMENT OF RESECTION. 343 ating the joint, might nearly be considered mortal ; whilst, if the joint be not implicated, the opera- tion of resection is not only not called for, but unnecessarily risks the life of the individual. The urgent necessity for an accurate diagnosis is evident. For the upper extremity this resource is par- ticularly applicable, as resection is now the rule of practice, having superseded amputation in all cases 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 bones form- ing it crushed, as soon as the excessive shock under which the patient may be suffering passes off, we proceed at once to operate. A primary resection is as essential as a primary amputa- tion, and is followed by as successful results. It should be performed within twenty-four or thirty-six hours, or before reaction sets in. Such cases do much better could the patient have been transferred to the general 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 until 344 TREATMENT OP RESECTION. reaction has come on, then by general, mild, anti- phlogistic treatment, and ice bladders or cold water dressings locally, we await 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 secondary; and these are, in turn, much more likely to succeed than when the operation is performed during the stage of febrile excitement. There are three or four rules neces- sary in all cases of resection, and which should not be forgotten during the operation, viz : Make the incision for exposing the heads of the bones in that portion of the extremity opposite to the main blood-vessels and nerves, so that these may not be exposed to injury. If possible, make the wound" lie in the line of the incision, and place the incis- ions in such a way as to permit a continued drain from the joint. Make these incisions free, so as not to cramp the operator in turning out the heads of the bones. An inch added to the incis- ion does not increase its serious character, and hastens the operation. Remove most of the syno- vial membrane, and save as much periosteum as possible ; the one is prone to take on inflam- mation; the other makes, and will, to a certain extent, reproduce the bone. In performing sec- i TREATMENT OF RESECTION. 345 ondary resections, the removal of all the diseased synovial membrane becomes one of the first ele- ments of success. More successes are obtained from resections of the shoulder joint than from any other articulation, the statistical tables of the final results of operations in favor of resection being conclusive over amputations. The following is the course recommended for performing the operation of resection, a substi- tute for amputation of the arm : — a U shaped flap, about three inches in length, is made of the deltoid muscle, on the upper and outer por- tion of the arm ; if there be any wound on this portion of the extremity, making one arm of the incision include the wound. The knife passing directly to the bone, from the clavicle or accromial process downward for three inches, makes a large flap of the deltoid, which is raised by a few touches of the knife. The circum- flex arteries are divided in this first incision, and should be at once ligated, otherwise, as they are of considerable size, the patient will lose much blood, and the steps of the operation ob- scured. By carrying the arm over the chest, the capsule of the joint is exposed and divided trans- versely, and with it the rotary muscles of the shoulder, when the head will protrude from its 34(3 TREATMENT OP RESECTION. position. The long head of the biceps is carefully removed from its bicepital groove and protected from injury. The bones are now examined ; a knife blade, or spatula, as a guard, is placed behind the bone so as to protect the soft parts and vessels from injury, and all of the injured portion is removed. When the ball has entered directly within the joint, only the surface may require excision ; but should the head of the bone be extensively spiculated, we must cut back to the sound bone, even if we are compelled to remove four or five inches of the shaft of the bone, as was successfully done by Stromyer for a gunshot injury: should the glenoid cavity be equally in- jured, the fractured portion is removed. The rule is, never to remove more of the bone than is abso- lutely called for, and not to open the medullary cavity if it can in an} 7 way be avoided. When the wound has been cleansed of all for- eign bodies, the flap is replaced and secured with one or two points of suture. As adhesion by the first intention is not usually expected, and gives no advantage over the final result by granulation, nice adjustment is not necessary. The patient is then put to bed and cold water dressings applied. Inflammation at first runs high, the parts around the joint are much swollen, and a collection soon TREATMENT OF RESECTION. 347 forms within the cavity 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, oedema, and pain which it diffuses over the neighboring- parts, involving the chest as well as arm. When suppuration becomes established, the swelling and pain subside ; granulations spring up, and even- tually close the wound. In the meantime the divided muscles have formed new relations by a lymphy exudation; they become more or less incorporated with the surrounding tissues, and by taking an insertion around the cut portion of the bone, form in time a closed capsule. A head to the bone is sometimes, in a measure, formed; in other cases the head of the bone becomes attached to the cavity by fibrinous bands. Of the cases of resection of the shoulder performed in the Crimea but few died ; and all those saved regained a useful limb, possessing all the motions, with the exception of those of the deltoid, which muscle is, to a certain extent, paralyzed from the division of its nerves, which cannot altogether be avoided in exposing the head of the bone. As suppuration will be excessive, and often long-continued, nourishment and even stimuli 348 TREATMENT OF RESECTION. may be demanded during the treatment. When abscesses form in the surrounding cellular tissue they should be open. It is a matter of but little importance in what position the limb is placed, and how it is secured, provided its position is comfortable to the sufferer. The uneasiness and irritation which the splints and bandages give, do much to prevent success. It matters little what length of limb the patient has, provided his life be saved, and the convalescence be speedy. A shortened arm does not affect its usefulness, and a slightly changed direction can be corrected in the after-stages of the treatment. The most effectual management is the simplest, and tedious daily dressings are to be discouraged; straighten- ing the limb upon the bed, a pillow, or a long, broad splint, without bandaging, being the best and most comfortable dressing for any resec- tion. The patient is kept in bed until the sup- purative stage is established, when he will be permitted to get up. His arm is then placed in a sling, and the water dressings are 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 oedema of the limb. Anchylosis rarely follows this oper- ation in the shoulder-joint. As a proof of the ' TREATMENT OF RESECTION. 349 efficacy of resection, Stromyer excised nineteen shoulder-joints with a loss of seven, chiefly from pyamiia. Of eight cases in which the operation was required, but from some mitigating circum- stances 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 the joints have been opened by a ball. Collections soon form, and the excessive swelling stretches the softened cap- sule, which, giving way, allows of the burrowing of pus and final discharge through open abscesses. After running a tedious, painful, and dangerous course, if the patient escapes with a shattered constitution and an anchylosed limb, he is fortu- nate. 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 nineteen died, whilst of forty resections under similar circumstances only six died. The results of the operations were also modified by the period of performing the resection. Of eleven cases ex- cised within twenty-four hours before reaction ensued, but one died ; of twenty cases between 350 RESECTING ELBOW-JOINT. the second and fourth day, or during the stage of irritation or excitement, four died; and of nine cases operated upon between the eighth and thirty-seventh day, only one died : an exempli- fication of a general rule laid down in the com- mencement of this chapter, that the wounded bear operations before the stage of reaction, or after the establishment of suppuration, much better than they do whilst suffering under high inflammatory excitement. This show r s the neces- sity of deferring operations. The elbow-joint, for gunshot wounds, transfix- ing its capsule and fracturing the bones, is best resected from the back of the joint, the patient lying upon his abdomen. An H, L, or T incision, taking in the breadth of the articulation, when sufficiently long, will expose perfectly the heads of the bones. There are no important vessels on this posterior 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 divid- ed, and the joint exposed, only remove the frac- tured head and all foreign bodies, and do not interfere with that bone which has not been injured. The lips of the wound are closed by HAND RARELY REQUIRES AMPUTATION. 351 sutures, and cold water dressings become the principal treatment. The limb is placed upon pillows, and not disturbed, if possible, until sup- puration is established. "When the soft parts are cicatrizing, and healing is nearly completed, pas- sive motions in the joint will prevent anchylosis, and a tumefaction bandage will remove the oedema of the limb. Instances of good results are recorded for injuries at the wrist-joint, where the spiculated ends of both radius and ulna have been satisfactorily removed; also, instances in which either of these bones have been removed entire, for chronic ostitis and necrosis brought on from gunshot injuries. Similar incisions to those recommended 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 tendons passing over a joint to sup- ply distant bones; and in the wrist particularly, many of the muscles which supply the fingers can be drawn out of the way and thus escape injury. 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 352 INJURIES TO INFERIOR EXTREMITY. torn off", or may be hanging by a fragment of skin, when they should be removed; but for ordi- nary guDshot lacerations of the hand, amputation of the entire hand is very rarely required. Dif- ferent bones of the hand and wrist are to be removed when irrevocably injured, with or with- out the metacarpal bones of the fingers or the thumb. Any fingers which can be saved will be better than the best artificial limb. In cases of lacerated hands in military surgery, when attempts are made to save the limb, under cold water dress- ings, 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 forming, 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 lay down the rule, that an amputation of the hand is never imperative, however frightful the injur} 7 to it may appear ; and there is much truth in the assertion. In the inferior extremity, we find the treatment of gunshot injuries somewhat different from those of the upper limb, on account of the minor degree HIP-JOINT INJURIES. 353 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 is often the only way of escape left to save the life of the wounded. We have elsewhere stated that when balls embed themselves in the pelvic bones, and their position can be discovered, provided a serious operation is not needed, they should be removed, as their presence will, sooner or later, give rise to trouble ; and also that all loose spiculse should be taken away. Sequestra frequently show them- selves from time to time during the treatment, and are withdrawn. When the ball strikes lower down, in the neighborhood of the tro- chanters, it usually splinters the bone, and frequently involves the ilio-femoral articulation. Such injuries are of the most serious char- acter, and are usually considered fatal. It is a question of much moment to inquire, how can modern surgery, with all of its appliances, im- provements and experience, assist in saving the life and limb of such seriously wounded? Within a few years the rule for all compound fractures of the femur was amputation of the limb; but the statistics from military hospitals in time of war .jo 354 HIP-JOINT- INJURIES. are so frightful — but few successes for the num- bers treated — that it was naturally suggested that the risks could not be materially increased by letting the patient take the chances with his limb on ; when, if his life was saved, it would be with, and not without his leg. This has settled down into a conviction for fractures of the upper third of the femur, which are now treated without amputation, inasmuch as nearly every amputation in the neighborhood of the trochanter and all at the hip-joint are fatal. If we are assured that the ball has crushed the head of the bone, then the operation of resection offers the best prospects of success for the patient; but it does 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 fracture of the upper portion of the shaft of a bone does not necessarily extend into the head, and vice versa. Unless the junction of the epiphy- sis with the shaft is struck, the fracture is more apt to be confined to a centre of ossification, so that, in the thigh as in the arm, a blow just below 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 HIP-JOINT INJURIES. 355 from the outer side of the hip, by which the frac- tured head might be removed. If any success is hoped for, those cases alone should be selected in which neither blood-vessels nor nerves are injured, nor the soft parts extensively torn. If all or any of such are injured, where experience teaches us that the chances from successful resec- tion are more than doubtful, do not have recourse to amputation which is so certainly fatal, but let the patient live his few remaining hours or days without being haunted by the ghost of a useless operation. Should he revive the reactionary stage, and still retain a good pulse and compar- atively unshattered constitution, then a secondary operation might give a chance of success. In the Crimean service, no amputation in the vicin- ity of the hip-joint was successful — every indi- vidual case died. This only corroborates the experience of other campaigns, and shows the inutility of such mutilations. When death, from a crushed thigh-joint is inevitable, it is hardly humane to amputate under the plea of giving the patient the benefit of the chances which experi- ence teaches us are nugatory. As regards resections in suitable cases, the re- port is a little more satisfactory. Of six resec- tions performed by the English surgeons in the 354 HIP-JOINT INJURIES. are so frightful — but few successes for the num- bers treated — that it was naturally suggested that the risks could not be materially increased by letting the patient take the chances with his limb on ; when, if his life was saved, it would be with, and not without his leg. This has settled down into a conviction for fractures of the upper third of the femur, which are now treated without amputation, inasmuch as nearly every amputation in the neighborhood of the trochanter and all at the hip-joint are fatal. If we are assured that the ball has crushed the head of the bone, then the operation of resection offers the best prospects of success for the patient; but it does not always follow that this diagnosis can be clearly made out, if the signs of intra-eapsular fracture be not present. Military surgical experience shows, that a fracture of the upper portion of the shaft of a bone does not necessarily extend into the head, and vice versa. Unless the junction of the epiphy- sis with the shaft is struck, the fracture is more apt to be confined to a centre of ossification, so that, in the thigh as in the arm, a blow just below 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 HIP-JOINT INJURIES. 355 from the outer side of the hip, by which the frac- tured head might be removed. If any success is hoped for, those cases alone should be selected in which neither blood-vessels nor nerves are injured, nor the soft parts extensively torn. If all or any of such are injured, where experience teaches us that the chances from successful resec- tion are more than doubtful, do not have recourse to amputation which is so certainly fatal, but let the patient live his few remaining' hours or days without being haunted by the ghost of a useless operation. Should he revive the reactionary stage, and still retain a good pulse and compar- atively unshattered constitution, then a secondary operation might give a chance of success. In the Crimean service, no amputation in the vicin- ity of the hip-joint was successful — every indi- vidual case died. This only corroborates the experience of other campaigns, and shows the inutility of such mutilations. When death, from a crushed thigh-joint is inevitable, it is hardly humane to amputate under the plea of giving the patient the benefit of the chances which experi- ence teaches us are nugatory. As regards resections in suitable cases, the re- port is a little more satisfactory. Of six resec- tions performed by the English surgeons in the 356 HIP-JOINT INJURIES. Crimea, one was successful, 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 p3 T semia, hospital gangrene and scurvy, much better results might have been ob- tained. So'me of the cases were doing well, with every prospect of final success, when they were swept off by one of the above diseases. In ampu- tations 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 be ob- tained by using violent extension. The leg, how- ever, must be fixed, to facilitate those movements, in changing 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, which I would much prefer, is de- pended 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 limb and life in cases in which compound fractures of the upper half of the thigh were treated without operation. Consolidated and useful limbs, with but little HIP-JOINT INJURIES. 357 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 com- pound comminuted fractures of the upper half of the thigh are not so fatal when attempts are made to save the limb as when the thigh is ampu- tated. 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 to the rule of immediate resections be made for the hip-joint, and that such cases, even the most suitable for the opera- tion, be deferred until suppuration be 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- pects are not altogether hopeless. When the pa- tient is in a measure placed in similar conditions to those affected with diseases of the bones, his prospect for a successful resection appears to be 358 IIIP-JOINT INJURIES. improved. Baudens says, that as the resection of the hip-joint only succeeds as a secondary opera- tion, 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 Crimee, with the sug-crestion that anv surgeon who has ever had a successful case of resection at the hip-joint, has always been eager to publish it; whilst many have been disposed to hide their misfortunes from the public, so that the tables, showing the relative advantages of primary and secondary resections, appear in their very best light. PRIMARY RESECTIONS AFTER GUNSHOT WOUNDS. Surgeons : Operated upon. Cures. Deaths. Larrey. (Volume 3, Clinique) J. Cooper. (Dictionary) Leteille. (Relatione du Siege d'Anvers, par M. H. Larrey) Hutin. (Memoires de Medicine et de Chi- rurgie Militaires) Sedillot. (Annales de la Chirurgie Fraucaise et Etrangere) G-oyon. (Expedition de Churchill, Algerie) Rochet. (Journees de Juiu, 1S4S) ftubiot. (These de Montpellier, 1840). ... French Crimean Service McLeod. (Crimean War) Stromyer 6 2 1 2 5 1 1 9 5 1« 1 36 1 5 1 1 3 9 4 1 35 * This successful case was found, after the articulation had been laid opeu. not to be a fracture extending within the joint, but confined without the capsule: and we arc. therefore, justified in the. belief that the case would have done equally well without the resection. COMPOUND FRACTURE OF THIGH. 359 1 1 1 1 1 1 1 1 1 1 3 1 1 12 3 SECONDARY OPERATIONS FROM GUNSHOT WOUNDS. Larrey. (Clinique, volume 5) Guthrie. (Clinic, volume 5) Baudens. (Traite des Plaies d'Armes a feu) Ferussac. (Bulletin des Science Medicales. volume^) 1 •• 1 Robert. (Journee de Juin, 1848) 1 .. 1 Guersant. (Journees de Juin, 1848) 1 .. 1 Vidal. (Traite de Chirurgie) 1 .. 1 Mounier. (Constantinople, 1S54) 3 •. 3 Legouest. (Constantinople, 1854) 1 .. 1 McLeod. (Crimean War) It has been suggested, that if the patient who has been operated upon could have facilities for slinging the whole body, it w T ould afford many advantages in the management of excisions of the hip-joint. A compound fracture in the upper third of the thigh should be treated in every respect as if in the arm. Unless the leg is so mangled that an amputation is an act of necessity, it should not be thought of. We have already said that, in field military surgery, amputation near the trunk is synonymous with death. The treatment must commence on the battle field by proper transpor- tation; as the judicious removal of fractured limbs is as important as an operation, and any neglect in this department will deprive the wounded man of all hope of retaining his limb, or often of having his life saved. We will carefully remove all loose 360 COMPOUND FRACTURE OF THIGH. and movable spiculre, dilating the wounds if neces- sary, to facilitate the thorough cleansing of all foreign bodies. Until suppuration is well estab- lished, the limb is kept in an easy position and sur- rounded with cold applications. All tight, reten- tive bandages are to be rejected, as they interfere with topical antiphlogistic applications. Dispense with bandages. On the eighth or tenth day, when the reactionary stage has passed, the wound is again to be examined for foreign bodies, and all portions of bone which may have become separ- ated by the inflammatory process must be re- moved ; or as sequestra, they will become incor- porated 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 sound one. It cannot be done, and the chafing and annoyance of splints and tight bandaging may react very seri- ously, if not fatally upon the constitution. The first thing to be attended to is the facilities for treating such a fracture. If we are striving for successful results, we must not expect to obtain them if a patient, with a compound fracture of the thigh, is being treated upon the ground or is lying upon a little straw. He must have a proper bed COMPOUND FRACTURE OF THIGH. 361 and a good firm mattress, prepared with a bed-pan hole, for facilitating nature's daily wants without the necessity of moving him. Upon this the patient is placed, lying on his back, with the leg extended. Two long straps of diachylon plaster are attached to the sides of his leg from the knee to the ankle ; they form a loop under the foot, and a weight is swung from this over the foot of the bed. This will be sufficient 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 plaster, or strips of bandage, will secure the limb to the splint, and at the same time leave the wound open for inspection and dressing. For the first week or ten days this will be all the apparatus needed. As the case ad- vances, splints may be more methodically applied by using long inner and outer splints of light board, well padded with loose cotton, and secured in position by bands of adhesive plaster or with tapes. The counter-extending bands are made by adhesive strips attached to the sides of the leg and carried under the foot, where they are secured to the end of the splint. Allow the ends of the bones to fill up the void made by the extraction 31 362 COMPOUND FRACTURE OF THIGH. of the spicule, as this hastens consolidation. With the exception of the mechanical appliances for the broken bone, the case is treated as for a long-continuous suppurating wound, by avoiding, in all cases, depletion and by giving liberal diet. Many of these cases will die ; but if we have facilities in a well-ventilated and well-organized hospital, we will have the satisfaction of saving some of the patients submitted to our care. In fractures of the middle and lower third of the thigh, not implicating the knee-joint, the question will again occur — what course is to be pursued with them ? These are still very serious cases, and are classed with those of the upper third. Where attempts are made to save them, as recommended by Guthrie, the fatality will not be very dissimilar to fractures nearer the trunk, and the moderate success which, under the very best circumstances, we will obtain, will depend upon the state of health of the sufferer and the conveniences for treatment. There are cases which often appear so trivial — only a small bullet hole leading to the crushed bone — that it seems barbarous surgery to con- demn the limb without an attempt at saving it. The young military snrgeon expects much from conservative surgery in such cases. We are in- i i COMPOUND FRACTURE OF THIGH. 363 formed by the experienced, that this striving after conservatism is the main canse of the heavy mortality. Surgeons generally are not prepared to believe how hopeless compound fractures of the thigh are, until the unwelcomed truth is forced upon them by an ever-recurring expe- rience, that many lives are sacrificed to attempts at saving 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 pursue ; but on the battle field, with the deteriorated material upon which we are operating, and the poisoned atmosphere of the wards into which the patient is to be carried, it is a fatal- error. Military surgeons must abandon their conservative intentions to expediency. It is for such cases that primary amputation of- fers the best chances for life. In rejecting am- putations we lose more lives than we save limbs. As a rule, amputations are less hazardous the greater distance we operate from the trunk, and the reason why amputations are urged for com- pound fractures of the lower and not upper por- tions of the femur is, that the chances being similar without it, amputations are much less fatal in the lower than in the upper half of the thigh. 364 PERFORATIONS OF THE KNEE-JOJNT. Resection of the shaft of the femur for a crushing of the bone has been often recom- mended and as often practiced, but the expe- rience of latter years discourages its performance, as the operation is more serious than the con- dition for which the remedy is used. When the splinters of bone are removed, there is con- siderable space for the play of the rough edges remaining, and which, therefore, give but little trouble. Should w.e 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 pus, 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 as well as much destruction to bones and muscles. Surgeons in the Crimea often had cause to regret attempts at saving fractured thighs, but never regretted an early amputation. 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- PERFORATIONS OF THE KNEE-JOINT. 805 pear, if the synovial sac he entered, and air he 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 after twenty-four or thirty-six hours. Should the patient survive the inflammatory stage, erysipelas, pyaemia or hectic will ultimately de- stroy life ; and although on the other hand, the effusions may he absorbed, and a good anchylosed limb saved, it is a very rare occurrence. If the soft parts are not much lacerated, or the blood- vessels and nerves behind the joint injured, such cases are well adapted for resection, and excel- lent 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 enable the surgeon to remove the foreign bodies, what- ever they may be, and with them the head of the injured bones. The section of the bones should be made in such a way that the surfaces will adapt themselves to each other. When the ex- ternal wound is closed by sutures, union by the first intention may, to a certain extent, be obtained. In the successful cases, the bones eventually become firmly united, and, with an anchylosed joint, the patient retains a useful 866 TREATMENT OP INJURED JOINTS. limb. After the resection, a long splint upon the back of the leg, reaching from the buttock to the heel, is all the apparatus required, whilst cold water dressings are alone applied around the joint. In cases of resection, the surgeon must not expect quick union in the wound, as that does not often occur in military surgery. A tedious suppuration, the formation of nume- rous abscesses, 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 suppose to be a trivial or doubtful case of knee-joint injury, we should use all of the routine of the antiphlogistic treatment. In a sin- gle puncture of the capsule, even when synovia has escaped, the orifice may heal by quick union ; but when local inflammation ensues, and runs such an acute course that the free application of leeches — twenty to forty to a limb — do not quell the inflammation, but, running on, we are led to infer that pus has formed within the joint, the articulation should be largely opened, and the joint thoroughly cleansed, whether we resect the COMPOUND FRACTURE OF THE LEG. 367 heads of the bones or not. There is no longer any injury from the admission of air, whilst there is serious fear of destruction of the cartilages should the collection of pus be retained. This free opening of the articulation may, in some cases, obviate the necessity for secondary resec- tions, as excellent results have been obtained by this apparently bold surgery, the patient saving his life and limb, with an anchylosed joint. The effect of this incision in allaying the general irri- tation is said to be marked. The course which will be 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, if possible, the limb also ; but, in our too-grasping disposition, we must be very guarded how we jeopard the one to save the other. It is in this respect that mili- tary surgery is so very different from civil prac- tice, as we are continually compelled to sacrifice limbs to expediency, when, under more favorable conditions, we would not hesitate to practice con- servative surgery. To introduce a single example: where a long and tedious transportation becomes necessary after a battle, it would be expedient to amputate much more freely than we would do 368 COMPOUND FRACTURE OF THE LEG. were hospitals in the immediate neighborhood of the battle field where the wounded could be treated. How, for instance, could we transport with any chance of success a resected joint, such as the shoulder or a gunshot fractured thigh or leg ? Under such circumstances an amputation would give the patient a much better chance for life, which should be always the main object. When facilities offer for attempting the preser- vation of a fractured leg, the same precautions are taken as in other fractures, for removing immedi- ately all loose or very movable fragments of bone. The limb is placed in a fracture box, or upon the double incline-plane, and by the constant applica- tion 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, by rules of practice which have been already fre- quently discussed. Should mortification appear in the wound a few days after the injury, Ave will find the only means 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 con- servative practice, but is seldom practiced. When \ rules for amputating:. 369 gunshot injuries occur about the ankle, crushing the bones, excision offers but a meagre resource. Mortification often follows upon such injuries, and amputation holds out stronger inducements for immediate and subsequent benefit. We have often referred to the fact that am- putations will ever be a necessity in military surgery; and, according to McLeod, had they been more freely practiced in the Crimea, a larger number of lives would have been saved. It was on that account that, in the distribution of labor, in field infirmaries, it was recommended that the surgeon who had had the greatest ex- perience, and upon whose judgment most reli- ance could be placed, should officiate as exam- iner; and. his decision should be carried out by those who may possess a greater facility for the operative manual. As a general rule, the fol- lowing conditions necessitate the loss of a limb, viz : When an entire limb is carried off by a cannon ball, leaving a ragged stump; or when .a limb is literally crushed up, although still attached to the body, it will be necessary to am- putate to form a good stump ; also, if the prin- cipal vessels and nerves are torn, even without injury to the bone; or if the soft parts are much 370 RULES FOR AMPUTATING. lacerated; or in cases of extensive destruction of the skin, as such cases offer very tedious cures if cicatrization is ever obtained; or in severe com- pound fractures; or often in apparently simple compound fractures, where experience teaches us that although the wound appears trifling to-day, in attempting to save it we will sacrifice a life a few days hence. Amputation is also compul- sory when mortification of the limb rapidly fol- lows upon an injury ; or when, in compound fractures or perforated joints, the profuse dis- charge or the continued irritation threatens a fatal issue ; also, where joints are crushed, and where resections are not admissible; or where a fracture of the shaft of a bone extends into a joint ; or in cases where secondary hemorrhage cannot be controlled by the ligature, or by any other hemostatic. Knowing that in such cases, sooner or later, the limb and life will be jeopard- ized, we must anticipate these troubles by ampu- tation. 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 opera- tions. Amputations for direct injury are styled RULES FOR AMPUTATING. 371 primary; those required for cases of mortification, profuse suppuration, secondary hemorrhage, or for necroses, are called secondary or mediate, and comprise all amputations performed after the first twenty-four or thirty-six hours, when reaction has set in. The experience of every battle field shows, that the mortality following the amputation of limbs which require immediate operation is always less than those performed some days after the infliction of the wound, although the milder cases were those retained, and the most severe those selected for immediate operation. As all military surgeons recognize the propriety of amputating condemned limbs within twenty-four or thirty-six hours after injury, before inflammatory reaction has set in, the subject requires no discussion. The rule in military surgery is absolute, viz : that the amputating knife should immediately follow the con- demnation of the limb. These are operations for the battle field, and should be performed at the field infirmary. When this golden opportunity, before reaction, is lost, it can never be compen- sated for. The rule in performing primary amputations is, to 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 Oil RULES FOR AMPUTATING. be performed at a joint, never amputate higher up; for instance, if an amputation cannot be per- formed upon the upper part of the leg, remove the limb at the knee-joint rather than amputate the thigh. In secondary amputations it may not be expedient to follow this rule; necessity or the desire to save life, which is always paramount, may compel us to amputate at a distance from the injury, as in cases of mortification. Gangrene should seldom, however, require a secondary amputation, if the rules for primary amputation be followed — of removing at once all limbs in which the blood-vessels and nerves are exten- sively injured in connection with the crushing of the bones. When mortification attacks a limb, it will be known by the change of color in the skin. When it occurs in the leg, which is its common seat, the foot changes from the natural flesh color to a tallowy or mottled white ; the tissues in a measure liquify, are cold, and be- come offensive — breaking up into more or less extended sloughs, saturated with an ichorous fluid. This gangrenous condition may stop at the ankle, either above or below 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 RULES FOR AMPUTATING. 373 the mortification, we amputate below the knee ; when otherwise, above it. These cases are usually unsatisfactory, 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. By the local use of pure nitric acid to the mortified surface, or the concen- trated Labarraques' chloride of soda or pyroligne- ous acid, we strive to limit the extent of the slough ; whilst, with carbonate of ammonia, qui- nine, brandy, and strong food, we support the system until some improvement makes its appear- ance in the stump. When all the sloughs have been eliminated and the stump has commenced to cicatrize, will be time enough to remodel the old amputation, by cutting off the protruding bone, which is always better than performing a second amputation. Having condemned a limb, we should wait until the nervous shock — from which most of the wounded suffer — subsides, and then give chlo- roform. Should we not have the time for its proper inhalation, we may inject a half grain or more of morphine under the skin, which will 874 RULES FOR AMPUTATING. produce a rapid blunting of nervous sensibilities ; and in rive minutes, or even in less time, the patient will be in a fit condition to stand the operation, with the least degree of constitutional shock. In the performance of all serious operations, when possible, there should be three assistants. One aid gives the chloroform ; a second com- presses the main artery, which is much better than using the tourniquet — an instrument which is now in a great measure discarded from prac- tice ; and a third holds the limb and supports the flap during the section. The aid who ad- ministered the chloroform during the incisions, can assist in ligating the arteries. Military sur- geons prefer the circular operation to the Hap, which they only use in the exceptional cases. With the circular stump, covered only by skin, there is less soft tissue to suppurate and slough, and a much more rapid cicatrization is effected. Experience, which has long recognized the utility of the circular operation for the leg, has now generalized it as the most useful amputation for the thigh or arm. Having assigned the aids their posts, and seen- that all the necessary instruments which may be needed are at hand — for a surgeon should RULES FOR AMPUTATING. 375 never commence an operation until he has satis- fied himself on this score — the surgeon removes the limh, ligates the vessels, and when all ooz- ing 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. In dividing the skin, the surgeon cannot be too careful to leave an ample flap to cover the heads of the bones. This is the first and most impor- tant rule in amputation. You cannot well leave too much skin, and can very easily com- mit the opposite error. The surplus of skin will be absorbed ; a deficiency can in no way be sup- plied. The rule is, to have the flaps so ample that no tension be necessary in closing the wound. One of the most constant as well as one of the most frightful exhibitions in military hospitals, where the surgeons have not yet gained expe- rience, is the protrusion of the bones from the stumps of amputated limbs, necessitating a sec- ond operation, should the patient survive the first. A little care will obviate all of this trouble, and save the surgeon much mortification. Any omission in this respect must be corrected before the stump is dressed; and if the bone is found so long that the skin cannot be made to cover it without traction, remove a section of bone with 876 DRESSING OF STUMPS. the saw, and not attempt, through want of hon esty, to conceal a badly-performed operation, and make the innocent patient the victim of our mis- placed pride. In ligating the vessels, tie every one which bleeds or is likely to bleed. It is not derogatory for a surgeon to apply ten, fifteen, or even twenty ligatures to a stump ; it shows that he understands his profession ; expe- rience has taught him the great trouble and an- noyance of reopening a stump to find a bleeding vessel, when he has but little time to attend to the urgent demands of the wounded. The rule is, neglect no small artery. As adhesive straps for supporting and sustain- ing the flaps are antagonistic to water dressings, they are useless in amputations, and are not used, except a small patch to secure the liga- tures upon the limb at one angle of the wound. A single layer of wet cloth is applied to the stump; this in turn is covered by a piece of waxed cloth, to keep in the moisture, and either an ice bladder or water bj~ irrigation is contin- uously applied over this outer cloth. The case should now be looked upon as a wound, and should be treated accordingly. The course la-id down for wounds is here strictly applicable, and should be closelv followed. Sutures are recom- DRESSING OP STUMPS. 377 mended in all operations, as they keep the flaps in apposition, not being influenced by the water dressings ; they also obviate much after-dress- ing. The use of sutures does away with adhe- sive straps, which, when water dressings are used, are always inconvenient and often useless. In certain cases of amputation, as in the circu- lar, where the skin alone forms the flap, the dressing may be changed, as follows: After ap- plying sutures to the entire length of the wound, draw the intervening spaces 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 liga- tures escape and where drainage from within is permitted. The object of the dressing is to con- vert the wound into a subcutaneous one, exclud- ing the air and hastening union. To the stump no other dressing is applied, the wound being exposed. ISTo water dressing is to be used, and the stump is left unmolested, except cleansing the effects of drainage; when, at the expiration of a week, the removal of the straps will com- plete cicatrization along the line of incision. In healthy patients and in a pure atmosphere, a rapid healing of stumps may in this way be ob- tained. The isinglass plaster will alone answer — 32 37$ DRESSING OF STUMPS. the diachylon being too irritating and not suf- ficiently pliant to seal hermetically the wound. We find but little use for ointments in dress- ing stumps, the wet cloth being much simpler, not irritating, and therefore more efficient. During the treatment of all wounds in milita- ry hospitals, previous want and exposure, which belongs to every army, however well organized, will show their influence ; and if the plan of abste- mious or antiphlogistic diet be adopted for those operated upon, from misguided views of the pa- thology of inflammation, the mortality will be heavy. Liberal feeding tells in the after-treat- ment of amputations ; and the great difference in the surgical statistics of the French and Eng- lish depends more perhaps upon the diet in their hospital practice than upon any one other cause. Tisanes cannot support a person in or- dinary health, and certainly cannot support him under the additional drain of an exhausting sup- puration. If patients are placed under identical- ly similar conditions, the successful treatment of amputations will be found to lean to the side of those who are the most liberally supported. Slops are out of place in a surgical hospital, and good cooking will be found as useful as good nurs- ing. Let nature be our guide. For the first CHLOROFORM INDISPENSABLE. 379 one or two clays after a serious operation there is but little disposition to eat. Under such con- ditions, I would not advise food to be forced ; but as soon as the patient expresses a desire to eat, foster his appetite with good, strong, nour- ishing, easily-digested food, and let his supply be liberal. Any attempt at starvation will be highly injurious. If the patient escapes the ordinary diseases incident to hospitals, viz: erysipelas, gangrene, pyaemia, etc., we must be extremely careful of him about the tenth or twelfth day. When the ligatures are escaping from the arteries, absolute rest should be insisted upon, and the patient should not be allowed to exert himself in any way until this fear of secondary hemorrhage is passed. We have elsewhere stated how this com- plication is to be met. Whenever operations are 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 used on all occasions with advantage ; whether for operations or for dressing painful wounds, as in the cleans- ing of compound fractures. The effects of chlo- roform are wonderful in mitigating the suffering of the wounded, and it is often instrumental in 380 CHLOROFORM INDISPENSABLE. the cure of wounds, from the rest and tranquility of mind which follows its inhalation. It also prevents excessive reaction in the paroxysms of traumatic fever. During the performance of capi- tal operations on the hattle field, death sometimes ensues from nervous exhaustion, produced by excess of suffering; the use of chloroform relieves the patient at least from this risk. Those brought up in the older school, before the days of anaes- thetics, in refusing all innovations, still insist on decrying the dangers of this potent remed} T , and moralize upon the duty of suffering, as submitting to an express infliction from on high. Although the French surgeons in the Crimea report the successful administration of chloroform to thirty thousand wounded, without a single accident, and McLeod refers to its great utility in the Crimea, where it was administered to twenty thousand soldiers, and more than realized the most enthu- siastic anticipations of the medical staffs, still we find some of the older school, who are in author- ity, sneer at its pretensions and magnify its dan- gers. Dr. Hall, who is at the head of the English medical staff, in giving instructions to the sur- geons upon entering active service in the Crimea, cautioned them against the administration of chloroform in the severe shock of serious gun- CHLOROFORM INDISPENSABLE. 381 shot wounds, as lie thinks that few will survive where it is used. But as he finds public opin- ion, which he calls mistaken philanthropy, against him, he disparages chloroform, and lauds the lusty bawling of the wounded from the smart of the knife, as a powerful stimulant which has roused many a sinking man from his apathetic state. Some of the older surgeons characterize the cries of the patient as music to the ear, and speak of it as an advantage to be courted, and not to be suppressed. Notwithstanding such advice, the universal use of chloroform in the Crimea and later in Italy, is a complete vindi- cation of the utility of the remedy, and proof of its necessity: and now we consider it an essen- tial among army supplies. For ourselves, who place unlimited confidence in its judicious admin- istration, and, with a large experience, we have never had the slightest cause to doubt its advanta- ges under every circumstance. We hope that the humanizing tendencies of the age, 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 as cold water is now used for keeping down inflammation. We do not hesi- 382 HOW TO GIVE CHLOROFORM. fate to sag, that it should be given to every patient requiring a serious or painful operation. We may hear now and then of an accident from its admin- istration, but who can tell us of the immense number who would have sunk from operations, had it not been administered? In its administration we must use the following precautions: The best apparatus is a folded cloth in a form of a cone, in the apex of which a small piece of sponge is placed. This is first held at some distance from the nose and mouth of the pa- tient, so that the first inhalation may be well dilu- ted with air. As the exhilarating stage is reached, the cloth should be approached to the nose, so that a more concentrated ether may be inhaled, which will rapidly produce the desired insensi- bility. Noisy breathing is the sign that the anaes- thetic effect is produced, when the inhalation should be suspended and the operation com- menced. Unless the operation is very tedious, do not renew the inhalation. Ingenious inhalors are more or less complica- ted, and are on that account more or less ineffi- cient. The great perfection of the above-men- tioned apparatus is its simplicity. Finding that much chloroform is wasted by evaporation from the handkerchief, I have for some years used a HOW TO GIVE CHLOROFORM. 383 common funnel as my inhalor, which, protects the hands of the person administering the chlo- roform, and prevents the loss from general evapo- ration. If a piece of heavy wire or a small bar of tin be attached across the interior of the fun- nel, about half-way toward its throat, the sponge containing the chloroform can be supported be- tween this bar 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 apparatus, when the air loaded with ether is inhaled. The funnel should be large enough to cover the lower half of the face, including nose and mouth, and the sponge should not come within two inches of the face, for should it touch the skin it would blister it. The eyes, being excluded from the appa- ratus, are not anno} T ed by the evaporation of chloroform. As the funnel does not fit accu- rately 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. Be- sides a great saving of chloroform, which is no small recommendation, the use of this instru- ment obviates the fear of suffocation, which is always present to my mind when I see chloro- form carelessly administered. When the cloth 384 HOW TO GIVE CHLOROFORM. is used, should the patient struggle — a ^ery com- mon occurrence — or should the assistant admin- istering the anaesthetic he 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 has already been influenced to such an extent that he has lost the voluntary control of his muscles, and cannot pull away the cloth, he is in a very dangerous condition, and the con- tinued thoughtlessness of the assistant might suffocate him. I can readil} r understand, in this way, why deaths should sometimes occur from the carelessness of administration, and am only surprised that it occurs so seldom. Were we as careless in the use of other potent remedies as we are of chloroform, cases of poisoning would be largely increased. In times of hurry, confu- sion and excitement, as after a battle, we can- not surround the safety and well-being of the wounded with too many guards for their protec- tion. APPENDIX. 33 Appendix ISTo. 1. REGULATIONS FOR THE MEDICAL DEPARTMENT OF THE CONFEDERATE STATES. 1 . . . .The Surgeon-General is charged with the administrative details of the medical department, the government of hospitals, 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 instruc- tions relating to the professional duties of medical officers ; and all communications from them, which require his action, will be made directly to him. 2 . . . . The senior medical officer on duty with an army corps in the field, is the Medical Director of that army, and he will have the general control of the medical officers. 3 . . . . The medical director will inspect the hospitals under his control, and see that the rules and regulations with regard to them and the duties of the surgeons and assistant surgeons, are enforced. 4 . . . . He will examine the ease books, prescription and diet books, and ascertain the nature of diseases which may have pre- vailed, and their probable causes; recommend the best method of prevention, and also make such suggestions relative to the 888 APPENDIX. situation, construction and economy of the hospitals, as may appear necessary for the benefit and comfort of the sick and the good of the service. 5 . . . . He will require from the medical officers of the com- mand monthly reports of the sick and wounded (Form 1), and from the data furnished by them, will make to the Surgeon- General a consolidated monthly report of the sick and wounded. 6. . . .He will make to the Surgeon-General a monthly return (Form 2) of the medical officers of the command. 7. . . .The Meilical Purveyors will, under the direction of the Surgeon-General, purchase all medical and hospital supplies required for the medical department of the army. 8 . . . . Medical purveyors will make to the Surgeon-General, at the end of each fiscal quarter, returns in duplicate (Form 3) of medical supplies received, issued and remaining on hand, stating to whom, or from whom, and when and where issued or received. Other medical officers in charge of medical supplies will make similar returns semi-annually, on the 30th of June and the 31st of December: and all medical officers will make them when relieved from the duty 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 will furnish abstracts of receipts and issues with their returns (Form 4). 9 . . . . Medical disbursing officers will, at the end of each fiscal quarter, render to the Surgeon-General, in duplicate, a quarterly account current of moneys received and expended, with the proper vouchers for the payments, and certificates that the ser- vices have been rendered and the supplies purchased and re- ceived for the medical service, and transmit to him an estimate of the funds required for the next quarter. 10. .. .The medical supplies for the army are prescribed in the Standard Supply Tables for Hospitals or Field Service. 11 ... .Medical and hospital supplies will be obtained by making requisitions, in duplicate (Form 5), on the Surgeon- General, forwarding them through the medical director of the command. If an army be in the field, and there be a medical APPENDIX. 389 purveyor in charge of supplies, requisitions will be made on him, after receiving the approval of the medical director. 12. . . .When it is necessary to purchase medical supplies, and recourse cannot be had to a medical disbursing officer, they may be procured by the quartermaster on a special requisition (Form 6) and account (Form 7). 13. . . .In every case of special requisition, a duplicate of the requisition shall, at the same time, be transmitted to the Surgeon- General, for his information. 14. . . .An officer transferring medical supplies, will furnish a certified invoice to the officer who is to receive them, and trans- mit a duplicate of it to the Surgeon-General. The receiving officer will transmit duplicate receipts 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 for storage or transportation, will forward to the Surgeon-General, with the invoice, the quartermaster's receipts for the packages. 15. . . .Medical officers will take up and account for 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. 16. . . .In all official lists of medical supplies, the articles will be entered in the order of the. supply table. 17.... The senior medical officer of a hospital will distribute the patients, according to convenience and the nature of their complaints, into wards or divisions, under the particular charge of the several assistant surgeons, and will visit them himself each day as frequently as the state of the sick may require, accompanied by the assistant, steward and nurse. 18.... His prescriptions of medicine and diet are written down at once in the proper register, with the name of the patient and the number of his bed ; the assistants fill up the diet table for the day, and direct the administration of the pre- scribed medicines. He will detail an assistant surgeon to remain at the hospital day and night, when the state of the sick re- quires it. 19. . . .In distributing the duties of his assistants, he will ordi- .'j90 appendix. narily require the aid of one in the care and preparation of the hospital reports, registers and records, the rolls and descriptive lists; and of another, in the charge of the dispensary, instru- ments, medicines, hospital expenditures, and the preparation of the requisitions and annual returns. 20 ... . He will enforce the proper hospital regulations to promote health and prevent contagion, by ventilated and not crowded rooms, scrupulous cleanliness, frequent changes of bed- ding and linen, occasional refilling of the bed sacks and pillow ticks with fresh straw, regularity in meals, attention to cooking, etc. 21. . . .He will require the steward to take due care of the hospital stores and supplies; to enter in. a book, daily (Form 8), the issues to the wardmasters, cooks and nurses ; to prepare the provision returns, and receive and distribute the rations. 22. . . .He will require the wardmaster to take charge of the effects of the patients ; to register them in a book (Form 9) ; to have them numbered and labelled with the patient's name, rank and company ; to receive from the steward the furniture, bed- ding, cooking utensils, etc., for use, and keep a record of them (Form 10), and how distributed to the wards and kitchens, and once a week to take 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 not required for use. 23. . . .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. 24 ... . 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, and all articles in use. He will ascertain who are present at sunrise and sunset, and tattoo, and report absentees. 25 .... At surgeon's call the sick then in the companies will be conducted to the hospital by the first sergeants, who will each hand to the surgeon, in his company book, a list of all the sick of the company, on which the surgeon shall state who are to remain or go into hospital ; who are to return to quarters as sick or convalescent ; what duties the convalescents in quarters APPENDIX. 391 are capable of; what cases are feigned; and any other informa- tion in regard to the sick of the company he may have to com- municate to the company commander. 2G . . . . Soldiers in hospital, patients or attendants, 'except stewards, shall be mustered on the rolls of their company, if it be present at the post. 27.... When a soldier in hospital is detached from his com- pany so as not to be mustered with it for pay, his company com- mander shall certify and send to the hospital his descriptive list, and account of pay and clothing, containing all necessary infor- mation relating to his accounts with the Government, on which the surgeon shall enter all payments, stoppages, and issues of clothing to him in hospital. When he leaves the hospital, the medical officer shall certify and remit his descriptive list, show- ing the state of his accounts. If he is discharged from the ser- vice in hospital, the surgeon shall make out his final statements for pay and clothing. If he dies in hospital, the surgeon shall take charge of his effects, and make the reports required in the general regulations concerning soldiers who die absent from their companies. 28 .... Patients in hospitals are, if possible, to leave their arms and accoutrements with their companies, and in no case to take ammunition into the hospital. 29.... When a patient is transferred from one hospital to another, the medical officer shall send with him an account of his case and the treatment. 30 ... . The regulations for the service of hospitals apply, as far as practicable, to the medical service in the field. 31. . . .The senior medical officer of each hospital, post, regi- ment or detachment, will keep the following records, and deliver them "to his successor: A register of patients (Form 11) ; a pre- scription and diet book (Form 12) ; a case book; copies of his requisitions, annual returns, and reports of sick and wounded ; and an order and letter book ; in which will be transcribed all orders and letters relating to his duties. 32. . . .He will make the muster and pay rolls of the hospital steward and matrons, and of all soldiers in hospital, sick or on duty, detached from their companies, on the forms furnished 392 APPENDIX. from the Adjutant-General's office, and according to the direc- tions expressed on them. 33. . . .The extra pay allowed to soldiers acting as cooks and nurses in hospitals, will be paid by the pay department. Such extra services will be noted on the hospital muster rolls, and for the sums thus expended the pay department will be reimbursed by the medical department. 34 ... . The senior medical officer will select the cooks, nurses and matrons, with the approval of the commanding officer. Cooks and nurses will be taken from the privates, and will be exempt from other duty, but shall attend the parades for muster and weekly inspection of their companies at the post, unless specially excused by the commanding officer. 35 ... , Ordinarily, hospital attendants are allowed as follows : To a general hospital, one steward, one nurse as wardmaster, one nurse to ten patients, one matron to twenty, and one cook to thirty ; to a hospital, where the command exceeds five compa- nies, one steward and wardmaster, one cook, two matrons, and four nurses; to a post or garrison of one company, one steward and wardmaster, one nurse, one cook, and one matron ; and for every two companies more, one nurse; at arsenals, where the number of enlisted men is not less than fourteen, one matron is allowed. The allowance of hospital attendants for a regi- ment in the field will be, for one company, one steward, one nurse and one cook; for each additional company, one nurse; and for command of over five companies, one additional cook. 36. . . .Medical officers, where on duty, will attend the officers and enlisted men, and the servants and laundresses authorized by law ; and at stations where other medical attendance cannot be procured, and on marches, the hired men of the army. Medicines will be dispensed to the families of officers and soldiers, and to all persons entitled to medical attendance; hospital stores to enlisted men. 3 7 . . . . Medical officers, in giving certificates of disability (Form 13), are to take particular care in all cases that have not been under their charge ; and especially in epilepsy, convul- sions, chronic rheumatism, derangement of the urinary organs, ophthalmia, ulcers, or any obscure disease, liable to be feigned APPENDIX. ;593 or purposely produced ; and in no case shall such certificate be given until after sufficient time and examination to detect any attempt at deception. 38 .... In passing a recruit, the medical officer is to examine him stripped; to see that he has free use of all of his limbs ; that his chest is ample ; that his hearing, vision and speech are perfect ; that he has no tumors, or ulcerated or extensively cicatrized legs ; no rupture, or chronic cutaneous affection ; that he has not received any contusion or wound of the head that may impair his faculties; that he is not a drunkard; is not sub- ject to convulsions, and has no infectious disorder, nor any other that may unfit him for military service. 39.... As soon as a recruit joins any regiment or station, he shall be examined by the medical officer, and vaccinated when it is required. 40. .. .Medical officers attending recruiting rendezvous, will keep a record (Form 18) of all the recruits examined by them. Books for this purpose will be procured by application to the Surgeon-General, to whom they will be returned when filled. 41. . . .The 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 certificates for discharge for disability (Form 1). 42. . . .After surgeon's call, he will make a morning report of the sick to the commanding officer (Form 14). 43. . . .Every medical officer will report to the Surgeon-Gen- eral and to the medical director the date when he arrives at a station, or when he leaves it, and his orders in the case, and at the end of each month, whenever not at his station, whether on service or on leave of absence ; and when on leave of absence, his post-office address for the next month. They will also acknowledge the receipt of all orders. 44.... When medical attendance is required by officers or enlisted men on service, or for the authorized servants of such officers, and the attendance of a medical officer cannot be had, the officer, or if there be no officer, then the enlisted man, may employ a private physician, and a just account therefor will be paid by the medical bureau. 394 APPENDIX. 45 ... . The account will set out the name of the patient, the date of and charge for each visit, and for medicines. The physician will make a certificate to the account in case of an officer, or affidavit in case of an enlisted man, that the account is correct, and the charges are the customary charges of the place. 4G....The officer will make his certificate, or the enlisted man his affidavit, to the correctness of the account, that he was on service at the place, and stating the circumstances prevent- ing him from receiving the services of a medical officer. 47. . . .When the charge is against an officer, he will pay the account if practicable, and transmit it to the medical bureau for reimbursement. In all other cases, the account will be trans- mitted to the medical bureau for settlement. 48 .... If the charge is against a deceased officer or enlisted man, the physician will make the affidavit, before required, to the account, and that he has been paid no part of it. 49.... No charges for consultation fees will be paid by the medical bureau; nor will any account for medical attendance or medicines be paid, if the officer or enlisted man be not on ser- vice. 50. . . .When it is necessary to employ a private physician as medical officer, the commanding officer may do it by written contract, conditioned as in Form 15, at a stated compensation, not to exceed $50 a month, when the number of officers and men, with authorized servants and laundresses, is one hundred or more ; $40 when it is from fifty to one hundred, and $30 when it is under fifty. 51 . . . .But when he is required to abandon his own business, and give his whole time to the public service, the contract may be not to exceed $80 a month; and not to exceed $100, besides transportation in kind to be furnished by the Quartermaster's Department, where he is required to accompany troops on marches or transports. But a private physician will not be employed to accompany troops on marches or transports, except by orders from the War Department, or in particular and urgent cases, by the order of the officer directing the move- APPENDIX. 395 ment ; when a particular statement of the circumstances which made it necessary will be appended to the contract. 52. .. .And when a private physician is required to furnish medicines, he will be allowed, besides the liquidated pay, from twenty-five to fifty per cent, on it, to be determined by the Surgeon-General. 53. . . .In all cases a duplicate of the contract will be trans- mitted forthwith by the commanding officer to the Surgeon- General ; and the commanding officer for the time being will at once discontinue it whenever the necessity for it ceases, or the Surgeon-General may so direct. 54 ... . The physician's account of pay due must be sent to the Surgeon-General for 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. But when it cannot be conveniently submitted to the Surgeon-Gen- eral from the frontier or the field, it may be paid on the order of the commanding officer, not to exceed the regular amount, by a medical disbursing officer or a quartermaster. 55 ... . The General-in-Chief 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. 56 .... As the hospital stewards are " attached to the Medical Department," their accounts of pay, clothing, etc, must be kept by the medical 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. 57. . . .The senior medical officer 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-General of the army, with his remarks thereon, and with the remarks of the company commander. 58.... When no competent enlisted man can be procured, 896 APPENDIX. the medical officer will report the fact to the Surgeon-General. Applications and testimonials of competency, from persons seek- ing to be enlisted for hospital stewards, may be addressed to the Surgeon-General. 59. . . .No soldier or citizen will be recommended for appoint- ment, who is not knoion to be temperate, honest, and in every way reliable, as well as sufficiently intelligent, and skilled in pharmacy, for the proper discharge of the responsible duties likely to be devolved upon him. Until this is known, he will be appointed as acting steward by the medical officer, with the approval of the commanding officer. 60. . . .Hospital stewards, appointed by the General-in-Chief, whenever stationed in places whence no post return is made to the Adjutant-General's office, or when on furlough, will, at the end of every month, report themselves, by letter, to the Adju- tant-General and Surgeon-General, as well as to the medical director of the military department in which they may be serv- ing; to each of whom they will also report each new assign- ment to duty, or change of station, ordered in their case, noting carefully the number, date and source of the order directing the same. They will likewise report monthly, when on furlough, to the medical officer in charge of the hospital to which they are attached. 61.... The jurisdiction and authority of courts-martial are the same with reference to hospital stewards as in the cases of other enlisted men. When, however, a hospital steward is sentenced by an inferior court to be reduced to the ranks, such sentence, though it may be approved by the reviewing officer, will not be carried into effect until the case has been referred to the General-in-Chief for final action. In these cases of reduc- tion, the application of the man for discharge from service, though not recognized as of right, will generally be regarded with favor, if his offence has not been of too serious a nature, and especially when he has not been recently promoted from the ranks. APPENDIX. 307 [It is urged that medical officers make requisition only for such medicines in the following table as are deemed indispensable.] Standard Supply Table for General and Post Hospitals. ARTICLES. Quantities for one year for commands of From 100 to 200. From 2oil to 300. From 300 to 400. 500 i 1,000 men. men. MEDICINES. Acacias lb. Acidi acetici lb. " arseniosi oz. " benzoici oz. " citriei . . .lb. " muriatic! lb. " nitrici lb. " sulphurici lb. " " aromatic!.. . .lb. " tannici oz. " tartarici lb . jEtheris sulphurici loti lb. Alcoholis butt. Aluuiiuis lb. Ammoniacia lb. Ammonias carbon atis oz. muriatis lb. Anthemidis lb. Antimonii et potass, tartratis.oz . Argenti nitratis (crystals). . .oz. " (fused) iz. Arnica? lb. Assafcetidae ... oz. Bismuthi subnitratis oz. Camphorae lb. Cardamomi oz. Catechu lb. Cera? alba>* lb. Cerati rcsinae lb. zimplicis lb. " zinci carbonatis lb. Chloroform] lb. Collodii oz. Copaiba? lb. Creasoti oz . Creta? prcparatae lb. Cupri sulphatia oz. Emplastri adhsesivi yds. " cantharadis lb. 2 4 4 l l * l 1 l 2 2 2 24 1 2 2 4 4 4 48 2 1 16 1 2 6 2 8 4 16 1 4 4 16 4 2 4 10 4 2 4 10 6 72 2 24 2 9 3 3 3 12 12 6 24 2 6 6 24 6 3 6 15 6 3 6 15 .9 8 24 2 2 ^ 4 4 24 4 4 4 S 8 8 96 4 24 32 24 4 12 4 4 4 16 16 8 32 2* S 8 32 8 4 8 20 8 4 8 20 12 16 5 S S 8 16 16 16 192 8 5 64 5 S 24 8 S ' 8 32 32 16 64 5 16 16 64 16 8 16 40 16 8 16 40 24 *To be issued I ) posts w hei e simple cerate cannot be sent without becoming rancid. 398 APPENDIX. SUPPLY TABLE FOR HOSPITALS— Continued. ARTICLES. Quantities for one year for commands of From 100 to * 10. From 200 to 300. From | 300 to 400. 500 men. 1,000 men. Emplastri ferri lb " hydrargyri lb " iehthyoeolla? • . -yds Extracti belladonna? oz " buchu fluidi lb " colchici acetici . . . .oz " colocynthidis conip.oz '• eolomba? fluidi lb " conii oz " • cubeba? fluidi lb " gen tiana? fluidi ... .lb " glycyrrhizae lb " hyoscyaini oz " ipecacuanha? fluidi. lb " piperis fluidi oz " pruni virg. fluidi. . .lb " rhei fluidi lb " sarsaparilla? fluidi. .lb " senega? fluidi lb " senna? fluidi lb " taraxaci fluidi lb " Valeriana? fluidi . . .oz " zingiberis fluidi. . . .11) Ferri iodidi oz " et quinise citratis oz " sulphatis oz Gauibogia? oz Glycerine oz Guaiaci resinae lb Hydrargyri chloridi corr. . . .oz " " mitis...lb " cum creta lb " iodidi oz " oxidi rubri oz Iodinii oz Lini lb Liquoris ammonia? lb " ferri iodidi lb " potass : arsenitis ...oz " soda? chlorinta?. . .bott " zinei chloridi . . . .bott Maguesise lb " sulphatis lb Mas^se pill : hydrargyri oz Mellis despumati Hi Morphia? sulphatis dr 1 2 3 4 J 1 2 24 3 13 9 12 2 4 6 8 1 2 3 4 1 2 3 4 8 16 24 32 1 2 3 4 1 2 O 4 1 2 3 4 1 2 3 4 6 12 18 24 2 4 6 8 4 1 2 24 l 2 3 4 l 2 3 4 l 2 3 4 2 4 6 8 | 1 2 24 1 2 3 4 1 2 3 4 8 16 24 32 4 1 2 24 2 4 6 8 4 S 12 16 2 4 6 8 2 1 2 24 2 4 6 8 4 1 2 2* 4 1 2 24 l 2 3 4 4 1 2 24 l 2 3 4 l 2 3 4 2 4 6 8 4 8 12 16 4 8 12 16 1 2 3 4 2 4 6 8 3 6 9 12 3 6 9 12 * 1 2 24 25 50 75 100 8 16 24 32 2 4 6 8 2 4 6 8 APPENDIX. 399 SUPPLY TABLE FOR HOSPITALS— Continued. 1,000 men. My rrhse lb • • Olei unisi oz. . '• cajuputi oz.. " caryophylli oz . . " cinnamomi oz. . " meuthcO piperita} oz . . ■' morrh.ua) . • .bott. . " oliva) bott . . " origani oz.. "' ricini qt. bott. . " terebinthinse qt. bott.. " tiglii dr.. Opii lb-- Picis abietis ..lb.. Plumbi acetatis lb. . Potasse acetatis lb . . " bicarbonatis lb . . " bitartratis lb.. " chloratis lb . . " nitratis lb.. " sulpbatis lb . . Potassii eyanureti dr. . " iodidi oz. Pruni virginiana) lb. Pulveiis acacia) lb . " aloes oz. " cantharidis oz. " capsici lb. " cinchona? lb. " ferri oz. " " per sulphatis . .oz. " glycyrrhiza) oz. ipecacuanha) lb. " " et opii. lb. " ialapas oz. " lini lb. " opii lb. " rhei oz. " sabina) oz. " sinapis nigra) lb. " ulini lb. Quassia) lb . Quinia) sulphatis oz. Rhei oz. Sacehari lb. aponis .lb. i 1 1 1 1 2 8 8 4 12 4 2 4 l l l l 2 1 1 i 1 8 2 4 j 2 1 1 2 1 4 i 4 8 4 1 6 2 JL 10-20 4 20 4 2 4 16 16 S 24 8 4 1 2 2 2 2 4 2 2 1 2 16 1 4 8 4 2 2 4 2 S 1 1 8 16 1 8 2 12 4 1 20-40 8 40 8 2 3 Q 3 3 6 24 24 12 36 12 6 2 3 3 3 3 6 3 3 2 3 24 2 6 12 6 3 6 3 12 2 2 12 24 2 12 18 6 2 30-60 12 (it) 12 2i 4 4 4 4 S 32 32 16 48 16 8 24 4 4 4 4 8 4 4 2i 4 32 2£ 16 64 64 32 96 32 16 5 8 S 8 8 16 8 64 8 16 16 32 8 16 4 8 4 8 8 16 4 s 16 32 2* 5 2* 5 16 32 32 64 2 J 5 16 32 4 8 24 48 8 16 2.V b 40-80 80-160 16 32 80 160 16 32 400 APPENDIX. SUPPLY TABLE FOR HOSPITALS— Continued. Quantities for one year for commands of From 100 to 200. From 200 to 300. From 300 to 400. 500 men. Seillae oz. Serpen tarise lb. Soda? bicarbonatis lb. boratis lb. et potass: tartratis ...lb. Spigelian lb. Spiritus ammon : aromatici. .oz. " ajtheris compositi. . .lb. " " nitriei lb. " lavanduhe comp. . . .lb. " vini galliei bott. S trychn ire dr. Sulphuris loti lb. Sy rupi scillse 11 1 . Tine-tune aconiti radiois ... .lb. . " digitalis oz. " ergotiv (Dublin)., oz.. " ferri chloric) i lb., " veratri viridis . ...oz.. Unguenti hydrargyri lb. , " " nitratis.lb. , Veratriae dr. i Vini colchici seminis lb. . Zinci acetatis z. , " sulphatis oz. . " ohlorid oz. . INSTRUMENTS. Buck's spongeholder for the throat no. Cupping glasses or tins no. Dissecting sets. Lancets, spring* no. " thuinbf no. Obstetrical sets. Pocket sets. Probangs no. Pulleys sets. Scarificators no. Splints (assorted) sets. Stethoscopes no. Stomach pump and case . . . .no. Syringes, enema."}; no. 4 8 12 16 J 1 2 2h 2 4 6 8 i 1 2 2* 3 6 9 12 i 1 2 24 2 4 6 8 i 1 2 2i 2 4 6 8 t 1 2 24 12 24 36 4S 1 2 3 4 1 2 3 4 3 6 9 12 1 2 3 4 4 8 12 16 4 8 12 16 1 1 2 2$ 4 8 12 16 1 2 3 4 1 1 2 2£ 1 2 3 I 5 1 2 24 i 2 3 4 i 2 3 4 i 1 1 2 i 1 1 1 12 12 18 18 1 1 1 1 I 1 2 2 4 6 S 8 1 1 1 1 1 1 1 1 6 6 6 6 1 1 1 1 2 2 2 3 1 1 1 1 1 1 1 1 1 1 1 1 :; 1 3 3 3 1 * Four extra fleams to each lancet. \ With rases. J 1 Davidson's; 1. 4-oz. : 1, 8-oz. APPENDIX. 401 SUPPLY TABLE FOK HOSPITALS— Continued. ARTICLES. Quantities for one year for commands of From 100 to 200. From 200 to 300. From 300 to 400. 500 men. 1,000 men. Syringes, penis, glass no. " " metallic. . . .no. " vagina* no . Teeth extracting sets. . Tongue depressor (hinge). . .no. , Tourniquets, held no . . " spiral no. Trusses, hernia; no. BOOKS. Anatomy cop. Chemistry cop. Dispensatory cop. Medical Dictionary cop. Formulary cop. " Jurisprudence and Toxicology cop. " Practice cop. Obstetricy cop. Regulations for Med. Dep't.cop. Surgery cop . Blank no. Case no. Meteorological Register ... .no. Order and Letter no. Prescription no. Register no. Requisitions Returns Reports of sick HOSPITAL STORES. Arrowroot lb. Barley lb. Cinnamon lb. Cloves oz. Cocoa Hi. Farina lb. Ginger, ground (Jamaica) . . .lb. Nutmegs oz. Tea lb. Whiskey, bottles of doz. 2 4 6 8 6 12 18 24 3 3 3 3 1 1 1 1 1 1 1 1 4 4 6 6 1 1 2 2 3 6 9 12 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 2 2 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 10 15 20 20 40 60 80 i 1 2 2i 4 S 12 16 10 20 30 40 5 10 15 20 i 1 2 2i 4 8 12 16 20 40 60 80 2 4 6 s 16 36 6 2 2 10 4 24 40 160 5 32 80 40 5 32 160 16 34 * Hard india-rubber, 1 ; glass, 2. 402 APPENDIX. SUPPLY TABLE FOR HOSPITALS— Continued. Quantities for one year for commands of From From From 100 to 200 to 300 to 200. 300. 400. 500 men. Wine, bottles of doz. BEDDING. Bed sacks no. Bedsteads, iron no. Blankets, woollen no. Coverlets no. Grutta percha cloth jds. Mattresses no. Musquito bars no. Pillow rases no . ticks no. Sheets no. FURNITURE, DRESSINGS, ETC. Bandages, suspensory* no. Binders' boardsf no. Corks, assorted doz. Corkscrews no. Cotton batting 11). " wadding lb. Flannel, red yds. Funnels, glass no. " tin no. Hatchets no. Hones (in wood)j ■ no. Ink powder papers. Inkstands no. Linen yds. Lint lb. Measures, graduated no. •' tin sets. Medicine cups and glasses|| .no. Mills, coffee no. Mortars and pestles, glass ..no.. " " " iron ... no. " " " wedge- wood no. Muslin yds. Needles, sewing no. Oiled silk or gutta percha tis- sue, or india-rubber tissue. yds. 2 4 6 8 10 20 30 -10 6-1 12-20 18-30 24-10 10-20 20-40 30-00 40-80 10 20 30 40 4 6 8 10 2 4 6 8 0-10 12-20 18-30 24-40 25 50 75 100 10 20 30 40 -10 80 120 200 4 8 12 16 •1 6 8 12 12 24 36 48 1 1 2 2 1 2 3 4 1 2 3 4 5 10 15 20 1 1 2 9 1 1 2 2 1 1 2 2 1 1 1 1 2 9 3 3 1 1 2 2 5 10 15 20 4 6 8 10 3 3 4 6 1 1 1 1 ■ 3 6 1) 12 2 2 2 3 1 1 2 2 1 1 1 1 1 2 2 3 25 50 75 100 25 25 25 25 4 6 6 8 Assorted, f 18 inches by 4. J inches by 1. |j 2 cups to 1 glass. APPENDIX. 403 SUPPLY TABLE FOR HOSPITALS— Continued. ARTICLES. Quantities for one year for commands of From 100 to 200. From 200 to 300. From 300 to 400. 500 men. 1.000 men. runs, bed no. . Paper envelopes* no. . " filtering quires. . ." wrapping quires . . " writingf quires. . Pencils, hair no. . " lead no. . Pens, steel doz. . Pill boxes papers. . " machine no.. Pins, assorted papers. . Quills no. . Rain gauges u o . . Razors no. . Razor strops no. . Scales and weights, apothe- cary's sets.. Scales and weights, shop. . sets. . Scissors no . . Sheep skins, dressed no. . Silk, surgeons oz . . " green yds.. Spatulas no. . Sponge lb. . Tape! pieces.. Thermometers and hygro- meters no. . Thermometers no. . Thread, linen oz. . Tiles no. . Tow lb.. Towels no.. Twine lb.. Urinals no. . Vials, assorted loz, . Wafers (V oz. boxes) no. . Wax, sealing sticks. . 2 2 3 4 100 125 150 200 i 1 2 2 10 12 15 15 12 20 20 20 12 18 24 30 6 8 10 12 2 3 3 4 3 6 9 • 12 1 1 1 1 2 4 6 8 25 24 50 50 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 2 2 2 3 4 6 8 10 X j. i 4 i 1 2 2i :3 Q 4 6 3 1 f i 4 8 12 16 2 2 2 2 1 1 1 1 4 4 G 6 2 3 3 3 1 2 9 3 20 30 50 75 1 1 1* U 2 3 5 6 6 12 18 24 1 1 2 2 3 3 4 4 250 20 30 50 18 6 24 1 16 50 1 2 2 2 1 4 12 1 5 12 1 32 2 1 150 3 10 48 3 6 * Assorted, '■'< sizes — "Official business'' printed on each, f Foolscap, letter and note — white: blue ruled, t One quarter, woollen: three quarters, cotton. 404 APrENDlX. If the following articles of Hospital Furniture cannot be ob- tained with the hospital fund, they may be procured from a quartermaster or medical disbursing officer, by special requisi- tion : ARTICLES. Basins, wash. Bowls. Brushes. Buckets. Candlesticks. Clothes Lines. Cups. Dippers and Ladles. Graters. Gridirons . Kettles, tea. . Knives and Forks. Lamps and Lanterns. Locks and Keys. Mugs. Pans, frying. " sauce. Pitchers. Plates and Dishes. Pots, chamber and chair. " coffee and tea. Sadirons. Shovels, fire. Snuffers. Spoons. Tongs and Pokers. Tumblers. Woodsaws. APPENDIX. 405 Standard Supply Table for Field Service. Quantities. ARTICLES. | Reg't 1 Bat. 1 Comp. ! 3 mos. | 3 mos. | 3 mus. MEDICINES. Acidi aeetiei lb. . " sulph. aroniatici Hi. . " tannici oz. . iEthcris sulphurici loti lb. . Alcoholis bott. . Al ii minis lb. . Ammonite carbonatis oz. . Antimnnii et potass, tartratis oz. . Argenti nitratis (crystals) oz. . " (fused) oz.. Camphora? lb. . Cerati resina? lb. . " simplicis lb. . Chloroformi lb. . Copaibas lb. . Creasoti oz. . Cupri sulpbatis oz. . Emplastri adha?sivi yds. . " eantharidis lb. . " iehthyocolla? yds.. Extracti belladonna} oz . . " colchiei acetici oz. . "' colocynthidis comp oz. . '■' glycyrrhizae lb. . Hydrargyri ehloridi corrosivi oz. . _ " ' " mitis lb.. Iodinii oz , # Liquoris Ammonia? lb. . " potass, arsenitis oz.. Magnesia? sulpbatis. lb. . Massa? pil : hydrargyri oz . . Morphia sulpbatis dr. . Olui caryuphylli oz. . " mentis a? piperita? oz. . " olivae bott. . " ricini ([ t. bott.. " terebiutbina? qt. bott. . " tiglii dr.. Pil ul : cathartic: comp: (U.S.) doz. . opii (U. S.) doz.. " quinia? sulpbatis (3 grs.) loz. . Plmubi acetatis lb. . Potassa? bicarbouatis 11,. , ■' chloratis 1!,. , " nitratis ..lb.. 1 1 2 2 10 1 16 2 2 2 4 2 4 10 4 10 1 2 16 2 4 4 4 20 16 4 1 2 8 12 8 2 8 8 8 1 2 1 1 1 5 i 8 1 1 1 2 1 4 1 1 1 2 5 2 5 1 1 S 1 I I 2 2 2 10 8 2 1 1 4 6 4 1 4 4 4 1 i 406 APPENDIX. SUPPLY TABLE FOR FIELD SERVICE— Continued. Quantities. Keg t I Bat. I Comp. 3 mos. 3 mos. 3 inos. Potassii iodidi oz. . Pulveria acaciae lb. . capsici lb.. " ferri per snlpbatis /.. . " ipecacuanha; lb.. " " et opii oz.. " lini lb.. " opii lb.. '■ rlici lb. . " sinapis nigros lb. . Quinise sulphatis oz. . Sacchari lb. . Saponis lb. . Sodas bicarbonatis lb. . Spiritus ammonias aroniatici oz. . " astheris nitjrici lb. . " vini gallici bott. . Tincturae ferri chloridi lb. . " opii oz. . Unguenti hydrargyri lb. . " " nitratis lb.. Zinci acetatis oz. . " sulphatis oz.. " cblorid oz. . INSTEUMKNTS. * A case of instruments for general operations, containing all instruments necessary for am- putations, resections and trephining. * A pocket case, containing all instruments re- quired in the daily routine of surgical dress- ings. * A case of assorted catheters. Buck's spongeholder for the throat no. , Cupping glasses and tinsf no. Lancets, spring no. " thumb (with cases) no. Pocket . sets. Probangs, whalebone no. . Scarificators no. - Splints (major) sets., s 4 4 2 A j. 4 2 1 s 3 4 16 8 2 1 i * 12 6 24 12 10 5 8 4 1 J 4 2 2 1 24 12 1 i 16 8 1 I i i 2 1 2 1 1 i 1 l 1(5 8 1 1 6 4 1 1 12 6 4 2 1 1 *These are instruments which a field surgeon cannot do without, and have, apparently, been accidentally omitted from the supply table of the Confederate service. fJIalf glass, half tin. APPENDIX. 407 SUPPLY TABLE FOR FIELD SERVICE— Continued. ARTICLES. Quantities. Reg't I Bat. I Comp. | 3«nos. I 3 mos. I 3 mos. Syringes, enema* no. " penis, glass no. " " india-rubber no. Teeth extracting sets. Tongue depressor (hinge) no. Tourniquets, field no. " spiral no. Trusses, hernia no. Anatomy (surgical) cop. . Medical Practice cop. . Regulations for medical department cop. . Surgery (operative) cop. . Thompson's Conspectus cop. . Blank no. . HOSPITAL STORES. Arrowroot Candles (sperm). Farina Ginger, (fluid extract). Nutmegs Tea .lb. .lb. Whiskey, bottles of doz BEDDING. Blankets, woollen (brown) no. Blanket cases (of canvas, after pattern) .. .no. Gutta perch a cloth yds. " bed coversf no. Musquito bars no. FURNITURE AND DRESSINGS. Bandages, J roller, assorted doz. 10 2 10 1 8 30 2 20-40 10-20 1 for 10 bli 4 4 6 12 14 10 i nkets 2 2 4 *1 Davidson's; 1 hard rubber, 6 oz. fSo constructed, as to form, when united a continuous spread, or covering 11 dozen, 1 inch wide. 1 yard long. 2 '• 2 « 3 3 4 408 APPENDIX. SUPPLY TABLE FOR FIELD SERVICE— Continued. Reg't ."> DDLOS Quantities. I Bat Comp. 3 mos. I 3 mos. Bandages, suspensory, assorted no. Binders' boards (18 inches by 4) no. Buckets, leather no. Corks, assorted doz , Corkscrews no , Cotton batting lb. " wadding lb. Flannel (red) yds. Hatchets no, Hones (4 inches by 1, in wood) no Ink, 2-ounce bottles no Knapsacks, hospital* no Lanterns no Lint lb Litters and stretchers, hand* no " horse* no Measures, graduated, assortedf no Medicine chests no " cups and glasses^ no " panniers no Mess chests (see note) no Mills, coffee no Mortars and pestles, Wedgewood (small)., .no Muslin yds Needles, sewing (assorted, in a case) no Oiled silk or gutta percha tissue, or india-rub- ber tissue yds Pans, bed[| no Paper envelopes, assorted^ no Paper, wrapping quires " writing^ quires Pencils, hair no " lead (of Faber's make, No. 2) no Pens, steel doz Pill boxes (wood j papers '• (tin) no Pins, assorted (large and medium) papers Razors no Razor strops > no 12 6 18 9 4 o 12 6 2 1 2 1 2 1 5 3 2 1 1 1 12 6 4 2 8 4 4 2 6 3 2 1 2 1 20 10 25 25 8 4 2 1 100 50 6 3 12 6 24 12 12 6 4 2 2 1 6 6 4 2 1 1 1 1 1 1 5 25 2 1 25 1 3 6 3 1 1 6 2 1 1 * According to pattern. | 6 ox. 12 oz., minim. I 2 cups to 1 glass. |! Of hanl india-rubber or other material. Shovel. $50 letter, 25 note. 25 large. ''OfnciiU Business" printed on each. 1i 2 foolscap 6 letter, 4 note, white ; blue ruled. APPENDIX. 409 SUPPLY TABLE FOR FIELD SERVICE— Continued. ARTICLES. Quantities. Reg't 3 mos. Bat. 3 mos. Comp. .3 mos. Scales and weights, apothecary's sets Scissors no Sheep skins, dressed no Silk, surgeons' oz " green yds Spatulas no Sponge (washed) lb Tape pieces Thread, linen oz Tiles no Towels no Twine lb Urinals no Vials, assorted (1 oz. and 2 oz.) doz Wafers (J ounce boxes) .". no Wax, sealing sticks 1 1 4 2 4 2 i i 1 i 6 3 1 I 4 2 9 * 1 2 1 40 20 ± 4. 4 4 2 4 2 1 1 2 1 1 2 1 i 4 4 2 i 1 1 1 10 j. i l l l NOTE TO PRECEDING TABLE. Furniture of Mess Chest. 8 Basins, tin. 2 Boxes, pepper and salt. 6 Cups, tin. 4 Canisters (for tea, coffee, sugar and butter). 2 Dippers and ladles. 1 Grater. 1 Gridiron. 1 Kettle, tea, iron. 12 Knives and forks. 6 Mugs (Britannia, half-pint). 1 Pan, frying. 1 Pan, sauce. 8 Plates (6) and dishes (2), tin. 1 Pot, iron. 2 Pots, coffee and tea, tin. 12 Spoons, iron [table (6) and tea («)]■ 1 Tray, tin. 6 Tumblers, tin. The Standard Supply Tables contain all the articles to be purchased by medical purveyors, except on the orders of the Surgeon-General; but any less quantity may be required or any article omitted at the discretion of the medical officer. 35 ,,,...,. ,. || "Vi-EI'X" '.r,' . ■■ MS; i •;.■ . APPENDIX. 411 Form 1 — Continued. DISCHARGES ON SURGEON'S CERTIFICATE, AND DEATHS. Name. Rank. * 3 o O Date of dis- Date of Surname. Christian name. 1 service. death. REMARKS. Notes. — Discharges on Surgeon's certificate, and deaths occurring among those of the command not on sick report, will be also reported, but separated from the Others by a*double line drawn across the page. The remarks will in each case Bpecify the manner in which the disease originated, when it is known. In every case of the death of an officer, whether on duty or not, a special report is to be made to the Surgeon-General 412 APPENDIX. Form 1 — Continued. ENDORSEMENT. REPORT OF SICK AND WOUNDED. FOR. THE Quarter ending 186 , Station : Surgeon. COMMAND. Regiments. Companies. APPENDIX. 413 Ai-fi *" .5 1^ e it o 1 ? ■h. < no CU o o E- 5 -* > a (B is s a Rank. Post or station. 1 H 12! d m O c ' U (D 5) . &S if- 2 5 - O > C +a B 5 ots:^ 3 Sao = ~j= Qrj c S 3 ^c a) *^ _>> & t- S -u' r S •- « a 13 « Tl c2, H C3 O B»aS : 8 o s 5 fcS- 414 APPENDIX. 03 •pireq uq •o^a 'papnadxa ju^ox •esn •^nspiooT! apr^'pioA'Bnn £c[ pa^oj^sop jo ^soq; •pgnssj •5[0is gqj q^TM. pgpuadxg; •p3}ox ■tutty -oj ^sv\ aonis paAiaoa'jj •njruaj )sv\ %v ptreq uq to K W O < . a go < 2 « 3 !E ^ ^O" CO K S ►^ O o PS ■>"* 5 .£^ APPENDIX. 415 '>• O e PR 5 & oa 'I^ ! •8 -0M 'fOA •J5 -0 N ""OA '9 "OM ' no A •q -or -no a •f -ox -noA •g -or -noA (3 j» o H K TK»ox •g -ojtf -no a ■f -o^r -noA ■g -o^ -no A - 6 - 0JS[ - ™A 'I 'ON -n o A (S o eft « e a < 3 & ^ H o Eh « 416 APPENDIX. 13 o> +3 cS £ a cS -a a O <« M Eh O ■< ai <* K) a rt ► 13 a c« .a a O f& rO N ■— ' o DQ PS B H O -4 03 K H m s o £ K C -4 K S> ^O" '£ x 03 J ' !s o 'a 0> o o M PS .i c« o3 ■0 O |3 » < «tj -a £ rti <0 J-. fco =2 cS 418 ArPENDIX. H « APPENDIX. 410 en W « < W tf •a?a ■o^g •o?a =5 •88J500 •ilpu'ujg; ©■ ■ani^ & •tiaX o •jtfSng •aoi-jj 1-5 a H «l ft 420 APPENDIX. The remarks will note to whom the ar- ticles were delivered ; what money, etc. were left by those who die, and to whom they were given. •oj5i •0}3 •343 ■sipusd\iuj{ •Sia^snjf '•>1K •srrei9A() •s^a^pef •sreog ■XirediaoQ J§ ID U A ° a 3 3 cS d o APPENDIX. 421 o5 M » a The remarks will state how articles have been lost, and by whom destroyed, or the persons sus- pected, etc. •pj'BAigjs o% pgnjn}9)j •J9pJ0 A"q p9jf0J;S9(J •;no umom •ijsoq; •o;a •o?a •SJJJOtf •S9ATU2 •suoodg •S9in82 ■s^a^at-jg ■sijaaqg ■sj[obs pag; ■sj[nng[ •n9q3;i5( .10 pjtfii jo -oj>j 422 APPENDIX. rH Ph 1-1 K H H c/J> I— i « O o w Ph Pd w PS m •paia •qSno[jnj oq •[■Djidsoii iiuauaS 0} ?uag •aoiAjas raojj poSjuqasifl •p8^J0S3(J •A^np o} panan^ay; •pa^irapy j ft s o o •Xu'cdraoQ •sdaoo jo ^aoraiSa'jj •jfa^y; Names. APPENDIX. 428 •a OQ >> EH t> ■3 a o NAMES. bCd 53 a o a a .2 <§ EH 3 ., ® -r -^ ^ a it -^3 .3 -3 ft * .« -a 3-^« ° t_, o <~ o 9 a S3 i 03 r3 si « H/ft* P H Q go o8 a o C3 —I _£ 13 ? 53 -3 ^> 03 ^ & .Z ^r, S3 a o " a> >a - S3 S3 ft § & J3 2, 3 3 o £J5 | ° | «g fj ^ 03 "S fe^i o 6 e> .z a CQ +^ _3 r^H •£- ^ p_,-u . -03 « =3 ~.o h3 g J *° =« J ^ ^ '£ -?< ° § o a d ^ -^ M «3 2 53 5 -a . » a m 13 J3 B ta ° .2 -a ■*> j, a to +3 5 tf 2 2 e3 3 «" *= _ t " s a ° t s ° CO >>£-£ 13 £| 53 n O +J Fj . .. H 53 rO Pi m -w sj "3 _ a o ™- s 53 53 M S3 ,„ 03 £ X"^ xa es a 03 o q 53 a 53 X, £ £ ° a - £ ° m *« a ^ ^o „ .2 £ & 53 53 ^ O ' Sj .> S "S O O O d h o — M ."£ cs M c^ a. rt o op' ' a^a "" x >-. — ^ r— a S § 5 3 53 'S CO ^ .a '- 2 *. -.: C3 03 03 53 „ t. J a=2 = /^ -ar-^53 ^o-ra^ _ - tJ ^ c '^a3"S -53t< 3 C3 bC !-. ^ •- > _ •« .O -w ■a ■- 03 03 „ ^H a is 2 o rt 'o 53 c x .2 .2 ft is "§ ^ 2^a a— S 2 ^a o „ o a« J 03 w S '3 S & a 2 ° ^3 ^i .S 'd 53 •z'H ^3x3 424 APPENDIX. Form 13. ARMY OF THE CONFEDERATE STATES. (Coat of Arms.) Certificate of Disability for Discharge. A B, of Captain 's company, ( — ), of the regi- ment of Confederate States , was enlisted by , of the regiment of , at , on the day of , to serve years ; he was born in , in the State of , is years of age, feet inches high, complexion, eyes, hair, and by occupation, when en- listed, . During the last two months said soldier has been unfit for duty days. (The company eorrfmander will here add a statement of all the facts known to him concerning the disease or wound, or cause of disability of the soldier ; the time, place, manner, and all the circumstances under which the injury occurred, or disease origi- nated or appeared ; the duty or service or situation of the soldier at the time the injury was received or disease contracted, or sup- posed to be contracted ; and whatever facts may aid a judgment as to the cause, immediate or remote, of the disability and the circumstances attending it.) C D, Commanding Company. (When the facts are not known to the company commander, the certificate of any officer, or affidavit of other person having such knowledge, will be appended.) I certify that I have carefully examined the said of Captain 's company, and find him incapable of perform- ing the duties of a soldier because of (here describe particularly the disability, wound, or disease ; the extent to which it deprives him of the use of any limb or faculty, or affects his health, strength, activity, constitution, or capacity to labor or earn his subsistence). The Surgeon will add, from his knowledge of the facts and circumstances, and from the evidence in the case, his professional opinion of the cause or origin of the disability. E F, Surgeon. (duplicates). Notes. — 1. When a. probable case for pension, special care must be taken to state the degree of disability. 2. The place where the soldier desires to be addressed may be here added Town— County — State — APPENDIX. 425 ^ < id '3 '5 £ •siaj.iBnb nj •jujidsoq ttj ■p^ia •l^tflsoq •paSanqosiQ; •jfynp o^ psajnp'jj o 5-i •saojiunb nj •jujidsoq nj •5[.")tS UD51T?X s =. c g 1-s •S.I3J.Il!llb UJ •jc^idsoq nj < 6 o < A 36 42(j APPENDIX. Form 15. CONTRACT WITH A PRIVATE PHYSICIAN. This contract, entered into this day of , 18 — , 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 perform the duties of a medical officer, agreeably to the Army Regulations, at {and to furnish the necessary medicines). And the said promises and agrees, on behalf of the Confederate States, 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 com- pensation, and in lieu of all allowances and emoluments whatso- ever {except that for medicines furnished, which shall "be at the rate of per cent, on his monthly pay, to be determined by the Surgeon-General). This contract to continue till determined by the said doctor, or the commanding officer for the time being, or the Surgeon-General. [seal.] Signed, sealed, and delivered, ) in presence of — ) [seal.] I certify that the number of persons entitled to medical at- tendance, agreeably to regulations, at is , and that no competent physician can be obtained at a lower rate. , Commanding Officer. AL'PENDIX. 427 Form 16. A Monthly Statement of the Hospital Fund at month of , 186 — . -. for the Dr. To balance due hospital last month, ... 1,532 rations, being- Avhole amount due this month, at 9| cents per ration, ... - Cr. By the following provisions, at contract prices: 283£ lbs. of pork, at 6 cents per pound, 600 lbs. of fresh beef, at 4c. per pound, 1,61 2 T 2 g lbs. of flour, at 2 cents per pound, 10 lbs. of hard bread, at 3^c. per lb. 70 lbs. of rice, at 6 cents per pound, 56 lbs. of coffee, at 9 cts. per pound, 193-Jg lbs. of sugar, at 8 cts. per pound, 1 7^ qrts. of vinegar, at 5c. per quart, 15 T 5 g lbs. of candles, at 12c. per pound, 61^ lbs. of soap, at 6 cents per pound, 16| qrts. of salt, at 3 cents per quart, 12 galls, molasses, at 28c. per gallon, PURCHASED. 2 prs. of chickens, at 87JC. per pair, - 4 qts. of milk, at 7c. per quart, 3 doz. oranges, at 25c. per doz. Total expended, Balance due this month, $17 01 27 60 32 244 35 4 20 5 04 15 51 85* 1 83f 3 674. 50* 3 36 [12 18J $ 00 145 54 114 96f $30 574. -, Surgeon. [ Date.] 428 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 absence, 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 effects.] And that, in consequence thereof, he is, in my opinion, unfit for duty. I fur- ther 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 recovery is distant and uncertain, it must be so stated.] Dated , this day of . Signature of the } Medical officer. | Al'l'ENDlX. 429 APPENDIX. 48 L EXTRACTS FROM TITR REGULATIONS FOR THE UNITED STATES ARMY. (Edition of 1857.) QUARTERMASTER'S DEPARTMENT. 715. .Provides "that soldiers be not permitted to leave the ranks to assist the wounded, unless by express permission, which is only to be given after the action is decided. The highest interest and duty is to win the victory, which only can insure proper care of the wounded." 716.. "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 the service of the ambulance wagons, and other means of removing the wounded." 717. ."The ambulance depot, to which the wounded are car- ried 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 ambulance, and to the wounded who can walk." 71 8.. "The active ambulance follows the troop engaged to succor the wounded and remove them to the depot. For this purpose, the conductor should always have the necessary assist- ants that the soldiers may have no excuse for leaving the ranks for that object." 719. .The medical director of the division, after consultation with the Quartermaster-General, distributes the medical officers and hospital attendants, at his disposal, to the depots and active ambulances. He will send officers and attendants, when prao 432 APPENDIX. ticable, to the active ambulances, to relieve the wounded who require treatment before being removed from the ground. He will see that the depots and ambulances are provided with the necessary apparatus, medicines and stores. He will take post and render his professional services at the principal depot. 720. .If the enemy endangers the depot, the Quartermaster takes the orders of the General to remove it, or to strengthen its guard. 721 . .The wounded in the depots, and the sick, are removed, as soon as possible, to the hospitals that have been established by the Quartermaster-General of the Army, on the flanks or rear of the army. 782. .In sieges, the field officer of the trenches sees that men and litters are always ready to bring off the wounded. 929. .No officer making returns of property shall drop from his return any public property as worn out or unserviceable un- til it has been condemned, after proper inspection, and ordered to be so dropped. 935.. .Every officer having public money to account for, and failing to render his account thereof quarter- yearly, with the vouchers necessary to its correct and prompt settlement, within three months after the expiration of the quarter, if resident in the United States, and within six months if resident in a foreign country, will be promptly dismissed by the President, unless he shall explain the default to the satisfaction of the President. (Act January 31, 1823.) 936. .Every officer entrusted with public money or property shall render all prescribed returns and accounts to the bureau of the department in which he is serving, where all such returns and accounts shall pass through a rigid administrative scrutiny before the money accounts are transmitted to the proper offices of the Treasury Department for settlement. 991.. .The sick will be transported on the application of the medical officers to the Quartermaster. 1005. .Assistant surgeons, approved by an examining board and commissioned, receive transportation in the execution of their first order to duty. 101 3.. The allowance and change of straw for the sick is regulated by the surgeons. APPENDIX. 4oo 1043. .Officers receiving clothing or camp and garrison equip- age, will render quarterly returns of it to the Quartermaster- General. 1073. .Issues to the hospital will be on returns by the medical officer, for such provisions only as are actually required for the sick and the attendants. The cost of such parts of the ration as are issued will be charged to the hospital at contract or cost prices, and the hospital will be credited by the whole number of complete rations due through the month at contract or cost prices (see Note 7) ; the balance, constituting the Hospital Fund, or any portion of it, may be expended by the commissary, on the requisition of the medical officer, in the purchase of any article for the subsistence or comfort of the sick, not authorized to be otherwise furnished (see Form 3). At large depots or general hospitals, this fund may be partly expended for the benefit of dependent posts or detachments, on requisitions ap- proved by the medical director or senior surgeon of the district. 1074. .The articles purchased for the hospital, as well as those issued from the subsistence storehouse, will be included in the surgeon's certificate of issues to the hospital, and borne on the monthly return of provisions received and issued. Vouchers for purchases for the hospital must either be certified by the sur- geon or accompanied by his requisition. 1075. .Abstracts of the issues to the hospital will be made by the commissary, certified by the surgeon and countersigned by the commanding officer. 1079. .An extra issue of fifteen pounds of tallow or ten of sperm candles, per month, may be made to the principal guard of each camp and garrison, on the order of the commanding officer. Extra issues of soap, candles, and vinegar, are permit- ted to the hospital when the surgeon does not avail himself of the commutation of the hospital rations, or when there is no hospital fund ; salt, in small quantities, may be issued for public horses and cattle. When the officers of the medical depart- ment find anti-scorbutics necessary for the health of the troops, the commanding officer may order issues of fresh vegetables, pickled onions, suur-erout, or molasses, with an extra quantity of 37 -Jo4 APPENDIX. rice and vinegar. (Potatoes are usually issued at the rate of one pound per ration, and onions at the rate of three bushels in lieu of one of beans.) Occasional issues (extra) of molasses are made— two quarts to one hundred rations — and of dried ap- ples of from one to one and a half bushels to one hundred ra- tions. Troops at sea are recommended to draw rice and an ex- tra issue of molasses in lieu of beans. When anti-scorbutics arc issued, the medical officer will certify the necessity, and the cir- cumstances which cause it, upon the abstract of extra issues. EXTRACTS FROM GENERAL ORDERS. I. Ambulances will not be used for any other than the specific purpose for which they are designed, viz: the transportation of the sick and wounded ; and those hereafter provided for the army will be made according to a pattern to be furnished the quartermaster's department by the Surgeon-General. II. Paragraph 963 of the Regulations for the Army is so far amended as to allow the medical director and medical purveyor of a military department one room each as an office ; and fuel therefor from the 1st of October to the 30th of April, at the rate of one cord of wood per month. Officers of the. medical department may, by virtue of their commissions, command all enlisted men, like other commissioned officers. Paragraph 13, Army Regulations, will not be inter- preted to restrict that authority. 1. .Boards of Survey will nut lie resorted to for the condem- nation of public property, but only to establish data by which APPENDIX. 435 questions of administrative responsibility may be determined, and the adjustment of accounts facilitated: such as to assess the damage which public property has sustained from any extra- ordinary cause, not ordinary wear, either in transit or in store, or in actual use, and to set forth the circumstances and. fix the responsibility of such damage, whether on the carrier, or the person accountable for the property or having it immediately in charge ; to report from examination the circumstances and amount of the loss or deficiency of public property by accident, unusual wastage, or otherwise, and fix the responsibility of such loss or deficiency ; to make inventories of property ordered to be abandoned, when the articles have not been enumerated in the orders ; to assess the prices at which damaged clothing may be issued to troops, and the proportion in which supplies shall be issued in consequence of damage that renders them at the usual rate unequal to the allowance which the regulations con- template; to verify the discrepancy between the invoices and the actual quantity or description of property transferred from one officer to another, and ascertain, as far as possible, where and how the discrepancy has occurred, whether in the hands of the carrier or the officer making the transfer ; and to make in- ventories and report on the condition of public property in the possession of officers at the time of their death. The action of the Board for the authorized object will be complete with the approval of the commanding officer, but liable to revision by higher authority. In no case, however, will the report of the Board supersede the depositions which the law requires with reference to deficiencies and damage. 2 . . Boards of Survey will not be convened by any other than the commanding officer present, and will be composed of as many officers, not exceeding three, as may be present for duty, the commanding officer and the officer responsible in the matter to be reported on being excluded; but in ease the two latter only are present, then the one not responsible will perforin the duties, and (he responsible officer will perform them if no other officer is present. The proceedings of the Board will be signed by each member, and a copy forwarded by the approving officer 1u the head-quarters of the department or army in the field, as 436 • APPENDIX. the case may be, duplicates being furnished to the officer accountable for the property. 3. .All surveys and reports having in view the* condemnation of public property, for whatever cause, will be made by the com- manding officers of posts or other separate commands, or by inspectors-general, or inspectors specially designated by the commander of a department or an army in the field, or by higher authority. Such surveys and reports having a different object from those of Boards of Survey, will be required independently of any action of a Board on the same property. 4. .When public property is received by any officer, he will make a careful examination to ascertain its quality and condi- tion, but without breaking packages until issues are to be made, unless there is cause to suppose the contents defective ; and in any of the cases supposed in the first paragraph, he will apply for a Board of Survey for the purposes therein set forth. If he deem the property unfit for use, and that the public interest re- quires it to be condemned, he will, in addition, report the fact for that purpose to the commanding officer, avIio will make a critical inspection, or cause it to be made by an inspector-gen- eral or special inspector, according to the nature of his com- mand. . If the inspector deem the property fit, it shall be received and used. If not, he will forward a formal inspection report to the commander empowered to give orders in the case. The same rule will be observed, according to the nature of the case, with reference to property already on hand. The per- son accountable for the property, or having it in charge, will submit an inventory, which will accompany or be embodied in the inspection report, stating how long the property has been in his possession, how long in use, and from whom it was received. The inspector's report will state the exact condition of each article, and what disposition it is expedient to make of it : as, to be destroyed, to be dropped as being of no value, to be broken up, to be repacked or repaired, or to be sold. The inspector will certify on his report that he has examined each article, and that its condition is as stated. If the commanding officer, who ordinarily would be the inspector, is himself accountable for the. property, the next officer in rank present for duty will act as APPENDIX. 437 the inspector. The authority of inspection and condemnation will not, without special instructions, extend to commanding officers of arsenals with reference to ordnance and ordnance stores, but may in regard to other unserviceable supplies. 5 . . An officer commanding a department or an army in the field, may give orders, on the report of the authorized inspectors, either to sell, destroy, or make such other disposition of con- demned property as the case may require, excepting with refer- ence to the sale of ordnance and ordnance stores ; but if the property be of very considerable value, and there is reason to suppose that it could be advantageously applied or disposed of elsewhere than within his command, he will refer the matter to the chief of the staff department to which it belongs. No other persons than those designated, or the General-in-Chief, will order the final disposition of condemned property, excepting in the case of ordnance and ordnance stores, which are to be dropped or broken up ; horses which should be killed to prevent conta- gion, and provisions or other stores which are deteriorating so rapidly as to require immediate action. In this last case, the inspector may order the destruction or sale of the stores, and, in the other cases, he may direct the dispositions above indicated with reference to them. The inventories will be made in duplicate : one to be retained by the person account- able, and the other to accompany his accounts. When the action of the inspector has been final, a copy of the inventory will be forwarded through the department, or other superior head-quarters, to the chief of the staff department to which the property belongs. When the action of the department or other superior commander is required, the original inventories will be sent to the head-quarters, and returned with the final orders thereon to the person accountable for the property, and a copy of the inventory and orders will be forwarded from the depart- ment or other superior head-quarters to the chief of the staff department to which they relate. G . . Ever}- inspector, member of a Board of Survey, and com- mander acting on their proceedings, shall be answerable that his action has been proper and judicious, according to the reg- ulations and the circumstances of the case. 43S APPENDIX. 7. .As far as practicable, every officer in charge of public property, whether it be in use or in store, will endeavor, by timely repairs, to keep it in serviceable condition, for which purpose the necessary means will be allowed on satisfactory requisitions ; and property in store so repaired will be issued for further use. Unserviceable arms will be sent to an arsenal for repair, before accumulating in excess of the surplus arms in the company. Provisions and other j)erishab]e stores will be repacked whenever it may be necessary for their preservation, and their value will justify the expense, which will be a legiti- mate charge against the department to which they belong. Public animals will not be condemned for temporary disease or want of condition, but may, by order of the commanding officer, after inspection, be turned in for rest and treatment, if unfit for service for which they are immediately required. 8. .Public property shall not be transferred gratuitously from one staff department to another ; but when offered for sale, and required for the public service in another staff department in which its use is allowed by regulations, it may be bid in on the order of the commanding officer, or purchased at a fair valuation, to be determined by a Board of Survey, if there should be no other bidder. 9. .Paragraph 926, Arm}- Regulations, and so much of any previous orders or regulations as conflicts with the foregoing, are rescinded. It is desirable to furnish ambulance transportation for forty men per one thousand — twenty lying extended and twenty sitting. Both two and four wheeled ambulances are desirable for the hospital service. A two wheeled ambulance is the best for the conveyance of dangerously sick or dangerously wounded men. It is recommended that the following schedule of transports for the sick and wounded, and for hospital supplies, be adopt ml for a state of war with a civilized enemy : For commands of less than three companies, one two wheeled ATrKNDTX. 439 transport cart for hospital supplies, and to each company one two wheeled ambulance. For commands of more than three and less than five com- panies, two two wheeled transport carts, and to each company one two wheeled ambulance. For a battalion of five companies, one four wheeled ambu- lance, five two wheeled ambulances, and two two wheeled trans- port carts. For each additional company less than ten, one two wheeled transport cart. For a regiment, two four wheeled ambulances, ten two wheeled ambulances, and four two wheeled transport carts. The transport carts to be made after the models of the two wheeled ambulances (their interior arrangement for the sick excepted), and to have solid board flooring to the body. It is recommended that in future hospital tents be made ac- cording to the pattern of the present tent and of the same material, but smaller, aud having on one end a lapel so as to admit of two or more tents being joined and thrown into one with a continuous covering or roof. The dimensions to be these : In length, fourteen feet; in width, fifteen feet ; in height (centre), eleven feet, with a wall four and a half feet, and a "fly" of appropriate size. The ridge pole to be made in two sections after the present pattern, and to meas- ure fourteen feet when joined. It is contemplated that such a tent will accommodate from eight to ten patients comfortably. The following allowance of tents for the sick, their attendants, and hospital supplies is recommended : COMMANDS. For one company • . . For three companies For five companies. . For seven companies For ten companies . . Hospital tents. Sibley tents. Common tents. The adoption of a hospital knapsack is recommended to be 440 APPExmx. carried by a hospital orderly upon the march or in battle, who is habitually to follow the medical officer. The knapsack to be made of light wood ; to be divided into four compartments or drawers, and to be covered with canvas. The purpose of this knapsack is to carry, in an accessible shape, such instruments, dressings and medicines as may be needed in an emergency on the march or in the field. The dimensions of the hospital knap- sack to be those of the ordinary knapsack. APPENDIX. 4+1 COEEBSPONDBNCE. The Surgeon-General directs that official letters, addressed to him by medical officers of the army, be written on letter paper (quarto post) whenever practicable, and not on note or foolscap paper. Also, that the letter be folded in three equal folds parallel with the writing, and endorsed on that fold which cor- responds with the top of the sheet ; thus : (Name and rank of writer.) (Post or station and date of letter.) (Analysis of contents.) Appendix jSTo. 2. MEMOBANDIJM INFORMATION OF MEDICAL OFFICERS IN THE ENGLISH ARMY, ON" TAKING THF3 FIELD FOR ACTIVE SERVICE. 1 . . . . The ambulance equipment for one division of the army, consisting of two brigades of three battalions each — the battal- ions being 800 strong, should consist of two large store wagons, to be under the care of a purveyor's clerk, at the head-quarters of the division. These wagons to contain a reserve supply of medicines, materials, medical comforts, tents and bedding. Each battalion surgeon should have a pack-horse for the conveyance of his instruments, a few medical comforts for immediate use ; such as a bottle of brandy, half pound of tea, one pound of su- gar, and four ounces of arrowroot, a few tins of essence of beef, some medicines, and a supply of surgical materials agreeably to the printed scale laid down in the regulations. A spring wagon should also be attached to each battalion for the removal of the wounded off the field, and for the conveyance of the hospital canteens, A and B, with twelve sets of bedding, ten canvas bearers, and the hospital marquee on the line of march : or, when the spring wagons are either small, or required for the 444 APPENDIX. conveyance of sick and wounded, a reserve wagon might be attached to each brigade for the carriage of these articles. Canvas bearers with long poles, and shoulder straps, in pro- portion of two to every hundred men, will also be required. 2. . . .Before a division takes the field, the principal medical officer should satisfy himself by personal inspection, that the equipment of surgeons of regiments is complete in every respect, and it would be a necessary precaution for him to see the pack horses loaded in his presence, as by that means he would ascer- tain that no straps, buckles, or cords were wanting. 3. . . .When an action with the enemy seems inevitable, the surgeon of each regiment will make arrangements for the re- moval of the wounded of his corps from the field, and it would be desirable for him to give some instructions to the bandsmen, and others employed in that duty, how to apply a field tourni- quet, to restrain dangerous hemorrhage until the assistance of the medical officer on the field can be obtained ; and for this purpose a tourniquet should be given to each party of bearers. The bearers should also each of them carry a canteen full of water. 4 . . . . While the troops are advancing, the medical officers will follow with the spring wagons and bearers, and any other con- veyance that is available ; but when they deploy, or form for action, all, except one medical officer per regiment, will move a short distance to the rear, out of musket range, and will prepare for affording aid to the wounded, and performing such primary operations as may be deemed absolutely necessary. For this purpose the surgical panniers must be brought up, and instru- ments, ligatures, dressings, and cordials (brandy) got ready, and, above all things, an abundant supply of water provided, for the safe and easy conveyance of which, the leather bags, or skins, formerly recommended, would be found most convenient. Dr. Hall takes this opportunity of cautioning medical officers against the use of chloroform, in the severe shock of serious gun- shot wounds, as he thinks few will survive where it is used. But, as public opinion, founded, perhaps, on mistaken philanthropy, he knows, is against him, he can only caution medical officers, and entreat they will narrowly watch its effects, for however barbarous it may appear, the smart of the knife is a powerful APPENDIX. 445 stimulant, and it is much better to hear a man bawl lustily than to see him sink silently into the grave. 5 . . . . One medical officer for each regiment, generally the junior assistant surgeon, should follow the troops within musket range, so as to be at hand to check any alarming hemorrhage, and to expedite the removal of the wounded off the field to the rear, and for this purpose the bearers should be placed under his orders, and the regimental spring wagon be so stationed as to be within easy reach, to convey them to where the surgeon and his assistants have established themselves. The field-assist- ant should carry with him, in his haversack, his pocket case of instruments, with a few ligatures ready cut, two field tourni- quets, some but, and two or three bandages ; and he should be accompanied by three men, one with a knapsack, or haversack, containing one pint bottle of brandy, or some other stimulant, twenty-four bandages, half a pound of lint, three sponges, six long and six short solid splints, two old sheets cut into quarters before starting, for the purpose of rolling fractured limbs in, and so preventing them from sustaining further injury on the men's removal from the field. This is best accomplished by placing the old linen under the limb, and rolling the splint up in it from the outer edge, and rolling toward the limb on each side, and then securing the whole with two or three bands of tape. In this way Dr. Hall thinks medical officers will find they can tem- porarily secure fractured limbs better and much more expe- ditiously than in any other manner. The orderly should have in his haversack, in addition to the above articles, a piece of tape, some pins, and two or three rolls of tow. He should carry a canteen, either of wood or india-rubber, full of water, and a drinking cup. The second man should carry a canvas bearer, with shoulder straps, and, like the former, should have a canteen full of water. The third man, I think, should be armed, to pro- tect the party against stragglers and marauders, and, like his fellows, carry a canteen fall of water. The second assistant sur- geon should receive the wounded from the field, see them care- fully placed in the spring wagon, and then accompany the spring wagon to where (lie surgeon and third assistant arc stationed, ready to afford them the surgical aid they may require. For 440 APPENDIX. this service the second assistant surgeon should be accompanied by two men to assist in placing the men carefully in the wagon ; these men should accompany the wagon, and assist in like man- ner in taking the wounded out. These men should likewise carry canteens full of water, and there should be a skin of water as a reserve, in the wagon, with a drinking cup. 6 . . . . The site selected by the staff-surgeon of brigade for the reception of the wounded from the field should be as sheltered as possible ; and if not easih' distinguished, a flag should be put up; and if any houses be near, calculated for the reception of wounded men, they should be taken possession of at once, and an abundant supply of water, and, if possible, straw provided. 7 . . . . Should the action prove decisive, tents can be pitched for the temporary accommodation of the wounded; but should the army advance, the surgeon, and one assistant, at least, should accompany their regiments, leaving one or two assistants, accord- ing to the number of wounded, to aid the divisional staff, who will pitch 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 readily made into broth by adding hot water), wine, and brandy, etc., ready. Should the army unfortunately meet with a reverse, all avail- able transport must be pressed for the removal of the wounded to the rear, and they must be sent off as speedily as possible ; but neither here, nor on the field of battle, should any one be carried whose hurts are so slight as to admit of his walking. Nor should commanding-officers 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 appropriate the spring wagons for the special conveyance of themselves and their luggage ; and positive orders should be given to prevent bandsmen, drummers, or pioneers, specially told off to assist the wounded, from being left in charge of officers' horses and effects. 8. . . .Should the army have to effect a landing on an enemy's coast, with an opposing force to meet it, the men should eat a good meal before leaving the ships, and should cook whatever provisions it is necessary to serve out to them before the start. Pork is better than beef for this purpose, as it warms up more ArPENPIX. 447 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 the 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. 9 . . . . Should a landing be effected, and any horses be disem- barked, the surgeon's pack-horse and panniers should be amongst the first. 10. . . . As 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- manding-in-chief, returns of casualties made out agreeably to the following form : Return of Killed and Wounded in the Regiment, in the Action of -— . Killed. Wounded. Total Wounded. Danger- ously. Severely Slightly 1! KM ARKS. Officers. Non-com- missioned officers and pri- vates. Names of officers kill- ed and wounded to be inserted here. RARE BOOK COLLECTION THE UNIVERSITY OF NORTH CAROLINA LIBRARY 3C27 Conf.