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UNITED STATES OF AMERICA
WASHINGTON,  D.C.
OPO  16—67244-1
 
 
 
MANUAL
MILITARY SURGERY,
FOR THE USE OF
SURGEONS IN THE CONFEDERATE ARMY;
WITH AN APPENDIX OF THE
Stoics and Sedations of the Pdtral geprtmcni
     CONFEDERATE ARMY.





              BY


       J. JULIAN CHISOLM, M. D.,
             m
PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF THE STATE 01'

          SOUTH CAROLINA, ETC.
  LIBRARY
SURGEON GENERAL'S OFFIC!

  ffl&r
       CHARLESTON i   "  —

BYANH A COti.SWKLL, No. 3 BROAD BTKEET.

         1SC1. 
Mon Tried



 C2
APWKDtGRCES MEDICAL UMft*
     WASHINGTON, ■. C.   ■"" 
PREFACE.
  In putting forth this Manual of Military Surgery for the use
of surgeons in the Confederate service, I have been led by the
desire to mitigate, if possible, the horrors of war as seen in its
most frightful phase in military hospitals.   As our entire army
is made up of volunteers from every walk of life, so we find the
surgical staff of the army composed of physicians without surgi-
cal experience.   Most of those who now compose the surgical
staff were general practitioners, whose country circuit gave them
but little surgery, and very seldom presented a gunshot wound.
Moreover,  as our country had been enjoying an uninterrupted
state of peace, the collecting of large bodies of men, and retain-
ing them in health, or the hygiene  of armies had  been a study
without an  object,  and therefore without interest.  When the
war suddenly broke upon us, followed immediately by the block-
ading of our ports, all communication was cut off with  Europe,
which was the expected source of our surgical information.   As
there  had been  no  previous  demand  for  works  on  military
surgery, there were none to be had in the stores, and our physi-
cians  were  compelled  to follow the  army to battle  without
instruction.   No  work on military  surgery  could be purchased
in  the Confederate States.   As military surgery, which is one of
expediency, differs so much  from  civil practice, the  want of
proper  information has already made itself seriously  felt.   In
        A* 
IV
PREFAOK.
 times of war, where invasion  threatens, every citizen  is ex-
 pected  to do his duty to his state.   I saw no  better means of
 showing my willingness to enlist in the cause than by preparing
 a manual of instruction for the use of the army, which might
 be the  means of saving the lives and preventing the mutilation
 of many friends  and countrymen.   The  present volume con-
 tains the fruit of European  experience, as dearly purchased in
 recent campaigning.   Besides embodying the experience of the
 masters in military  surgery as to the treatment of wounds, I
 have incorporated chapters upon the food, clothing and hygiene
 of troops; with directions how  the  health of an army  is to be
 preserved,  and how  an effective  strength is  to be  sustained;
 also, the duties of military surgeons, both in the camp and in
 the field.   In  an appendix will be  found the regulations and
 forms for the use of the Medical Department of the Confederate
 army.   In  preparing this volume, I have  not hesitated to add
 to my own  experience in the treatment of surgical injuries, any
 useful information which I could obtain from the most recent
 German, French  and English works, on military surgery; and
 in many instances, where the language used by them expressed
 to the point the subject under discussion, I have not hesitated to
 transfer entire sentences directly  to these pao-es.  I make this
 acknowledgment, en  masse, of the very liberal  use  of the fol-
 lowing works, as quotation marks were sometimes overlooked:
  Maximen der  Kriegsheilkunst,  von  L.  Stromeyer, Hanover,
 1855; supplement der Maximen  der  Kriegsheilkunst,  von L.
 Stromeyer, Hanover, I860; Loeffler Behandlung der  Schuss-
 wunde, Berlin, 1859;  Histoire Medico-Chirurgicale de la Guerre
de Crimee, par le docteur  Adolphe Armand, Paris,  1858;  La
Guerre  de  Crimee, par L. Baudens, Paris,  1858; Res Plaies
dArmes a feu; Communications—Faites a 1'Academic Nationale
de Medecine, Paris,  1849;  Notes of the  Wounded, from the 
PREPACK.
V
Mutiny in  India, by George Williamson, London, 1859 ;  Coles'
Military Surgery, with  Experience of Field  Practice in  India,
London,  1852;  Gunshot  Wounds of  the  Chest,  by Patrick
Fraser, M.  D., London, 1859 ; Guthrie's Commentaries on Mili-
tary Surgery,  London, 1855; McLeod's Notes on the Surgery
of the  Crimean War, London,  1858 ; Hennen's Principles of
Military Surgery; Larrey's Military Surgery; Ballingall's Out-
lines of Military Surgery; Gross' System of Surgery; Erich-
sen's Science and Art of Surgery; Jackson on the Formation,
Discipline, and Economy of Armies. 
 
INDEX.
Abdominal wounds........................................... 301
Ambulance carriages  for the wounded.........................  86
Amputations, rules for....................................... 374
Amputation of arm, when required............................324
Amputation of lower  extremity, when required................. 369
Amusements in camp.........................................  59
Anaesthetics................................................ 379
Arm, injuries to............................................ 320
Arteries, wounds of.......................................... 152
Assistant surgeon, duties of.... ............................. 106
Balls,  different wounds by.................................... 135
Beds for soldiers.............................................  55
Beds for hospitals...........................................  64
Boots for soldiers............................................  32
Camps.................................................  53
Camp  duties of surgeon..................................... 100
Carriers for the wounded....................................  92
Chest  wounds............................................. 276
Chloroform.................................................. 379
Circular amputations  to be preferred.......................... 374
Clothing of troops.........................................  26
Clothing, physiology of......................................  27
Clothing, allowance of by the Confederate Service..............  37
Cleanliness, importance of....................................  40
Cleanliness of camp........................................  57
Cleanliness, when excessive, injurious to wounds...............337
Compression in head  injuries..................................  2-id
Concussion in head injuries..................................  23a
Cold water only dressing for wounds..........................  164
Color  of uniform............................................   35
Coffee, utility of in an army..................................   42
Confederate medical  service...................................   " 
Vlll                         INDEX.

Compound fracture of arm................................... 323
Compound fracture  of leg.................................... 359
Depression of skull......................................... 257
Diarrhoea..................................................  11
Diet in hospitals...........................................  77
Division of labor in field infirmaries........................... 115
Diseases vs.  wounds........................................  21
Diseases of Maryland.......................................   4
Diseases which an army will encounter in  the Middle States.....  10
Dressings carried by each soldier..............................  97
Dressings required in the battle field........................... 110
Dressing of wounds.......................................... 130
Dres>iug of stumps.......................................... 376
Duties of a surgeon in camp.................................. 100
Duties o£ a surgeon on the  battle  field......................... 109
Dysentery..................................................  12
Endermic use of  morphine.................................... 188
Enlistments.................................................  13
English medical  service......................................  S9
Erysipelas.................................................. 192
Erysipelas common to  middle States...........................   8
Examination of wounds...................................... 124
Extraction of foreign bodies.................................. 148
Face wounds................................................ 268
Female nurses in military  hospitals...........................  75
Field surgery................................................ 119
Foreign  bodies in wound..................................... 145
Fracture of the skull......................................... 250
Fracture of the jaw......................................... 269
Fracture of the ribs.......................................... 299
Fracture of the upper extremity............................... 32$
Fracture of the lower extremity............................... 389
Food.......................................................   11
French medical service.....................................  90
Gaiter, in universal  use in the French  army....................  33
Gangrene................................................... 210
General  hospital.............................................  C7
Gunshot wounds............................................. 133
Hat, military...........'.....................................  35
Head injuries................................................ 237
Hectic...................................................... 23.3
Hemorrhage, primary........................................ 152
Hemorrhage, secondary...................................... 169 
                             INDEX.                           IX

Hemorrhage, abdominal...................................... 314
Hip-joint injuries.......................................m. .. 353
History of wounds necessary for diagnosis...................... 147
Horse litters for the wounded..................................  85
Hospital tent................................................  63
Hospital attendants..........................................  65
Hospital gangrene............................................ 210
Inflammation of bone........................................267
Illinois, medical topography of................................   S
Inferior extremities, injuries of................................ 352
Intestinal wounds............................................ 306
Injuries of skull............................................. 247
Internal treatment  of wounds................................ 183
Injuries of superior extremity................................. 320
Joints, injuries of superior extremity.......................... 31(1
Joints, injuries of lower extremity............................ 352
Kentucky medical and physical topography....................   7
Knee-joint injury........................................... 364
Leg, compound fracture of....................................367
Ligating arteries........................................... 154
Litters......................................................  82
Lower jaw, fractures of....................................... 270
Lower extremity, injuries of.................................. 352
Lung wound................................................282
Maryland, topography of.....................................   1
Material of armies..........................................  16
Malarial fevers..............................................  10
March, precautions during....................................  49
Medical service of  the army..................................  87
Medical department of the English service.....................  89
Medical department of the French service......................  90
Medical department of the Prussian  service................  • .91-94
Medical department of the Confederate service..................  St>
Mess.......................................................  47
Morphine endermically................................_•...... 188
Mortality of  our troops in Mexico.............................  20
Mortification attacking a limb................................ 372
Neck wounds...............................................273
Nervous shock............................................... 127
Night air................................................... 2(17
Nurses in hospital............................................  75
Orifices of entrance and exit.................................. 134
Opium in gunshot wounds.................................... 187 
X                            INDEX.

Ostitis...................................................... 267
Overcoat for soldiers.........................................   34
Over-care of wounds......................................... 337
Perforating wounds of skull.................................. 265
Perforating wounds of chest.................................. 280
Primary hemorrhage......................................... 152
Probing of wounds......................................... 123
Preparations for a battle by the  surgeon....................... 100
Primary dressing carried by each soldier.....  .................   97
Privies in camp..............................................   57
Precautions before a inarch...................................   49
Prussian  medical  service.....................................   91
Prussian  medical service on battle field........................   94
Purification of hospitals......................................   69
Pysemia.................................................... 201
Rations in the Confederate service............................   45
Recruits....................................................   19
Resections.................................................'. 343
Removal  of foreign bodies.................................... 148
Ribs, fracture of.........................-.................... 299
Rules for amputation........................................ 369
Sanitary corps of carriers.....................................   92
Scalp wounds............................................... 249
Shoes.......'................................................   32
Shirts......................................................   31
Secondary hemorrhage...................................... 169
Sequelae of gunshot wounds................................... 232
Severely  wounded to be left with the enemy....................132
Skull injuries................................................ 247
Spent ball.................................................218
Stumps, dressing of.......................................... 376
Surgeon,  duties of............................................ 100
Surgical preparation for battle................................ 110
Straw for beds...............................................   65
Statistics of killed in Mexico..................................   21
Tennessee physical and medical  topography....................    7
Tents a labri................................................   53
Tents for hospitals...........................................   63
Tetanus..................................................... 221
Thigh, compound fracture of..................................359
Thirst, how relieved.........................................   50
Transportation for the wounded...............................   81
Transportation to the general hospital.........................129 
INDEX.
XI
Trephining................................................. 256
Treatment at the field infirmary............................... 122
Treatment of gunshot wounds................................. 127
Typhus fever.............................................   15
Typhus cases to be isolated..................................   73
Typhoid fever...............................................    8
Virginia topography.........................................    5
Vegetables necessary for the soldier............................   43
Volunteers..................................................   16
Water, taken with caution whilst on a march...................   49
Water dressing..............................................  162
Wounds, gunshot.............................................  132
Wounds, local treatment of...................................  161
Wounds, general treatment of.................................  is.'!
Wounds of head.............................................  237
Wounds of face..............................................  268
Wounds of neck.............................................  273
Wounds of chest.............................................  270
Wounds of abdomen........................................  301
Wounds, early treatment of...................................  119 
 
CHAPTER   I.
The Physical and Medical Topography of the Frontier
  States—Maryland,  Virginia, Kentucky, Tennessee,
  Illinois and Missouri—their Geology, Climate, and
  Diseases; at what seasons prevalent, and how treated
  by the local physicians.
  The war which is now being carried on  between
the United States and Confederate States has lo-
cated itself, as it were by mutual consent, upon the
frontier, which  threatens to be the scene of most
of the battles between the contending armies.  As
the middle region of what was formerly called the
United States will witness the brunt of these con-
tests, a brief description  of the country, with a
history of the diseases most prevalent at  different
seasons of the year, cannot but interest those who
will  have  the  sanitary condition of our troops
under care;  as it may  assist army surgeons in
adopting  a system of hygiene and  prophylactics
which will be useful  in keeping oft" diseases.

  Maryland, the first of these border States upon
the Atlantic  coast,  is naturally divided  into two
       1 
Maryland:
distinct physical regions :  the one, an  elevated
region, traversed by various ridges of the Allegha-
nies, the other, a flat country, scarcely rising above
the level of the sea,  which in turn is cleft un-
equally by the Chesapeake bay.  The lowlands on
either side of the bay are more or less sandy, and
are freely indented by  estuaries  and  checkered
by water courses.  That  portion of the State bor-
dering on the Chesapeake  is formed of lowlands
and meadows.   On the margin of these are salt
marshes of considerable  extent.   Many  of  these
are inundated by high tides,  especially after the
prevalence of south winds, which force the waters
of the Chesapeake and  its branches toward its
sources.  As the tides recede, many pools are left,
which in hot  weather form stagnant foci of in-
fection.   The  lowlands  are covered with a rank
growth, the decomposition of which during the
summer and autumn  months  charges the atmos-
phere  with  offensive and deleterious  effluvia.
Along  these water courses and in the neighbor-
hood of such lowlands, malaria abounds, and in-
termittent and remittent fevers are endemic.
   The climate, as in all Southern latitudes, is very
variable upon the coast, and the excessive moisture
in an exhilarating atmosphere, when  connected
with the heats of summer*, predispose to affections 
ITS TOPOGRAPH V.
of the mucous membranes.  The warm weather
induces engorgements of the portal  and hepatic
circulation, with consequent derangement and in-
terruption of the biliary secretion, with congestion
and irritability of the intestinal mucous membrane.
The sudden changes of temperature, making a rise
or fall of several degrees of the thermometer, often
in a few minutes, when taken in connection with
suppression  of perspiration, will explain  the fre-
quency of gastric disturbances, with diarrhoea and
dysentery.   These form the common diseases  of
the country during the summer months, and im-
press, to  a greater or less extent, all morbid condi-
tions.
  As the land recedes at some distance from the
bay, it becomes uneven.   It gradually rolls into
upheaved hills, the highest of which  are not over
one hundred feet in height.  As the western por-
tions  of  the  State are  approached, the  land  be-
comes very hilly  and rough.   The high  ridges,
which attain an elevation  of 2,000 feet above the
level  of the sea, intercept  valleys remarkable for
the exuberant richness of the soil, which lies upon
a substratum  of limestone.  This  is the mining
portion of the State, which  yields coal  in great
abundance,  and also  iron.   The  water of this
region is very free from impurities,  whether  ob- 
4
MARYLAND:
tained from the  numerous  streams,  wells,  or
springs.   Mineral  waters  are  found  in several
localities,  to many  of wrhich invalids resort  with
benefit.   During the summer months,  the  high-
lands of the State are very healthy; and, except
upon the low margins of the water courses, where
the mild forms of malarial fevers are met with,  no
diseases can be  called local.  During the winter
months, catarrhal  affections and pneumonia are
the diseases of the low countries, whilst typhoid
fever often  rages as an  epidemic in the highest
regions of the State.
  Malari<d fevers of  this region  commence  their
incursions about the middle of July, and continue
three or four months.  They take on either remit-
tent or intermittent forms,  and are of every grade
of intensity, from the fevers of a day to those fatal
after three  or  four paroxysms.  Intermission or
remission is their never-failing  characteristic,  by
which they can always be  recognized, and  their
lurking influence over other diseases detected.  In
later years these fevers have assumed a more  man-
ageable type, and yield  readily to quinine when
given  early  and  in sufficient quantity.
   Dysentery occurs annually in both the high and
low portions of  the country, and in  some seasons
assumes the epidemic  character.  "When this dis- 
ITS TOPOGRAPHY.
5
case appears during the autumn months, its asso-
ciation with malarious influences can be discerned,
and the treatment, which is tedious, must be modi-
fied more or less on account  of this combination.
When the fever which accompanies this intestinal
disease shows  a periodic  tendency more or less
marked, the curative power of quinine in its treat-
ment is proved to be of decided utility.
   Catarrhal fevers often prevail  extensively over
large districts of country, owing,  perhaps, to the
presence of some subtle poison in the  air which
has eluded scientific inquiry.   When prevalent, it
brings under its influence almost every person  in
•those districts where it makes its appearance. The
course of the disease is to recovery after torment-
ing its victims  from one to six weeks, and then
leaving them much enfeebled. The mild expecto-
rant plan of treatment is the course generally pur-
sued by the local physicians, except where perio-
dicity shows itself, when a few doses of  the potent
medicine, quinine, may, as if by magic, restore the
patient to health.

   Virginia  similates, closely, Maryland as to  its
topography.  The coast line, running inward for
one hundred to one hundred and  twenty miles, is
low and sandy, similarly  indented with  estuaries, 
0                 VIRGINIA :
into which the numerous rivers of the State empty.
The lagoons are lined by low, marshy swamps, in
which, during the summer  months,  malaria is
generated.  As we leave this belt, advancing west-
ward, the country is found undulating, with rolling
lands.   The soil is somewhat sandy, but on  the
maro-ins of the  rivers  are  extensive alluvions of
great fertility, producing fine crops of grain  and
tobacco, and supporting a healthy, sturdy popula-
tion.  The climate is salubrious, although variable.
Traversing the centre of the State from north-east
to south-west  is  the Blue  Ridge and  Alleghany
chain of high  mountains, rich in  mineral produc-
tions, and enclosing fertile valleys, which wTill vie
with any lands on the continent in productiveness.
These valleys  are filled with  medicinal springs of
great virtue.   Many are of world-wide  reputation,
and  are  annually resorted to  by thousands  for
health and pleasure. Among them are found lime,
soda, sulphur,  magnesia,  alum, and  chalybeate
waters; also, hot, warm and cold springs.  As the
beautiful  scenery, the bracing air, and  excellent
accommodations have  their sanitary  influence,
especially when assisted by the medicinal waters
which abound everywhere through these mountain
ranges, the  sick and halt  from  the most distant
portions of the country are assembled here during 
ITS TOPOGRAPHY.
the summer  months.  !N"or are  they often  disap-
pointed in  the cures which they seek.   Change of
life and scene is a most potent remedy for good
to those whose  multifarious duties at home are
constantly  at war with all the laws of health.
  Western Virginia, like the eastern portion of the
State of Kentucky, with which it joins, is a broken
country, abounding  in the finest limestone  water.
The soil is  fertile, based upon a substratum of blue
limestone,  which  forms the basis of this  entire
region.  In some portions, the soil is a rich black
loam,  and very productive ; in  other portions,
there is a reel, yellowish or whitish clay, not so well
adapted  for grain crops.  When a substratum of
clay is covered with a layer of vegetable mould, it
constitutes a soil  of unrivalled  fertility, in  which
the blue grass {poa 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  are  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, wdiich 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  OF  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 seaboard 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.
  Tltc diseases which  an army must encounter dunny
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 o^ quinine
should be extensively relied upon, and  pannot 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
hilly  country, wTe  come to a genial climate  and
salubrious country, where  general  health  can be
preserved.  Xo  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 epidemically 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
ami 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 arc
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.
13
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
days.  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 showTs a marked remission.   Opium in
guarded doses is found invaluable in controlling
the looseness  of the bowels, in quieting delirium
and inducing sleep.  The bowTels, when a tendency
to constipation exists, are kept 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  OF  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 vpest  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 in  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 showr 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 owTe 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
 hiffh  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 tirms 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.  Notwith-
 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 twrenty-five pounds weight.   AH, 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, the}7 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 wras 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 by  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 1854. 
STATISTICS OF KII^ED 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 
 ^2       STATISTICS  OF RILLED 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 Panmure, 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 showT 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  by 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 required to certify
on honor, that the  recruit  passed by him "is free
from all  bodily defects and mental infirmity, which
would in any way disqualify 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 TROOrS.      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 :  Not robust, too slender, unsound,
broken-down constitutions, general  unfitness,  im-
becility,  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 wTe 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 be
 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 marches, 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 THYSIOLOGY OF CLOTHING.        27

weighty 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 wdiich the blanket gives
the Spaniard or Arab in hot weather, is similarly
accounted for.   The radiating properties of wool
exceeds its conducting  or absorbing powTers,  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 
30
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  soldier'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  projection to the body and abdomen 
CLOTHING OF TROOPS.
31
from damp, whilst a jacket—which is a very poor
costume 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 Irygienic utility.  In winter they retain
the animal heat and support the healthy function
of the skin, whilst in summer they absorb more
readily  the  excess of perspiration,* which  occurs
under severe exercise;  and wdiilst 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 baud 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  baud as 
32
CLOTHING OF TROOPS.
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 officers.   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
good shoe or boot  adds often as much to the efii- 
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  inarch 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 wTet 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 with 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 
34
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 wThich, 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 wreather.   In
addition to the gaiter, many of the French troops
wear greaves made of heavy patent leather, wdiich
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 wreather.
  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  easy,  to  permit of
any  movements  without  binding.  The French
have  added  a  hood, to   protect the  head and 
CLOTHING OF 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
are 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.  Red, 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, wdien turned down, protects, in
a measure,  from the  rain  or from the rays of the 
^.6           CLOTniNG 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 Haveloek, which
consists of a cap cover with a long  cape attached,
and,  hanging dowm 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 ami 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, I)r. MeLeod 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. 
3*
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 wdio 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 be 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
 for drying it;  two pocket handkerchiefs ;  an over-
 coat of heavy material, 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
P E R S O N A L C LEA N LI N ESS.
 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 ami  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.   lt 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  coffee 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 wTith  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 soup; it then makes a very nutritious meal.
Even water, with a little salt, makes it much more
palatable and nourishing.  Fresh bread is always
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, 
4(5                 THE MESS.

ten pounds of rice, six pounds of coffee, 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 quantit}7 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 issues
(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 army, 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  eNperienced 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,
two 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.
19
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 wall  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 fills 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
inarch, 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
              AflWED FO«CES MEDICAL  UBRAR*
              *    WASHINGTON. 9 C. 
50
SUC.GK.NTIONS  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 quantity 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 (lav's march.   The officer  in charge of 
CAMT.
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 w7ith 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 
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 huno- 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 wTere 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 
BED OF SOLDIER.
 year.   When straw or hay is used for bedding, it
 should be renewed as frequently as possible, and
 the straw should be turned, well beaten and thor-
 oughly aired daily, with exposure to the sun when
 possible.   In  the French camp straw is given out
 every fifteen days; in our army regulations twelve
 pounds is allowed per month in  barracks.   As a
 soldier always sleeps in his clothes,  if he has a
 thick bed of dry straw to lie on, he can cover him-
 self with his blanket; but if otherwise, he should
 lie on  his blanket, well doubled, to  protect him
 from the damp soil, and cover with his overcoat.
 If he  has an india-rubber cloth, he should  always
 lie upon it, as the very best use he can make of it
 to  protect him  from  disease.  It is an excellent
 substitute for straw in field life, more cleanly and
 protects better  from  dampness ;  it is always  at
 hand and always ready for use.  Sheep skins were
 tried  by  the  French as a  substitute for  straw
 They were found to attract moisture and  propa-
 gate vermin, and were, therefore, rejected.   As
 the tent is always too small for the number which
 occupy it, they should sleep  with their heads  as
 far as possible from each other.   In the circular
 tent they  should sleep with  their feet  toward
the vertical  axis,  and their  heads around the
periphery, so as to  increase  to the utmost their 
BED OF SOLDIER.
respective  areas for respiration.   After reveille,
the  tents  should be  opened,  sides  thoroughly
beaten,  straw  turned  and  exposed  for several
hours.
  Extreme cleanliness should prevail  within and
without  the  tent.   In an  encampment the tents
should never be crowded, but ample space should
be left around each  tent  for  changing its posi-
tion  at least  every four  days, so as to purify the
soil  infected  by habitation.   The earth floor of
a  tent  attracts  and absorbs  impurities  which,
unless changed,  would  soon render it  a  source
of disease.   Permanence  of  camps  rapidly in-
duces infection.  This frequent changing of tents
gives, to  be  sure, additional trouble  to the offi-
cers, but  this is  more  than  counterbalanced by
the health and efficiency of the command.-  All
the garbage  of the camp should be thrown at  a
distance  from the tents, and should be  buried
every evening.    The privies for the  men  are
ditches, from three to five feet deep and three feet
broad.  They should be placed at  least  one hun-
dred  yards from  the camps and in an opposite
direction  to  the  wind  currents,  so that offensive
odors will be blown away.   The slaughter  pens
should also be placed at  a similar distance. Every
evening  the  offal of the day  should  be covered 
5S
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.
50
which act in 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 bloody 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 aecordeou, appeared to
be  the order of the day.
  Pets in  various forms were commonly found 
(50
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.
  Xot the  least  attractive  incident  connected
with the triumphal march  of I\rapoleon's  Italian
army through  Paris, in  August,  1859, wTas 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 the 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 longing 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. 
CTI APTER  III.
 Hospitals, Regimental and  General—Hospital Tents,
   with  Equipment—Number of Attendants allowed—
   Care necessary  in preventing  Infection— Value of
   Fumigation—Fevade 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 re<n-
 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 being joined or thrown into
one, with a continuous covering or roof;  such a
tent accommodates, comfortably,  from eight  to
ten patients.   The following  is the allowance  of
tents  for the  sick, their attendants and hospital
supplies—being accommodation for ten per cent.
of the command:
COMMANDS.	HOSPITAL TENTS.	SIBLEY TENTS.	COMMON TENT
For three companies... For five companies.... For seven companies... Fur ten 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 Avith the army
and  to be  broken up at an hour's notice.  They
should  never,  therefore,  be  encumbered  Avith
chronic cases, nor should they eA7er  be permitted
to be crowded.  As soon  as  a case  threatens to
remain longer than eight or ten days in hospital, it 
64              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  Avith  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, aud,  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  on 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 
                 llOhPlTAL TENTS.               f'i5

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 Avater, as a purifier.
  The straw  should be changed  as  often as pos-
sible, even  twice a Aveek, 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 Avith  animal  exhalations.
This change of location  is  particularly  required
whenever any of  the low  grades of contagious
diseases  appear within its  walls,  or eases  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  coni-
      6 
66
HOSPITAL TENTS.
panics,  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.
  Xot the  least important personage in  the hos-
pital organization  is the sentinel,  Avho guards the
door, and  sees that neither  ingress nor  egress is
permitted  except  upon orders from the  surgeon.
It is only  in this  Avay  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 wishes
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.
67
 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  hospital, for the use of  a division
 of the army, is usually located in some town or
 city  contiguous to  the army;  or,  should  these
 be  too distant, Avithout  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 steAvard, 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
wdien  no longer required in the hospital.  In a
general hospital there is always a dispensing officer
or apothecary, Avho  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 pyaemia,  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 Avith hospital cloth-
ing.  In European general military hospitals the
patient leaves  everything behind  him  Avhen he
enters its  wards.   He  receives  a bath  and  is
dressed up in the hospital clothes;  his own are
Avashed and stowed aAvay, 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 Avashed
in boiling water, are fumigated  for  twenty-four
hours in a closed chamber or tent Avith chlorine
gas.  With itch patients, sulphur fumigations are
substituted for chlorine.
  When  any Ioav form  of disease  makes  its ap-
pearance  in  a ward, it Avould  be  better could it
he temporarily abandoned.  Then, let it undergo
a thorough  cleansing  and whitcAA'ashing,  Avith 
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  seriously injured,  Avith  extensively
suppurating wounds.   Should any one  enter, at
midnight, a Avard thus inhabited, the  insufferable
smell, and the apparent wreight 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
tAvo 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  obseiwa-
tion during the Schleswig-Holstein Avar.  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 are 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 Avards.  The surgeons of their
immense  military  hospitals   thought  that  they
derived decided benefit from  adopting  the  Turk-
ish custom of fumigating Avith 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, by using  chlorine fumiga-
tions at 6, a. m., and at 7, p. m., the  dried sage at
7£, 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
Avhether 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  AvindoAv is
never left open.  We Avould judge that they were
intended to give light,  and  not air.   The only 
11
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  Avith his German  patients.  He
Avould only alloAV them  to  smoke  provided they
Avould 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  alxnnilia-
ble  smell that they compel  you  to open  the windows."
When these means  are used, Avithout affording
the impure air means of escape they only act as
masks,  disguising,  by their stronger  odors, the
offensiAre and injurious exhalations from the sick.
It quiets the anxieties of the nurse without in any
Avay benefiting the patient.   It must never be for-
gotten that many symptoms Avhich are said to be-
long to a disease, depend upon the circumstances
under Avhich it is treated, and many of these can
with truth be accredited  to bad ventilation; hence 
           PURIFICATION OF HOSPITALS.          78

the different phases Avhich diseases assume Avhen
treated in hospitals or in private practice.  If such
causes Avill  produce  disease  (a  fact Avith which
every one is familiar), hoAv 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 Avhich
he had long been  lying, Avith its closed Avindows
and musty smell,  to a  light, cheerful, Avellwenti-
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 gi\Ten 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
       7 
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  Avell  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,  pyaemia or
hospital gangrene, it is best to  close it and turn
out all patients.  It would be much safer  for the
sick and Avounded  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; Avhilst  combating  the  elements  would
give him at least a chance of coming off conqueror.
Any temporary,  avell-ventilated structure—a  hut
rudely made of  rough boards—would be much
healthier than gorgeous palaces writh gilded cham-
bers, in which death sits  in  state to  receive  its
victims.
  In general  hospitals,  the  blessings  of   a wo- 
           PURIFICATION  OF  HOSPITALS.          lO

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 neAV era
dawning for suffering humanity, and the benefits
which she was bestoAving 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 sAATcet 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 man}' 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 Avhich  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 Avar,  when their
many and peculiar  services cannot be dispensed
Avith. To the surgeon, a good, kind, reliable nurse
constitutes more than  half  the treatment  of the
sick.  It is  Avith  the  most  serious  cases  that
their adArantages in nursing are best displayed.
McLeod,  avIio  studied  carefully woman's services
in the  Crimean hospitals,  says:  "A woman's
services  in a hospital  are invaluable if they Avere
of no further use  than to attend to the cooking
and  the  linen departments;  to  supply 'extras'
in the Avay  of little comforts to the worst cases;
to see that the medicines and Avine 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  Avill,  they cannot  be  dis-
pensed  Avith;  but for inferior posts,  strong, ac- 
DIET IN  HOSPITALS.
tive, respectable  paid nurses,  who have under-
gone  a preliminary  training  in  civil hospitals,
should alone be employed.  In the camp hospitals,
which, Avith 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 requisition from the medical  attendant,
and Avhich  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 Avith
the ward-master,  if  the  cleaning, etc., were not
properly attended to by his male corps."
   Tlw  dieting  of  patients in  a  hospital is  ahvavs 
7^              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 Avhich the issue of rations
does not include.  To be 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, Avhere,
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 Avithout 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  non 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.
be  useful  as a  basis  in  preparing  one for  indi-

vidual  hospital  seiwice.

    A Scheme of Diet for Patients in the Military Hospital.
Bread...........1  lb.
Beef or Mutton,. .1  lb.
Potatoes, or A .. .1  lb.
Beans,  or.. > .. .1  oz.
Rice,......J .. .4  oz.
Ar'!j;ct'es for soup, 4  oz
HALF DIET.
Bread,..........1 lb.
Beef or Mutton,.. J lb.
Potatoes, or ]  ... 1 lb.
Beans, or.. >  .. .4 oz.
Rice,......J  .. .4 oz.
Bread.......... \ lb.
Tea,........... £ oz.
Sugar,.........2  oz.
Milk for tea, ...4  oz.
Corn Meal,.....1  lb.
V'enet'es for soup, 4 oz.lMilk,..........1  pt.
Siilt.............1  oz. Salt,............1
Tea, or )........ J oz. Tea,............4 oz.
Coffee, J........1  oz. | Sugar,..........2 oz.
Sugar,..........2  oz.; Milk for tea,.....4 oz.
Milkfortea,.....4  oz.[Molasses,.......1 oz.
Molasses,.......1  oz.jCorn Meal,......1 lb.
Corn  Meal,......l  lb.jSoup,...........£pt.1....................
Soup............1  pt. i.........................................
  Areal, 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, Avith 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, Avith 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  TN HOSPITALS.
   The diet would  be  distributed  in the following
order:
Brkakfast
Bread,.......4 lb. Bread,....... 4 U>. Bread,  i lb.
Tea or coffee,. I  pt.|'IYu..........1  pt. Tea, ..1  pt.
Hominy <fc molasses [Hominy & molasses Gruel,  l pt.
Beef or mut'n, 1  lb. Beef or mut'n,  J lb.
Dinner
'"l
f" Bee
) Sou
   p.........1  pt. Soup.........1  pt.
Bread........ 4 lb. | Bread,.......4 lb.
Beans, pot'es or rice| Beans, pot'es or rice

Bread,....... 4 lb. Bread,.......4 lb.
Tea or coffee, .1  pt. Tea...........1  pt.
Gruel, 1  pt.
Milk,..l  pt.
Bread,  i lb.
Tea, .. 1  pt.
Gruel, 4 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
  [{(gituental  Surgeons and Assistants in camp 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 hot
uncommonly the indirect cause  of  an increased
mortality.  The injury inflicted  upon  a Avounded.
man by a transportation of even a feAv hours, over
bad roads, and in  unsuitable vehicles, is incalcu-
lable.   Wounds Avhich 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 
s
 s-                HAM) LITTERS.

 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 Avhy many
 should die during the transportation, and makes
 us wonder  hoAV  so  many escape Avith  life, after
 undergoing such  unutterable hardships.

  Litters.—The  common and  best means  of
 moving  A\rounded men  for  short  distances  is
 upon litters, which may be prepared in  adA^ance,
 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 seAved 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.   AVhere comrades  from the ranks
are expected to carry off the wounded, this is the
only  litter which is of service,  as any two soldiers 
HAND  LITTERS.              83
are prepared to act as transports, without hamper-
ing themselves during  the  fight Avith  extra  bag-
gage.
  Such  a litter is, however, very defective, as the
weight  of the patient sags the yielding  blanket
until it  nearly reaches the ground, AAmilst the mus-
kets are pressed  in  upon  the haunches  of the
bearers,* which renders  it impossible for them to
proceed Avith  ease or celerity.  The proper litter
or stretcher is made of strong sacking or canvas,
six feet four inches  long and two feet Avide.  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
Avide, with rings at the ends, Avhich  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, Avill 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
Avounded 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 Avhich is capable of carrying off  a wounded
man with all  the comfort  with which his situation 
S |.              FRAMED LI1TERS.

admits.   A pike head attached to the pole makes
it a formidable Aveapon of defence.   Each of those
who are expected  to  transport the Avounded is
armed Avith 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
pilloAV, 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 loiiir transportation,  very
feAV of them are fit 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 Avounded 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 Avounded 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 wTounded.  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, Avith
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 strougly recommended.

   Horse  Litters.—Xext 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 tAvo persons.   AVhen the mules
are  led by men Avell trained for this  duty, trans-
portation   by this means is Avell  suited   to the
comfort of the Avounded; but if the muleteers 
£G           AMBULANCK 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 doAvn.
   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  Avounded 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 iavo- 
          MEDICAL SERVICE OF AN  ARMY.       87

wheeled transport cart for hospital supplies, and
to each company one two-Avheeled ambulance car-
riage.  For commands of more than three or less
than five companies, tAvo 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-Avheeled and two two-Avheeled transport carts;
and for each additional company less than ten, one
two-Avheeled transport  cart.   For a regiment, tAvo
four-Avheeled  ambulance wagons, ten tAvo-AArheeled
ambulance wagons, and  four two-w7heeled 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 Avell 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 Avhose efiiciency will compare favorably
with the profession of any country.
  During  Avar, the medical  department increases
pari passu Avith the army.   These appointments
should  be made Avith a full knowledge of the
weighty responsibilities  attached to  the medical 
88        CONFEDERATE MEDICAL SERVICE.

staff, without  whose  constant  solicitude for the
health and Avell-being of the  troops committed to
their  care, the effective  strength of an  army Avill
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
cah  exert on  the  vicissitudes of Avar,  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 soldier,
who would  otherwise lose or compromise his life,
so Araluable  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 Avounded on the battle field depends in
a great measure the success of treatment; and in
any encounter Avhich deserves the name of a battle
the wounded must necessarily be neglected by this
deficient  medical staff.   Our  experience in  the
Mexican Avar  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 Avas the subject of  general  comment in the
Crimea, Avhere  the medical staff  Avere 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 
90
FRENCH  MEDICAL SERA'ICE.
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, Avith 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, Avhich is a very numerous  one, consists
of medical inspectors or head surgeons of infirma-
ries, staff  surgeons  of the first class, Avith 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.
91
Europe belongs  to  the Prussian  service, and is
composed as folloAVs:
  Each battalion of one  thousand  men has  a
surgeon and assistant surgeon, who are thoroughly
instructed in the duties Avhich they are expected
to perform.  Besides these, there is to every  corps
d'arruce of thirty thousand  men, a staff  of  forty
surgeons, who,  in time  of Avar, 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 seiwice, composed of eleven
surgeons each.  These act as a reseiwe on the battle
field, opening field infirmaries which folloAv 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 Avounded.  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, Avhen men Ave re shot doAvn  from the
ranks, they Avere borne to the back by their com-
rades in arms, who transported them to the field
infirmaries, where the surgeons attended to their
Avounds.  Although a  most praiseworthy  act of
devotion to a fallen friend, it Avas 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 Avounded,  they never return until the
fight is over, and thus three are lost to the com-
pany instead of the  one Avounded.  Besides, with
the  very best intentions, these comrades are not
instructed how to carry the Avounded so that they
should suffer least detriment, and  the final result
cannot be but  injurious to the Avounded.   The
sanitary corps, which iioav  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,  Avho 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.        93

the wounded are promptly and carefully removed
from the places Avhere they fall to the infirmaries.
There  are surgeons connected Avith  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 sIioav the  assistants Iioav 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 Avith most comfort, and
giATe 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  Avounded 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.  Not 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.  AVhen  not wanted  on
the battle field, experience  makes  them careful
nurses upon the wounded.
   The following is the course pursued by the Prussian
medical corps of a division of thirty  thousand  men 
94         SANITARY  CORPS OR CARRIERS.

ivhen 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 Avounded must
therefore be found,  and all hospital  stores should
be concentrated  at this hospital.
  Directly behind the line of battle, and  mov-
able Avith  it, are placed the  light  field infirm-
aries   Avith their special  staffs.  They  are  the
main   stations for  medical  service, as all  the
wounded pass through these on their Avay to the
general hospital.  At  these field infirmaries, the
wounded receive the first thorough  examination.
Many operations  deemed imperative  are here per-
formed.  All  Avounds  are here  cleansed, foreign
bodies of every kind extracted,  hemorrhage con-
trolled, and the first proper dressing applied.  As
the wrounded are brought to this point as they are
shot down, their Avounds 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
ahvays a  division  of  labor,  and each  surgeon,
knowing  his   duty,  accomplishes the  greatest
amount of Avork 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 Avounded.   More  importance is placed  upon
these suhdivisions  of labor than we would, at first
sight, recognize.   It  is Avell  known  that many
hands can be  efficiently worked by one head, and
that Avhen a  surgeon of much  experience  and
mature judgment  determines Avhat 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  Avhy 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 
9(3
SANITARY CORPS OR CARRIERS.
for accurate diagnosis  becomes  imperative,  and
this  first  examination  should never be  slurred
oArer, hoAveA^er 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 sequelse. Many
a  limb and life would be preserved were it jwssible 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 Avhat 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 Avith their  assistants,
rather than follow  their respective regiments into
the fire.   Thus  much  time  is  saved  and  the
Avounded  receive  more attention, and  keeping
them together in this way renders it easy to  com- 
           SANITARY CORPS OR CARRIERS.         97

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  folloAvs: Every soldier car-
ries a small  package three  inches  long and one
inch thick, Avhich  contains  the following  articles,
\\z:  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 Avith two pins.  This
should  be  put  in  a particular place in  the knap-
sack,  where it can  ahvays be   found.    Should
     *Loeffler. Behandlung der Schusswunde;  Berlin, 1859.
       9 
98
SURGICAL STAFF,
there be  tAvo Avounds, the  oiled  silk and cloth
may be  di\rided  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  Avound.   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 Avounded are  ob-
tained from this  individual package, the  very few
extra articles  needed being furnished from  the
infirmary supplies.
  Stromyer, in his surgical writings on  the Schles-
wig-Holstein Avar, speaks  of the  medical depart-
ment of the  army as modelled  upon the military.
Beside the regimental surgeons, each brigade had
a  brigade surgeon  Avith  three assistants.   The
larger divisions of the army Avere  equally supplied
Avith superior medical officers and staff*.  On the
battle field the surgeons  of  the army  established
infirmaries for  the immediate care of the wound-
ed,  \ATho Avere, after the first dressings, sent into
the more permanent infirmaries.

  In the Confederate service, where so small a
surgical  staff is recognized, Ave Avill 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, Avith volun-
teer  surgical aid as  our reserve corps.   This will
not diminish the arduous duties of the regimental
surgeons and their assistants, Avho 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 Avarfare, in introducing arms of precision,
of immensely increased  range, and perfected in-
struments of destruction, has  created a neAv era
in military  surgery.   The conical ball of double
weight has become the common missile, and Avhen
discharged from a rifle it flies Avith fearful velocity.
Such balls, Avhen  traA*ersing  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
spicule are driven in every  direction, transfixing
limbs  and even  impaling those standing in the
neighborhood.   In Crimean  experience, a  serious
wound Avas 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 Avho compare
the  dead on recent  battle fields Avith 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 .Avounds  are   produced by the
Minie ball,  Avhich requires  all  the  resources of
surgery to successfully counteract.
  Let us noAv 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.—AVc
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,
SAveep 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 OF 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 wrhich  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 Avith 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 AATith in civil prac-
tice, but he has  a Avider field  for  observing the
influences  of  external modifying  circumstances,
as exposure,  improper food, imperfect clothing, 
102         CAAIP DUTIES OF SURGEON.
irregular work, Avant 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 oavu, Avhilst 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 croAvding together, Avith
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 Avithin  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 SURG.E0N.         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 pre Anient 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  Avith  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,  Avith  frequent ablutions  of  the  body
and clothing of soldiers, should nevrer 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  Iioav  they can
best be  disposed  of.
  The hospital  tents  Avill  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 Avith  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 Avill  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 Avhich  the  surgeon Avill
state  Avho are to  remain  or go into hospital;
Avho are  to  return to  quarters as  sick  or con-
valescent ; Avhat duties the convalescents in quar-
ters are capable  of performing;  Avhat 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 Avill
then  distribute  the  patients   in  the  hospital,
see  that they  are properly  provided with com-
fortable beds;  enter in  the  proper  register the 
            CAMP DUTIES OF SURGEON.         K'O

name, the case,  the  disease; and in the diet and
prescription book the medicines Avhich the case
requires.  If  his  assistant  is  not  present,  he
prepares the  medicines  and superintends  their
administration.  He Avill 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 Avill 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 Avhich  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 Avill 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, Avill  make monthly, to 
106       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, Avith  a
statement of the hospital fund.  He Avill also keep
the folloAving records, from which the condensed
report to  the  superior  medical  officer  is draAvn,
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
Avounded ; 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 approAral of the commanding officer, cer-
tifying that the same are necessary 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
Avhen 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.  AVhen a detachment is sent off
on special service, the assistant surgeon accompa-
nies it as medical officer.
  AVhen 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
\AThich is  their  daily  routine, soon  breaks them
down, and many an over-zealous surgeon becomes
a prey to the diseases Avhich his constant efforts are
trying to quell in others.   This is  particularly the
case Avhen typhus is raging in camp, Avhen 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
surgeons to take care of themselves as to attend to
the sick; for should they needlessly sacrifice their
lives, they entail severe suffering on their regiments. 
 lOS        DUTIES OF ASSISTANT SU KGEoN.

 The Crimean surgeons Ave re severely censured, alter
 spending all day in the typhus and cholera hospi-
 tals, AA-ith tainted atmospheres, for remaining there
 during the night also,  when there was no necessity
 for it.  It Avas a useless and dangerous imprudence,
 an exaggeration of duty, Avhich deprives  the army
 of well-informed men, and impairs the  utility of
 the service.
   In the Crimea, the surgeons  Avould 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 Avas not  only  to gain  dexterity
 in the operative manual, but also to find out Avho
 were the most skilled and  therefore most worthy
 of being intrusted Avith important duties.   It is
 said that the  mortality of  the army amounted to
 two  hundred per day, which  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.
109
  Duties of the Surgeon on the Battle Field.—
The common fear Avhich 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 braA^c 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, Avhich takes possession of the bravest,
and cannot be  driveii  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 iioav 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 gunpoAvder Avhich  makes
men forget their origin; by its magic Avand Avomen
are made brave, and cowards heroes.  In the eager-
ness of the fray, an intoxication guides all to acts
of daring.   AAHio, in his  sober  moments, Avould
walk up to the mouth of a loaded  cannon to which
a torch is being applied? Yet on the battle field
find the man Avho, 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 Xature has so constituted us,
or the terror of pursuing what duty dictates Avould
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 Avhich 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 Avounded.  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
Avounded, are at hand in sufficient quantity.  Water
he  has not overlooked, as an abundant supply Avill
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.         HI

supply of brandy to revive those exhausted from

hemorrhage,  oil  to grease  their wounds,  and a

little tea, sugar, and such medical comforts  as Avill

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 wrater.

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 cotton 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 uon 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 sajd 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 mcau recommendation. 
112       DUTIES OF SURGEON ON FIELD.

great facility in  moving about the field where his
services may be  most required, whilst it dispenses
with the hospital store wagon, Avhich is altogether
too cumbersome to follow  light troops in their
varied and active movements.  In European armies
every regiment has such a pannier, Avhich  is con-
tinually resupplied from the medical store wagons.
The commanding  general  may  sometimes have
good reasons, under particular circumstances, for
ordering the medical  Avagons  to  remain  behind
with  the  baggage;  then  the  conveyance  of all
needful medical  supplies for the Avounded on pack
horses becomes imperatiATe.
   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
feAv medicines which the infirmary Avould  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 should  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 by mules wTould be the most comforta-
ble transportation for the wounded.   In European
armies, a distinct body of  men are employed for
conveying the Avtfunded, so that practiced hands
may soothe  the agonies  of transportation.  This
is by far the most humane  course,  and as a mark
of civilized Avarfare should be  of uniATersal adop-
tion.   It is  highly  important that a similar body
be instructed to  act as  nurses as Avell as attend
immediately  upon  the wounded, as  this timely
assistance  may  save many  lives on the fjeld.   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 folloAvs  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,
tAvo field  tourniquets, a bottle   of  brandy, and
one of laudanum  or morphine, or other medi-
cines Avhich 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
Avounded carefully  in  the wagons;  and  also fol-
lowing them, are at hand to assist in unloading
the  Avagons  at the field infirmary.
  AVhen the troops deploy or form for action, the
surgeons, Avith 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.
  AVhere 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 Avounded  can seek  surgical  aid.  Instead of
each regimental surgeon establishing such for his
regiment, it Avould be much better if they would
concentrate  for  indiAudual  assistance,  when the
Avounded 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 knoAvs Avhat roll he has  to  play,
and  does  not interfere  Avith others, a great deal
more Avork can be accomplished than where each
one acts independently  for himself.  The force of
this will appear, AAdien it is remembered that all
experience shows  the medical staff' of an army,
however numerous, to be always too feAv 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,  Avith the
most  approved and destructive arms Avith  very
long range, and Ave Avill 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  Avagons, under  charge  of the quartermas-
ter and assistant surgeon Avith his orderlies.   They
station themselves in  the rear of the advancing
line,  Avhere they  can  distinctly  see what hap-
pens, and remove immediately, without the range
of the shot, those who may fall Avounded.  It is
imperiously 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 wrounds,
what is omitted  on the  battle field  immediately
after the injury is received is never made up, with
Avhatsoever 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 Avounded  are thought
of by their comrades, who, in scouring the field,
find many a  dear friend Avhose  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 hcematosis—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 gears 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, he
is  at once approached by the assistant surgeon, 
       FIELD SURGERY WITH THE TRANSPORTS.    119

who  looks at  his  w7ounds, applies the  hasty
dressing Avhich they require,  then placing him
comfortably on  the  litter, attends to his  trans-
portation.  He can do  as much for the  Avounded
in  [this  wray  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,  Avith  a  handkerchief or strip  of cloth,
a fracture apparatus is at once improvised, and the
thanks of the Avounded, hoav in comparative com-
fort, are freely bestowed during his transportation
to the infirmary or general hospital.  If  he has a
mangled limb, Avhich 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 AVITH THE  TRANSPORTS.

abdominal one,  Avith protrusion of the intestines,
he sees whether the boAvel is injured or  not.  If
not injured, returns it  carefully Avithin  the abdo-
men, and gives a large dose of morphine to ensure
quiet.   Should  the intestine be cut by the ball,
he Avarns 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,  Avill,
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 Avhere the acci-
dent has occurred,  and not wait until transported
to a more convenient place,  the life of the soldier
often depends.   Those Avounded in the  head,  if
insensible,  require very  careful  transportation;
they  should  be as little  disturbed  as  possible.
Chest  Avounds, head Avounds, and fractured legs
give the most trouble, as they require the  greatest
care in coiiAreying  them  safely to  the  designated
places for surgical treatment.
   It is seen  from this  rapid sketch that  the sur-
geon  Avho folloAvs  the troops into action  has 
WASTE OF BANDAGES.
J21
nothing  to  do Avith  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  eminent military surgeon—Mr.  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 aAvay
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 Avounds, most of the Avounded  might be sent
directly on to the field infirmary  without dressing.
The dressings, Avhen  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.  Only
       11 
122          EXAMINATION OF WOUNDS.

in cases of sharp hemorrhage would it  be neces-
sary to apply compresses and the roller bandage,
or Avhat is very rarely required, the tourniquet.
  Should the soldier have a large artery Avounded,
and  the hemorrhage be  excessive, Avhich  is but
 eldom the  case, the surgeon should instruct the
orderly, Avho superintends his transportation, hoAV
to make judicious finger pressure.   This is much
better  than the tourniquet, producing much less
engorgement of the injured tissues.
  Fit Id surgery, properly speaking, commences at the
field  infirmary.  Here all  wounds are thoroughly
examined,  and an accurate diagnosis  established.
The wounds 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, Avadding, 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 AVOUNDS.          123

sioiis, with rare exceptions.  It  is an intelligent
instrument, and, appreciating what it feels, it Avill
not only discover the character of foreign  bodies
complicating  the canal, but will  avoid increasing
the dangers by making new lesions  in the depth
of the  wound.  In  fresh  gunshot  wounds,  the
apertures  which the  balls  hoav  used in Avarfare
make, are large  enough to admit the finger Avhen
introduced with  care.   Very rarely is  it necessary
to dilate  a wound, 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  Avounds,   marks
the novice.
  Balls  are readily detected in a fresh wround by
placing  the  patient in the position  in which he
received the  injury, if the  direction  from  which
the ball came be  known.  Portions  of clothing
and wadding are detected with greater difficulty.
Before,  however, probing the wound for the  de-
tection  of foreign  bodies, be  quite sure that  the
clothing of  the  soldier  has  been  perforated.
Often a single orifice is seen leading into a limb
without exit,  which  would at once suggest an
embedded  ball;  A\'hen  an  examination  of  the
clothing would  show that the  ball  had  driven 
124
EXAMINATION  OF  AVOUNDS.
these into  the wound Avithout  sufficient  force
to  transfix  them,  and,  on  removing,  hastily,
the  clothing,  the  ball had been  extracted  by
this diverticulum pushed in before  it.   This ex-
amination  of the clothiug  Avill save much time
to  the  surgeon, and painful,  protracted, injuri-
ous probing  to  the wrounded.  AVhen  the shirt
or  draAvers  are not  torn, no foreign body  could
have been lodged  in the flesh wrhich they Avere
covering.  From the nature of fresh avouh/Is, the
examination  and removal of all  foreign bodies
Avill 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
nutted.  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  (Avhich  ought
to  be  rigorously excluded), to pass to  the bottom
of  the wound, this promotes the  decomposition of
the extravasated  fluids  and  exudations,  induces
suppuration  and  sloughing,  and  predisposes to
pyaunia, with its fatal  sequelae.  Many a limb and
life Avould  be  preserved  if the examination of
gunshot wounds  could  be limited to the  battle
field,  and  military  surgery  will  have  attained
great  perfection  Avhen  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  Avounds,
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.  No  haste should be permitted in this 
126       TREATMENT  OF  GUNSHOT WOUNDS.

examination to the injury of the Avounded through
carelessness  of  diagnosis.   Should large arteries
be  injured, they should  be ligated always in situ
above and beloAv the point injured,  and for this
purpose  the avoiukI  must be enlarged.
  As  a  general rule,  torn  tissues  Avill  reunite,
Avhilst  bruised,  crushed   tissues  slough.   All
Avounds  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, Avhich  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  Avhen  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 Avithout injury to 
NERVOUS SHOCK.
127
the main bloodwessels and  nerves, and without
complications Avith 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.   AVlieti 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
Avounds  might  be examined,  foreign  bodies  re-
mo\-ed, and  the wround, if simple, dressed whilst
a  soldier is  suffering  under  shock,  no  serious
operation, which Avould 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 Avounds, it may often be met
with iu the most trivial injuries.   It is recognized
by the  sufferer becoming cold,  faint  and  pale,
with  the surface bedeAved Avith a cold sAveat;  the
pulse  is small  and flickering;  there  is anxiety,
mental depression, Avith 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.   AVhen  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
Avound; and  Avhen  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
Avarm, 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.
   [n all painful operations, chloroform should  be
freely administered  to produce the desired  anaes-
thesia.  Like all valuable medicinal agents, which
Avhen  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 Avars, in recording the
advantages of chloroform in field surgery, show it
to be hoav one of the  indispensables for successful
practice.   It  saves  the  lives  of  many wounded,
who Avould perish  from  the shock of a second 
      TRANSPORTATION TO GENERAL HOSPITAL.   129

operation, and also  many who Avould have  been
considered as  Avithout  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
Avounded.   Transport   wagons are  in  constant
communication Avith 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  Avounded;  and
here the  regular treatment commences.  If it be
convenient for the Avounded to reach the general
hospital within tAventy-four hours  from the  re-
ception of their  injuries, many serious cases  for
operation, such as the  resections,  might Avell be
deferred  from  the  field  infirmaries  until  the
Avounded have arrived  at the  station where that 
130      COMAION DRESSINGS FOR WOUNDS.

quiet and rest, Avith medical  comforts, Avhich 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 Avhich 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 Avounds  receive
is a Avet cloth covered Avith  a  piece of oiled silk
or Avaxed cloth, and secured Avith a single turn of
the roll of bandage.  This keeps the Avound 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, Avhilst
the oiled silk keeps the.parts moist.   When  oiled
or india-rubber  cloth cannot  be obtained, and  no
facilities exist for keeping the  Avound constantly
wret, Avhilst 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 Avounds may have their edges paired
off and then brought together, Avith every prospect 
TEMPORARY  HOSPITALS.
131
      of speedy 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, Avhose 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 folloAv their com-
      mands, leaving  either  an assistant  or an extra
      medical attendant for  the Avounded, 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 Avounded.  Should the army unfortu-
      nately meet with a reverse, all available transport
      must be  pressed  into the service for the  remoA^al
      of the Avounded  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- 
1H2     SEA'ERE WOUNDED  LEFT TO ENEMY.

ment, there Avould be fewer to move later in the
day, Avhen a retreat was compulsory.  No Avounded
soldier, Avhose  injuries  are so slight that  he can
Avalk, should ever be carried, as he takes up a place
in the transport Avagon Avhich excludes one Avho
cannot assist himself.
   There are many cases of injury  to Avhich long
transportation  wTould  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.   AVhen  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 wrar speak dif-
ferent languages.   The  rule  now  recognized in
civilized warfare is,  always to  leave  competent
surgeons  with the Avounded  Avho  are  left to be
cared for by the enemy.

   Appearance or 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
momentam, transfixes the tissues  Avith 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, Avhen 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 AVOUNDS.

by  so   many   circumstances—the   form,  size,
velocity  and number of the  missiles; changes in
the missile  after its entrance into the  body and
prior  to  its escape;  the distance  of the Avounded
party, his  position,  his clothing,  foreign bodies
AAThich 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 AA'ho 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  two orifices  can be  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; Avhilst
after  traversing the limb in  making  itk exit,  the
tissues through Avhich it is  noAV pushing have no
support,  they are  stretched  inordinately before
they are torn, hence  the  flap-like lacerations of
this  exit,  Avith  sometimes  nothing  more  than
a  rent   or  split  in  the  skin.   All  who   are
familiar  Avith  the dri\-ing 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,  wTith 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 Avhere 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 flesh,
 has been knoAvn to break into six  pieces, each in
 exit  making  a corresponding Avound.
   Conical balls show much  less  deviation than
 round balls.  They usually folloAv 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 weight 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 WOUNDS

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,  Avhich permits of  considerable  moAre-
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 Avay, as it Avere  Avith such care, as
to avoid the great vessels among which the mis-
sile had channeled its  course.  So great is this
poAArer  of avoiding perforation in the large arte-
ries, that rarely does death  take  place  on the
battle   field  from division  of  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 extensiA^e destruction
folloAVS.
  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,  Avould  accompany it.
   A  certain amount  of hemorrhage  ahvays  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 sAvelling  which folloAvs
gunshot Avounds.
   The  pain  Avhich 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
bloAv Avith a supple Avalking cane, Avhilst  Avith a
       12 
138
NERVOUS  SHOCK.
few  the  pain is  Aery seA'cre,  and simulates  the
feeling  Avhich would be  produced  by  running
a  red-hot Avire   through  the  flesh.    McLeod
mentions the case  of an  officer who had both
of bis legs carried  aAvay, and who  only became
aware of the injury Avhich he had received Avhen
he attempted to rise.
  It  appears as if eveiy  gunshot Avound Avas
accompanied by a certain amount  of shock,  or
a partial paralysis of sensation, Avhich  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.   AVhen  this condition  passes  off",
then reaction brings  with  it  much  suffering.
In this  nervous shock,  Avith 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.   AVhen  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, HOAV CHECKED.        1^

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 Avounded  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
Avounds,  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
Avill   establish rapid cicatrization.
   Hemorrhage, Avhich 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- 
140
TOURNIQUETS DISCARDED.
jured,  they either cease bleeding spontaneously,
or the patient dies so rapidly, that art is of little
aA-ail.  If  the case is  not injuriously  interfered
with, the  natural hemostatics soon  controls the
bleeding.  The ragged character of the Avound,
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  ATessel, and stops any further
loss of blood.
   This spoidaneous arrest of hemorrhage  is usually
permanent;  and  if  the   ordinary   prophylactic
course  is  pursued  of absolute  rest and  quiet,
Avith the limb elevated  and bandaged,  no return
showrs itself.   Should,  on the contrary, meddle-
some  surgery suggest the use  of a tourniquet,
Avhich cuts off the circulation and especially the
veinous  return,  the   limb  soon SAvells, tissues
become  engorged, excessive  extravasation  in the
Avound folloAvs, and a train is laid for future mis-
chief.  The  field  tourniquet, in former  days, Avas
so  much in vogue that it was considered indis-
pensable on  the  battle  field,  and Avas  therefore
carried in large numbers,  to be  applied to every 
HEAIORRHAGE, HOW CHECKED.
141
limb  from which  rjlood  was trickling, or  from
which hemorrhage Avas feared.   Noav, 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 Avriters Avarn surgeons  of the too hasty
use of hemostatics, and suggest  that it is better
for  the  wounded to lose a little blood, Avhich Avill
diminish the heart's  propulsive  force,  than  have
the  wounded  tissues  filled  Avith  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 Avound, 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  Avound, 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, HoAV 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 Avith  the  per chloride or per
 sulphate of iron, which, as a poAverful astringent,
 when coming  in  contact Avith  fresh blood,  will
 immediately form  a clot.   A  lump of ice placed
 upon the compress Avill act  with equal efficiency.
 A sponge  or  compress, Avith or Avithout the iron
 styptic,  tied on the bleeding Avound, is all that
 the  surgeon superintending the transportation of
 the AATounded  is  expected to do.   Unless  the hem-
 orrhage  is  very violent,  threatening immediate
 destruction of  life, the tourniquet  is rarely re-
 quired.  All  recent  Avriters on  military surgery
 recommend that field tourniquets be dispensed
 Avith, 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 eATer 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 Avhere  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  Avhere the surgeons are assem-
bled, all bandages are  removed, and the wound
carefully examined.  A  glance  at  the Avound
when the clothing has been previously examined,
will often tell Avhen there  are  two orifices differ-
ing in appearance and in a direct line with  each
other, Avhether foreign bodies have lodged or not.
As the patient is  noAv  faint from  loss of blood
and from nervous  depression, the  wound not yet
being painful or sAvollen, 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 Avithout fear of repro-
ducing hemorrhage, as the finger  cannot displace
the clots AAdiich hold firmly to the  openings in the
vessels.  Every  surgeon has noticed Iioav rudely
a stump might be sponged, and what force  it
requires to  Avipe  away  clots which have formed
over the face of a smooth, incised, open Avound. 
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 Avound  should be, before SAvelling has
taken place.
  A  silver  probe will travel in the  direction
given to it by the surgeon, in examining fresh
Avounds, and as most persons 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 saAv a physician of experience, in seeking the
course of a ball  which  had lodged in the thigh,
apparently  Avithout 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 Avhich the probe had
taken.  This  example  is  sufficient'to show Avhy
military surgeons denounce the silver probe, and
distinguish by its use the tyro in surgical practice.
  The Avound is  examined from both  sides, with
the double object of finding foreign bodies Avhich
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 Avhich they possess;  as  an  injury  Avould
necessitate a very careful after-treatment to aA'oid
secondary hemorrhage.
  Should  but one  opening exist, and   all the
clothes of the  soldier  covering the Avound 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 Avound.   This is
particularly the case  when they become   satura-
ted Avith the  secretions.   ForeAvarned being  fore-
armed, the surgeon, remembering these  difficul-
ties, will examine with special care  for these soft,
foreign complications.   When found the}-  should
be extracted, as their  presence is certain to estab-
lish  a high  degree of  inflammatory  excitement,
Avith profuse subsequent suppuration.
   This effect Avas well shoAvn in the case of a pri-
ATate 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
niSTORY OF CASE  IMPORTANT.
The ball entered the chest at the anterior fold of the
armpit,iractured the clavicle, and after a course of
nearly six inches,  Avas stopped by the tough skin
over the posterior portion of the shoulder.   The
ball Avas readily detected  by  the  regimental  sur-
geon, and, by  an  incision through the  skin,  Avas
easily  removed.   Inflammation of a high grade
followed.   He  was sent up to a city  hospital  one
Aveek after the accident, Avhen he  Avas losing from
three to four ounces of pus daily from the Avound.
On the day  after his admission, in examining the
wound, I detected in  the  shoulder Avound some
substance resembling a slough, and upon extract-
ing it, found a mass of Avadding 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 noAV,  for the  first
time, showed the  deficiency  in the lining  of his
coat from w7hich this mass had been torn.  The re-
moval  of  this irritant diminished the  discharge
immediately, so that, in the succeeding twrenty-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 Avounds.   Often, the course of
the ball cannot be discovered without  it.   What 
           HISTORY  OF CASE IMPORTANT.        147

surgeon,  hoAvever  great  his  experience,  seeing
a Avound  made in  the  arm by a  ball, wrould
think of  looking in  the  opposite thigh for its
place of lodgment,  did  he  not  learn  that  the
injury was received from abo\Te, whilst mount-
ing a scaling-ladder,  with  arms raised above  the
patient's head?  The ball entering the  back  of
the arm near the  elboAAr,  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, Avhere
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  Avhich 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 parrs vary  with
qxqyy 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  Avhich it was  when the  injury Avas re-
ceived.
  The   Avound  ha-ving  been carefully examined 
148        REMOVAL OF FOREIGN BODIES.

by the finger 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 Aveight upon its accomplishment.  The ques-
tion  is not  so  much  whether balls  can  remain
innocuous in the  flesh, but do they ?  Those  Avho
have had  experience in gunshot wounds in the
field, knoAv how excessive is the irritability caused
by the presence of a ball in a wound; hoAV 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  Avith  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
InATalides, 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 Avhich  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,  Avithout  ad-
vancing to any  extent the merits of the   instru- 
150
REMOVAL OF FOREIGN  BODIES.
ment.  A  very good  bullet forceps is one ter-
minating Avith  a sharp prong on either blade, at
right angles to the blade, so that Avhen  closed
the points are  protected  by  the blades.   These
act as an  axis upon  which  the  ball may  he
rolled  out  of the wound, instead of being  drawn
out  as Avith  the dressing  forceps.
  AVhen a ball is firmly imbedded in  bone, it is
removed by  boring into it with  a  gimlet, Avhich
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 Avhich
it had traversed.
  Baudens, in  noting the difficulty of extracting
these  subcutaneous balls, ascribes  it to a layer
of cellular tissue,  Avhich  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
Avarn  you from.  It is sufficient to mention that
such  mistakes haAre happened  to military sur-
geons.
  By  foreign  bodies we   mean  balls,  pieces  of
clothing, spicuke of bone,  Avhich have  been bro-
ken off and  are loose in the wound,  and any
articles about the person  which may  have been
driven before  the ball.  These should  all be re-
moved immediately after the  injury has  been re-
ceived, and before swelling or infiltration renders
the task difficult.  AVhen  done early, the AA^ound
will be found sufficiently  large to alloAV of the
easy extraction without dilating.  It is only Avhen
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 Avas 
152        REMOVAL  or  FOREIGN BODIES.

formerly  the  constant rule  of practice,  is uoav
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  Avound, cannot be readily ex-
tracted  without  injury to  the  soft  parts.  This
old medical dogma Avas  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, Avhich can only be prejudicial to  the
case,  from the  irritation and  inflammation Avhich
Avill 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 arc  very  much swollen and very
painful.   The surgeon  Avill 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 Avound.
   The  above  rules  apply  chiefly   to  gunshot
wounds of the extremities ; those of the trunk and 
I'RIMARY HEMORRHAGE.
153
head  offer so many exceptions to the above, and
require,  in  a  measure,  such  special treatment,
that the course to be pursued in these wounds,
complicated  Avith  foreign bodies, Avill 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 Avhen
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 Avounds
Avith  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  Avounded, 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,  AA'hen compared to that
of the  corresponding vessel in  the opposite limb,
shows  conclusively some hindrance to the  circu- 
154
LIGATION  OF ARTERIES.
lation.  AA'hen  no external hemorrhage  exists,  an
absence of pulsation in the course of the  artery
beloAv the Avound 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,
Ave knoAV 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, AAdiich  Avas tied over the wound,  the
artery should not be  interfered Avith.   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
preATentive treatment.
   The ligation  of an artery,  Avhich  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  Arery 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, Avhich 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 ansAvered
by the loss of the limb and even life, whether the
circulation will be re-established in time to save
the  member from mortifying.  AVhen 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 Avarmth and
enveloping in flannels to support  life  in it  until
the circulation  be re-established, Avhen the  limb
becomes actually warmer than its colleague.   The 
15(3
LIGATION OF ARTERIES.
arterial supply  is  now disseminated  in vessels
much nearer to the surface than  before, Avhere its
chief channel Avas deeply embedded in the tissues.
The rapidity of this collateral development in the
limb is Avell exhibited  in primary and secondary
amputations.  AVhen 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  Avound  should be
dilated, the bleeding mouths of the artery found,
and a ligature applied, both above and below the injury.
This has become the  fixedf 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 arc familiar Avith the anastomosis
or  collateral circulation in blood-vessels.   When 
             LIGATION OF ARTERIES.           157

the current of blood is stopped at any one point,
it Avill soon find its Avay through  many circuitous
routes  round to the very point through Avhich its
straight course had been checked.  AVhen an arte-
ry is divided, it is Avell knoAvn 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, noAV 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 giAre tone to  the arterial Avails) is
only partial, the  Avails  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,
hoAvever,  is  scarlet  or arterial  blood from  the
upper end of the Aressel, dark or veinous colored
blood for its loAver end.
  Guthrie lavs doAvn the two folloAving rules as
the gre:.!:  principles of surgery, to be  observed in
the  cases of wTounded arteries,  and Avhich ought
neATer 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  spot injured,
unless such operation  not only appears  to  he but is
impracticable.
  AA'hen it is  necessary to  ligate an artery,  the
surgeon must be guided by his  anatomical knowl-
edge, and by the pulsation  in  finding 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.   AVhen  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  ATessel-is  comparatively
isolated,  easily  discoATered, 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, A\Thich  hampers
the search.  When Ave  approach  the artery, use
the grooved  director  to isolate  those  cellular
layers  in Avhich  the vessel is  ahvavs found.  The
point  of the  knife should never  be  used for this
purpose.  The lips of the Avound 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.
  AA'hen  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 Avound
and secured under  a strip  of adhesive plaster,
attached to the immediate neighborhood  of the
Avound.  This mode of  disposing of  it will pro-
tect it from becoming entangled in the  ordinary
dressing,  and  be  draAvn  upon  Avhen these are
daily removed.   AVater  dressings  Avould be the
proper  after-treatment.   The thread  will  have
come away spontaneously, by the eighth, tAvelfth
or  sixteenth  day,  according to  the  size of the
vessel ligated.
  AVhen it is  necessary to  ligate  the  artery  in
its   course  above the  seat  of  hemorrhage,   I
Avould prefer using  a fine  silver  Avire  ligature.
This is well twisted upon the  artery,  and then
cut off", leaving  only  the loop  writh  one or tAvo
twists in the  Avound.  The advantage  is, that
the foreign body  being  very small, not Aveighing
more  than  one-third  or  one-half of  a   grain,
creates but little irritation, and the  Avound can  be
healed  in  a  few  days  by  quick  union.   This
wTill 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  give's 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  Avhere  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,  il
must be by  the adoption of  the  silver   Avire
ligature,   Avhich  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 Avire 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 knoAvn  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 healinq of the wound, and sjionld
be kept in subjection  as  much as possible.   This is
effected  by  the  continued application  of cold,
Avhich, 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  Avas consi-
dered  essential  in  the  healing  of all  wounds,
by  permitting the escape  of  so much poisonous
matter,  AAdiich  had  accumulated  in the  system,
and Avhich  must either now  find a  vent,  or, if
retained,  Avould  be  considered  the  satisfactory
cause of  any sickness  which  the Avounded man
may ever suffer from hereafter.   The wound was
therefore  plugged Avith a lint tent, piles of greasy
lint in cushions Avere applied, and after  covering
Avith a sufficient number of compresses and band-
ages, a forcing bed Avas formed,  which  supplied
pus  to the  satisfaction  of  all  interested ;  and it
Avas common enough to see life drain away from
this opening.
  This smothering  of wounds and  smearing on
of greasy ointments, which  the Avounded  formerly
encountered, Avas 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, Avith  its rapid  poisoning; hos-
 pital gangrene,  Avith  its  sudden  collapse,  and
 erysipelas, Avith  its thousands of  Auctims, 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.   Arote  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 water 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 Avith  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 AVOUNDS.

 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 Avater 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,
 Avaxed  cloth,  or  india-rubber   tissue   is,  that
 should the  Avater  supply accidentally  give out
 in  the  suspended \ressel,  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 Avell
 understood  that they be  disturbed as seldom as
 possible, compatible Avith 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
 Avet compress coArered Avith oiled silk and secured
 by a flannel roller or outer compress,  is always at
 hand, and Avill  be found to combine, in a simple 
              TREATMENT  OF  AVOUNDS.           165

 form, all the properties of a poultice.   It is light,
 moist, soft, and is kept warm by absorbing animal
 heat, Avhich the  oiled silk and outer  compress
 retains.   If Ave add  to these, cleanliness, facility
 of medication,  and the readiness with  AA'hich 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.  AVhen  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-
 ytstw 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,
 Avho  have their hands usually  full, and is withal
 effectual.  AVith the judicious application of cold
 the surgeon can defy inflammation.  Cold acts by
 keeping doAvn temperature, constringing 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 Avater dressings are
 obtained  through the evaporating properties  of
 Avater, 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 adjiiATants.  AVhilst 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 Avounded  patient
feel chilly, the cold dressings  will  not  be used 
TREATAIENT OF AVOUNDS.
167
until  reaction has taken  place.   There are a few
persons with AAThom cold  Avater is not admissible.
In all cases the feelings of the patient Avill be 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 Avaxed cloth.   This
Avill soon attain the temperature of the  bod}% and
Avill keep the parts  moist  and soft.  The  dress-
ing requires  to be changed twice in  twenty-four
hours; not that the compress would get  dry, for
the perspiration from the part Avhich is kept in
by  the  oiled silk would  bathe it  in a continual
and permanent moisture.  The object in changing
is to get rid  of this  secretion, Avhich, by decom-
posing, Avould irritate the wound.
  A question  of great  moment  is, when  shoidd  we
desist from  water  applications and change for  some
more useful or appropriate  dressing/   According to
the present  rational vicAvs  of surgeons, no other
dressing is  ever  required, however  serious  a
Avound 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,  Avhich  we  call  a  healthy  fluid,  is  a
heaA-y drain upon the system.  It  is  made  from
the richest ingredients of the blood, Avhich  were
intended for the repair of tissues.  Once converted
into pus, it is unfit for any further useful purpose,
and is  therefore  a  wTaste  of precious  material.
This discharge is  not more  necessary to  the  heal-
ing of Avouuds than to the  nutrition of the body.
Extensive wounds, healing by the  first intention,
do very Avell Avithout its intervention.  Large sub-
cutaneous Avounds, when CATen their sides are not
kept in  apposition, heal Avith rapidity Avithout the
formation of pus.  Under  a scab Ave  find tissues
form, by  Avhat has  been  called the  remodeling
process, Avithout it; and it should be our constant
effort to heal all Avounds, and I would  say  espe-
cially gunshot wounds, Avith  the least  possible
discharge.  Hence the water dressing can be con-
tinued beneficially for Aveeks, 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 AAdiich have heretofore held
universal sway in the treatment of wounds.  All of
these can be dispensed witli for the more simple 
SECONDARY HEMORRHAGE.
16'I
dressing.  Should the wound require stimulation,
the nitrate of silver  wash, grs. xx to the ounce,
when brushed over the part, Avill suffice; or tinc-
ture of iodine,   or  iron,  or  some  stimulating
astringent  might be  equally applied in addition
to the Avater dressing, so that any imaginary con-
dition  of  the wound  might be  successfully  met
hv 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 in 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 Avards of  military hospitals.
   We have  already said that  a surgeon is never
 warranted in cutting doAvn upon  an  artery and
 tying it upon suspicion—he must be an eye-Avit-
 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  Avith  it  the
       life of the patient.  This is  specially the case in
       recent Avounds,  before nature  has  prepared a
       collateral circulation, so that the rule which Ave
       have laid doAvn is imperative, nenr ligafe an artery,
       however large, in which lumorrhage has sj)onta>wously
       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 Avill
       prevent its return.
         In  the  ordinary course  of gunshot  wounds,
       suppuration  is established about the fifth or sixth
       day,  Avhen  the track of the wound  commences
       to  be  organically cleansed  of all  those  tissues
       Avhich  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.   HoAvever  large  the artery reopened
       by  this process,   the escape of  blood  seldom
*      occurs  with   an  impulse,  but Aoavs  away in a
       continuous stream, which marks its  escape from
       the tovyr end of the vessel. 
SECONDARY HEMORRHAGE.
171
  AVhen   hemorrhage,  eAren  from  the  femoral
arterv, 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 loAver end  of the ATessel; so
that Avhen 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 tAventy-
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  undeiv
stood, the rules laid doAvn 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  outAvard  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,  Avhich  nearly fills its cylinder.
The lowrer portion of the vessel,  having been  in
a measure paralyzed by the division of its  coats,
Avhich had cut  off its supply of  nerves, acts Avith
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  Avound, prevent-
ing the blood from following  its accustomed chan-
nel, nature is at once busy, opening and enlarging
the circuitous by-Avays and alleys of the circulation,
so as to restore the supply to  the extremity threat-
ened  with starvation, or, in surgical  parlance,
mortification.  As Avhen 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  by-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  Avell as  down the  limb,  and finding  an
open gate  at  the loAver 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, haAre taken
its  place, marred its  brilliant  color, and  dimin-
ished  its clotting properties.  Xo  material  then
exists for stopping up the  vessel, as in the upper
end of the divided  arterv, and the result  is, that
secondary hemorrhage nearly always occurs from
the lower  ends.
  This being  Avell understood, Ave  can  now ex-
plain Avhy  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 loAver 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 Avounded ends
of the arterv is, that there  is  always  sonic  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,  Avhich had not been suspected
until  a post-mortem  examination  revealed  the
source  of bleeding.  AVhen  the ligature  is  ap-
plied  to the bleeding mouths,  this accident can-
not happen.
  The course  which  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 OATer  bad  roads, or the sloughing of
the Avound, hemorrhage reappears, the limb should
be  at once  bandaged  from, the  extremity  up-
Avard, 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 Avith  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 Avound.   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 AAdiich control the force of the circulation,
as veratrum  viride,  digitalis, etc.   By 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 arterv after the  escape of the ligature.   But
should the parts  be so situated   that this  pres-
sure cannot  be  applied for  a sufficiently  long
time, or  should it not control the bleeding, then
the proper course is to ligate  the mouths  of the
arterv in the Avound Avithout  further delay.  Xo
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 cannot  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 Ugating after the second hemorrhage. 
 176   TREATMENT OF SECONDARY HEMORRHAGE.

   You  must not be  deterred  from placing a liga-
 ture on the open mouths of an arterv 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 sIioavs 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.   Ligate
 in the wound under any circumstances, when it  is pos-
 sible.   The swelling and infiltration of tissues, rcn-
 ders the search after  the injured artery difficult,
 but the surgeon, avIio, looking to the  side  of hu-
 manity, considers it a sacred duty to do everything
 for the interest of the  Avounded, must not allow
 difficulties  to  interfere  with  his proper  course.
 Safety  lies  alone in this operation.  The difficul-
 ties  must  be met  and  overcome.
   The  folloAving  appearances will  be observed
 in the  wound, and will assist in the search :  After
 dividing the infiltrated  tissues, should the  injury
 have been  received over forty-eight  hours, par-
 ticularly if five or six days have intervened, the
 ends  of the vessel Avill  be  found incarcerated in
'a  mass of greenish yellow fibrine which indicates
 in a  remarkable  manner  their  situation.  That
 wdiich  conceals the lower mouth of the vessel is
 always  in  smaller quantity.  Where post-mortem 
      TREATMENT OF SECONDARY HEMORRHAGE.  177

examinations are made, a probe  introduced  into
the artery from below would make its appearance
at  a point under  the  yellow patch,  raising a
thin portion as it protrudes;  and should  the pa-
tient  have been  destroyed  by secondary  hemor-
rhage, an opening will usually be  found in  this
pellicle.   Through  the  upper  portion  of  the
artery the probe  Avould  pass  down Avith much
more  difficulty,  owing  to  a contracted  tube
plugged  with coaguhe—conditions Avhich do not
exist  in  the  loAver portion.  These lyniphy,  yel-
lowish green spots are,  then, our guides after
the Avound has  been freely dilated.
  In a surgical  operation, especially in  ligating ar-
teries, never cramp oneself from the fear of mak-
ing too large an opening; the  error is ahvays on
the other side.  Having found and ligated  the
orifices, the Avater dressing should be  continued
as before, care being taken not to apply it should
the limb become cool and pale. This is not usu-
ally  the  case  after secondary hemorrhage,  for
the return of  the  bleeding indicates  a re-estab-
lished circulation, Avhich the ligature at the bleed-
ing mouths cannot iioav influence  to the injury of
the  limb.  Should  it be  impossible to find  the
bleeding  mouths, after a long and careful  search,
then we will be reluctantly compelled to adopt the 
 178   TREATMENT OF SECONDARY  HEMORRHAGE.

 less satisfactory operation of ligating the  artery
 above the wouml ;  hoping that it may obviate fur-
 ther  operation.  Often, however, when this last
 plan has been adopted, a return of the hemorrhage
 necessitates a  second ligature  upon some higher
 point; and should this fail, as is not frequently the
 case,  amputation of the limb Avill be the only re-
 sort to save life.  Amputation must be equally re-
 sorted to if,  after the  application  of a ligature,
 the circulation not  being re-established,  morti-
 fication of  the limb ensues.   In either case  am-
 putate above the seat  of the  ligature, so  as to
 ensure  a supply of blood  to  the stump  for  its
 nutrition.
  These are some  of the dangers incurred Avhen
 the surgeon does not adopt the  only proper course
 to stop  the  trouble  at  its commencement.  Mili-
 tary hospital  statistics  show  heavy mortuary lists
 where this  rule is  not  recognized and  followed.
 As the  ligature  acts as a foreign body,  and must
 come  away, it is  of  little  importance what is
 used  for  that  purpose, a strong cotton, flax  or
silk thread,  fulfils  all  the indications  required.
W^hen applied,  it should  not be interfered  with
until  it has  either come away  of its own accord,
or ten to  fifteen  days  have elapsed,  Avhen cau-
tious  tractions might be attempted to  hasten  its
removal. 
PUNCTURED  AVOUNDS.
179
  Silver  Avire has  been  spoken  of as  ligatures
for  arteries.   However well  it ma}'  ans\A7er  in
fresh  wounds Avhere union  by the first intention
can be obtained, it is. quite out of place in sup-
purating  wounds,  as Avhen  ligatures  are applied
for  controlling  secondary hemorrhage.

  Punctured  wounds made  by the bayonet or sabre,
require  similar  treatment.   If the  history and
appearances  clearly indicate the character of  the
wound,  there will  be  no  need of  probing  for
imaginary foreign bodies.   Such  Avounds usually
bleed more  freely  than in  gunshot.   The hem-
orrhage is susceptible  of control by  the same
means ; pressure being preferred  to   ligation  of
arteries.   The  treatment  should  be   cold  Avater
dressings, —  irrigation   preferred.   Protect  the
wound from air if possible, by covering it Avith
adhesive plaster, or collodion, and  dress it as  sel-
dom  as possible.   Once probing  of  such a  wound
should satisfy the  curiosity of any surgeon.   A
frequent  repetition  of  this  meddlesome  surgery
must  end in mischiet, beside  the needless pain
inflicted upon the Avounded  man.
  Should a bayonet or sabre wound transfix one
of the natural  cavities, the  internal injury may
be rapidly fatal from hemorrhage, or the injury 
180
PUNCTURED  WOUNDS.
inflicted  upon the contained organs  may, sooner
or later,  lead to the destruction of  the wounded
by Arisceral inflammation.   Under  ordinary condi-
tions, when such  Avounds  exist  in the  extremi-
ties, Avhere no large vessels are implicated, they
require  no  special treatment.   It  is  a  class of
wounds not as  frequently  met with in  military
surgery as one would suppose.   The newly intro-
duced  sabre bayonet,  when  plunged  into  the
body leaves  but  little  Avork  for  the  surgeon.
Such cases seldom leave the battle  field  alive.
  AVhen   the ordinary  bayonet has  buried itself
deeply in a limb,  suppuration  may appear in the
march of the wound.   Should pus  be  suspected,
and fears exist that it  may be pent up  under a
fascia, it  would be necessarv to dilate  the Avound
to permit of its free escape.  Under no other con-
dition, except for  serious hemorrhage,  where it is
necessary to ligate the open mouths of the bleed-
ing  vessel,  should a punctured wound made by
either sAVord or bayonet be dilated.
  Simple incised  Avounds,  as sabre cuts, will be
closed  by adhesive plaster  (or  sutures  which are
preferable, should there be any tendency to gap-
ing), to  be  followed by the cold wrater dressing.
Should the Avound be not of a serious character,
it may be left  even Avithout  after-dressing—the 
          HEALING OF GUNSHOT AVOUNDS.       1S1

little oozing from its edges, when  drawn together
by straps or sutures, dries into a scab along the
line of wound, and excludes air Avith its pernicious
influences.  This permits of  the remodelling pro-
cess, and cicatrization is effected  Avithout suppu-
ration.
  In  gunshot wrounds, the sAvelling which sIioavs
itself a fewr hours after  the  injury has  been  re-
ceived,  continues  increasing until  the  comple-
tion  of the third  clay,  Avhen it has attained  its
acme  with  commencing  suppuration.   Should
sloughing  occur, it  Avill sIioav itself by the sixth
or seventh.   On  the  eighth  or  ninth  day, the
slough is  in most  cases separated from the  edges
of the track of the  ball,  and in a few  days more
will  have  disengaged itself.  AVith  the cleans-
ing of the Avound, the inflammation gradually sub-
sides, the swelling diminishes, purulent discharge
lessens  in quantity, and the wound  commences
contracting.  The middle portion  of the track first
closes, and  with it,  the  opening  of exit, leaving
a funnel-shaped canal, which diminishes from day
to day, becoming more superficial, until no depth
is left to  the orifice" of entrance,  Avhich cicatrizes
with  a depression, marking  distinctly  the nature
of the injury AAdiich has been received.   This is
the ordinary course Avhich gunshot wounds take
when judiciously treated in good constitutions. 
182
GENERAL TREATMENT.
  The general treatment of such cases consists chief-
ly in interfering Avith the general health as little
as possible.  The  commonly prescribed antiphlo-
gistic remedies are, Avitli but few exceptions, not
required.   The endless list of emetics, purgatives,
diuretics,  and diaphoretics, to Avhich some Euro-
pean writers still  cling  with Avonderful tenacity,
can be dispensed with Avith benefit.
  Guthrie, Avho represents this class, in speaking
of the inflamed stage  of gunshot  Avounds,  says,
that the treatmeut for subduing this  should be
active:  "the patient, if robust, ought  to be bled
(if  no endemic disease prevails), vomited, purged,
kept in the recumbent position,  and cold  applied
as long as it shall be found agreeable  to his feel-
ings; when that  ceases  to  be the case, Avarm
fomentations ought to be resorted to, but they
are to  be abandoned the instant the inflammation
is subdued and suppuration well  established."
  Active  purgation and vomiting  are  incompati-
ble with that degree of quiet which is laid doAvn
as a fundamental rule in the treatment  of gunshot
Avounds.  As  suppuration is usually long contin-
ued, and debility,  with a certain degree of emacia-
tion, usually  accompanies the march  of gunshot
wrounds, the disposition should rather be to harbor
strength to support this drain than to  despoil  the 
         INTERNAL TREATMENT OF WOUNDS.     183

system.  The modern practice of support rather
than depletion hastens  convalescence, and is the
only rational practice.
  General  and  local blood letting are  only  re-
quired  in  a  few special  injuries  of particular
organs, which will be hereafter mentioned.
  Emetics, as such, are never required in the gene-
ral treatment of wounds.  AVhen very small doses of
the emetic preparations  are given,  to induce relax-
ation and for  generalizing the  circulation, in this
way deriving the excess of blood from the wound,
they may be useful.   Small doses  of tartar emetic
may, Avith other  remedies, form a good prescrip-
tion in cases of excessive reaction.  Mild purga-
tives are in  constant requisition, both for their
detergent as well as derivatory effects.
  The granulations of a Avound are  said to be a
better  index  of  the  condition of the  intestinal
canal than the tongue, as they are  much  more
impressible  by any cause which  induces an  irri-
table condition of the  system.   Keeping watch
over the digestive organs;  preventing,  by prop-
er diet, any indigestible  food  from  getting  into
them, whilst the  excretions which empty into this
great sewer  are not allowed to  remain and disturb
the system,  will be at all times judicious  practice.
Diaphoretics  and diuretics are the  milder anti- 
184      INTERNAL TREATMENT OF AVOUNDS.

phlogistic  and  derivative  remedies, Avhich  may
frequently be called upon  to  quiet the pulse and
equalize the circulation.
  The  ordinary  febrile  reaction  Avhich so fre-
quently  follows  the  receipt  of  severe injury,
should  give  the  surgeon  no  annoyance per se.
It is only a symptom, an indication of the extent
of sympathy between the  local irritation and the
system  at  large.   When, by judicious local treat-
ment, the nervous  excitement  near the wound
subsides, the  pulse will, pari passu, lose  its fre-
quency  and irritability.  It is not a disease Avithin
itself, requiring to be especially attacked.   In the
general treatment of wounds, diet and rest are the
two  great  remedies, Avhich in by far the majority
of wounds, even the most serious, are all that is
required for  successful treatment.   Should  there
be  an  excess  of  general  excitement, Avhich   a
purge with a diaphoretic or diuretic is not able to
quiet, we would administer to  such, some one  of
that class of medicines which are  known to  con-
trol  the excitement of  the circulation, quiet the
brain, and act as sedatives upon the nervous sys-
tem  generally,  as opium,  hyoscyamus, conium,
belladonna, digitalis, veratrum viride, etc.
  AVhen  local reaction  is  excessive, with  great
swelling and  heat,  there is a class  of medicines 
         INTERNAL TREATMENT OF AVOUNDS.      185

Avhich might be  giv^en with advantage.   They
act by  increasing the tone  of  blood-vessels, and
thereby  cause a  contraction in  their walls and
diminution of their calibre.   Upon such remedies
much reliance might be placed.   Among these are
found the mur. tinct. of iron, tinct. of belladonna,
wine of ergot and others, which play a conspicuous
part.   It is by  contracting  the blood-vessels  to
such an extent  that  a sufficient  supply of blood
cannot  be transmitted  for  the  nourishment  of
distant  tissues, that mortification follows the  too
liberal and long-continued use of ergot.  By this
property of producing contraction  in blood-ves-
sels, uterine  hemorrhages  are  checked,  or  the
action  of the grand  womb,  with its immensely
developed bloodwessels,  excited.  The entire pro-
fession  have  adopted  the  mur.  tinct.  of iron  as
nearly a specific, against the  fearful inflammatory
reaction  of erysipelas; for stronger reasons, it is
equally   efficacious in  simple  inflammatory  en-
gorgements.   Belladonna shows its general action
by dilating the pupil—an effect explained  by the
change  in the circulation of the  blood-vessels  of
the iris.   Its  advantages in relieving injection  of
the blood-vessels of the eye  are  Avell known  and
largely  used.  It is spoken  of as the remedy  for
the rapid relief of congestion of the  spinal cord.
      16 
186      INTERNAL TREATMENT OF WOUNDS.

Although these are the individual effects of such
remedies, they are not the specific action of these
medicines.  Their influence belongs to the econ-
omy,  and in  affecting  all the  tissues,  those  feel
their  influence most which are  offending, as there
Avould be the Avidest field for the remedy to show
its common effects.
  Inflammation  is a  perverted  condition of the
blood and blood-vessels of a part, which means a
modified  state of nutrition. ' There are two  dia-
metrically opposed means of correcting this con-
dition and restoring health.   One is, by reducing
the amount of  blood carried  to  the  part which
threatens to overAvhelm the vital functions of such
an inflamed portion of the body.  This is effected
by bloodletting,  vomiting, purgation,  abstemious
diet, and the entire list of depletory or spoliative
remedies, which weaken the  enemy  to  such an
extent as to alloAv of the part attacked success-
fully  coping  with the disease.   But  Avhen the
disease is  conquered, the victory is as disastrous
as a defeat, a long convalescence being required
to restore the  patient to his former state of health.
The other method is, by increasing the tone, both
of part and  system, by supporting agents Avhich
strengthen the garrison, increase the vital powers
residing  Avithin  the tissues for resisting the en- 
         INTERNAL TREATMENT OF WOUNDS.      187

 croachments of disease, and  thus are enabled to
 drive out the enemy, hoAvever violently the attack
 may be made.   These successes are attained  Avith
 but  little loss  on the  part of  the system Avhich
 comes out  of  the  fire unscathed.   Our object,
 then, should ahvays be to  cure disease by  using
 such remedies as Avill cause the least possible loss
 to the economy.
   In all  injuries, were it  not  for an  exquisitely
 sensitive nervous system, we Avould have but little
 systemic sympathy, and, therefore, but little per-
 sonal annoyance.  In the inferior  animals, Avhose
 sensibilities are of a Ioav description, limbs can be
 torn off wuthout deleterious  effect, and  Avithout
 producing   inflammation.   These  inflammatory
 tendencies are  only observed  as  Ave  advance in
 the scale  of animal  life, until  Ave  find in man a
 perfection  of a neiwous system,  Avith its corres-
 ponding  susceptibilities to  physiological  as  wTell
 as pathological   impressions.    If  Ave  could, by
 some  metamorphosis in man, temporarily revert
 to the  more primitive developments,  Ave wTould
 diminish the dangers  of local  trouble ; or if we
 could take possession, as it were, of the  nervous
 functions  and reduce them to their loAvest stage
for extending sympathies, Ave could equally keep
down  irritation,  and  to a  great  extent jugulate 
188
MORPHINE ENDERMICALLY.
the tendency to establish congestion and, subse-
quently,  inflammations.
  Opium, by which we can  effect  this subjection,
will ever be the greatest boon to the military sur-
geon j—it is  a remedy  which  should never  be
absent from  his  reach.   Going on the field, he
should have  his  pockets Avell stored with it for
immediate use; and in the entire treatment of the
Avounded it  wull  ever hold a conspicuous place.
Morphine is, perhaps, the best article for  wound-
ed men, as it has lost in preparation some of its
astringent properties, which, as opium or lauda-
num, would  produce too great a tendency to con-
stipation.
   The  endermic  method  of using  this  remedy
would prevent endless suffering on  the battle
field, or  in hospital practice.  When morphine is
taken into the  stomach,  it  is  dissolved in  the
fluids there  found, and then undergoes  absorp-
tion.  This takes place with  greater or less rapid-
 ity, according to  the nervous  excitement under
 Avhich the system is laboring.   At times, its ab-
 sorption is very  slow, and its  effects  upon  the
 system,  from the small  quantity found in the cir-
 culation, very indifferent.   Under other circum-
 stances, very large doses are administered in  vain,
 to produce  the  soothing  effects of  the drug.  It 
            MORPHINE ENDERMICALLY.          189

remains,  perhaps,  unchanged in  the  stomach;
whilst  under  the  same  condition,  if  a much
smaller dose,  in  solution, be injected under  the
skin of any portion  of the body, its full effects
are obtained in a fewT  minutes.   The  following
cases will  show the marked efficacy of the remedy
when used hypodermically:
  Mrs. C. had been operated- upon for cataract by
division of the lens.  A'iolent inflammation ensued,
ending  in the destruction  of the  eye,  and  for
three days she suffered agony; day and night  she
was  rolling about the bed  in spite  of  repeated
doses of morphine.   Finding that one-half grain
every two or three hours produced  no alleviation
other suffering, I tried the experiment of injecting
one-third  of a grain  under the skin covering  ihe
sternum.  A AVood's endermic syringe was used;
absorption Avas immediate;  in two minutes  she
was  relieved;  in five,  all pain had disappeared,
and  in  ten minutes  from the injection,  she  Avas
sleeping soundly  for the first time  in  seventy
hours.
  Mr. M.  Avas  accidentally shot in the neck Avith
a Colt's pocket revolver.   His head  being turned,
the ball entered the skin over the larynx, coursed
downward and backward through  the  posterior
triangle of the neck, and Avas found under the 
190
MORPHINE  ENDERMICALLY.
skin  of  the  shoulder  over  the spine  of  the
scapula,-  and  removed.    Considerable  sAvelling
and extravasation followed, which,  diffusing it-
self, discolored that side of the neck.   Some of
the  brachial plexus  of nerves  must  have been
injured,  as the  patient  Avas  soon  seized Avith
violent pains, shooting down toward the fingers,
Avhich,  although never  altogether absent, would
increase to torture as eA^ening advanced.  ToAvard
morning they  would remit and alloAV of sleep,
after a restless  and  painful night.   Gum  opium
and morphine in large doses gave him no relief.
The  arm  wras  so  sensitive that he  Avould  not
permit its  being handled.   One-fourth of a grain
of morphine iu  three or four drops of Avater was
injected  under the skin of the  shoulder; in five
minutes  all pain had left him,  and his arm could
be  examined rudely  Avithout the slightest suffer-
ing.
  By the  use  of this  little  instrument, a  new
and extensive field for doing good is open  to  the
humane military surgeon, and he Avho is the fortu-
nate possessor of this talisman, will receive daily
the thanks and  blessings of his suffering patients.
When chloroform  cannot be  obtained, I would
suggest this mode of blunting sensibility, imme-
diately before operations are performed  or pain- 
MORPHINE ENDERMICALLY.
191
ful  and tedious dressings are made.  It will  be
found a good substitute, and one  which will yield
its  full effects  without  delay  or  trouble.  There
are  very few injuries requiring operation which  do
not demand the free use  of opium.  Narcotising
the  patient immediately before the  operation, and
keeping him under its influence for some hours, is
among  the best means of preventing an excess
of reaction.  The  rapidity of action when mor-
phine is used endermically is a very great advan-
tage on the  field,  where every moment is  of
value.   For complete  narcotism, Avhere  a suffi-
cient quantity of morphine  is used, five  minutes
are  all  that is  required;  wdiilst  with chloroform
we  all  know  that,  when under  excitement,  its
inhalation is often extended from thirty  to sixty
minutes, and even longer—time  wThich  the field
surgeon can ill spare. 
CHAPTER   VI.
Complications which arise during the treatment of gun-
  shot wounds—Erysipelas, contagious and infectious
  character—Constant  tendency  to  debility—Treat-
  ment, general and local—Pyemia, a  rare disease in
  our country; symptoms—Theory of multipled ab-
  scesses—Great  remedy; Prevention  by rigid observ-
  ance of hygienic  regulations—Loccd and  (general
  treatment—Hospital  Gangrene,  its  appearances,
  how recognized; causes giving  rise to it—Thorough
  ventilation necessary to successful treatment — Local
  applications, actual cautery, etc.—Tetanus  charac-
  ters;  march—Rarity  of cure in military surgery—
  Local and general treat me id upon which  most  reli-
  ance can be placed— Woorara in  Tetanus—Hectic,
  from loneg-contiuned suppuration—Permanent  and
  Periodic Pains.

  Erysipelas.—We have  already  entered, in de-
tail, into the  causes  of  secondary  hemorrhage,
which is  one of the most  alarming  complications
that can  befal the Avound.   A second, that  is 
ERYSIPELAS.                193
  to both  surgeon and patient,  is erysipelas.  This
  disease appears to revel in  the depressing  influ-
  ences Avhich follows armies, and  sometimes,  as an
  epidemic, attacks all  AATounds, ravages limbs, and
  makes its heaps of victims.   For  several years,
  particularly  during the winter months, erysipelas
  has appeared, at times, even as an epidemic in the
  States, especially in the middle region of country.
  Our  troops can, therefore, hardly be expected to
  escape its ravages.   Although it frequently occurs
 as an idiopathic disease, its  most frequent excit-
 ing cause is a wound.
   Gunshot Avounds  in patients debilitated by the
 many depressing influences of camp life, are pecu-
 liarly prone to attacks of erysipelas.   The variety
 more  frequently met  with among  troops is the
 phlegmonous, or as it is now called, the  cellulo-
 cutaneous  variety.   It makes its appearance  with
 violent inflammatory symptoms, intense swelling,
 tension,  redness, pain,  heat, and  effusion.    It
 extends rapidly  from  the wound as a centre,  and
 soon  covers a large area, accompanied by symp-
 toms  of  inflammatory  fever,  with  dirty,  foul
 tongue, and deranged  gastrio-intestinal secretion.
 It will be remarked that the  pulse,  although fre-
 quent and full, has no strength, and  general pros-
tration ensues at a very early  day.   Often  by the
       17 
194
ERYSIPELAS.
fourth day the hardened cedematous tissue already
feels boggy, indicating the extensive formation of
pus  and  sloughs under the skin.  The Avound
usually gives  outlet to these at an early day.  But
as the disposition of the disease is not  to  localize
itself, the active effusion thrown out in the extent
of tissues undergoes  a pusy  conversion, Avhich
leaves this matter disseminated in all  the tissues
Avhere the effusion had been  poured out.   It is in
this manner that the extensive  purulent dissection
of limbs takes place; AAdien the  muscles are  isola-
ted, blood-vessels separated from the surrounding
connections, bones exposed from their periostium,
and joints opened, a general destruction of  cellu-
lar tissue ensues.   Shreds, or  layers resembling
strips  of wret chamois  leather may  be  pulled
away.   The  extensive  loss  of support  to  the
skin causes it to break down  in sloughs, which
makes a  vent for the escape  of  this  accumulat-
ing fluid.   Nature,  in  its weakened  condition,
cannot stand this drain of  its best  nutrient  mate-
rial; and prostration,  feeble, irregular pulse,  dry
tongue, diarrhoea, delirium, and finally coma, ends
the scene.  Or, should judicious treatment check
its inroads, a tedious convalescence and  a shat-
tered constitution remains  to the patient.
  Erysipelas can ahvays be recognized by its  dis- 
ERYSIPELAS
in;)
tinctive characters of Avidely extended  local in-
tlanimation, Avith  tendency to rapid suppuration
and sloughing of the Avound.
  The prognosis  of this  complication  is ahvays
serious, when it  occurs after gunshot wrounds,  in
military   surgery,  because  the  constitutions  of
the patients have been undermined, to  a certain
degree, by the hardships aud  irregularities which
all soldiers in time of Avar must submit to.
  In the treatment of gunshot wounds it must be
remembered, that erysipelas, which is a very fatal
complication, is often produced by a careless dis-
regard of  those hygienic regulations  Avhich are so
essential in the proper organization of a hospital.
Over-crowding, bad ventilation,  want  of cleanli-
ness,  are  constant causes for its production  and
propagation.   As the disease is clearly contagious
as well as  infectious, the  directors of  military
hospitals must be very careful hoAv they permit a
case  of erysipelas to be introduced  into  a  ward
with  wounded men; for inoculation will at once
ensue, and when  erysipelas has taken  possession
of a  ward, it is  with great difficulty eradicated.
Its effects can  be  traced  first  upon contiguous
patients, whose wounds, healing  kindly prior to
the introduction  of this focus of contamination,
now  take on erysipelas.   The system soon shoAvs 
196
ERYSIPELAS.
the depression  under Avhich the patient is labor-
ing.  Some further complication, with Ioav visce-
ral inflammation of either the membranes of the
brain or  lungs or  intestinal  surface ensues,  and
life is overAvhelmed by this  combination.
   Erichsen, in  his Science  and Art of Surgery,
mentions  the following case in proof of the  con-
tagion of erysipelas, as having occurred in one of
his Avards at University  College  Hospital.  "The
hospital  had  been free  from any cases  of this
kind for a considerable time, when,  on the  15th
January, 1851, at about noon, a man Avas admitted
under my care, with gangrenous  erysipelas of the
legs, and placed in the Avard.   On my visit two
hours after his  admission, I  ordered him removed
to a separate room, and  directed the chlorides to
be  freely  used in the Avard from  Avhich  he had
been taken.  Notwithstanding these precautions,
hoAArever,  two  days after  this,  a patient,  from
Avhom  a  portion  of necrosed  ilium  had  been
remoAred  a fewr Aveeks  previously, and who Avas
lying in the adjoining  bed to that in  which the
patient with the erysipelas  had been temporarily
placed,  was seized Avith erysipelas, of which he
speedily died.   The disease  then spread to almost
every case in  the ward, and proved  fatal to sev-
eral patients who  had  been recently operated 
            TREATMENT OF ERYSIPELAS.         197

upon."   If such be its tendency in civil hospitals,
hoAv frightful will its march be among the Avound-
ed  in military hospitals.  Such  cases  should be
kept  exclusively  to themselves,  or they entail
incalculable loss upon the Avounded.
  The antiphlogistic treatment of erysipelas, espe-
cially the phlegmonous variety which we are iioav
considering, has for man}' years been abandoned;
and he who attempts to cure erysipelas in military
surgery by depressing agents, will pay heavily for
his  rashness.   However violent its  symptoms are,
the surgeon must not be  deceived.  It is a disease
of murke<l debility: its  violent attack  is  only a
mask to be thrown oft' in  a few days, and often in
a few hours.  AVhen the plan of attack is so well
known,  as it is in erysipelas, where  a study of the
natural  history  of  the  disease  has  invariably
sIioavii, in its march, certain and speedy prostra-
tion, the surgeon is highly culpable who does not
commence Avith the earliest treatment to build up
and support  the  system,  and thus  prepare  it to
Avithstand the  depression which  is so  sure  to
ensue, and which, if overlooked, will be so  fatal.
  Prevention is always more judicious than  cure,
and, therefore,  our first care should be—by the
strict  observance  of those hygienic  regulations
for  ventilation and cleanliness, and against over- 
198         TREATMENT OF ERYSIPELAS.

crowding—to keep the wards o\' an hospital with
so pure  an atmosphere as to give no encourage-
ment for  this low  class of  diseases to  intrude
themselves.   When a  case  appears, isolate it at
once, and use every precaution against contagion.
The sponges, bandages, etc., used by this patient,
should be  confined  exclusively to himself; for if
the same sponge be used for a dozen, they would
all  be as surely  inoculated.   Fresh air  is indis-
pensable in  the  successful  treatment of this dis-
ease.   Leave  all  the windoAvs open for thorough
ventilation, running the  risk of catarrhal affec-
tions, Avhich  are  trivial Avhen  compared to  the
serious character of the disease under discussion.
  The treatment, ever  having in vieAV the steady,
onward  march  of the  disease   to  suppuration.
sloughing,  and  prostration,  unless  a barrier is
thrown across its path, should be from the com-
mencement  stimulating  and  supporting.  This
tonic course  is  prefaced  by some mild  cathartic
to cleanse  the bowels  of impurities Avhich rapidly
accumulate in them, and  excite healthy secretions
from the digestive organs.  For  this purpose, the
comp. coloeynth pill  Avould be  a good  prescrip-
tion,  although  a  dose  of  castor  oil  or sulph.
magnesia,  would,  in  the  majority of  cases, fill
every indication.   Without waiting the action of 
TREATMENT OF ERYSIPELAS.         199
this cathartic,  which is expected to have only a
moderate effect, we at once prescribe what is now
called  the specific by  many, and  recognized as
useful  by  all,  the tincture  of the  muriate  of
iron,  thirty  minims,  in  a  Avineglass  of water,
every three hours.  Besides  acting as  a general
tonic,  and also  through  its mineral  acid upon
the liver, promoting biliary secretion, it affects
directly  the  blood-vessels,  producing contraction
in their  Avails,  and a diminution of their calibre,
relieving congestion, and  preA^euting,  to a great
extent,  effusions.  I have  seen  it  cut  short  a
traumatic erysipelas of the face after  an exten-
sive operation for cheiloplasty, in thirty-six hours
from its  appearance.
  In connection  with the  mur. tine, of iron, and
of equal  importance with it, is brandy and nour-
ishment.    Erichsen says:  "I have  seen the best
possible  results follow  the  free administration  of
the brandy and  egg mixture, to which I am  in
the habit of trusting  in  the majority  of these
cases."   Its liberal use  will restore strength, soft-
en the  tongue,  and remove delirium.   AVhen the
skin is dry and harsh, mild diaphoretics  should be
used, and as anodynes are always required in the
treatment to allay pain  and to give sleep, Hovers'
powders  would be a valuable agent.   By adopting 
 200         TREATMENT OF ERYSIPELAS.

 this course of attending to the secretions, keeping
 the bowels  soluble,  and  supporting  the system,
 even from the  very  commencement  against  that
 prostration  Avhich is certain, sooner or  later, to
 sIioav  itself, this  scourge  in  military  hospitals
 will be most successfully controlled.
   Considering the disease as one  of marked de-
 bility, most reliance should be placed upon the
 general treatment.   All  local applications should
 tend to relieve engorgement.  In the early inflam-
 matory stage,  before suppuration  is established,
 painting the limb with the per chloride of iron,
 or a dilute tincture of iodine, or using compresses
 soaked with tincture of  arnica, etc., would tend
 to promote healthy action.   Cold water, by irriga-
 tion, or iced applications, would be as useful here
 as  in  any  other engorgements.   All  of  these
 applications  may be  accompanied with  the  me-
 thodically  applied roller,  Avhich  will  compress
 the limb,  and by its mechanical support prevent
 infiltration  and  congestion,  and  relieve tension
and swelling.   Sugar of  lead  lotions are highly
lauded.   Free  incisions  are - recommended by
many  surgeons to relieve the  engorged  vessels.
They give great relief to the patient, but it is  a
question Avhether they do not increase the irrita-
tion and hasten  the  suppurative stage,  an  effect 
PY.EAIIA.
201
 not to be desired, as the entire armamentarium of
 the surgeon  is directed against the formation  of
 pus.
   When pus  has formed, Avhich will be recognized
 by the  doughy sensation of the parts into Avhich
 the fingers sink Avhen pressure is made, and a
 little  later by  fluctuation,  incisions,  sufficiently
 free  to admit of the ready escape of pus, should
 be made, and  stimulating water  dressings con-
 tinued to hasten  the elimination  of the  sloughs,
 and  diminish  the  amount   of  secretion.  The
 tincture  of arnica,  or spirits  of camphor, or La-
 bariaque's  chloride of soda,  diluted  with  from
 six to ten  parts of Avater, or diluted tincture  of
 iodine, make  an excellent stimulating application.
 Wherever  pus shows  a  disposition to   bag,  it
 should  be  let  out by incisions.   As  the  skin,
 largely  undermined,  is  disposed  to slough ex-
 tensively, it  should  be supported  by  properly
 applied bandages, which, by diminishing the cav-
 ity within, will prevent  burroAving of pus, and
 cause the skin  to  adhere to the  deeper parts as
 soon as adhesive action can be excited.

   Pycemia, a disease very common in Europe, and
a scourge of  their  military hospitals, is a  disease
but little known  among us,  and therefore  not 
202
PYA2MIA.
likely to attack our Avounded, unless we  neglect
necessary hygienic precautions.   AVhen it shows
itself in a hospital like its kindred disease erysip-
elas, it  is not satisfied until it has sAvept off its
hundreds, and is  a  pest hard to be  got  rid of.
The great  similarity in causes, symptoms and
effects,  are sufficient grounds for associating this
with the  large  class of asthenic diseases, among
Avhich erysipelas and hospital gangrene are promi-
nent.   It is  impossible to  control  the symp-
toms and prevent a fatal issue, Avhen, as  acute
pyaemia, it seizes upon  the  Avounded-in military
hospitals; it is therefore much more to be feared
than  its  kindred disease just  mentioned.    Aj-
though  this  disease  is  ahvays  associated  with
Avounds, no wound,  however  trivial, or hoAvever
Avell advanced  toAvard cicatrization,  is safe  from
its  attack  until completely  healed.  The  dis-
ease is supposed  to be  caused by the absorption
of the ichorous fluids decomposing in the wound,
Avhich produces a general poisoning of the blood,
rendering it unfit for sustaining  the  economy.   It
has been called an  acute decomposition of the
blood.
   The  phenomena  Avhich  accompany  this  af-
fection are,  great depression  of the  poAvers  of
the system,  and the  formation of  abscesses  in 
                     PYAEMIA.                 203

 various  parts  of the  body.  In  the prodrome,
 which may precede  the  explosion  of the  disease
 by tAventy-four or thirty-six hours, the  patient  is
 restless,  anxious,  ill  at ease, with forebodings of
 impending trouble.  He looks pale and sallow, has
 loss of  appetite,  and  generally deranged  secre-
 tions.  The  disease  commences by  severe  chills,
 Avhich, in the acute cases, are repeated Avith much
 irregularity.   In the subacute variety, these chills
 appear  at such  regular intervals,  folloAved by
 high fever and terminating in profuse sweats, as
 to induce the  belief  of malarial fever.   In many
 cases the skin is hot,  with a pungent  feel, irre-
 spective  of the chills;  in others,  the chilly and
 feverish  sensations alternate.  The pulse is feeble;
 face pale, Avith anxiety of  countenance  and ten-
 dency to delirium ; tongue  foul, a  tendency for
 sordes to collect on the teeth, and the tongue to
 become dry;  stomach uneasy, with  bilious  vomit-
 ing, and  thirst constant.  The suspension of secre-
 tions gives a dull yellowish icteric tint to the skin.
 As the pulse  becomes more and more enfeebled,
 the patient may complain of pains  in his joints,
 simulating rheumatism,  and  simultaneous with
 these, a reddening of the skin, Avith swelling of the
joints.   Collections of  a  pusy  character will soon
 after be  detected, distending the synovial  sacks. 
204                 PY.EMIA.

Collections   also  occur  in  the  cellular  tissue,
and  even in  the substance  of  organs.   These
form  rapidly  and Avithout much  inconvenience.
Often, the  sAvelling  alone — Avhich has appeared
during the  night, unaccompanied  Avith  pain, red-
ness or heat—indicates that a  large collection of
pus has already taken place.
  AVhilst these symptoms progress,  the Avound
usually becomes  foul  and  sloughy, ceasing  to
secrete  pus.  This is not the invariable rule,  as
surgeons have noticed cases in Avhich  the  appear-
ance  of the  wound  Avas no   indication  of  the
destructive  disease which had laid its relentless
hand  upon  the injured.   The  disease may even
run its fatal course  Avithout material  changes  in
the wound.   Certain injuries are  more likely  to
be followed by pyaemia,  and those of  bone  are
said  to be  peculiarly exposed.   As  in all such
low diseases, typhoid  symptoms ensue at an early
day, and usually carry off the  patient at the end
of the first Aveek.  Often  stupor comes on as early
as the fourth day.  An examination  after death
will  reveal  a  rapidly advancing  decomposition,
with gas in the blood-vessels, and purulent  col-
lections  in  many  organs, as  the lungs, liver,
spleen, kidneys, heart and brain.   Similar  collec-
tions are found in  most  of  the large joints,  be-
side the multiplied abscesses of  the cellular tissue. 
PYAEMIA,
205
   The theory of the metastatic character of the
 abscesses, or the  sudden change of place  of such
 deposits  by  absorption  and  redeposit  has long
 been  abandoned.   Pus,  we noAV  know,  to be a
 modified  nutrient  fluid, wdiich,  from an  impair-
 ment of  its vitalizing  principle,  falls  short of its
 object of repairing  tissues.   This exudation leaves
 the blood-vessels  under ordinary acute inflamma-
 tion,  and  is draAvn out  by  the  excited tissues
 which are   not  able to   consume  the  excess
 Avhich they have  demanded from the  circulation.
 This  fluid, how at  rest Avithout the blood-vessels,
 attempts a formation of  its own, developing cells
 of this plasma, which  simulate closely the A\diite
 cells in the progressive development of the blood,
 and  are  supposed  by some  pathologists to be
 identical with  them.  This is pus.  When   the
 entire circulating fluid has become poisoned, its
 entire plasma or liquor sanguinis is impaired.  It
 is from this plasma  that the blood-cells are to be
 generated.  The usual process of development is
 commenced, Avhite  cells  form  as  colorless blood
 corpuscles, and Avhen the continued de\Telopment
 into  the  red  or perfect  cell is attempted, many-
 failures  occur.  There are,  besides, many which
had exhausted their formative powers in attain-
ing  the  degree  of  development  necessary  to 
206
PYvEAlIA.
perfect the Avhite cell.   These remaining as  such
continue in the circulation.   AVhen the blood of
a  pysemic  patient  is  examined,  a very  large
number of  such colorless cells are found in the
blood, sufficient to  modify its color,  and it  is in
autopsies  that  the  separation of these AA'hite  cells
from the generating fluid  sIioavs  the  deceptive
appearance  of  pus  in the  blood,  or  emboli in
the  large vessels at the heart.
  Blood in  this condition, Avith   an   impaired
liquor  sanguinis,  is  unfit  for  its  duties  as  a
life-supporting  fluid.   The various'  tissues of
the  body,   not receiving the  kind  of  nourish-
ment appropriate for their  healthy function, be-
come irritated.  Nature  tries to  make up the
deficiency in  quality by quantity.   The  irritated
parts are supplied with an excess  of the impaired
nutritive  fluid, which, escaping  from  the  capil-
laries, is received into the loose tissues.  This is
rapidly converted into pus, by the development c*'
Avhite or colorless cells in it, which is the height
of vitality in such an exudate.
  Experience,  Avhich sustains  this vieAV, shows
the disease to be purely a-blood poisoning; a gen-
eral disease with its local manifestations, which
are unimportant.  When the blood has been thus
thoroughly  deteriorated,  no remedy which art 
PYEMIA.                 207
possesses can  restore it to  its  former  healthy
condition, and the patient  dies.
  Our great remedy  lies in  prevention, the hygi-
enic precautions  of  rigid  cleanliness, thorough
ventilation, good food, and proper shelter, wuthout
over-croAvding, will, if property  insisted upon  by
the medical superintendent, go far to keep away
if they do  not altogether prevent the occurrence
of pyaemia.  Too much  attention cannot be paid
to  the detail  of cleanliness in  the  ward.  The
slop buckets,  which  are  such  a  common nui-
sance, should be  examined  with care, frequently
emptied, scoured  daily Avith  lime,  and always
kept covered, that the  emanations arising  from
decomposing urine, which  is  very deleterious in
hospital Avards, cannot escape.   The bed and body
linen  of the patients should  be  daily  changed,
doors and windoAvs must be kept open.  If any
difficulty exists in this  respect, from the inatten-
tion of nurses  or fears of  patients,  it would be
better  to take out the sashes  so as  to ensure
continued  renewal of  the  atmosphere, day  and
night.
   There is  a popular dread of night  air  which
should be  exploded.  The  purest air we have in
cities is the night  air, and  is  the very  article
which is so much needed in hospitals.  If the pa- 
208
P Y.EM I A.
tient  is  properly covered  in  bed,  there is  no
fear of  his  taking  cold, or  contracting  other
injury  from   the  continued  renewal  of  pure
air.  These precautions must not be commenced
when pyaemia  has  already  shown itself, but are
those necessary to fre  taken wherever the serious-
ly wrounded are treated, or some low form of dis-
ease Avill soon break out.  Any one AATho will visit,
during the night, a ward filled with suppurating
wounds,  will perceive the degree of vitiated air,
and see the necessity  for free ventilation.
  It is a bad principle to concentrate the seriously
wounded; always scatter  them over the building,
mixing them  in with inmates from other diseases.
This increases the available space for the seriously
wounded, and  prevents  the  depressing effect  of
the concentrated  emanations  from so many exten-
sively  suppurating  wounds.   It is for a similar
reason that we  have already recommended that
rooms should not be  kept too long in use Avhen
occupied by  the  severely wounded.   As the air
becomes  poisoned,  the  ward  requires to be un-
occupied two weeks  of  every  two months, for
cleansing  and purification.
  When  pyaemia threatens  to become  general
in  a military  hospital,  the  seriously  wounded
should be put, if possible, in  tents, or  be allowed 
PYEMIA.
209
double space in a constantly-ventilated  room, and
an additional quantity of nourishing food should
be given out to the sick.  Feeding  the Avounded
on broths and other  slops,  is paving the  way  to
the debility which is a precursor of pyaemia.  All
small operations should be a\Toided,  and even the
hasty opening of  abscesses guarded against.   The
best  protection  against  this  disease is  a whole
skin.  When the acute form of the  disease shows
itself,  surgery  can  do  but  little  to  assist the
patient.  If it be possible, more benefit  Avill  be
derived from changing the patient  into fresh air
than from any other remedy.   Our entire  reliance
should  be placed  upon the stimulating tonics.
Strong, nutritious, easily digested food,  and opium
to allay pain and restlessness, are  the means  re-
quired.  The tendency to delirium  should not
prevent  the free use  of this  last remedy,  for
although it Avould increase the difficulty  if it  be
given in inflammation of the  brain  or meninges,
it allays pain, removes restlessness, stops mutter-
ing, and induces  quiet sleep, wdien given in cases
of debility accompanied by delirium.  As in ery-
sipelas  the  acid  preparations of iron,  as  a  blood
touic, may be exhibited.
   Although so   little* is to  be  expected in  the
acute  form of blood poisoning,  in  the  subacute
       18 
210
HOSPITAL GANGRENE.
 or  chronic pyaemia, much benefit will be derived
 from  rigidly pursuing  the course of  treatment
 just marked  out.   By  the stimulating  and sup-
 porting  plan, with  change of air, many patients,
 after a long struggle, may be saved.
   The important indication for local treatment in
 pyaemia  is to prevent the accumulation of putres-
 cent fluids in the wound by cleanliness—and  the
 frequent application of chlorinate Avashes, which
 remove  fcetor and stimulate the granulating sur-
 face.   The  abscesses  Avhich  form during  the
 march of the disease, should  not be too hastily
 opened,  as  this  course, pursued with the  many
 collections, Avill  induce  rapid  prostration.

  Still another fatal complication to which gunshot
 wounds  are  liable, is hospital  gangrene, the  name
 being  significant of the cause of this  pest, as it
 is never  seen as  an isolated  disease without  the
 crowded  wards of a hospital.  It is highly prob-
 able that, like the former diseases which Ave have
just considered, it is a blood poisoning, depending
 upon a foul, infected atmosphere, operating upon
 a depraA7ed and enfeebled constitution.  It seldom
 attacks the strong and robust, but most frequently
 those who haAre become debilitated by exposure,
 disease, want of proper food,  intemperance, etc.;
 so  that  in a crowded hospital, when  gangrene 
HOSPITAL GANGRENE.
211
threatens  to  devastate  the wards,  you  might
select,  in  advance,  the  cases  which will  most
probably be first attacked.   Many surgeons con-
sider it a constitutional disease, occurring  from
a strictly local cause, which is  found Avithin the
walls  of the  hospital.   All surgeons recognize
its  contagious  as well  as  infectious  character,
and the facility  of transmitting it by sponges or
dressings used in common in a ward.
  The  facility with  which  the  air of a ward or
even hospital becomes  impregnated Avith  this
poison, wrould  shoAv that animal exhalations,  espe-
cially from  those suffering under  this  disease,
possess  the  poAver  of  diffusing  it.   Burgman
reports, that hospital gangrene prevailed  in one
of the  Ioav Avards at Leyden, Avhilst  the ward or
garret above it Avas free.  The  surgeon  made an
opening in the ceiling between the two, in order
to ventilate  the  loAver or affected Avard,  and in
thirty hours three patients   in  the  upper room,
who lay next  the opening, were attacked  by the
disease, Avhich soon  spread through the A\diole
ward.
  Guthrie, confirms the above by his experience,
which,  he says, left no doubt upon the mind of any
one Avho had frequent opportunities of seeing the
disease, that one case of hospital  gangrene Avas 
212    APPEARANCES OF HOSPITAL OANORENE.

capable of infecting not  only  every ulcer in the
ward but in every Avard near it, and ultimately
throughout  the  hospital, however  extensive  it
may be.
  Both English and French surgeons, in the Cri-
mean war, recognized the  atmosphere as clearly
the vehicle of its  extension, and that its increase
or diminution depended upon the crowded condi-
tion of the  wTards and the degree of ventilation.
They,  also,  observed the certainty with which it
increased Avhen  the  same sponges Avere used for
gangrenous and healthy wounds.  It may be con-
sidered a thoroughly contagious disease.
  Those who observe the  march of the  healing
process of Avounds, within and  Avithout hospitals,
knoAV Iioav easily the one is  cured, and Avith Avhat
difficulty a tedious cure  is obtained in the other.
Where the exhalations  from many  suppurating
wouuds  are concentrated in a ward, the cicatriza-
tion of  all  wounds, even  the most  simple, are
retarded, and contagion of any  kind readily pro-
pagated.
  In military hospitals, hospital gangrene will be recog-
nized bg the following appearances:   Although the
patient may have recently shoAvn feverish  symp-
toms,  with  loss  of appetite,  yellowish  or pale
skin,  dirty  tongue, and deranged  bowels, the 
       APPEARANCES  OF  HOSPITAL GANGRENE.     213

first appearance of the disease is recognized in the
changes which  the  Avound  undergoes,  which  has
led many to believe it  to be, at  first, a local  dis-
ease, in time infecting the system.   The granulat-
ing surface of a healthy sore, about taking on  this
sloughing phagedaena,  becomes dry and painful.
The  florid  hue of the granulations rapidly disap-
pear, and is replaced by a dirty gray or ash-colored
slough, which  fills the wound and  forms a pulta-
ceous and adherent covering to the  granulating
surface.  As this gray slough increases in extent
and depth, the surrounding surface  becomes oedem-
atous, SAvollen  and of a livid red or purplish color.
This engorged  appearance of the contiguous  skin
always precedes the advance of the gray slough.
The  edges of the ulcer are abruptly cut,  under-
mined and  everted, gradually assuming a circular
outline, irrespective of the form of the wound prior
to its  invasion.   The gray, tenacious mass, being
formed of the  mortified  tissue, holds its place
and  cannot be  wiped off, although  it sways to
and  fro when  any attempt  is made to cleanse the
wound.
   The liquefaction  of these mortified tissues soon
commences, and a  dirty, thick, highly offensive,
irritating fluid, produced from the putrefaction of
the slough, escapes from  the wound,  diffusing a 
214    APPEARANCES OF  HOSPITAL  GANGRENE.

peculiar odor which, AA'hen once smelt, Avill ahvays
be  recognized.   This  is the poison  Avhich  pos-
sesses such powers of infection Avhen brought in
contact Avith healthy Avounds.
  Once  the  disease has fairly rooted  itself,  its
raArages are extensive and rapid.   One can nearly
see  the extending line of  slough, and often in
twenty-four  hours  large  portions  of  the  skin,
cellular tissue, and  muscles will have  mortified.
These changes in the wound are accompanied by
a severe burning, stinging,  lancinating  pain.
  Pari passu with this local destruction the system
is gradually or rapidly showing the influence of the
poison.  Although the symptoms may be at first
of an  inflammatory  character, accompanied by a
high  fever,  the  pulse soon loses its strength, the
mind  is  peevish,  fretful  and  desponding,  the
tongue  becomes  dry  and  brown.    The  pain
accompanying these changes is  so severe as  to
depri\Te  the   patient  of sleep.  As  the febrile
accompaniments  of the  disease rapidly assumes a
typhoid  cast, delirium   ensues  and,  Avith a  ten-
dency to coma, becomes a prominent symptom.
  Should the case not terminate before  the elimi-
nation of the sloughs commences, the separation of
these  may  open  large  vessels,  from which  the
hemorrhage will rapidly destroy life.   The  great 
       APPEARANCES OF HOSPITAL GANGRENE.    215

 nen^es and arteries appear to resist the gangrenous
 destruction longer than the muscular or cutaneous
 structures.  These yield in the end, and repeated
 hemorrhages close the scene.
   I Avitnessed an  epidemic  of hospital gangrene,
 in  Milan, during the summer of  1859.  A large
 number  of Austrian  wounded had been  put in
 a barrack prepared  for their reception.   They
 had undergone  many hardships,  retreating daily
 before a  victorious  enemy, and  had,  prior  to
 the  battle  of  Solferino,  tasted   no  food  for
 forty-eight hours.  They had  been  deceived by
 their leaders, who had  taught them  that  certain
 death aAvaited them should they fall into the hands
 of  the  Italians.  With  these  impressions,  the
 wounded hid themselves in the ditches and under-
 brush of the extended  battle field, where many
 perished.  Some Avere not discovered for two or
 three days, when they were sent to the  hospitals.
 The previous  hardships  which the Austrians  had
 undergone, their lymphatic tendencies, their irre-
 gular living, with the moral depression of repeated
 defeat, exposed them  to the  ravages of the lowest
 forms of disease.  Hospital gangrene raged fear-
 fully among them,  destroying numbers.   Many of
their  wouiida were frightful from  the  extended
 sloughing, and their worn frames  and gaunt vis- 
216    APPEARANCKS OF HOSPITAL GANGRENE.

ages indicated a  fearful  combat Avith  disease.   1
Avas particularly struck Avith the mental depression
under  which  many  of  them Avere  suffering—
amounting to despondency.  This Avas further in-
creased by the attendants and  surgeons not speak-
ing the German language, so that neither could
their  Avants be  known  nor  could  sympathy be
extended  to them.   From this combination  of
depressing causes, an epidemic of sloughing pha-
gadcena appeared, which  Avas appalling  even  to
those accustomed to see  disease in its most fearful
form.
   McLeod tells us that,  in the Crimea, during the
heat of the summer  of  1855, not a few  of those
operated  upon were lost by  a gangrene of a most
rapid and fatal form.  All of those attacked  by it
were  carried off.  In  the case of a few, who lived
long  enough for the full development \)f the dis-
ease, gangrene in its most marked features became
established; but most of  them  expired  previous
to any sphacelus of the part, ovenvhelmed by the
violent poison  Avhich  seemed  to  pervade  and
destroy the whole  economy.   ''The cases of all
those who died  in my Avards  seemed  to be doing
perfectly Avell up to sixteen hours, at the furthest,
before death.  During the night previous  to death,
the patient Avas restless, but  did not  complain of 
LOCAL TREATMENT.
217
any particular uneasiness.  At the morning' visit,
the expression seemed unaccountably anxious, and
the pulse very slightly  raised,  the skin moist, and
the tongue clean.  By this time the stump felt, as
the patient expressed it,  heavy, like lead,  and a
burning, stinging pain had begun to shoot through
It.  On  removing the  dressing,  the  stump  Avas
found slightly swollen and hard, and the discharges
thin  and gleety, colored Avith blood, and having
masses of matter, like gruel,  occasionally  mixed
with it.  A few7 hours  afterward, the  limb  would
be greatly SA\rollen, the skin tense and Avhite, and
marked along its surface  b}r prominent blue veins.
The  cut  edges  of the stump  looked like  pork.
Acute pain was felt.  The constitution by this time
had begun to sympathize.  A cold  sweat covered
the body, the stomach was irritable and the pulse
weak and frequent.   The respiration became short
and hurried, giving evidence of the great oppres-
sion  of which the patient so  much  complained.
The heart's action graduallv and surelv got weaker
till, from fourteen to sixteen hours from the  first
bad symptom, death relieved his sufferings."
  In  the treatment of hospital gangrene, avc must con-
sider  it frequently  a  local  disease,  with  rapid
tendency to constitutional poisoning.   One  of our
early duties would be to  destroy the accumulating
      19 
218
LOCAL TREATMENT.
 poisonous ichor  in  the wound to prevent further
 infection, Avhilst,  at the same time, avc correct those
 depressing causes Avhich predisposed to the disease.
 Guthrie says,  that  constitutional treatment, and
 every kind of simple, mild, detergent applications,
 always   failed  unless accompanied  by  absolute
 separation, the utmost possible extent of ventila-
 tion and the greatest possible attention to clean-
 liness;  and not even  then without great loss  of
 parts in many instances.
   The local remedies act as caustics, and compose
 the  most energetic of the  pharmacopoeia.   The
 French and German military surgeons prefer the
 actual cautery to all other applications to check
 the encroachments  of the  disease,  although Ar-
 niand even speaks  of this remedy, upon  which
 much reliance  was placed, as exceptionally check-
 ing  the  progress  of mortification.   " After  a
 thorough cauterization, the  eschar  separates rap-
 idly, and often exposes a  second infected surface
 of  greater extent."   His  individual  experience
 gives the  preference to  tincture  of iodine  as
 a  local  application.   The  best  results  were
 obtained wrhen a compress saturated with it was
 applied   to  the  wound.   Guthrie recommends
 the liberal use of the concentrated mineral acids,
especially the fuming nitric acid.  McLeod refers
to the nitric acid as the most efficacious means  of 
                LOCAL TREATMENT.             219

stopping  the  sloughing process.    Laborraque's
chloride of soda, pyroligneous  acid, creasote, per
chloride of iron, lemon  juice, etc.,  are frequently
used with benefit; but general experience in mili-
tary surgery gives the preference  to the  mineral
acid preparations.   These are  to  be  followed by
irrigation,  which Avashes away  the ichorous dis-
charges  as rapidly  as they form,  and  prevents
further infection.   Powdered  charcoal,  camphor
and bark poultices  are  useful  applications.
  The local treatment alone, Avithout the constitu-
tional, would be followed by no good results.  The
most important  of all  the constitutional remedies is
change of air.  If the patient  could be removed from
the atmospheric influences of the infected  Avard,
his chances  for recovery  would be greatly  in-
creased.  Baudens states that Avithout isolation all
treatment will show itself poAverless.   Carrying the
patient from the ward to a tent-would be followed
by  immediate  amelioration—fresh  air being  the
great rerruedy.  Keeping the intestinal action free
by a little blue  mass, or compound  extract of colo-
cynth,  and the  liberal  use of tonics and stimulat-
ing diet, Avith wine or brandy and opium, will com-
plete the treatment.   Opium is required in every
stage of the disease, and is administered in large
and repeated doses to allay the pain, irritability and 
220        SIMILARITY  OF  LOW DISEASES.

sleeplessness, Avhich so generally attend the severe
cases of gangrene.  The diet throughout should
be highly nutritious and  should be  liberally  pre-
scribed.  McLeod, in his experience in the English
service,  states "that  nitric acid, applied locally,
and  the  exhibition of  the tincture of the muriate
of iron internally in half drachm doses, three times
a day, proved to be the most efficacious  means of
stopping it, as it  appeared in  our hospitals."
  It is thus seen that the  three most fatal compli-
cations to gunshot Avounds are the  three kindred
diseases, erysipelas, pyaemia,  and  hospital  gan-
grene, all   recognizing  a  common  origin — viz.,
imperfect ventilation  and  Avant  of proper  atten-
tion  to  cleanliness, Avith  the  absence  of  those
hygienic regulations  necessary  for the  health of
an army.
   With  proper care from the medical corps, these
diseases, which  are  the  chief  scourges to  the
wounded, and the causes  of nearly all the deaths,
can  be in a measure, if not altogether, prevented.
Once they  have made their appearance  in a  hos-
pital, they  Avill never leaATe until the building is
closed,  and the  proper measures for purification
resorted to.   PrcATention, in this  instance as in all
others, will be found better than attempts at cure,
as many of these diseases, once they appear, are 
                    TETANUS.                 221

quite unmanageable, and tend naturally to a fatal
issue.  All of these diseases are benefited* by the
isolation of  the  patient in  a pure  atmosphere,
when the  infectious character  of the disease  is
counteracted, and the patient is in the best condi-
tion for successful treatment.   In all of them the
antiphlogistic treatment cannot  be  too  severely
condemned.  However  useful such a course may
be in  a  civil  hospital, or in private practice, Avith
patients unexposed to hardships,  who  are robust
and have  not  been  influenced  by  depressing
agents,  in  a  military hospital Avith  the  material
which  compose  the inmates,  an antiphlogistic
course should not be thought of.   The  supporting
plan, Avith stimulating tonics, is the.only rational
course that promises success, and should be used
throughout the treatment.  Attending to the  se-
cretions Avith mild remedies, allaying pain,  and
inducing  refreshing  sleep  by means  of opium,
good diet, and due regard to hygienic regulations,
will be the course of practice to be pursued.

  Tetanus. — Another  fatal   complication   of
wounds, depending, however, upon very different
circumstances from  those  recently considered,  is
tetanus or lockjaAv: a disease fearfully malignant
under  any circumstances,  and  with  scarcely  an 
'>•>•;
TETANUS.
exception in military  surgery.  Fortunately, this
is  never an  epidemic,  nor can it infect  a hos-
pital,  although  pathologists  have  recently  at-
tempted to prove its origin traceable to an animal
poison.   This disease is much more frequent with
us than it is in  Europe, Avhere  it is  rarely  met
with.    In  the  Crimean service,  McLeod  men-
tions but thirteen eases as occurring in camp and
in the hospitals.
  This  disease, Avhich does not  depend upon the
size of the wound  from which the patient is suf-
fering, appears to be caused frequently by sudden
atmospheric  changes connected  Avith  dampness.
Larrey,  in  his  experience  both  in Germany and
Egypt,  found it in those wounded,  who,  after
sustaining great exertions during the fight on a
\rery hot day,  were exposed to the  cold, damp
night air on the field, Avithout shelter.  After the
battle of Bautzen, where the wounded were left
on the field during the night, exposed to severe
cold, Larrey found on the following morning that
more than one hundred were  affected  by  tetanus.
In very hot climates it requires but little excite-
ment to produce it—a trifling puncture or scratch
is  at times  sufficient to cause  an attack,  and it
has been noticed by  military surgeons that the
scraping of the skin by a ball, wuth bruising of the 
SYMPTOMS OF TETANUS.          223
nerves,  is more liable to this complication than
the more severe wounds.
  The proximate  cause appears to be  some  in-
jury to the nerves of the body,  not  necessarily
connected  Avith an  open wound, as it  has been
knoAvu to follow the blow of a  Avhip or a sprain.
AVounds,  in  certain  situations are thought to
favor its  appearance,  viz.,  injury  to  the hands,
feet, joints, etc.  It may occur very speedily—a
fcAv  hours  after the injury has been received, or
it may not occur for days.   Barely does it attack
chronic wounds  after the  twentieth  day.   Its
common period for appearing is between  the fifth
and  fifteenth  day,  when,  perhaps, the simple
wound  has completely cicatrized.   The  premo-
nition  of  uneasiness on  the part of the patient,
with vague fears  of impending  trouble,  disturbed
digestion,  etc., are not often obserAred.
  The first symptom AAdiich we  usually recognize
is a complaint of soreness of the throat, which,
in ordinary cases precedes, by  some hours, the
contraction of the muscles of the jaAV and  pinch-
ing of the features.   The spasm, instead of com-
mencing in the injured part, alwrays shows itself
first in those muscles supplied by the fifth pair of
nerves, and although in sudden and violent cases
the  spasmodic contraction of  the  muscles gen- 
221          TREATMENT OF TETANUS.
 erally may rapidly folloAv the locking of the jaAvs,
 or  appear to be even simultaneous  Avith it, they
 are  never found  to  precede it.  The locking of
 the  jaAvs; the contraction  of the  muscles of the
 neck, especially the sterno-cleido-mastoid, which,
 by bounding under the skin, accurately defines the
 triangles  of the neck; the  hardened condition of
 the  abdominal .muscles, the knots  formed  over
 the  region of the recti  muscles during the par-
 oxysm; the stiffening of the muscles of the  legs,
 Avhilst those  of the  arms  remain free; the sar-
 donic  expression  of  the face; clear  brain;  sleep-
 lessness;  profuse  sweating;  incessant  desire  to
 drink, and difficulty  in accomplishing  it;  with
 the  occurrence of paroxysms of violent muscular
 contraction  every few   minutes,  Avith  loss  of
 strength in the  pulse, and  rapid prostration, de-
 fine the disease so accurately that it  becomes one
 of those most easily recognized.
  Any one Avho has ever felt a cramp  of the calf
 muscles,  may have  a faint  appreciation  of the
 intense  pain Avhich  a  permanent  and violent
 cramp of all  the  muscles must produce—a pain
 sufficient  to  destroy  life promptly, through ner-
vous exhaustion.
  The prognosis of this  disease is so serious, and
the  treatment, hoAvever  conducted, so unsatisfac- 
TREATMENT  OF TETANUS.
225
 tory, that many surgeons of large experience have
 mner cured  a case  of traumatic tetanus.   That
 fruitful source of information, pathology, gives us
 no instruction  in this  disease'.   An  autopsy re-
 veals nothing  commensurate  Avith the intensity of
 symptoms.   A slight  congestion of the  spinal
 cord  and medulla  oblongata, is  all  that can be
 discerned.  From the symptoms, we judge  of the
 disease as one  of intense nervous irritation.   Rec-
 ognizing the exhaustion Avhich  so  soon  shoAvs
 itself,  the  treatment as laid  doAvn  by  the most
 recent authors, and the  one now generally  adopt-
 ed, is one of  support  to  both  the nervous  and
 muscular systems.
   Larrey has cut short the disease in its incipient
 stage  by  amputating  the  limb,  or  dhuding the
 nerve  Avhich   is supposed  to  be  at fault.   Other
 surgeons, by isolating the irritation,  have  been
 equally successful.   Such results are,  hoAvever,
 rarities in  practice, the operation often failing
 Avhen  performed at the very commencement of
 the  symptoms, and always  Avhen   the disease
 shows  confirmed general  spasms.    At  times,
 patients  suffering from  tetanus  get  Avell  under
 the most varied treatment. Xearly every power-
ful remedy in  the  pharmacopicea has been  rec-
 ommended as a sovereign cure  by  those avIio 
226          TREATMENT OF TETANUS.

may have derived some benefit from  such  in  the
treatment of tetanus.   Disappointment is sure to
follow the confidence placed in any of these arti-
cles.  The most judicious course is to disclaim all
specific  remedies,  and be guided  by the symp-
toms; allay, if possible, the  intense  nervous ex-
citement,  and  support the  system  against  the
ensuing exhaustion.
  The local treatment should consist in examin-
ing the wound for  foreign bodies,  and removing
them, if possible, as they are frequently the ex-
citing cause of nervous irritation, under the pre-
sumption  that unless the local cause be removed
we can expect but little abatement  of  the general
tetanic  excitement.   Should  no foreign  body be
found, if it be possible, an incision  may be made
on the cardiac side of the wround, to divide  the
nerves implicated,  and paralyze their sensibility.
The powerful acids and  the actual cautery have
been  recommended for  the  similar  purpose  of
destroying the  excited  nerves at the seat  of
injury.   A solution  of  morphine, atropine  or
kindred preparations,  may be instilled  into the
wound for their sedati\Te action, and the  simple
water dressing continued.
  The constitutional  treatment will  have for its
object to  remove all general and internal causes 
             TREATA1ENT OF  TETANUS.          227

Avhich  may keep up excitement.   We should con-
stantly  bear in mind  thai tetanus is an affection  of
debility,  and that the violence of the spasmodic
paroxysm gives a false appearance  of strength
to the  patient, whilst  the principal  source  of
danger  and  death  is  from  fatigue,  induced by
the energy of  the muscular movements  and the
consequent want of rest.
  As the  bowels  are   always constipated  and
loaded  with  offensive  foecal  collections,  Avhich
might  assist  in  sustaining the excitement  of the
nervous system, they should be at once  emptied
by a large dose of calomel, with  gamboge, aloes,
or scammony.   AVhen  a  difficulty  is found  in
administering this, from the.locked  condition  of
the jaw, one or tAvo drops  of croton oil can be
placed within the teeth, when, mingling with the
saliva,  it will be swallowed.   Three or four times
the ordinary dose Avill be required to relieve the
torpid bowels.   The patient should then  be kept
perfectly quiet—if possible by himself, as the stir-
ring about  of persons, noises,  draughts,  etc.,
excite  sudden and repeated paroxysms of  spasm.
Ice bladders, blisters, or chloroform  applications,
may be made  to the upper portion  of the spine
to allay, if possible, the irritation of this region.
  Although opium is universally  administered  as 
228          TREATMENT OF TETANUS.

an  internal  .sedative,  its effects  are  not  often
obtained CA*en  Avhen  given in large doses.   It  is
believed that it often  remains unabsorbed in the
stomach,  and,  therefore,  Avithout  action.  The
same for conium hyoscyamus and the  entire class
of sedatives  Avhen  given in the  form of pill or
extract.  Unless  medicines  are  given  dissolved,
they  are not likely to  be absorbed, or they are
taken up so sloAvly that their good effects are not
perceived.
  Recently, in tAvo cases  of traumatic tetanus, I
haA'c tried  the hypodermic! administration of mor-
phine in £  grain doses, dissolved in a few drops of
Avater, and injected by means of a Wood's syringe.
The effect of the  remedy in  a  fcAv minutes  Avas
decided, but Avas not persistent;  partial relaxation
of the jaAvs could ahvays be effected, so that nour-
ishment might be taken, and sleep could, also, be
induced.  It is by far  the  preferable  mode of
using  opium, as its  effects  can  be speedily  and
Avith certainty obtained.  In  one case, in Avhich I
injected l-10th grain of atropine  under the skin of
the arm, the  effect  upon the pulse Avas so imme-
diate that,  in  five minutes, it had increased  from
eighty to one hundred and fifty beats.  . It rapidly
affected the  salivary and  mucous  glands of the
mouth — diminishing  their  secretions  without, 
             TREATMENT OF TETANUS.          229

howeA'er,  producing dilatation  of the pupils  or
causing relaxation  of  the muscles.   As no  bene-
ficial  effect  folloAved the  atropine injection, mor-
phine had to be used, when relaxation to a cer-
tain extent was immediately obtained.
  The liberal use of belladonna has been recom-
mended, and, from its great utility in relieving
congestions of the loAver portion of  the  spinal
cord,  we might naturally infer similar good effects
for the  medulla   oblongata.   The tincture  of
canabis indica  has been highly extolled.   Some
cases  have  recovered  under its use, but a very
much larger number  have died in spite of its ad-
ministration.  Stimulating  and nourishing  fluids
must  be liberally administered at regular  inter-
vals, and, notwithstanding the difficulty in  sAval-
lowing, the nurse should insist upon its being taken.
Many a  fatal case can be  laid to the charge of
carelessness in nursing, where the  Avishes  of the
patient  are  permitted  to   regulate the  nurse's
duties.  Beef tea,  eggs,  milk,  custards, egg-nog
and Avine- must be frequently poured  down  the
throat of the umvilling patient, and, if the mouth
cannot be  sufficiently opened,  the  inhalation  of
chloroform, or the endermic  use  of morphine
should be used to  effect it.  I have seen  excel-
lent results Avith  cither of these relaxing  agents. 
230          TREAT M EN T OF TETANUS.

I have found porter  an excellent tonic in  such
cases, as it  combines both  sedative,  nourishing
and stimulating or supporting properties.  Under
the frequent  inhalation of chloroform,  the spasms
can often be kept under control.
  By pursuing the above  course  of keeping the
patient quiet, using sedatives Avith forced nourish-
ment, and relieA-ing the loaded  intestines by cro-
ton oil, I have  had the good fortune of  saving
three tetanic patients  out of  six  cases  which
have  come  under my personal observation.  As
the  three  first  cases  Avhich  I treated Avere all
restored  to  health,  although  they  were  very-
severe, I imagined that I had found a successful
mode  of treating tetanus,  and  published  the
same in the Charleston Medical  Journal for 1857.
Since that time, I have  had three cases under ob-
servation and lost them all,  notAvithstanding the
same course was pursued  as in the  successful
cases.
  AVhen the  patient is able,  constant smoking of
strong segars  may be  useful  in  quieting the
excited  nervous system.  The impression  among
many observing  surgeons  is, that the patient is
destroyed by exhaustion, called by some  starva-
tion.   It is  known,  that  if the  patient can  be
kept  alive to the sixth  day  after  the  attack, 
TREATMENT OF TETANUS.          231
there is a  likelihood of his  recoATery, and that
by the  tenth day  he may  even be  considered
convalescent.  If the debilitating  effects of the
disease  can  be  counteracted  by the free admin-
istration of very nutritious food, such as brandy
and eggs,  etc., many surgeons  believe  that the
nervous irritation Avill Avear itself out.  It is based
upon this belief, and the  known failures of the
spoliative plan  of treatment,  that the above plan
is hoav recommended.
   AVoorara  poison  has been  recommended as an
antidote from its known powerful  sedative ner-
vous action  and its marked influence  in  counter-
acting the effects of strychnia.  When poisonous
doses of these substances are  given  conjointly, no
poisonous  effects   are  observed.   The  striking
similarity between the spasms produced by strych-
nine and those of  lockjaw, suggested the use of
woorara in   this latter disease.  As experiments
proved  it efficacious in the tetanus of  animals, its
field of usefulness  Avas enlarged to the human
subject.   Several cases of  its successful  use  in
chronic  tetanus are  reported.  There  is  much
difficulty in  obtaining  good  specimens of this
remedy.  As no two possess similar  properties,
each must  be tested by  experiment  before it
can  he  tried upon  the  human subject.  Cases 
HECTIC FEA'ER.
are reported AAdiere  its use hastened  the  death of
the  patient.   It  Avas  first  used  by inoculation,
now it is administered in the form of a mixture:
ten  grains  of  the Avoorara  to  a  six ounce mix-
ture—a tablespoonful every half hour until perfect
relaxation is produced.  Should poisonous effects,
Avith death-like symptoms, sIioav themselves from
an over-dose, artificial  respiration will support life
and  sustain  the action of the heart until the poi-
son  is  eliminated from  the circulation  by  the
kidneys.  The rationale of the remedy is to keep
the  spasms  from  killing  the  patient  by  their
violence, until  the morbid state calling  them into
play has exhausted itself.
   The not infrequent sequela of severe gunshot wounds
is long-continued discharge, producing emaciation and
hectic, with its gradual dissolution of body and soul.
It is  not  at all surprising that the  daily dis-
charge of  a  Avound, Avhen at all  profuse, should
cause  debility, as  avc liaA-e already  characterized
pus  as the nutritive  essence of the circulating
fluid.  If the surgeon, avIio has many suppurating
wounds under his  care, overlooks the fact that he
must make allowance for this drain  and feed  the 
HECTIC  FEVER.
233
wound as well as the patient, the  Avound being
more imperious in its demands than the economy,
deprives  the latter of its due  supply of  nourish-
ment, and progressive starvation  must follow.   It
is on this account that what is called the antiphlo-
gistic treatment, when  fully carried out in the
treatment of  suppurating wounds,  is injurious,
and  that the supporting plan is  required.  With
diet,  Ave have a  poAverful weapon  for  weal  or
woe   in  surgical  practice.   Soon  after injuries
have  been received, vrhen  reaction  runs  high, by
abstemiousness Ave can  do much to quiet exces-
sive  irritability.  But  as soon as this stage has
passed, and  suppuration has become  established,
then the  course of diet should be modified;  now,
libera] diet  is  necessary to prevent  the febrile
complication,  which, in  the early  stage of the
wound, abstemiousness controlled.
  The use of an  abundance of strong nutritious
food, by  enriching  the  blood, will  increase the
vital properties of the plasma, improve the tone
of the tissues, stop the excessive demands of the
irritated  Avounded parts, and diminish the drain.
This treatment, with the liberal use  of the astrin-
gent  tonics, and  the injection  of  stimulating
astringents into the wound  (as nitrate of silver,
ten grains to one ounce of water, or  tincture  of
      20 
234
PERIODIC  PAINS.
 iodine, or the acid tinctures of iron diluted, one
 part to five of Avater),  Avill gradually diminish  a
 discharge, Avhich, under less supporting treatment,
 Avould continue  for a much longer period.   The
 economy cannot Avithstand this constant  drain; it
 becomes  irritable in its weakness.  In  its efforts
 to tliroAv off the yoke,  it still  further  enfeebles
 itself.  Daily fevers, Avith their profuse  sweats,
 reappear  Avith  fearful  regularity.   Finally, the
 blood  becomes so poor, that it deteriorates  rap-
 idly,  and  the useless  material  which  is ejected
 from the  circulation, irritating the organs through
 which it passes,  causes diarrhoea, and also copious
 deposits  in the urine.  The quadruple drain from
 wound, skin,  boAvels and kidneys, cannot  long
 be resisted.   Debility gradually  increases, the pa-
tient  rapidly  Avastes  to  a living skeleton, having
 literally melted away, and at last dies from sheer
exhaustion—the  conjoined result of mal-nutrition
and Avasting discharges.   Such is hectic  fever.
  Another sequela of gunshot  Avounds is more or
less permanent or periodic pain  in the  injured limb,
connected  or not Avith  paralysis of certain  mus-
cles, the nervous supply to which has been impair-
ed by  the ball in its  passage.   When a nerve has 
PERIODIC PAINS.              235
been  completely  divided,  permanent paralysis,
with  atrophy  of the muscles, ensues—the  limb
gradually dwindling, if the muscles,  indirectly de-
stroyed, be important to  the  common  movements
of  the  extremity.   A  bruising of the nerves,
Avithout  division, is also folloAved by a paralysis
more  or less persistent, which time,  however, and
stimulating embrocations will, to a  great extent,
remedy.  This  is not so much the  case in sabre
wounds.   AVhere a  nerve is divided by a sharp,
cutting  instrument, Avhen the tissues are  not dis-
placed and the wound heals Avithout suppuration,
both experiments upon animals and  experience in
man  sIioav that a  reunion  of  the  ends of the
nerves is effected, and nervous action restored to
its former  integrity.
  AVhen nerves are  pricked, or in any  other way
injured  without  complete  division, very severe
neuralgic pains, Avith spasmodic action of the mus-
cles of the limb, ensue.   These  pains  extend up
and  doAvn the  injured limb, and, as in  cases
reported by Guthrie, have,  Avith irregular  inter-
missions, annoyed the patient for years.  In one
case, although the severity  of the symptoms sub-
sided  after six  or  seven years, annoyance was,
at times, experienced forty years after  the injury
had been received.   A coldness  of the  parts sup- 
236
PERIODIC  PAINS.
plied  by the injured  nerve is  not  an uncommon
effect, and  is more  or less  persistent.   Sudden
changes  in  the temperature,  cold Aveather,  or
mental excitement,  are among the exciting causes
of such attacks  The  best means of mitigating the
suffering, independently of the application of Avarm
flannels,  is the free use  of stimulating narcotic
embrocations.  Any combination from the many
articles of the materia medica, of stimulating and
narcotic,  or anaesthetic ingredients, would  fulfil
the indications  of treatment.  The internal' use
of quinine, aconite,  hyoscyamus,  belladonna  or
opium, will blunt sensibility.
   The endermic use of morphine in one-fourth
grain  doses,  or  aconitine,  one-sixteenth  of  a
grain  dissolved  in  two or three drops  of Avater,
Avill  give  immediate  relief—in  some  instances
a  permanent  cure  has folloAved the first  injec-
tion.   Great  reliance  Avill hereafter be  placed
upon this new method of treatment.   A complete
division  of the nerve  at  fault  has been  recom-
mended, and practiced Avith some good results;
but the divided nerve is liable to become diseased,
or its cut ends SAvell into a neuroma, Avhich, incor-
porating  itself AA'ith  the cicatricial tissue, Avould,
from the amount of pressure exercised by the new
formations, allow of  only  temporary relief. 
CHAPTER
VII.
Treatment of wounds of the different parts of the body,
  or topical surgery—Wounds of  the head;  Concus-
  sion;  its characters  and  treatment—Compression;
  its symptoms—Variety  of wounds  of  the  head;
  their prognostic value—Simple wound of the scalp;
  treatments—Fracture without  depression; course to
  be pursued when  inflammation of the brain threat-
  en*—Fracture,  with depression,  to be treated with-
  out an operation—Trephining  very  rarely  called
  for—Compound fracture, with depression and com-
  pression;  trephining even  here of doubtful propri-
  ety—Perforating wounds of the cranium complicated
  with foreign bodies.

  AVounds  of the  head, AA'hen received in battle,
require a special treatment, AAdiich cannot be en-
grossed in the routine practice for wounds. Owing
to  the  proximity  of the  brain  and membranes,
and the  facility Avith Avhich shocks or direct  injury
can be transmitted through the protecth-e  envel-
opes, injuries of the head  possess  a peculiar sig-
nificance.   All  Avounds of the  head are more or 
238
CONCUSSION.
less serious, as  the surgeon can  never kiunv in
advance Avhether the brain be injured, and  what
amount of irritation or inflammation will ensue
upon such  an occurrence.   Hence  the necessity
of caution in prognosis and treatment, Avhich the
experienced surgeon Avill always exhibit, however
trivial the Avound  may appear.
  Injuries of the head would  divide themselves
into those  produced from shot,  those from the
bayonet or clubbed musket, and those caused by
the blow of a sabre.  AVounds  are found of every
grade  of intensity, from  a simple scratch to ex-
tensive  destruction of the  soft  and hard parts,
with or without those phenomena recognized as
concussion  and  compression.   As  these  terms
will be continually  referred to  in  speaking ot
the treatment of head injuries, we  will, in brief'
define the meaning which the surgeon  attaches
to them.

   Concussion, or stunning,  appears to be a shock
to the brain by which its substance is more or less
shaken, with interference of its  circulation, and
often injuiy to  its structure—its  functions being
buf-pended for a certain period.   Immediately as
an injury upon  the  head has been  received, if at
all severe, the patient is knocked senseless.  He 
CONCUSSION.
239
lies perfectly  insensible,  motionless, and all but
pulseless.  His face and surface becomes pale and
cool; the breathing,  although feeble,  is  regular
and  easily perceived; the pupils  irregularly con-
tracted  or  dilated;  sphincters  are  relaxed,  in
common with the entire voluntary  muscular sys-
tem,  so  that  the contents  of the bladder and
boAvels often  escape  involuntarily.   After con-
tinuing  in  this  condition  for  a  few  minutes,
hours or days, he  gradually recovers  conscious-
ness.   The  heart  first  regains  its  accustomed
action, the  pulse gradually undergoes  develop-
ment, and the skin  becomes  warmer.  At this
period vomiting usually comes on, which arouses
the action of the heart.  This organ, under the
excitement of emesis, drives blood to the brain,
and with this free supply of stimulus to the gene-
ral controlling organ, the patient rapidly rallies.
   This is the common  picture of concussion  as
seen  in surgical practice, and the combination  of
its symptoms  will be more familiarly recognized
as those of ordinary fainting  or syncope.  The
extremes Avould be those cases in \Adiich the pa-
tient staggers, but, after supporting himself for an
instant against, some house, fence or tree, recovers
himself and, Avithout further annoyance,  continues
his employment;  or those in Avhich  the  patient is 
2411                concussion.

picked up  apparently dead, with relaxed muscles,
pale surface,  glassy eye, scarcely perceptible pulse
and  very feeble and  irregular  respiration.   The
death-like  appearance  becomes more and more
confirmed,  the breathing gradually ceases, and the
pulse  imperceptibly  flitters  away,  Avithout  any
sign of consciousness  from the moment of injury.
   In fatal  cases,  where  concussion  had been
present, the  brain  has  been found  more or  less
injured, and  so highly congested  as to exhibit a
dusky hue.  Fissures have been  found in its sub-
stance, or  extravasations of blood in  numerous or
concentrated spots. In certain instances the brain
has apparently shrunk from the excessive shaking
or vibrations to AAdiich "it  has been  subjected, so
that it no  longer fills the cavity of the skull.   In
some fatal  cases Avhere the  brain had  been fissured,
the  commotion among  its particles  had  at  once
annihilated its functions, so that the  heart's action
had instantly ceased and no blood had been driven
to the mangled  brain to be extravasated into its
substance.    In  cases   of  nearly   instantaneous
death from concussion or  stunning,  the  brain, on
examination, appeared  in every respect  healthy.
On  the  other hand,  in cases  of perfect recovery
after concussion,  Avhere  the  patient  had  lived
some time (weeks  or months)  in the full enjoy- 
            TREATAIENT OF CONCUSSION.         2-11

ment of all of his faculties, and had  died from
some disease totally foreign to the former head
injury, extenshre  lesions have  been found  in the
brain, and traces of large and extended extravasa-
tions of blood covering the  hemispheres as Avell
as in the cerebral substance.  The irritable con-
dition  of the brain in Avhich the patient is often
left, after concussion of limited duration, Avith the
impairment of memoty, or of some one   of the
special senses  or  even partial paralysis,  would be
physiological proof of cerebral injury.   Although
its symptoms are usually transient, we may, doubt-
less, consider  it a contusion or interstitial lacera-
tion of brain substance.
  As this  is an alarming condition, to those not
familiar  with  the  march  of such  lesions, those
interested in the  injured man  are ahvays  clamor-
ous for active  interference, and it is with difficulty
that the  surgeon can  free himself from the urgent
solicitations of friends who  believe that, unless
prompt  means are used,  the  accident  must ter-
minate fatally.  The  surgeon, under such  circum-
stances,  requires all of his  presence of mind, and
with firmness pursues strictly the non-interference
plan of 'treatment.  The course  which  rational
surgery  now  recommends is  to lay  the  patient
horizontally, Avith  his head perhaps a  little lower
       21 
242         Treatment of concussion.

than  his'body, so that the brain  may have the.
benefit of gravitation to assist  in  its supply  of
blood.  He  is Avrapped  in Avarni  blankets, hot
bottles are placed around his  body, and dry fric-
tions  may be used to  excite the re-establishment
of the circulation in  the extremities;  but  beyond
this the surgeon  should not interfere.   The safest
practice consists in doing as Utile as possible.   The use
of stimuli on  the one  hand  or  bleeding  on the other
are to be especially a net studiously avoided.
   Only a few years since bleeding  was the prac-
tice in stunning,  and the  amount of  mischief done
by this universal  mania for  bloodletting was often
irreparable.  We might  as  well bleed in  a faint-
ing fit and expect good results.  Wre find, as  in
syncope, that the heart scarcely pulsates ;  so little
blood  is driven to the surface that  it  is pale and
cold.   The  same for  the  brain wdiere so little
blood  circulates   that, from want  of its   proper
stimulus, its functions are temporarily suspended.
Were  it  possible to  draw  away much blood, the
cessation of the  nervous  functions would  become
permanent.   Modern  surgery,  in   studying the
natural history of disease and injuries, sees now,
what it should long  since  have recognized,- that
nature, in her elesire to harbor the  circulating
fluid,  tries to  put a  safeguard  against the rash- 
           TREATMENT OF CONCUSSION.         243

ness of surgeons, by shutting up  the bulk of this
living fluid  in the  inner  recesses of  the body,
where it cannot be easily despoiled.  On account of
this change  in practice, we now seldom hear of
deaths from  concussion, which  was comparatively
of common occurrence a few years back.
  As regards stimulation, we must also  desist as
long as it is possible, and, when its administration
is compulsory, give it with a most cautious, spar-
ing hand.  Remember that the degree  and dura-
tion of shock  depends upon the  extent  of injury
which the brain has  received, and that  nature,
ahvays the  most  skilful physician,  adopts this
concussion  as  a  safeguard  to  prevent  further
lesion.  How are we to know  that the  brain has
not sustained severe injury, extensive bruising or
laceration, and that this extreme depression  of
the brain, Avith consecutive control of the heart's
action, is not especially indicateel to prevent hem-
orrhage Avithin  the  brain  substance and rapid
death from  compression  by extravasated blood.
AVe know  this, that  after severe  injury to the
brain, when, through  officious  meddling and the
free use of brandy,  the symptoms of concussion
early disappear,  violent reaction  is  induced, aiid
internal hemorrhage or violent inflammation soon
shows itself;  and that, for the  doubtful  gratifica- 
244
TREATMENT OF CONCUSSION.
tion  of seeing  the  patient rapidly  revive, avc
have  the  mortification  of seeing him as rapidly
destroyed.
   Cases of concussion, absolutely requiring stimulants,
are but verg, very seldom met with  in practice.  Even
A\rhen of a very severe  form, all that is necessary,
in the vast majority of  cases, is to  apply warmth
to the surface, and carefully to  Avatch the case.
   Should  it  so  happen—but  this  occurs  very
rarely — that the patient is manifestly  in danger of
sinking from depression  of the circulation,  then
stimulants must be resorted to.  As  long as the
pulse does not lose its  strength under concussion
of the brain,  desist from active interference, should
the  insensibility  last  for hours or  even  days.
After-trouble will be avoided by alloAving nature
to take its oavu  course unmolested.   AVhen  from
the great  and long-continueel  depression stimuli
are  called  for to  prevent threatening  dissolu-
tion,  their effects should  be  carefully Avatched,
and as  soon as reaction is apparent,  Avith an im-
improving pulse, at once elesist from further inter-
ference.  As is the state of depression, so will be
the  state  of reaction.   When  the depression  is
extreme,  the  reaction  Will  be  correspondingly
excessive,  and, especially  so, if  stimuli have been
freely aelministered. 
COMPRESSION.
245
  When the patient has recovered from the state
of insensibility, he should be kept perfectly quiet,
excitement of  every  kind  should be  carefully-
avoided, the diet should be  abstemious, the head
kept  cool, and  tendency  to constipation  cor-
rected;  but,  beyond  this,  no treatment  is  re-
quired  until  expressly called for  by  excessive
reaction, with  symptoms  of congestion  or  in-
flammation  of  the brain.   The  precautionary
bleeding,  with  repeated  doses  of  calomel, to
keep  off  symptoms,  which,  in  the  majority of
cases, would not have occurreel,  was the  routine
practice  of the  old school,  and  cannot  be too
severely criticised.    The  complications  Avhich
might  arise in  injuries  of the head, after more
or less  serious  concussion, will be hereafter con-
sidered.
  Concussion  is  ahvays  simultaneous  Avith  the
bloAv, and  gradually decreases, if death does  not
carry off the patient early.   Compression, the con-
dition with Avhich it is often allied,  usually conies
on  some  little time  after  the reception  of in-
jury,  although  it may appear either  at the mo-
ment, or may  not  shoAv itself for  days or  even
weeks after the injury.   The name explains the
lesion.  Compression is  pressure  made  upon the 
246
COMPRESSION.
brain, either by a  portion of the  skull or some
foreign body drh'en into or upon the cerebral mass;
or by an escape of blood from some torn vessel,
which, by forcing itself into  the unyielding skull,
compresses  its  contents, or by effusion of lymph
or pus, aa hich inflammation causes to be deposited
within the cavity of the skull.  The symptoms by
which this condition Avould be recognized, are as
follows:—The  patient lies in a  state of coma,
stupor, or lethargy, being paralyzed more or less
completely,  both as  regards motion  and sensa-
tion.   He  is heavy, insensible,  and  drowsy, at
times ansAvers  mutteringly  when  rudely  shaken
or loudly spoken to,  but immediately afterward
is again breathing slowly, heavily and laboriously,
as if in deep sleep.   Shoulel his face be examined,
the lips and cheek on one siele will be  found to
flap, during  expiration, with a blowing sound, as if
smoke was  being  blown from the mouth as in
smoking.  There is paralysis of that  side of the
body opposite to the seat of injury, and as a neces-
sary consequence, both in expiration or in attempts
at speaking, the  corner of the mouth is draAvn
OATer to  the sounel  side.   The  countenance  is
usually pale, cold,  and ghastly,  although it may
be flushed  with a  hot and  perspiring skin, the
eyelids are  parti}' or completely opened, with the
pupils  dilated and  insensible to  light; the pulse 
COMPRESSION.                247
 is sIoav,  the heart  acting under great oppression;
 there is  constipation from torpidity of the boAvels,
 with involuntary discharge of the faeces.   From
 Avant of action in  the  bladder the urine  is  re-
 tained,   and  unless  drawn  off will  decompose
 within the organ, Avhen, from accumulation, either
 the  bladder will rupture Avith poisonous infiltra-
 tion, or  the blood becomes poisoned from absorp-
 tion.  These  symptoms  are  not  always equally
 marked—the  degree depeneling upon  the  cause.
 Unless the causes  of compression be  removed,
 the  case usually terminates fatally, although cases
 are  not  rare, in which,  after weeks  of uncon-
 sciousness, reason has gradually been  restored—
 the  accompanying  paralysis slowly disappearing.
  Having  now  explained the two conditions of
 concussion and compression, which so commonly
 accompany severe  wounds of the head, we are
 better prepared to study  this special class  of in-
juries.
  The divisions which experience  has proved of
 practical utility, are:
  1. Injury to the. soft parts alone, uncomplicated with
 injury to skull or brain.
  2. Wound of soft  parts,  with simple fracture of the
 skull.
  3. Wound  with depressed fracture of the skull, but
without symptoms of  compression. 
248               COMPRESSION.
  4. Compound depressed fracture of the skull, with
symptoms of compression of the brain.
  5. Perforating  wounds  of  the  skull,  complicated,
with foreign bodies.

  From the peculiar formation of the  skull and
the resistance  Avhich it offers to  bloAvs, unless a
shot strikes it fairly at right angles, it does  not
perforate; but  Avhether it be a grape, musket, or
pistol  ball, it flies off at a  tangent,  or, running
 beneath the skin  upward, dowmvard, or laterally,
escapes.   The head  may even be struck  with a
round  shot Avithout serious  injury.  The patient
may, or may not be  knocked cIoavii by the  bloAv;
severe pain is  felt, and a puffing  up  of the part
instantly  follows.  When the hair is  removed,
although  there  may  be  no   discoloration  of the
skin, there is  abundant evidence of subcutaneous
lesion, which,  unless counteracted, will soon de-
velop  inflammation  and extensive  suppuration.
The severity  of  the  bloAv  upon  the  head may
have knocked  the patient senseless:  and  in this
condition, he  is  founel by the litter  carriers.
  The transportation of head  injuries requires great
care, and  the best transports should be devoted to
this service.  Wrhen the patient arrives at the field
infirmary, he is laid down, with head low, until he 
COMPRESSION.
2411
recovers  himself.  The restoration is left to na-
ture;  cold  water may be  clashed into the  face,
but all stimulation should be avoided unless the
pulse  is found  to  flag, Avhen a little  brandy may
be cautiously given.  The surgeon takes adA-an-
tage of the insensibility of the  patient, shaves
the head at the point of  injury, and gives the
wound a thorough examination.   AVhen  reaction
has taken place, and the  patient  is restored to
consciousness,   should the  wound have been  a
simple one  of  the  soft  parts,  the  cold  Avater
dressings is all that will be required, and shoulel
be applied  according  to general  principles.   The
thin,  Avet compress,  with oiled or  Avaxed. cloth
should cover the Avound and head for some dis-
tance around  the injury,  and  instead  of tying
these  in place by  the roll  of bandage, the  better
plan  is to  adopt  the head  net of the  Prussian
medical  service.   It  is a round piece of  coarse
netting made of cotton yarn: a string ties  under
the chin  to keep the  dressing on, and a  drawing
string, running around the net, like a  purse string,
attaches it  securely to the head  around the tem-
ples.  This is an admirable dressing  for  all head
iujuries,  which  require light, cool, and  efficient
applications.
  Should the soft parts  have been  much  bruised, 
250     TREATMENT OF FRACTURE OF SKULL.

the ice bladder will  be required  to  keep down
excessi\re  suppuration.  To prevent mischief, all
injuries of the head demand rest and quiet, avoid-
ance  of stimulants,  and  abstemious   diet.   l>v
adopting  this course in uncomplicated  Avounds,
whether gunshot or sabre, a speedy cure is usually
obtained.   Effusions  of  blood  under  the  skin
should not be interfered with; incisions  are not
required.   If the effusions are alloAved to remain
excluded  from air, the cold Avater dressings with
arnica will cause  their  rapid absorption; if the
skin is punctured  and air admitted, suppuration
will surely ensue.   Should  suppuration occur,  as
soon as pus can be clearly detected, let it out by
a  small incision.   If this be neglected  at the
proper  time, the  pent-up  pus will  separate the
periosteum from the  skull, and cause, perhaps, a
necrosis of the bones.  AVhen  suppuration has
been  well established, an  oiled cloth  is  substi-
tuted  for water   dressings  by  many  surgeons,
although  the  growing disposition is  to continue
the water dressings  until  cicatrization is com-
pleted.
   When the skull has been fractured by a ball, sabre
blow, or fragment  of shell, the treatment should
in no material respect differ from the course pur-
sued in a  simple scalp wound.  A simple or com- 
        TREATMENT OF FRACTURE OF SKULL.      251

 pound fracture of  the  skull, uncomplicated with
 injury to the brain  or its meninges,  should be
 managed according to  the  ordinary principles of
 surgery, remembering  always, hoAvever, that  the
 brain is in  near proximity, and  may  have been
 injured, although no symptoms are present for de-
 tecting such a lesion.  If the patient is insensible,
 we adopt the means already recommended for re-
 moving shock, viz: place the body in a horizontal
 posture,  and leave the  case  pretty much to  na-
 ture— avoiding  eArerything  tending to  internal
 stimulation.  AVTiilst  insensible,  Ave examine the
 Avound  thoroughly, using the finger as a probe;
 and if any loose speculae of bone  be  felt  quite
 free in the wound unconnected with  the   soft
 parts, they should  be removed.  If attached, they
 must  be left to escape  spontaneously  after sup-
 puration is established.
  Gunshot fractures are usually distinctly limited
 to the portion  struck,  and seldom ramify as do
 fractures from diffused blows.  It is this concentra-
 tion of the force within  a small compass, and the
 extended injury  to the inner tablet of the  skull,
 which  render  gunshot  injuries of  the head  so
 serious.  AVhen  avc are satisfied, from a careful
 examination of the condition of the bones, that
they remain in their normal position without de- 
252     TREATMENT OF FRACTURE OF SKULL.

pression, the head is shaved and the Avound care-
fully closed Avith a strip of adhesive plaster, so as
to exclude air.  As soon as the patient has revived,
the cold water or ice treatment is at  once insti-
tuted.   Should there have been but little shock
from  the injury, these  wet  applications  should
be commenced  Avith on  the battle fjtld.
   AVhen the patient  is put to bed  (which should
be as soon  as possible, for early treatment is all-
important),  his  head and shoulders  should  be
elevated; quiet and absolute rest should be strict-
ly  enjoined; the room   should  be darkened;  all
stimuli, including  light  and  noise,  should  be
avoided;  the bowels should  be freely opened by
a saline,  mercurial,  or aloetic  cathartic;  and  for
a few  days, abstemious  diet prescribed.  These
precautions  are necessary to  prevent irritation of
the brain, with subsequent congestion, inflamma-
tion,  and effusion.   If the patient appears irrita-
ble and peevish, Avithout heat  of head or fulness
of pulse, give opium to epuiet him.
   The  case  should be watched Avith care, and if
symptoms of  congestion of the  brain  threaten,
Avith  injection of the face, red eyes, hot skin,  forci-
ble throbbing  of the carotids, increasing  head-
 ache,  with  an earl} tendency to  delirium,  the
 patient should be at once bled, the head should 
TREATMENT OF FRACTURE  OF  SKULL.     253
he  shaved,  and an  ice  bladder be assiduously
applied OArerthe entire scalp; the intestines should
be  freely acted upon  for  the  revulsive  effect
upon  the brain, and for  a similar  reason, sina-
pisms should be applied to the legs  and  thighs.
Should relief not be  promptly obtained, leeches or
cups might  be  applied to the mastoid processes.
Calomel  was formerly the universal  prescription
for threatening  cerebral inflammation.  Salivation
was induced as early as possible, and when  the
system was  brought under its influence, the  pa-
tient  was   considered  comparatively  safe.   In
modern surgery, calomel  has  lost its high posi-
tion,  and the  dependence  upon  its  salivating
powers is annually diminishing.   Many  still  ad-
minister it, but  not wdth the confidence of former
times.
  Should this threatened inflammation  not sub-
side under this course of treatment, but after a
period of high  febrile  excitement the  delirium
becomes  merged into stupor,  with noisy breath-
ing, dilated  pupils,  slow, labored pulse, relaxed
sphincters and  paralysis, the  case indicates com-
pression from effusion, within or  upon the brain,
and chances  for life become  very doubtful. Per-
haps,  a thick layer  of lymph may  have formed
upon  the cerebral  surface, or a quantity of serous 
254     TREATMENT OF FRACTURE OF SKULL.

fluid collected in the ventricles, or a circumscribed
or diffused abscess in or upon the brain.   This
lymphy effusion sometimes covers the entire sur-
face of one or both hemispheres.  The arachnoidal
membrane appears to be the one chiefly inflamed.
It  is thickened,  semi  opaque,  adherent to the
brain surface,'and reddened in patches.   The pia
mater and brain substance is highly injected.
   If,  with the occurrence of these symptoms, the
patient be  seized  with chills,  the scalp wound
becoming dry, and the  tissues putty, or a collec-
tion  forms  under  the periosteum, lifting  this
membrane from the bones which appear dry and
yellow, it Avould indicate,  in many instances,  a
circumscribed collection of pus  within  the  skull.
These symptoms  might be, but very  rarely are,
relieved by the use  of  the trephine   As  a  gene-
ral  rule,  the  operation  hastens the fatal  catas-
trophy.   Unless  an external abscess, with  the
 characteristic  puffy scalp,  defines  the collection
 of effusions within, the trephine should not be
 used.  It often  happens  after trephining, that
 these supposed collections have not been found,
 and  it  is only after the operation that the  secre-
 tion  of pus has  been  established.  AVhen air  is
 admitted, suppuration is certain; whilst Avithout
 the  operation the effusions are known, in  many 
             INTERNAL  HEMORRHAGE.           255

instances, to  have  been  absorbed—the patient
recovering after remaining insensible, in one case,
as long as tAventy-one elays.
  Cole, in his Military  Surgery, mentions cases of
fracture of the skull from ball, without the skin
being torn.   Unless the bones are much detached,
as they Avere in one of his cases,* the condition
can only  be  suspected.  Such  injuries  must  be
treated under  the  antiphlogistic  expectant plan.
Await  symptoms before active  surgical  interference  is
instituted, and we will never regret it.
  There are  a  series of cases, in  which injury to
the skull  is  complicated with  internal bleeding.
The  insensibility Avhich seized the patient at the
moment  of  injury  Avill  pass  off, and  the con-
sciousness will be regained,  but only for a time.
The  patient, after  a longer or shorter interval,
feels heavy and dull, and  indisposed to exertion;
finally, a  strong  disposition  to  sleep conies over
him, Avhich,  deepening into coma,  ends  in  all
the symptoms of Avell marked compression.   This
is  an instance  in Avhich the surgeons, of twenty
years  since,  would  have  trephined,  as  the only
chance of saving the patient.  JSTow, Ave would lay
down an  equally  broad  rule, that  his only hope of
recovery  is   in  avoiding  the  trephine.   Pursue
a  rigid antiphlogistic  course;  free   venesection, 
256
TREPHINE USELESS.
 when  assisted  by  ice  bladders  to  the  entire
 scalp,  Avill stop  further loss of blood,  reduce
 the action of the  heart, and  permit the effused
 blood  to clot,  so  as to  close the  openings  in
 the  torn  blood-vessels ;  then,  by  free  purga-
 tion,  act upon  the  bowels,  both for  a deriva-
 tive effect, arid to  promote  the absorption  of
 the effusion.  If you can  stop the further  escape
 of blood, that which has  been effused will  gra-
 dually be removed,  and  the  symptoms of com-
 pression  will  as gradually pass  off,  after having
 continued for  days,  or  even  weeks.   Trephine
 such a patient,  and what certainty have we that
 we will  find  the point  where  hemorrhage has
 taken place, or that the blood is  still  fluid, and
 can  be  removed—both  very improbable results.
 Blood-vessels  may  have  given waj7  at  any other
 portion of the  brain than at  the portion  corre-
 sponding to the point where the skull is injured.
 The recoil of  the  contents of  the skull may have
 ruptured  vessels diametrically opposite  to the in-
jured point.   Autopsies  not unusually reveal such
 conditions.
  The operation of  trephining is  always very
 serious per se, and  is sufficient of itself to  cause
 cerebral  or meningeal inflammation, which will
 nearly always  terminate  fatally.  The operation is
 often more serious than the condition for which it 
FRACTURE WITH DEPRESSION.
257
is used, and, although the patient might recover
from either, he  succumbs  under the  combination.
Experience  and autopsies  have shown us  many
cases of extensive intra-cranial hemorrhages, which
have been  unaccompanied  by symptoms denot-
ing such an accident;  and the  traces of such have
been found when the patient,  recovering from his
head injury, had fallen a victim to some totally
foreign disease.  Had such a condition been sus-
pected, and the surgeon used  his instruments, an
autopsy at a much  earlier day  would have re-
vealed the condition.
  The third variety of injury of the head,  with depres-
sion of the skull,  belongs to  a more serious class of
wounds.   The complication is detected at once by
examining  the  Avound with the finger, when the
sinking of the bones is felt, the extent  of injury is
detected, and the condition of the depressed por-
tion, Avhether en masse or  spiculated, determined.
The broken  fragments, if quite loose, should be
removed  within the first twenty-four hours, before
reaction sets in.  When concussion has passed off,
and no symptoms  exist indicating  injurious pres-
sure upon the brain, the case should be treated in
every respect as if no depressed fragments existed.
Unless we  see clearly that the bone is very much
spiculated, and that sharp  fragments are  piercing
      22 
 258         FRACTURE AVITH DEPRESSION.

 the meninges, avoid all instrumental interference,
 even to dilating the wound, for the purpose  of
 facilitating a more accurate diagnosis.
   AVe  shoulel  never  be  anxious  to  see the
 symptoms of  concussion  rapidly  disappear;  let
 nature abide her time; watch the case and see that
 the  patient suffers no  detriment.   Examine fre-
 quently the pulse, but not the head, and as long
 as it sustains itself,  everything is Avorking to the
 advantage of the wounded.   By  rapid  reaction
 torn  blood-vessels may not  have had  time  to
 become plugged up,  and  internal  hemorrhage,
 which is always serious,  might ensue.  As soon
 as  the  pulse  commences to  improve, then we
 commence cold applications, which, if assiduous-
 ly applied,  may  prevent the  after-A-enesection.
 When  bloodletting  is  required, it is  preferable
 to bleed moderately from a large  opening, to  be
 repeated, if necessary.  The object is to obtain its
 sedative and  revulsive effect, and to  despoil  to
 as limited an extent as possible.   If from  six  to
 ten  ounces, from a Jarge opening in the  vein,
 Avill  produce  a sensible feeling of faintness,  do
 not draw from  sixteen  to twenty.   This  sedative
 effect might  be sustained by  leeches or  cups  to
the  neck, and  by  small  doses  of tart,  emetic,
veratrum viride, or  eligitalis—never, however, 
FRACTURE AVITH  DEPRESSION.        259
 pushing  these  remedies to  ATomiting,  which, by
 tending to congestion of the head, would act inju-
 riously.  Revulsives to the  intestines,  as recom-
 mended in the treatment of simple fractures, Avith
 ice to the head, are the remedies upon which most
 reliance is to be placed.   Free purgation  is not
 desirable, as the frequent change of position would
 be injurious to the patient.   Should the  integu-
 ments and pericranium inflame Avith much savcII-
 ing,  pain  and  tension,  with  febrile  reaction,
 incisions, or rather scarifications, may be made
 to release the pent-up  fluids.   These, if possible,
 should be made at a  distance from the seat of
 fracture—the object being  to  protect the injured
 bones from atmospheric influences.
   Surgeons are now becoming familiar  with the
 fact  that considerable  depression may  exist  in
 the  external tablet  of  the  skull without the in-
 ternal being fractured—the external layer  being
 driven  into  and  condensed  within the  diploe.
 Also, that both tablets may be depressed, com-
 pressing the brain, Avithout causing  harm at any
 subsequent period.  Observation has multiplied
 these cases  to  such  an extent as  to   modify
the entire treatment of head  injuries.  Although
 the cranial  cavity  is filled  with brain,  its con-
tents  are  continually undergoing  changes  from 
260        FRACTURE AVITH DEPRESSION.

the exeessh^e  vascularity  of the  brain  substance,
and, also,  from  the  free  communication  Avhich
exists  betAveen  the fluid  filling  the ventricles
and the veinous  plexus Avhich abound  in  the
brain.   By diminishing the blood  and Avater in
the brain,  accommodation  can be  made  for the
depressed bone.  As a general  rule, in  gunshot
wounds, with depression  of fragments, .no  re-
markable  symptoms  exhibit themselves,  until
there is a determination  of blood  to the head
from reaction, from mental or bodily excitement.
Rational  practice   would   lead  us to  combat
the tendency to congestion  by rest,  quiet,  cold
revulsives  an el venesection,  rather  than  by the
trephine, which  experience has shown to be so
unprofitable.  Opium   is now  used with much
greater  freedom in the  treatment  of  injuries  of
the liea'd than formerly  and, Avhen  administered
with discretion,  will,  to  a  certain extent,  take
the place of trephining.  AVhenever  the patient is
restless, sleepless,  and irritable with delirium,
should  the face not be red,  nor head hot, it can
be used with safety and benefit.
   When suppuration is established  in  the wound,
and granulations commence to  form, those por-
tions of bone Avhich cannot be saved, will gra-
dually  become  detached  and  will  escape.   A 
           FRACTURE WITH DEPRESSION.        261

tendency to bleeeling in the granulations of the
wound is an  indication  that the fragments of
bone  have  become  loose  and  are ready  to  be
removed.   This symptom,  which  is  a valuable
one, must be noted.

   The fourth variety  of injury  to the head, where a
compound fracture,  with depressed fragments,  is con-
nected with symptoms  of compression, is a  very seri-
ous accident,  and  is the  only variety of compli-
cated head  Avound  in  which  surgeons consider
instrumental  interference  calleel   for.   Even  in
this  instance, the  propriety of  trephining   is
doubted  by many of large experience,  although
no doubt exists that,  in  some cases, immediate
relief has followed  the lifting  of the  depressed
bone.  It is said,  that the  successful  treatment
of such cases  will elepend more upon the  condi-
tion of the brain and membranes than  merely
upon the depression.  Should these be  lacerated,
or in any Avav injured, inflammation  Avill  sooner
or later  sIioav itself.  The  operation  of trephin-
ing, under such circumstances, would increase the
local  irritation, expose  the  injured  tissues  to
injurious  atmospheric influences,  and  hasten on
a  violent and usually  fatal inflammation.
   If the brain  and  membranes be  not injured, 
262
FRACTURE WITH DEPRESSION.
then it  is  said that the brain  will soon  become
accustomed to the  pressure, and, although  in-
sensibility  may  continue for hours, days, or,  aa
in many instances of ultimate recovery, for weeks,
the symptoms of compression will gradually pass
off.  By not  using  instruments, the surgeon has
the  satisfaction  of knowing  that  he  has not
increased  the local trouble by a serious opera-
tion.   The removal  of the symptoms  of com-
pression being  very  gradual,  excessive  reaction
is not likely  to  folloAV, and as no  air has been
admitted to  the  effusions beneath the skull, the
probability of suppuration  will be  much dimin-
ished.   AVhen  effusions have  taken place, the
depressed bone  acts  as  a covering, excluding air
with  its injurious  chemical influences.    Fluids,
uncontaminated  by  decomposition,  can  be  ab-
sorbed.   When  the skull is opened, and  the free
admission of air is permitted,  suppuration, with,
perhaps, pyaemia, is prone  to occur.
   Stromyer,  who is one of  the highest authorities
on gunshot  wounds  of the head,  and  who,  aa
surgeon-in-chief of the Schleswig-Holstein army,
had  every  facility  for  studying  his  favorite
branch  of  surgery, gives us as the result of his
experience,  observation  and study,  that  the tre-
phine can be abandoned in military surgery.   In 
FRACTURE WITH DEPRESSION.
263
 a supplement  to  his Avork on  Military  Surgery,
 recently  published,  he  states,  uthat in military
 surgery trephining is never needed.—When the case
 is so severe  as to require the trephine in gunshot
 wounds, the patient  will die in spite of it."—In
 the last tAvo campaigns, in which he hael charge of
 the army,  he has not trephined.  Loeffler, a dis-
 tinguished surgeon in  the  Prussian service, who
 has  published  one of the best books of instruc-
 tion  for military  surgeons,  after acknoAvledging
 Stromyer  as the  master in  all relating to the
 treatment  of gunshot  Avounds  of  the head, en-
 dorses his  views in opposition to trephining.
   McLeod gives the following  as  the  Crimean
 experience:—"As to the use of the  trephine—the
 cases and time for its application—less difference
 of opinion, I belie\Te, exists  among  the experi-
 enced army surgeons than among civilians; and I
 think the  decided tendency among  them  is  to
 endorse the  modern  'treatment  by  expectancy,'
 and to avoid operating except in rare cases.  In
 this, I believe  they judge  wisely;  for when we
 examine the question  carefully, Ave find that there
 is not one single indication for having recourse to
 operations,  which  cannot, by the  adduction  of
pertinent cases, be shown  to be often  fallacious."
Hewett, in  a  series of lectures on injuries of the 
264
FRACTURE AVITH DEPRESSION.
head, published in the Medical Times and Gazette
for 1859,  which form the most complete treatise
extant on  the  subject, is  equally  adverse to the
trephine.   Guthrie,  Cole,  and   Williamson, in
their reports, equally confirm  the  dangers of the
trephine, and the great fatality accompanying its
use.
  The  entire  records of  the science  may be
searched  in  vain,  to find a  duplicate series of
successful  cases  to that  reported by Stromyer.
Of forty-one  cases of fracture,  with  depression
from gunshot wounds, in many of which it was
probable that the brain and membranes  were in-
jured, only seven died—all the rest recovered.  In
only one  case Avas there   any operative  interfer-
ence, although signs of secondary compression appear-
ed in several. The antiphlogistic treatment, carefully
carried out, was alone adhered to.
   No surgeon can doubt  that  the  operation  of
trephining has  cost many  a man his  life, and
although  many  cases  have  recovered after the
operation, it is a  question whether, in the major-
ity  of  cases,  more  rapid  recovery   would  not
have been obtained without it.
   AVhen  symptoms of compression ensue  in the
course of treatment, continue the steady, onward
use  of antiphlogistic remedies.   At this June- 
FRACTURE AVITH DEPRESSION.        265
ture, many surgeons recommend calomel pushed
to salivation, which some state to be synonymous
with salvation.  There is no unanimity, hoAvever,
on  this head; the modern  tendency  is to  treat
such cases without the use of mercury.
  When balls penetrate or perforate the cranium,
the detached piece of bone is driven before the
ball into the substance of the brain.   The resist-
ance which  the  ball  meets changes its course,
and glancing from the   depressed  fragment,  it
takes   a different  direction,   burying  itself in
the brain at some distance from the  piece of
bone.    In by  far the majority  of cases,  death
is  instantaneous,  or  soon folloAvs  the receipt
of injury.   There  are,  nevertheless,  a few ex-
ceptions to  this  rule,  in which  the  patient,
recovering from  the  shock  and  sequela?,  has
carried  the ball or other missile  in his brain for
years;  and, eventually  dying of some disease un-
connected  with the  head, an  autopsy reveals
the ball embedded in  the brain,  and surrounded
by  a  mass  of  lymph.   Of ninety-one  cases of
penetrating  and perforating gunshot  wounds of
the head  which Avere admitted  into hospital in
the Crimea,  all, Avithout exception, proved fatal.
  When the openings are  examined, it will be
found  that the hole made in the outer tablet is
      23 
266
FRACTURE AVITH  DEPRESSION.
more or less  smooth, Avhilst the  orifice  in  the
inner tablet is much  more  extensively fractured,
and  usually much spiculated.  This condition of
the orifices is owing more to the direction of the
blow than from  any  supposed brittleness in  the
inner tablet; for, should the ball traverse from
within outward,  the reversed condition  is found.
It would be folly to attempt  the search after
such  foreign bodies for  the purpose of removing
them, as such a piece  of  meddlesome surgery
would  ensure  a fatal issue, whatever hope of
recovery might have been entertained.  We have
heard of such an instance, where a physician
had probed the brain with  a silver probe to find
a ball, but hope never to  see  such  a piece of
barbarous  ignorance.
   Cole,  in  his Indian  Reports,  mentions  " that
tnere are many  soldiers  now doing  duty in  our
ranks, for w7hom (having been wounded in their
heads during the late  war) the medical  officers
had not the smallest hope; and  every  military
surgeon, who has had much practice in the field,
has learned not to despair so long as life remains."
The thorough probing of such cases, to satisfy the
curiosity of a surgeon, would soon  have destroyed
all hope with the life of the patient.
   The general treatment  of such cases should, in
no Avise, differ from that laid down for the treat- 
           FRACTURE  AVITH DEPRESSION.         267

ment of head  injuries in general.   The  concus-
sion and compression, Avhich.are well markeel and
always present, must be met Avith all the precau-
tions already pointed out.
  We  might now  sum up, in a few  Avords, the
rational  and   successful  treatment  of gunshot
wounds of the  head.   In concussion, unless there
is evident  sinking, leave the case to nature, anel
aAroid,  studiously, both  stimulation  and ATenesec-
tion.  When the patient is restored to conscious-
ness, should  inflammation of the brain threaten,
if there be  no congestion of the face, give opium
to allay  irritation.    Should  congestion  be evi-
dent, use the antiphlogistic treatment  locally and
generally, commencing Avith venesection, and Avith
ice  applications  to  the  head.   In  every  case,
absolute  quiet  and  rest are  essential.  For the
want of a proper sentinel at the door of the ward
in which  head injuries are being treated,  many
cases have  been lost.   All gunshot injuries of the
head are  serious, however trivial they may ap-
pear, inasmuch  as violent inflammation often fol-
lows slight Avounds;  all, therefore,   should be
carefully watched.
  Chronic  ostitis or periostitis, resulting  from  gun-
shot wounds, possesses no peculiarity, and should
be combated by iodide of potassium. 
CHAPTER VIII.
Wounds of  the Face—Fractures  of  the  upper  and
  lower jaw—Wounds of  the neck—Large  vessels
  avoid the perforating ball— When  large arteries in
  the  neck are divided, the necessity of ligating  the
  bleeding mouths.

  Wounds of the Face, when  they do  not im-
plicate  the brain, are not  usually of a  serious
character.   The  severe cuts about the face, made
by the sabre or by pieces of shell, should be treat-
ed for adhesion  by the first intention.  The lips
should be brought together by  sutures, and cold
water  dressings will complete the cure.  The ex-
cessive sAvelling, which accompanies many inju-
ries  of the face,  especially  gunshot wounds  and
burns  from  explosion of powder,  is  rarely con-
trolled  by  cold  water  dressings.   It  runs ita
harnilesss course, moderated  by the cold applica-
tions, and  subsides  at the end of a few days.  In
the Italian  campaign, I saAV cases in which Min-
nie balls  had traverseel  the breadth  of the face, 
AVOUNDS OF THE FACE.
269
passing  through each molar  bone,  without leav-
ing any  injurious sequelae.   The  rapidity with
which all wounds of the face heal has often been
remarked.
  The  most common injuries  to  the face from
gunshot Avounds  are fractures  of the upper and
lower jaws.   Balls often become  embedded  in
the soft, spongy  bones  of the  face, and, if  not
discovered in time, are discharged spontaneously.
AVhen the bones of the face are struck by a grape-
shot, or a flattened conical ball,  there may  be
great destruction  of the  features, followed  by
shocking deformity.
  The  senses  are not unfrequently  destroyed—
Bight or smell  being often impaired, if not com-
pletely lost  after  gunshot injuries.  AVhere  the
Avound has been  received  in the  orbit, the loss
of vision is  not only very  probable, but there is
great fear that the cause  producing the  injury,
Avhether it be  a ball, bayonet,  or  a SAVord point,
may have perforated the thin plate of the skull,
entered  the  brain and may  induce  cerebral   in-
flammation.   Many  cases  of  apparently  trivial
wounds of the eyelids  have terminated fatally,
and  an  autopsy  revealed  serious  injury  to  the
anterior  lobes  of the brain  and  its  enveloping
membranes.    Such  cases  should   be  carefully 
270           AVOUNDS OF THE FACE.

watched, anel any cerebral symptoms, which  may
arise, should be actively met by the antiphlogistic
treatment, heacleel by venesection.
  From the great vascularity of all the structures
composing the  face, Ave would expect  to have
serious hemorrhage  accompanying  all injuries—
for controlling which, the astringents of  iron Avill
be  frequently required.   The  vessels are  so nu-
merous that the  direct  application of  ligatures
cannot be made.  In fractures of the upper jaAv,
the bones  are  always  more or less spiculated,
with  one or more teeth loosened  or completely
detached.    As  all  portions  are  freely  supplied
with  blood-vessels, union will  take place among
the fragments, even after considerable shattering
of the bones.   Unless the fragments  are  either
completely  detached  or but  slightly adherent,
they  should not  be taken aAvay, but  should be
replaced with care,  as, in time, consolidation may
take  place  and very little permanent deformity
will be left.   Should some of these fragments die,
they will be found loose,  often as early as  the sixth
or eighth  day,  and should  be removed.    The
cold  Avater dressings,  to relieve   the  excessive
swelling, with an occasional dose of salts,  is the
only medication required.  The wound in the face
should be closed.Avith adhesive plaster, and, after 
WOUNDS  OF THE  FACE.
271
careful adjustment  of  the  movable fragments,
and the  use  of cold  water dressings for a few
days, the case is left pretty much to nature.
  When  the  soft parts, as Avell as the bones, are
crushed, secondary hemorrhage frequently recurs,
as the sloughing tissues come away.  Formerly,
the difficulty  of restraining this loss of blood was
so great  as to require, in many cases, the  ligation
of the main  vessels in  the  neck.  We uoav find
the thorough application of  the per-chloride or
per-sulphate of iron an  efficient remedy.   Should
necrosis follow injuries to the bones of the face,
the dead pieces  of bone should be removed as
they become  loosened,  or a special operation may
be  undertaken for  ridding the face of the local
cause of trouble.
  Fractures of the lower jaw are not a  rare  ac-
cident on  the battle  field,  whether from shot
wounds or other accidents.   At  times,  the entire
jaAV may be swept off by a round shot, leaving the
mouth  and  throat exposeel.   One of the  most
fearful  cases  on recorel is one in  which the  en-
tire face Avas carried  aAvay  by a  cannon ball,
leaving nothing  but  the skull proper, appended
to  the  A'ertebral  column.    The  opened  gullet
marked  the  former  site  of  the  features.   The
patient lived ten hours, and  from the  frequent 
272
AVOUNDS  OF THE  FACE.
 change of  position,  and  the  squeezing  of the
 hand AA'hen  his  Avas taken, it Avas thought that
 consciousness remained up to the time  of death.
  The surgeon accompanying the transport usually
 senels  injuries of the face to the field  infirmary
 untouched,  or, shoulel the lower jaw  be broken,
 applies a folded handkerchief or baud  under it to
 support it.   It is permanently put up  in  a paste-
 board  splint, avcII padded Avith carded  cotton, and
 secured by  a  folded cloth or double-tailed  ban-
 dage.  One  band passes   over  the vertex,  sup-
 porting the  jaws, whilst  the other passes  from
 the front of the  chin behind the head, and  then
 around the  forehead, where it is secured by  pins.
 Before the   elressings are  applied,  the  wounds
 should have  been examined carefully with the
 finger, and all perfectly-detached spiculse of  bone
 should have  been removed.  The surgeon must
 be prepared  to meet much swelling and profuse
 salivation.   All wounds of the bones  of the face
 being compound, suppuration is  soon established,
anel the secretion of pus is copious.  It Avill add
much to the comfort of the patient if  his  mouth
be swabbed out daily Avith a piece of  soft rag  or
sponge attached to a thin  piece of wood.  From
the difficulty in  swallowing, fluid' nourishment
 must be prescribed.   The constant thirst of those 
WOUNDS OF  THE NECK.
273
wounded will  be relieved by small doses of mor-
phine, or  by acidulated drinks, made either with
diluted nitric  acid or vinegar.  Injuries about  the
face are very liable to  erysipelatous attacks.   The
treatment by  the tincture of the muriate of iron,
locally and generally,  will  stop its progress.

   Wounds of the neck, with injury to the numerous
large  vessels  Avhich  course  through this  con-
stricted region, are  among the serious  accidents
in battle.  From the  anatomy of this region, we
would suppose that a missile  could not traverse
the neck in any direction Avithout destroying some
important part, nerve or artery.   We find, after
every great battle, perforations by balls in every
direction, accompanied by  violent hemorrhages;
yet, with the first fainting brought on from shock
and loss of blood,  Ave find a  spontaneous cessa-
tion of the bleeding, and  the onward progress of
the case becomes one of continued convalescence,
to perfect cicatrization. I have seen  conical balls
perforate the neck antero-posteriorly, entering just
above the sterno-clavicular junction, and passing in
the midst, if not through, the largest vessels of the
body,  Avithout producing a fatal hemorrhage.  I
have also seen them perforate the throat laterally,
on a level Avith and  just behind the angle of  the 
274
AVOUNDS OF THE NECK.
loAver jaw,  and  a  cure  equally  follow.   It is
wonderful  how the great vessels escape, or  the
rapidity with Avhich clots form ami the wounds of
such vessels close.  McLeoel reports one hundred
and  twenty-eight  cases, more or  less  severely
injured in the neck, with but four deaths.   Many,
to be sure,  die  on  the battle  field  in  a few
moments after receiving a serious  injury to  the
large arteries; but, undoubtedly, many also  re-
cover.
  The powerful  iron  styptics  are the only local
remedies applicable on  the battle field, as  the
patient could not otherwise bear the  transporta-
tion ; and  the  assistant surgeon, following  the
troops, has neither the time nor conveniences  for
ligating the bleeeling  mouths of the divideel ves-
sel, however  urgently  it may  be calleel for, to
save life.   The precautions which Avere urged in
discussing  the means  of arrest  of hemorrhage in
wounds generally must here be carefully applied ;
and  should secondary hemorrhage occur, and be
renewed, notwithstanding the  careful application
of the iron  styptic,   the safety  of the  patient
will  then lie only iu the ligation of both bleed-
ing orifices.   The anastomosis is  so  free  in  the
neck, that  all  other   operations will  be  futile,
and  the  patient  will  perish.   A ligature  upon 
              WOUNDS OF THE NECK.           275

the carotid  artery, both  above and  below  the
wound,  has  been  reported  a  failure in control-
ling  a hemorrhage, which  was only checked by
dilating the wound and ligating the  artery at the
point injured.  In enlarging the wound, the in-
cision will always be made parallel with the axis
of the neck, so as to avoid  injuring important
nerves or blood-vessels. 
CHAPTER  IX.
Wounds of the Chest—Flesh wounds—Effusions ivithin
  the  cavity  when the pleura is injured— Wounds of
  the  heart  or  lung—A  transfixed  chest does not
  necessarily  imply a perforated lung — Diagnostic
  value of the various symptoms—Haemoptysis, Dysp-
  noea,  Collapse,  Emphysema — Treatmeni of chest
  wounds—How inflammatory complications are to be
  combated— The treatment of a fractured rib.

  Wounds of the Chest, Avhen taken as a class,
are perhaps  the  most  fatal of  gunshot Avounds.
Many are shot down, and  die more or less rapidly
on the battle field from internal hemorrhage, with
its accompanying  suffocation,  and  are  returned
among  the  killed.  Eraser, in an  excellent trea-
tise on  chest Avounds,  based upon data obtaineel
in the Crimea, states the mortality to have been
twenty-eight per  cent,  of all chest wounds, and
seventy-nine per cent,  of those in Avhich the lung
had been injured.  The  Russian report gives as
their  mortality in chest wounds  ninety-eight per 
             FLESH AVOUNDS OF CHEST.          277

cent., which  is  sufficient proof of their  serious
character.  The danger in wounds of the thorax
is from visceral complications.  Should the lung
be severely injured, the  case usually terminates
fatally.
  From  the  peculiar  formation  of the  thoracic
box  and the  curve  of the ribs, balls, in striking,
are often deflected from the straight line, and, after
a longer or shorter  course, escape Avithout having
penetrated the  chest.   Often, the two  openings
correspond so accurately in direction, as to estab-
lish  a  strong   conviction of  a  direct  passage
through  or across the thorax,  when the  wound
has been but a subcutaneous  one throughout.   I
have seen an  instance in which a  ball, which had
entered the chest just below the left armpit, was
removed from a  similar position in the right side,
and, although  it had apparently traversed  the
thorax,  no inconvenience  was  experienced;  its
entire course had been subcutauoeus.  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
finger 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 AVOUNDS OF CHEST.

little  treatment.   The  cold  water  dressing  fills
every indication,  and its  application  for  a  feAv
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  military surgeons in
which balls 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, which 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
Avhich it  exercises over the brain and  circulation, 
       INFLAMA1AT0RY 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 sequela? of wounds.  When giATen in
 combination with  nitrate  or carb. of soda, its
 nauseating  effects are counteracted.
   The evil which the surgeon fears  from perfo-
 rating wounds, folloAved  by inflammation, is that
 a  serous, or sero-purulent  effusion may rapidly
 accumulate in  the thoracic cavity, anel  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 
280
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 feAv ounces to  several pints.   AVhen 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.
  AVhen the  surgeon has recognized  such  collec-
tions  as rapidly forming in the chest after gunshot
w^ounds,  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 seA'enth  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
loAvest 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 iufallible
signs laid down by authors, military surgeons of
experience inform us that  no  one  symptom is
sufficient  for  making a  diagnosis.   AVhen  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  AA'ound 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.  AVhen
       24 
282        SYMPTOMS  OF  LUNG AVOUNDS.

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 wrounds  of entrance and of exit,
with the  certainty of the  cavity being transfix-
ed, the natural belief Avould lead to a  perfora-
tion of the  lung.  A straight line between the
Avounds passes apparently  through the substance
of  the  lung, but  the  ball  in  perforating  the
rib had  been deflected  from its  straight  course,
hael folloAved,  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
Avithout touching the  contained organs.
  The  lung  may,  on  the  other hand,  be  se-
verely  injured when  no perforating wound ex-
ists.  A  blow by a  spent ball,  or  a  fragment
of shell, may make  a very superficial  Avound or
bruise  in the skin, and yet may shatter  one or
more  ribs, driving the spiculae  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 AVOUNDS.
283
great to have  caused  irreparable injury to the
lung.  The severity of  the  symptoms  Avill 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  he 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 Ioav 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 Avith
blood, and suffocation becomes  imminent, Avith
out  much  external  loss.   The  danger  from
hemorrhage is greatest  during  the first twelve 
284        SYMPTOMS OF LUNG AVOUNDS.

hours,  and  is  pretty  well  over by  the  second
daA\  It may,  however, continue for eight or ten
days,  gradually diminishing in quantity.  With
the flow  of blood from  the  Avound, 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.  Fraser, in his  recent work
on  gunshot wounds of the chest,  places a  less
value on haemoptysis than do  other military sur-
geons.   Guthrie  considers  it a proof  of lung
wound,  so does  Baudens, 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 blooel.   In  twelve cases of recovery, three had
haemoptysis.   He, therefore, infers  that  spitting
of blood  is a very deceptive  diagnostic  sign of
lung wound.  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 hearel 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.   AVhen
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
Avith 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, Avith 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 wround, 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,  Avhether 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 sAvord point  or bayonet,
and  also in cases of fractured  ribs, when  sharp
spiculse of bone have abraided the  surface of the 
SYMPTOMS OF LUNG AVOUNDS.
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 AVOUNDS.

certainty  in  diagnosis  is attained.   The  imme-
diate  danger and intensity of the symptoms will
depend upon  the  depth of penetration.  AVhere
the chest  is only superficially wounded, although
the force of the bloAv 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 off in
a  feAV 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.  AVhen
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  ciuantity  as
haemoptysis, whilst it  flows  from the  external
Avound in the  side.  If both  openings in lung
and  chest be  free, the blood escaping is min- 
          TREATMENT OF LUNG WOUNDS.        289

gled Avith  air when  the patient  coughs.  AVith
the loss of blood, the surface becomes cold  and
bedewed Avith a colel  perspiration;  the pulse is
weak and  tremulous, becoming more  and more
enfeebled until syncope comes  on, Avhich  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,  AAdiich 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  eATen directly  on to the general
hospital;  but should the distressing  symptoms
       25 
290
TREATMENT  OF LUNG AVOUNDS.
above mentioned folloAv 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 draAV 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
A^eneseetion, 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,  where 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 AVOUNDS.        291
 having  been   carefully closed Avith  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, Ave 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 Avound, 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 OF LUNG AVOUNDS.

search, close the Avound, and aAvait developments.
This examination  should  be made  before  reac-
tion comes  on.  Should avc 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, Avhen suppuration is A\'ell  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 elyspncea,  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 LUNG AVOUNDS.        293

er opportunity.   The collection  is  retained  in
certain  cases, Avhen  no dyspnoea exists, for the
purpose of retarding, and finally  controlling the
bleeding, by  pressure upon the lung and its in-
jured  blood-A'essels.  After  the  third or fourth
day, the tendency to  hemorrhage  having ceased,
anel  the wounel  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 Avas taken to favor the flow7
of fluids  from  the chest, anel  dilatation of the
Avound Avas 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  onAvard,
simple water dressing Avill be the only local treat-
 ment  requireel  for  the  Avound.  If  the   orifice
from  a punctured Avounel  has healed, Avith es-
 caped  blood remaining  Avithin  the  chest,  the 
 294        TREATA1ENT 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 Avithdrawn
 through a puncture made at the most dependant
 portion of the chest.   This operation, unless  call-
 ed for by urgent or elistressing symptoms, should
 never be hastily  performed,  but should, on the
 contrary, be  delayed as  long as possible.
   During the  treatment of perforating Avounds of
 the  chest,  elyspncea, whenever urgent,  should
 ahvays 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
 Avound  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,
 avc have  already recognized  a valued aid for
 checking hemorrhage, and  its remediable advan-
tages should be appreciated.   As a syinptom, 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 
           TRK.ATAIENT OF LUNO AVOUNDS.        295

stimuli  must  be administered  only  in  small
quantity and  with  great  caution.   AVhen   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 pueumonia 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  Avhich  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  recove-
ries have been made  without recourse  to   the
lancet.  Guthrie uses the lancet, which he desig-
nates  the first  and  most essential  remedy,  and
which he says should  be  resorted to in every 
 296        TREATMENT OF LINO AVOUNDS.

 case.   The venesection, Avhich he repeats  when-
 ever the inflammatory symptoms show an increase,
 is  vigorously  folloAved by  large  eloses  of  tartar
 emetic in  pneumonia,  anel  calomel in pleurisy,
 the object being to affect  the gums as  soon as
 possible.   This is the treatment of the old school,
 Avhich  recent experience does not uphold.  Guth-
 rie states  "that in the Crimea bloodletting  had
 not been so favorably vieAved, nor found so  ser-
 viceable,  nor  so necessary."'   Eraser,  from  Cri-
 mean  experience,  states that  in  the prevention
 and reduction of inflammatory action in perfora-
 ting  Avounds 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 Avith.   When the heart  and  pulse
 are both Aveak, a common  condition  after severe
 wounds, the abstraction of blood  Avill 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  folloAving gunshot wounds,
 and Avhich is equally applicable to chest Avounds.
 Even Avhen the lung  is inflamed Ave Avould prefer
 the mild,  expectant anel antiphlogistic  treatment
to the spoliative.   Absolute  rest,  cooling bever- 
TREATMENT OF LUNG AVOUNDS.
297
 ages, moderate nourishment, avoiding OATer-stimu-
 lation, with small doses of tart, emetic, veratrum
 or digitalis,  with the liberal use  of opium, and
 attention to  the intestinal secretions, Avill 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  betAveen the injured  lung and thoracic
 Avail, which will at once isolate the  injured portion
 and prevent  inflammatory sequela*.  As  gunshot
 Avounds  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.  A\:e must  remember this in the treat-
 ment, and  not use depressing agents.  AVhen 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 luiio- 
298        TREATMENT OF  LUNG AVOUNDS.

to the  thoracic  Avail  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 would 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
Avounels  lays  doAvn general  laAvs 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 Avails 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 OF LUNO  WOUNDS.
29!)
   In cases of fractured ribs,  from gunshot injuries,
 the  bone  is usually  spiculated,  and some of the
 fragments may accompany the ball  in its  omvard
 course.   Upon examination  with  the  finger—
 executed Avith  great caution from the  fear of
 pushing the fragments  into  the chest  and  con-
 verting  a  simple  wound   into  a  perforating
 Avound,  ahvays a serious accident—these irregu-
 lar  fragments, if detected, should  be  remoA-ed,
 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  pleurae
 and  lung.   AVhen removed, and the sharp edges
 of the  rib, which turn  in  toward the  cavity,
 are  excised, the Avound  should be  closed with a
 Avide,  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 spicuhe are not displaced, a broad  adhesive
strap is the only  local apparatus required.   Ne-
crosis of the rib  very commonly folloAvs  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 Avill be discovereel by drawing out the
lips of the wounel Avith  a tenaculum, Avhen the
vessel shoulel 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.
   AVhen foreign bodies, as balls, pieces  of bone,
cloth, wadding, etc., are  driven into the pleural
cavity  they  produce fatal  results, by inflamma-
tion anel  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  bore  a fair  relative  proportion
to  other  wounds,  immeeliately  after a  battle,  a
lew  days sufficed to remove them—so that, by
the end of  the  first  Aveek, there Avas scarcely one
to be seen.  As  a  rule,  all who have received 
302
PERFORATING WOUND.
wTounds of the large abdominal viscera die—the
exception, of restoration to health, being rarely
met Avith.  Like Avounds of the chest, Avhere  the
abdominal Avails are not perforated, but the  en-
tire, track of the ball lies in the thickness of  the
muscles, the w^ound is  simply a flesh Avound 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, Avhilst, 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 Avhy attempts
should not be made to cause union in the muscles,
anel, therefore, avoiding the peritoneum, I  would
include all  the  tissues,  even to  the  transversalis
fascia,  in the suture.  When this  is  clone, the
cicatrix will  be firmer,  and  there  will be less
probability  of secondary  hernia—a very common
accident after injury  to the abdominal walls.
  In probing abdominal  wounds, the only  object
to be  sought by the examination is  Avhether the
wound 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 wound; whilst with
the finger,  or a gum bougie,  the course  of the
wound, should it be a flesh wounel, 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 AVOUND.
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  Avithin  the abdomen,  closes  the
wound by sutures,  if it be  an   incised Avound;
or a broad strip of  diachylon plaster, if a gun-
shot Avound.  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, Avhich 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.
C05
cavity  is  impossible  without  inflicting  injury
upon  the  bowel,  the intestine should be  drawn
to one side, and,  using great caution, the wound
should be  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  AA'ithin  whilst enlarging the Avound.   The
return of  the boAvel  should  ahvays be effected
by  the  ambulance  surgeon  before  the  case  is
transported to the field  infirmary,   inasmuch  as
the croAvding of  the  Avounded  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 within the abdominal cavity, and
not forced  under the sheaths of the abdominal
      26 
306
INTESTINAL INJURY.
muscles, Avhere it Avould  strangulate and  rapidly
destroy life.
   Should the case not be seen until  several houra
had elapsed,  the intestine should be  equally  re-
turned Avhether it be congested or inflamed; but
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 Avound, 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 Avet or oiled cloth, until the
wounded soldier reaches the field infirmary, when
it is closed Avith 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 oft* 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 seAving  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 alloAved 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 folloAvs.
   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 boAvels Avould haA'e been  suspended, and
 the Avounded 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 throAvn into the peritoneal caATity where
it  Avould produce  fatal inflammation, on account
of the  adhesions of the  boAvel near  an external 
308
INTESTINAL INJURY.
outlet, will escape  externally,  Avhich  diminishes
materially the  risk run  by  the patient.   The
threads usee! in closing the  opening in the intes-
tine either escape through  the bowel by stool,
or are discharged through the abdominal wound.
  AVhen examining the external Avound AA'hen no
protrusion exist, should we find an escape of fecal
matter—AAdiich  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 boAvel  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 boAvel  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
Avill form  adhesions to the peritoneal eelge 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 faeces
seeking their normal passage, or an operation at
some  subsequent period remoA^es the deformity.
  In examining  the archives of surgery, Ave find
cases  in which  portions  of the intestines have
been  cut  off, the cylinder of the boAvel reunited
bv  sutures,  and excellent recoveries  obtained.
These experiments  have been  tried  successfully
upon  animals, and instances are met Avith Avhere
the human subject has  been saved by a similar
operation.  I ha\re recently had under my care a
lunatic,  avIio,  some  months  since,   attempted
suicide  by opening  his  abdomen,  dnuving  out
his bowels, and  cutting off two feet of intestine.
Dr. Gaston, of Columbia, S. C, Avho had the case
under charge, brought the  two ends of the intes-
tine together, and  securing them  by  carefully
arranged  sutures,  returned  them   Avithin  the
cavity.  The patient  made  a  perfect recovery.
This  accident, Avhich 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 Avound
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.  ■
  AVith 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 Avill 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, Avill 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  Avound 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  nowr  be
given, although  it would be better to wait one or
two  days  longer, when the risks of reopening or
disturbing  the wound would be  but slight.
  If peritoneal inflammation be  excited  Avith  fe-
brile  reaction,  with  pain greatly  increased  by
pressure  over  the  abdomen,  more particularly
in the  neighborhood of the wound, Avith 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 internals.   If the patient  be
young and plethoric, and the  inflammatory symp-
toms are early  recognized, the  lancet might  be
used; but  usually in military surgery this reme-
dy is badly  borne.   Calomel was  formerly used
with the opium, and Avas  considered the main
dependence,  but  is  now  being  generally dis-
carded, as all advantages gained  are accredited
to the opium.
   Sometimes, in a feAV 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, shoAvs 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
has  been knoAvn 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 effects we might, at times, trace
 the resting place of the ball.  When paralysis of
 the  lower limbs  follows an  abdominal gunshot
 Avound, 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  Avails.   If the latter,  dilatation of the wound
will  expose it, and the  vessel should be ligated.
      27 
 314   HEMORRHAGE FROM ABDOMINAL INJURIES.

 AVhen 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  A'iscera 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  with  the urine;
 the  escape  of  special  secretions, as bile, urine,
 or fa'ces  by the Avound ;  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 Avounds, which
on the Avhole 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  wounds  of  the  kidney, frequent micturition
Avith  bloody  urine  marks the injury; Avhilst  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: shoulel 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 Avith 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  parts
often obstructs the ready Aoav 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.
  AVhen the neck of the blaelder, or the prostatic
part of  the  urethra has  been  divideel,  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 doAvn 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  folloAvs, 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 Avithout 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  n,»w 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  shoAvn  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, Avhilst,
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; anel should the patient
rally from this condition, AAdiich 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, wdth the foot, a
cannon ball  rolling on the ground, and Avhich is
just about exhausting its force, perhaps Avith only
momentum  sufficient to carry it one or two  feet
further, yet it crushes the  limb put out to oppose 
THE EFFECT OF SPENT  BALLS.        319
it.  Baudens, in warning persons to avoid cannon
balls, however sloAvly they may be rolling on the
ground, mentions the case of a grenadier of the
guard, sleeping  on  his side on  th'e 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  Avounds, these  will
not require to be again noticed.   Those which we 
INJURIES OF  THE EXTREMITIES.
321
will noAv 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  in
diminishing  mortality  and mutilation.  Xot that
amputations  Avill  ever be  abolished, for many
lives can be saved in  no  other Avay 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 Avho removes crushed limbs
Avith the greatest skill, and saves the patient  by
successful  after-treatment, will ever  deserve the
high position which humanity and  philanthropy
will bestoAV  upon him.
   In gunshot Avounds  of the extremities,  Ave find
a much greater vitality and resistance to  injuries
in the  upper  than  in the loAver  limbs, which
Avould  modify the treatment of  similar  injuries
located  in these two portions of the  boely.   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,  Avhen, 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 neA'er 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 spiculae  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 extend into
 the  joints,  or the  cases for operation would  be
 much  more  numerous than  they hoav  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 knowleelge of those agencies
 antagonistic to the healing of wounds, and wdiich
 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 Avithout delay, to the general
 hospital, where the  treatment  commences   On
 the field,  the  ambulance surgeon can do nothing
 but  aelminister 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 sling  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 Avet or greased
cloth  is ahvays  put over the Avound for its  pro-
tection  during  the transportation.
   AVhen he arrives at the hospital, the limb  is
carefully  examined.   The  external  Avound  may-
give no indication of the extent of internal injury.
When the finger is introduced  and  the wound
carefully explored,  the degree of  crushing AA'ill be
ascertained, anel the  question at  once  proposes
itself,  Avhat course shall Ave 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, Ave should, with Sir Charles Bell, contem-
plate Avhat Avill  be the  conelition of the parts  in
twelve  hours, in  six  days, or  in  three months.
" In twelve hours the inflammation, pain and ten-
sion of the Avhole limb, the inflamed countenance,
the brilliant eye, the sleepless anel restless condi-
tion,  declare the impression the  injury is making
on the limb anel on the constitutional powers.   In
six days, the limb, from the groin to the toe,  or
from the shoulder to the finger, is SAVollen to half
the  size  of the  body;  a violent phlegmonous
inflammation pervades the Avhole; serous effusion 
should the limb be amputated ?     325
 has taken place in the whole  limb, 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
 tAventy-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 
326     SHOULD THE LIMB BE AMPUTATED?

action has been Avell  established.   Should ery-
sipelas attack the wound, an amputation  is im-
practicable; and AA'hen gangrene  has supervened,
during the  stage  of reactionary excitement,  Ave
are driven to an  operation under  the most un-
favorable  circumstances.
  There   are  many  compounel  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 with  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, Avhich has fractured the bones of the arm
without implicating a joint, the following  is the
course to  be pursued.   At  the field infirmary
the Avound is carefully  probed  with  the  finger,
and its spiculateel condition  noted.   All loose
fragments  are  to  be  removed  at this first ex-
animation  before  reaction  ensues,  for it  aauII be
very injurious to  the wound, as Avell as exces-
sively  painful to  the soldier,  to continue  such
examinations from day to day.   The first exami-
nation should ahvays 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 spiculae,
the further removal should  not  be  attempted
during the stage of excitement  and febrile reac-
tion Avhich will come on after twenty-four hours,
and which  will run its  course in six or  eight
days.   When this  subsieles,  then and not before,
we  make  the  second examination, and by  the
use of  instruments,  remove any loose  fragments 
328             REMOVE  SPICULE.
 which  Ave  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,  wdiich  cannot be  too  severely
 condemned as useless, injurious, and  very painful.
   Modern surgery recommends that all  spiculae,
 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-
 culae, Avhich 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.   Xo 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  Avith  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, Avhich 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 round 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.
Hutin, the surgeon of the institution.  He states,
that  those  spiculae Avhich  had  been  attached
to the soft parts, and which were alloAved 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
eliininative action, Avhich 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
spiculae,  and thus simplify the wound.   If these
be retained, endless  suppuration, continued suffer-
ing, Avith exacerbations  of all the symptoms at the
escape of  each  fragment,  will gradually exhaust
the  vital forces, and entail its sequelae of maras-
mus, diarrhoea  and  hectic."   Suppuration Avill
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  remain,  and the  necessity 
REMOVE  SPICUL/E.
331
 of extracting every piece which is not extensively
 attacheel to the soft parts, ghres his experience as
 decidedly  in  favor of the  modern  practice of re-
 moving  all movable  spicidce 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 Avith
 the old ball,  it Avas  desirable  to meddle as  little
 as possible with the fragments; but this is the
 teaching of only a feAv.  However,  to my mind,
 the  question  assumes  a totally  different  light
 when vieAved  by  the pathological  results which
 we had occasion to witness."
   Some surgeons go  further, and recommend that
 not only  should all spiculae be removed, but that
 the sharp,  irregular  ends of the bones should be
 saAved 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, Avill expedite  the  cure.
In  surgery,  wdienever  Ave  are  in  doubt,  we
should ahvays give the patient the benefit of it;
and in the subject  under  consideration, knowing
that the removal of spiculae, 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  wounel as  much  as
possible, and treat the case as one of  simple frac-
ture.  Inflammation and suppuration we expect;
they  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 pilloAv,  or loosely
 secured to a broad, long splint, which will support 
        PAIN NOT NECESSARY FOR HEALING.     333

the entire extremity.  AATe 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 Avhich is  better than the
continued renewal of wet cloths.  The general
treatment during  this period  of  inflammatory
excitement,  is  diet, rest, quiet,  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  Ave 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, Avhilst a free vent is allowed
in the apparatus for the escape of discharges from
the Avound; 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  Avill  ahvays  be
shortened,  AA-here  many spiculae  have  been re-
moved.   AVe acknoAvledge  this fact in anticipa-
tion, anel never attempt, by traction and counter-
extension, to restore it to its former length.   AVe
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, Avill make the best
application.   The  tumefaction   bandage  is  not
noAv insisted  on, and  by many surgeons is nearly
altogether discarded.  In gunshot injuries, where
wre  have  an  open  avouik! 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
Avhen disarranged; Avhilst, 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 Avith  perfect consoli-
dation.  In  animals with compound fractures, Ave
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 Avith  astringents to  allay
profuse  discharges, or with antiseptics to remove
faetor, or  with  stimuli  to  promote  granulations,
will  be the proper  course, wdiilst 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,
otherAvise  they  will  become surrounded by new
formations,  anel as sequestra, incarcerated  in  an
involucrum, will only be expelled after much time
and  trouble. From  time  to time, when spiculae
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 has 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  excesshTe,  becomes a  serious obstacle
to rapid  cicatrization.   It is a common error for
surgeons to place  a wounded limb over  a basin
of wTater, and sponge  and  rub  it as if they were
cleansing a piece of porcelain.  I have seen others
dress gunshot Avounds 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 Avipe or  wTash the granulating  surface
of a wound.  Wipe around the edges and remove 
338     AVHEN ARE AMPUTATIONS REQUIRED?
any secretions which might have collected upon
the skin, but leave the pus, as the best covering
Avhich healthy granulations can have.   Under its
protection, the plasma, Avhich  is thrown out from
the blooel-vessels,  will rapidly form tissues;  but
rub or Avash 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 will  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.
OAving to the free  anastomosis of the blood-vessels 
               AVHEN 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-
ij        plication,  as it necessitated an amputation, which,
        under the  ordinary circumstances attending hos-
        pital  treatment,  Avas  not  far  removed from  an
t        early  dissolution.  Xor have we much to boast
        of: for,  when amputations  near the  trunk  are
        required,  notwithstanding all  the  improArements
        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
        wounel.  The  dangers  are  serious  enough Avith 
840        SYMPTOMS  OF JOINT AVOUNDS.

the smallest puncture, but  when  the  wound is
large and lacerated, extensive local mischief and
constitutional disturbance is  sure to ensue, lead-
ing with certainty to the  destruction of the joint,
and  usually destroying the  patient.   Ileiice,  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, Avhere,
from the very small  size of the wound, we hope
that no  trouble  Avill supervene, that  violent in-
flammation shows itself and  life is  sacrificed.
  A wounded joint,  under the ordinary  hospital
treatment,  Avill pursue the following course:
  AVhen a ball has perforated the joint, the peri-
od of reaction is not long absent.   In extensive
wounels 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, anel
will   soon  involve all the  structures.   All  the 
SYMPTOMS OF JOINT AVOUNDS.
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 founel 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 feAv days open con-
tinuous  passages to  the joint,  from  which  a
constant discharge  of  purulent  matter escapes.
If the  patient  is  not  elestroyed  in  the  early
stages of the disease by  erysipelas, pyeemia, etc.,
in connection Avith the  irritative  fever, he falls 
342     NECESSITY OF 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  wounels 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 elay, 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 eliagnosis 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, Ave  proceed at once to operate.   A  primary
 resection is  as  essential as a  primary  amputa-
 tion,  and  is  folloAved by  as  successful  results.
 It should  be performed within  tAventy-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 OF  RESECTION.
reaction has come.on, then by general, mild, anti-
phlogistic  treatment, and ice  bladders  or cold
water  dressings  locally, we  aAvait the establish-
ment of suppuration, when  the operation  might
he  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 wdien the
operation is performeel  during the stage of  febrile
excitement.  There  are  three or four rules  neces-
sary in all cases of resection,  and Avhich 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 Avay 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.  RemoA'e 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  Avill, to a certain
extent,  reproduce the  bone.   In performing sec- 
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 dowirward  for   three  inches,
 makes a large flap of the deltoid, Avhich 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, Avhen the  head will protrude from its 
346         TREATMENT OF 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 anel vessels
from  injury,  and all  of  the injured portion  is
removed.    AVhen the  ball has  entered  directly
within  the  joint, only the  surface  may  require
excision;  but should  the head  of  the bone  be
extensively  spiculated,  Ave 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 any way be avoided.
  When the wound has been cleansed of all for-
eign bodies, the  flap is replaced anel 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  arounel
the joint are much swollen, anel a collection soon 
TREATAIENT OF RESECTION.
:U7
 forms within the cavity from which the bones have
 been removed.   The  escape of this  decomposed
 blood and pus from the wounel 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 neAV relations by a
 lymphy  exudation;  they become  more or less
 incorporated Avith 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, Avhich
 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 Avill 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 Avhich 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 slight!}7 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, Avithout 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 Avater dressings are continued until
a complete cure is  effected.  AVhen the parts are
nearly cicatrized, it Avill 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
pyaemia.   Of eight cases  in which the operation
Avas 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 burroAving
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 coirvaleseence, 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 elied : an exempli-
 fication of a general rule laid down in the  com-
 mencement of  this  chapter,  that  the  Avounded
 bear operations before the  stage of  reaction, or
 after the  establishment  of suppuration,  much
 better than they do Avhilst  suffering  under  high
 inflammatory excitement.   This shows 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 wTater  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  Avill  remove   the
 oedema  of  the  limb.  Instances of  good results
 are recorded for injuries at the wrist-joint, AA'here
 the spiculated ends of both radius  and ulna have
 been  satisfactorily removed;  also, instances in
 Avhich 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, Ave
 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, Avhen they should be removed; but for ordi-
nary gunshot 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 Avhich can be saved Avill be
better  than the best artificial  limb.  In cases of
lacerated hands in military surgery, Avhen attempts
are made to save the limb, under cold water dress-
ings, the  inflammation Avhich 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 anel granulations are forming, the
swelling subsides,  the  torn  portions  are draAvn
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 injury 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 A-ascularity, 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,
Avhere  it is  often the only  way of escape left to
save the life of the wounded.
  AVe  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 spiculae should
be taken aAvay.  Sequestra frequently show them-
seh'es  from time to time  during the  treatment,
and  are  withdrawn.   When  the  ball  strikes
loAver  (Ioavii, 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, Avith  all of its  appliances, im-
provements and experience, assist in saving the
life and limb of such seriously wounded?   AVithin
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 mini-
bers treated — that it Avas 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 (Ioavh
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 eloes  not ahvays
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 Avith  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  Avound 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 Avhich neither  blood-vessels  nor nerves  are
 injured, nor  the soft  parts  extensively torn.   If
 all or any of such  are injured, Avhere experience
 teaches us that the  chances  from successful resec-
 tion are more than doubtful, do  not  have recourse
 to amputation Avhich 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 Avas  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  Avas made  more  comfortable.
Had the conveniences for treatment been greater,
anel the general sanitary  condition of the troops
better, with less pyaemia, hospital gangrene  and
scurvy, much  better results might have been ob-
tained.  Some of the cases wrere eloing 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, hoAv-
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, Avhilst 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.  AVater 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 Avith  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 Avhen 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 performeel  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  Avith diseases of the bones, his
prospect for a successful  resection appears to be 
358
HIP-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.
   AVe preface the following  table, taken from  Ar-
mand's Histoire  Medico-Chirurgicale de la Guerre
de Crimee, Avith  the suggestion that an}' surgeon
who  has ever had a successful case of  resection at
the hip-joint, has ahvays been eager to publish it;
Avhilst 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:
j Operated)     j
  upon.  Cures. Deaths.
Larrey.  (Volume 3, Clinique;............
J. Cooper.  (Dictionary).................
Letcille.  (Relatione du Siege d'Anvers, par
  M. H. Larrey).........................
Hutin.  (Memoires de Medicine et de Chi-
  rurgie  Militaires)......................
Sedillot.  (Annales de la Chirurgie Franeaise
  et fitrangere).........................
Guyon.  (Expedition de Churchill, Algerie)
Iluchet.  (Journees de Juin, 1818)........
Gubiot.  (These de Montpellier, 1840).  ...
French Crimean Service..................
McLeod.  (Crimean AArar)................
Stromyer...............................
 5
 1
 1

 9
 5
 1

36
1*
35
 * This successful case was found, after the articulation had been laid open, not
to be a fracture extending within the joint, but confined without the capsule; and
we are, therefore, justified in the belief that the case would have done equally
well  without the resection. 
CO.AIPOUND FRACTURE OF THIGH.
359
SECONDARY OPERATIONS FROM GUNSHOT AVOUNDS.
Larrey.  (Clinique, volume 5).............
Guthrie. (Clinic, volume 5)..............
Baudens.  (Traite des Plaies d'Armes a feu)
Ferussac.  (Bulletin des Science Medicales,
  volume 3).............................
Robert.  (Journee de Juin, 1848).........
Guersant.  (Journees de Juin, 1848)......
A'idal.  (Traite dc Chirurgie).............
Mounicr.  (Constantinople, 1854).........
Legouest.  (Constantinople, 1854).........
McLeod. (Crimean AVar)................
12
   It  has been  suggested, that if the patient who
has been operated  upon  could have facilities for
slinging the  whole body,  it would afford  many
advantages  in  the  management  of excisions of
the hip-joint.
   A  compound fracture in the upper third of the
thigh shoulel 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.   AVe have already said that,  in field
military surgery, amputation near the  trunk is
synonymous  Avith  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 ha\Ting
his life saved.   We will carefully remove all loose 
300
COMPOUND FRACTURE OF THIGH.
and moArable spicula?, elilating the Avounds if neces-
sary,  to  facilitate the  thorough cleansing of all
foreigu  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
Avith topical antiphlogistic applications.  Dispense
with bandages.   On the eighth or tenth elay, 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,  anel be
the cause of much trouble and suffering.
  In  all compound  fractures,  Avith  much loss of
bone, it  is ahvays 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 Avithout
 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, Avhere 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 w ill die ;  but  if avc have
facilities in a well-ventilated and well-organized
hospital, Ave 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 Avith  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, Ave will  obtain,  will depend
upon the state of health of the sufferer and  the
conveniences  for treatment.
   There are cases Avhich often appear so trivial—
only a small  bullet hole leading to  the crushed
p,one_that it seems barbarous  surgery to con-
demn  the limb without an  attempt at saving it.
The young military  surgeon expects much from
conservative surgery in such  cases.  We  are  in- 
          COMPOUND FRACTURE OF THIGH.       363

 formed  by the  experienced,  that this striving
 after conservatism is the  main cause of the heavy
 mortality.   Surgeons generally are not prepared
 to  believe how hopeless compound fractures  of
 the  thigh  are,  until the  unwelcomed  truth  is
 forceel  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,  Ave
 should  attempt to save  the  limb—-it is the proper
 course  to pursue; but  on  the  battle  field,  with
 the  deteriorateel  material  upon   which we are
 operating,  and  the poisoned atmosphere of the
 Avards into Avhich  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 Ave save limbs.
 As  a rule,  amputations  are  less  hazardous the
 greater  distance Ave operate from  the  trunk, and
 the reason Avhy 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-JOINT.

  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  remeely  is  used.    When
the splinters of bone are  removed, there is con-
siderable space  for the play  of  the rough edges
remaining, and  Avhich,  therefore,  give but little
trouble.
  Should  avc  attempt to saAre a fractured thigh
in its loAver 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 burroAving 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 Avell  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.      365

pear,  if the synovial sac be  entered, and  air be
admitted, or a foreign body lie within the joint,
violent  synovitis,  with great pain, swelling and
heat, and with excessive  inflammatory fever, will
come  on after  twenty-four or thirty-six  hours.
Should the patient survive the inflammatorystage,
erysipelas,  pyaemia or hectic will  ultimately  de-
stroy  life ;  and  although on the other hand,  the
effusions may be absorbed, and a good anchylosed
limb saved, it is a very rare occurrence.   If  the
soft parts are not much lacerated, or the  blooel-
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 Avay that the  surfaces  will
adapt themselves  to each other.   When  the ex-
ternal AA'ounel is closeel 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 
36(5
TREATMENT  OF 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 eloubtful  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 Avithin the joint,  the
articulation should  be largely opened,  and  the
joint thoroughly  cleansed, Avhether avc 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 Avith 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 Ave 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  Ave  would  do 
368       COMPOUND  FRACTURE OF THE LEG.

were hospitals  in the immediate neighborhood  of
the battle field where the Avouneled could be treated.
How, for instance, could Ave transport  witli any
chance  of success  a resected joint, such  as the
shoulder or  a  gunshot fractured thigh  or leg ?
Under such  circumstances  an amputation  woulel
give the  patient a  much better chance for life,
Avhich  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 immeeli-
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, Avhilst we use those remedies
already suggested for keeping down  an excessive
reaction, Ave 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 Avill
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 elboAV.  It is recommended as a con-
servative practice, but is seldom  practiced.   AVhen 
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 lhTes  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 Avhen
 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 A^essels and nerves are torn, even Avithout
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 obtaineel; or in severe com-
 pound  fractures; or often  in  apparently simple
 compounel fractures, where  experience  teaches us
 that although the wound appears  trifling to-day,
 in attempting to  save it we will sacrifice a life a
 feAv  days hence.  Amputation is also  compul-
 sory when mortification of the limb rapidly fol-
 Ioavs  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 iavo 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 Avithin 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 AA'hen an amputation can 
372          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, Avhich is ahvays 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  folloAved—of removing  at once all limbs  in
which  the blood-vessels  anel  nerves are exten-
sively  injured in connection  with  the  crushing
of  the  bont;s.   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 Avhite;  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 aboA'e  or  below  it, elepending
upon the seat of injury ; or it may creep up to
the  knee,  where  it ecpially shoAvs  a disposition
to  limit its  extension.  AVhen 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, AA'ith 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 Avounded suffer—subsides, and then give chlo-
roform.    Shoulel wTe not  have  the time  for  its
proper inhalation, Ave may inject a half grain  or
more of morphine under the  skin,  which will 
374         RULES  FOR AMPUTATING.

produce a rapid blunting of nervous sensibilities;
and in  five 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 seconel  com-
presses  the main  artery,  which  is much  better
than using  the tourniquet—an instrument  Avhich
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 wdio ad-
ministered  the chloroform during the incisions,
can assist in ligating the  arteries.   Military  sur-
geons  prefer  the circular operation to the flap,
Avhich  they  only  use  in  the  exceptional  cases.
With the circular  stump,  coArereel  only by  skin,
there is  less soft tissue to suppurate and slough,
and a  much more  rapiel 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 AA1PUTATING.          375

 neA'er commence an operation until he has satis-
 fied himself on  this score—the surgeon removes
 the  limb, 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 Avound.
   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   Avell
 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 avcII as one of the
 most frightful exhibitions in  military hospitals,
 Avhere 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  Avith 
376
DRESSING OF STUMPS.
the saw, and  not attempt, through  Avant 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  eA^en 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 woundeel.  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 by 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  laid
doAvn  for wounds is  here strictly applicable, and
should be closelv followed.   Sutures are recom- 
DRESSING OF 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 Avith 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 Avound,
  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 Avound into  a subcutaneous  one, exclud-
 ing  the  air and hastening union.  To the  stump
 no other dressing^ is applied,  the wound being
 exposed.  No 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 
37S
DRESSING OF STUA1PS.
the diachylon  being too irritating and  not  suf-
ficiently pliant  to  seal  hermetically  the  Avound.
AVe  fin el but little use  for  ointments in  dress-
ing stumps,  the wTet  cloth  being much simpler,
not irritating, and therefore  more efficient.
  During the treatment  of all Avounds in  milita-
ry hospitals, previous want  and exposure, Avhich
belongs  to every army, however well organized,
Avill show their influence ; and if the plan of abste-
mious or antiphlogistic eliet be adopteel for those
operated upon,  from misguielecl 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 tliQ surgical statistics of the French anel 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 Avho 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 days  after a seriojis operation  there
 is but little disposition to eat.   Under such con-
 ditions, I  Avould  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,
 pyaunia, etc., Ave  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
 Avay until  this fear  of secondary hemorrhage  is
 passed.  AVe 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 Avhich the surgeon should
 never be Avithout, and which  might be used  on all
 occasions with advantage;  Avhether for  operations
 or for dressing painful wounds, as in  the cleans-
 ing of compound  fractures.   The  effects  of chlo-
roform are Avonderful in mitigating  the suffering
of the Avounded,  and it is  often  instrumental in 
380        CHLOROFORM INDISPENSABLE.

the cure of Avounels, from the rest and tranquility
of mind which  folloAvs  its inhalation.   It  also
prevents excessive reaction  in  the  paroxysms  of
traumatic fever.  During the performance of capi-
tal operations on the battle 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 ames-
thetics, in refusing  all innovations, -still insist on
decrying the  dangers  of this potent remedy, and
moralize upon the duty of suffering, as submitting
to an  express infliction from on high.   Although
the  French  surgeons  in the  Crimea report tfie
successful  administration of chloroform to thirty
thousand wounded,  without a  single accident, and
McLeod refers to its  great  utility in the Crimea,
where  it Avas administered to  twenty  thousand
soldiers, and  more than  realized the most enthu-
siastic  anticipations of the  medical staff's, 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   aelministration  of
 chloroform  in  the severe  shock of serious gun- 
CHLOROFORM INDISPENSABLE.
381
shot Avounds, as he  thinks  that few will survive
Avhere  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, anel
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 remeely, and proof of
its necessity: and  now  Ave  consider it an essen-
tial among  army  supplies.   For  ourselves, who
place unlimited confidence in its judicious admin-
istration, and, Avith 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 Ave  hope  to  see
amesthetics used as liberally in allaying the pain
of surgical affections as colel Avater is iioav used
for keeping  down inflammation.   We  do not hesi- 
882         HOW TO  GIVE  CHLOROFORM.

tate to say, that  it should  be r/ircn  to every jxiticut
requiring a serious  or painful operation.   \\re  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.  ISToisy breathing is the sign that the ames-
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  annoyed 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 very com-
mon occurrence—or should the  assistant  admin-
istering the  anaesthetic  be at  all  interested in
the operation, the cloth  is thrust down  upon the
face of the patient, respiration  is impeded, and
suffocation  is imminent.   Suppose  the  patient
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 readily 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-*
siou 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 No. 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,
lor 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 case 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 
oSiS
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-funeral a monthly return
 (Form 2) of the medical officers of the command.
   7. . . .The Medical  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  3<>th 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 ti) 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-
(ieneral, 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- 
390
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.
   2fi. .. . 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.
   37 .... 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.
393
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 endi 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 aciount 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.
  46.... 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
 inarches  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
 ureent 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, op 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, 
390                    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 known 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.
397
[It is urged that medical officers make requisition only fir such medicines in the
               following table as are deemed indispensable.]

Standard  Supply Table for General  and Post Hospitals.
Quantities for one year for commands of
From
100 to
 200.
From
200 to
 300.
From
300 to
 400.
500  i  1.000
men.   men.
MEDICINES.
 Acii;-;;e...................lb.
 Acidi acetici...............lb.
   "  arseniosi.............oz.
   "  benzoiei.............oz.
   "  citrici........     .. .lb.
   "  muriatici............lb.
   "  nitrici...............lb.
   "  sulphurici............lb.
          "     aromatici... .lb.
   "  tannici..............oz.
      tartarici......'.......lb.
 iEtheris sulphurici loti......lb.
 Alcoholis................bott.
 Aluminis..................lb.
 Aramoniacia...............lb.
 Ammonia; carbonatis.......oz.
     "     muriatis.........lb.
 Anthemidis................lb.
 Antimouii et potass, tartratis.oz.
 Arjrenti nitratis (crystals).. .oz.,
    "       "    (fused).....oz.,
 Arnica;....................lb.
 Assafoethho...............oz.
 Bismiithi subnitratis........oz.
 Camphors.................lb.
 Cardamom i................oz.
 Catechu...................lb..
 Ceras albae*...............lb.,
 Cerati resinas............lb.,
   "  zimplicis............lb.,
   "  zinci carbonatis......lb..
Cbloroformi................lb..
 Collodii..................oz..
 Copaiba;...................lb..
Creasoti...................oz.,
Crctte preparatse...........lb..
Cupri sulphatis
Emplastri adhsesivi.
cantharadis
.vds.
..lb.
 2
 4
 4
 1
 1
 4
 1
 1
 1
 2
 2
 2
24
 1
 4
 8
 4
 l
 3
 1
 1
 1
 4
 4
 2
 8
 4
 2
 2
 8
 2
 1
 2
 5
 2
 1
 2
 5
 3
4	6
1	2
1	2
2	3
2	3
1	2
2	3
2	3
2	3
4	6
4	6
4	6
48	72
2	3
1	2
16	24
1	2
2	3
6	9
2	3
■2	3
2	3
8	12
8	12
4	6
16	24
1	2
4	6
4	6
16	24
4	6
2	3
4	6
10	15
4	6
2	3
4	6
10	15
6	9
 8
 24
 24
 4
 4
 24
 4
 -1
 4
 8
 8
 8
1)6
 4
 n
32
 24
 4
12
 1
 4
 4
16
16
 8
32
 24
 S
 8
32
20
 8
 4
 8
20
12
i'l'o be issued to posts where simple cerate cannot be sent without becoming rancid. 
398
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.
Emplastri ferri............lb.
     "    hy drargy ri.......lb.
     "    ichthyocollae ..  .yds.
Extracti belladonnas........oz.
    "    buchu fluidi.......lb.
    "    colchici acetici ... .oz.
    "    colocynthidis comp. oz.
    '•    colombae fluidi.....lb.
    "    conii.............oz.
    "    cubebaa fluidi......lb..
    "    gentiauas fluidi ... .lb.,
    "    glycyrrnizse.......lb..
    "    hyoscyami........oz.
    "    ipecacuanhas fluidi.lb.
    "    piperis fluidi .....
    "    pruni virg. fluidi.
    "    rhei fluidi.......
    "    sarsaparillas fluidi
    "    senegas fluidi....
    "    sennas fluidi.....
    "    tarasaci fluidi...
    "    valerianaa fluidi..
    "    zingiberis fluidi..
Ferri iodidi................oz..
  "  et quinias eitratis......oz..
  "  sulphatis.............oz..
Gainbogias................oz..
Glycerine.................oz..
Guaiaci resinas.............lb..
Hydrargyri chloridi corr... .oz..
     "        "     mitis.. .lb..
     "      cum creta.....lb..
     "      iodidi..........oz..
     •'      oxidi rubri.....oz.
.lb..
.lb.,
.lb.
.lb.
.lb.
.lb.
. oz.
.lb.
Iodinii.
oz.
.lb.
Liquoris ammonias......
         ferri iodidi....
   "     potass: arsenitis
   "     sodaa chlorintas.
   "     zinci chloridi ..
Magnesias.............
    "    sulphatis.....
Mas-a; pill: hydrargyri.....oz
Mellis despumati...........lb
Morphia? sulphatis  ........dr
..lb.
..lb.
. .oz.
bott.
bott.
..lb.
.  lb.
1
4
3
2
1
1
8
1
1
1
1
6
2
4
1
1
1
2
4
1
1
8
4
2
4
2
4
2
4
4
1
4
 1
 l
 2
4
 4
 1
 2
 3
 3
 4
25
 8
 2
 2
 2
 1
 6
 4
 2
 2
16
 2
 2
 2
 2
12
 4
 1
 2
 2
 2
 4
 1
 2
 2
16
 1
 4
 8
 4
 1
 4
 1
 1
 2
 1
 2
 2
 4
 1
50
16
 4
 4
 3
 3
24
 3
 3
 3
 3
18
 6
 2
 3
 3
 3
 6
 2
 3
 3
24
 2
 6
12
 6
 2
 6
 2
 2
 3
 2

 3
 6
 12
 12
 3
  6
  9
  9
  2
 7.")
 24
  6
  6
 4
 24
12
 8
 4
 4
32
 4
 4
 4
 4
24
 8
 24
 4
 4
 4
 8
 24
 4
 4
32
 24
 H
16
 8
 24
 8
 24
 2)
 4
 24
 4
 4
  8
 16
 16
  4
  8
 12
 12
  24
100
 32
  8
  8 
APPENDIX.                       399
SUPPLY TABLE  FOR HOSPITALS—Continued.
Quantities for one year for commands of
Myrrhas...................lb..
Olei anisi..................oz..
  '• cajuputi..............oz..
  " caryophylli...........oz..
  '■ cinnamomi............oz..
  " menthas piperitas......oz..
  •' morrhuas............bott..
  " olivas...............bott..
  " origani...............oz..
  " ricini............qt. bott..
  " terebinthinas.....qt. bott..
  " tiglii.................dr..
Opii......................lb..
Picis  abietis..............lb..
Plumbi acetatis............lb..
Potassc acetatis............lb..
    "    bicarbonatis........lb..
    "    bitartratis..........lb..
    "    chloratis...........lb..
    "    nitratis.............lb..
    "    sulphatis...........lb..
Potassii cyanureti..........dr..
    "    iodidi.............oz..
Pruni virginianas.......... .lb..
Pulveris acacias............lb..
    "    aloes..............oz..
    "    cantbaridis........oz..
    "    capsici............lb..
    "    cinchonas.........lb..
    "    ferri..............oz..
    "      "  per sulphatis . .oz..
    "    glycyrrhizas.......oz..
    "    ipecacuanhas.......lb..
    "         "      et opii.lb..
    "   jalapas............oz..
    "    lini...............lb..
    "    opii..............lb.,
    "    rhei...............oz..
    "    sabinas............oz..
    "    sinapis nigras......lb..
    "    ulmi..............lb--
Quassia;...................»>• •
Quinias sulphatis...........oz..
Rhei......................°*--
Saechari...................">• •
Saponis...................'"• ■
From 100 to	From 200 to	From 300 to	500	1,000
200.	300.	400.		
4	1	2	24	5
1	2	3	4	8
1	2	3	4	8
1	2	3	4	8
1	2	3	4	8
2	4	6	8	16
8	16	24	32	64
8	16	24	32	64
4	8	12	16	32
12	24	36	48	96
4	8	12	16	32
2	4	6	8	16
*	1	2	24	5
1	2	3	4	8
1	2	3	4	8
1	2	3	4	8
1	2	3	4	8
2	4	6	8	16
1	2	3	4	8
1	2	3	4	8
I-	1	2	24	5
1	2	3	4	8
8	16	24	32	64
4	1	2	24	5
2	4	6	8	16
4	8	12	16	32
2	4	6	8	16
1	2	3	4	8
1	2	3	4	8
2	4	6	8	16
1	2	3	4	8
4	8	12	16	32
i	1	2	24	3
i	1	2	2i	5
4	8	12	16	32
8	16	24	32	64
i	1	2	24	5
4	8	12	16	32
1	2	3	4	8
6	12	18	24	48
2	4	6	8	16
4	1	2	2i	5
10-20	20-40	30-60	40-80	80-160
I	8	12	10	••'>
20	1 40	00	80	160
A	1 s	12	16	32
 
400
APPENDIX.
SUPPLY TABLE  FOR  HOSPITALS—Continued.
Scillas.....................oz.
Serpentarias...............lb.
Sodas bicarbonatis..........lb.
  "   boratis..............lb.
  "   ct potass :  tartratis ...lb.
Spigelia*...................lb.
Spiritus ammon : aromatici. .oz.
    "    astheris compositi.. .lb.
    "      "    nitrici......lb.
    "    lavandulas comp... .lb.
    "    vini gallici.......bott.
Strychnia; ................dr.
Sulphuris loti..............lb.
Syrupi  scillas..............lb.
Tincturas aconiti radicis ... .lb.
     "    digitalis..........oz.
          ergotas (Dublin)., oz.
     ''    ferri chloridi......lb.
     "    veratri viridis ....oz.
Unguenti hydrargyri.......lb.
     "       "      nitratis.lb.
Yeratrias.................dr.
Vini colchici seminis........lb.
Zinci acetatis..............oz.
  "   sulphatis.............oz.
  "   chlorid............. oz.

          INSTRUMENTS.

Buck's  spongeholder for the
  throat..................no.
Cupping glasses or tins.....no.
Dissecting...............sets.
Lancets, spring*...........no.
   "    thumbf..........no.
Obstetrical...............sets.
Pocket...................sets.
Probangs.................no.
Pulleys..................sets.
Scarificators..............no.
Splints  (assorted).........sets.
Stethoscopes..............no.
Stomach pump and case ... .no.
Syringes, enemaj..........no.
Quantities for one year for commands of
From
100 to
 200.
 From
200  to
 300.
From
300  to
 400.
500
men.
 4
 4
 2
 4
 3
 4
 2
 4
 2
 4
12
 1
 1
 3
 1
 4
 4

 4
 1
 4
 1
 4
 1
 1
 4
 1
12
 1
 1
 4
 1
 1
 6
 1
 2
 1
 1
 1
 3
 1
 4
 1
 6
 1
 4
 1
 4
 1
24
 2
 2
 6
 2
 8
 1
12
 1
 1
 6
 1
 1
 6
 1
 2
 1
 1
 1
 3
12	16
2	24
6	8
2	24
9	12
2	24
6	8
2	24
6	8
2	24
36	48
3	4
3	4
9	12
3	4
12	16
12	16
2	24
12	16
3	4
2	24
3	4
2	24
3	4
3	4
1	2
1	1
18	18
1	1
2	2
8	8
1	1
1	1
6	(i
1	1
2	3
1	1
1	1
1	1
3	3
Four extra fleams to each lancet   t With raKee.  J I Davidson's: 1. 4-oz.; 1, 8-oz. 
APPENDIX.
401
SUPPLY  TABLE FOR HOSPITALS—Contiuued,
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, field..........no.
     "      spiral.........no.,
Trusses, hernias............no.,

             BOOKS.

Anatomy...............cop.
Chemistry................cop.
Dispensatory  ............cop.
Medical Dictionary.......cop.
   "    Formulary........cop.
   "    Jurisprudence and
          Toxicology.....cop.
   "    Practice..........cop.
Obstotricy................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       >..........no.
Reports of sick J

        HOSPITAL STORES.
Arrowroot................lb.
Barley....................lb.
Cinnamon................lb.
Cloves ....................oz.
Cocoa.....................lb.
Farina....................lb.
(linger, ground (Jamaica).. .lb.
Nutmegs..................oz.
Ten.......................lb.
Whiskey, bottles of.
..doz.
 5
20
 4
 4
10
 5
 4
 4
20
 2
4	6	8
12 3	18 3	24 3
1	1	1
1	1	1
4	6	6
1	2	2
6	9	12
1		1
1		1
1		1
1		1
1		1
1		1
1		1
1		1
1		2
1		1
2		3
1		1
1		1
1		1
1		1
1		1
1	1	1
10	15	20
40	60	80
1	2	2h
8	12	10
20	30	40
10	15	20
1	2	24
8	12	16
40	60	80
4	6	8
16
36
 6
 2
 2
10
 4
21
 40
160
  5
 32
 80
 40
  5
 32
160
 16
* Hard india-rubber, 1; glass, 2.
34 
40.2                       APPENDIX.
SUPPLY  TABLE FOR HOSPITALS—Continued.
Wine, bottles of...........doz..

            BEDDING.

Bed sacks.................no..
Bedsteads, iron............no..
Blankets, woollen..........no..
Coverlets..................no..
(Jutta percha cloth........yds..
Mattresses..............• .no. .
Musquito bars.............no..
Pillow cases....'...........no..
       ticks...............no..
Sheets....................no..

   Fl'RNITl'RE, DRESSINGS, ETC.

Bandages,  suspensory*.....no..
Binders' boardsj...........no..
Corks, assorted............doz..
Corkscrews..............no..
Cotton batting.............lb..
  "     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..
Quantities for one year for commands of
From
100 to
 200.
From
200 to
 300.
 10
 6-10
10-20
 10
  4
  2
 6-10
 25
 10
 40
 4
 4
12
 I
 1
 I
 5
 1
 1
 1
 1
 2
 1
 5
 4
 3
 1
 3
 2
 1
 1
 1
25
25
 20
12-20
20-40
 20
  6
  4
12-20
 50
 20
 80
21
 1
 2
 2
10
 1
 1
 1
 1
 2
 1
10
 6
 3
 1
 6
 2
 1
 1
 2
50
25
From
HOO to
 4oo.
 500    1000
men.   men.
6	8
30	40
18-30	24-40
30-60	40-80
30	40
8	10
6	8
18-30	24-40
75	100
30	40
120	200
12	16
8	12
36	48
2	2
3	4
3	4
15	20
2	2
2	2
2	2
1	1
3	3
2	2
15	20
8	10
4	6
1	1
9	12
2	3
2	2
1	1
2	3 •
75	100
25	25
6	8
12
* Assorted, f 18 inches by 4.  J inches by 1.  |. 2 cups to 1 glass. 
APPENDIX.                       403
SUPPLY TABLE  FOR HOSPITALS—Continued.
 Pans, 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..............no..
 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..
 Tapef................pieces..
 Thermometers and  hygro-
  meters.................no..
 Thermometers.............no..
 Thread, linen.............oz..
 Tiles.....................no..
 Tow......................lb..
 Towels..................  no..
 Twine.....................lb..
 Urinals...................no..
Vials, assorted............doz..
Wafers (J oz. boxes)........no. .
Wax, sealing...........sticks. .
Quantities for one year for commands of
From
100 to
 200.
From
200 to
 300.
From
300 to
400.
500
men.
  2
100
  h
 10
 12
 12
  6
  2
  3
  1
  2
 25
  1
  1
  1

  1
  U
  2
  4
  i
  4
  3
  4
  4

  2
  1
  4
  2
  1
20
  1
  2
  6 ■
  1
  3
  2
125
  1
 12
 20
 18
  S
  3
  6
• 1
  4
 24
  1
  1
  1

  1
  1
  2
 2
 1
 4
 3
 2
30
 1
 3
12
 1
 3
  ::
150
  2
 15
 20
 24
 10
  3
50
 1
 1
 1
 2
 4
 J
12

 2
 1
 6
 3
 2
50
 14
 5
18
 2
 4
  4
200
  2
 15
 20
 30
 12
  4
 12
  1
  8
 50
  1
  1
  1

  2
  1
  3
 10
  4
  24
16

 2
 1
 6
 3
 3
75
 14
 6
24
 2
 4
1,000
men.
   I)
250
   3
 20
 30
 50
 18
   6
 24
   1
 16
 50
   1
   2
   2

   2
   1
   4
 12
   1
   5
 12
   1
 32

  2
  1
  8
  4
  5
150
  3
 10
 48
  3
  6
  * Assorted. 3 sizes—'-Official business." printed on each, f Foolscap, letter and
note—white; blue ruled.  J One quarter, woollen: three quarters, cotton.
% 
404                    APPENDIX.

  H the following articles of Hospital  Furniture cannot be c
tained with the hospital fund, they may  be procured from
(juartermaster or medical disbursing officer, by special requi
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.

                                      I      Quantities.
Reg't   Bat.  I Comp.
3 mos.  3 mos.  3 mos.
                  MEDICINES.
Aeidi acetici............................lb.
  "   sulph. aromatici....................lb.
  "   tanniei............................oz.
/Etheris sulphurici loti...................lb.
Alcoholis..............................bott.
A lu minis................................lb.
Ammonias carbonatis....................oz.
Antimonii et potass, tartratis.............oz.
Argenti nitratis (crystals)................oz.
           "    (fused).................oz.
Camphorae............................«.lb.
Cerati resinas...........................lb.
   "    siniplic-is..........................lb.
Chloroforini.............................lb.
Copaiba-................................lb.
Creasoti................................oz.
Cupri sulphatis..........................oz.
Emplastri adhassivi.....................yds.
     "     cantharidis...................lb.
           ichthyocollas...........".....yds.
Extracti belladonnas....................oz.
     "'   colchici acetici................. oz.
     ■'   colocynthidis comp..............oz.
     ''   glycyrrhi/ae.....................lb.
Hydrargyri chloridi corrosivi.............oz.
     "         "    mitis................lb.
Iodinii.................................oz.
Liquoris Ammonise......................lb.
     ''   potass, arsenitis.................oz.
Magnesias sulphatis......................lb.
Massas pil:  hydrargyri..................oz.
Morphias sulphatis.......................dr.
Olei caryophyllL........................oz.
  " nieulhas piperitas....................oz.
  " olivas.............................bott.
  '' ricini..........................qt. bott.
  " terebiuthinas...................qt. bott.
  '- tiglii...............................dr.
Pilul: cathartic: comp: (U.S.)..........doz.
  "   opii (U.  S.).......................loz.
  "   quinias sulphatis (3 grs.)...........doz.
Plmnbi  acetatis..........................lb.
Potasses bicarbonatis.....................lb.
    ■'    chloratis........................lb.
    •'    nitratis.........................lb.
 1
 1
 2
 2
10
 1
16
 2
 2
 2
 4
 2
 8
 2
 2
 2
 4
10
 4
10
 1
 2
16
 2
 4
 2
 4
 4
 4
20
16
 4
 1
 2
 S
12
 8
 2
4	2
1	1
4	2
4	2
4	2
1	4
4	i
1	A
4	i
 
406
APPENDIX.
SUPPLY TABLE FOR FIELD SERYICE—Continued.
ARTICLES.
      QUANTITIES.
!  lie-1 |  ltat.  I  Comp.
| 3 mos. | 3 mos. |  3 mos.
Potassii iodidi..........................oz. .
Pulveris acacia?.........................lb..
    "    capsici.........................lb..
    "    ferri per sulphatis...............oz..
    "    ipecacuanhas....................lb..
    "         "       et opii.............oz..
    "    lini.............................lb..
    "    opii...........................lb..
    ''•    rhei............................lb..
    "    sinapis nigras....................lb..
Quinias sulphatis........................oz..
Sacehari  ...............................lb..
Saponis.................................lb..
Soda- bicarbonatis.......................lb..
Spiritus ammonias  aromatici..............oz..
    "   astheris nitrici....................lb..
    "   vini gallici.....................bott..
Tincturas ferri chloridi...................lb..
    "   opii.............................oz..
Unguenti hydrargyri.....................lb..
    "          "     nitratis.............lb..
Zinci acetatis...........................oz..
  "   sulphatis..........................oz..
  "   chlorid............................oz. .

                 INSTRUMENTS.

*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..
Probaugs, whalebone...................no..
Scarificators............................no..
Splints (major)......................sets..
 8
 4
 4
 4
 1
 8
16
 2
 4
12
24
10
 S
 1
 4
 2
24
 1
16
 1
 4
 2
 2
 1
 1
16
 1
 6
 1
12
 4
 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.
  f Half glass, half tin. 
APPENDIX.
407
SUPPLY TABLE  FOR FIELD SERVICE—Continued.
|      Quantities.
  Reg't I  BatT  I Comp.
| 3 mos. | 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)................
Medical Practice..................
Regulations for medical department.
Surgery (operative)  ...............
Thompson's Couspectus............
Blank............................
■ cop.
.cop.
.cop.
.cop.
• cop.
. no.
HOSPITAL STORES.
Arrowroot...............................lh.
Candles (sperm)..........................lb.
Farina...........  ......................lb.
Ginger, (fluid extract)...................lb.
Nutmegs................................0Zi
Tea  ....................................lb.
Whiskey, bottles of.....................doz.
Blankets, woollen (brown)................no.
Blanket  cases (of canvas, after pattern).. .no.
Gutta percha cloth......................yds.
  "      "   bed coversf.................no.
Mosquito bars..........................no'
          FURNITURE AND DRESSINGS.

Bandages,J roller, assorted..........
.doz.
10
 2
10
 1
 8
30
 2
20-40 10-20
1 for  10 bla
         4
12
      10
    nkets
       2
4  I    2
6      4
14
*1 Davidson's; 1 hard rubber, 6 oz.
f So constructef], as to form, when united a continuous spread or covering.
£1 dozen, 1 inch wide, 1 yard long.
 2  '-2     "3
 2  ••   »A   "    3    "
 1-3     "    4    "
%  "   S'A   "    5  •  "
Yi  -   4     «    «    « 
408                        APPENDIX.
SUPPLY TABLE FOR  FIELD SERVICE—Continued.

                                        I       QUANTITIES.
ARTICLES.
| Reg't  I  Bat.  I Comp.
I 3 mos. ', 3 mos. | .'! nios.
Bandages, suspensory, assorted...........i.o.
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 (1 inches by 1, in wood)............no.
Ink, 2-ouuce 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, bcd||.............................no.
Paper envelopes, assorted^................no.
Paper, wrapping.....................quires.
  "    writing*].....................quires.
Pencils, bair............................no,
  "     lead (of Faber's make, No. 2).....no.
Pens, steel.............................doz.
Pill boxes (wood;....................papers.
    '■      (tin).........................no.
Pins, assorted (large and medium).....papers.
Razors.................................no.
Razor  strops............................no.
12	6
IS	y
4	2
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
S	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
* According to pattern.
f 6 oz. 2 oz., minim.
J 2 cups to 1 glass.
|i Of hard india-rubber or other material.  Shovel.
j!50 letter. 25 note, 25 large.  '• Official Business" printed on eacu#
'2 foolscap, 6 letter, 4 note, white; blue ruled.     ■         ' 
APPENDIX.
409
SUPPLY TABLE FOR FIELD SERVICE—Continued.
Quantities.
 Reg't I  Bat.
3 mos.  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 (i ounce boxes)..................no
Wax, sealing................."........sticks.
1	1
4	2
4	2
4	i
1	• 4
6	3
1	4
4	2
2	1
2	1
40	20
4	i
4	2
4	2
1	1
2	1
 1
 2
 1
 i
 4
 2
 i
 1
 1
 1
10
 i
 l
 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 (i rater.
 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 
 
APPENDIX.
411
                     Form 1—Continued.

DISCHARGES ON SURGEON'S CERTIFICATE, AND DEATHS.
Name.		Rank.	Regiment.	a a a, a o	Disease.	Date of dis-charge from service.	Date of
Surname.	Christian name.						death.
							
REMARKS.
  Notes -Discharges on Surgeon's certificate, and deaths occurring among those
ofTeTommanaaXn0"4 Sport, will be *^but,para^ from th
others by a double line drawn across the page  The """•"" ^lin

Tn^TroM^^
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. 
Form  2.
Return of the  Medical  Officers  of the  Rcrjular Army,  Volunteer Corps,  end Militia,  indudin,/  Physicians employed
                 ■under contract, Herring  in  the  Department of -------, for the Month  of -------,185—.
No.	Names.	Rank.	Post or station.	WiTn what troops serving.	Remarks.
					
                                                                                                                   Surgeon.
    Note.—The names will be arranged in the following order: 1st. Medical Officers of the Regular Army; 2d  Those of Volunteer P
and Militia: 3d. Private Physicians. In the column of-'Remarks" will be noted all changes.in the position'of Medical Officers and I'Hv'.f
Physicians, whether on duty, or on leave of absence; giving the number, date  and source of the order directing or authorizin-'^uch rlrino-n
the time of the departure of the officers from their posts and the date of their return to duty.  If to a new post  its position must hn
indicated by reference to some known point  as------miles north from------river, town, or post-office. The remarks oppo-dte the inmes
of Private Physicians, will state,  in addition to the above, the name and rank of the party making the contract  the Wo,. th«>,.., !f Ti?„
monthly compensation, and the date of their discharge from service.                              6           "■    ",UC tne,t-°l- the
    The Meilical Directors will require from the Medical^Officers and ^Private Physicians in their respective Departments, monthly reports
to enable them to make out and transmit this Return to the Surgeon-General. 
                       Form 3.
RETURN OF MEDICAL  AND  HOSPITAL  PROPERTY.

	d	,		^		►»*s	Sh			
		u		o		.Q a	«2			
	3	■s		01		*2		o		
				ja			a	a>		
										
Articles and Characters	eS			J3		o «3		13		
or Quantities.	d	.s •a				$ 3	O "3	a CD p.		Remarks.
	a	o> .		IS		s s				
		E: °		q		° fe-			a	
	.q	SS	c6	P.	©	es	S3 a> u <a	C3	.a	
	a	0> "^	o	M		o 3	o 3	if		
	o	PS	H	w	M	h-5	£	H	O	
										
    I certify, on honor, that the above return is correct, to  the best of my knowledge, and that the medicines and
stores have been expended with the sick belonging to the army alone.
                                                                                -------------> Surgeon.
    ?i. B.—Returns will always be transmitted in duplicate, and by different mails. 
                                                   Form  4.

Abstract of Medical and Hospital Property received and issued at ------, )')i the quarter ending on the ------ day of
                                 ------, ISO , by--------------,  Medical Purveyor.
	received.						ISSUED.								
Articles and Characters or Quantities.	d c	e<i d 3 C >	d 3 o >	d 3 O >	d 3 o	o	r-i O 3 o >	o 3 O >	CO o 3 o >	o 3 O >	o 3 o >	50 O 3 O >	o 3 O >	CO o 3 o >	"3 o H
						i									
I certify that the above abstract is correct.
                                                                          -------------, Medical Purveyor.         4*.
N. B.—Invoices and receipts must accompany this abstract.                                                         £J 
                                      Form  5.

              REQUISITION FOR MEDICAL AND  HOSPITAL SUPPLIES.
                          Station : ------.        Period :------.
                                 From------to------.                            •
Command: Officers,----;  Enlisted Men,----; All others entitled to Medicines,----; Total,

Articles and Characters or Quantities.	On hand.	,,r . , ' Articles and Characters Wanted. „ ^ or Quantities.		On hand.	Wanted.
Acacisc. - ' - - - lb. Acidi acetici, - - - lb. " arseniosi, oz.					•
Date :
                                                                                                Surgeon.

    N. B.—Requisitions will exhibit the quantity of each and every article  "on hand," whether more wanted or not.
They will be transmitted in duplicate, and by different mails. 
                                Form  6.

     SPECIAL REQUISITION FOR SUPPLIES  OF  MEDICINES,  Etc.

Requisition for Medicines (Hospital Stores, etc.) required at--------, for -----
Acet: plumbi, lb. i.
Pulv : cinchonee, lbs. x.
    Etc., etc.
    Etc., etc.
  I certify that the medicines above required are necessary for the  sick at ------, in consequence of [here state
whether from loss, damage, etc., etc.], and that the requisition is agreeable to the Supply Table.

                                                                                      ------------, Surgeon.
Approved :                                                                  ------------,  Commanding Officer.
Received,------186—, of------------, the articles above enumerated.
                                                                                      ------------, Surgeon. 
                                                Form  7.

ACCOUNT FOR MEDICINES, etc, PURCHASED BY A SURGEON OR AN OFFICER OF THE QUARTERMASTER'S DEPARTMENT.
  I certify that the articles above charged, for the use of the sick at------, are agreeable to the foregoing requisition,

and that the charges arc reasonable and just.


                                                                                      ------------, Surgeon.
  Received,----- 186—, of--------,----dollars and----cents, in full of the above account.

                                                                                                      A. B.

  Note. — The above certificate may be signed by the Surgeon making the requisition, or by any Surgeon or Assistant

Surgeon belonging to the army.
cc
The Confederate States,


                                             To A B,                                                Dr.


                Acet:  plumb: lb; i, at 50 cts.  -----.......$50
                Pulv :  cinchon :  lbs : x, at $2.....-......20 00    >*
                      Etc., etc., etc.                                                                           2

                                                                                                             W
                                                                                                             SS
                                                                                                             o 
Form  8.
ACCOUNT  OF HOSPITAL STORES, FURNITURE, Etc., ISSUED.
Date.	2	u ce fee 3	03	q3	>> 13 a a M	o a	d	d	d			Remarks.
	Lbs.	Lbs.	Oz.	Qts.	Qts.	Lbs.	Etc.	Etc.	Etc.			
												
 
                                        Form   9.

ACCOUNT  OF CLOTHING,  ARMS,  EQUIPMENTS,  Etc.,  OF PATIENTS  IN  HOSPITAL.
No.
Regiment
or corps.
>-.						.a						
												
												
												
s o 5J			0) 6	^	I	c	K	s	w			
When delivered.
Remarks.
  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. 
Form  10.
ACCOUNT OF FURNITURE, COOKING UTENSILS, BEDDING, etc., IN USE.
u a 6 7<	■A 1	O	si	o M a s	o	p o o ft	> "a	.3 o	5	d										o iJ	3 O 3 -o	u o i3 o >> ^= 01 o ft	T3 u (S « o © a Fh 3 a>	Remarks. «
																								The remarks will state how articles have been lost, and by whom destroyed, or the persons sus-pected, etc.
 
	> 3 CO I
	Rank.
	Regiment or corps.
	Company.
	o M
	Admitted.
	Returned to duty.
	Deserted.
	Discharged from service.
	Sent to general hospital.
	On furlough.
	Died.
	w a ;» w CO
•XiaN3cI.IV
£?f 
                         Form  12.
PRESCRIPTION BOOK,  DIET BOOK, AND  DIET TABLE.
NAMES.	Sunday.	Monday.	Tuesday. t	Wednesday.	Thursday.	Friday.	Saturday.
.		•					
		•					
							
  mv.„ „^onoa In tViR PrescriDtlon iiooK are 10 ue unou up mm ™o p^ow.^.^.^ —< »«"6-"> -~~  v™^ „. „«.*.....„„v,..u8
Ji.n?.V«dtto?iSSiie. to be given at each time.  The diet of the patients will be divided into full, half, and
l    * V-hi designated in the Diet  Book by the letters F. H. and L.;  and in order that the steward may have precise
Suctions fo? delivering the hospital stores, etc., the surgeon will, from time to time, insert in the Diet Book written
instructions ior         *>  f    h   u ,  •  his store room wnlch he may think necessary to each degree  of diet.   To
d  vrelentMDrfxample on low diet, a certain quantity of tea, sugar, etc.  To each ten on half diet, a certain
eacn ten paiieu«.          These proportions will soon  become  familiar to the steward, who has only to refer to the
Otters in the'Diet Book, to ascertain the whole quantity of any article to be delivered for  the day, as well as the quan-
leuers in iuc x-io   Wv__ nnv Honor is directed, or any other article not contained in these general instructions of the
Sur^rthe'prct q^S "jffi for^h patient will be noted in the Diet Book.  The Diet Tables are to be filled
ip daily from  the Diet Book, and hung up in each ward of a general hospital. 
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 commander 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 whicli 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 proliable ease for petition.  sy« rial can  nniHt In- taken to Mate
           the degree of disability.
        z  The place  where the a,,lil,rr desires i-. I,i-iinine.m^il run l.e h.-. <■ a i I.- I
           7>.ii/7l—             fvaiiity              State 
                           Form  14.
MORNING REPORT OF THE SURGEON OF A REGIMENT, POST, OR GARRISON.
	Company.	Remaining at last report.		o a a H	Total.		3 O CJ 3 t. 3 O	-3 ft	"c3 I* cp 3 . hc_g -w o 02	T3 CD ft	Uemaiiiiiig.		
Date.		"c3 "3. o ,a • s	U <o 3 s M		3 '3, o ,3 3 M	u o u 3 o* 3 M					"3 "3. o .3 3 M	3 3 h-1	Remarks.
													
 
426                    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------
(tt)id 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  jnonthly 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. 
APPENDIX.
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 whole amount due this month,
    • at 9£ cents per ration,    -
  Cr.
By the following provisions, at contract prices:
  283£
  690
l,612T2g
   10
   70
   56
  193-J-a
   *H

   61*
   161
   12
lbs. of pork, at 6 cents per pound,
lbs. of fresh beef, at 4c. per pound,
lbs. of flour, at 2 cents per pound,
lbs. of hard bread, at 3£c. per lb.
lbs. of rice, at 6 cents per pound,
lbs. of coffee, at  9 cts. per pound,
lbs. of sugar, at 8 cts. per pound,
qrts. of vinegar,  at 5c.  per quart,
lbs. of candles, at 12c.  per pound,
lbs. of soap, at 6 cents per pound,
qrts. of salt, at 3 cents per quart,
galls, molasses, at 28c. per gallon,
           purchased.

2 prs. of chickens, at 87|c. per
    pair,    -     -
4 qts. of milk, at 7c. per quart,
3 doz. oranges, at 25c. per doz.

     Total expended,

     Balance due this month,
$1  75
 0  28
 0.  75
$17	01
27	60
32	244
0	35
4	20
5	04
15	51
0	85|
1	83?
3	67i
0	m
3	36
L12 18?
2 78
$ 0 00

145 54
114  96|

$30  571
-, Surgeon.
[ Date.] 
42S                     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.  AVheu 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.  ) 
                          Form  18,

RECORD OF  RECRUITS EXAMINED BY
—,  AT
Where Born.
Date.
Name.
Town or County.  State or Kingdom.
Age.
Profession.
By whom
 enlisted.
Remarks.
SO 
 
APPENDIX.
4:;i
                   EXTRACTS
                        FROM THE

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 depdts 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."
  718.."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 prac- 
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 Hanks 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, wliere 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.
   1013. .The allowance and change of straw for the sick is
 regulated by the surgeons. 
APPENDIX.
433
   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 commissan', 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, sour-crout, or molasses, with an extra quantity of
        37 
434                     APPENDIX.
rice and vinegar.  (Potatoes  are  usually issued at the rate of
one pound per ration, and onions at the rati' 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 are
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 not be 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 discrepany 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 case the two latter
only are present, then the one  not responsible will perform the
duties, and the 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
(o the head-quarters of the  department or army in  the  field, as 
436
APPENDIX.
the case may  be,  duplicates being  furni.shed  to  the  officer
accountable for the  property.
  3. .AH 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, who  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
ordinaril} 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, whicli 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.
  6. . 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. 
438
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  perishable  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, Army 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, adopted
for a state of war with a civilized enemy:
  For commands of less than three companies, one two wheeled 
APPENDIX.                    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, and 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.	Hospital tents.	Sibley tents.
1
1
1
1
1
For one company. . .
For three companies
For five companies. .
For seven companies
For ten companies . .
The  adoption of a hospital knapsack is  recommended to be 
440                    APPENDIX.
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
                 CORRESPONDENCE.
  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 No. 2.
             MEMORANDUM
                        FOR THE

INFORMATION  OF  MEDICAL OFFICERS

                IN THE ENGLISH ARMY,
          ON TAKING THE FIELD FOU ACTIVE SERVICE.
  1. .. . The ambulance equipment for one division of the ami}-,
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  ajiy 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 seciiim 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 lint, 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 binder 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 full 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 sprint
wagon to where  the surgeon and third assistant are 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 easily 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, whenwounded.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 
ATPENDIX.
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:
lieturn of Killed and Wounded in the ------ Regiment, in  the Action

                         of------■
	Killed.	r)iinj;i-r-uusly.	Wounded.		Total Wounded.	Remarks.
			Severely	.slightly		
Officers. Non-com-IlliNfsilMH'll officers and pri-vates.						Names of officers kill-ed and wounded to be inserted here.
 
 
'V'  *f.>t
Chisolm, Manual of military surgery, WQD C544m 1861
Condition when received:  The half leather volume had
been recased at some time in the past. The front fly page and
the t.p. bore stiff linen tape at the gutter.  The t.p. was
missing  the top right corner. All three pages bore small
foredge tears. A foldout located at page 410 was detached
and in poor condition. Some folds had failed and others were
weak.
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it

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