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MILITARY SURGERY, 
 
 FOR THK USE OF 
 
 SURGEONS IN THK CONFEDERATE STATES ARMY; 
 
 oHplanafonr pates jjJ[ all Isrful derations. 
 
 BY 
 
 J. JULIAN CHISOLM, M.D., 
 
 PROFESSOR OK SURGERY IK THK HEDICAL COLLEGE OF SOUTH CAROLINA, 
 i RQEON IN THK CONFEDERATE STATUS ARMY, ETC. 
 
 THIRD l:PITI»> f'ARKFI'LLT REVISED AND IMPROVED. 
 
 COLUMBIA: 
 F.VAXS AND COGS WEI I 
 1864 
 
Entere 1 according to Ad of Congress, Id the yeai 1864, bj 
 
 J. J. CHI80LM, M.H.. 
 
 In the Clerk's office "f the Dist iict Court of tlic Confederate States for the 
 
 District of Booth Caroline* 
 
 Kvank 4 Cooswr.i l. Printers, Colombia, 8, C, 
 
HS.2L 
 
 SAMUEL PRESTON MOORE, C. S. A., 
 
 Sl'Rr.EON-UBNKRAI, OF TUB CONFEDERATE STATUS ARMT, 
 
 IN APPRECIATION or THE VERY EPFICIEN1 MANNER IN ivhii n HE 
 
 HAS AHIlANIItn AND CONDUCTED THE BEST OHGANIZET1 OF 
 
 ALL THE J'EPAKTMENTS OK Ml R AKMY. THIE 
 
 BOOK rS RESPECTFULLY 
 
 hli>i> A i El' 
 
PREFACE TO FIRST EDITION. 
 
 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 sur- 
 gical 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. 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 
 blockading of our ports, all communication was cut off with 
 Europe, which was the expected source of our surgical informa- 
 tion. As there had been no previous demand for works on mil- 
 itary surgery, there were none to be had in the country, and our 
 physicians were compelled to follow the army to the battle with- 
 out instruction. No work on military surgery could be pur- 
 chased 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 times of war, where invasion threatens, every citizen is ex- 
 pected to do his duty to his state. 1 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 contains 
 the fruit of European experience, as dearly purchased in re- 
 cent campaigning. Besides embodying the experience of the 
 
VI PREF \' I 
 
 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 i* to 1" sustained; 
 also, the duties of military Burgeons, both in th>' camp ami iu the 
 field. 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 
 tu the point the subject under discussion, I have not hesitated 
 to transfer entire sentences directly to these pages. I make 
 this acknowledgment en masse 6f the very liberal use of the 
 following works, as quotation marks were sometimes over- 
 looked : 
 
 Maximen der Kriegsheilkunst, von L. Stromycr, Hanover, 
 L855; Supplement der Maximen der Kriegsheilkunst, von L. 
 Stromyer, Hanover, I860; Loeffler Behandlung der Schuss- 
 wunde, Berlin, 1859; Histoire MeMicc-Chirurgicale dela Guerre 
 de Crime*e, par le Docteur Adolphe Armarid, 1'aris, 1858; La 
 Guerre de Crimee, par L. Baudens, Paris, 1858; I>es Plaiea 
 d'Armes a feu; Communications — Paites a l'Acade*mie Nation- 
 ale de Medicine, 'Paris, 1849; Notesof the Wounded, from the 
 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 Fra- 
 Ber, M.D., London, lx. r >y; Guthrie's Commentaries on Military 
 Surgery, London, 1855; McLeod'a Note, on the Surgery of the 
 Crimean War, London, 1858; Hennen's Principles of Military 
 Surgery; Lairey's .Military Surgery; Ballingall's Outlines of 
 Military Surgery ; Gross' System of Surgery ; Erichsen's Science 
 and Art. of Surgery ; Jackson on the Formation. Discipline, and 
 Economy of Annies: SeMilot, Medicine Operatoire, Paris, 1859 ; 
 A Practical Treatise on Military Surgery, by F. II. Hamilton, 
 M I>., New York, 18C1; Report Medical Department (Army) 
 ordered by the Bouse of Commons to be printed, July 3, isotj; 
 Gavin on Feigned Diseases, London, 1848. 
 
 August, 1861. 
 
PREFACE TO THE THIRD EDITION. 
 
 After three years of incessant and bloody warfare I have been 
 called upon to embody, in a new edition of " The Manual of Mil- 
 itary Surgery," the large experience of the medical staff of our 
 army. It has been my aim to condense, in a concise, practic.il 
 form, the improvements in the treatment of gunshot wounds which 
 have been developed during our active campaigns, and repeated- 
 ly confirmed upon thousands of wounded. In collecting this ex- 
 perience, I am under heavy obligation to my friend, Surgeon 
 II. Baer, P. A. C. S., who was kindly permitted by Surgeon F. 
 Sorrel, C. S. A., the accomplished and efficient Inspector-General 
 of Hospitals, to collate for me condensed tabulated reports of all 
 the papers in his office, comprising the official reports of all the 
 hospital and field surgeons of the Confederate army. Only 
 those who have undertaken to tabulate statistics can appreciate 
 the labor of Surgeon Baer. Through his assiduity we have an 
 opportunity of contrasting our surgical experience with that of 
 European armies. An examination of these tables will show to 
 what proficiency surgery has attained in the Confederate 
 States. 
 
 June, 10, 1864. J. J. CHISOLM. 
 
I N 1 > E X 
 
 A. Page. 
 
 Abdominal wounds 887 
 
 viscera, rupture of .">:"> I 
 
 Abscess on the brain 297 
 
 Accident to stumps -421 
 
 Ambulance corps 112 
 
 corps in tbe Prencb service ' 1-1 
 
 wagons 1 04 
 
 Amusements in camp 57 
 
 Amputation at ankle-joint 471 
 
 of arms 46fi 
 
 at elbow-joint -102 
 
 of foot 4 72 
 
 of forearm 169 
 
 of finger I. r >l 
 
 of band 4. r >7 
 
 at bip-joint is:', 
 
 at knee-joint I. so 
 
 of leg 1 7 ('» 
 
 modes of operating 117 
 
 necessity for 409 
 
 necessary in secondary hemorrhage 212 
 
 primary ::fi(l 
 
 at shoulder-joint 409 
 
 table of .111! 
 
 of tbigb IM 
 
 of toes 4 71 
 
 treatment after l2o 
 
 Anal fistula . r i2:> 
 
 Anchylosis i:;;. 
 
 Ankle-joint, injury to IDs 
 
 ion of I'.is 
 
 Annual allowance of clothing 2-> 
 
 Anterior wire splint of Smith .".'.'7 
 
 Appearance of gunshot wounds 167 
 
X INDEX 
 
 Arm. amputation <>f 
 
 treatment iu inn-tun- of 
 
 : lit-iii<.rrh:i^e 168 
 
 4^'.' 
 
 i\ill:ir\ . ligature ol 
 
 carotid, ligature of .'iU^ 
 
 1 1. ligature of ">1 1 
 
 femoral, ligature of >lfi 
 
 fibular, ligature of 614 
 
 humeral, ligature of 
 
 iliac, ligature of 51 s 
 
 I Ingual, ligature of 511 
 
 radial, ligature of 504 
 
 .-n l 'i-l a via n, ligature of 507 
 
 superior thyroid, ligature of BIO 
 
 tibial) ligature of 513 
 
 ulna, ligature of 503 
 
 gimeotal surgoon, duties of 128 
 
 hospital lurgeon, duties of 88 
 
 a general hospital 88 
 
 in Beld hospital C:( 
 
 Axillary artery, ligation "I 
 
 U. 
 
 for trnopi :i7 
 
 Balls, dei lation of 168 
 
 Bit of 
 
 D Of I-l 
 
 Battening ol 101 
 
 Boding ol 161 
 
 rorrepi IU 
 
 incarceration <>t 166 
 
 in peh !•■ r.ivin 
 
 866 
 
 I ! Ill V 1 I B 
 
 Battle-flold 1 88 
 
 medloal mppliat t"i 168 
 
 i.. nt ..i grounds on 166 
 
 Bayonet wi.un.l- 'J I .; 
 
 
 
 ...t in hospitals s i 
 
 ite 86 
 
 Bivonae 17 
 
 Bladder, gunsbol wound "I 
 
IN'hF.X XI 
 
 Bleeding vessels, how found 207 
 
 Brachial artery, ligation of 50.5 
 
 Brain, abscess on '. 297 
 
 concussion of. .- 274 
 
 foreign bodies in . .299 
 
 compression of 27 S 
 
 hemorrhage on 2S7 
 
 inflammation of 285 
 
 Boots of soldier 22 
 
 Bread in the army 88 
 
 C. 
 
 Cacolet of the French army i . . . 104 
 
 Cam] 4S 
 
 amusements in , r >7 
 
 cleanliness of , r i] 
 
 duties of surgeon 121 
 
 employment in 55 
 
 Caloric properties of clothing 17 
 
 Capacity of hospitals Sli 
 
 Carotid artery, ligation of ."ills 
 
 Causes of secondary hemorrhage 20fi 
 
 Cerebral inflammation, treatment of 2*.> 
 
 Chest wounds .; 1 1 
 
 Chloroform \^~ 
 
 Ch opart's amputation of foot 473 
 
 Clavicle, resection of 4S9 
 
 Cleanliness necessary to health 2S 
 
 in hospitals S7 
 
 Clerks, duties of in general hospitals CVI 
 
 Clothiug for troops 20 
 
 physiology of I ; 
 
 issued to soldiers 25 
 
 -upply necessary to health 20 
 
 particles in wound Ms 
 
 C>>at of soldiers 20 
 
 Code of regulations in general hospital 22 
 
 Coffee for soldiers .',2 
 
 Cold, effects of i:;; 
 
 Cold water treatment in gunshot irouuds 1 93 
 
 Color of clothing 21 
 
 Compound fractures 
 
 fracture of arm 
 
 h .i' lure ol leg 107 
 
Ml 1\|.|\ 
 
 Compound- fractures o| thigh 
 
 Compression "t brain l'7* 
 
 Cononsston <<f l>r:iin i'7 ! 
 
 Confederate urmv medical stall I"* : 
 
 i 'onfederate biscuit 
 
 < !onical balls, effeeti <•> 1 1<» 
 
 itum] 426 
 
 ripti I 
 
 rlpl net Ifi 
 
 Contracted limbi 432 
 
 Cooking Dtensili in Confederate army it 
 
 D. 
 
 Danger "f an Inearoerated ball 180 
 
 -inn of skull 280 
 
 Deviation of balls 182 
 
 Dieting <>i patients in hospital M 
 
 Diet-table for hospitals BJ 
 
 Disarticulation ;it elbow-joinl 168 
 
 hi bip-joinl 
 
 Ill lilll'C-jllillt 
 
 at shoulder-join I MSB 
 
 :ii mrlst joint 458 
 
 Discipline in general hospital 7" 
 
 Disturbing influences of wounds 2(>1 
 
 Disinfection of hospitals 60 
 
 ■founds 183 
 
 Duties "i :i sistant regimental surgeon 129 
 
 of inn uli ii hi no rps IIS 
 
 iatanl hospital surgeon »'. s 
 
 ul chief surgeon in general hospital BIB 
 
 of chief matron 77 
 
 of clerks in general hospital '. lii* 
 
 of division surgeon W 
 
 <>r hospital stewards 79 
 
 of nm see in genera] hospital 74 
 
 ■ I patient in general hospital 7'.' 
 
 of hospital sergeant 79 
 
 of surgeon on the battle-field 182 
 
 ol surgeon at field infii mar; 140 
 
 of regimental surgeon In earn] 121 
 
 ■ ■I surgi i in Prussian army U8 
 
 of ward-maste] in general hospital IS 
 
'Ml S 
 
 Effects of conical balls Il'.l 
 
 of spent-balls 355 
 
 Elbow-joint, amputation of 463 
 
 resection of 386 
 
 operation of resection I '.):; 
 
 Employment in camp 55 
 
 Encampment 48 
 
 Enderinie use of morphine 222 
 
 English losses in Crimea II 
 
 English army medical staff Ill) 
 
 Entrance of balls 159 
 
 Enrolling service 15 
 
 Equipment of soldier 27 
 
 Erysipelas 22<> 
 
 Examination of wounds 172 
 
 of wounds at field infirmary L49 
 
 of recruits 13 
 
 Exit of balls 1 59 
 
 Exposure in open air 6 
 
 Exposure of troops from rural districts to diseases 2 
 
 Extraction of balls 181 
 
 F. . 
 
 Face wounds. , , 302 
 
 Facial artery, ligation of oil 
 
 Feigning disease Ill 
 
 Female nurses in hospitals 03 
 
 I'Vvcr, hectic 25. > 
 
 Femur, compound fracture of $95 
 
 Femoral artery, ligation of >\> 
 
 Fibular artery, ligation of 514 
 
 Field duties of surgeon 1 I o 
 
 Field infirmaries, organization of 1 •".'.' 
 
 Field infirmaries, treatment of wounds at 146 
 
 Field surgery 1 .">•> 
 
 Finding of balls 182 
 
 Fing0r, the proper probe 117 
 
 Finger, amputation of 151 
 
 Fi-lula in an 625 
 
 Flannel shirt* for soldiers 21 
 
 Flattening of balls 161 
 
 Flour ration m tl- ai my 
 
 • ball .1-1 
 
XIV INDEX. 
 
 bodies in brain 
 
 in irouods 1 IV 
 
 how found 170 
 
 iii ^kull 
 
 ronoTa] of 179 
 
 Forearaii amputation of 169 
 
 Food of the soldier 81 
 
 Four-wheel ambulance iragon 1 04 
 
 Fracture of arm, treatment of 
 
 of teg 107 
 
 gunshot 
 
 Of rib* 
 
 of thigh 
 
 of skull 
 
 French ambulance corps ^ ... 1 1 I 
 
 French loeaos In Crimea 1 1 
 
 Frost-bite '• '■" 
 
 Fumigations of hospitals 
 
 • 0. 
 
 <;.iit> r for Boldiers - '■ 
 
 Gangrene, hospital 
 
 General hospitals 64 
 
 discipline in 71 
 
 Gunshot fractures 
 
 (tun shot wounds, appearance ol IftJ 
 
 i if abdomen 
 
 of bladder ■ •' 
 
 of cheat 810 
 
 general treatment ol 
 
 of heart ■"■l i 
 
 hemorrhage in 104 
 
 of head 273 
 
 of hand 
 
 bi the intostinet : >l I 
 
 of the kid my 
 
 of the lung '■!.' 
 
 of the neck *■ • •"."7 
 
 pain in 185 
 
 progress of 214 
 
 of spine 333 
 
 of Btomaoh 349 
 
 symptom 
 
INl'l \ XV 
 
 11. 
 
 Haemostatics 169 
 
 Halt during a march Hi 
 
 1 1. m .) , amputation of 457 
 
 litter 100 
 
 wounds of 38S 
 
 Hardships, effects upon young men 8 
 
 Hat for soldier 24 
 
 Havclock 25 
 
 Head wounds 272 
 
 trephining in 291 
 
 Health of recruits 7 
 
 Heart wounds 311 
 
 Hectic fever .255 
 
 Hemorrhage, amputation for 212 
 
 arrest of 1 68 
 
 on the brain 2S7 
 
 in gunshot wounds 1 >\ I 
 
 secondary 2(>."> 
 
 Hip-joint, resection of I'.'.MI 
 
 amputation of 483 
 
 the method of resection of 195 
 
 Horse-litter 104 
 
 Hospital attendants 62 
 
 bed-ticket 81 
 
 cleanliness of 87 
 
 capacity of 86 
 
 discipline in 7!i 
 
 diet ;n; 
 
 disinfection of '.in 
 
 female nurses in 93 
 
 gangrene 298 
 
 general fit 
 
 knapsack I :,(i 
 
 regimental fiO 
 
 stewards, duties of 70 
 
 statistics 12 
 
 • tents BO 
 
 ventilation of s<» 
 
 Huaierus, compound fracture of 
 
 Humeral artery, ligation of M)5 
 
 Hydrocele* • : >26 
 
 Hygienic property ol ulotbing 19 
 
 Hygiene, rob* "f in hofpitalj " 
 
Wl I.M'KN 
 
 I 
 
 Ih,< artery, ligation of 518 
 
 Improvement of surgeoni In the army 131 
 
 ■ ration .if ball*, danger of 180 
 
 Infirmary OOtpi 112 
 
 Infirmariec in the field 139 
 
 field, surgeon - al 110 
 
 Inflammation of the brain 283 
 
 of ilio skull 801 
 
 Injuries to tlio ankle-joint |o > 
 
 to the head 288 
 
 to joints :;?n 
 
 to knee -joint (OS 
 
 to skull, trephining for ".".'I 
 
 Intestinal wounds 341 
 
 J. 
 
 Jaw, resection of 1^7 
 
 Joint, injuries to 870 
 
 stiff 1.1 
 
 K. 
 
 Kidney, gunshot wonndi of 851 
 
 Knapsaok, hospital 138 
 
 Knee-joint, disarticulation of 188 
 
 injuries 105 
 
 n ootion of 197 
 
 I. 
 
 I. oli. in lo.,|, Hal 86 
 
 M ] i u tat loll ii I I7t> 
 
 OOmpOUnd fracture of I"? 
 
 Ligation of arteries 198 
 
 ■ f axillary artery 8 
 
 of brachial " 
 
 of oarotid " " 
 
 of facial " ' Oil 
 
 of femoral " ' 515 
 
 of fibular " 511 
 
 ol iliac " 518 
 
 of lingual " 511 
 
 of radial " _ >04 
 
 ibi 1 avian •■' 
 
 I i iperi r thyi 10 
 
INDEX. XV11 
 
 Ligation of tibial artery 512 
 
 of ulnar " 503 
 
 Ligatures upon bleeding vessels 211 
 
 Limbs contracted after gunshot wounds 432 
 
 Lingual artery, ligation of 511 
 
 Lisfrano'e amputation of foot 471 
 
 Litter-carriers 112 
 
 Litters, hand 100 
 
 horse 104 
 
 Lock-jaw 257 
 
 Lower jaw, resection of 487 
 
 Lung wounds 315 
 
 M. 
 
 Malingering Ill 
 
 Marching, preparation for 12 
 
 order in • 18 
 
 Material of armies 2 
 
 Matron, duties of in hospital 77 
 
 Maxillary bone, inferior, resection of l s 7 
 
 superior, " " 488 
 
 Mayor's posterior wire splint 1 397 
 
 Medical outfit for a regiment 128 
 
 staff of armies 107 
 
 staff in Confederate army 108 
 
 stall of English army 110 . 
 
 .-la If of Prussian army Ill 
 
 studies in the army l.'!l 
 
 supplies for battle-field 1 '■'>'■'> 
 
 Medicated water dressing for wounds 200 
 
 Messing in the army 40 
 
 Morpbine, endcrmic use of 222 
 
 Mortitieation of stump 416 
 
 Mortality in armies 11 
 
 N. 
 
 Neck wounds 307 
 
 Necrosis of skull 30 1 
 
 Nervous shock 1.'>I 
 
 Night nurses, duties of ..■• 7'i 
 
 Norses, duties ol in general bospital 71 
 
 O. 
 
 Opium in gunshot wound* 
 
 2 
 
.Will 
 
 Id infirmaries 
 
 ■ itrance and exit of balls. 160 
 
 Outfit) medical) for ;i regiment 128 
 
 lier 28 
 
 P. 
 
 periodical 
 
 I'n in In gun snot wounds 165 
 
 Painful stumps 134 
 
 Panniers f"r Held service 186 
 
 ■ in general hospital 79 
 
 regulations l"r in general hospital 
 
 Pelvis, balls in 
 
 Perforated wounds of skull 
 
 Peroneal artery, ligation of .HI 
 
 Periodic pains 267 
 
 Pirogoff's amputation at ankle-joint 476 
 
 Phagedenic ulceration in gunshot \\ ounds 235 
 
 Physiology of clothing It; 
 
 ior tibial artery, ligation of )13 
 
 wire splint of Mayor 
 
 Preparation of rations in 
 
 Primary amputations 
 
 hemorrhage, arrest of 164 
 
 Privies, construction of in the field ••'. 
 
 Probes, examination with NT 
 
 Probing of wounds 1 7."> 
 
 Progress < t gunshot wonnds 214 
 
 Prussian army, medioa! staff <•!' ill 
 
 duties of surgeons in 1 1 ."> 
 
 I'n , theory ol it- formation. . . .' 248 
 
 Pys mis 246 
 
 u. 
 
 Radial artery, ligation of KM 
 
 Rations, preparation of 10 
 
 in the Confederate army 87 
 
 Recruits 1 
 
 Rooruits, health of 7 
 
 Recruiting servioe Ll 
 
 Rectal fistula 525 
 
 Regimental hospitals 60 
 
 Regimen t, medical outfit of l^ s 
 
 Regulations In general hospital 7'.' 
 
INDEX. xix 
 
 Regulations, oode of in general hospital S2 
 
 for patients in general hospital 84 
 
 Removal of foreign bodies 17? 
 
 Requisitions by medical officers 1-7 
 
 Resection of anklo-joint l !,s 
 
 of clavicle 189 
 
 of elbow-joint 386 
 
 of elbow-joint, operation for 493 
 
 of hip-joint 390 
 
 of hip-joint, operation for. - 195 
 
 of knee joint 197 
 
 of lower jaw I s " 
 
 statistics of 877 
 
 of shoulder-joint 380 
 
 of shoulder-joint, operation for 191 
 
 treatment of 185 
 
 of upper jaw I s s 
 
 of wrist-joint 
 
 of wrist, operation for I'M 
 
 Ribs, compound fracture of 331 
 
 Round halls, the comparative effects of 11 U 
 
 Rupture of abdominal viscera 354 
 
 S. 
 
 Sabre wounds 213 
 
 Scalp wounds 2s I 
 
 Scurvy 35 
 
 lary hemorrhage •. 2o:> 
 
 ■it of tli e guard, duties of in hospital 7* 
 
 Is for hospitals S3 
 
 Shelter tents 50 
 
 Shirts for Boldiers 21 
 
 Shoe- for soldiers 22 
 
 Shoulder joint, disarticulation of 489 
 
 resection, operation for 19] 
 
 resection of 
 
 Shock, nervous Iflfl 
 
 Sinks, in the Geld i$ 
 
 Skull, wound- of, with depression 
 
 Skull, inflammation of 291 
 
 Skull, perforating wounds of 298 
 
 Sloughing of gunshot wounds 230 
 
 Bmith'i anterior splint 397 
 
 Spent-balls, effects of 
 
XX IM'EX. 
 
 Bpiae woaodi 
 
 Staff, medical of armies 107 
 
 medical of Confederate army 106 
 
 medical of English army 110 
 
 medical of Prussian army Ill 
 
 Mai it- lies of army in Mexican war '.• 
 
 of amputation* in Confederate army 861 
 
 oomparatirc of amputations 1 12 
 
 of Ghimboraao hospital 12 
 
 of disarticulations .'171 
 
 of English and French in the Crimea 11 
 
 of hip-joint resections 
 
 of joint injuries 
 
 of ligatiou of arteries 502 
 
 of resection of shoulder-joint '!77 
 
 of thigh fractures 
 
 *tiff joints 1.50 
 
 Stomach, gunshot wounds of 848 
 
 Stumps, accidents t . 121 
 
 conical 136 
 
 inert ideal ion in -tl. r > 
 
 1 mill ful 124 
 
 Subclavian artery, ligation of 507 
 
 Superior thyroid artery, ligation of ill 
 
 Supply of clothing necessary to health 2»> 
 
 Supplies, medical, for battle field I •'<:> 
 
 D, as- ist ant 68 
 
 in chief, duties ol in Im-pital 68 
 
 in Confederate army LOS 
 
 of division, duties of in hospital 07 
 
 duties of in Prussian urmy 116 
 
 duties of in oatnp 128 
 
 duties of oa battle-field I '■'■'■ 
 
 lo be lelt with the wounded 164 
 
 at Bold infirmaries 148 
 
 morning call I '-' I 
 
 Buseeptibilities of soldiers 1 
 
 Syme's Hinpuiation at ankle-joint 17 1 
 
 Bymptomt accompanying gunshot wounds 168 
 
 T. 
 
 I ibli "i imputations 861 
 
 oompound fraotures of thigh 395 
 
 disarticulations •'" 
 
INDEX. XX! 
 
 Table of hip-joint resections 39.) 
 
 joint wounds. 872 
 
 ligation of arteries 502 
 
 primary amputations 112 
 
 resections 377 
 
 Tents, hospital fill 
 
 improvised 17 
 
 knapsack 50 
 
 shelter 50 
 
 \vnrniin:,' of I'.) 
 
 Tetanus ?:,: 
 
 Thigh, amputation of is I 
 
 gunshot fractures of 395 
 
 Tibial artery, ligation of ,'>1 2 
 
 Ticket for hospital beds St 
 
 Time necessary to make a soldier I It 
 
 Transportation of the sick and wounded '. <J',l 
 
 of wounded to hospital 152 
 
 Treatment of cerebral inflammation 285 
 
 of chest, wounds 322 
 
 of compound fractures 362 
 
 of concussion of brain 275 
 
 of depressed fractures 290 
 
 of face wounds 30 I 
 
 of erysipelas 2:^0 
 
 of frost-bite I.V.I 
 
 of gunshot wounds 215 
 
 of hospital gangrene 212 
 
 of periodio pains 270 
 
 of pyemia, preventive 251 
 
 of ribs, fractured 880 
 
 of resections :;7'j 
 
 of skull, fractured 284 
 
 of secondary hemorrhage 207 
 
 of tetanus 286 
 
 of thigh fractures .',9!i 
 
 Of wounds H)2 
 
 of wounds on battle-field 114 
 
 of wounds at field infirmary 148 
 
 Trephining in fracture of skull -y.n 
 
 mode of operating 519 
 
 in Mexican war ;t 
 
xxn IM ; 
 
 I . 
 
 Ulnar artery, ligation of 
 
 Pppor jaw, roseotion of I s - 
 
 Utensil I rat* army 
 
 v. 
 
 
 
 Ventilation of hospitalt 99 
 
 
 
 >. ruptun "i 
 
 Volunteers i 
 
 W. 
 
 , ambulance 104 
 
 Ward-master, duties of 7.". 
 
 Warming of ten U 1'.' 
 
 Water dressing for v. inndi 199 
 
 Wbiskoj for 
 
 Wire splint for gunshot fractures 
 
 Wound to Deleft with l.'i I 
 
 Is of abdomen 
 
 bayonet SIS 
 
 ..i bladder I 
 
 of obt -i 
 
 disturbing inflaenoes of 
 
 entrance and axil of balls 169 
 
 examination of 1 72 
 
 909 
 
 ntof 914 
 
 f 1 57 
 
 of the hand 
 
 or tin- head 
 
 <>( the heart 914 
 
 hemorrhage in 194 
 
 of int' tine 
 
 of joints 
 
 of tbi 
 
 ol the knee join) 105 
 
 ( >r the long 
 
 of the b« ■ 
 
 pain in 198 
 
 knll 
 
 progrei • "t ... .21 I 
 
 probing of 
 
TNI'! XXIII 
 
 Wounds, sabre ■». . . .21.'! 
 
 of the spine 833 
 
 ui' tlic stomach :i !!) 
 
 treatment of at field infirmary 14fi 
 
 treatment of on battle-field 115 
 
 local treatment of I'd' 
 
 Wrist-joint, resection of 387 
 
 amputation of 468 
 
 operation fur resection of. r.i i 
 
CHAPTER I . 
 
 SOSOBPTIBILITIKS OF SOLMERS — MATERIAL OF AlSMIES — RECRUITS — 
 
 Conscripts — "Clothing — Cleanliness — Food — Marching — En- 
 
 CAHPHENTS — Amusement's, etc. 
 
 As the strength of an. army depends more- upon 
 the health and physical development of the soldier 
 than in mere numbers, the hygiene of camps, and the 
 susceptibility of soldiers to disease, has long been a 
 worthy study for military leaders. When men are 
 taken from civil life, where they are accustomed to 
 think and act for themselves, and arc gathered togeth- 
 er as. soldiers, the very act of acknowledgment, or 
 mustering in, deprives them of all liberty-, and makes 
 them dependent upon their superior officers. They 
 must now live after a formula — with its drills, labors, 
 fatigues, privations, exposures, guard duties, night- 
 watchings, long marches, and rigid discipline. This 
 new life, which is so different from their former 
 habits, establishes a new era, similar to acclimation, 
 and which i> as marked in its effects upon the consti- 
 tution of the soldier. 
 
 Like acclimation, this sudden change from civil to 
 military Life constitutes a physiological and moral 
 eri>is, which is evinced in an increased mortality, as 
 an initiation, for the first year over succeeding years 
 of service. 
 
 Tlir physical and organic revolution which this 
 change engenders establishes a special pathology for 
 soldiers, which differs, in many respects, from the 
 
J MATERIAL OF AKMTK- 
 
 regular forms which are observed in tin' routine of 
 civil practice. 
 
 The diseases of camps are few, and exhibit a strik- 
 ing uniformity <>f character, depondenl upon numer- 
 ous depressing causes, t<> which all soldiers are 
 equally liable, ami which belong in common to every 
 army, irrespective of nationality and climate. Con- 
 tinued exposure and fatigue, bad and insufficient food, 
 >ali meat, indifferent clothing, want of cleanliness, 
 poor shelter, exposure at night to sudden changes of 
 temperature, infected tents and camps, form a com* 
 bination of causes which explains the fatality of an 
 army in the field. 
 
 Troops are u-ually drawn from tin- rural districts, 
 
 Where they have never heen exposed to those mor- 
 bific causes which are incidental to tin 1 atmosphere of 
 
 cities, and which entail a series id' infantile diseases 
 
 upon the growing generation. The unavoidable ex- 
 posure, and the general liability to these causes while 
 
 in tran-it, to which city troops arc exempt, make 
 SUCh diseases a fearful BCOUrge in armies. The 
 measles, a mild disease, which excites no alarm under 
 
 ordinary conditions of protection from the weather, 
 
 strikes terror in a camp, where it- Bequeltt, of pneu- 
 monia and phthisis, are truly fearful. This disease 
 alone has laid a heavy percent age upon the effective 
 
 Btrength of our army. Add to this, ami kindred 
 eruptive diseases, glandular affections, tuberculosis, 
 
 capillary bronchitis, typhoid and malarial fevers, with 
 
 diarrhoea and dysentery, and we have already summed 
 
 up the chief causes of army mortality and deterio- 
 ration of Strength. All of these diseases can, to a 
 certain extent, he avoided by recourse to a proper 
 hygiene, Which has not heen valued by commanding 
 officers, and in many instances has neither been 
 
MATERIAL OF ARMIES. 6 
 
 recognized nor urged by the health officers of the 
 command. Until the claims of hygiene are duly 
 considered, and its necessity acknowledged, the mor- 
 tality will continue from causes which can readily be 
 counteracted. 
 
 After nearly three years of bitter experience, we 
 are only now learning the art of war; and as men arc, 
 with us, the greatest desideratum — nearly the entire 
 male population of the Confederacy being in the field 
 — officers arc beginning to feel the importance of the 
 following maxim: "Although the arms are the fight- 
 ing weapons, the soldier is the machine which wields 
 them;" and as there will be, even in the most active 
 campaign, at least an average of twenty marching 
 days for one fighting day, if the soldier's welfare, 
 health, and comfort have not been carefully attended 
 to during the twenty days, his musket will be of very 
 little use to him on the twenty-first. It is to him, 
 therefore, that the greatest attention is due. 
 
 Prudence and forethought should be leading traits 
 in the character of military men, and are most con- 
 spicuously exhibited in the carrying out of all those 
 details so necessary in the preservation of an efficient, 
 force to fight with. An army will always be bur- 
 dened with heavy mortuary lists, extensive hospital 
 
 organizations, a large pay-roll, and comparatively 
 Few efficient troops, unless officers take the most 
 lively interest in the general welfare of their men, 
 and cease t'> consider professional advice offensive 
 and intrusive. 
 
 As it takes much time and considerable outlay to 
 make soldiers, it behooves the government to keep 
 them ina useful condition, which can only be effected 
 by the unceasing labors of the medical staff, and the 
 rigid enforcement of all sanitary regulations by com- 
 
1 MATERIAL OF ARMIES. 
 
 manding officers. A tnong volunteer i roops, where the 
 regulations of r regular army can not :it once be 
 enforced, it should be the duty of the officer In com- 
 mand t'> appeal tf> the g I sense of the Boldier 
 
 through tlir orders of the day, and gradually to instil 
 such wholesome rules of hygiene as will make them 
 individually careful for the general good. The sick 
 list will offer a fair criterion of the military status of 
 an officer, and his capacity for taking care of his men, 
 which is one of the first rules in military science. 
 
 1 ; i « ri" its. — Iii times of peace an army is formed 
 of recruits, who are enlisted with much care. Bach 
 individual, before he is received, undergoes a critical 
 examination by the recruiting medical officer, who 
 rejects all blemishes, as well as those conditions Bhow- 
 inga predisposition to disease; the object gained 
 being the selection of a body <•!' men who, from phy- 
 sical and vital perfection <>f organization, will besl 
 i external morbid influences. 
 
 Conscripts and Volunteers. — In times of war, 
 
 especially he t ween contiguous countries, win- re nation- 
 al animosity rages high, entire communities rush to 
 arms, ami with one accord adopl Camp life, with its 
 exposures and trials. This is very conspicuously 
 shown in the present struggle for the independence of 
 the Confederate States, where tlte army absorbs the 
 
 entire male population, except such as are physically 
 
 unable to be useful in any arm of the service. Under 
 the conscript laws which the Confederate States have 
 adopted, the instructions to enrolling officers are 
 rather to prevent those within the prescribed ages 
 from escaping duty, than to select men for their phy- 
 sical perfection of organization. Every able-bodied 
 
MATERIAL OF ARMIES. 
 
 'man, between the ages of eighteen and forty- five, is 
 not only enrolled, but actually pal into the field. 
 These form the movable army of the republic. Be- 
 side these, each state has called out, to assist in the 
 local defence, all such as are capable of bearing arms, 
 between the ages oi' sixteen and eighteen, and from for- 
 tv-five to sixty. Such, however, is the determination 
 of our people to establish their independence, and to 
 free themselves from oppression, that these prescribed 
 ages do not limit enlistment; hut without these limits, 
 wherever there is health, to enter the army seems to 
 be the predominant passion — so that many states of 
 the Confederacy present the singular fact, and appa- 
 rent anomaly, of having in the field a much larger 
 number of men than are represented by their entire 
 voting population. Entire districts have thus given 
 up their health}* male population — the only repre- 
 sentatives being old decrepid men, or invalid, maimed, 
 and broken-down soldiers. 
 
 Among those wlio take up arms in defence of their 
 rights, or for the protection of their homes and 
 families, are necessarily found men from every por- 
 tion in life — from those enjoying the most refined 
 and cultivated social privileges, to the street laborer 
 — all having a common cause to support; men of 
 every variety of constitution, temperament, and 
 idiosyncrasy; in whom every form of disease is found 
 larking, and ready to show itself upon the slightest 
 provocation. Those who have Led Lives of ease and 
 luxury are suddenly called upon to assist in the stern 
 and laborious duties of the soldier, to share in the 
 commm toil, and to bttffel with the elements. The 
 liar mode of living, and other hardships which 
 they daily undergo, to which the majority arc to- 
 tally unaccustomed, are more injurious than the ex- 
 
fl MATERIAL OF ARMIE8. 
 
 posures to which they submit, and to the sanitary 
 
 influence of which they owe. unwittingly, much of 
 
 the health which soldiers enjoy. Exercise in the 
 op 'u air count tracts many of the would - he injurious 
 effects of exposure j and soldiers, who have lived for 
 in. >nth-< without tents, sleeping under the protection 
 of trees, exposed to the dew- and rain^, find them- 
 selves suffering from colds and catarrhal affections 
 only when they are permitted, under furlough, to 
 enjoy a lone; wished -for visit to their families, with 
 the now doubtful comfort of a close room and BOf! 
 l»ed. The physical improvement is surprising, which 
 the gloved members of high lite exhibit, after even a 
 few weeks campaign, although followed under the 
 in » - 1 disadvantageous circumstances of inclement 
 weather. 
 
 This was well shown among the troops protecting 
 the batt >ries in the neighborhood of Charleston har- 
 bor, prior i • the taking of Fort Sumter. When the 
 call to arm- was made, the militia — composed, in a 
 large maasure, of clerks, merchants, and professional 
 in. mi. 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 t hem. of delicate frames, and frail constitutions, 
 
 exposed themselves upon sandy islands, directly upon 
 the Bea- beach, with little or no protection. They 
 were badly housed, irregularly fed, and miserably 
 
 watered. Their daily duties were, with pick and 
 
 shovel, to throw up redoubts, establish batteries, ami 
 mount heavy ordnance, during the day; while their 
 
 nightB, when not spent in anxiously watching for an 
 expected invasion, or performing tedious guard duty 
 during a vty long spell of stormy wintry weather, 
 were forgotten in sweol oblivion upon the wet sand, 
 
MATERIAL OF ARMIES. 7 
 
 at times without the shelter of a tent. Notwith- 
 standing such exposure, the sanitary condition of the 
 troops was excellent; and many, of delicate frame, 
 returned to their homes, at the expiration of two 
 months, sturdy, robust men, with an addition, in 
 some cases, of twenty-five pounds weight. All, with- 
 out exception, 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 hotter classes of citizens, go through campaigns 
 of great exposure, with many privations, much better 
 than the heavily- built yeomanry. This can be ac- 
 counted for in the personal care of the one, and the 
 known carelessness of the other. For the same 
 reason, officers are comparatively exempt from thoso 
 diseases which ordinarily fill the hospitals with sick 
 from the ranks. The immunity from infantile dis- 
 eases which the adult inhabitants of cities possess, on 
 account of attacks during childhood, is one of the 
 most noted reasons why city troops suffer less in a 
 campaign than soldiers from the country. 
 
 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 collected, indiscrimi- 
 nately, under a pressure. Many of them were youug, 
 ill-conditioned, undeveloped in body, unconfirmed in 
 constitution, and hence without stamina or powers of 
 endurance. When compelled to undergo the hard- 
 ships of a Biege, where the strength of full-grown 
 men soon failed, they were very quickly used up. 
 Unaccustomed to either the work, food, or exposure 
 to which they were compelled to submit, they were 
 
MATERIAL 01 AUMIKs. 
 
 readily affected by diseases — and, when severely at- 
 tacked, they usually died ; or, it they Burvived, their 
 convalescence was painfully prolonged, and the least 
 imprudence produced a relapse. Napoleon, in making 
 a demand for troops, asked for men, as he well knew 
 that boys only encumbered the hospitals and road- 
 Bides. 
 
 An English Crimean Burgeon, in speaking of the 
 character <>t the troops Benl to the Bast, and oi 
 the hardships to which they submitted, mentioned to 
 me that premature old age, decrepitude, with feeble^ 
 bent frames, wrinkled faces, and grizzly locks, were 
 Been in youths of two or three and twenty — the 
 effect of two winters' toil, want, and misery. 
 
 Our own experience does not corroborate that of 
 European armies. The spirit anil chivalry of our 
 youth — the result of their education and mode of 
 living— -induced large numbers between the ag< 
 
 Join-teen and eighteen to enter the army. These 
 
 have shared the toils, fatigues, and privations of our 
 troops, in one of the most active Beries of campaigns 
 in the experience of modern warfare. So tar from 
 encumbering the hospitals, they now comprise our 
 most robust and best soldiers, capable of undergoing 
 great fatigue and privations and equal to any emer- 
 
 ey. 
 
 In examining the statistics of the Mexican war. we 
 find the well -estahlished rule, that volunteers sutler 
 more than regulars, confirmed, although the material 
 of which the volunteer force was composed was much 
 
 superior to the average of armies 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 
 different arms of the service. 
 
MORTALITY IN ARMIES. 5> 
 
 The three classes of troops in the war with Mexico 
 were: the old or standing army, composed of men ac- 
 customed to the fatigues and routine of a soldier's 
 life; ten regiments Of enlisted men, carefully selected 
 by recruiting surgeons ; and 73,000 volunteers, taken 
 at random from all walks of life.* The total loss in 
 the old arm}', by deaths, discharges, resignations, and 
 desertions, exclusive of discharges by expiration of 
 service, was 7,033 in an aggregate force of 15,736 — 
 being 50.70 per cent, for the whole service of twenty- 
 six months, or a monthly loss of 1J95 per cent. In 
 the ten new regiments, using the same basis, the total 
 loss was 3,830 in an aggregate strength of 11,186 — 
 being 34.22 per cent, for the whole service of fifteen 
 months, or a monthly loss of 2.28 per cent. 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 period of service of ten months, 
 or a monthly loss of 2.78 per cent. When it is re- 
 membered that tjie old army stood the brunt of all 
 the early engagements, and that many of the volun- 
 teer regiments were never in battle, the dangers of 
 camp life to volunteers and raw recruits become more 
 conspicuously evident. The old army sustained a 
 loss of 5.03 per cent, from killed in battle or dying 
 from wounds — a loss of 792 men from 15,730. The 
 ten new regiments met with a loss of 143 from 11,186, 
 or 1.27 per cent. The volunteer corps, numbering 
 78,260, lost in buttle and from wounds only 613, or 
 0.83 per cent.; while the actual sick list, carefully 
 compiled, and leaving out all losses to the army ex- 
 cept from sickness, amount to 15,617, Or 26.83 per 
 cent. 
 
 'Medical Btatiatfca U. 8. Army, 1839 to 1854. 
 
".<• MORTALITY IN A.RMI1 
 
 These statistics, collected with great care by 1 1 » * • 
 
 irgeon-general of the I * ni t <•<! 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. 
 
 Oar very extended experience in this war for Con- 
 federate Independence confirms the established rule 
 thai it takes time to make a^oldier, and that it 
 requires at least t welve months for a recruit t" exhaust 
 tin- list of initiatory diseases, and inure himself t«> 
 the privations, exposures, ami labors of veterans of 
 tin' Confederate army. This preparation does not 
 show itself t<> so great an extent when the army is 
 stationary. hut tfll>. without fail, under forced march- 
 esand hard fight im:. with little food, and as little rest. 
 The first year of tin- campaign the hospitals were 
 
 filled with the Bick, ami hut the skeletons of large 
 
 regiments represented the efficient strength on field- 
 days. Now the Bick-roil is wonderfully small, ami by 
 
 jar the majority of the army vigorously robust. The 
 liability to sickness i-. however, Btrikingly shown 
 among the conscripts whioh are being continually as- 
 signed to old regiments t<> fill up vacancies No 
 reliance can be placed upon such until the initiatory 
 acclimation of several months, on sick-roll ami in bos- 
 pital, ha- been passed. Even then, when, to all 
 appearances, they go through the routine of camp duty 
 with the ease of veterans, a march at once exhibits 
 their incapacity for the serious work of a soldier.. 
 
 A- not only the valuable live- of ci I i/.en -oldiery , 
 
 forming, morally, sooially, ami pecuniarily, our very 
 best people, should be to the utmost protected, bul also, 
 from the enormous expense ami trouble incurred by a 
 nation in training ami in transporting an army for 
 
 distant service, it is imperative that the medical stall' 
 
MORTALITY IN ARMIES. 11 
 
 labor to disseminate among tbe troops thoso rules of 
 hygiene, which, when considered in its widest souse, 
 are so profitable in sustaining an effective military 
 strength. 
 
 We have just seen that, in our own wars, as in all 
 that have ever occurred, an army is rarely decimated 
 by the fire of an enemy. Those killed in battle are 
 but a handful, when compared to the victims of dis- 
 ease. 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 strategic point, from 
 which they had to be driven under a murderous fire, 
 lost but 1,549 men in battle and from wounds, all 
 told ; while 10,986 died in Mexico from disease, be- 
 sides the hundreds — I would be well within bounds 
 should 1 say thousands — who returned home to die 
 among their friends from the effects of diseases con- 
 tracted in ramp. For some time after the war, vol- 
 unteers formed a noted proportion of the inmates of 
 civil hospitals, and the chronic diseases under which 
 they were laboring were with great difficulty eon- 
 trolled. 
 
 In the Crimean service, the statistics collected by 
 Lord Panmure, Minister of War, show the English loss 
 to have been ll.\~u — of wliuh number 3,448 were 
 killed in bat tie, or died from t he effects of wounds re- 
 ceived. The French I"--, as reported to his govern- 
 ment by M. Scribe, inspector-General of the French 
 medical service in the Crimea, exhibits the frightful 
 
 1088 by death of 63,000, while the admissions into hos- 
 pital numbered 1 1 1,668. 
 Tie- report from the Surgeon-General of the United 
 
 States, in giving a medical history of their colossal 
 
12 MORTALITY IN ARM1 
 
 armies for the year ending June 30, 1862, gives a gen- 
 eral mortality of 67 per thousand — of which 60 per 
 thousand died of and L7 per thousand from 
 
 WOUnda and injin\ 
 
 The statistics of our armies would be found equally 
 Btriking with those already mentioned. Our list of 
 killed and wounded, although very large, by no means 
 equals our mortuary li-t from disoa 
 
 the beginning of the war found us without an or- 
 ganization, and a vfiry large number of surgeons taken 
 from civil practice, who required a long and tedious 
 education before they were prepared to make useful 
 and carefully -collected reports no complete statisti- 
 cal tables, showing the proportionate losses by wounds 
 and diseases in our armies, have been as yet com- 
 piled. A bureau for collecting and collating the re- 
 ports of all medical officers lias recently been organ- 
 ized, and. under the active supervision of Surgeon 
 
 rrcl, with an efficient staff, we may soon look for 
 valuable contributions to medical science. A refer- 
 ence i<> ill*- reports of Confederate military hospitals 
 will, bowevor, uphold tin- constantly- corroborated 
 fart, that the missiles hurled by an enemy bounti- 
 fully supplied with all tin- improved ami perfected 
 implements <>f modern warfare, are comparatively 
 innocent when contrasted with the ravages of dis- 
 
 Surgeon Met 'aw. in charge <>\' ( Ihimborazo Hospital, 
 at Richmond, in compiling hi< report from Novem- 
 ber I. 1861, to November I, 1863, gives 17,176 ad- 
 missions into his hospital, of which number ' > . 7 1 ' ► 
 were from gunshot wounds. There were3,03l deaths. 
 of which 877 were from the effects <>!' wounds. Prom 
 the convenient position of Richmond, with railroad 
 communications to the many battle-fields of Virginia, 
 
RECRUITING SERVICE. 13 
 
 and the ready transportation for wounded men. this 
 report may be considered a fair proportion of the Bick 
 and wounded in our armies — which would show at 
 least ten dying from disease for every one dying from 
 the effects of wounds. 
 
 The above statistics arc sufficient to show that the 
 efficiency of an army docs 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 80 valuable to an army, can be preserved. 
 
 Recruiting Service. — The first protection which 
 an army has is in the recruiting service, which is :i 
 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 demands 
 that this examination be thorough, both in regard 
 to moral and physical disabilities. The regulations, 
 therefore, enjoin that — "In passing a recruit, the 
 medical officer is to examine him stripped, to see 
 that he has the free use of all his limbs; that his 
 chest is ample; thai his hearing, vision, and speech 
 is perfect; that he has no tumors, ulcerated, or ex- 
 tensively-cicatrized legs; no rupture, or chronic cu- 
 taneous affection ; thai he has Dot received any con- 
 tusion or wound of the head that may impair his 
 faculties; thai he is nol a drunkard, is not subjeel 
 to convulsions, and has n<> infectious or other dis- 
 order that may unfit him for military service." The 
 Burgeon is also required t<> certify, on honor, thai the 
 recruil passed by him "Isfrei from all bodily d< 
 
14 RECRUITING SERVICE. 
 
 and mental infirmity, which would in any way dis- 
 qualify him from performing the duties of a soldier;" 
 and should it appear that the recruit was, at the 
 time passed, physically unfit to perform all the du- 
 ties for which he was mustered into the service, the 
 Burgeon who recommended his acceptance becomes 
 pecuniarily liable for the pay of the soldier during 
 the time which he bas been attached t<> the army. 
 As the recruit must he between the age of eighteen 
 
 and thirty-five years, at least five feet tour inches 
 in height,* and able --bodied, we can understand why 
 an army, selected by a rigid observance <>(' the above 
 regulations, composed of healthy, robust men. in the 
 
 71g0r of manhood, when brought under thorough 
 
 discipline, is in the hot condition to preserve a high 
 Btandard of health. 
 
 To show with what stringency the laws on this 
 subject are usually observed, we give the recruit- 
 ing list of the United States Army lor 1S:">2. The 
 
 total number examined were 16,064— of these 13,338 
 were rejected ; -,-H> were alone received into the 
 
 service. A.mong the causes Of rejection are found 
 
 the following: Not robust, too slender, unsound, brc* 
 ken-down constitutions, general unfitness, imbecility, 
 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; cicatrices, tumors; diseases 
 of hones joints, skin, heart, testis, and tunica vagi- 
 nalis; also of arms, eyes, ears, glands, chest, throat, 
 
 •The height of recruits required in the French army, is five feet 
 one inch : in the United States army, five feet four and a half inches; 
 in the English service, livo feet live and a half inches. 
 
ENROLLING SERVICE. 15 
 
 and abdomen; detective hearing, speech, and vision; 
 ulcers, goitre, ascites and anasarca, obesity, etc. 
 
 When we take into consideration the little dis- 
 parity of age with the absence of so many predis- 
 posing causes of disease, we can readily See why the 
 soldier by profession has so great an advantage 
 over the volunteer force, into which an}- one desirous 
 of performing duty is received, however unfitted be 
 may be. physically, for the toil and privations of 
 camp life. 
 
 Under the General Conscript act, now enforced in 
 the Confederacy, the instructions to the enrolling 
 officer are to allow no one capable of performing any 
 duty to escape, rather than select men for their 
 physical perfection. The result is that many, totally 
 unfit for military duty, are forced into the ranks, from 
 whicb they are soon transferred to the hospitals, 
 where they remain a useless expense to the govern- 
 ment — increasing the number without adding to the 
 strength of our forces. In the meantime, the country 
 loses their labor in the agricultural or mechanical 
 occupations to which they had been accustomed, and 
 in the pursuit of which they would have been really 
 useful. Where an entire male population is conscribed 
 and enrolled for active service in the field, it Increases 
 greatly the expenses without adding to the effec- 
 tive Btrength of the army. The same precautions, 
 with critical examination into the physical condi- 
 tion of conscripts, should be made as ordered in the 
 enlistment of soldiers; and stub as surgical experi- 
 ence foresees will be the constant inmates of mili- 
 tary hospitals, should be permitted to aid the gov- 
 ernment in a civil capacity, by preparing those ar- 
 ticles of prime necessity upon which an army can 
 be alone supported. 
 
L6 CLOTHING OF TROOPS. 
 
 To OBTAIN THK OTMOST CAPACITY OF LARoR FROM 
 Ml n. IHKV MUST BE PROPERLY CLOTHED AND WELL 
 
 11. d — Those are the prerequisites, withoul which 
 their powers of resistance to exposure and « 
 sive exertion are not developed. A soldier is com- 
 pelled to familiarize himself with many occurrences 
 which experience in actual war shows to be common, 
 often called upon for Laborious work, t<> expose 
 himself t<> wind and rain, heat and cold, to snffer hun- 
 ger and fatigue, to travel at eight as well as during 
 
 the day, to sleep dressed and accoutred in cloak or 
 blanket. He must be taught, when thus exposed, to 
 secure bis person from disease, and to ward nil' in- 
 jurious consequences. In short, he oughl t<> be put 
 in possession of the besl remedies for every contin- 
 gency which may possibly happen in military servko. 
 This i> particularly the case with an armed body 
 which may he called upon at any moment to exert 
 
 great efforts in making forced marches, and. under 
 
 many privations, to meet a hold and determined 
 enemy, ami to repulse a superior force. The strength 
 m ,//< army is calculated rather by the physique of its 
 men than by numbers, as experience shows that, other 
 things being "/</.//. men who have been well taken care 
 nf are capable of opposing successfully double (If force 
 badly provide d. 
 
 To PRESERVE HEALTH AND EFFICIENCY, TROOPS 
 
 must i:k well clothed. — This is one of the weighty 
 questions in the economy of an army, and has been 
 the Bubject of much study and experiment by mili- 
 tary leaders. 
 ♦The object of clothing is to protect the skin from 
 
 • Levy on Hygiene, l s ->-v Jaokson on the Formation, Discipline, 
 and 1 Irmies. 
 
PHYSIOLOGICAL EFFECTS OF CLOTHING. 17 
 
 diurnal variations or annual perturbations of tho at- 
 mosphere, while it absorbs excretions, and thus be- 
 comes the means which allows man to enlargo his 
 native sphere, and successfully resist extremes of tem- 
 perature in tho torrid or frigid zones. The caloric 
 properties of clothing must be considered under the 
 triple relation of absorption, reflection, and conduc- 
 tion. Every body, whatever be its temperature, is 
 continually throwing off heal from every portion of its 
 surface, the amount of radiation depending upon its 
 temperature and extent of surface. Tho human body, 
 having a superior temperature to that of tho surround- 
 ing atmosphere, reflects heat to such a degree as 
 would be incompatible with life, were it not con- 
 trolled, to a great extent, by the non- conduction of 
 living tissue, and the protective influence of clothing. 
 The first retards the transmission of heat from the 
 centre of the body, while the second acts as a screen. 
 
 If two bodies, unequally heated, bo placed in prox- 
 imity to each other, there exists a tendency to pro- 
 duce an equilibrium of temperature. A third body 
 interposed would intercept entirely the heat until it 
 be also heated, so that it may emit from the side 
 corresponding to the cold bod}- that which it absorbs 
 from the warm body. Clothing, placed between man 
 and the atmosphere, exercises this protective influ- 
 ence in proportion to its power of reflection and con- 
 duction ; and as clothing is a bad conductor of heat, the 
 outer surface of the dress seldom acquires tho tempera- 
 ture of the person which it covers. The incarceration 
 of a layer of air between the person and the clothing, 
 and also that which enters into the meshes of tho 
 cloth, still further retards the transmission of caloric — 
 heat passing to and through the clothing very slowly, 
 and the layer of incarcerated air being a very poor 
 
 B 
 
18 PHYSIOLOGICAL BFFFCT8 OF CLOTHINO. 
 
 conductor. On a -quiet, cold day, when we are Bur- 
 roanded by a little atmosphere of our own warming, 
 we feel much more comfortable than when this non- 
 conducting layer is constantly displaced, as on a windy 
 day, when, although the thermometer indicates a 
 much higher temperature, the cold ia Bevorely felt. 
 
 It is the action of thee - which explains 
 
 why the exterior of the clothing of a Boldior, bivou- 
 acked without shelter under the clear sky, is colder 
 than the surrounding air. As bad conductors, the 
 heal whioh escapee from the skin traverses slowly the 
 
 thickness of clothing ; hut. a- a i as it reaches the 
 
 external surface, it is radiated or emitted rapidly. 
 The protection of a tent, or even a cloak, countor- 
 
 bs this radiation. The inverse protection whioh 
 the blanket gives the Spaniard or A rah in hot weath- 
 er, is similarly accounted for. The radiating proper- 
 
 a of wool exceed its conducting or absorbing pow- 
 and throw ofl the great heat of the sun before 
 
 it can penetrate the thickness of clothing and reach 
 
 the w , arer's skin. 
 
 Besides the property just enumerated, the hy- 
 
 metric powers of different fabrics, condensing 
 
 moisture from the air and absorbing pe^spira- 
 
 . are of much importance in the Banitary 
 
 >nomy of clothing. In either case, their power 
 of conducting heat is increased; and, therefore, 
 the more moisture they oontain in their meshes, 
 the colder they are as apparel. The Mind which 
 the doth imbibes takes the place ,,i air, and be- 
 comes a cause of refrigeration by evaporation, 
 robbing the neighboring skin of its heat to form 
 aqueous vapor. Linen, for instance, imbibes at 
 once moisture from any source, and chills the 
 body by the evaporation of this moisture; tins 
 
PHYSIOLOGICAL EFFECTS OF CLOTHING. 19 
 
 material for articles of clothing exposes the body 
 to sensations of cold and dampness, and necessa- 
 rily to the diseases which are brought on by 
 such exposure. Cotton fabrics, although not so at- 
 tractive to moisture, permit absorption and evapora- 
 tion to a considerable extent; while woollen goods 
 condense moist are as badly as they conduct heat; 
 from them evaporation goes on so very gradually as 
 scarcely to chill the external surface of the clothing. 
 
 The hygrometric properties of clothing are in- 
 timately connected with their action upon the 
 skin, when considered as an organ of absorption 
 and excretion. Cutaneous perspiration varies in 
 quantity, according to the powers of conduction, 
 radiation, and heat - absorbing properties of cloth- 
 ing, which can not modify the exhalation, al>- 
 BOrption, and sensibility of the skin, without 
 reacting upon its functions. The energy of cuta- 
 neous 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 antagonism which 
 existB between animal heat and external temperature. 
 Tin' source Of animal heat increases or diminishes 
 it- activity according to changes in the atmosphere; 
 but the unequal production of heat causes corre- 
 sponding oscillations, in the movements of respiration 
 and circulation, in the action of the muscles, and the 
 brain. Clothing affects, then, all the functions of 
 the economy, and may clearly represent the question 
 Of health. 
 
 A- the objeel of clothing is usefulness and conve- 
 nience, the best uniform is that which will protect the 
 body from the inclemencies of the weather, and which 
 
■It TROOPS 
 
 mpedes the movements whioh are connected with 
 military duties. Experience in the Held teaches what 
 can l>c dispensed with, <>r what can be added with ad- 
 vantage. The clothing selected depends much upon 
 the habits ofa people, and the country in which the wal- 
 ls carried <m. We can readily understand how absurd 
 it would be in the English government Bending their 
 home troops, in their thick red coats, leathered necks, 
 and shakoed heads, to <1<> field duty on the Bcorching 
 plains of India. There arc certain portions <>t' the 
 clothing which experience shows arc conducive to 
 health, in all countries, and under every circumstance. 
 
 The clothing for troops should be made of wool, whether 
 the material />< heavy or light, to suit the climate. 
 
 This rule should be particularly observed in the 
 ( !on federate Bervioe, where, during an active campaign, 
 the army being constantly in motion, the large portion 
 of our troops bivouac for weeks, or even months, hav- 
 ing no other Bhelter than such as can be improvised 
 from the bark and branches of trees. Heavy woollen 
 
 Clothing alone can protect them from disease whilst 
 
 sleeping on the wet ground which forms their nightly 
 
 Collch. 
 
 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, bo 
 as not to impede the expansion of the chest when 
 closely buttoned. I n the I 'out die rate service the jack- 
 et is now in very general use, and is preferred by our 
 troops for its greater convenience in the performance 
 of the drill, and in marching. Besides, from the con* 
 Btanl bivouacking of our army and the Bleeping of our 
 men around fires, the tails of the coat are so frequently 
 burnt off, to the detriment of the suit of clothing, that 
 they have, on this account, been to a great extent dis- 
 
CLOTHING FOR TROOrS. 21 
 
 carded. The trousers should be of good, heavy woollen 
 material, made also free for the easy play of the limbs. 
 When the bottoms are faced with leather or enamelled^ 
 cloth, it is found a great protection in had weather, 
 and also from the dews, keeping the legs dry and 
 warm. Flannel shirts, coming well down upon the 
 thighs, and drawers of the same material, are of great 
 hygienic utility, and should farm a portion ofthedress 
 of every soldier, whether he has been accustomed to 
 wear flannel or not. In winter the} T retain the animal 
 heat and support the healthy function of the skin, 
 while in summer they absorb more readily the excess 
 of perspiration which occurs under severe exercise. 
 While agreeable to the wearer, they prevent sudden 
 arrests of perspiration, and are thus a protection 
 against diarrhoea and dysentery, which are so fatal to 
 armies. These should be furnished in sufficient num- 
 bers to enable the soldier to change his shirt when he 
 has been exposed to rain, as he may thus prevent 
 pneumonia and bronchial affections. 
 
 In the French service, where flannel underclothing 
 is not in such constant use as in the English and 
 American service, every soldier carries a band of flan- 
 nel, with which he envelopes his abdomen, as a safe- 
 guard from abdominal affections, Baudens, one of the 
 surgeons-in-chief of the Crimean service, speaks of this 
 hand as essential to the health of the troops, and, at 
 the same time, refers to the much better and more 
 convenient protection which the English flannel shirt 
 gives to the men. The liability of Losing the flannel 
 girdle, and its very partial protection, is a serious ob- 
 jection to its use. For similar reasons, heavy socks 
 should always lie given to soldiers, as they retain 
 warmth to the feet — which, being at the greatest 'lis- 
 tance from the centre of the circulation, are leas! 
 
22 CLOTHING FOB TROOP8. 
 
 capable of resisting cold, and therefore require n 1 * »— t 
 protect ion against injury. 
 
 1 'in- feel mi-.' part of the person of a soldier bo essen- 
 tial for the performance of military doty, thai their 
 condition should be particularly attended to by the 
 officers. 77m r half-boots should be well 
 
 made, of good, durable material, and well fitted t<> the 
 . \ to 1 be wearer. The solos Bhould 
 I"- broad, thick, and firm, high -quarter* d, bo as I 
 dude mud or sand, and closely fitting around the 
 instep, bo that tenacious clay can n«>t easily drag it from 
 >t. A good shoe or bool aiMs often as much t<> 
 the efficiency of the Boldieras a good weapon. BCaroh- 
 ing is as necessary a quality as fighting, and is made 
 ; the requisites in becoming a memberofthe Im- 
 perial Guard of the present French emperor. When 
 the ahoes <l" aot tit the wearer who is compelled to 
 use them. Bore i"«»t . a very troublesome complaint in 
 
 the army, is brought On. From thi-> cause, men (iii the 
 
 march are found lagging behind from lameness, and 
 
 are exposed t" be out off by marauding parties of the 
 
 enemy. The leather should he well smeared with 
 . oil, wax, tallow, or other composition, to make 
 them water-proof, soft, and more durable. This should 
 he done daily in wet weather. One pound of tallow 
 ami hair a pound of rosin melted together, and applied 
 hot with a painter's hrush, and renewed until neither 
 
 sole nor upper leather will take up any more, 18 found 
 
 an admirable leather preservative. The grease alone 
 
 WOUld, in time, rot the leather, hut the addition of 
 
 rosin gives the compound antiseptic properties. 
 Iii the Crimean service the Russian half- hoot was 
 
 found BO Superior an article over the boots or shoes of 
 the Allies, that they were soughl for with avidity upon 
 the dead, as soon as they were shot down, and were 
 
CLOTHING OF SOLDIERS. 23 
 
 more prized than any otfier article of wearing apparel, 
 
 so conducive were they to t lie comfort of the wearer. 
 They protected the feet perfectly from the mud in 
 which the troops lived for months. Our government 
 found so much difficulty i" furnishing a sufficient 
 amount of shoes, that our troops were often barefooted, 
 going into battle over frozen ground without shoes, 
 and after a victory supplying their wants from the 
 Federal dead. After every battle, when the burial 
 parties are ordered to their work, the shoes of the slain 
 will have already disappeared. It was only bj' a 
 general appropriation of clothing found on battle-fields, 
 that many of our soldiers were made comfortable. 
 
 The French gaiter used in the Crimea was made of 
 heavy Avhite cloth, covering two-thirds of the foot, and 
 extending some distance up the leg. usually over the 
 knee. It facilitates walking, and prevents enlarge- 
 ment of the veins, while 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 provided with them. The}', as a substitute 
 for the boot, might be added with advantage to the 
 equipment of the soldier. When made of leather, they 
 become hard after getting wet, and, by pressure, exco- 
 riate the ankles. Beside which, the leal her is cold in 
 winter and very hot in summer. The only advantage 
 in the leather gaiter is durability ; the cloth wears out 
 much sooner, and also becomes saturated with moisture 
 in very wet weather. In addition to the gaiter, many 
 of the French troops wear greaves, made of heavy 
 patent leather, which cover the leg to the knee, shut- 
 ting in the bottom of the pants. This gives them 
 .t facilities in walking, as it protects the leg of the 
 pantaloon from becoming foul with mud. which is an 
 
 endless annoyance to troops marching in bad weather 
 
 Every soldier should have an overcoat of stout cloth 
 
24 CLOTHING OF SOLDIERS. 
 
 reaching below his knees, with a cap -ingthe 
 
 This, like all other a of clothing, 
 
 mid bo mil- easy, to permit of every movement 
 without binding. The French have added a hood, to 
 pr ■■ ; the hea 1 and neok in ba I weather from cold, 
 win 1. and ruin, whieh is a great protection, diminish* 
 ing the frequency of catarrhal affections. When on 
 guard duty in bad weather, the hood is a great comfort, 
 and it is also of groat utility in protecting the bead 
 and neck from the damp ground when sleeping. Cri- 
 mean soldiers found i his addition a great improvement. 
 
 In selecting a color for a uniform, it should he 
 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 ifl an item of no small importance, 
 when the deleterious emanations accompanying large 
 bodies of men are oonsi lere I. Beside whieh. ex- 
 perience in battle Bhows that certain colors make 
 much bettor marks to fire at than others; and. ac- 
 cording to calculations, a soldier dressod in light cloth 
 is much less liable to be hit than in dark. The 
 following percentage is said to be the relative lia- 
 bility : red, twelve; rifle-green, seven; lu-own, six; 
 Austrian bluish -gray, five. Red, which is the most 
 attractive and fatal color, is more than twice as much 
 so ;is gray, which is the least. 
 
 The best military h<it in use is a li.^ht, soft fell, 
 with a sufficiently high crown to allow space for air 
 over the brain. The rim can be fastened up in fair 
 
 weather; and, when turned down, protects, in a 
 measure, from the rain or from the rays of the sun. 
 In a warm climate, the light color of the hat adds 
 much to the comfort of the wearer. The small. 
 French, jauntily-fitting kepi is light, but does not 
 protect the face; and, when made of dark materials, 
 
CLOTHING OF SOLDIERS. 
 
 25 
 
 concentrates the solar rays upon the head. This, 
 however, can be in a measure obviated by adding 
 a llavelock, which consists of a cap-cover with a long 
 cape attached, hanging down upon the shoulders, 
 which 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 
 wearing a light and high-crowned hat is that, under 
 exposure to the sun, as during a march, a small, wet 
 handkerchief placed in the crown will not onty pre- 
 vent sunstroke, but will add much to the comfort of 
 the soldier. 
 
 According to the army regulations of the Confedei*- 
 ate service a soldier is allowed the uniform and 
 clothing stated in tho following table, or articles 
 thereof of equal value : 
 
 CLOTIIINT.. 
 
 Cap, complete 
 
 Cap-cover 
 
 Coat 
 
 Trousers 
 
 Flannel shirt 
 
 Flannel drawers 
 
 Bootees,* pairs x . . . 
 
 Stockings f 
 
 r stock 
 
 < I rent -ma: 
 
 Stable frock (for mounted men) 
 
 Fatigue overall (for engineer! and ordnance) 
 Blanket 
 
 FOR THREE TEARS. 
 
 1st. 
 
 2 
 
 I 
 
 O 
 
 3 
 3 
 
 3 
 4 
 
 1 
 
 1 
 
 1 
 1 
 1 
 
 2d. 
 
 1 
 1 
 1 
 2 
 3 
 2 
 4 
 
 ..: . 
 
 3d. 
 
 1 
 
 1 
 1 
 
 a 
 
 :i 
 2 
 4 
 
 
 
 i 
 
 i 
 i 
 
 Total 
 
 for 
 
 threo 
 
 year*. 
 
 I 
 
 3 
 1 
 7 
 9 
 7 
 12 
 12 
 1 
 1 
 1 
 S 
 
 • •Mounted men may rcceivo one pair of "boots "nnd pro pair of 
 "booteos," instead of/our pair of booteoe. 
 
 
 
CLOTHING OF BOLDIEES 
 
 In the field, there should be always a supply of 
 clothing at band, to replace the loss by unavoidable 
 accident During the Crimean service, Dr. BicLeod 
 informs us that the deficiency of clothing, which was 
 so much oomplained of, was one of the mosl prolific 
 sources of subsequent dieeaae among the English 
 troops. The truth of this statement was corroborated 
 by our experience in the campaigns of 1861 and 1 v ol'. 
 where a greal amount of sickness could be traced 
 to insufficient clothing. 
 
 liers arc expected to have always an extra 
 suit of underclothing, and usually have an extra pair 
 of pants and shoes. It. :it the weekly inspections, 
 their clothing is found deficient, it is the duty of the 
 to report such instances to company offi- 
 oers, who are instructed to draw from the quarter- 
 master Buoh articles as are necessary for the cWnfort 
 of their men. Should they have already drawn all 
 the clothing which army regulations allow, the value 
 of such extra clothing will be deducted from their 
 monthly pay. This regulation, when attended to 
 prior to a march, insures a chango of clothing, which 
 isential to cleanliness and comfort. 
 
 One of the universally admitted maxims for pre- 
 serving health in a campaign, irrespective of climate 
 or locality, is, that soldiers must protect themselv 
 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 
 
 quipment of a soldier. The india-rubber cloth is 
 
 a water-proof covering for him during exposure, and 
 
 will always make tor him a dry bed, upon which he 
 can find health as well as comfort. 
 
 We make the following extract, on the extent of 
 a soldier's equipment, from Jackson's Formation, Dis- 
 
CLOTHING OF SOLDIERS. 27 
 
 ciplinc, and Economy of Armies, hi the form and 
 fashion of a soldier's equipment, "The adjustment of 
 the kind and quantity of articles termed necessaries is 
 a matter of importance, and as such requires to be 
 well considered. It is demonstrably proved, to the 
 conviction of all persons who have served with armies, 
 that superfluous baggage — that is, baggage beyond 
 the narrowest measure of utility — instead of bringing 
 comfort to the possessor, is a cause of great annoy- 
 ance 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 soldier requires for his comfort and the 
 preservation of his health; and, as such, it is all that 
 he ought to he permitted to possess. Where persons 
 have not more than one change of raiment, the strong 
 impression of necessity obliges them to prepare for the 
 return of want. Where there is a superfluity, the 
 necessity does not present itself so forcibly, and hence 
 the dirty clothes are crammed into the knapsack, 
 where they accumulate in quantity, without obliging 
 the individual to recollect that they are not fit for 
 066 until they are washed. It thus often happens 
 that a soldier who has four or more shirts in his 
 possession, has not one fit for use — while a soldier 
 who possesses no more than two, has generally ono 
 in his knapsack ready for the contingent occasion." 
 
 The following is considered to be a full equipment 
 for a soldier on service, namely : two flannel shirts; 
 two pair of heavy socks ; two pair of flannel drawers J 
 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 buttons, for mending clothes; one small 
 shoe-brush, with blacking; combs and hair-brush; 
 tooth-brush; one pice of a iap; a sponge for washing 
 
2S CLEANLINESS NECESSARY FOR HEALTH 
 
 the body, and a towel for drying it; two pocket 
 handkerchiefs; an overcoat of heavy material, besides 
 hi- uniform. He Bhould also have a heavy blanket — 
 r it" lined with stout osnaburgs, to increase its 
 durability and warmth — and two yards oi india- 
 rubber < 1 < » 1 1 1 to protecl him from the weather. He 
 should also carry a knife, fork, and spoon, a <a n t .-i-n 
 for water, and a haversack for carrying dressed pro- 
 visions. It' those articles of clothing not in use be 
 put up in a neat and compact manner, and enveloped 
 ill oiled cloth so as to be secure from wet, and do- 
 posited in the knapsack for easy carriage, the soldier 
 will not be incommoded by their bulk or encumbered 
 by their weight; and, possessing within himself every- 
 thing actually necessary for us,', will be independent 
 of the delay- and accidents so common to the bag- 
 gage-wagons. 
 
 In the above lis! we have purposely omitted shav- 
 ing apparatus, as every soldier in the field Bhould 
 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 malarial influences, acting 
 
 as a sieve to the lungs. It also purifies from dust the 
 
 atmosphere inhaled during marches, and thereby pre- 
 vents many troublesome diseases. Cleanliness die* 
 tates that the hair be cut closo to the head, and, 
 although the beard be allowed to grow, it should also 
 be kept within bounds. 
 
 Cleanliness. — Nothing contributes more to preserve 
 health than porsonal cleanliness; and a-> the i'v<-^ use 
 
 Of soap LS a prophylactic as well as a civilizer, it 
 
 should he regularly distributed to the men. Daily 
 ablutions should never be omitted; and, if possible, 
 
 the chest and arms, as well as tho face and neck, 
 
CLEANLINESS NECESSARY FOR HEALTH. 29 
 
 should be well sponged. Baths should be used when- 
 ever opportunity permits. Whenever our troops en- 
 camp near a stream, it is now the practice of careful 
 officers to have the men marched down by company 
 to bathe, and this is repeated as often as cleanliness 
 requires. Keeping the shin clean prevents fevers and 
 bowel complaints in warm climates. The largo expe- 
 rience of our various campaigns only confirm the. fact 
 that the most cleanly are always the most healthy. 
 Baudens, in insisting upon cleanliness, says, "That the 
 contrast in the sickness 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 equipment, yet 
 these beautiful battalions leave in their passage a 
 strong smell of barracks not to be mistaken." 
 
 Not only the tents, but the persons of soldiers as 
 well as their clothing, should be daily inspected. 
 However particular men ma}" be in civil life, as soon 
 as they are put into tho field not only are all habits of 
 cleanliness neglected, which we would have supposed 
 had been incorporated with their very nature, but 
 men seem actually to take pleasure in being careless, 
 and comment upon the little need of corporeal ablu- 
 tions. Days pass without the use of water, and filth 
 and vermin soon reign triumphant. It requires time to 
 prove to volunteers the fallacy and dangers of such a 
 coarse, which a sail experience corrects. The result of 
 
 this carelessness, during the first year of the war, was 
 that lice, which are an accompaniment of armies, 
 
30 CLEANLINESS NECESSARY FOR HEALTH. 
 
 were do Btrangera to out Boldiera. The were 
 covered with them, and infected all their b 
 from the genera] to the private, and only with t lie 
 utmost care could the cleanly keep bhems< 
 from iliis disgusting companionship. One of the 
 strongest reasons why regalara enjoy better health 
 than volunteers, ia thai the one are daily insp 
 by their officers, who insist upon their focea being 
 washed, heads combed, etc.; while the volunteers, 
 with whom the regulations of s Btriol discipline are 
 not enforced, are allowed to abuse the privilege of 
 following l ho bent of their own inclinations. In the 
 beginning of the war it was deplorable to Bee the 
 condition of our besl society in camp. Then, in the 
 Confederate hospitals, it waa r»->t rare to administer 
 the first hath to volunteers who had been six months 
 in service, without ever having used water beyond 
 their (aces. It would be a sanitary regulation of 
 great value, it' general ablutions could be made a por- 
 tion of the daily drill. A heavy penalty of extra 
 fatigue duty should be imposed upon those who did 
 the requirements of hygiene and clean- 
 liness. A.B the in Baity for a more rigid discipline 
 
 haa bee .me apparent both to Officers and men. the 
 
 linea have been gradually drawn, until at present our 
 army of volunteers, with indep indent views of the 
 duties and obligations of soldiers, have imperceptibly 
 d into a bo !y of regulars, governed by those 
 strict rules which military experience has shown iu- 
 
 dispensable tO the sanitary condition Of ail army ; and 
 
 hygiene, in all of its details, is now much more carer 
 fully observed. The frequent in an of stall' oili- 
 
 er-- have stimulated both medical and line omoers to 
 a more rigid performance of their duties, and hygienic 
 
 regulation- are now enforced. He is not only the 
 
FOOD FOR SOLDIKRS. 31 
 
 best, but also will becomo tbe most popular officer, 
 who attends himself to all these detailed comforts of 
 his men. 
 
 Pood of the soldier should be plain, nutritious fare, 
 well cooked, which, with exercise as an appetizer, he 
 will find no difficulty in enjoying, however monoto- 
 nous his daily ration may be. For a working 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 
 character of the diet, however, must depend, to a 
 certain extent, upon the seasons, and the ability of the 
 commissary to meet the demands of the army. High- 
 ly-seasoned dishes are neither possible nor desirable 
 for the soldier! Toil, fatigue, and often hunger, will 
 make any wholesome food savory. "The plain repast 
 is sufficient for sustenance; and a plain repast gives 
 all the gratification to the palate of a hungry and 
 thirsty man that a soldier ought to permit himself to 
 receive."* 
 
 For the English there is no beverage like 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 pre- 
 fer coffee, to which they give the highest prophyln 
 tic virtue. This is the stimulating drink of the 
 troops, and its free use makes the men much more 
 healthy and cheerful. 
 
 A- neither coffee nor tea can bo obtained by OUT 
 
 troops, inasmuch as the stringency of the blockade 
 
 udes i"'!h of tii.~.. articles from commissary 
 
 stores | except in sum II quantity for hospital use), whis- 
 
 •Jarksun' f Armies. 
 
32 FOOD FOR SOLDI! 
 
 key at times becomes a necessary issue to sustain the 
 health of the army under Bevere trials. 
 
 The Turks place great reliance on coffee as a pre- 
 servative I dysentery ; and BicLeod states, as a 
 N Bull of hie Crimean experience : " I have no <l<>ubt 
 that, if the precaution had been taken to Biipply the 
 troops every morning with 1 * * » t coffee, as they went on 
 or returned from doty, much of our mortality might 
 have been avoided." 
 
 As roasted and ground coffee has become a tixe<l ar- 
 ticle of trade, it would be much better for the troops 
 if it could be served out in this form, mixed with a due 
 proportion of Bugar, particularly when they are upon 
 extra duty, as it not only Bavee them much time, but 
 insures the proper preparation of a supporting bever- 
 age. 
 
 [f coffee can not be obtained, the best substitute is a 
 pint of hot Boup, which might be prepared from fresh 
 beef when thia article is abundant ; but, what is still 
 better for army purposes, from a Bpiced Boup-cake, 
 which is made of choice portions of beef, farinaceous 
 ingredients, and spices — the whole cooked, compressed, 
 and desiccated. These cakes occupy but a small 
 space, can be easily carried, will keep for months: 
 and, by cutting them uj> in the proportion of a pint of 
 
 boiling water for each Cake, and allowed to hoil for 
 ten or tilt ee n minutes, a pint Of excellent . well -lluvoivd 
 
 ip can be made. It requires no longer to make a 
 pint of good soup, with one of Jones' soup-cakes, than 
 would be required to make a cup of coffee, with the 
 coffee already parched and ground. 
 
 On account of the very great exposure to which our 
 troops must submit, without the protection of tents to 
 shield them from the drenching rains or the heavy 
 nightly dews, when it could be obtained, a dram of 
 
FOOD FOR B01UIEB8. ■ .'53 
 
 whiskey, issued as a ration, has been found very ben- 
 eficial in sustaining the health of our men. From 
 the scarcity of this, with all other stimulants, its use 
 has not been general, nor continued for any length of 
 time ; but when it could be procured, the advantages of 
 the issue were veiy decided. In the malarial region 
 upon the coast of South Carolina, among the swamps 
 and rice fields of this very insalubrious country, a 
 daily issue, during the summer months of 1862, of 
 whiskey medicated with an infusion of tonic barks, 
 was found to produce the most decidedly beneficial 
 effects on the appearance and condition of the men — 
 filling the ranks, and improving the physique of com- 
 panies — when, before its use, the force of the regi- 
 ments, broken up by climatic diseases, was represented 
 only in hospitals. 
 
 It may be needless to say that good water is even 
 more necessary than good food, and should be ob- 
 tained, at any cost, for the use of the troops. There is 
 no one item so prolific in disease as drinking bad 
 water — so strikingly exemplified in the Western 
 Army at the time of, and after, the Battle of Shiloh, 
 when, from tbe scarcity of good water, and the filthy, 
 muddy condition of the little which could be obtained, 
 an epidemic of diarrhoea and dysentery, with typhoid 
 complications, decimated, and at one time threat- 
 ened to destroy our army. Should troops be so 
 Unfortunate as to be in a place where stagnant or 
 ditch water has to be used, it can be purified by boil- 
 ing with a luinj) of charcoal; after which it should lie 
 freely agitated in the air, to restore to it the vivifying 
 properties which the heat had driven off. Should the 
 water he turhid.a pieceofalutn thrown into a hucket- 
 
 ful will quickly settle the deposit and restore its 
 
 crystalline character. If more time be allowed, the 
 
8 I FOOH KOR SOLDIERS. 
 
 better plan would be to filter the water by Sinking a 
 barrel with holes bored in the side; into this a much 
 smaller barrel, with the bottom knocked out, is placed, 
 and the intervening Bpace between the barrels filled 
 with Straw. The water which passes through the 
 holes leaves all imparities upon the straw, and springs 
 Up a- dear, potable water in the smaller barrel. 
 
 Fresh meat is a frequent issue to armies, and is the 
 m<>st common issue to our troops. It is usually boiled 
 or roasted over the fire into a tough mass, known as 
 frizzled beef, which tests the capacity of even a sol- 
 dier's digestion. The proper mode of cooking this 
 ration is in soup, which is always palatable, whether 
 thickened with flour, hard bread, or such vegetables as 
 the country affords. A French military proverb says 
 that "Soup makes the Boldier." In the use of fresh 
 meat, let it always he remembered that a fundamental 
 rule in the culinary art is to boil meat slowly and roast 
 it quickly. 
 
 The Tree use ol fresh vegetables is the only mode 
 of preventing the appearance of scurvy among tho 
 troops. When these can not be obtained, the free use 
 of dried vegetables, as rice, potatoes, corn meal, etc., 
 will tend lo sustain health and vigor. 
 
 A distinguished military surgeon has remarked that 
 lo 1,000 francs spent in fresh vegetables will save 
 500,000 franCS from the expenses of sick soldiers en- 
 tering the hospital, beside the use of the men for 
 
 active service. Of the dried vegetables, rice is among 
 thebesl for feeding troops. It is easily carried, easily 
 
 I. easily digested, and is one of the most whole- 
 some of the farinaceous articles -correcting, as it 
 often does, the tendency to intestinal fluxes, and yet 
 in the rice-growing country of the Confederate States 
 it is issticil very sparingly to our troops. 
 
FOOD FOR SOLDIERS. 35 
 
 In the Crimea, where the temporary absence' of 
 fresh vegetables was a great and serious privation, 
 lime-juice, citric acid, and sour-crout were extensively 
 used to prevent and stop scurvy. Acid fruits are anti- 
 scorbutic, and veiy 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, healthy drink. This corrective 
 protected, to a certain extent, the English soldiers 
 from scurvy, while with the French it was widely 
 epidemic and very fatal. Vinegar, when freely dis- 
 tributed, also assists in preventing this scourge among 
 troops. Vinegar, molasses, and water, when mixed in 
 proper proportions, make a veiy refreshing and palat- 
 able drink, not unlike lemonade, and possessing 
 similar antiscorbutic properties to lemon-juice. 
 
 Scurvy has often appeared in our armies, and during 
 the spring of 1863 it was quite prevalent in the Army 
 of the Potomac. It was corrected by the issue of 
 antiscorbutics, but more especially by the use of wild 
 herbs, which were collected by men sent out for that 
 purpose. With beef and the herbs an excellent soup 
 was made, which was found the best corrective for the 
 scorbutic symptoms. 
 
 One of the worst articles which can be issued to 
 troops in the Held, without conveniences for cooking, 
 is wheat flour. Fresh bread all will acknowledge to 
 be good tare, and is always hailed with satisfaction; 
 but to issue raw Hour as the vegetable element of a 
 ration, with no means of cooking it into an edible 
 bread, is an act of cruelty to troops who have no 
 nvaiis .it' obtaining other food than that which the 
 commissary department allows. In our corn country, 
 where corn meal or grist is a common article of food, 
 8 staple liked by all, and the mode of cooking it easy 
 
36 FOOH P>R SOLDI! 
 
 And familiar — tin- article itself abundant, cheap, 
 forming the very best of food for man — why this article 
 should not be generally issued instead of unwhole- 
 
 b e flour, which can only be made into the most 
 
 indigestible of dough-cakes, into which the teeth stick 
 
 in vain attempts at mastication, can not bo satis: 
 
 rilv explained. Economy, the health of the troops, 
 and general satisfaction in the army, would be the re- 
 sult of the change from wheat flour to corn meal. If 
 
 orders were issued to carry portable ovens with the 
 
 troops, so thai g 1 bread could be daily prepared, 
 
 which '-an very easily be done, or if ovens were built 
 wherever troops locate, then would flour be a useful 
 issue. 
 
 Bi8CnitS, Or hard bread, is B common article of diet 
 ill camp life, because it is easily preserved and trans- 
 ported. When eaten as dry biscuit, it acts like il 
 
 Bponge in the mouth, exhausting salivary Becretion. 
 When possible] and rarely is it inconvenient, soak it 
 in tea, coffee, or SOUp ; it then makes a very nutritious 
 
 meal. Even water, with a little salt, makes hard 
 bread much more palatable ami nourishing. When 
 
 boiled with -diced bacon and water it is a very satis- 
 factory meal for our Boldiers, one always relished, hut 
 
 not very often enjoyed. 
 
 Necessity, the parent of everything useful, even in 
 the domestic economy of armies, has driven our sol- 
 diers to a method of using their Hour ration which, in 
 absence of other fare, make- a palatable and an edi- 
 ble bread, which is known in t lie army as Confederate 
 Biscuit. It is prepared as follows : Cooking utensils 
 
 being of the most simple eh a racier and of the smallest 
 
 possible number in our army, a mess-pan, camp-kettle, 
 
 or even tin cup, is often found to embody all the re- 
 quisites for conking the daily meals. Where extra 
 
FOOD FOR SOLDIERS. 37 
 
 cooking is desired, apparatus must be improvised. A 
 piece of bark or the bend of B barrel composes tbe 
 kneading-trough, upon winch tbe flour is worked with 
 salt and water, or with melted grease, when the beef 
 issued can supply tallow. This muss is either baked 
 or fried in a pan; or, drawn out as a cord, is twisted 
 around a ramrod, and baked over tbe fire. When tbe 
 army is moving, and cooking utensils can not be got 
 at, a bole scooped in the ground with a bayonet 
 makes a ready mixing-bowl, and tbe ramrod, always 
 at band, completes tbe paraphernalia of the kitchen. 
 The bread made in this way is reported excellent. 
 Fresh bread is always preferable, when it can be ob- 
 tained. 
 
 Bacon is. par excellence, the laborers' and soldiers' 
 meat in America, and goes further, by weight, than 
 any other. It never produces surfeit, is always ac- 
 ceptable, very easily cooked, and. with its rich juice, 
 will make the dryest farinaceous diet savory. It has 
 the very great advantage, when properly cured, of 
 keeping for a length of time, under any condition, 
 which makes it far preferable to any other meat for 
 troops. It can also be eaten raw, as on a march, 
 when neither time nor convenience exists for cooking 
 it < >ur soldiers, who are very often forced to this al- 
 ternative, have not. apparently, suffered from its very 
 frequent repctil ion. 
 
 In the Confederate service, the full ration, which our 
 troops have seldom issued to them, 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 p< 
 
 beans, or. in lieu thert of, ten j ounde ix pounds 
 
n :: SOLDIERS. 
 
 of coffee, twelve pounds of Bugar; also, four quarts of 
 vinegar. The ration is completed by adding one and 
 one-half pounds of tallow, one and one-quarter pounds 
 of adamantine, or one pound of Bperra candles, four 
 pounds of soap, and two quarts of salt, to one hundred 
 ration-. < >n a campaign, or on marches, or on board 
 transports, the ration of hard bread is one pound. 
 
 Extra issues of soap, candles, and vinegar are per- 
 mitted (<> the hospital, when the Burgeon does not avail 
 himself of the commutation of the hospital rations. or 
 when there is no hospital fund. 
 
 Desiccated vegetables may be issued onceperweek, 
 in lieu of beans <>r rice; and should a tendency to 
 scurvy appeal- among the troop-, the commanding 
 officer may. by advice of the medical officer, direct 
 their more frequent issue. Two "issues" per week of 
 "desiccated vegetables" may be made in lieu of beans 
 or rii 
 
 Potatoes and onions, when used, will always be in 
 lieu of rice or l>cans. Potatoes at the rate of one 
 pound p'l- ration; onions at the rate of three pecks 
 
 per hundred rations. 
 
 When fresh beef can be provided, so a- to eosl not 
 more than an equivalent of salt pork, it i- issued to the 
 troops five times a week, it ha- often occurred that 
 
 beef was the sole meat issue for weeks continuously, 
 and as often the army would he for days without an 
 issue of meal of any kind — hard biscuit or wheat flour 
 being the -ole article of food used. Often has a few 
 ear- of corn to man and horse been the day's ration in 
 our army. 
 
 When, from excessive fatigue or exposure, the com- 
 manding officer may deem it necessary, he may direct 
 the issue of whiskey to the enlisted men of Ids com- 
 mand, nut to exceed a gill per man for each day. 
 
FOOD FOR SOLDIERS 39 
 
 Tea may be issued in lieu of coffee, at the rate.of one 
 and a half pounds per hundred rations. 
 
 When the officers of the medical department find 
 antiscorbutics necessary for the health of the troops, 
 the commanding officer may order issues of fresh vege- 
 tables, pickled onions, sour-crout, or molasses, with an 
 extra quantity of rice and vinegar; potatoes are 
 usually issued at the rate of one pound per ration, and 
 onions at the rate of three bushels in lieu of one of 
 beans. Occasional issues (extra) of molasses arc made 
 — two quarts to one hundred rations; and of dried 
 apples, of from one to one and a half bushels to one 
 hundred rations. 
 
 When antiscorbutics arc issued, the medical officer 
 will certify the necessity ami the circumstances which 
 cause it. upon the abstract of extra issues. 
 
 Such arc the supplies which our troops would be al- 
 lowed tohave in peacetimes, and in the beginning of the 
 war most of the articles may have been issued; but the 
 army has not, for many months, enjoyed the privilege 
 of whetting their appetites upon this attractive bill of 
 fare of the commissary-general's. Habit has taught 
 them to live upon a much smaller list, and in much 
 smaller quantity. From the scarcity of many of the 
 articles enumerated above, they have been rescinded 
 from the issue, and the ration has been reduced to its 
 simplest form "f beef and Hour. Owing to a badly- 
 organized and deficient transportation, one portion of 
 the army i- surfeited with such things as another 
 division seldom sees. Notwithstanding the scanty 
 and very indifferent fare, our veteran troops, who have 
 become accustomed to it. sustain robust health. 
 
 Daily it Uions should hi- made to the troops; 
 
 for when, from the laziness of coma two <>r 
 
 three days rations are given out at a time, through 
 
40 PREPARING RATIONS. 
 
 the proverbial carelessness or improvidence of soldie 
 the provisions arc either wasted or all are eaten in one 
 • lav, and two days' starvation, if not sickness from gor- 
 mandizing, follows. 
 
 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 one of the 
 mess appointed special cook than to allow the soldiers 
 to cook in turn. A division of labor is clearly the 
 preferable plan. It would be economical and benefi- 
 cial, if government would allow two professed cooks 
 for each company, as the health of the army would 
 be improved materially by having good tare. Fire- 
 wood, of course, must be liberally provided, as it is 
 one-half of a soldier's existence. 
 
 The entire health of troops depends upon the 
 quality, quantity, variety, and the regularity with 
 which the provisions are supplied. The effective 
 condition and strength of the army, with a diminu- 
 tion of the sick-, and consequently a diminution in the 
 hospital expenses, will depend, in a great measure, 
 upon the commissary department. In 1847 the high 
 price of provisions doubled the number of sick in tho 
 French army, sending one-fifth of the effective regi- 
 ments into the hospitals. The better paid, select 
 corps, who could increase their supply of nourish- 
 ment, escaped those diseases which prevailed among 
 the common soldiers. Fxperienco shows that, in a 
 besieged city, when scarcity prevails, pestilence fol- 
 lows in the wake of famine. 
 
 Officers as well as soldiers usually club together 
 into messes, which is not only more agreeable, but 
 also profitable for all concerned. 
 
 Officers' messes should consist of tho company offi- 
 
Messing. 41 
 
 cers — four persons. The colonel, lieutenant-colonel, 
 major, adjutant, and sergeant-major, with the com- 
 missary, quartermaster, surgeon, assistant surgeon, 
 and chaplain, could easily arrange two or three 
 messes. 
 
 Messes of privates and non-commissioned officers 
 should number six persons, for obvious reasons, so 
 that the details for guard duty would always leave 
 four in charge of the tent. 
 
 Articles wanted for a mess of six, when transpor- 
 tation is abundant, and articles readily obtained : Two 
 champagne baskets, covered with coarse canvas, with 
 two leather straps with buckles; six tin plates; six tin 
 cups; mx 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 teapot, one coffee-kettle. Two 
 years' experience, the rapid movements of our army, 
 and deficient transportation, with the impossibility of 
 supplying the wear, tear, and loss of camp utensils, 
 have modified the list of necessary culinary articles, 
 and our soldiers are now accustomed to prepare their 
 rations with very little in the shape of cooking uten- 
 sils. If each man has a tin cup, and each company a 
 camp-kettle, one or two frying-pans, and an axe to 
 cut wood with, they would consider themselves well 
 provided with all necessary apparatus. In the present 
 condition of the cooking utensils of our army, one 
 wagon readily carries the cooking paraphernalia ot 
 a regiment. 
 
 It is always a good rule to accustom an army to 
 adopt the modes of living common to the inhabitants 
 D 
 
42 PREPARATION POU MARCHING. 
 
 of the country in which the army is found, as certain 
 peculiarities of living are naturally adapted to cer- 
 tain climates. 
 
 Although war brings with it privations and irregu- 
 lar living, which it is impossible to prevent, the mode 
 of living of a soldier, to a certain extent, should fol- 
 low a fixed standard. His meals should be equally 
 distributed through the day, and he should never ho 
 put to work without having broken his fast, however 
 light the meal be. In camp, soldiers should live with 
 regularity, and the breakfast and dinner hour should 
 be respected; and as three meals a day is the custom 
 of our people, this regulation should be adopted. It 
 is on the march that circumstances prevent the car- 
 rying out of rules, and that our troops suffer the 
 greatest privations. Very few armies have been more 
 exposed, and suffered more from hunger and fatigue, 
 with so little dissatisfaction and straggling as ours. 
 
 The following is the order which experience has 
 proved to be the most useful in the Confederate army: 
 Our troops are accustomed to move at short notice, 
 and, therefore, often with empt}^ haversacks, and no 
 prospect for a meal dining the day. When a march 
 has been determined upon, the ration (which is now 
 one pound of flour and half pound of bacon, the latter 
 being usually issued in lieu of beef when troops are 
 under marching orders) is cooked in advance, or 
 bread may be issued, which, with raw bacon, will 
 make a palatablo meal. Usually, three days rations 
 are served and cooked prior to moving, and under 
 these conditions a hasty meal will be taken before 
 falling into line. Our men have neither the hot cup 
 of coffee or tea, nor have they the hot soup, nor drink 
 of whiskej', which is tho inarching preparation of an 
 army with a more extensive commissariat than ours. 
 
ORDER IN MARCHING. 43 
 
 They move with alacrity, and often break their fast 
 while in motion. The start, especially in summer, 
 should always bo at the break of day. After march- 
 ing three-fourths of an hour, the column stops for 
 twenty minutes. In resuming the march, a halt is 
 made for ten minutes after each hour. From twenty 
 to twenty-five miles a day is considered good march- 
 ing for an army, although, on an average, it does not 
 exceed fifteen, and may l>e divided in the following 
 order: Nearly three miles maybe made during the 
 first hour of marching; then a halt is ordered for 
 twenty minutes, during which the men should remove 
 their knapsacks and recline upon the ground, as 
 standing gives but little relief. Two miles an hour 
 can be made for the remaining portion of the da}^. 
 After marching for three or four hours, a halt should 
 be ordered, especially in summer, until the heat of the 
 day passes, when the march may be resumed. During 
 the mid-day rest, if any opportunity exists, the shoes 
 and stockings should be removed and the feet bathed, 
 which, by removing dirt and acid secretions, will pre- 
 vent excoriations. It may also bo advantageous, at 
 such times, to change socks from one foot to the 
 other, so that the seams may come at different por- 
 tions of the foot, which will prevent continued and 
 injurious pressure. Soaping the sock will also pre- 
 vent excoriations, and add much to the comfort of a 
 soldier while on a march. 
 
 In crossing a river, when there arc no bridges, the 
 men ford it, and continue the march in their wet- 
 clothes, until they dry. It is found that when they 
 arc allowed, as they are in European armies, to take 
 oil their pantaloons and shoes, that much delay is oc- 
 casioned, and the column is thrown thereby into dis- 
 order. A sentinel guards any fresh- water spring 
 
44 ORDKK IN MARCHING. 
 
 which i.s met in the march, to deter soldiers from 
 gorging themselves — a very wise measure, which 
 prevents much sickness. An aphorism worthy of 
 
 remembrance is — Brink always before marching^ and 
 while on the march moisten the month often, bat drink 
 Seldom. Water should always be taken in reserve, 
 and with precaution. When taken in great quan- 
 tities, it weakens and fatigues the organs of digestion, 
 increases perspiration, and enervates the entire sys- 
 tem. It is particularly injurious to drink rapidly and 
 freely when heated from exercise, as sudden death 
 sometimes follows this imprudence. 
 
 The soldier should accastom himself, when thirsty, 
 to drink slowly and in small monthfals, 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 required, while much, hurriedly drank, 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; other- 
 wise, the dry air, often loafled with dust, will parch 
 the lining membrane of the mouth — a very distress- 
 ing sensation when it can not be relieved by drinking. 
 Arabs, in crossing sandy deserts, where but little 
 water can bo found to allay the intense thirst of their 
 hot climate, adopt the wise precaution of tying a 
 handkerchief over the mouth, which keeps out dust, 
 and, by preventing conversation, prevents, to a great 
 extent, thirst. It would be well for troops upon a 
 march to profit by their experience. 
 
 When, during a march or halt, the fatigued and 
 thirsty soldier finds water, instead of rushing to it at 
 
ORDER IN MARCHING. 45 
 
 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 possi- 
 ble quantity of water supply his necessities. Wash- 
 ing the face slackens thirst. When water can not be 
 Obtained, a bullet or pebble in the mouth, or chewing 
 a green leaf, will cause a secretion of ^saliva, and, by 
 keeping the mouth moist, will temporarily allay 
 thirst. As good water is not always to he obtained 
 on a march, a soldier should never lose an oppor- 
 tunity for filling his canteen with fresh water. If the 
 canteeus be covered with a light-colored woollen cloth 
 the water will keep cooler than in bright tin, which 
 absorbs heat more rapidly, and extends it to the con- 
 tents of the canteen. 
 
 When troops have had an early start, and are not 
 marching in the face of an enemy, they should 
 bivouac about ten o'clock in the morning, and lie 
 over during the heat of the day, as soldiers on a 
 march should, if possible, be protected from the mid- 
 day sun. Here they will have time to cook their 
 mid-day meal, and refresh themselves from their 
 fatigue. The experienced soldier never forgets to 
 keep in reserve a certain proportion of meat or other 
 food, against a deficient distribution, or the want of 
 time for properly preparing it, during the continued 
 march. The want of this precaution, which old sol- 
 diers adopt, is severely felt by recruits. The meal 
 should be taken in the shade, under some protection 
 from the sun. A few branches, properly arranged, 
 will form a comfortable shelter. The main meal of 
 meat, etc, should be taken alter the evening halt, at 
 the end of tin- day V march. 
 
 The officer in charge of the troops should always 
 know the road over which he is to travel the next 
 
46 BIVOUAC KINO DURING A MARCH. 
 
 day, : * ii*l when he is compelled t<> bivouac in placos 
 where the prospect t''>r getting wood is bad, each sol- 
 dier should carry on his knapsack a small quantity to 
 cook his mid-day meal with. 
 
 W 1 1 > ■ 1 1 troops are ordered on a forced march, or <>m 
 scouting service, their food should be prepared in 
 advance, for t\\" or three days rations, or they should 
 be furnished with Buch as can be rapidly cooked ; 
 sausage or meat-cakes, with biscuit, would be an 
 llent issue at Buch times. 
 
 Tu the evening halt, which should beat about live 
 o'clock iii the afternoon, bo as to allow the men to 
 improvise camp comforts, the site selected for the 
 camp, when possible, should be on iisin^ ground, free 
 from low places, and in proximity to water and wood. 
 These rules become of special importance in estab- 
 lishing a camp for even a few days' stay. It is pru- 
 dent 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 
 wood is. as a general rule, sufficient to turn or break 
 currents from these low places, and protect from their 
 hurtful influence. It would Wc preferable to camp in 
 
 tbe direction Of the regular wind currents, so that 
 emanations may be wafted in the contrary direction. 
 When i he halt i-- only for tho night, although the 
 camp-wagons, with the tents for the officers, may have 
 come up, they prefer, with the men, to bivouac under 
 tbe clear sky, or geek shelter under a few branches, 
 with which they form a rough shfed that will protect 
 
 them from dew. 'The bivouac is, from necessity, the 
 mode of living of most of our troops during the active 
 campaign, which extends over several months of each 
 year. At tbe breaking up of the winter encampment, 
 
 i 
 
BIVOUACKING DURING A MARCH. 47 
 
 all tents, with the exception of a few for the use of 
 officers, are turned over to the quartermaster, to bo 
 transported to some depot in the rear, where they 
 remain, unless the army, in maneuvering, occupies 
 a position which it will retain for a lengthened 
 period, when the tents are again issued. As our 
 troops move with celerity, and as transportation is 
 always deficient, it is a desideratum to march with 
 the smallest amount of baggage, and our men willing- 
 ly leave their tents — even field-officers preferring the 
 protection of their blankets and india-rubber cloths 
 under the open sky, to the trouble of unloading their 
 wagon of its camp equipage. If possible, dry grass or 
 leaves form their bed, and, lying in their greatcoats 
 and upon their india-rubber cloths, they can enjoy 
 peaceful slumber. 
 
 In marching through a wooded country, as is our 
 own, it is surprising to see with what dexterity a 
 mess can build for themselves a shelter for the night. 
 On a regular march the column usually halts for 
 the night at about five o'clock in the afternoon, 
 which gives the men ample time to prepare their hut 
 or tent, after the following method: Two sticks, four 
 and a half feet long, with a fork at one end, arc 
 planted in the ground, a ridge-pole placed in the 
 forks. A large blanket thrown over the ridge forms 
 a comfortable tent, which can be perfected in ton 
 minutes; or branches may bjB laid either side of the 
 ridge-pole to the ground, which would enclose the 
 area of a tent. In summer it is preferable to cut 
 the forked sticks longer, and, leaving one side of 
 the shed opposite t<> the direction of the wind open, 
 incline the branches only upon one side, which will 
 give those sleeping under its sloping roof protection 
 from the dews or lain, and also, to a certain extent. 
 
48 ENCAMPMENT. 
 
 from malarial emanations wafted by the currents 
 of air over the temporary resting-place of the army. 
 
 If there is no cover for the men, then they build 
 fires, and sleep around these — lying as so many radii 
 of :i 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 '>ne would suppose. 
 If the men are warmly clad, they always enjoy more 
 health when hivouacked than when under tents; and 
 as experience has taught our men the advantages 
 of this life in the summer months, they leave their 
 tents behind without regret, and with them such con- 
 tagious diseases as had clung to the army while they 
 remained in their permanent camp. Necessity has 
 also forced some of our veteran troops to dispense 
 with Jill shelter; even during the hitter cold of the past 
 winter, the only cover which the men had being the 
 leafless trees of the forest. The army, in constant 
 motion, would lay down at night by their camp-fires, 
 and, after a sound night's sleep, our soldiers would 
 often find themselves in the morning nearly buried 
 in snow. They would shake oft* the snow, rekindle 
 their fires, and at least enjoy the satisfaction of never 
 suffering from catarrhal affections. 
 
 No troops should ever bivouac upon damp, marshy 
 soil, where a single night's exposure in summer would 
 poison numbers with malaria, or in winter would 
 be the fruitful cause of pneumonia or rheumatic affec- 
 tions. 
 
 The site of ;i permanent camp should he dry. with 
 good drainage — the dryness of the soil being tested by 
 digging, to see that a stratum of water docs not imme- 
 diately 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 
 
WARMING TENTS. 4!> 
 
 ditch should bo dug around (lu'in, with the earth 
 banked up against the tent to keep out the. cold and 
 rain. When troops in tho field go into "winter- 
 quarters, it is customary to build for their protection 
 log-houses, cabins, or huts, covered in with boards, 
 long segments of bark, or with a fly. At times, deep 
 holes are excavated, and roofed over with planking ; 
 a ditch around the enclosure, which should bo always 
 deeper than the excavation, and filled with loose 
 stones, will keep the apartment dry. In a very cold 
 climate theso make, perhaps, the warmest and most 
 comfortable of winter-quarters. 
 
 The method commonly adopted in our army for 
 warming tents, is to construct a chimney at the back of 
 the tent, of sticks built up in pen-form, well covered 
 with clay, and capped with a flour-barrel — the open 
 portion in the tent being formed by arranging two 
 rows of upright sticks three or four inches apart, 
 forming thi'oe sides of a square, the interval between 
 which rows is filled with clay. Tho back of the tent 
 is slit, and the edges secured closely to the sides of the 
 chimney, which throws the fireplace into the tent, 
 and makes very comfortable, warm quarters. 
 
 An excellent modo of making a tent comfortable 
 in cold weather, is by excavating a basement about 
 three feet deep, which will at the same time give 
 more room, and permit of a stove or fireplace in the 
 centre of tho tent. The dirt from within should 
 bo banked up against the outer side of the tent, to 
 keep out cold and moisture. Communicating ditches 
 should be provided, to facilitate drainage. Of tents, 
 tho circular offers tho best protection against tho 
 wind, is least Liable to bo blown down, and is most 
 useful for winter. 
 
 Tim light shelter-tent of the French troops, as 
 
50 6HELTER-TENT. 
 
 introduced by Marshal Bagoaud, is found most con- 
 venient daring the Bummer months (or an army in 
 tho field, and has been generally introduced into 
 the Confederate Bervice as the army tent. The tent 
 is made of the knapsack of tho Boldier, 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 spread open are 
 thus united, the centre supported by two -ticks three 
 feet long, and the angles staked to the ground by 
 small camp-pins, the two or four persons to whom 
 the sacks belong, by thus joining property, have a 
 tent that will keep them from exposure to the sun, 
 and also protect them from rain or dew. This tent is 
 not more than three feet high at its ridge. In hot 
 and dry weather, instead of pinning the two sides to 
 the ground, one of them can lie hung horizontally to 
 brandies of trees, leaving one side open for thorough 
 ventilation, while tho horizontal portion protects 
 tho sleeper from unduo exposure. Tho size of this 
 tont can be increased to any extent by joining stock, 
 as all such sacks are of tho same size, with buttons 
 and button-holes arranged equidistant. 
 
 By employing this excellent suggestion, } r ou avoid 
 loading the shoulders of a soldier, or transporting 
 tents for the army, which is often impracticable. In 
 u few minutes after the day's march has terminated 
 tents are pitched, and the camp assumes its regular 
 appearance, without waiting for the baggage train. 
 
 Rider's tent-knapsack is made as follows: It is com- 
 posed of a piece of gutta-percha cloth, five feet three 
 inches long by three feet eight inches wide. Two 
 of the borders are pierced with button-holes for brass 
 studs, a third border has a double edge, between 
 which may be inserted and buttoned a second knap- 
 
soldier's bed. 51 
 
 Sack, while the fourth edge would have the straps find 
 hackles necessary to elose the knapsack. The weight 
 of the gutta-percha sheet, when prepared, is throo 
 pounds. The additional accoutrements carried by tho 
 soldier arc two sticks, three feet eight inches long 
 and one and a quarter thick, which may be divided in 
 the middle, with the pieces securely attached to each 
 other by a ferule; also a small cord. When used as 
 a knapsack, the clothing is packed in a bag, and the 
 gutta-percha is folded around it, lapping at the ends, 
 so that tho clothing is protected by two or three 
 thicknesses of gutta-percha. Four knapsacks button- 
 ed together will form a sheet ten feet six inches long 
 by seven feet four inches wide, and when pitched on a 
 rope three feet four inches above the ground, covers an 
 area of six feet six inches wido by seven feet four 
 inches long, which will accommodate five men, and 
 may be made to givo shelter to seven. The sheet can 
 also be used upon the ground, and is a great protection 
 against dampness. 
 
 In a regular camp the soldier's bed should never bo 
 directly upon the ground — as the earth always con- 
 tains moisture enough to permeate the clothing, and 
 rheumatism, pleurisy, pneumonia, and such kindred 
 affections, may be the consequence. If beds can not be 
 obtained, branches or dried leaves or straw should be 
 used, upon which the blankets are spread. An ele- 
 vated bed can be made by supporting rails upon four 
 forked sticks with riding pieces; leaves or straw put 
 upon these, and covered with a blanket, will make an 
 excollenl couch. This answers the double purpose of 
 koeping the body from the damp ground and of e leva t- 
 bag it into a layer of purer air. When tin 1 tent is 
 ailed, as is usually tho case, the exhaled air, loaded 
 with carbonic acid and other impurities, settles to the 
 
'<2 soldier's bed. 
 
 ground. Unless free circulation (-fair i> permitted in 
 the tents, persons Bleeping npon the ground would be 
 continually inhaling this poisoned atmosphere, to their 
 
 injury. 
 
 The soldier's bed should be always dry. All moist, 
 decomposing materials, such as green grass or leaves, 
 collected in a tent lor a permanent bed, arc more in- 
 jurious than sleepingnpon the soil, owing to the gases 
 escaping from their decomposition. True economy 
 would dictate a painted cloth for the floor of the tent, 
 as this would prevent the exhalation of moisture from 
 tho earth's surface, is convenient, always ready, and 
 less expensive than straw. It can he cleaned every 
 (lay with little trouble, without cost, and requires to 
 be freshly painted only once a 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 thoroughly aired 
 daily, with exposure to the sun when possible. In the 
 French camp, straw is given out every fifteen days j 
 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 upon, ho 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, lie should always lio upon it, as the 
 very best use he can make of it to protect himself from 
 disease. It is an oxcellcnt substitute for straw in 
 field life. morO cleanly, and protects bettor from 
 dampness; it is always at hand, and always read}' for 
 use. Sheepskins were tried by the French as a substi- 
 tute for straw. They were found to attract moisture 
 and propagate vermin, and were therefore rejected. 
 
CLEANLINESS OF A CAMP. 53 
 
 As the tout is always too .small for the number 
 which occupy it, the inmates should sleep with their 
 heads as far as possible from each other. In the cir- 
 cular tent, they should sleep with their feet toward 
 the vortical axis and their heads around the periphery, 
 so as to increase to the utmost their respective areas 
 for respiration. After reveille the tents should bo 
 opened, sides thoroughly beaten, straw turned, and 
 exposed for several hours. 
 
 Extreme cleanliness should prevail within and with- 
 out the tent. In an encampment the tents should 
 never be crowded, but ample space should be left 
 around each tent for changing its position at least 
 every week, so as to purify the soil infected by habi- 
 tation. The earth floor of a tent attracts and ab' 
 sorbs impurities which, unless changed, would soon 
 render it a source of disease. Permanence of camps 
 rapidly induces infection. This frequent changing of 
 tents gives, to be sure, additional trouble to the 
 officers and men who may not appreciate its advan- 
 tages, but this is more than counterbalanced by the 
 health and efficiency of the command. All the 
 garbago of the camp should be thrown at a distance 
 from the tents, and should be buried every evening. 
 
 The privies or sinks for the men are ditches, 
 from three to five feet deep and three feet broad, 
 Screened from view by branches stuck in the earth. 
 A crotched stick is driven into the ground at each end, 
 and a pole laid across to serve as a seat. These sinks 
 should be dug narrow and deep, so as to leave as littlo 
 Bpace a-^ possible for evaporation. Usually three 
 sinks are dug for each regiment, viz: ono for the 
 men, one for the use of line officers, and one tor 
 the field and stall' officers. The common laws of 
 hygiene insist that these bo prepared immediately 
 
54 CLEANLINESS OF A CAMP. 
 
 upon the establishment of an encampment, and that 
 the men be compelled to use them under ;i penalty. 
 The want of these, and the negligence in insisting upon 
 their use. may be considered one of the chief causes 
 
 of the fearful amount of sickness which existed in the 
 summer of 1861 in our armies. Gentlemen who 
 composed our volunteer regiments would not obey 
 
 the orders to use these sinks, and as the offieers did not 
 insist upon what the men objected to as unnecessarily 
 troublesome, the result was that, with but few excep- 
 tions, our regimental camps were accumulations of 
 tilth of every description, which could be detected at 
 a distance while approaching them. It was not sur- 
 prising that disease and death followed in the 
 wake of such inditferenco to all laws of decency and 
 hygiene. 
 
 As soon as a camp is established, the quartermasters 
 of regiments locate the sinks, and fatigue squads pre- 
 pare them for use. A patrol guard is then established, 
 whose duty it is to see that the grounds about the 
 camp are not defiled. All delinquents are punished 
 with fatigue duty in policing the camp under the 
 guidance of the officer of the day, who always has 
 under his charge a Dumber of unruly men, who pay the 
 penalty of infringing military rules by devoting all of 
 their spare time to the cleansing of the camp, in bury- 
 ing offal, and in digging new sinks when those in use 
 have been sufficiently filled. Under the feeling of 
 responsibility which is now felt in the army, and 
 the more stringent reports of brigade and division 
 inspectors, a much more wholesome condition exists 
 in enforcing such sanitary regulations of cleanliness, 
 etc., as the massing of men absolutely require. 
 
 The privies should be placed at least one hundred 
 yards from the tents, and in an opposite direction 
 
EMPLOYMENT IN CAMP. 55 
 
 to the wind currents, so that offensive odors will 
 be blown away. Where proximity to the water 
 permits, they should be established over the running 
 stream. This will remove a great and common 
 source of infection, which is very difficult to coun- 
 teract. The slaughter-pens should also be placed at a 
 similar distance. Every evening the offal of the day 
 should be covered with three or four inches of earth, 
 or :i sufficient layer to prevent any smell arising from 
 the day's deposit. When the trench is two-thirds 
 full it should be closed, and another of similar dimen- 
 sions opened. 
 
 In permanent camps, dead animals, horse-dung, 
 and all animal refuse, should be buried, otherwise 
 the stench from them would be very injurious to 
 the health of the troops. But as, notwithstanding the 
 utmost eai-e, in the most salubrious situations, diseases 
 will in time show themselves — from the inevitable ac- 
 cumulation of poisonous materials, resulting from the 
 growing infection of the soil, with its poisonous emana- 
 tions, 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. 
 
 As the daily drills do not suffice to develop the 
 physical organization of the soldier, he might be 
 usefully employed upon public works, which may 
 revert to his individual benefit — as the erection of 
 batteries, the making of military roads, draining the 
 sites of camps, etc. For months the roads in the 
 vicinity of .Manassas, where the Army of the Potomac 
 were stationed, were nearly impassable, and transpor- 
 tation was so exceedingly difficult, that the army 
 suffered severely for proper food. Had the troops 
 
56 AMUSEMENTS IN CAMP. 
 
 boen ordered to work the roads instead of loitering for 
 months in camp, the service would bsve been mate- 
 rially advanced. 
 
 The same want of forethought occurred around 
 Charleston, where a large army was kept idle for 
 months, while the laboring agricultural population 
 were taken from their farms when they could ho 
 least spared, to erect works which the soldiers would 
 gladly have done, the more especially if they could 
 have received the extra pay allowed to these laborers. 
 The provisions would have heen more abundant, and 
 soldiers could have been taught to labor, and by 
 degrees inured to hard work, with all of its advan- 
 tages, if they had heen put in the trenches. In the 
 Army of Virginia the soldiers were found not only 
 always ready but willing to engage in such work as 
 was required; and often, when ennui had taken pos- 
 session of the camp, and homesickness threatened 
 to break out as an epidemic, an order to erect works 
 was always hailed with pleasure, and in twenty-four 
 hours the entire camp would resume its accustomed 
 gayety. Works were erected which we never cx- 
 pocted to use, simply to keep the men employed, and 
 make them contented and happy. 
 
 To enliven and relieve the toil and tedium of camp 
 life, amusements are a very necessary portion of tho 
 daj'-'s duties; and it is found that lively music from 
 the military bands every afternoon, will elato tho 
 men and remove monotony. Singing and music 
 should be a portion of tho military education, as offer- 
 ing an agreeable modo of passing the many idlo 
 hours of camp lite which usually hang so heavily 
 upon the soldier. Temporary gymnasia might be 
 established, and gymnastic exercises should be en- 
 couraged as conducive to hoalth, strength, agility, and 
 address. 
 
AMUSEMFNTS IN CAMP. 57 
 
 The manly play of ball, with its invigorating exer- 
 cise, is the common amusement in a Confederate 
 camp. In winter this gives place to mock-battles 
 with snowballs, when regiments and brigades arc 
 marshalled against each other in amicable array, and 
 take as much pride in attacking and in repelling 
 assaults, and taking prisoners, as they have felt on 
 the battle-field in taking and holding an enemy's 
 position. Besides ball-playing, soldiers in camp 
 amuse themselves with rolling ten-pins, shooting 
 marbles, throwing quoits, racing, wrestling — any of 
 which are preferable to card-playing, which, in camp, 
 is inseparable from gambling. Cock-fighting is also 
 an amusement of permanent camps, both officers and 
 men in our volunteer army participating in this sport. 
 Animal pets are very seldom met with in the army. 
 As our troops find difficulty in supplying themselves 
 with sufficient food, foraging for animals can not be 
 thought of. This feeling of sympathy with the brute 
 creation has been crushed by the hardships which 
 have destroyed thousands of noble horses, the private 
 property of officers and men, who have lost their 
 favorite blooded pets from the gradual starvation at- 
 tendant upon a permanent deficiency of food. 
 
 In the summer of 1850, during the Italian cam- 
 paign, I was at Milan when a largo body of French 
 troops, returning from the bloody field of Solferino, 
 arrived. In a few minutes their shelter-tents were 
 pitched, under tho shade of tho trees on the- broad 
 boulevard which surrounds the city, and tho soldiers 
 were allowed to follow the bent of their own in- 
 clination. Card- playing, dominoes, fortune-telling, 
 wrestling, and dancing to the discordant tunes of a 
 hand-organ, or the sharp notes of an accordeon, ap- 
 peared to be the order of the day. 
 
OS AMUSEMENTS IN CAMP. 
 
 1' ts in various forms were commonly found among 
 the troopsj and those were guarded with Bcrupuloua 
 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 ita very near 
 proximity to the battle-field and railroad facilities 
 for transportation — it was not unusual to see a sol- 
 dier, nearly exhausted from the tedious dressing of a 
 frightful wound, when he had passed from the hands 
 of the surgeon, take from his bosom a little sparrow, 
 and from the cheerful chirp of this little bird appear 
 to derive much consolation. 
 
 Not the least attractive incident connected with 
 the triumphal march of Napoleon's Italian army 
 through Paris, in August, 1859, was the pets accom- 
 panying 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 command, 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, while tho caresses of the company, 
 and the pleasant faces with which his presence would 
 always be recognized, show the appreciation of his 
 companionship. These little incidents arc introduced 
 to show the longing of all men for objects of affection, 
 and also how many a tedious and otherwise, unbear- 
 able hour in camp life is pleasantly spent in fostering 
 those fine feelings of the human heart which keep 
 soldiers, accustomed to blood, from becoming de- 
 graded and brutal. 
 
CHAPTER II. 
 
 Hospitals, Regimental and Ceneral — Hospital Tents, with 
 Equipment — Number ok Attendants allowed — Duties of 
 Surgeon in charge or a General Hospital — op Division 
 Surgeon — Assistant Surgeon— Apothecary — Hospital Stew- 
 ard — Ward -Master — Nurses — Matrons — Laundresses — 
 Tatients — Cleansing op Hospitals — Care necessary in pre- 
 venting Infection — Value op Fumigation — Female Attend- 
 ants — Hospital Diet, etc. 
 
 The accommodations for the sick form a very im- 
 portant department in the economy of an army, and, 
 as a rule, are never sufficiently ample. With every 
 body of troops in the field there arc two kinds of 
 hospitals — the regimental and the general. With 
 regular armies there should always ho a third — tho 
 convalescent hospital — situated in some salubrious, 
 rural location, where convalescents, b}- inhaling pure 
 air, and enjoying the pleasures of country life, can 
 rapidly rebuild their shattered constittitions. 
 
 For the army in Virginia, during the summer and 
 autumn of 1861, convalescent hospitals were estab- 
 lished at points well adapted for the purpose, and 
 were of essential benefit. Tho Virginia springs are 
 known to all tho world ; at such places of resort 
 every convenience exists for accommodating largo 
 numbers of visitors. At some of these watering- 
 places tho hotels and numerous cottages were con- 
 verted into extensive hospitals, where convalescents 
 from measles and typhoid fever could use the min- 
 eral waters, enjoy the fine scenery, and recruit rap- 
 idly. 
 
60 
 
 REGIMENTAL HOSPITAL. 
 
 The regimental HOSPITAL is usually under tents 
 ■when in the field, if a suitable building in the im- 
 mediate vicinity of the encampment can not bo 
 obtained. According t<> army regulations, the tents 
 used as hospitals in the Confederate service should he 
 fourteen feet in Length, fifteen feet wide, and eleven 
 feet high in the centre, with a wall four and a half 
 feet, and a "fly" of appropriate size. The ridge-pole is 
 made in two sections, measuring fourteen feet when 
 joined. On one end of the tent is a lapel, which 
 admits of two or more tents being joined or thrown 
 into one. with a continuous covering or roof; such 
 a tent accommodates, comfortably, from eight to ten 
 patients. The following is the allowance of tents for 
 the sick, their attendants, and hospital supplies — being 
 accommodation for ten percent, of the command : 
 
 COMMANDS. 
 
 HOSPITAL TEKTS. 
 
 SIBLEY TENTS. 
 
 COMMON TENTS. 
 
 For three companies.. . 
 por five companies . • • 
 Fur seven oompanies. . 
 Fur ten companies 
 
 1 
 
 2 
 2 
 3 
 
 1 
 1 
 1 
 I 
 1 
 
 1 
 1 
 1 
 1 
 1 
 
 Owing to tbo sparcity of manufactories and tho 
 stringency of the blockade, tents have always been 
 scarce in our army from the very commencement 
 of our troubles. At sundry times we have been com- 
 pelled, in our sudden change of position, and from in- 
 sufficient transportation, to destroy our tout equipage 
 to prevent their falling into the hands of the enemy. 
 Having no reserve supply from which to draw, our 
 army has, at such times, not only been compelled to 
 live without tents, but tho hospital supply has been 
 materially curtailed. Rarely lnis a regiment more 
 
REGIMENTAL HOSPITAL. 61 
 
 thai) two walled tents to accommodate its sick, and 
 much more frequently but one walled tent and one 
 fly. On this account, only those eases which promise 
 to ho transient indispositions or acute diseases arc 
 retained for treatment in the regimental hospitals. 
 They must always he considered hut temporary 
 structures, to he moved with the army, and to bo 
 broken up at an hour's notice. They should never, 
 therefore, he encumbered with chronic cases, nor 
 should thoy ever be permitted to be crowded. As 
 soon as a caso threatens to remain longer than a 
 few days in hospital, it should be transferred to tho 
 general hospital for treatment. 
 
 To ensure a comfortable abode for tho sick, tho 
 site of the regimental hospital should be selected with 
 much cai-e — the dryest spot in the camp should bo 
 chosen, and the tent well ditched, to give thorough 
 drainage. The floor of the tent should be carpeted 
 with oil floor-cloth or painted canvas, which will pro- 
 tect the sick from the emanations from the soil, and 
 will prevent the soil from imbibing animal effluvia, 
 at the same time keeping out all moisture, which is so 
 deleterious to those lying upon the ground. This 
 painted cloth strictly belongs to tho hospital tent, 
 and, as an essential part, should not be overlooked. 
 A certain number of bedsacks also belong to tho hospi- 
 tal. When these are filled with straw, they make 
 a much more comfortable bed than straw thrown 
 in heaps, which is the common modo of treating 
 the sick in the field. There is much comfort in 
 appearances, and these beds add much to the neat- 
 ness as well as cleanliness of the tent. The beds are 
 arranged on either side of the tent, with the beads 
 turned toward the wall. Could the beds be elevated 
 upon boards tor six or twelve inches, they would place 
 
62 HOSPITAL ATTENDANTS. 
 
 the sick in a purer atmosphere thai) when lying OD the 
 
 flour, where the heavy, deleterious gases of expiration 
 
 Collect. In good weather, ventilation of these tents 
 should always lie insisted upon. 
 
 The straw should be changed as often as possible, 
 oven twice a week, if it can be procured; while, if the 
 patient can get up, the bed should be well beaten and 
 
 thoroughly aired daily. 
 
 It often occurred, in the medical experience of 
 the Confederate service, that straw could not bo 
 procured — the inmates of the regimental hospital being 
 compelled to lie directly upon the ground, which was. 
 at times, damp, and even muddy, with no india-rubber 
 cloths to protect them, and often without blankets 
 to cover them. The suffering from the want of these 
 necessary articles has been very great, and yet the 
 men, in the beginning of the war, would prefer remain- 
 ing in camp when sick, rather than enter the general 
 hospitals, against which they had the strongest 
 antipathy. 
 
 Personal cleanliness of the patient is as important <is 
 that of the tent. Ablutions should bo freely used, 
 although it may not be possible frequently to change 
 the underclothing. Whenever the condition of the 
 patients permit, the tent should be moved once a 
 week, if it be only a few yards from its former position, 
 so as to enclose a fresh piece of soil not contaminated 
 with animal exhalations. Tins change of location IS 
 
 particularly required whenever any of the low grades 
 of contagious diseases appear within its walls, or cases 
 
 under treatment take <>n an asthenic character. 
 
 The hospital i8 allowed a certain number of attend" 
 ants, to attend to the coiumis.-aiy and medical duties 
 
 of the establishment Bach company has one steward, 
 
 one nurse, and one cook ; for each additional company, 
 
HOSPITAL ATTENDANTS. 63 
 
 one nurse is added ; and, for commands of over five 
 companies, one additional cook, if required. As a rule, 
 one nurse is taken from the ranks for every fen 
 men sick in regimental hospital. When there are but 
 few cases under treatment, the supernumerary nurses 
 and cooks are returned to the ranks. The surgeon 
 is general superintendent of the hospital. Under 
 his direction the steward, who, in the Provisional 
 Army of the Confederacy, is usually a physician taken 
 from the ranks, takes care of the hospital stores 
 and supplies, and sees that the nurses and cooks 
 perform properly their respective duties, and acts as 
 medical dispenser and apothecary to the regimental 
 hospital. If intelligent, he can readily be entrusted 
 with prescribing for mild cases of disease, and thus 
 relieve the surgeon of much trouble. 
 
 Not the least important personage in the hospital 
 organization is the sentinel who guards the door, and 
 sees that neither ingress nor egress is permitted, 
 except upon orders from the surgeon. It is only in this 
 way that patients can be prevented from committing 
 imprudences which may cost them their lives. This 
 guard should be constantly furnished to the hospital, 
 and the surgeon is to signify to the commanding officer 
 ol t lie regiment the particular orders which he wishes 
 to »be given to the non-commissioned officer command- 
 ing it, and to the sentries. 
 
 Those treated in a tent hospital always convalesce 
 much more rapidly than those collected together in a 
 large hospital building, where, in proportion to the 
 magnitude of the establishment and number of pa- 
 tients, we flttd the convalescence of the sick pro- 
 longed, the number of deaths increased, and the 
 germs of contagious diseases developed. In concen- 
 trating a number of sick under one roof, although 
 
64 GENERAL HOSPITALS. 
 
 many facilities for troating thora are gained, yet the 
 laws of hygiene will be, to a certain extent, ana void* 
 ably violated. Yet, Prom the very transionl nature 
 of regimental hospitals, more permanent institutions 
 
 for the siek must necessarily l>e established. 
 
 General hospitals are usually located in some town 
 or city contiguous to tho army; or, should such 
 locations he too distant, without facilities of trans- 
 portation, buildings are taken possession of, or erect- 
 ed, near the military position, to be used as a general 
 hospital. The organization of this, with its surgical 
 staff, its Stewards, ward-masters, and nurses, is upon 
 a much larger scale than in tho regimental hospital. 
 
 Early in tho war, when our large and increasing 
 army was undergoing acclimation, with thousands of 
 sick, extensive general hospitals were required for im- 
 mediate use, with no time allowed for the erection of 
 proper buildings. The medical department was com- 
 pelled to use factories, storehouses, hotels, college S, 
 or such large buildings as could be found contiguous 
 to the position of our armies. In Richmond alone, 
 numerous buildings, to accommodate nearly thirty 
 thousand patients, were fitted up as hospitals. Tho 
 same course was pursued elsewhere. At the present 
 time, however, such temporary hospitals have, to a 
 great extent, been replaced by newly- erected build- 
 ings, specially arranged for the convenience of the 
 sick. The general plan of organization which ap- 
 pears to meet with most approval, allows of the con- 
 centration of a large number of sick under ono 
 supervision — the general hospitals recently construct- 
 ed oumbering from ono thousand to five thousand 
 beds. The advantages accruing from this arrange- 
 ment are the greater facilities for treating the sick, 
 an increase of comforts, with the groat advantage 
 
GENERAL HOSPITALS. 65 
 
 of sustaining a rigid military discipline, the greater 
 readiness with which discharged soldiers arc returned 
 to dut}', a more perfect organization, with a more 
 judicious division of labor, without increasing oom- 
 monsurately the expenses of the institution, or re- 
 quiring .pro rata so many officers; and last, but not 
 least, of rather diminishing the mortuary list or per* 
 centage of deaths. 
 
 The general plan upon which an institution of this 
 kind is now established, is by erecting a number of 
 one-story houses, about eighty feet long by thirty feet 
 wide, well ventilated by means of slatted cupolas. 
 Such buildings will each accommodate comfortably 
 from ]'<»rty to titty patients and arc multiplied so as 
 to accommodate from one thousand to five thousand 
 patients. The concentration of so many buildings 
 forms a village, with regularly laid out streets, those 
 running in one direction being one hundred feet wide, 
 while the cross streets are fifty feet in width. Each 
 house being surrounded by streets, ensures thorough 
 ventilation, and prevents over-crowding. In such a 
 general hospital there are many divisions, each com- 
 prising about five hundred beds, and each being a 
 perfect hospital within itself, with all offices necessary 
 for successfully carrying on such an establishment, 
 viz: kitchens, laundries, mess-rooms, baggage-room, 
 linen-room, store-room, and guard-room. For the 
 general QSO of all t he divisions, are a bakery; a guard- 
 house or prison for enforcing obedience ; a chapel, in 
 which service is daily held, bath-house, with hot, 
 st. ■am, cold, shower, and plunge baths; operating 
 room, with dead-house; &fficesaud houses for officers 
 
 and employees; stables, and privies —the latter being 
 distinct buildings for privates, non-commissioned offi- 
 cers, officers, and matrons. 
 F 
 
60 DUTIES OF STJnOEON IN CHAROE. 
 
 Ordinarily, the following hospital attendants are 
 allowed: :i hospital Bteward, acting as mess steward; 
 a hospital Bteward, acting as apothecary; r ward- 
 master for ovory one hundred patients; two chief 
 matrons; two assistant matrons; two ward matrons 
 to each one hundred patients : one nurse t<> every ten 
 patients — but should this number be found not suffi- 
 cient, the government allows the employment of as 
 many as are necessary for the careful nursing of the 
 sick; a laundress for every twenty patients, and a 
 cook for every thirty. In the Large general hospitals 
 each division of the hospital is presided over by a 
 surgeon, who has a number of assistant Burgeons 
 under him — one t<> every seventy patients. Bosides 
 the number of employees enumerated above, there is 
 a steward, who looks after the servants; a baggage- 
 master, and an apothecary's clerk; and the surgeon, 
 who is in charge of the entire establishment, is al- 
 lowed one or more clerks for office duty. A military 
 guard completes tin' Btaff of a general hospital. 
 
 The following are the duties assigned to each of 
 these officers, and for the proper performance of 
 which he is held Btrictly responsible by the surgeon, 
 who is the administrating officer in charge of the 
 institution. 
 
 The surgeon-in-chief, who is in charge of a largo 
 general hospital, is the responsible head of such an 
 institution, and is constituted commander of such a 
 
 pOSt. It is his duly to define the duties of all otlieers 
 attached to the instit at ion, and see that all of tho 
 regulations of the hospital are rigidly enforced, lie 
 
 receives and enforces all Official order.-,, approves all 
 
 requisitions, endorses all certificates for furloughs or 
 discharges given by his subordinate medical officers, 
 takes charge of the hospital fund and attends to its 
 
DUTIES OF DIVISION SURGEONS. 67 
 
 judicious disbursement, and keeps up a continued sur- 
 veillance over all depart incuts of the establishment, 
 inspecting at 8UOh irregular times when he may bo 
 least looked for. His time is so absorbed in adminis- 
 tering the affairs of the hospital, examining books, 
 etc., that he can pay.but little attention to the special 
 care of the sick; and except in the capacity of a con- 
 sulting and operating surgeon, and president of the 
 examining board, composed of bis division surgeons 
 and himself, leaves the treatment of the patients to 
 bis division surgeons and bis staff of assistants. 
 
 The division surgeon, who has charge of one of the 
 divisions of the general hospital, is held responsible 
 by the chief surgeon for the proper enforcement of 
 all the rules and regulations of the hospital in his re- 
 spective division, obeying all orders emanating from 
 bis chief. He inspects every department of his divis- 
 ion daily, sees that all employees attend to their re- 
 spective duties, and renders a daily morning report to 
 tbe chief surgeon, with a copy of the daily register 
 for his division, lie appoints a medical officer of the 
 day from bis staff of assistants, whose duty it is to 
 attend to all urgent calls of tbe sick in the division, 
 during the twenty-four hours that he is on guard. 
 He grants permits to patients to leave the hospital; 
 approves requisitions of the hospital steward; makes 
 out hospital pay-rolls, and a monthly report of 
 sick and wounded in bis division; keeps copies of all 
 requisitions, quarterly reports, and also copies of all 
 orders and lottors; and filos all applications for fur- 
 lough, detail, transfer, and discharge, for the action of 
 xamining board. Although he usually takes no 
 ward himself, be visits daily all of the serious cases in 
 bis division, accompanied by the assistant in charge 
 of Buch patients, and, with the chief Burgeon, per- 
 
68 
 
 PfTIKS or ASSISTANT SURGEONS. 
 
 forms must of the operations required in his division. 
 The division surgeons, with tin- chief surgeon as pr< 
 ident, constitute a board of examiners, whose duty it 
 is to investigate tin eases of all applicants for trans- 
 fer, detail, furlough, or discharge. 
 
 itant surgeons are the general practitioners of 
 the hospital, and are expected to assist the chiof sur- 
 geon and division surgeon in enforcing rigidly the 
 rules of the hospital, obeying all orders emanating 
 from their division surgeon. It is their duty to visit 
 their patients at least twice daily, and as much often- 
 er as the serious charactor of cases may require. 
 They must write each proscription in lull, including 
 diet, iii the proscription and diet hook, giving the 
 name of tin- patient, and number of his lied and ward 
 in every ease, ami will see that their directions are 
 strictly carried out. in prescribing alcoholic stimuli 
 of any kind, they will specify the quantity which 
 each patient should receive, with directions in full for 
 its administration. In prescribing it for themselves 
 or any hospital attendant, they must certify that it is 
 for medicinal purposes, and that it is necessary for 
 the treatment of the ease for which it is prescribed". 
 They wdll report daily, by eleven o'clock, to their 
 division Burgeon, all deaths, desertions, convalescents 
 lit for duty with their commands, or those for polico 
 duty; the number of vacant beds in their ward, giv- 
 ing the numbers of each; and also a weekly report 
 (every Monday ), giving the name, rank, company, 
 regiment, division, ward, bed, and disease of each 
 patient under their charge. They will write and tile 
 with the division surgeon, for the action of the exam- 
 ining board, and not commit to the patients them- 
 selves, recommendations for furloughs, transfers, or 
 discharges, stating in each the regiment, company, 
 
DUTY OF CLERKS. 
 
 69 
 
 
 bed, ward, and disease of patient, and post-office ad- 
 dress, as we'l as railroad depot nearest to their desti- 
 nation, and notify the applicant when and where to 
 appear. In no ease will they deliver a paper to an 
 applicant that requires action of a superior officer. 
 They will write upon the bed-ticket the diagnosis of 
 each patient's disease. 
 
 One assistant surgeon from each division of the 
 hospital /will be detailed daily as officer of the day. 
 lie will visit and prescribe for any patient in the 
 division who may require his services, during the 
 day or night while he is on duty, writing the pre- 
 scription for such in the prescription and diet hook of 
 the ward, lie will inspect each ward in the division 
 every six hours, and will, in the absence of the divis- 
 ion surgeon, exercise all the functions pertaining to 
 that officer. When relieved from duty he will make 
 a report in full to the division surgeon, of everything 
 that may have transpired in the division, giving the 
 hours of his different visits to the wards, etc When 
 not on duly in the wards he will remain in the oflicc 
 of the division surgeon, so as to be readily found in 
 ease he is wanted. 
 
 It is the duty of the clerk* to keep the books, ami 
 to perform all such writing as the surgeons may 
 direct, In all large general hospitals a clerk is as- 
 signed the duty of baggage-master, whose duty it is 
 t,> receive the baggage of ail patients, properly la- 
 belled and delivered to him by the ward-master 01' 
 head nurse of each ward, to whom he will give a 
 oipt lor tin' same, delivering the baggage to the 
 Bame only upon the retttrn of the receipt. The bag- 
 gage-room has its shelves divided into as many com- 
 partments as there are beds in the hospital, into 
 which are placed, in alphabetical order, the properly 
 
70 DUTIES OF HOSPITAL STEWARDS. 
 
 of the patients, the baggage always being labelled 
 with name of patient, rank-, company, regiment, «li vis- 
 ion, ward, bed, and post-office. It is the duty of tho 
 baggage-master to see to the safety of the articles 
 entrusted to Ids care, and. for their better protection, 
 he occupies quarters adjacent to the baggage-room. 
 
 The hospital &t* wards, receiving commissions from 
 the Secretary of War after an approved examination 
 before an examining board, are entitled to obedience 
 from all enlisted men in hospitals — both patients, ward- 
 masters, and cmploj-ees — and he, in turn, owes prompt 
 obedience to the commands of his surgeon. lie should 
 be honest, temperate, intelligent; writing legibly and 
 correctly, with some knowledge of book-keeping, phar- 
 macy, and minor surgery. In a small hospital tho 
 hospital steward has, under the surgeon, a general su- 
 perintendence of hospital; regulates its police, dis- 
 cipline, ventilation, lighting, and warming; attends to 
 provision returns; carries out the surgeon's instruc- 
 tions as to the management of the hospital fund; 
 makes purchases for the hospital; takes care of hos- 
 pital stores; sees that the cooking is properly per- 
 formed; takes charge of the dispensary, puts up pro- 
 scriptions, as well as renders assistance in dressing 
 of wounds; sees that tho hospital property is duly 
 cared for — and, in fact, is responsible to the surgeon 
 for the general administration of the institution. 
 
 In hospitals of one hundred beds and upwards, 
 these duties become so onerous that two hospital 
 stewards are assigned to duty in the same institu- 
 tion—one as apothecary, to attend to the dispensary 
 and the dispensing of medicine; the other as mess 
 Steward, to look alter the administrative duties of the 
 hospital. When hospitals are as largo as many such 
 establishments now in full operation attached to our 
 
DUTY OF DRUGGIST. 71 
 
 army, comprising from one thousand to four thousand 
 beds, they require the services of several hospital 
 stewards. 
 
 To each division of such a general hospital there 
 are usually two or more commissioned hospital stew- 
 ards — one, and sometimes two, acting as druggists, 
 one as moss steward, to look after hospital property 
 and the attendants, and one as clerk. It is the duty 
 of the druggist to put up only such prescriptions as are 
 written out by a medical officer of the division to which 
 he is attached, and will issue nothing unless so direct- 
 ed, lie will use, on all occasions, the scales and meas- 
 ures in the compounding of medicines, keeping all 
 apparatus about the dispensary scrupulously clean, 
 and everything in order. He will be held responsi- 
 ble by his division surgeon for the proper care and 
 dispensation of all medical supplies committed to his 
 charge. Five days before tho end of each month he 
 will furnish tho division surgeon with a statement 
 of the quantity of all medical supplies on hand, and 
 the quantities of such as will be required for the en- 
 suing month. None but such as are authorized will 
 be allowed to enter the dispensary. 
 
 It is the duty of the clerk to keep a register of 
 the daily admission of patients into the hospital, to 
 make out a morning and monthly report, to fill out 
 hospital pay-rolls, and to perform any other duty in 
 writing for the hospital directed by the surgeon. 
 
 The. mess steward takes care of the hospital stores 
 and supplies, receives and distributes rations, pre- 
 pares provision returns, keeps a record of all tho 
 transact ions of bis department, and renders a written 
 
 report t<> the surgeon at the end of every month. Ho 
 takes charge of the valuable effects of sick and de- 
 ceased patients, labelling and keeping a proper regis- 
 
IZ DUTIES OF WARD-MASTER. 
 
 terof the same; visits daily, and reports the condition 
 ol the sinks of his division to the Borgoanl of the 
 police guard ; ascertains who are present at roll-call 
 ;ii sunrise, sunset, and tattoo, and reports absentees, 
 The kitchen and cooks are placed immediately under 
 his supervision, and he is held responsible for the 
 cleanliness of the kitchen, as well as for the proper 
 preparation of the food. He also prepares and issues 
 to each patient a meal-ticket, receiving the samo 
 at the door when the patients enter the mess-hall j 
 at the same time supplies them each with a knife, 
 fork, and spoon, which each must return to the 
 steward as he leaves the hall after the meal. When 
 a steward is not specially assigned to the duty of 
 looking after hospital property and supervising the 
 servants, the mess steward must consider this as a 
 portion of his duties, lie is also expected to visit 
 every portion ol' the establishment three times eVery 
 day, the last visit being after taps, and see that every- 
 thing is kept in perfect order. In his office, in a con- 
 spicuous place, is hung up a table containing the 
 names of all the attendants of the institution, with a 
 list of their respective duties. 
 
 In every hospital, and in each division of an exten- 
 sive general hospital, there is a general ward-master, 
 whoso duty it is to commence the day by having all 
 the wards and the grounds surrounding the buildings 
 swept, and i he dirt collected in piles ready t'<>r removal, 
 and also to see thai no filth accumulates in the cham- 
 bers or buckets about the wards, lie lakes charge; of 
 the effects of each patient upon admission, has the same 
 properly labelled with the patient'fl name, rank, com- 
 pany, and regiment, together with the ward and num- 
 ber of his bod, and has the same properly registered 
 in a hook kept for that purpose, and delivered to the 
 
DUTIES OF WARD-MASTER. id 
 
 baggage-master to be stored away in the baggage- 
 room. When a patient loaves ilic hospital, all of 
 
 his effects are restored to him by the ward-master. 
 Should the patient be discharged from the arm}-, it- 
 is the duty of the ward-master to retain possession of 
 all government property which the patient, as a sol- 
 dier, had the use of, and when such accumulates, to 
 turn over the saint 4 to those officers who issue them. 
 All money and jewelry he delivers to the surgeon for 
 safe keeping. Ho receives from tho steward the fur- 
 niture, bedding, cooking utensils, etc., for use, keeps 
 a record of them (Form 10, Med. Reg.), and a st a le- 
 nient of how distributed to the wards and kitchens, 
 and once a week renders a written inventory of the 
 same to tho steward, with a statement of any loss or 
 damage, returning to him such as are not required for 
 use, and receiving from him such articles as are neces- 
 sary for the ensuing- week. 
 
 The ward-master distributes to each chief nurse 
 in a ward such articles, accompanied by an inventory, 
 as the comfort of tho sick may require, and for which 
 those receiving are held strictly responsible. The 
 ward-master reports daily the number of vacant beds 
 in the wards; takes charge of all soldiers returning 
 to their regiments at the clerk's office, and conducts 
 them to the military guard. When a patient dies, he 
 will pin on his breast, previous to committing I lie body 
 to the " dead-house," his name, rank, regiment, compa- 
 ny, number of bed, ward, and division in which he died, 
 and report tho same to the division surgeon. They 
 are no! allowed to receive a patient in their wards 
 unless accompanied hy a permit from the division 
 surgeon. These permits, together with orders for 
 transferring patients from beds or ward- to others, 
 will bo carefully preserved as vOucherf 
 <; 
 
7 \ DUTY OF NURSES. 
 
 In general hospitals one nurse is allowed to every 
 ten patients; and where the wards contain many beds, 
 a head nurse presides over each ward, who is held 
 responsible, by the ward-master, for the order, disci- 
 pline, and cleanliness ofthe ward. It is his duty to Bee 
 that the beds are kepi constantly arranged— all cham- 
 ber utensils cleaned immediately after being used, 
 ward properly kept, meals to patients confined to bed 
 furnished at proper hours ; that the medicines arc sent 
 for to the dispensary, received from the druggist, and 
 arranged in a closet prepared expressly for this pur- 
 pose in each ward, in which the medicine belonging to 
 each patient is placed at a number corresponding to 
 the bed occupied by the patient; that at the proper 
 time the medicines are administered to the patients 
 as directed by the medical officers; that the patients 
 obtain such diet as may he prescribed, and no other: 
 that the ward is properly ventilated, and sufficiently 
 warmed in winter, and that the police regulations 
 established by the surgeon in charge are scrupulously 
 complied with, lie will maintain order and disci- 
 pline among attendants and patients, and will report 
 every neglect of duty and disobedience of orders. Ho 
 will allow no patient to keep arms, accoutrements) 
 knapsacks, or packages in his ward, nor to intro- 
 duce any fruits or improper diet. 
 
 When the surgeon visits the ward, it is the duty of 
 the head nurse to accompany him from hed to bed, 
 with slate or memorandum-hook, in which lie will note 
 all directions of the surgeon as to the administration 
 of medicine, diet, etc., and is held responsible for their 
 proper fulfilment, lie allows no patient to enter his 
 wai'd without a bed-ticket from the surgeon, which ho 
 immediately deposits in its proper receptacle at the 
 head of the bed to be occupied. He will promptly 
 
DUTY OF NURSES. 75 
 
 report the departure of patients from his ward on 
 furlough, discharge, desertion, or unauthorized absen- 
 tees, delivering the bed-ticket of the same himself 
 to the clerk — never allowing patients to do so. Ho 
 conducts all patients returning to their regiments 
 to the clerk's office, after having procured their 
 baggage, and there delivers them to the charge of (he 
 ward-master. He receives and receipts for clothing 
 to he washed, to the patients and attendants of 
 their respective hods, turns them over to the matron 
 in charge of the laundry, and takes a receipt for them. 
 He defines the duties of his assistants. As these 
 duties are responsible and important, (he chief nurse 
 of a ward should he sober, honest, industrious, intelli- 
 gent, and take an interest in his duties. 
 
 In wards of over twenty heds, the head nurse ex- 
 ercises chiefly supervision and general responsibility. 
 The heds are divided equally among the remaining 
 nurses, each of whom is held responsible for all that 
 pertains to such as are put under his care, lie will 
 insist that convalescents, who arc able, make up their 
 beds immediately after rising in the morning, and will 
 himself arrange the heds of such as are unable to do it 
 for themselves. The assistants arc held responsible 
 for the cleanliness of their patients — bathing, wash- 
 ing the face and hands, and combing the hair of such 
 as are unable to do this for themselves. In every in- 
 stance, where a bed-pan or chandler is used, the nurse 
 must immediately remove it from* the ward. When 
 the personal or bedclothes of a patient are soiled, they 
 should also he changed without delay* and, when 
 the character of the case requires it. the bedclothing 
 should lie protected b\ gutta-percha (doth or oiled 
 silk. 
 
 It is the duty of the assistant to accompany the 
 
prn OS M RSES. 
 
 surgeon while visiting the patients under his charge, 
 in nl either take down upon a memorandum-book the 
 directions of the surgeon as regards the diet, admin- 
 istration of medicines, or the general care of each 
 patient, or have free access to the memorandum-book 
 of the chief nurse. For such patients as are con- 
 fined to bed he will obtain the prescribed diet, and 
 will see that all who are able will eat in the mess-hail. 
 A 11 medicines prescribed the nurse will administer with 
 his own hands; and to facilitate the administration 
 at regular periods, it is customary in some general 
 hospitals to mark the day by adopting ship time — 
 
 Bounding the bell at every hall-hour. For instance, 
 commencing at mid-day, the bell is struck once for 
 half-past twelve o'clock, twice for one o'clock, three 
 times for half-past one, and so on until it is struck 
 eight tinier for lour o'clock, when the series is recom- 
 menced. Besides such special duties, the general du- 
 ties of the ward— as sweeping, scrubbing, cleaning of 
 windows., management of tines, cleansing of water- 
 closets, etc., bringing of meals to the sick who are 
 unable to visit the mess-hall, etc., — are distributed 
 among the assistants, the head nurse making the as- 
 signments. 
 
 One night-nurse is assigned to each ward, and for 
 each division a head nurse, whose duty it is to visit 
 every ward every hour in the night, to inspect the 
 fires and lights, and see that the nurses attend to 
 their respective duties. 
 
 The arrangement which is adopted in some of our 
 large general hospitals is to have one general ward- 
 master for a division of the' hospital ; one section ward- 
 master to a section of four wards, or ahout one hun- 
 dred and twenty beds; one subward-master or head 
 nurse to each ward, with two nurses as assistants — 
 
DUTIES OF MATRON. 77 
 
 these being usually negroes — one of whom, with the 
 sub ward-master, is on duty every day in each ward 
 of thirty beds. At night one nurse is left in each 
 ward, a head nurse to each section, and a ward- 
 master to each division, so that the nurses are on 
 duty for twelve hours and off for a similar period, 
 while the other officers are on duly all day, and every 
 fourth night alternating. Night-nurses are never 
 called upon to assist in the hospital in the day. 
 
 One chief matron, with an assistant, is put in charge 
 of the laundry anil linen-room. Her duty consists in 
 receiving from the nurses the soiled clothes from their 
 respective wards, both of the patients and from beds, 
 marking and mending these before they are sent into 
 the laundry, and count out daily to the laundresses the 
 number of pieces to be washed, requiring the same num- 
 ber to be returned to her linen-room; to distribute clean 
 clothes, both for beds and patients, to the wards, and 
 report to the surgeon such laundresses as may fail to 
 comply with her regulations, or may extort money 
 from soldiers for washing. She keeps a hook, in which 
 is entered all receipts and issues of both soiled and clean 
 clothes from patients, as Well as bed-linen, giving re- 
 ceipts, enumerating articles, to laundresses and nurses 
 for the same. 
 
 One chief matron, with an assistant, takes charge of 
 the pantry, kitchen, and mess-room. She is responsi- 
 ble to the surgeon for the proper preparation of all 
 diet, and for the cleanliness of her department. She 
 provides suitable diet and delicacies for all the ill 
 patients, as directed by medical officers, and takes 
 charge of all stimuli required by the sick. 
 
 An important officer in every general hospital is the 
 sergeant of (he guard, who is responsible lor the or- 
 derly conduct of all inmates of the institution. It i- 
 
T v SERGEANT OP THE Q1 Aim. 
 
 his duty t<> prevent the peace and comfort of the sick 
 from being disturbed by noises in the precincts of the 
 hospital. He sees that the hospital isproperly guard- 
 ed, day and night j that oo pationt, attendant, or sub- 
 officer leave the institution without a proper written 
 permission from the Burgeon in charge; and that the 
 police regulations for Btreets and sinks are daily en- 
 forced. He takes charge of, and eon duets under guard, 
 discharged soldiers returning to their regiments, to bar- 
 racks, or railroad, as he may ho directed. He executes 
 the rules and regulations pertaining to the guard- 
 house, and makes a daily report to the surgeon in 
 charge of the hospital. The guard of the hospital 
 mess with the convalescents, and their rations are 
 drawn upon the provision returns of the hospital. 
 When a detachment from the post guard or provost 
 guard can not he obtained for a hospital, a guard can 
 be formed from such soldiers as the examining hoard 
 recommend for light duty, and as unfit for active 
 field servioe. 
 
 Patients, upon arrival, will immediately report to 
 the central register office, to be assigned quarters. 
 They will turn over all arms, accoutrements, baggage, 
 etc., etc., to the baggage-master, receiving a cheek for 
 the same. They will not be allowed to smoke in the 
 wards, nor spit upon the floors or walls, nor commit 
 nuisances of any kind. They will take their medi- 
 cines as directed, and abstain from the use of fruits 
 and diet forbidden by the surgeon. They will report 
 themselves to the clerk's office to receive bed-tickets, 
 which they will present to the head nurse upon enter- 
 ing the ward tO which they have been assigned. 
 They are prohibited from loafing about the clerk's 
 office, drug-store, or kitchen. All applications for 
 transfers, furloughs, and discharges must be made to 
 
- GENERAL DISCIPLINE OF A HOSPITAL. 79 
 
 the assistant surgeon of their wards, which will be 
 properly forwarded — and, if granted, be returned to 
 them at their wards. They will obey the steward, 
 ward-master, nurses, and all officers of the hospital ; 
 and, when convalescent and fit for light duty, assist 
 in policing the hospital, under the direction of the 
 ward-master or commandant of the guard. 
 
 In the general discipline of a hospital, the surgeon 
 in charge is commandant of the post or institution, 
 and exacts implicit obedience from every inmate of the 
 establishment, and he is expected to conduct the in- 
 stitution in accordance with the rules of strict mili- 
 tary discipline. As the responsibility of the entire 
 hospital rests solely upon the surgeon in charge — the 
 government recognizes no other chief — he must, in 
 turn, hold his assistants to a strict accountability; and 
 they, in turn, their subordinates — so that every attache 
 of the establishment is held strictly responsible for 
 everything in bis keeping. 
 
 In all well-regulated military hospitals the follow- 
 ing regular order of duties is observed : Reveille is 
 called at five, a. m., in summer, and six, a. m., in 
 winter; and, fifteen minutes later, the morning roll is 
 called for all the attendants, who immediately after- 
 ward commence the general cleansing of the hospi- 
 tal. Such convalescents as are able, alter washing 
 and dressing themselves — wash-rooms being provided 
 in all hospitals — make op their own beds, and assist in 
 putting their portion of the ward in order. At seven. 
 a. m., in summer, and at eight, a. m., in winter, is the 
 hour for breakfast, when all convalescents, and such 
 attendant- as are not required in the wards, assemble 
 and march to the mess-room. For such patients as are 
 unable to leave the ward, breakfast ia brought by the 
 nurses, and those who can not feed themselves are i'vd. 
 
GENEKAL DISCIPLINE OF A HOSPITAL. 
 
 The attendants in the wards take their meals imme- 
 diately alter it is served to the patients. 
 • The chief nurse now Bees that the wards are 
 cleansed and put in thorough order for the sur- 
 geon's call, which is at eighl in summer, and nine in 
 wintor. At these hours, when the call is sounded, 
 each patient repairs to his bed, where he remains 
 until the visit is completed, while each medical offi- 
 cer commences the morning visit to the wards ui 
 his charge. The medical officer examines each 
 patient carefully, and the prescription and diet tor 
 each is entered in a book kept for that purpose. 
 Aiur the visit, these hooks an' carried to the dispen- 
 sary, where the medicines are prepared, and duly 
 labelled with ward, bed, name of patient, date of pre- 
 scription, dose, ami time of administration. At the 
 same time the steward copies off the diet for conva- 
 lescents, and also the prescribed diet for the sick, 
 which list is given to the chief matron of the cooking 
 department to he prepared. 
 
 Every part of the hospital is swept thoroughly every 
 morning, and such portions in which dirt accumulates 
 are res wept as frequently during the day as cleanli- 
 ness requires. The kite hen Bhould be kept as clean 
 as tin; wards, ami besides the early morning sweeping, 
 Bhould he swept jut- after every meal. The grounds 
 around the hospital, with the walks, should also ho 
 swept rvrvy morning. After the morning use of the 
 wash-room, this is also put in order, ami kept so 
 during the day. The privies, after being thoroughly 
 scrubbed < \rvy morning, are put in charge of an at- 
 tendant or guard, who inspects them after their use 
 hy every patient, in order to fix the neglect of clean- 
 liness upon the guilty party. These, with all other 
 portions of the establishment, are whitewashed as 
 
GEiNERAL DISCIPLINE OF A BOSPITAL. Si 
 
 often as neatness requires. A tier the surgeon's morn- 
 ing visit to the wards, should they require it, the 
 soiled spots upon the floors are washed and rapidly 
 dried, using but little water in the cleansing, end the 
 entire floor is well scrubbed with dry sand, and 
 swept. This dry-scrubbing is found far preferable to 
 the flooding of the wards with water, which causes so 
 much annoyance and del rinicut to the patients. During 
 the intervals of attendance upon the sick, the nurses 
 and attendants in the wards will find ample employ- 
 ment in keeping tlie floors, walls, and windows of the 
 wards clean. Bed-sacks are refilled with straw at 
 least once a month, at which time the ticking should 
 bo washed in boiling water. 
 
 At one, r. m., the dinner-hour, convalescents .are 
 again marched to the mess-room, and food supplied 
 to those detained in the wards. At five, p. M., the 
 surgeon's afternoon call, the patients are visited in 
 the wards as in the morning. Supper is served at six, 
 v. m. At eight o'clock tattoo is heat, at which time 
 the night-watches are set in the wards, and patients 
 prepare for retiring. At- nine o'clock (taps) all 
 unnecessary lights are extinguished, and all patients 
 must be in bed. The steward now pays his third 
 visit to the wards, to see that everything is in order 
 for the night. During the night the officer of the 
 day visits frequently tlie wards. Should any patients 
 be absent from their beds, the nurse reports the fact 
 to the ward-master, who embodies it in his morning 
 report. On one daj of every week, usually on Sun- 
 day, when the attending surgeons have completed 
 their visits, usually between eleven and twelve o'clock, 
 the chief surgeon makes a general inspect ion. The 
 steward goes through the hospital immediately he- 
 fore the surgeon's visit, to see that everything is in 
 
82 OODK OP REGULATIOl 
 
 order. At this inspection nothing, either in tho wards 
 or the patit'iits. should escape the observation of the 
 surgeon Accompanied by liis staff, he should visit 
 every portion of his establishment — wards, kitchen, 
 B tore-room, baggage room, dispensary, bath-room, and 
 privies. During tliis inspection of the wards, each 
 patient romains at bis bed. 
 
 With some modifications, the following will com- 
 a code of regulations, which is drawn up by the 
 surgeon, to be printed, and posted in each ward, and 
 other conspicuous places in the hospital: 
 
 CODE 01 KKoi LA.TI0N8. 
 
 1. Xn officer, attendant, or patient is allowed to 
 leave the hospital without a written permission from 
 the surgeon. The pass will be shown to the Bentinel 
 on |>'i-t. on issuing from the institution, and given to 
 him on the return of the bearer. 
 
 '1. Profane or obscene language, and disorderly 
 duct of any kind is strictly forbidden ; and no Bpit- 
 t i 1 1 lt on the floor, nor defacing in any way the walls, 
 will be allowed. Nor will Bmoking be allowed in the 
 wards, unless by special permission of the surgeon. 
 
 8. No patient shall be admitted into a division 
 without a ticket of admission from the surgeon in 
 ohargo; nor into a ward without a ticket from the 
 division surgeon; nor returned to duty until reported 
 to the division surgeon. Nor shall transfers of pa- 
 tients from one bed or ward to another be allowed, 
 unless ordered by the division surgeon. 
 
 4. The beds are to !>»• made up every morning by 
 attendants, or oftener, if necessary. Convalescents 
 
 who are able must make u j > their own beds. 
 
 5. No patient will oconpy his bed without undress- 
 ing- 
 
CODE OF REGULATIONS. 83 
 
 6. Every patient, who is able, will wash his face and 
 hands at Least every morning, and keep the rest of 
 his body clean. Those unable, will be attended to by 
 the nurses. Every patient, whose condition does not 
 forbid it, will take a hath upon admission. 
 
 7. During the morning visit of the surgeon, every 
 patient and nurse must he in the ward, and patients 
 ■who are able will stand at the side of their beds until 
 examined b\ the surgeon. 
 
 8. All patents must be in bed at nine o'clock, 
 when all lights are extinguished, unless otherwise 
 directed, except in the office, and one in each ward, 
 which will be lowered. All talking in the ward is 
 prohibited after this hour. 
 
 9. Xo patient or nurse will be allowed to enter the 
 office, dispensary, or kitchen, unless on business. 
 
 10. No provisions, no spirituous liquors of any kind, 
 shall be brought within the hospital without the 
 permission of the medical officer of the day, nor will 
 friends or relatives of the patients be allowed to 
 distribute such articles without permission of tho 
 surgeon of the ward. 
 
 11. Patients will give prompt obedience to tho 
 steward, ward-master, and nurses, in all lawful 
 commands. Any infractions of discipline, disobedi- 
 ence of orders, drunkenness, or disorderly conduct, will 
 be promptly punished. 
 
 12. Patients and attendants arc requested to report 
 promptly to the division surgeon any neglect of duty 
 on the part of any attendant or officer, deficiency 
 of diet, loss of clothing Bent to the laundry, etc. 
 In case the division surgeon does not give redress, the 
 matter will (when their is ju>t -round of appeal) be 
 laid before the surgeon in charge for final action. 
 
 13. All official communications must he sent through 
 the proper channel. 
 
84 HOSPITAL REGULATIONS As REGARDS PATIENTS. 
 
 I'])" 1 the arrival of a patient a1 a general hospital, 
 he is al once carried to the office, where his order for 
 ri<lii*I — i- »i* is taken and ti!."l away, as also his descrip- 
 tive list, so thai the Burgeon in charge may en 
 upon it all payraonts, stoppages, and issues of clothing 
 which may !».• made to him while in the hospital. 
 Should the patienl bo ordered to hospital without this 
 descriptive list, it will be the duty <>t tho clerk to 
 obtain one from the commander of the company 
 to which the patienl belongs. His name, rank, compa- 
 ny, regiment, etc., etc., having been carefully regis- 
 
 . his effects are turned over to a ward-master, who 
 
 has them duly entered upon tho 1 k kepi for this 
 
 purpose by tho baggago-master, and put away in the 
 
 ige-room. Any money and other valuables which 
 he may haw are givon to the steward or Burgeon for 
 safe-keeping and a receipt given to the patient for the 
 same. Such items arc also duly entered in a book kept 
 for that purpose, lie should then bo carried to the 
 bath-room, unless bin condition forbids it. and finally 
 is received into a ward where a hod has boon assigned 
 him. 
 
 The following form of bed-ticket is placed in a con- 
 venient frame, at each bod, and forms a succinct 
 synopsis of the history of each patient. When filed; 
 these comprise a duplicate register: 
 
 Division 
 
 Name — 
 
 GENERAL llosl'i I \l,. 
 
 _, Ward -, Bed 
 
 \ . 
 
 Residence or post -office 
 
 Regiment . < Jompany 
 
 Previous ocoupation . 
 
 Admitted . 
 
 W here from 
 
 -. By whose order 
 
I10SPITAL REGULATIONS AS REGARDS PATIENTS. 85 
 
 Disease , Dale of commencement 
 
 Scat , Character of wound . 
 
 When , Where received . 
 
 Operation . 
 
 Dale of , Result 
 
 Supervening disease 
 
 Final disposition , Pate 
 
 Remarks. 
 
 -, Ward Surgeon. 
 
 On the back of this bed-ticket may be placed a 
 statement of the effects of the patient, as follows : 
 
 AKTICI.ES. 
 
 NOS. ! 
 
 ARTICLES. 
 
 NOS. 
 
 
 
 
 
 Uniform-coat 
 
 Socks 
 
 
 
 
 
 
 
 
 
 
 
 
 In leaving the hospital, the patient is turned over by 
 the head nurse of the ward which he occupied, with 
 his bod-tickot, i" the ward-master, who conducts him 
 to the clerk's office, where he obtains his descriptive 
 list, endorsed by the aurgeon, showing the state of Ids 
 account, ami also his discharge papers, and such valu- 
 ables as he left in charge of the 9urgeon. It' the pa- 
 tient is discharged from the army, it is the duty «>f 
 the hospital Burgeon to make out his final statement 
 of pay and clothing. He i> then conducted by the 
 
 ward-master to tho baggage-room, from which his ef. 
 fects are obtained, when he is turned over to the mili- 
 tary guard, to be conducted to the rendezvous appoint- 
 ed t"i- -'nli as are ready to return to the army. This 
 plan of keeping discharged patients under guard until 
 
86 l OPACITY 01 HOSPITALS. 
 
 they are returned to their regimental commanders 
 has been found necessary, on account of the general 
 disposition of soldiers discharged from hospital to loi- 
 ter for days, and sometimes for weeh rejoining 
 their commands. 
 
 In" every hospital, over-crowding is always to |bo 
 guarded againBl ; and, as a certain number of cubic 
 feel are allowed each patient, hospital surgeons are in- 
 structed to have a statement of the cubic measure and 
 capacity of each ward placed conspicuously in oaoit, 
 so that the inspector, at a glance, can see that this 
 important regulation against crowding is observed. 
 The number of cubic feet allowed each bed of a ward 
 is eight hundred ; hut as height docs not compensate 
 for area — as all the dangerous gases Btagnate in the 
 lower strata, near the floor of the room — it would he 
 bettor to allow each patient so many square feet, say 
 eighty square feet, tor each bed. For those who are 
 
 sick with typhus-fever, or the severely wounded, twice 
 this area, or at least one hundred square feet, will not 
 he too much Bpaco, if it he desirable to prevent pyae- 
 mia, hospital gangrene, orysipelas, and othor fatal 
 complications, from showing themselves. Rooms with 
 Less than ten feet ceiling are not lit accommodation 
 for the sick. 
 
 With a constant tendency to a poisoning of I he ai- 
 mOSphere "from imperfect ventilation, all precautions 
 
 of cleanliness can not he too rigidly enforced. In the 
 cleansing of hospitals, too frequent scouring is preju- 
 dicial to the sick, and is found to induce low forms of 
 disease. In French hospitals, the wooden floors are 
 waxed and rubbed daily, which avoids the excess of 
 moisture in the atmosphere of a ward. In our mili- 
 tary hospitals (he floors are sanded and dry-scruhbed 
 daily, only the very dirty Bpots being washed. Eveiy 
 ten davS or a fortnight the entire floors arc washed over. 
 
CLEANLINESS IN HOSPITALS. 87 
 
 Spittoons should be furnished to every bed, and the 
 sick should be prohibited from spitting- upon the floors. 
 These spittoons should be cleansed daily, and newly 
 sanded; and, when much used, the sand should be 
 changed twice daily, or they may become offensive and 
 injurious. All urinals, bed-pans, and chamber-pots 
 should be emptied as soon as used, and never be ill- 
 lowed to remain soiled in the ward. The bunks in the 
 hospital, after being in use for three or four weeks, 
 should be taken out of the wards, well scoured, and 
 exposed to the weather, before they are returned. As 
 soon as a bed is vacated, if it has been in use moro 
 than ten or fifteen days, the straw should be burnt 
 and the sack washed and refilled. Blankets should also 
 be frequently changed and washed. Personal cleanli- 
 ness is essential in a general hospital. If conveniences 
 are at hand, the patient, upon admission, should bo 
 bathed and placed in clean clothes, and in a clean bed. 
 The beds should always be kept in order, whether oc- 
 cupied or not, and should a patient leave it only for a 
 few minutes, it should be put in order by the attending 
 nurse while he is out of it. 
 
 Such a general hospital should, among other things, 
 be liberally furnished with hospital clothing, which, in 
 Confederate hospitals, consist only of shirts and draw- 
 ers. In European general military hospitals the pa- 
 tient leaves everything behind him when he enters its 
 wards. He receives a hath, and is dress, m1 up in tho 
 hospital clothes; his own arc washed and stored away, 
 properly labelled by the ward-master. SliMuld.be bo 
 suffering under any contagious disease, as the itch, ty- 
 phus lever, etc., his clothing, after being well washed in 
 boiling water, are fumigated lor twenty-four hours in 
 a closed chamber or tent with chlorine gas. With itch 
 patients, sulphur fumigations are substituted for chlo- 
 
 rl n Q * 
 
CLEANLINESS IN B08PITA 
 
 Tho ward-master should nevorallow the wards of a 
 hospital to be encumbered with the packages or ac- 
 coutrements of the inmates, but all Boch should be 
 stored away in a Btore-room, where a Beriee of pi 
 holes, two feel square, are arranged, and numbered as 
 arc the beds, so that each inmate of the hospital has a 
 square allotted to bim wherein to deposit his private 
 stores. Where the hospital is well organized, every 
 article which the patient brings in is deposited in the 
 Btore-room. 
 
 Whenever an infectious or contagious epidemic 
 threatens to invade a hospital, the vigilance of the 
 sanitary police of the institution should be redoubled, 
 
 in order to remove or counteract those causes which 
 might assist in producing or disseminating such dis- 
 ease. A thorough examination of the building should 
 be made; all offal,* of whatever character, should be 
 
 removed as BOOn as discovered. This relates especially 
 to the using of chamber utensils in the wards, which, 
 under no circumstances, should bo allowed to remain 
 soiled. Cleanliness in every depart men! musl he en- 
 joined. The diet of the patients should he improved 
 in quality, and more liberally distributed; and wine, 
 or some stimulating drink, should be given to conva- 
 lescents, who should be examined daily, so that any 
 irregularity in the functions ol their digestive organs 
 may he corrected. Free ventilation of the building, 
 the frequent changing of bedding, avoidance of all 
 crowding in the ward, ami an increase in the number of 
 cubic feet to cadi patient, the separation of convales- 
 cent-, who should he sent away from the infected 
 building, the early burial of the dead, both for its 
 moral as well as hygienic benefit, are some of the many 
 precautions which surgeons in charge of hospitals will 
 adopt 
 
VENTILATION OF HOSPITALS. 89 
 
 When any low form of disease makes its appear- 
 ance in a ward, this portion of the building should bo 
 temporarily closed for the reception of patients, and 
 should undergo a thorough cleansing and whitewash- 
 ing. Heating the air contained within the closed 
 room by means of stoves, so as to attain a high tempe- 
 rature, or fumigations with chlorine may, at times, be 
 required to destroy the fomitcs causing the disease, 
 and render the ward again habitable. This closing 
 and general cleansing should also be adopted when- 
 ever a ward has been occupied for a length of time by 
 those seriously injured, suffering with extensively sup- 
 purating wounds. Should any one enter at midnight 
 a ward thus inhabited, the insufferable smell and the 
 sensation of oppression from inhaling the atmosphere 
 would at once explain the danger from low forms of 
 infectious diseases, and the necessity for not only con- 
 slant cleanliness and continued ventilation, but also 
 for purifying the same at intervals. 
 
 Stronger, in his Maxims of Military Surgery, based 
 upon experience and observation during the Schleswig- 
 Holstein war, states that such rooms should be thrown 
 out of use for two weeks after every two months oc- 
 cupation. This he lays down as an important hospital 
 regulation. Chemical disinfectants were not found 
 useful by him as long as the rooms were occupied; the 
 rooms must be vacated. For occupied rooms, draughts 
 of fresh air are the only good disinfectants ; and to obi ain 
 this end, without detriment to the sick, the windows 
 should open near the ceiling, and the sashes should ho 
 so arranged that the upper one can be lowered, which 
 admits fresh air without pouring a cold current direct- 
 ly upon the sick. The Blight exposure t'> catarrhal 
 affections is not to be considered, when compared to 
 the danger of introducing infoctious diseases, by per- 
 il 
 
dim.nh - CAS 
 
 knitting a foal and unrenewed atmosphere to be inhaled 
 bj* the wounded. It is owing to the advantages for 
 ventilation that tents arc bo much better than wards 
 for typhus and severely wounded pationtn, the more 
 especially when wounds show a Bloughing tendency. 
 Pure air, continually renewed, is essential for the cure 
 of typhus and hospital gangrene. Abundance of fresh 
 air covers a multitude of in* venienc< 
 
 In the arrangement of a Confederate military hospi- 
 tal of recent construction, this general imperfection 
 of ventilation is, to a great extent, obviated. The one- 
 story frame building, with boards not fitting very 
 closely together, and a permanent ventilator in the 
 roof, creates continued interchanges of air, which en. 
 ables the patients to live in a constantly renewed atmos- 
 phere. This will account, t<> a great extent, lor the 
 comparatively small mortuary percentage in the mili- 
 tary hospital practice of the Confederate States — being 
 an average of about four per cent.* 
 
 In the Crimean service, the French attached great 
 importance to the fumigation of their wards. The 
 surgeons of their immense military hospitals thought 
 that they derived decided benefit from adopting the 
 Turkish custom of fumigating with dried Bage, which 
 was burnt in the wards three times a day, in addition 
 to the use of chlorine fumigations morning and even- 
 ing. 
 
 A saucer of chloride of lime was also placed under 
 the bed of each typhus patient. It is a question 
 whether these fumigations act from the medicinal 
 virtues which tiny possess, or upon hygienic princi- 
 
 *A consolidated report of tho hospitals in the Department of Virginia, 
 j r> >ni September, 1862, to December, 1863, inclusive, prepared by Sur- 
 geon W. A. drriugton, Medical Director, gives total admitted, 293,165 j 
 deaths, 10,2-18. 
 
 
DISINFECTANTS. 91 
 
 pies. The European nations have such a dread of 
 draughts, that a door or window is never left open, 
 which induces the belief that they were intended to 
 give light and not air. 
 
 This difficulty of ventilation through the windows, 
 which are the proper media for it. is the common 
 subject of complaint among the medical si all' of hospi- 
 tals. Stromyer had to enter into a regular compact 
 with his (xerraan patients. He would only allow 
 bhera to smoke, provided they would keep the win- 
 dows open, using this subterfuge to ventilate the 
 wards. A celebrated English medioal lecturer placed 
 the value of fumigations in their true light, when he 
 said: "Fumigations are of essential importance} they 
 make such (in abominable smell that they compel you to 
 Open the windows." When these means are used, with- 
 out affording the impure air means of escape, they 
 only act as masks — disguising, by their strong odors, 
 the offensive and injurious exhalations from the sick. 
 They quiet the anxieties of the nurse, without in any 
 way benefiting the patient. 
 
 It must never he forgotten that many symptoms 
 which are said to belong to a disease, depend upon 
 the circumstances under which it is contracted or 
 treated, and many of these can with truth lie -accred- 
 ited to. had ventilation; hence the different phases 
 which diseases assume under treatment in hospitals 
 when contrasted with cases in private practice. If 
 such causes will produce disease (a tact with which 
 ©very one is familiar), how much more likeiy are they 
 to modify those already existing'.' Every physician 
 of experience ami observation has seen serious cases 
 
 of fever, which threatened a fatal issue, commence to 
 improve from the moment that the patient was 
 changed from the room in which he had long been 
 
92 RULES "F HYGIENE. 
 
 lying, with its closed windows and musty smell, to a 
 light, cheerful, well-ventilatod chamber. This is al- 
 ways attributed to change of scene, while the true 
 cause, change of air, is overlooked. 
 
 Typhus patients, and cases of hospital gangrene 
 particularly, should always be treated in tents, and 
 ample room he given to each. Over-crowding is 
 certain to produce such a condition of the atmosphere 
 as to heighten the mortality. It also becomes im- 
 perative upon those taking care of such infectious 
 patients to breathe the air as little as they can; live 
 out of the room ok tent as much as possible, compati- 
 ble with the proper attendance upon the sick. 
 
 Surgeons placed under such circumstances, in a 
 badly-ventilated hospital, must take additional care 
 of themselves. Personal cleanliness becomes a ne- 
 cessity; the liberal use of the hath, and the frequent 
 changing of their clothing, will be found a wise sani- 
 taiy precaution. Their diet should consist of simplo 
 and easily digested food, with stimuli in moderation. 
 They should avoid all excesses, both in eating and 
 drinking — as those addicted to intoxication and gor- 
 mandizing are placed in the same category with the 
 weak and poor, from which classes the mortuary 
 tables m ; epidemics are chiefly made. In taking ex- 
 ercise in the open air, fatigue must be avoided. His 
 mind must be free from all anxiety or personal fear of 
 the disease, lie should take a full proportion of 
 sleep, and in the general care of his person should 
 watch eveiy indisposition, and correct derangements 
 of the digestive system before they lead to more 
 serious conditions. 
 
 The medical attendants in typhus hospitals, or in 
 such as are infested with pyajmia, gangrene, etc., should 
 frequently change places with those in charge of more 
 
FEMALE NURSES IN HOSPITALS. 93 
 
 healthy institutions; otherwise, the permanent medi- 
 cal attendant, inhaling daily- this poisoned atmosphere, 
 will he 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 fumi- 
 gated and well aired. The bed and body linen of 
 sueh patients should also be changed daily T . As ty- 
 phus is known by its infecting nature and its easy 
 transmission, the hospital wards can not be protected 
 by too many hygienic regulations. When a hospital 
 has become infected with typhus, pyemia, or hospital 
 gangrene, it is best to close it and turn out all pa- 
 tients. It would be much safer for the sick and 
 wounded to stay in the streets or lie in the field, than 
 be sent to such an infected establishment. His per- 
 mit for admission is his death warrant, while com- 
 bating the elements would give him at least a chance 
 for successful treatment. Any temporary, well-ven- 
 tilated structure — a hut rudely made of rough boards 
 — or a tent — would be infinitely preferable to gorgeous 
 palaces with gilded chambers, in which Death sits in 
 Mate to receive his victims. 
 
 In general hospitals the blessings of a woman's 
 care, her ever-watchful eye and soothing words, her 
 gentleness and patience, have added largely to tho 
 Comforts of the sick. Florence Nightingale, when she 
 made her disinterested otfer to nurse the sick in the 
 Crimea, could have little foreseen the new era dawn- 
 ing for suffering humanity, and the benefits which 
 she was bestowing upon future generations. 
 
 It is woman's peculiar prerogative, as it is her earth- 
 ly mission, to give comfort to those in distress; and 
 when the English adopted the custom long prevalent 
 
Ml 1 All NURSES IN HOSPITALS. 
 
 in Franco, to allow female nurses to minister t<> the 
 wants of those Buffering in military hospitals, the 
 wounded felt that half their Bolicitude was removed. 
 Now a Sister's care will bathe the Bufferer's aching 
 head, or offer biro the cooling draught to allay bis 
 parched thirst; will sympathise with liis pains, and 
 give sweet consolation to bis -dejected -s]>iri t ; and, by 
 removing that overpowering weight of loneliness, by 
 which the sick in hospital far from home and friends 
 are oppressed, will often pave the road to speedy con* 
 valescence. A cheerful look, a kind word, a pleasant, 
 smile from one of these self-denying Sisters, has 
 many a thrill of pleasure through a stricken souL The 
 Burgeon sees, at his next visit, the fruit of this pleas- 
 antly-administered draught, which, perhaps, be blindly 
 attributes to his own nauseous drugs. 
 
 The experience of Confederate hospitals, in recog- 
 nising the vast amount of good which female nurses 
 accomplish, and the incalculable service which they 
 are capable of performing, when judiciously selected 
 and properly organized, is a sufficient reason why 
 
 they should he attached 1" every hospital, and .spe- 
 cially in times Of war, when their many and peculiar 
 
 services can uo1 be dispensed with. To the BurgeOn, a 
 
 gOod, kind, reliable nurse constitutes more than half 
 the treatment of the sick. It is with the most serious 
 that their advantages in nursing are best dis- 
 played. McLeod, who studied carefully woman's ser- 
 vices in the Crimean hospitals, says: "A woman's 
 services in a hospital are invaluable, if they were of 
 
 bo further use than to attend to the cooking and the 
 linen departments; to supply 'extras' in the way of 
 little comforts to the worst cases; to see that the 
 
 medicines and wine ordered are administered at tho 
 
 appointed periods, and to prepare and provide suita- 
 ble drinks. 
 
FEMALE NURSES IN HOSPITALS. 95 
 
 "As to the employment of 'ladies,' I think they are 
 altogether out of place in military hospitals, exeept 
 as superintendents. As heads of departments, :is or- 
 ganizers, as overlookers, 'officers' of the female 
 corps, if you will, they can not he. dispensed with; 
 but for inferior posts, strong, active respectable paid 
 nurses, who have undergone a preliminary training in 
 civil hospitals, should alone he employed. In camp 
 hospitals, which, with an army in the field, are merely 
 the temporary resting-places of the sick, men should 
 alone he employed as nurses; but in the more fixed 
 hospitals in the rear, the lady superintendents and 
 ttnder-nurses, should, in my opinion, always he added 
 to the regular staff. Their attention should be limited 
 to the had cases, and they should have the entire con- 
 trol ol' the linen, medical comforts, and cooking. 
 
 "All cleaning should be done by men. There 
 should be a lady superintendent over each division 
 of the hospital, responsihle to the surgeon as well as 
 to her own lady chief. Then there should be a store 
 of 'extras' under her charge, distributable on requisi- 
 tion from the medical attendant, and which depot 
 should he 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 responsihle for the due performance, by her 
 female subordinates, of their duties, and have a right 
 to interfere with the ward-master if the cleaning, 
 etc. is not properly attended to by his male corps." 
 
 The material of which the Confederate army is 
 composed differs so totally from that of armies ordi- 
 narily — the ranks being made up of the besl people 
 of the land — that ladies, forming the society of the 
 country, have taken a very conspicuous pari not only 
 in the formation, bat in the preservation, of our ar- 
 
HOSPITAL DIKT. 
 
 mics. They have given ap their sons, husbands, and 
 fathers willingly to their country's call ; have fed and 
 clothed them while in the field ; ami when stricken 
 down by disease, or the enemy's missile, they have 
 taken their }»la<i-s by the oouch ol pain, and, by their 
 gentle and assiduous attentions, have mitigated large- 
 ly the horrors of war. They have established hospi- 
 tals, ami. by private means ami their individual efforts, 
 have successfully conducted large establishments — liv- 
 ing memorials of their patriotism and devotion. 
 Without the instrumentality of the nohlo women of 
 the Confederate Stales, in toning political opinions, 
 in infusing the fire of patriotism, in dispelling doubts, 
 fears, and i^loom, in exhibiting a courage and bold- 
 nes.s in the presence of danger, an unshaken con- 
 fidence in ultimate BUCCOSS, a settled faith, a bound- 
 less liberality, ami a devotion to the soldier, our 
 struggle for independence would have been a much 
 more serious undertaking, and success much more 
 doubtful. 
 
 The dieting of patients in <i hospital is always a 
 matter of considerable moment, and one which re- 
 quires much attention, 'flic surgeon has discretion- 
 ary powers to order any extras which the patients 
 may need, and which the issue of rations does not 
 include. To be enabled to supply these extra articles 
 at a time when they are wanted, the surgeon in 
 charge of a hospital is furnished with funds, tor the 
 judicious outlay of which he becomes personally re- 
 f-pousihle. 
 
 This hospital fund for supporting the commissariat 
 of a hospital, is collected by commuting the number 
 of rations which the patients are entitled to draw, at 
 a certain rate, changed from time to time by the 
 government. The hospital is allowed to purchase at 
 
nospiTAL i>ikt. 97 
 
 cost such articles as the commissary department can 
 furnish, which amount is charged against the daily 
 allowance and the hospital credited with the differ- 
 ence, which may he either left in the hands of the 
 commissary, he paying all bills contracted for the 
 comfort of the sick, when approved by the surgeon 
 in charge, or the cash difference between the ration 
 drawn and the amount allowed is turned over to the 
 surgeon in charge of the hospital, to be expended by 
 him for the benefit of the patients, either for luxuries, 
 comforts, or articles of hospital furniture — the pur- 
 chases not being restricted to articles of subsistence. 
 This fund is ample to meet every want of the sick. 
 
 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 re- 
 quire to be guided by seme 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 surgeon in charge of the hospital, 
 and contains those articles of diet which would be 
 best suited to the many, and which the markets at 
 the same time can readily furnish. As this is a sine 
 qua non in a hospital, and gives much trouble in its 
 preparation, 1 have here introduced, as a guide, a diet 
 table, which might be useful as a basis in preparing 
 one for individual hospital service. 
 
 Two drachms of tea or four of coffee, with ono 
 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 cue pint ofsoup 
 
 given to each patient, with his proportion of the 
 
 boiled meat. The vegetables, :i- rice, potatoes, or 
 
 i 
 

 llo-TMrAI. DIET. 
 
 . are frequently changed, to give variety to the 
 meal. 
 
 /'.'. I for /'■ilirntx in the Military [fcpitiil. 
 
 I I I I. I'llCT. 
 
 niKT. 
 
 Bread 1 lb. Bread | lb. Bread i lb. 
 
 Beef or mutton . . .* lb. Beef or mutton.... j lb. Tea J or.. 
 
 Potatoes, or") 1 lb. Potatoes, or") I lb. .Sugar 2 os. 
 
 Beans, or . . > . . . .4 oe. Beans, or.". > I os. Milk fur tea. . . .1 "/.. 
 
 Rice J ... .4 ob. Rice J 4 os Corn meal 1 lb. 
 
 Vegefesfor soup. .4 os. Veget'es for soup. .4 oz. Milk 1 pt. 
 
 Salt 1 oc. Sail 1 os. 
 
 Tea, or ) i os. Tea i os 
 
 Coffee, j 1 os. Sugar 2 os 
 
 SugaT 2 oz. Milk for tea 1 os 
 
 MiUf for tea 1 os Molasses 1 07. 
 
 1 os. Corn meal 1 lb 
 
 Corn meal 1 Up. Sou] i pt 
 
 Soup 1 pt. 
 
 Veal, fowls, or bacon; Snob quantities, in lieu of beef and mutton, 
 aa tbo medical officer may prescribe. 
 Wine, wbi.-k'-v. porter, or ale, at the surgeon's discretion. 
 
 The diet would be distributed in the following 
 order : 
 
 Brkakfast. 
 
 Dinner. . . 
 
 !i»pi>kr. . . . < 
 
 Bread 4 lb. 
 
 Tea or ooffec . . 1 pt 
 Hominy & molasses. 
 
 Bread * lb 
 
 Tea 1 pt 
 
 1 loniiny & molasses. 
 
 Beef or mutton. J lb. Beef or mutton.} lb. 
 
 Son 1 1 pt. Soup 1 pt 
 
 Bread h lb. Bread | lb. 
 
 Beana,potat's or rice Beans,potat'a or rice 
 
 Bread i lb. Bread h lb. 
 
 Tea or coffee. ..1 pt. Toa 1 pt. 
 
 Bread.. ..J lb. 
 
 Tea 1 pt. 
 
 Gruel. . . -i pt. 
 
 (irucl. 
 Milk.. 
 
 . 1 pt. 
 .1 pt. 
 
 Bread. ...J lb. 
 
 Tea 1 pt. 
 
 Gruel. • • • i pt. 
 
 The attending surgeon adds what he wishes to the 
 above diet, to suit any individual case in the hospital. 
 
C II A P T E R III. 
 
 Mbdicai, Service of thk Abmt— Tub Mkans of Transporting the 
 Sick and Wounded — Hand-Litters — Horse-Litters — Amui'lanck 
 Wagons, inc. 
 
 The transportation of the sick and wounded of an 
 army is always a matter of difficulty, and is not un- 
 commonly the indirect cause of an increased mortality. 
 The injury inflicted upon a wounded man by a trans- 
 portation of even a few hours over bad roads, and in 
 unsuitable vefucles, is incalculable. Wounds which 
 had been doing well prior to the move, take on at 
 onco an unhealthy appearance: some slough, ery- 
 sipelas or mortification shows itself in others, while 
 all feel more or less its malignant, injurious influence, 
 even with the best transports, and under the most fa- 
 vorable circumstances. The jolting of a broken limb 
 for three or four hours over a rough road, is indescrib- 
 able torture. The prostration and exhaustion de- 
 picted upon the faces of the wounded after such a 
 transfer, explains at once the problem why such num- 
 bers die during their transportation, and makes us 
 wonder how so many escape with life, after under- 
 going such unutterable hardships. 
 
 The transportation of the sick should also be a 
 source of anxious solicitude on the part of a quar- 
 termaster whose humanity has not been bereft of every 
 spark of sympathy. H is said that, in the service, a 
 familiarity with Buffering and privation, and the usual 
 demoralising agents always at work and so widely 
 diffused through an army in the field, destroy all the 
 
100 HAND-LITT1 
 
 finer feelings of a man, making him nol only careless 
 • Inii callous i" the wants of others. It is only 
 similarity of suffering that can produce sympathy in 
 feeling. Could those in the quartermaster's depart- 
 ment undergo the same treatment which falls t<> the 
 Lot of the sick and wounded daring transportation, 
 would be ;i few more comforts extended t<> those 
 who are periling their lives for their count ry's Bafety. 
 
 The following are the usual modes of transporting 
 those wounded during a buttle : 
 
 LlTTSUS. — Tlie common and best means of moving 
 wounded men, for short distances, is upon litters, 
 which may be prepared in advance, or be an impromptu 
 manufacture. In case of necessity, a litter can be im- 
 provised from the blanket ofa Boldior. This is doubled 
 upon itself, a slit being made through the end corners 
 sufficiently large to admit the barrel ofa musket ; one 
 musket is passed through the fold of the blanket, an- 
 Other through the slits in the ends, and a litter is 
 ready for use. Soldiers' blankets are :it times prepared 
 for this service, by having strong loops Bewed to the 
 corners, bo that when the blanket is doubled the * • ■ n r 
 loops will come on one straight Bide ; one musket 
 is passed through the tour Loops, the second between 
 
 the folded blanket. Where comrades from the ranks 
 are expected to carry off the wounded, this is the only 
 Litter which is of service, us any two soldiers are 
 always prepared to act as curriers without hampering 
 themselves during the fight with extra baggage. 
 Such a litter is, however, very defective, as the weight 
 of the patient sags the yielding blanket until it. nearly 
 reach.- the ground, while the muskets arc pressed in 
 upon the haunches of the bearers, which renders it im- 
 possible for them to proceed with ease or celerity. 
 
HAND-LITTERS. 101 
 
 A more useful and equally simple litter or stretcher 
 is made of strong sacking or canvas, six foot four 
 inches long and two feet wide. A broad hem is taken 
 up on either side, through which passes a stout pole 
 eight feet long. Two iron or steel rods, two feet long, 
 terminating in rings at the extremities, slip over the 
 ends of the poles and form the stretchers. These, keep 
 the poles separated and prevent any sagging of the 
 litter. A shoulder strap, with loops to receive the 
 poles, completes an apparatus which is capable of car- 
 rying off a wounded man with all the comfort which 
 his situation admits. A pike-head attached to the pole 
 makes it a formidable Aveapon of defence. Each of 
 those who are expected to transport the wounded is 
 armed with such a pike, and carries one iron stretcher 
 and canvas bottom strapped upon his knapsack. Any 
 two of these carriers meeting together will be enabled, 
 in a few minutes, to equip an efficient litter. When 
 laid on the litter, the soldier's knapsack is under his 
 head as a pillow, and his musket lies alongside of him, 
 or may be hung from the side of the litter by loops 
 placed there for that purpose. This is the best litter 
 that can be devised for an army in which there is 
 deficient transportation, and in our service should 
 be generally adopted, as they will be borno by the 
 ambulance corps without complaint, and will be 
 always at hand when required. 
 
 A framed litter is one of very questionable utility, as 
 it is a very bulky article, and ono easily broken, 
 so that usually, after a long march, very few of them 
 are tit for service. 
 
 The litters used in the Confederate service, as seen in 
 plate 1, are composed of canvas, t wenty-four inches 
 wide, securely tacked to two horizontal bars eight 
 feet long; the Stretchers, which slip over the handles, 
 
DAND-LITTEB8. 
 
 and to which the canvas is temporarily secured by 
 straps, being a square bar of wood, with a loop <>t' 
 band iron over the omls, forming the eyes through 
 which pass the handles. The-'' are convenient, as 
 they fold in a small compass for transportation. A- 
 the stretching apparatus, which i- loose, is sometimes 
 lost or misplaced, which renders the litter us< 
 it may be secured to the side bars by substituting for 
 the iron loop hinges or hooks. A steel rod, folding 
 upon it- centre, can he so connected to the side- of the 
 
 litter beneath the sacking as t<> unfold with the litter, 
 and ad as a stretcher without tear of becoming 
 detached. Short folding legs, working upon an iron 
 ptVOt, and kept in place by a Btop-block or an iron 
 hook, complete the apparatus. In the Confederate 
 service (en of these form the quota of each regiment 
 
 in the tield. 
 
 'I'h esc framed litter- have been a source of constant 
 annoyance to regimental Burgoons. To he made 
 Btrong enough to bear tin- ordinary usage for which 
 they are intended, they are necessarily heavy, and 
 therefore a cause of complaint with the ambulance 
 corp-. whose duty it is to bear them. Our wagon 
 transportation having been always deficient, with no 
 room for litter- in the hospital wagon or ambulances, 
 the litter-bearers, to relieve themselves of tin' weight 
 of a litter, accidentally break tin' woodwork against a 
 rocb or tree, and then rip oil' the sacking, which they 
 afterward use as a litter by cutting holes in tin- four 
 corners ami using two poles cut by the roadside, 
 
 when they are called upon to convey wounded men. 
 Others throw away the litters as so m as they are 
 annoyed by the weight. Unless the infirmary corps 
 are made responsible for the litter- which are put 
 in their possession, and be made to pay for any loss or 
 
IIANP-LTTTEItS. 103 
 
 injury sustained, litters will always be deficient in our 
 army. 
 
 Another objection to the framed litter, especially 
 with feet, is that they are often used as beds and 
 lounges for officers, although this application is 
 expressly prohibited, and while thus used are frequent- 
 ly broken by persons tin-owing themselves upon them, 
 or sitting upon one of the sides. As the feet are 
 seldom required, it is an improvement to omit them in 
 the construction of litters. 
 
 Williamson, in his Notes on the Wounded from the 
 Mutiny in India, published in 1859, has, in the appen- 
 dix, a plate and description of a dooley — a kind of litter 
 used for the conveyance of the sick and wounded 
 in India. In the field service it forms the patient's 
 bed as well as means of conveyance, from the time of 
 his being wounded until he is cither cured or dies. 
 It consists of a framework, resembling a bedstead 
 in miniature, six and a half b}' two feet, with light 
 posts, which run below the bed six inches. This 
 is slang by two ropes placed on either side from 
 the bead and foot, and running up triangularly — the 
 pole upon which the litter is supported passing 
 through the apex of these two triangles. A tarpaulin 
 cover, with side curtains, excludes the sunlight and 
 gives privacy to the wounded. When the bearers 
 arrive at the encampment, they run the dooley into 
 the hospital tent, take out the pole with the tarpaulin 
 covering and curtains, with which they make their 
 tent, leaving the patient comfortable in his bed. 
 These wore found to answer admirably in the Crimea, 
 
 where they were used to a limited extent. This is the 
 
 comfortable conveyance tor a sick or wounded 
 .;., and it > introduction generally into the English 
 service ha- been strongly recommended. 
 
1 1 1 ( BOH B8. 
 
 Horsb-Litteus. — Ni'.xt to band-litters for the trans- 
 portation of wounded men are horse-litters, made 
 three feet wide, with poles sixtoon feet long, folding in 
 the middle for convenience of transportation. Eon 
 or males take the place of men — the poles acting 
 as shafts, and Bupported by back-strapa or by a saddlo 
 with t ti lt-. as in ordinary harness. Bach horse-litter 
 earrios two persons. When the mules are led by men 
 well trained for this duty, transportation by this 
 means is well suited to the comfort of the wounded ; 
 but if the muleteers are raw hands, who, holding tho 
 mule by the head, attempl to lead it. instead of allow- 
 ing it to pick its own way. the joltings and sudden jars 
 make thi-< litter anything bul a bed <»t down. 
 
 The French use what is called a cacolet, a kind 
 of arm-chair, which is suspended <>ii each side of a 
 pack-saddlo n]> m a mulo. 'Tin.' mechanism of this 
 ebair is so arranged that it can be unfolded, so as to bo 
 converted into a bed or a litter. It offers either a 
 comfortable seal for tho trivially wounded, or a bed for 
 the moro sorious; and each mule can thus carry 
 two men comfortably from tin- field to tho infirmary. 
 In hilly countries, over bad, rough roads, this is found 
 :i much bettor conveyance than vehicles. 
 
 Tin' two and four-wheeled carriage or ambulanct </•■/</- 
 ons, which have been adopted in every civilized army, 
 are considered indispensable for field service, and for 
 the transportation <>f the wounded. Both are so ar- 
 ranged as to allow of the woundod boing carried ly- 
 ing, reclining, or sitting. The, omnibus is the most, ex- 
 pedition*) means of removing those slightly wounded, 
 who arc no! able to walk from the field. Whore the 
 roads arc good, in an open ion n try, this vehicle should 
 not i"- overlooked. The four-wheeled spring ambu- 
 lance wagon is the most comfortable for the wounded, 
 and also the most useful for the servico. 
 
AMBULANCE WAGON. 105 
 
 In the Confederate service the four-wheeled spring 
 wagon, as seen in plate 1, is the one in general use, 
 although the two-wheeled wagon is also used. It con- 
 sists of a box body, three and a half feet wide and 
 seven and a half feet long, placed upon three springs. 
 Two stuffed seats run the entire length of the wagon; 
 and the drop from this, which is attached to the seat 
 by hinges, and is equally cushioned, can be elevated 
 horizontally, and supported by feet, which, with the 
 scat, will form a continuous bed over the entire wag- 
 on. Such wagons will transport two men lying, or 
 from ten to twelve sitting — the inmates being protect- 
 ed from the sun and rain by a cloth cover and side 
 curtains, supported upon a frame. Two five-gallon 
 kegs, secured under the bottom of the wagon, carry 
 water for the sick and wounded. 
 
 The Coolidge, two-wheeled ambulance wagon, which 
 is in use in the Federal army, is a very ingenious but 
 complicated arrangement, and is liable to be broken 
 by the ordinary uses of the service. In these, instead 
 of seats, there arc two frames, which can be used as 
 litters. These run upon rollers on the bottom of the 
 wagon. The frames have folding legs and sliding 
 handles, which occupy no available room. Upon the 
 t<>]) of the litter is a frame, divided into three portions, 
 folding in such a way that the head of a wounded man 
 can be elevated nearly to a sitting posture, or the leg 
 equally elevated, should the peculiarity of the wound 
 require it. A partition through the body of the wag* 
 on separates the t wo patients which the interior of the 
 wagon accommodates. Under the driver's seat is a 
 box, which can be used as a medicine-chest. This ve- 
 hicle is intended for one horse in shafts, "i* two in 
 tandem. 
 
 When transportation is abundant, the Confederate 
 
106 A.MBULANOB WAGON. ^^^ 
 
 • allows, for every command of Loss than three 
 companies, one two-wheeled transport cart for bospi- 
 
 tal supplies, and t" each company one two-wheeled 
 ambulance carriage. For commands <>t' more than 
 three or less than five companies, two two-wheeled 
 transport run-., and to each company one two-wheel- 
 ed ambulance carriage. For a battalion of five com- 
 panies, one four-wheeled and five two-wheeled ambu- 
 lance carriages, and two two-wheeled transport carts; 
 and foreach additional company, less than ten, one two- 
 wheeled transport cart. For a regiment, two four* 
 wboeled ambulance wagons, ten two-wheeled ambu- 
 lance wagons, and four two-wheeled transport carts. 
 This number, however, has never been received by a 
 regiment, and often one wagon for transporting the 
 hospital apparatus, ami <>no four-wheeled (rarely two) 
 ambulance wagons complete the actual supply to regi- 
 ment - in tin- field. 
 
 Where there are many sick to he moved from camp 
 to a general hospital, should the transportation in 
 ambulance wagons be deficient, advantage is takm of 
 tli.- return of empty eommissary wagons to the rear 
 t'. Bend oil' the sick, ami vehicles <.f every description 
 may be impressed lor this Bpecial service. 
 
 
C II A P T E 11 I V. 
 
 Medical and Surgical Staff of Armies — Tub Medical organiza- 
 tion in the Confederate service; English service; French 
 service ; Prvssian service — Infirmary Corps, or litter-car- 
 riers for transporting the wounded from the field — Duties 
 of the Hospital Surgeon — Duties of the Regimental Surgeons 
 and Assistants in camp and on the rattle-field — Medical sup- 
 plies allowed in the field — Preparations needed on the kve 
 of a battle — Positions occupied by the Medical Staff during 
 TnE fight. 
 
 Medical Service of the Army. — Tho medical staff 
 of an army is selected with care by an examining 
 board, whose rigid inquiries into the literary and pro- 
 fessional attainments, as well as into the moral and 
 physical condition of the applicant, keeps the staff 
 purged of inferior men, and forms a body of scientific 
 Investigators whose efficienc}- will compare favorably 
 with the profession of any country. 
 
 During war, the medical department increases part 
 passu with the army. These appointments should bo 
 made with a lull knowledge of the weighty responsi- 
 bilities attached to the medical stall', without whose 
 constant solicitude for the health and well-being of the 
 troops committed to their care, the effective strength 
 of an army will be materially reduced. With a view 
 to ensure, at all times, the most active and efficient 
 treatment for the sick in the arm}', ami particularly 
 during active service, it is not only essential thai the 
 medical officers should be men of ability and of high 
 professional qualifications, but that they should pos- 
 sess physical energy adequate to their arduous duties. 
 
I 08 MEDICAL st \i r OF AN A.BMT. 
 
 It is a common impression that Burgeons alone arc 
 wanted in the army, under the erroneous belief that 
 tho only risks to which troops arc exposed are the 
 bullets of tho enemy. As we have elsewhere shown 
 that for one killed by the enemy at least eight die of 
 disease contracted in camp, this will be sufficient prool 
 that the physician must be even more important than 
 the surgeon. Long before the first shot is fired, there 
 arc diseases to contend against. Whether in camp 
 or on the march, diseases are constantly developing 
 themselves. Surgery has its periods, and although 
 hospitals may he filled with wounded men immedi- 
 ately alter a fight, beds are soon vacated t<> be refilled 
 
 by the eVer-COming sick. Some of the wounded die, a 
 
 large proportion rapidly get well and are discharged, 
 
 and the protracted cases are sent home to recruitj 
 hut these leave no vacancies, as their places are im- 
 mediately tilled by the sick. 
 
 Tii.' advantages of having an experienced surgical 
 stall' in the field, and the influence which it can exert 
 on the vicissitudes of war, must he acknowledged by 
 e\«ry thinking man. Vet, medical advice is seldom 
 asked or listened to by those in command, so lone; as 
 Buffering and death are not cruelly felt. The proper 
 understanding between the surgical and military staff 
 of an army, with concert of action, will Bave many a 
 soldier, who would otherwise h.-<" or compromise his 
 lite, so valuable to the country in time of need. 
 
 In the Confederate Bervico but two grades in the 
 medical stall' are recognized — surgeons and assistant 
 Burgeons, with the respective assimilative rank of 
 major and captain. The head <>t the medical depart? 
 menl is presided over by a surgeon-general, with tho 
 rank of lieiitenant-eoloncl of cavalry, which is the 
 highest grade in the service, ami which position is held 
 
MEDICAL STAFF OF AN ARMY. 109 
 
 by seniority of commission. There are other merito- 
 rious positions, viz : of medical directors and inspect- 
 ors for field and hospitals, and medical purveyors of 
 the army, which are appointments hy the Burgeon- 
 general, and are considered offices of responsibility 
 and trust, although without increased rank. 
 
 In the Confederate service each regiment, nominally 
 of one thousand men, has one surgeon and one as- 
 sistant surgeon. Where several regiments are united 
 into brigades, the oldest commissioned surgeon in tho 
 brigade assumes the position of brigade surgeon, who, 
 however, is not relieved from regimental duty. When 
 brigades are thrown together into divisions, the sur- 
 geon upon the staff* of the major-general assumes the 
 position and duties of division surgeon. The union of 
 several divisions, comprising a corps d'armee under tho 
 command of a lieutenant-general, has a chief medical 
 officer with the title of corps surgeon, or medical di- 
 rector of the corps; and when two or more corps 
 d'armee. form an army, the medical affairs of such a 
 bocly of men is supervised by. a medical director rec- 
 ommended b} r the surgeon-general, and appointed 
 by the Secretary of War, at the solicitation of the 
 general in command. 
 
 In times of peace, two medical regimental officers are 
 found scared}* sufficient to attend to the sick; while, 
 in times of epidemics or war, they are incompetent to 
 offer that assistance which the sick and wounded 
 require. Many a life has been sacrifice^ to procrasti- 
 nation. Upon the first and immediate attention to tho 
 wounded on the battle-field depends, in a great meas- 
 ure, the success of treatment ; and in any encounter 
 which deserves the name of a battle, the wounded 
 must necessarily be neglected by this deficient medical 
 staff 
 
11" MEDICAL BTAFF OJ TIIE ENGLISH ARMY. 
 
 Our large experience has proved the inefficiency of 
 our regimental medical staff. European experience 
 confirmfl the observation, that two medical men are 
 not sufficient t<> take care of the health of a full regi- 
 ment of a thousand men. This was the subject 
 of general comment in the Crimea, where the medical 
 stall were unanimous in the demand for additional 
 medical assistance, [n active Bervice, every full regi- 
 menl should have at least one surgeon and two assist- 
 ant Burgeons, these differing only in rank, their duties 
 being similar. Bosides the regular regimental Bur- 
 geons, there is in the Confederate service a medical 
 corps to take charge of military hospitals, while regi- 
 mental officers accompany their commands. 
 
 In the English service, the medical department is 
 composed of regimental Burgeons, 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 their 
 assistants, either take charge of military hospitals, or 
 act as medical supervisors for a brigado, composed of 
 three or more regimonts. Tho assistant staff sur- 
 geon holds the same rank as the regimental Burgeon. 
 When many brigades are collected into a division, a 
 stall' surgeon of long service is appointed to direct 
 
 the medical and surgical affairs of the division ; and 
 
 when a large force, consisting of several divisions, 
 with their respective generals and physicians, is 
 brought into the field for actual Bervice, and placed 
 under a general-in-ohief, a dical stall' officer, bear- 
 ing the title of inspector-general, is appointed to su- 
 perintend ami COUCentratO all the movements of tho 
 
 lical department of the army. The medical de- 
 partment takes the military, thereforo, as its model. 
 In the French army a somewhat similar organ iza- 
 
MEDICAL STAFF OF THE PRUSSIAN ARMY. Ill 
 
 tion is found. Besides Burgeons and assistant Bur- 
 geons attached to regiments, the military hospital 
 staff, which is a very numerous one, consists of medi- 
 cal inspectors or head Burgeons of infirmaries, stall* 
 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 Europe 
 'belongs to the Prussicui service, and is composed as 
 follows : 
 
 Bacb battalion of one thousand men lias a surgeon 
 and assistant surgeon, who are thoroughly instructed 
 in the duties which they are expected to perform. 
 Beside these there is, to every corps d'armee of thirty 
 thousand men, a staff of forty surgeons, who, in time 
 of war, take charge of the general military hospitals 
 opened for the reception of the sick and wounded. 
 This division has also attached to its medical depart- 
 ment three infirmary staffs for light field service, 
 composed of eleven surgeons each. These act as a 
 reserve on the battle-field, opening field infirmaries 
 which follow the troops, and give the first aid and 
 dressing to the wounded. This gives a proportion of 
 nine surgeons to every two thousand men; and. not- 
 withstanding this large number, there arc periods 
 when even a larger number of Burgeons would not bo 
 sufficiently numerous to give proper and immediate 
 assistance to the wounded. 
 
 In most European armies the dispensing of medi- 
 cines is performed by apothecaries, who complete the 
 medical organization. In the English service the 
 siatanl Burgeon or hospital steward acts as apothe- 
 cary. In the Confederate army, as physicians of 
 experience are numerous in the ranks, one of these 
 
I 12 AMBULANCE CORPS. 
 
 usually receives the appointmont of hospital steward 
 in the field, or apothecary, with the rank of hospital 
 steward in the general hospitals, and upon him de- 
 volves th<- preparation and dispensing of drugs. 
 
 In recenl European campaigns a very important 
 addition has been made to the surgical service. It is 
 the ambulance corps, or carriers of the wounded. Here- 
 tofore, when men were shot down from the rank's, 
 they were home to the haek hy their eomradesdn- 
 arms, who transported them to the field infirmaries, 
 where the surgeons attended to their wounds. Al- 
 though a most praiseworthy act of devotion to a fall- 
 en friend, it was often called for when help could 
 Least l'e Bpared, as the taking away of so many fight- 
 ing men from the ranks enfeehlcs the strength of the 
 command, ami diverts the attention of the soldiers, if 
 its demoralizing effect does not break up the corps* 
 It is also well known that, if any from the ranks are 
 drawn from the fight to carry off the wounded, they 
 never return until the light is over, and thus three 
 are lost to the company instead of the one wounded. 
 Besides, with the very best in tent ions, these comrades 
 
 are not instructed how to carry the wounded so that 
 (ley should Buffer least detriment, and the final result 
 can not he hut injurious to the wounded. The amlui- 
 
 lance corps, which now forma a very essential part of 
 every army, is a regularly organized body of nun, 
 carefully selected for their strength and courage, who 
 are taught how to carry Wounded men. These prac- 
 ticed hands are under military discipline, commanded 
 hy officers whose duty it is to see that (he wounded 
 arc promptly and carefully removed from the places 
 where t hey fall tot he infirmai 
 
 The assistant surgeon of a regiment accompanies 
 i he ambulance corps to superintend the judicious 
 
DUTIES OF AMBULANCE CORPS. 113 
 
 transportation of the wounded. While thus employed 
 he is only expected to offer temporary assistance. 
 Should there be fearful hemorrhage, he may apply a 
 tourniquet, or show the assistants how to compress, 
 effectually, a bleeding vessel. He arranges broken 
 limbs so as to have the wounded man conveyed with 
 the greatest degree of comfort, and gives, perhaps, a 
 dose of morphine when much suffering is felt, but as 
 long as active fighting is going on he has no time to 
 offer more than this temporary assistance. 
 
 This ambulance corps, with litters, ambulance wag- 
 ons, pack-horses, and all other facilities for transport- 
 ing wounded men. should be in the advance, imme- 
 diately behind the line of battle. Their post is one 
 of great risk as well as of heavy responsibility ) for, 
 not unfrequcntly, they lose their lives in accomplishing 
 their benevolent task. Both humanity, civilization, 
 and economy dictate that such a corps should be 
 appended to every army in the field. When not 
 wanted on the battle-field, experience makes them 
 Careful nurses for the sick and wounded. 
 
 The ambulance corps, as connected with each 
 brigade in the Confederate service, is composed of two 
 men from each Company of a hundred men, selected for 
 braveiy, strength, endurance, and good character — 
 the object being t<> make this corps as efficient as 
 possible. When suitable in other respects, physicians 
 or students of medicine found in the ranks, are 
 Bolected. The duties of the ambulance corps are very 
 trving requiring undaunted courage as well as great 
 endurance, to enable them to work uninterruptedly 
 under fire, following closely the line <>f battle, with 
 their lives exposed at every moment from the missiles 
 oftheenemy,andyet unarmed and without excitement. 
 This brigade ambulance corps is under the command 
 
114 frknch ORGANIZATION OF AMBULANCE CORPS. 
 
 of .1 lieutenant. The men. selected from each regi- 
 ment, two from every hundred men, are in charge 
 of a sergeant, who is frequently a medical man — the 
 conscript law n<>t exempting physicians under thirty- 
 five years of age from military servic* — and patriotism 
 having induced many of much more extended practice 
 to take the field. The members of this corps are 
 designated by wearing around their eaps a red hand. 
 with (tmbxdance corps printed in conspicuous white 
 letters. Each carries a large canteen tilled with 
 water. Their duties are to follow their regiments into 
 the fight, accompanied by the assistant surgeon, and 
 convey to a place of safety such as art' shut down ami 
 too severely wounded to get oil' the field without 
 a-^istance. When the army is in motion, the infirmary 
 corps marches in the rear of its regiment, hearing the 
 five litters now allowed to each regimental corps. 
 When in camp, they are employed about the hospital 
 a- attendants upon the sick. In many regiments they 
 are never railed upon for guard duty during an active 
 campaign, and are allowed all the privileges granted 
 the, color-guard. Winn an army goes into permanent 
 camp they are returned to the ranks, to resume their 
 duties as an ambulance corps as soon as the campaign 
 is resumed — the men who have been instructed in this 
 duty being continued in it. 
 
 The French organization,* which may serve as a 
 model for the formation of a hospital corps, is as 
 follows: One captain, one subaltern, one sergeant- 
 major, one pay sergeant. live sergeants, or upper ward- 
 masters when in hospital, ten corporals or under ward- 
 mast ers, two buglers (indispensable for sounding halts 
 ami advance in the transport of the wounded ), ninety- 
 
 •Artielc Ambulance, Co lopcdia of Practical Surgery. 
 
MEDICAL STAFF IN PRUSSIAN ARMY. 115 
 
 six privates or orderlies, one tailor, one shoemaker, ono 
 cutler (a most useful artisan to keep surgical in- 
 struments in repair), one carpenter, lour cooks. 
 When employed in hospital, these are distributed 
 in the proportion of one ward-master for every 
 hundred patients, and one orderly for every twelve. 
 The wagons and cars will also be under the command 
 of their proper officers ) non-commissioned officers, 
 with wheelwright, farriers, saddlers, etc., are also 
 to be attached to the corps. When on a march, should 
 there be a deficiency of transport wagons, the ambu- 
 lance wagons carry the hospital stores, also the packs 
 of weak men not requiring transportation ; they also 
 pick up such men as are not able to proceed with 
 their companies, or those who are compelled to 
 fall out of the ranks from indisposition. When troops 
 on a march arrive at a place where good water 
 can be obtained, the hospital corps should fill their 
 canteens for the use of the sick. When the troop? 
 are bivouacked, the hospital corps should be employed 
 in throwing up huts, or in establishing temporary 
 hospitals in any adjoining buildings, and in preparing 
 some light food for the sick which they have brought 
 in. 
 
 The following is the course pursued l>y (he Prussian 
 medical corps of a division of thirty thousand men when 
 going into /><ittle: The reserve corps of forty surgeons 
 establish a general hospital at some sale and con- 
 venient point, four or five miles from the battle-field. 
 Here all the appliances aro concentrated tor giving 
 proper attention to the injured} and mosl of t h .• 
 serious and tedious operations are to he performed, 
 under judicious consultation. As this is the resting? 
 place from the field, accommodations musl he ample; 
 
116 MEDICAL STAFF IN PRUSSIAN ARMY. 
 
 ry facility for treating successfully the seriously 
 wounded must, therefore, be found, and all hospital 
 stores should bo concentrated at this hospital. 
 
 Directly behind the line of battle, and movable with 
 it. are placed the light field infirmaries, with their 
 special stalls. They arc the way-stations for medical 
 service, as all the wounded pass through these on 
 their way to the general hospital. At these field infirm- 
 aries the wounded receive the first thorough exami- 
 nation, and many operations deemed imperative are 
 here performed. All wounds are here cleansed, foreign 
 bodies of every kind extracted, hemorrhage controlled, 
 and the first proper dressing applied. As the wound- 
 ed are brought to this point as they are shot down, 
 their wounds have undergone but little change; the 
 system is still suffering from a certain amount of ner- 
 vous -hock, which makes it the proper time for effecting 
 a thorough examination without giving pain. 
 
 In these, as in the general hospital, there is always 
 a division of labor, and each Burgeon, knowing his 
 duty, accomplishes the greatest amount of work in his 
 special department. The division always recognized^ 
 is the examiner, the operator, and the dresser. Those 
 who arc most skilled in these various departments are 
 expected to give the benefit of their skill and experi- 
 ence tO the wounded. .More importance is placed upon 
 these subdivisions of labor than we would, at first 
 sight, recognize. It is well known that many hands 
 can be efficiently worked by one head, and that when 
 a surgeon of much experience and mature judgment 
 determines what course should be pursued, there are 
 many competent to carry oul his suggestions, who were 
 not sufficiently prepared to establish a thorough diag- 
 nosis and foresee the probable issue. 
 
MEDICAL STAFF IN PRUSSIAN ARMY. 117 
 
 The importance of examining a wound as seldom 
 as possible being acknowledged, it is easy to under- 
 stand why the most proficient surgeons in the service 
 should be appointed, as diagnosticians, to examine, 
 thoroughly, the wounded, and determine upon a course 
 of treatment. In gunshot wounds, above all others, 
 the necessity for accurate diagnosis becomes impera- 
 tive, and this first examination should never be slurred 
 over, however urgent the demands upon the surgeon's 
 time. Except in very obscure cases, a second examina- 
 tion should never be made, as it always gives pain, in- 
 creases irritability, heightens inflammation, and per- 
 mits air to gain access to the very depth of the 
 wound, which is sure to promote the decomposition 
 of the exudates around the wound, with its suppura- 
 tive and sloughing sequehe. Many a limb and life, 
 would be preserved were it possible to limit the examina- 
 tion of the wounded to the field infirmary. Let it be re- 
 membered that the first examination is always less 
 painful and dangerous than any subsequent one. All 
 surgeons agree upon the success of primary opera- 
 tions, when compared to secondary, after inflamma- 
 tion has set in. How to proceed, or what wounds to 
 condemn, requires nice discrimination — heme the ne- 
 cessity of devoting the talent and experience of tho 
 staff to this very important duty. 
 
 In the Prussian service, the regimental surgeons are 
 Concentrated in groups with their assistants, rather 
 than follow their respective regiments into the fire. 
 Thus, much time is saved and the wounded receive 
 more attention; and keeping them together in this 
 way renders it easy to command 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 por- 
 
il v BUDIOAL STAFF IN PRUSSIAN ARMV. 
 
 tion of the sanitary corps in the proper transporta- 
 tion of the wounded.* 
 
 In the same service, the "primary dressings for the 
 wounded are carried by each soldier, so that all necessa- 
 ry bandages are <»n the spot, and no time is losl wait- 
 ing for the bandage boxes or hospital stores. The 
 genera] plan adopted by the entire army is as follows: 
 Every soldier carries a small package, three inches 
 long and one inch thick, which contains the following 
 articles, viz: two pieces of old, soft, clean linen, nine 
 inches square; a piece of oiled silk or india-rubber 
 tissue, nine inches long by five inches wide; a small 
 ball of lint ; a bandage two and a half yards long and 
 two inches in width. One piece of the linen is fold- 
 ed double and rolled tightly over the lint, and over this 
 the piece of oiled silk is rolled, the bandage rolled 
 around this, and the whole enveloped in the second 
 piece of linen, and fastened with two pins. This 
 should be put in a particular place in the knapsack, 
 where it can always be found. Should there be two 
 wounds, the oiled silk and cloth may be divided to 
 make a double dressing, and one piece of cloth may 
 be used by the surgeon as a towel. In this small but 
 very useful package is found the requisite dressings 
 for every gunshot wound. It saves the surgeon the 
 annoyances and delays incidental to the transportation 
 of hospital stores. In the light field infirmaries, near- 
 ly all the dressings of the wounded are obtained from 
 this individual package — the very few extra articles 
 needed being furnished from the infirmary supplies. 
 
 Stromyer, in his surgical writings on the Schleswig- 
 Holstein war, speaks of the medical department of 
 the army as modelled upon the military. Besides the 
 
 *Lceffler. Behandlun;* dor Sehusswuiide. Berlin: 1859. 
 
MODERN MISSILES OF WAR. 110 
 
 regimental surgeons, each brigade had a brigade sur- 
 geon with three assistants. The larger divisions of 
 the army were equally supplied with superior medical 
 officers ami staff. On the battle-field the surgeons of 
 the army established infirmaries for the immediate 
 Care of the wounded, who were, after the first dress- 
 ing, sent into the more permanent infirmaries. 
 
 Modern warfare, in introducing arms of precision, 
 of immensely increased range, and perfected instru- 
 ments of destruction of heavy calibre, has created a 
 new era in military surgery. The conical ball of dou- 
 ble weight has become the common missile, and when 
 discharged from a rifle it flies with fearful velocity. 
 Such balls, when traversing soft parts, produce exten- 
 sive destruction, but seldom bury themselves. Com- 
 paratively few of these are to be extracted after a 
 battle. Should they impinge upon a bone, the split- 
 ting and crushing is so extensive as to necessitate 
 more frequently amputations and resections. 
 
 This conical ball seldom fails to take the shortest 
 cut 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. Rarely are they deflected from 
 their course, as is the round ball, which is turned by 
 every little obstacle, taking up a position at striking 
 variance with any rule of propulsive forces. in 
 steady hands frightful wounds are produced by the 
 minic ball, which require all the resources of surgery 
 to manage successfully. 
 
 The following interesting table, taken from the 
 recent work of ML Legouest on Army Surgery, pub- 
 lished in Paris in L8Q3, will give an idea of the rela- 
 tive momentum, and the relative tendency t<» do 
 mischief, of round and rifle balls. To exhibit the 
 power of penetration of balls, a target was made 
 
120 
 
 MODERN MISSILES OF WAR. 
 
 tting up plank of one inch in thickness, twenty 
 inches apart, each numbered as in the following 
 table 
 
 X..i. 
 
 1 
 •J 
 
 l 
 
 :t 
 
 ■i 
 
 
 '• 
 
 7 
 
 s 
 
 
 
 
 
 
 l 
 
 r.r. 
 B 
 
 10 
 8 
 
 • > 
 
 4 
 
 : 
 
 u 
 
 i 
 
 a 
 
 ~> 
 
 
 
 1 
 
 
 
 
 
 
 By an examination of this table it will be seen 
 that, with the round ball and smooth lnu-o. :it a dis- 
 tance of five hundred yards, only two shots perforated 
 the first plank, and one only, oul of one hundred and 
 twenty shot, traversed the second plank of one inch 
 in thickness; while the majority of the rifled conical 
 shots perforated the first plank, n large number the 
 second, third, fourth, and oven fifth, while one trav- 
 ersed the entire target of eight planks — which indi- 
 cates, in a very striking manner, the facility with 
 which rifled conical shut overcome the resistance of 
 opposing bodies, and accounts for the straight course 
 which they usually take through a limb, and the 
 rarity of their inoarcoration in the tissues. 
 
 Jn making experiments for tho above table, it was 
 also remarked that, for the first two hundred yards 
 from the muzzle of the piece, tho round ball moved 
 with the greatest velocity; this was readily over- 
 come, however, by atmospheric resistance, and gravi- 
 tation soon brought it to the ground. In all instances 
 where a mark was Bhot at from a distance of two 
 
 hundred yards, tie- round hall was the first to strike; 
 Over this distance the velocity of the round ball was 
 
 rapidly diminished j while the conical hall shot from 
 the rifle continued its momentum undiminished. 
 
 Another missile, which has been more extensively 
 
CAMP DUTIES OF A REGIMENTAL SURGEON. 121 
 
 used in the present war than in any preceding, is the 
 rifled shell, as fired from artillery. In both contend- 
 ing armies rifled artillery appears to he a weapon 
 upon which much reliance is placed, and which is 
 brought into continual use — artillery duels not onty 
 preceding each battle, but being a constant element 
 in the fight. Whether used at a distance of fivo 
 miles, as in the Siege of Charleston, or at short range, 
 the explosion of shells among troops makes frightful 
 wounds. The mutilation of the slain upon every 
 hat tie-field attests the terrible efficacy of the rifle 
 shell and modern artillery missiles. 
 
 Let us now define the duties of a surgeon in the 
 .Confederate service in the regimental hospital, in 
 camp, and on the battle-field. 
 
 • Camp Duties of a Regimental Surgeon. — We have 
 already shown that the fire of an enemy never deci- 
 mates an opposing arm}'. Disease is the fell destroyer 
 Of armies, and stalks at all times through encamp- 
 ments. Where balls have destroyed hundreds, insid- 
 ious diseases, with their long train of symptoms, 
 and quiet, noiseless pi*ogress, sweep away thousands. 
 To keep an army in health is, then, even more im- 
 portant than to cure wounds from the battle-fields. 
 But, as surgeons in the service arc expected to bo 
 skilled in both departments, so that, in either case, 
 the troops under their care might suffer no detriment, 
 tiny should be thoroughly prepared for the very re- 
 sponsible positions which they fill. Conservative sur- 
 gery requires much more at the hands of the surgeon 
 than the destructive practice of former times. Every 
 Burgeon should now prepare himself for the field, by 
 familiarizing himself with operative Burgery. Half- 
 knowledge leads to meddlesome surgery, which is far 
 
122 CAMP DUTIE8 OF A REGIMENTAL BUROEON. 
 
 worse than no surgical assistance. Many a wounded 
 soldier has felt heavily the busy hand of the willing sur- 
 n who lacked the guiding h id. The Burgeon in the 
 nfederate service has charge of a number of very 
 valuable lives, as the very best men in the country arc 
 in the army, and the necessity imposed — by the al>- 
 sence of consulting aid — of deciding tin- most serious 
 and critical cases upon his own unaided judgment 
 demands, upon his part, self-reliance, which can only 
 be based upon previous preparation. Cam]) life gives 
 a surgeon much food for thought and ample personal 
 experience, but gives him no time to consult authors 
 and improve himself with books. lie does not sei 
 ureal a variety of diseases as are met with in civil 
 practice, hut he lias a wider field for observing the 
 influences of external modifying circumstances — as 
 exposure, improper food, imperfect clothing, irregular 
 work, want of cleanliness, and depressing or exhila- 
 rating mental influences upon young, healthy men. 
 The diseases of a soldier, like those of most trades, 
 are peculiar — each trade begetting its own, while it 
 M-ives 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 espe- 
 cially the crowding together, with the animal emana- 
 tions from BUch a number of living beings, that gives 
 Character to the phases of camp disease. 
 
 The preservation "f the health <>/ ike soldier being the 
 sole '(uii/ of the military surgeon, he will lie expected to 
 use rvrvy means within his reach to attain this de- 
 Birable end, and more especially by a rigid observance 
 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 
 
CAMP DUTIEB OF A REGIMENTAL .SURGEON. 123 
 
 very few of these can not 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 Bign of indisposition. Hygiene must 
 first claim his attention, under the adage, "Preven- 
 tion is better than euro." If the troops are about 
 forming an encampment, he must examine the ground, 
 and see whether any causes exist for rendering the 
 place insalubrious. When in a friendly country, ho 
 should seek information from the local physicians, 
 which will not only give him a better insight into the 
 sanitary condition of the point selected, but will also 
 instruct him upon the diseases prevalent in the local- 
 ity, and the means which local experience and obser- 
 vation have proved most effective in controlling such 
 diseases, lie must see that, when practicable, the 
 troops in camp are supplied with dry straw for beds, 
 and that they air the same daily, along with their 
 tents, so as to ensure a healthy place for repose. 
 With the officers of the regiment, he must ace to it 
 that the soldiers are properly clothed, and well fed 
 with wholesome, nutritious food, and supplied with 
 an abundance of good water, and, from time to time, 
 should suggest to the commanding officer such 
 changes in the diet as will be conducive to the health 
 Of the command. If the water is bad, ho should 
 study how it can be improved, so as not to act inju- 
 riously upon the men. Cleanliness of the encamp- 
 ment, of the tent, and also of the body and clothing 
 0f soldiers, should never be forgotten. He should 
 point out to the commanding officer all nuisances 
 which promise to be detrimental to the health of the 
 corps, and urge their removal— suggesting how they 
 
 Can beet be deposed of Much of the sickness in the 
 
1 .' I CAMP DUTIES OF A REGIMENTAL BURG! 
 
 army can !"• attributed to a dereliction of this duty 
 upon the pari of the medical officer. 
 
 The hospital tents, with the approbation <>i" the 
 commanding officer, will be pitched upon a dry, well- 
 drained Bpot, if a bailding can not be obtairfed tor 
 hospital use, and it is the duty of the regimental Bur- 
 geon t" attend to the proper furnishing of the same 
 with all possible conveniences for the sick. 1 1 »• will 
 enforce all proper hospital regulations to promote 
 health and prevent contagion, by ventilation, scru- 
 pulous cleanliness, frequent changes oi bedding, linen, 
 etc. 
 
 At the Burgeon's morning call the sick of the regi- 
 ment will bo conducted to the hospital by the lirst 
 sergeants of 1 1 1 * * various companies, who will each 
 hand t<> the Burgeon a list of all the Bick of the com-! 
 pany, on which the Burgeon will state who are to 
 remain or go into hospital, :ui<l who are to return to 
 quarters as Bick or convalescent} what duties the 
 convalescents, in quarters, are capable of performing j 
 what cases arc feigned, and any other information in 
 regard to the si<-k of the company be may have to 
 communicate to the oompany commander. Il<' will 
 then distribute the patients in the hospital; sec that, 
 they are properly provided with comfortable bods; 
 enter, in the proper register, the name, rank, com* 
 pany, and disease, and in the <lh't and prescription 
 
 1 k the medicines which the case requires, [f his 
 
 assistant is not present, and his steward is not com- 
 petent, he propares the medicines and superintends 
 their administration. He will visit the hospital each 
 day, as frequently a* the Btate of the Bick may re- 
 quire. Should any Boldier be taken suddenly sick, 
 his case is at once reported to the surgeon, who will 
 
('AMP DUTIES OF A REGIMENTAL SURGEON. 125 
 
 visit and prescribe for him in his tent, unless the case 
 threatens 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 perfectly recover- 
 ed ; for which purpose it is the duty of the surgeon to 
 make, daily, at morning parade, a particular inspec- 
 tion of these men, so as to prevent any remaining 
 longer exempt from duty than the state of their 
 health renders absolutely necessary. After the sur- 
 geon's call, lie will make a morning report of all the 
 sick and disabled to the commanding officer. He also 
 recommends that leave of absence be granted, on fur- 
 lough, to those convalescents who will recover more 
 rapidly by change of air, scene, and life; or discharges 
 for those whom experience has proved physically 
 unfit for the arduous duties of camp life. When it is 
 his opinion that a case can not be as conveniently 
 treated in camp as in a general hospital, he recom- 
 mends a transfer to the commanding officer, and for- 
 wards with the patient a descriptive list, a history of 
 the case, and the course of treatment which has been 
 pursued. 
 
 When soldiers are discharged, as cured, from the 
 hospital, or die, or are fhrloughed or discharged from 
 service, if is the duty <>f the surgeon to notify, imme- 
 diately, the captain of the company to which the sol- 
 dier belongs, so that the proper steps may be taken 
 which the necessities of the case may require. 
 
 The regimental surgeon is the recognized head of 
 the regimental hospital and is responsible for the 
 organization and proper keeping of the same. He 
 will, therefore, prepare and enforce all of those rules 
 so necessary in a well-regulated hospital, for estab- 
 
120 CAMP M A REGIMEN PAL f 
 
 lishing order and keeping np a military organiza- 
 tion. When soldiers enter snch q hospital, all control 
 iv« >m without is suspended, and line or staff officers 
 are do! allows! to interfore in any way with the 
 managomenl of the oaae. The surgeon distributes the 
 patient-, according to convenience and the nature of 
 their complaints, into hospital tents, or leaves them 
 in their own quarters, and visits them each day as 
 often as the state of the sick may require, Accompa- 
 nied by the steward and nurse. He keeps the proper 
 register of the hospital, and directs the prescription 
 and di.t of the sick; superintends the preparation of 
 the reports, records, pay-rolls, and descriptive lists; and 
 also keep- a constant supervision over the dispensary, 
 instruments, medicines, and hospital Btores, as also 
 
 over the hospital expenditures, and the preparation of 
 
 the requisitions and returns. He keeps an order and 
 letter book, in winch is preserved copies of all requisi- 
 tions and invoices, as well as all orders and letters 
 
 relating to his duties. He makes a monthly report to 
 the medical director, and a quarterly report to the 
 Burgeon-general, of the sick and wounded and of 
 deaths, and also of certificates for discharges from dis- 
 ability — all of which are forwarded through the brigade, 
 division, and corps surgeon to the medical dire 
 lie will also prepare the muster and pay rolls of the 
 hospital Steward. Should a soldier die in the hospital, 
 
 i be surgeon takes charge of his offsets and reports the 
 sane, turning over all money and other articles except 
 clothing to the quartermaster of the regiment, taking 
 therefor receipts in duplicate, one of which he for- 
 wards to the commander of the company of which the 
 soldier was a member, to he s,.nt by him to the family 
 of the deceased, and the other to the Second Auditor 
 of the Treasury, lie will enforce the proper hospital 
 
CAMP DUTIES OF A REGIMENTAL SURGEON. 127 
 
 regulations to promote health and prevent contagion, 
 by examining daily into the hygienic condition of the 
 hospital as regards cleanliness, ventilation, over-crowd- 
 ing, proper food, etc. He will require the steward to 
 take due care of the stores and supplies, to keep a 
 regular account of all issues, to prepare the provision 
 returns, and to receive and distribute the rations. 
 
 As the sick in all hospitals are not able to consume 
 the ample supply of food which the government re- 
 cognizes as a ration, and which is issued to all sol- 
 diers, whether well or side, the surgeon should direct 
 the steward to draw from the commissary only BUCh 
 quantities as are required for the hospital, and to 
 commute in money for the stores not drawn. This 
 surplus forms a hospital fund, an account of which 
 the surgeon keeps, and which can be expended for 
 comforts for the sick, both as regards subsistence or 
 hospital furniture. The condition of this fund is 
 transmitted, monthly, to the surgeon-general. 
 
 AIL requisitions upon medical purveyors for hospi- 
 tal and medical stores must come from the senior sur- 
 ge in, with the approval of the commanding officer, 
 certifying that the same are necessary for the sick, 
 and that the requisition conforms strictly to the Blip* 
 ply-table for field service. These requisitions are 
 drawn out by the surgeon in the proper form (No. 5 
 of Medical Regulations), always in duplicate, stating 
 what medicines arc on hand, and for how many 
 required, and arc sent to the modical director, or, 
 should there he no one acting in his district, to tllS 
 surgeon-general, for approval, All Btores received 
 from the medical purveyor must be receipted for in 
 duplicate to the ijurgeon-goneral, by the senior aur 
 gcon, who also notifies the medical purveyor ol their 
 reception. 
 
 
L2S 
 
 MKHK Al. OUTFIT Y'M A REGIMENT. 
 
 The following comprises tho medical outfit for a 
 regiment medicine-chest : 
 
 AllTIOI.KS. 
 
 NTITY. VW 
 
 Aluminia 
 
 Caoaphorte- ... 
 
 Cerati Bimplioia 
 
 Raainsa 
 
 Bmplastrum Cantbaridia 
 
 Alcobnlia 
 
 < lopaibaQ 
 
 Oloum Olirae 
 
 •• Rioini 
 
 " Terebiuthinir 
 
 lb. 
 
 bot 
 
 B * 
 
 Aoacia, pulv 
 
 Capaioum, pulv. . . . 
 
 Magnesia Sulpbatia. 
 
 bb Bitartratia . 
 
 Palveria Cinoh«mae< . 
 
 " Lini 
 
 " Khci 
 
 Quiniffi Sulpbatia. . . 
 
 Binapia N igrae 
 
 Bodes Bioarbonati8. . 
 Bolphurua Loti 
 
 Aoidi Tartarici 
 
 Bydrargyri Chlor. Mitis . 
 
 Plumbi Acetal ia 
 
 Potaasii [udidi 
 
 Pulveria ' Ipii 
 
 Sodte i i Potuaa. Tartralia. 
 
 Cbloroforini 
 
 Liquoria Ammonias 
 
 Bpiritua AStheris Comp. . . 
 
 " " Nitrioi. . 
 
 Syi n|i SoillaD 
 
 linot. Opii 
 
 •• Campb 
 
 Vini Colobipi Sominia. . . . 
 
 Hydrargyri Cum Creta. . . 
 
 Pulveria Aloea 
 
 I pecac. el * » | . i i . . 
 Zinc! Sulpbal i- 
 
 8 os. 
 
 S OZ. 
 
 2 oc. 
 2 " 
 2 " 
 2 " 
 
 Argenti oitratia, fused 
 
 Antin ii el Putoss. Tartratia 
 
 Perri el Quiuiaa Citratie 
 
 [odinii 
 
 lAorpbiaa Sulpbatia 
 
 Dnguenti Hydrargyri. 
 
 .M:.v-;i- pil. Hydrarg; 
 
 Nit rat ia. 
 
 Hi. 
 
 C f B* 
 
 £ ?? E. 
 
 1 » D" 
 
 2 8 B 
 
 Z 5' 
 5' 
 3 ^2. 
 
 — £ " 
 
 ?r a. „: 
 
 W r» S> 
 
DUTIES OF ASSISTANT REGIMENTAL SURGEON. 
 
 129 
 
 Ahtici.es. 
 
 ■Quantity. VESSELS 
 
 Bandages, roller, assorted . 
 
 Eniplnstruui, adhesivi 
 
 " Iohthyocollse 
 
 Measures, graduated 
 
 Mortar and Pestle 
 
 Oleum Tiglii 
 
 Pencils, hair 
 
 PilulsB Cathartic Com p. . . . 
 
 " Opii 
 
 Scales anil weights 
 
 Spatulas 
 
 Sponge 
 
 Tiles 
 
 A store-chest, with the following contents, accom- 
 panies the medicine-chest: 
 
 Instruments. Amputating, Bets. .No. 
 
 Ball Forceps " 
 
 Bougies, gum elastic " 
 
 Catheters '• 
 
 '■ silver " 
 
 Cuiqung-tJlasses...-. " 
 
 Pocket Sets " 
 
 Lancets, spring " 
 
 " thumb " 
 
 Trobnngs " 
 
 ScariBcators " 
 
 Splints assorted 'set ofl4) " 
 
 Syringes, enema •' 
 
 penis " 
 
 Troth, extracting, sets " 
 
 Toorniqncts, field " 
 
 spiral " 
 
 l'i macs. Hernia " 
 
 Arrow- Root lbs, 
 
 Candles " 
 
 • Nutmegs ol 
 
 Tea His 
 
 Whiskey, quart bottles doz 
 
 Bandages roller '• 
 
 Bandages, suspensory nos 
 
 Binders' Hoards •' 
 
 • 'oiks doi 
 
 Cork-Screws ■ 
 
 Cotton Batting 
 
 " Wadding 
 
 Flannel, red 
 
 Hatchets 
 
 Bones 
 
 Ink. 2 OK. bottles 
 
 Lint 
 
 Muslin 
 
 Needles 
 
 Paper envelopes 
 
 | '■ wrapping 
 
 " writing 
 
 Pencils, hair 
 
 " lead 
 
 (Pens, steel 
 
 Pins, assorted 
 
 Bason 
 
 Rasor-8trop 
 
 - 
 
 silk, surgeons' 
 
 Sponge 
 
 Tape 
 
 Thread, linen 
 
 Towels 
 
 Twine 
 
 Wafera, '-.,. "/. boxes , 
 Wax. Sealing 
 
 •yds. 
 
 ..lbs. 
 .yds. 
 .nos. 
 
 .quires. 
 Nob, 
 
 doz, 
 
 .papers. 
 
 ....lbs. 
 
 .dos. 
 
 .-lbs. 
 
 Duties oi Assistant Regimental Surgeon. — The 
 duties of the assistant regimental surgeon are, in 
 
130 DUTIES Of ASSISTANT REGIMENTAL BURGEON. 
 
 many respects, similar to those of the Burgeon. If 
 be lias the confidence of his superior, the patients arc 
 equally divided between them; he treating a certain 
 number of >i<k. ordinarily without interference from 
 the Bonior Burgeon, except they be serious cases, 
 when he seeks advice from the regimental Burgeon. 
 Although this is the common course pursued, it is not 
 bo from right, but by sufferance of the senior Bur- 
 geon. In the army regulations, the senior surgeon 
 being the superior officer, the assistant surgeon is 
 under his control. Besides attending to a number p# 
 patients, he is expected to make up medicines, and 
 Bee that the patients get them at the proper time, 
 apply dressings, bandage fractured limbs, keep the 
 register, diet, and prescription hooks, and assist in 
 compiling the monthly and quarterly returns. When 
 a detachment is sent off upon special service, the 
 assistant surgeon accompanies it as medical officer. 
 
 When epidemics occur in camp, then the duties of 
 the medical officers become very arduous; the daily 
 and nightly toil which they are compelled to undergo, 
 the fatigue of body and anxiety of mind which is 
 their daily routine, soon breaks them down, and 
 many an over-zealous surgeon becomes a prey to the 
 diseases which his constant efforts are trying to sub- 
 due in others. This is particularly the case when 
 typhus is raging in camp; when a neglect of those 
 hygienic precautions which the medical officers are 
 instilling into the men causes many a victim in the* 
 medical ranks. Under such conditions, 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 may entail 
 severe suffering on their regiments. The Crimean 
 surgeons were severely censured, after spending all 
 

 PURSUIT OF MEDICAL STUDIES. 131 
 
 day in tlie typhus and cholera hospitals, with their 
 tainted atmospheres, for remaining there during the 
 night also, when there was no necessity tor it. It 
 was a useless ami dangerous imprudence, an exagge- 
 ration of duty, which deprives the army of well- 
 informed men, and impairs the utility of tho service. 
 
 In the Crimea, the surgeons would frequently meet 
 together for scientific conference and for mutual in- 
 struction. Here each gave his experience, and com- 
 pared the results of different methods of treatment. 
 Their meetings always terminated in practising am- 
 putations, resections, and the ligation of arteries on the 
 dead subject. The object of this was not only to gain 
 dexterity in the operative manual, but also to find out 
 who were the most skilled, and therefore most worthy 
 of being entrusted with important duties. It is said 
 that the mortalit}' of the army amounted to two hun- 
 dred per day, which gave ample material for such 
 practice. These meetings were presided over by one 
 of the most distinguished staif surgeons or medical di- 
 rectors, who would often deliver to the society prac- 
 tical 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. 
 
 In some of our armies this excellent [dan has been 
 adopted — societies in the field having been formed for 
 interchanging views and advancing the general science 
 of military surgery, in Richmond, the child' head- 
 quarters of the army, an association of army and navy 
 Burgeons has been formed, presided over by the sur- 
 geon-general, which has collected within its limits the 
 medical and surgical talent of the Confederacy. Ai 
 its meetings the important and mooted subjects of mili- 
 tary surgery are freely and thoroughly discussed, and 
 
132 DUTIES OF THE BURGEON ON THE BATTLE-FIELD. 
 
 much valuable information elicited. In order to reach 
 the individual experience of army surgeons, questions 
 of special interest arc proposed, and disseminated by 
 means of a circular, by tbc presiding officer, to tbe 
 medical officers of the army throughout the entire 
 Confederacy, and ample time is given to obtain indi- 
 vidual opinions, based upon experience, which are 
 brought forward when these questions are discussed 
 before the association. By adopting this plan the very 
 best results are obtained, and the experience of the 
 medical staff collected. 
 
 Duties of the Surgeon on the Battle-field. — 
 The common fear which depresses the soldier on the 
 
 eve of a battle, more than any other, is not so much 
 death, but tbe dread of mutilation. Bullets are neither 
 respecters of parts nor persons; and tbe prospect of 
 lining an eye, an arm, or leg, makes many a brave man 
 quail before the ordeal through which he is to pass. 
 So that, before a battle, there is a vague, uneasy rest- 
 lessness — a foreboding of coming evil — which takes 
 possession of tbe bravest, and can not lie driven off ex- 
 cept by the commencement of the tight. The early 
 booming of cannon braces all for action ; all thoughts 
 of fear or self are now discarded, tbe 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 something in the 
 smell of gunpowder which makes men forget their 
 originj by its magic spell women are made brave, and 
 cowards heroes. In tbe eagerness of the fray an in- 
 toxication guides all to acts of daring. Who, in his 
 sober moments, would walk' up to the mouth of a 
 loaded cannon to which a torch is being applied ? Yet, 
 on the battle-field find the man who, at the word of 
 
MEDICAL SUPPLIES REQUIRED ON THE FIELD. 133 
 
 Command, and while under the stimulating intoxica- 
 tion from gunpowder, would not face certain destruc- 
 tion ! Fortunate it is that nature has so constituted us, 
 or the terror of pursuing a course which duty dictates 
 would be agonizing indeed. The surgeon on the battle- 
 field must participate in the dangers, without the 
 stimulation of the conflict ; he requires, therefore, a 
 double proportion of courage to sustain him in the try- 
 ing part which he has to perform. 
 
 Upon the eve of a battle, the regimental surgeon 
 has much to do to prepare facilities for the treatment 
 of the wounded, lie must see that the hospital stores 
 are brought up with the ammunition wagons — as the 
 articles for treating the wounded and saving the life 
 of comrades arc fully as important as those for the de- 
 struction of the enemy. lie examines his stores, and 
 satisfies himself that nothing which will be required 
 for the wounded has been omitted or forgotten. Re 
 examines his instruments, his supply of bandages, 
 lint,* india-rubber cloth, oiled silk, or waxed cloth, etc.; 
 
 *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 nine qi«i Hon 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, wc 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 uurccognized cause of pain. 
 
 Mayor, in his work, " /Jandages el Apparcil d Patuement," after 
 mentioning that the use of raw cotton had been proscribed without 
 cause in the treatment of wounds, reiterates what would be evident to 
 every serious investigator, that far from being hurtful, this su1> 
 so light, 5'- »oft, -" clean, w dimple, f abundant, and bo easily obtained, 
 
l.'il MEDICAL SUPPLIES REQUIRED OH Till. FIELD. 
 
 Ibc rule adopted in European armies being, t<> have 
 roady dressings for one-fiflli <>f the command going 
 into action. He sees thai chloroform and opium, or 
 morphine, the chief source of comforl to the wounded, 
 arc at hand in sufficient quantity. Water he has not 
 overlooked, as an abundant supply will be needed to 
 meet tbe incessant . unmitigated thirst of the wounded. 
 !I«' should be well supplied with astringents, of 'which 
 the perchloride or persulphate «»i' iron is the best Id 
 control annoying hemorrhage. So should also havea 
 moderate supply of brandy to revive those exhausted 
 from hemorrhage, oil to grease their wounds, and a 
 
 U the very best n r t i < • 1 < ■ thai con be used. All will acknowledge that, fur 
 protecting parts from pressure, aud for equalizing tbe pressure of tbe 
 apparatus, this is t lie preferable article for many reasons. For the 
 dressing of wound.* lint is used, because ii i.- thought soft and soothing 
 to the raw surface — how much better, on this very account, is cotton 
 than the finest lint? If cotton is used, and its claims recognized as an 
 application to the raw, inflamed, sensitive surface of a burp, with how 
 much more reason could it he applied to tbe comparatively healthy sur- 
 face of a wound? Tbe best lint is obtained by scratching clotb until it 
 yields a soft down, which, when obtained, i- nothing but raw cotton, 
 \i/ : reducing the cloth to its primitive element. Hereafter there will 
 nol be that ilc in a ml foi liul as hi rotofoi c ; and, in times of war, the fe- 
 male population of e < ntry will not bo called upon to use nil of tln-ir 
 
 exertions in Bcraping lint from rags, many of which already contain the 
 germs of disease, when any number of hale- of cotton lint can be ob- 
 tained at once, and at little expense, and without trouble. Female 
 labor has been much more profitably employed, during our struggle 
 fur Independence. Lint has been but little used, as the cold water appli- 
 cation to wounds is the universal treatment in the army, which excludes 
 the ii.-e of lint, Many leading army surgeons haie discarded lint alto- 
 gether as an encumbrance t'> Burgioal dressings, 
 
 Much can also be said of new cloth verniu the old linen of titno- 
 honored reputation. Suffice it to say, in this connection, that an army 
 should never clog Its movements by an exci of baggage, and that the 
 old linen (which can be used but once) required for an army is no 
 small item. New cloth can be washed a dozen times, if required, which 
 in itself is no mean recommendation. 
 
PANNIERS FOR FIELD SERyiOE. L35 
 
 little tea, sugar, and such medical comforts as will re- 
 fresh and .support the wounded. 
 
 Having selected from the general stock those 
 articles which he will need, such as all articles for 
 dressing, viz: cotton, lint, cloth, bandages, oiled silk, 
 sponges, ligatures, adhesive plaster, splints for treating 
 all varieties of fractures, amputating and dressing in- 
 struments, with medicines and stimuli, and a lull sup- 
 ply of good water— they are carefully put upon a 
 pack-mule in two strong, iron-bound hexes, called pan- 
 niers, one hanging on either side of the saddle. One 
 is usually devoted to medicines — the other is used for 
 dressing apparatus. This distribution gives the sur- 
 geon great facility in moving about the field to those 
 positions where his services may be most required, 
 while it dispenses with the hospital store wagon, 
 which is altogether too cumbersome to follow light 
 troops in their varied and active movements. In 
 European armies every regiment has such a pannier, 
 which is continually resupplied from the medical store 
 wagons. The commanding general may sometimes 
 have good reasons, under particular circumstances, 
 for ordering the medical wagons to remain behind 
 with the baggage; then some other conveyance for 
 all needful medical supplies for the wounded becomes 
 imperative. 
 
 Panniers are used only to a limited extent in our 
 armies, from the scarcity of supply. We are, there- 
 fore forced to use ambulance wagons instead of pack- 
 horses in our rapid movements. 
 
 As panniers are sometimes objected to on account 
 of their si/.e. and as modern surgery recognizes but 
 few medicines as really necessary on the field, light 
 
 leather water proof cases, which are carried by an or- 
 derly, are found preferable A great convenien 
 
 
136 HOSPITAL KNAPSACK. 
 
 the surgeon is the modern addition < »1" a hospital 
 knapsack t<> bis equipments, which enables his orderly 
 to carry conveniently, for immediate use, such articles 
 as the attendance upon the sick and wounded require. 
 
 The hospital knapsack which has been issued to tin* 
 Confederate army is framed similarly to the ordinary 
 knapsack, but larger, being sixteen inches long, four- 
 teen inches wide, and six inches deep. The interior is 
 divided by wooden partitions into four compartments, 
 with a broad band of leather tacked across the lower 
 portion of the enclosure to prevent the contents from 
 dropping out. A leather apron, similar to that of an 
 ordinary knapsack, covers the front of the knapsack. 
 The frame is surmounted by a horseman's valise, 
 which is convenient for carrying large bottles, dress- 
 ings, and instrument-. 
 
 The hospital knapsack contains the following drugs, 
 viz: tannic acid, 1 oz.; nitrate of silver, fused, \ oz.; 
 simple cerate, ] Hi.; chloroform, J lb.; adhesive plaster, 
 2 yards; isinglass plaster, 2 yards; powdered alum, 2 
 oz.j aromatic spirits of ammonia, 2 oz.j Hoffman's ano- 
 dyne, 2 oz.j brandy, 1 bottle; muriate tincture of iron, 
 4 oz.; laudanum, \ oz ; paregoric, 4 oz.; comp. cathartic 
 pills, t do/..; camphor and opium pills (camphor 2 
 grains, opium 1 grain each), 1 doz.; opium pills (1 
 grain each), 2 doz.; acetate of lead and opium pills (lead 
 2 grains, opium 1 grain each), 2 doz.; and quinine pills 
 (.'{ grains oach), 4 doz. And in a haversack, made of 
 wator-proof enamel led cloth, is carried bandages, 6 rolls; 
 Sperm candle, 1 ; lint, I ft).; medicine cup, 1 ; pins, 1 
 paper; and 2 pieces of Bponge. Assistant surgeons 
 should carry a small leather haversack, with a flap 
 cover, to button for security. This will contain his 
 pockot instruments, torsion forceps, light dressings, 
 pins, sponges, ot< 
 
HOSPITAL KNAPSACK; 137 
 
 In making the daily rounds of the sick in camp, 
 when they arc scattered in their tents and not con- 
 centrated within a hospital enclosure, this knapsack, 
 with contents, carried by an orderly or the hospital 
 steward of the regiment, will save much delay and 
 trouble in the dispensing of drugs. "When carried on 
 the battle-field many articles may be dispensed with, 
 and in their stead the knapsack should contain lint, 
 bandages, adhesive plaster, sponges, and a bottle of 
 sweet oil, with pins and tape, for the dressing of 
 wounds; a bottle of the perchloride of iron, for control- 
 ling hemorrhage; field tourniquets; a bottle of mor- 
 phine, for allaying pain ; chloroform, should an urgent 
 case demand an immediate operation to save life, and 
 a quart or more of brandy ; also candles and matches, 
 which arc indispensable, as no efficient aid can be giv- 
 en to the wounded upon the field after darkness sets 
 in, without them. The orderly who carries the knap- 
 sack also carries, suspended to his person, a large 
 canteen, three times the ordinary size, filled with 
 water, and also a tin cup. The knapsack should be so 
 arranged that all the contents will be exposed to view 
 without unpacking. 
 
 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 formula, then the 
 hospital stores could in a great measure be dispensed 
 with, and with few additions to the individual stock, 
 the wounded could receive careful dressing. The 
 instruments and few medicines which the infirmary 
 would require could then be readily moved from place 
 to place, following the line as the din of battle re- 
 cedes from the points where the fight had com- 
 menced. 
 i. 
 
138 Ml INS OP TRANSPORTING THE WOUNDED. 
 
 The surgeon Bhould examine the means of trans- 
 porting the wounded from whore they tall in the field 
 infirmary. These Bhould consist of at least two 
 Btretchers for every one hundred men engaged, al- 
 though in European ar mien four are allowed to each 
 company, besides light ambulance wagons, spring* 
 • arts, or any other conveyance of transportation, to 
 accommodate in the proportion of forty persons for 
 o very one thousand troops. The allowance of ambu- 
 lance transportation in the Confederate servico is for 
 twenty lying and twenty sitting por one thousand 
 men, added to which arc five litters to each regiment. 
 
 The character of the transport service will depend 
 upon (he character of the country in which the war 
 is carried on. In a level country, wagons are the 
 most serviceable ; while in hilly localities, litters car- 
 ried by mules would lie the rnosl comfortable trans- 
 portation for the wounded. In Confederate a- in 
 European armies, a distinct body of men are employ- 
 ed for conveying the wounded, so that practised 
 hands may soothe the agonies of transportation. 
 This is by tar the most humane course, and, as a mark 
 of civilized warfare, should be of universal adoption. 
 It is highly important that a similar body be instruct- 
 ed to act as nurses as well as attend immediately 
 upon the wounded, as this timely assistance may save 
 many lives on the field. In those armies in which 
 this ambulance corps has not yet been introduced, 
 the regimental quartermaster, in charge of the pio- 
 neers and musicians, form a temporary body of car- 
 riers. Besides the litters, each hearer carries a can- 
 teen full oi water, and the assistant surgeon, who 
 follows the litters and directs the transportation, is 
 accompanied by two men as orderlies. One of these 
 
 orderlies, who habitually follows the medical officer, 
 
ORGANIZATION OF FIELD INFIRMARIES. 139 
 
 whether in battle or on the march, carries the hospi- 
 tal knapsack. One of the orderlies is armed, to pro- 
 tect the party against stragglers and marauders. 
 The surgeon, for a similar reason, should be also 
 armed with a revolver. The orderlies assist the sur- 
 geon in placing the Wounded carefully in the wagons; 
 and also following them, are at hand to assist in un- 
 loading the wagons at the field infirmary. 
 
 When the troops deploy or form for action, the 
 surgeons, with their assistants and pack-horses, move 
 a short distance to the rear, out of the range of the 
 shot, and they establish there the field infirmary. It 
 would be convenient if some house could be used for 
 this temporary hospital. 
 
 Where this can not be had, the shade of trees or the 
 shelter of a hill-side will answer the temporary 
 wants of the surgeon. If the body of troops about 
 entering into battle is a large one, with an extended 
 line, several of these points should be selected and 
 marked by a suitable red flag, which designates the 
 spot where those slightly wounded can seek surgical 
 aid. These locations should be selected as near as 
 possible to the line of battle, so that they may bo 
 easily reached by the wounded. They should be 
 readily recognized, protected from the enemy's fire, 
 well supplied with water, and, if possible, with straw 
 and shelter for the wounded. These sites should be 
 known to the commanding officer, so that he might 
 extend his orders to the infirmary, should it be w 
 sary, during the fight. 
 
 Before tin- medical army staff was properly organ- 
 ized, and their plan of WOrk studied, so as to render 
 the Btaff D1081 efficient, surgeons accompanied the 
 troops into the fire, and took position along the line 
 Of battle, where they could give immediate succor to 
 
140 DUTIES OF SURGEONS OF FIELD INFIRMARIES. 
 
 the wounded. Experience Bhowed them that, thus 
 isolated from each other, and having no means of car- 
 rying with them the various instruments which they 
 would require, it was impossible to perform any but 
 the most trivial operations; hence the necessity of 
 rabling Burgeons together at 4fc various field in- 
 firmaries, where, by assisting each other, all the nec- 
 essary operations may be successfully undertaken 
 [nstead of each regimental surgeon establishing Buch 
 an operating site for his regiment, the plan which is 
 now adopted in the Confederate service, and which 
 has decided advantages, is to establish a division or 
 corps field infirmary, at which all the surgeons of the 
 division or corps concentrate. The advantages of this 
 concentration are that medical officers can always bo 
 found by their commanders, and can assist each other 
 in the care of the wounded. It often happens that 
 but a portion of the opposing troops are actually en- 
 gaged in the fight. Under the old plan of regimental 
 infirmaries, the two medical officers of the regiment 
 engaged would have morelo do than they could pos- 
 sibly attend to — the wounaed remaining unattended 
 for hours — while medical officers of regiments not in 
 the fight would be idle. Now, by concentration ami 
 mutual assistance, the wounded can he attended to as 
 rapidly as they are brought in. The division or corps 
 surgeon establishes and directs the surgical affairs of 
 the field infirmary, and the ambulances of the division 
 are also concentrated at this point, and thus offer 
 great facilities for removing rapidly the wounded, as 
 soon as their wounds are examined, to positions in the 
 
 rear. 
 
 When surgeons combine at the field infirmaries, the 
 usual course is to be operator and assistant in turn — 
 relieving each other when fatigued. It would be far 
 
DUTIES OF SURGEONS OF FIELD INFIRMARIES. 141 
 
 better, however, to establish at once, if possible, a 
 division of labor; lot there be an understanding that 
 those best adapted by experience to undertake certain 
 duties, should confine themselves strictly to the same. 
 When each one knows what role he is to play, and 
 does not interfere with others, a great deal more work 
 can bo accomplished than where each one acts inde- 
 pendently for himself. The force of this will appear, 
 when it is remembered that all experience shows the 
 medical stall' of an army, however numerous, to be 
 always too few on battle days. Remember, that all the 
 wounded must undergo a thorough examination, and all 
 needful operations should be performed within twenty-four 
 hours, or the wounded suffer from the neglect. Now, 
 take into consideration the very small surgical stall' 
 of our army, and the accuracy of fire of the contest- 
 ants, with the most approved and destructive arms 
 with very long range, and wc will immediately sco 
 the necessity of economizing time and labor. 
 
 Moreover, among the officers of every brigade are 
 found Burgeons of experience and judgment, but 
 among them are also men of purely theoretical 
 knowledge, just from the schools, who always exhibit 
 an eager desire to use the knife, without the judg- 
 ment and experience necessary for deciding when 
 operations are required. Such officers can be heard 
 boasting of the number of operations which they have 
 performed, rather than the number of cures which 
 thc\ had obtained. Many a limb has been sacrificed 
 to this inordinate thirst for operating, as many a 
 DH ve and stalwart soldier reports the safety of a use- 
 ful limb to his own resistance to such indiscriminate 
 mutilation. Such Burgeons require restraint. After 
 every encounter the cases for legitimate operation 
 are, unfortunately, so numerous that even the most 
 
14_' DUTIES <>K Bl »F PIELD [NFIRMAR1 
 
 ambitions can, in time, have their desire for operating 
 satisfied. The judgment of such officers should be 
 guided by the experience of otheii ; and hence the 
 useful division of labor at the fiold infirmaries, into 
 who examine wounds and determine the general 
 course ol treatment required, and those who perform 
 such operations as, in the experience of the board of 
 examiners, are necessary for the safety of the wounded. 
 
 The movements and portion of the troops, and the 
 character of the ground, must establish the necessity 
 for tlio greator or less concentration of surgeons at 
 the fiold infirmaries. As the troops advance, they 
 arc followed by the bandsmen or litter-bearers, and, 
 it' the country permits it. the ambulance wagons, un- 
 der charge of the quartermaster and assistant Bur- 
 geon, aecompaniod by his orderlies. These Btation 
 themselves in the roar of the advancing line, where 
 they can distinctly Bee what happens, and remove 
 immediately, without the range of the shot, those 
 who may fall wounded. It is imperatively demanded, 
 on the score of humanity, that the wounded be re- 
 moved from the field of battle, with a> little delay as 
 possible, for early treatment. In gunshot wounds, 
 above all others, to obtain success early surgical as- 
 sistanco is of the greatest moment. Therein is the 
 -reat advantage of having a special transport corps — 
 otherwise the excitement of battle, or the eagerness 
 of pursuit, carries the line to a distance from the 
 ground where the battle tirst commenced; and it is 
 only after the victory is achieved that the wounded 
 are thought of by their comrades, who. in BCOUring 
 the fiold, find many a dear friend whose life has paid 
 the forfeit of delay. 
 
 The practice, too frequent in our service, of taking 
 off the surgeon of a regiment with a woundod officer, 
 
DUTIES OF SURGEON ! OF FIELD INFIRMARIES. 143 
 
 and leaving the command exposed to fire without 
 competent surgical aid, is an abuse of authority which 
 can not bo too severely denounced; and any officer 
 should be severely censured who, from selfish motives. 
 would allow his command to be thus exposed. An- 
 other act for censure, which should render a surgeon 
 liable to court-martial for dereliction of duly, is in so 
 far forgetting his position as to assume the offensive, 
 and enter pell-mell into the fight. The temptation 
 is strong; but among the first lessons to be learned by 
 a military surgeon is that of self-restraint and rigid 
 attention (o those duties which are connected with 
 his position. His duties lie with the wounded, and 
 not in the charge. The comfort, if not the lives, of 
 many are in his keeping, and all unnecessary exposure 
 which he voluntarily incurs can hut be detrimental to 
 the service. In the early campaigns of the war, sur- 
 geons under fire often forgot their positions and re- 
 sponsibilities by entering into the light. A more 
 wholesome discipline has altogether corrected this 
 evil. 
 
 When our troops remain in possession of the field, 
 the enemy having fallen hack, the surgeons attached 
 to the ambulance corps should proceed without delay 
 to the front of the line, with all possible means of 
 transportation, to collect the wounded; and as moat 
 frequently night has set in before the enemy has yield- 
 ed, torches should be carried by the hospital or 
 ambulance corps, to facilitate this important and hu- 
 mane search, which is too frequently neglected. 
 
 When our army retreats ami our wounded have to 
 be left, some of our surgeons should be lefl in attend- 
 ance, and supplied with necessary dressings — as no 
 dependence should he placed upon the medical stores 
 
 of the enemy, which may be oxhausted, or he of an 
 inferior quality. 
 
CHAPTER V. 
 
 TrBATWRHT up QbBSHOT WOOBDB— WHAT Sliori.n BR DORR OH TBI 
 
 Field bv tiik Assistant BOROROR in command of tiik I.ittkiis — 
 
 TllK. TllEATMENT AT TIIK FlRLD [RKRMARY — IloW Wnl'NDS SIIOI.LD 
 III: KXAMINEH. 
 
 When a soldier falls or is wounded in battle, he is 
 at once conveyed by the litter-carriers from the line 
 of battle to a short distance in the rear, where the 
 assistant surgeon looks at his wounds, applies tin- 
 h:isty dressing which they require, and, placing him 
 comfortably on the litter, attends to his transporter 
 lion. He can do as much for the wounded in tins 
 way as if he were actively engaged in operating. 
 Should the injury permit the wounded man to walk, 
 a compress and bandage is placed upon his wounds, if 
 thev be severe, and he is directed to the field infirmary. 
 In, however, by far the majority of cases of flesh wounds 
 from rifle or musket balls, no dressings are applied by 
 the surgeon of the ambulance corps. The Avound 
 does not bleed much, and the dressings would neees- 
 
 sarily be so hastily put <>n and again removed at the 
 field infirmary, that much saving of time and material 
 is effected by sending such cases directly to the in- 
 firmary for careful examination and appropriate dress- 
 ing. In those will) fractured limbs, a rapid glance, 
 quick intelligence, and an inventive turn, at once tells 
 the surgeon what is required, and suggests the means 
 of effecting it. With a sword-blade, a ramrod, or a 
 bayonet, with a handkerchief or strip of cloth, a fract- 
 ure apparatus is at once improvised, and the thanks 
 of the wounded, now in comparative comfort, are 
 
TREATMENT OF WOUNDS ON THE FIELD. 145 
 
 freely bestowed during his transportation to the in- 
 firmary or general hospital. If he has a mangled 
 limb, which hangs by a very small portion of the 
 soft parts, its separation should be at once effected 
 b} T cutting through the mangled tissues. Should he 
 be suffering much pain, which is not usually the 
 case, the surgeon, whoso pockets are well stored with 
 morphine, gives him an anodyne powder, and at onco 
 transports him to the infirmary, where the neces- 
 sary operation is performed. If the wound be an ab- 
 dominal one, with protrusion of the intestines, he 
 sees whether the^ bowel is injured or not. If not 
 injured, he returns it carefully within the abdomen, 
 and gives a large dose of morphine to ensure quiet. 
 Should the intestine be cut by the ball, he warns 
 the carriers and assistants from interfering until the 
 Abounded man be carefully transported to the in- 
 firmary. Those wounded in the head, if insensi- 
 ble, require veiy careful transportation; the} T should 
 be as little disturbed as possible. Fractured legs 
 give the most trouble in transporting from the field, 
 as they require the greatest care in conveying them, 
 safely to the designated places for surgical treatment, 
 it is seen, from this rapid sketch, that the surgeon 
 who follows the troops into action has nothing to 
 do with amputations, resections, extracting foreign 
 bodies, etc. ; these form no portion of his duties. His 
 province is solely to prepare tin 1 wounded lor success- 
 ful transportation, and beyond this he should not in- 
 trude his attentions. The great perfection of rilled 
 weapons has its influence upon the duties of the field 
 Burgeon, as the rapid and frequent changes of the 
 battle-field threaten to restrict, within very narrow 
 limits. Held surgery with the ambulance corps, and 
 necessitate very hasty dressing 
 
 M 
 
1 |«; TREATMENT AT T 1 1 K FIELD INFIRMARIES 
 
 An eminent military surgeon — Mr. Guthrio— states 
 that bandages applied "n the (i- l«l of battle are, in 
 general, bo many things wasted, as they become dir- 
 ty and stiff, and arc usually cul away and destroyed 
 without having been really useful. There is much 
 truth in this statement. Much of the hasty dressing 
 by the transport surgeon can very well be dispensed 
 with. As lie has neither the time, nor is it bis duty, 
 to examine carefully the wounds, most of the wound- 
 ed might he sent on directly to the field infirmary 
 without dressing. The dressings, when removed at 
 the lidd infirmary, are so soiled tha^t they are thrown 
 away. Time, which is so valuable, and also material, 
 which is never in excess, bul most frequently defi- 
 cient, can be saved by adopting this course. Only 
 in cases of active hemorrhage would it be Decessary 
 to apply compresses and the roller-bandage, or, w hat 
 i^ more rarely required, the tourniquet. Let all other 
 - of flesh wounds receive their first dressing at 
 the field infirmary. 
 
 Should Ihe soldier have a large artery wounded, 
 and the hemorrhage be excessive, which is but sel- 
 dom the case, the Burgeon should instruct the orderly 
 who superintends his transportation how to make 
 judicious finger-pressure. This is much better than 
 the tourniquet, producing much less engorgement of 
 the injured tissues. 
 
 d >vr<j<r)j, 'properly speaking, commences at the fit Id 
 infirmary. Eere all wounds are thoroughly exam- 
 ined, and an accurate diagnosis established. The 
 wounds are thoroughly cleansed; all foreign hodies 
 which can he, arc removed, and the first dressing 
 made. W the wounds are trivial, they arc dressed, 
 and tic in, n sent to rejoin their companies. 
 
 When the wounds are quite recent, before the tis- 
 
CLOTHING DRIVEN IN BY BALL'S. 147 
 
 sues become engorged, there is a temporary absence 
 of pain and a relaxation of the injured parts, which 
 favor an examination. The wound should now bo 
 examined throughout its entire extent to determine 
 the presence of foreign bodies, whether they be balls, 
 wadding, portions of clothing, detached spiculee of 
 bone, etc. For this purpose the finger is the proper 
 probe, and should be used on all occasions, with rare 
 exceptions. It is an intelligent instrument, and, ap- 
 preciating what it feels, it will 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 make arc large 
 enough to admit readily the finger when introduced 
 with care, as the balls now used in warfare are of 
 greater diameter than the finger. Very rarely is it 
 necessary to dilate a wound with the probe-pointed 
 bistoury 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 occa- 
 sions, for exploring recent wounds, marks the novice. 
 Halls are readily detected in a fresh wound, by 
 placing the patient in the position in which he re- 
 ceived the injury, if the direction from which the ball 
 came be known. Portions of clothing and wadding 
 are detected with greater difficulty. Before, how- 
 ever, probing the wound for the detection 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 OHCO 
 Suggest an embedded ball; when an examination of 
 the clothing would show thai the ball had driven 
 
 tln-sc inio the wound without sufficient force to trans- 
 fix them. and. on removing hastily the clothing, the 
 
1 18 CLOTHING DRIVEN in r.Y BA1 ' 
 
 ball had been extracted by this diverticulum pushed 
 in before it. This examination of the clothing will 
 much time t<> the Burgeon, and painful, protract- 
 ed, injurious probing t<> the wounded. 
 
 Among the wounded Federalists from the Battle of 
 Manassas in the general hospital at Richmond, ;i case 
 came under my observation which well exemplified the 
 necessity of observing this rule. It was that of a Ger- 
 man who had heen shot in the head, over the left 
 parietal bone. As the scalp was wounded and the 
 bones crushed, the escape of fragments during the 
 treatment left an opening through which the pulsa- 
 tions of the 1 1 rain could be readily discerned. As thi 
 was no counter-opening, the conclusion was entertain- 
 ed that the ball had entered the skull, and was now 
 lying embedded in some portion of the brain. The 
 case was exhibited as one of those rare instances in 
 
 which a foreign body Could remain in contact with the 
 I n-ain without producing cerebral disturbance. It was 
 not until some week-s after admission that his cap was 
 examinod, when it was found indontod and stiffened 
 with blood, showing that it had heen pushed into the 
 wound before the ball. The cap had been slightly cut 
 by the sharp edge of bone from the pressure of the hall, 
 but there was no opening sufficiently large to permit 
 a ball to pass. An earlier examination of the cap 
 would have robbed the case of much of its interest. 
 
 When the shirt or drawers are not torn, no foreign 
 body can have lodged in the flesh which they were 
 
 covering. Prom the nature of recent wounds, tin' 
 
 examination and removal of all foreign bodies will 
 be more easily accomplished, and with f'ss pain and 
 danger to the wounded, when undertaken at an early 
 period. This should be done carefully, thoroughly, 
 and witle. ui delay 
 
REPORT OF EXAMINATION SENT WITH WOUNDED. 149 
 
 A Tegular report should be kept of all the cases 
 dressed at the field infirmary, and a brief description of 
 each case should be sent on with the patient to the gen- 
 eral hospital; so that if proper officers, in whose 
 judgment the hospital staff can confide, had previously 
 examined thoroughly the wound and sent on their re- 
 port, no further examination would be needed. The 
 pinning a paper to the coat of the wounded when he is 
 conveyed from the infirmary, upon which is written 
 the history of the wound, saves time and trouble at the 
 regular hospital, and relieves the patient from much 
 unnecessary pain. If the surgeon be trustworthy, his 
 diagnosis should be respected, and no further investigation 
 permitted. Many serious cases can be protected from 
 annoyance and further injury by adopting this simple 
 expedient. In many cases this is the only examina- 
 tion Which the wound will need. 
 
 The neglect or insufficiency of the first examination 
 is often the after-cause of the loss of a limb, and even 
 life. After-examinations heighten irritation and in- 
 flammation in the wound, and, as they permit air 
 (which ought to be rigorously excluded) to pass to the 
 bottom of the wound, this promotes the decomposition 
 of the extravasated fluids and exudations, induces 
 suppuration and sloughing, and predisposes to pyaemia, 
 with its fatal sequelae. Many a limb and life would be 
 preserved, if the examination of gunshot wounds could 
 be limited to the battle-field; and military surgery 
 will have attained great perfection when a thorough 
 diagnosis is obtained by this first examination. 
 
 The extent and nature of gunshot wounds are often 
 ascertained at a glance. Touching a limb may be 
 sufficient to indicate to the experienced Burgeon the 
 extent ami character of tin- wound, and suggesl the ap- 
 propriate treatment ; while other wound.-, as those in 
 
 
150 REPORT OF EXAMINATION BENT WITH WOUNDED. 
 
 the neighborhood of joints, may require all the skill and 
 scrutiny of the most experienced to obtain a satisfac- 
 tory diagnosis, Xo haste should be permitted in this 
 examination, to the injury of the wounded, through m 
 carelessness of diagnosis. Should large arteries be in- 
 jured, they should be ligated always in situ abovi ■ml 
 below the point injured, and for this purpose the wound 
 must be enlarged. 
 
 A.s a general rule, torn tissues will reunite, while 
 bruised, crushed tissues slough. All wounds in which 
 a probability exists of union, by the first intention, 
 should be nicely adjusted by adhesive plaster. The 
 great inconvenience of the ordinary diachylon plaster, 
 which requires heat to make it adhere, must exclude 
 it from field service. The Husband's, or isinglass phis. 
 ter, is much more easily applied, requires no heat — a 
 little moisture being all that is needed— is not injured 
 by hot weather, and when closing a wound, gives as 
 much support as the diachylon. It also excludes com- 
 pletely the air, with its injurious influences, which is 
 not its least advautage. Diachylon plaster is rather 
 required for hospital practice, where it is used to dress 
 suppurating stumps, from which the continued dis- 
 charge of pus would loosen strips of isinglass plaster. 
 
 Should a limb he 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 immediately the 
 condemnation of the limbj held surgery here proves 
 
 itself the only successful surgery, as all statistics 
 clearly show, [f the limb is simply fractured, without 
 injury to the main hlood-ves ids and nerves, and with- 
 out complications with joint injuries, the}* should he 
 considered simple fractures, and dressed as such at the 
 field infirmary. If, in connection with a condemned 
 
REPORT OP EXAMTNATrON SENT WITH WOUNDED. 151 
 
 limb, other mortal injuries exist, the impropriety of 
 performing an amputation is clearly seen, and surgeons 
 must not be seduced from this course by fondness for 
 operating. When joints are crushed, or the heads of 
 bones perforated, resections are urgently demanded, 
 and should be performed before violent reaction takes 
 place. 
 
 It is, of coarse, understood that, although wounds 
 might be examined, foreign bodies removed, and the 
 Wound, if simple, dressed while a soldier is Buffering 
 under shock, no serious operation, which would still 
 further depress the nervous powers, or cause a further 
 loss of blood, should be performed until extreme de- 
 pression subsides. Although the nervous shock accom- 
 panies the most serious wounds, it may often be met 
 with in the most trivial injuries. It is recognized by 
 the sufferer becoming cold, faint, and pale, with the 
 surface bedewed with a cold sweat. Tiie pulse is small 
 and flickering; anxiety and mental depression is also 
 present, with, at times, incoherence of speech. Often 
 this shock is very transient when accompanying sim- 
 ple wounds. A drink of water and a few encouraging 
 words may lie sufficient to dispel it. When it persists, 
 even where the injury appears trivial, it forebodes 
 trouble, and a more careful examination may detect a 
 fatal injury. It is the duration, more than the. degree 
 of shock, which marks the serious character of the 
 wound; and when this constitutional alarm persists, 
 there is great tear that hidden mischief is lurking, and 
 irgeon should l>e very guarded in his opinion of 
 the case. Keeping the patient warm, in the recumbent 
 posture, with blankets and hot bottles, administering 
 wine, brandy, whiskey, <>r ammonia, hartshorn to the 
 
 nostrils, frictions and cataplasms to the extremities, 
 
 is the course pursued to restore nervous energy. 
 
152 TRANSPORTATION TO GENERAL HOSPITAL. 
 
 In all painful operations chloroform Bhould be freely 
 administered to produce the desired anaesthesia. Like 
 all valuable medicinal agents which, when taken in 
 overdoses, are poisonous, it can remove Buffering <>r 
 destroy life according t<> its administration. The 
 Crimean, Italian, and Confederate wars, in recording 
 tin- advantages ot chloroform in field surgery, show it 
 to be now one of the indispensables for successful prac- 
 tice. It saves the lives of many wounded, who would 
 perish from the shock of a second operation ; and also 
 many who would have been considered as without the 
 pale of surgical art can now, thanks to this invaluable 
 remedy, be benefited by surgery. 
 
 In our country railroads traverse every portion of 
 the states, and as battles usually occur in the imme- 
 diate neighborhood of thoroughfares between large 
 cities, it is not improbable that they will be found in 
 the immediate vicinity of battle-fields. If such be the 
 case, a sufficient number of ears should be kept in 
 readiness for the use of the wounded. Transport 
 wagons are in constant communication with the field 
 infirmaries. As the wounded are attended to, they 
 should not bo allowed to accumulate around the infirm- 
 ary, hut be sent off at onee to the nearest ' railroad 
 station, from whence they will he distributed in the 
 
 towns nearest to the scene of action. General hospi- 
 tals should have heen previously prepared in these 
 localities for the reception of the wounded; and here 
 the regular treatment commences. 
 
 Daring a general engagement each field infirmary 
 should he in constant communication with this general 
 temporary hospital which the medical director has 
 located, and as soon as the wounded are examined and 
 dressed*, they should lie sent without delay to this 
 point. This allows the field infirmary to change its 
 
TRANSPORTATION TO GENERAL HOSPITAL. 153 
 
 position, and to follow the division to which it is 
 attached. If this transportation of the wounded be 
 properly attended to, no wounded should be left by 
 night at the field infirmaries. 
 
 By not allowing an accumulation of wounded at 
 field infirmaries we avoid confusion, and prevent our 
 men from being made prisoners, should there be a re- 
 verse of our arms and an advance of the enemy upon 
 the site of our field hospitals. Should the ambulance 
 wagons not be sufficient to transport the wounded, 
 wagons, carts, carriages, and, in fact, every species of 
 vehicle, should be impressed from the neighboring in- 
 habitants, so as to ensure for the wounded a place 
 of safety and comfort. 
 
 If it be convenient for the wounded to reach the gen- 
 eral hospital within twenty-four hours from the recep- 
 tion of their injuries, many serious cases lor operation, 
 such as the resections, might well be deferred from the 
 field infirmaries until the wounded have arrived at the 
 station where that quiet and rest, with medical com- 
 forts, which are so necessary for a successful result, 
 can be obtained. When the wounded are brought to 
 the field infirmary they are not attended to in the or- 
 der in which they arrive. Those most seriously injured 
 always receive the earliest attention, officers and sol- 
 diers awaiting their turn. If the trivial accidents had 
 been dressed upon the field, they should pass directly 
 on toward the railroad or the general hospital, without 
 stopping at the field infirmary. 
 
 The common dressings which all gunshot wounds 
 receive is a wet cloth, covered, if possible, with a piece 
 of oiled sillc or waxed cloth, and secured with a single 
 turn of the roll of bandage. This keeps the wound 
 moist, and is the most soothing, comfortable, efficient, 
 and simple dressing which can be devised. By wet- 
 
154 rO BE LEFT WITH THE WOUNDED. 
 
 ting the outer bandage, the cold produced by evapora- 
 tion is transmitted through t<> the wound, while the 
 oiled silk keeps the parts moist. When oiled or itidia- 
 rubber cloth <:m not be obtained, and no facilil ies exisl 
 for keeping the wound constantly wet while the 
 patient in being transported to the general hospital, a 
 cloth well greased with olive oil is the best substitute 
 for the wet dressings. Many ragged wounds may 
 have their edges pared oil' and then brought together; 
 with every prospect of a speedy union, provided the 
 after-treatment with cold dressings is judiciously fol- 
 lowed. 
 
 It is understood that all those who can he conven- 
 iently moved, should he transported at the earliest 
 possible moment to general hospitals, established in 
 contiguous towns, should there be no facilities for 
 this transportation, or the serious character of the 
 wound render transportation dangerous, then any 
 
 in the neighborhood contiguous to tin" battle- 
 field must he used as a temporary hospital for the 
 treatment of such seriously wounded, whose safety de- 
 pends upon absolute quiet, rest, and careful nursing; 
 or tents can be pitched for the temporary accommoda- 
 tion of such patients. 
 
 Should the army ad vancc/t he regimental suigvons 
 must follow their com m and s. leaving either an assistant, 
 or an extra medical attendant for the wounded —it bo- 
 
 ing pretkimed that a reserve modicar^corps had been at- 
 tached 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 vwvy 
 preparation for the comfort and accommodation of the 
 wounded. Should the army unfortunately meet with 
 a reverse, all available means of transportation must 
 he pr08Sed into the service for the removal of the 
 
SURGEONS TO BE LEFT WITH THE WOUNDED. 155 
 
 wounded to the rear, and fchey must he sent off as 
 speedily as possible. If this had been attended to from 
 the commencement of the engagement, (here would In- 
 fewer to remove later in the day, when a retreat was 
 compulsory. No wounded soldier, whose injuries are 
 so slight that he can walk, should ever he carried, as 
 he takes up a place in the transport wagon which ex- 
 cludes one who can not assist himself. 
 
 There are many cases df injury to which long trans- 
 portation would be certain death. If the general 
 hospital can not 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 surgeons and competent nurses to look after their 
 wants. When left without surgeons, they arc always 
 neglected, and man}'' 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 
 especially urgent where the nations at war speak 
 different languages. The rule now. recognized in civ- 
 ilized warfare is, always to leave competent surgeons 
 with the wounded who are left to be cared for by the 
 enemy. Such surgeons and nurses being always con- 
 sidered as non-combatants by a civilized enemy, are. 
 allowed to return to their corps as soon at their 
 services can he dispensed with, without detriment, 
 to the wounded prisoners. 
 
 The following excellent advice is offered by Dr. 
 Millengen to surgeons who may be placed in such 
 trying conditions : ''When surgeons are thus placed on 
 duty with an enemy, they must bear in mind tliat the 
 welfare of our wounded will, in a great degree, depend 
 
SB DO Bl i.i ir WIN I THE WOUNDED. 
 
 upon 1 1n- propriety ofthoir conduct. No irritation of 
 mind from disappointment, n<> national feeling, should 
 induce there to enter into unpleasanl discussions. 
 They should especially endeavor to cultivate a friend* 
 ly intercourse with their medical brethren, carefully 
 avoiding altercations <>n professional points, in which 
 in- .st probably they may differ. A deviation from this 
 prudential course has often proved the soun 
 
 jealousies and animosities, from which the wounded 
 
 ultimately suffered. When the enemy's wounded are 
 numerous, and their surgeons are not in sufficient 
 numbers to attend to them, wo sho.ihl invariably vol- 
 unteer our assistance, should our duties afford us 
 leisure. Such a line of conduct is ever appreciated; 
 and can not tail to lead to ultimate reciprocal advan- 
 tages and good feeling."* 
 
 Article Ambulance, in Costello'a Cyclupajdia of Practical Surgery. 
 
CHAPTER VI. 
 
 
 The character op Gunshot Wounds — Orifices of ENTRANCE and 
 exit — Primary Hemorrhage — Natural II.ematosis — Tourni- 
 quets HUT SELDOM REQUIRE!* IN Surgery — HOW HEMORRHAGE I OH - 
 TROLLED — Examination of Wound for Foreign Bodies should 
 only ile done once, rut that thoroughly and as soon as possible 
 
 after the accident tl!e hlstory of the case important-- 
 
 Lodging Foreign Bodies always give trouble, even years 
 
 after injury gunshot wolnds do not require dilatation 
 
 Necessity of Examining 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 Gunshot Wounds ; its adyan- 
 tages oyer all other applications — Secondary Hemorrhage, 
 how- treated — General or Constitutional Treatment of Gun- 
 shot Wounds. 
 
 Appearance of Gunshot Wounds. — AVc have 
 already stated that the more perfect and destructive 
 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. From the 
 effects of a cannon shot weighing six hundred pounds 
 to the ounce ball of an Enfield rifle, a small fragment 
 of shell, or still smaller buckshot thai enters into the 
 musket cartridge, we see every possible variety of 
 wounds, both as to extent and severity, although die 
 cases of gunshot injury requiring treatment are usual- 
 ly from rifle or musket balls, or small fragments of 
 
 shell. 
 
 Large round cannon hall have nearly Itch discard- 
 cd from modern warfare, and the pyramidal piles 
 which forVnerl I nil arsenals have now 
 
158 At Ti.Ali.W'l-: OF GUNSHOT WOUNDS. 
 
 place i<> elongated shol and bolts of three times the 
 former weight of metal, which are ejected from rifled 
 cannon with frightful velocity and wonderful preci- 
 sion, whon even at a distance of nearly five miles. 
 When these huge missiles strike the trunk they cnt 
 the body in two, and wnon they impinge upon ;i limb 
 they sweep all resisting tissues before them in their 
 onward career, leaving an irregular, blackened pulpi- 
 fied Btamp, in which detritus of bonea and muscle, with 
 coagulated blood, form an amalgam of lifeless tissue, 
 which the surgeon must remove by amputation. 'The 
 torn blood-vessels, however large, do not usually bleed 
 in such n stump. A spent ball of heavy weight will 
 disorganize the subcutaneous tissues, crushing the 
 bones, although the tOUgh elastic skin may remain 
 
 unbroken. Extensive echimosis appearing after a tew 
 hours, indicates the severity of the injury. 
 
 Fragments of shell from ten and twenty pounder 
 
 guns, which are the calibre of field-pieces, make Xi'vy 
 ugly wounds; and where they do not impinge against 
 hone-, tear dow n the tissues, leaving extensive suppu- 
 rating surfaces which heal very slowly. When they 
 
 bury themselves in a limb, the wound which they 
 make is irregular, often elongated, and usually smaller 
 than the diameter of the fragment embedded. 
 
 The conical shot, with its excessive momentum, 
 tram-fixes the tissues with groat rapidity, usually pass- 
 ing directly through the soft parts, rarely burying 
 themselves, and when not impeded in their transit by 
 very resisting media, the two orifices of entrance and 
 
 exit which they leave vary hut slightly in their ap- 
 pearances. 
 
 The entrance made by a conical hall in the skin is 
 more or less oval, depending upon the contraction and 
 ret i action of t he skin, and sometimes, although rarely, 
 
^^^^ ORIFICES OF ENTRANCE AND EXIT. 159 
 
 it presents even a linear appearance resembling an 
 incised wound. When the conical ball, entering point 
 foremost, and meeting some resistance in its course 
 through tlie tissues, is either changed in form or is 
 turned upon its side, the orifice of exit is found very 
 large and irregularly torn, with the surrounding tis- 
 sues much bruised. 
 
 Balls, whether round or elongated, usually make an 
 irregularly rounded entrance, surrounded by discol- 
 ored, depressed, inverted tissues — these having been 
 evidently mashed or crushed by the ball prior to its 
 entrance, and the skin drawn in to a certain extent 
 with it. When the ball is moving with great velocity 
 the orifice of entrance may be more or less round, 
 with loss of skin, and the edges smoothly cut, without 
 depression or inversion of its margins. The tissues 
 around the orifice of exit are lacerated, usually more 
 or less protruding, and the orifice probably larger, and 
 more irregular than where the ball entered. These 
 two orifices are, however, modified in appearance by 
 so many circumstances — the form, size, velocity, ami 
 number of the missiles; changes in the missile after 
 its entrance into the body and prior to its escape; the 
 distance of the wounded person, his position, his cloth- 
 ing, foreign bodies winch 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 who saw the occurrence, it would be 
 difficult 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 re- 
 membered that, in entering, the tissues which are 
 being perforated are supported by the entire thickness 
 
 of the limb, SO that often (he |» ;l || appeals to have 
 
 carried before it a piece ■•( flesh which it had out out 
 
 
160 OR! KICKS OF ENTRANCE AND EXIT. 
 
 as by a 'lie, and hence the more or less rounded form 
 of this opening. After traversing the limb, in making 
 
 its exit, the tissues through which the hall is now 
 pushing have no support. They are stretched inordi- 
 nately before they arc torn, hence the oversion of the 
 edges and the flap-like lacerations of this exit, with 
 sometimes nothing more than a rent or split in tho 
 skin. Observing field surgeons have noticed that, in 
 examining recent wounds, the finger in passing 
 through the orifice of entrance traverses a compara- 
 tively smooth channel in the same direction with the 
 inverted tissues. When the finger, on the contrary, 
 is thrust in at the orifice of exit, a sensation of rough- 
 ness is experienced as the ends of the inverted tis- 
 sues are encountered. The direction of these inverted 
 tissues, like splinters of wood, all running one way, 
 can, by careful manipulation, be used- in recent 
 wounds to assist in establishing a diagnosis. En- 
 gorgement of the tissues will mask, and suppuration 
 completely efface, all traces of direction of the soft 
 filaments. If a bone has been shattered, the direc- 
 tion of the spiculse will always determine the direc- 
 tion of the missile, as they are invariably driven in 
 front of the ball. All who are familiar with the 
 driving of a nail through a board, or firing at the same 
 with a pistol, will see a rough working of this princi- 
 ple. These peculiarities are, at times, so stamped 
 upon the clothing that, by an examination of them 
 alone, a diagnosis can be established. 
 
 It is often of consequence to determine the character 
 of these apertures, so as to distinguish between a 
 traversed ball, with its two orifices, or two balls em- 
 bedded. It must not be forgotten that one ball may 
 make several openings, by the hall being divided in 
 the limb upon a sharp crest of bone. < 'ases are not 
 
FLATTENING OF BALLS. 1(51 
 
 very rare in which a portion of a ball may pass out, a 
 fragment remaining behind. A single ball, by splitting 
 in this way against some obstacle in the flesh, has been 
 known to break into six pieces, each in exit making a 
 corresponding wound. 
 
 In removing balls, whether conical or round, from a 
 limb, most frequently indentations are seen upon their 
 flattened sides — imprints of the opposing tissues which 
 had offered the greatest, resistance to their onward 
 progress. Very often are such balls irregularly mash- 
 ed, and sometimes completely flattened, as if beaten 
 out by heavy blows bet ween two hard plates. "When 
 impinging against an osseous spine, or even a tendon, 
 I have seen a ball which presented tho appearance 
 as if a wedged-shape piece, involving one-fifth of its 
 substance, had been cut out by some smooth, sharp 
 instrument; and I have also seen balls completely 
 divided by meeting a similar obstacle. It has been the 
 habit to account for these changes in form and the 
 mashing of balls by their striking upon some hard, re- 
 sisting body before entering the tissues — as a tree, a 
 wall, the gun of a neighboring comrade, etc.; but very 
 frequently we remove flattened balls from persons 
 when no such explanation can be accepted. In these 
 cases we are forced to seek other causes for this 
 flattening of the missile, which we can only explain by 
 an increased temperature in the ball, the result of 
 friction and heat transmitted from the ignited charge, 
 which renders the metal so malleable as to receive im- 
 pressions from comparatively soft bodies. Those who 
 have observed the moulding of bullets must often have 
 been struck with the little force requisite to cut off the 
 necks of a dozen at a time while warm in the moulds. 
 But let the ball cool, and the separation of a single 
 neck of lead from the round mass becomes a serious un- 
 
 N 
 
lt'.'2 DEVIATION OF BALLS. 
 
 derbaking, requiring a very heavy blew. May ool 
 this increased temperature of a ball alsoexplain other 
 phenomena connected with gunshot wounds, viz: the 
 
 burning sensation imparted by a ball traversing the 
 tissues, the sensitive nerves magnifying its tempera- 
 ture, etc. ? 
 
 Conical halls show much less deviation than round 
 halls. They usually take a straight course, ploughing 
 through all opposing structures — nothing resisting the 
 penetrating force of these projectiles. They seldom 
 follow the contour of bones, as the round often do, but 
 at once crush them — their double weight and increas- 
 ed velocity making many more fractures than the 
 round ball of former wars. This perforating proporty 
 of conical-cylindrical halls, which is now the common 
 form of rifle missile, depends more upon its moment urn 
 than its shape, which, when placed under the same 
 condition with a round ball, would be even more 
 likely to be diverted from a straight course by resisting 
 media. This divergence of conical shot is strikingly 
 exemplified in ricochet firing over water. The heavy 
 conical shot are found to be so readily diverted as to 
 destroy the efficacy of ricochet firing, which, with 
 round ball, is very destructive. On this account elon- 
 gated conical balls, from rifle cannon, arc only effec- 
 tive when fired directly at an object. When conical 
 balls are carelessly made, they assume every possible 
 position in their flight, and when fired at a target are 
 found to strike with their side as often as with the 
 point. 
 
 In spite of the rapid passage of even conical balls, 
 some of the tissues, through their toughness and elas- 
 ticity, often escape direct injury from them. Arteries 
 come under this head. Owing to their peculiar struc- 
 ture, cylindrical form, and loose connections, lying in 
 
SYMPTOMS OF GUNSHOT WOUNDS. 163 
 
 a bed of very loose, cellular tissue, which permits of 
 considerable movement, they often escape transfixion, 
 when their position lies evidently in the direct course 
 of the ball. Every army surgeon has seen numerous 
 oases of gunshot injuries about the root of the neck, 
 where balls had traversed, in every conceivable direc- 
 tion; in some cases antero-posteriorily — in others later- 
 ally — going deeply through the soft parts, yet picking 
 their way, as it were, with such care as to avoid the 
 great vessels among which the missile had channelled 
 its course. So great is this power of avoiding perfora- 
 tion in the large arteries, that rarely does death take 
 place on the battle-field from division of the large 
 vessels of the extremities by bullets. 
 
 Phenomena accompanying Gunsiiot Wounds. — It 
 has often been noticed by hospital surgeons that, under 
 treatment, wounds from certain battle-fields assume 
 peculiar phases, which, at other times and under other 
 circumstances, they do not exhibit. I have often 
 heard it remarked by army surgeons that the wounds 
 from the several battles before .Richmond, viz: those 
 of the 26th, 27th, 20th, and 80th of June, and 1st of 
 July — exhibited a marked disposition to slough; while, 
 those from other battle-fields would heal up with great 
 readiness, the majority of those sent into hospitals 
 not being retained more than a few da}'s. This con- 
 dition of sloughing, wit li its direful accompaniments 
 of secondary hemorrhage, etc., can bo traced to the 
 combined effects of many depressing causes. In those 
 wounded during the battles about Richmond, we find 
 a ready solution in the bad condition of the troops, 
 owing to the enervating influences of camp diseases, 
 viz: measles, typhus, and malarial fevers, etc.; added 
 to which, our troops were very badly clothed and badly 
 
1G4 HEMOBRHAQB IN 0UN8HOT WOUNDS. 
 
 fed, often subsisting upon one-quarter rations; the 
 weather very inclement, with continued rains \ and our 
 troops morally depressed, by being forced back by 
 overwhelming numbers t«> cover their capital; and, 
 crowning all, the exhausting fatigue of fighting day and 
 night for six consecutive days, pressing the enemy 
 continually forward, and encountering him successfully 
 in five Bevere battles. This combination of depressing 
 causes had a very marked effect upon the recuperative 
 powers of our wounded men. and eases of profuse sup- 
 puration, with pyemia, erysipelas, hospital gangrene^ 
 etc., filled the hospitals. 
 
 A certain amount of hemorrhage always accompa- 
 nies gunshot wounds; but, owing to the irregularity 
 ami the asperities of the sides of the wound favoring 
 the clotting of blood, we usually find that the external 
 flow, however excessive it may be for a short time, 
 soon ceases, while concealed hemorrhage, to a limited 
 extent, extravasates blood into the surrounding 
 tissues. When the divided blood-vessels are so closed 
 that the blood-cells can no longer escape, sorous oozing 
 still goes on. increasing the in tilt ration. These are the 
 causes of the rapid swelling which follows gunshot 
 wounds. When arteries of considerable size are not 
 injured in the passage of a ball, a very characteristic 
 
 appearance in gunshot wounds is the dryness of such 
 when contrasted with wounds produced from other 
 causes. This dryness depends upon the laceration of 
 toe tissues, assisted perhaps by an excited action in the 
 
 divided vessels, from the application of the heated hall 
 
 in transit — which, all bough it has nol a sufficient elcva- 
 
 tion of temperature to sear the tissues, would, neverthe- 
 less, stimulate the snnill vessels to con traction, even to 
 the closure of their divided mouths. Those arteries 
 
 which are divided hy a hall in rapid motion will bleed 
 
PAIN IN GUNSHOT WOUNDS. 165 
 
 more than those injured by a slow or spent ball, and 
 large vessels, when injured, will, of course, bleed more 
 profusely than the smaller ones, and the hemorrhage 
 from those partially divided is always excessive. 
 
 The pain which accompanies the reception of gun- 
 shot injuries is often so trivial, that the attention 
 of the wounded is only called to the fact by blood 
 streaming down the limb. McLcod mentions the case 
 of an officer who had both of his legs carried away, 
 and experienced so little pain that he only became 
 aware of the injury which he had received when he 
 attempted to rise. The majority liken the striking of 
 a ball to a smart blow with a supple walking-cane, or 
 a sensation of heat through the part struck ; while 
 with a few the pain is very severe, and simulates the 
 feeling which would be produced by running a red-hot 
 wire through the flesh. 
 
 It appears that every minshot wound is accompanied 
 by a certain amount of shock, which in some would 
 be scarcely perceptible, but in many is well defined, 
 and in serious cases of wounds very persistent. Im- 
 mediately upon the receipt of injury, the features 
 of the patient may indicate alarm. His face indicates 
 anxiety and distress. He looks pale, with colorless 
 lips ; feels cold, trembles, and complains of feeling taint, 
 with perhaps sickness of stomach and vomiting. His 
 pulse is feeble and quick, respiration irregular, and in- 
 terrupted with sighs; his skin cold and moist, sometimes 
 wet with a clammy perspiration ; the features seeming 
 to shrink from tie- contraction of the blood-vessels, 
 which are comparatively emptied of blood. Whether 
 this general shock be marked or not, there is in all 
 gunshol wounds, immediately alter their reception, a 
 
 lo<ai shock or partial paralysis of sensatjon — a numb- 
 which is nature's preparation, permitting a thor- 
 
166 NEB 
 
 ough examination with little or no pain. The unusual 
 quiet of a hospital 1 1 » « * night following a battle h 
 been repeatedly noticed, and is accounted for by this 
 nervous shock. When this condition passes off, then 
 reaction brings with it much Buffering. In this ner- 
 vous shock, with the suspension of activity in the 
 
 circulatory tin id ion, lies the Safety of many a wounded 
 
 . er. 1 1 influence is immediately felt in the injured 
 'tissues. A.s the heart's action is controlled and the 
 pulse very feeble, the vessels are not distended with 
 blood, and the infiltration and engorgement «>t the tis- 
 sues are prevented. When nervous depression exists, 
 luit 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. Before reaction ens;, 
 the riot ha- had time to form and to solidity, and has 
 become bo firmly established that it can not be dis- 
 placed. By the addition of a fibrinous secretion from 
 the capillaries, the injured vessels remain thoroughly 
 and permanently plugged up. and the dangers from 
 immediate hemorrhage are prevented. Shock may ac- 
 company a very Blight injury, ami may exhibit itself 
 in the most courageous and intelligent, so that it can 
 not always he attributed to alarm. < >n the other 
 
 band, a very severe wound may be unaccompanied by 
 any perceptible agitation. 
 
 The duration of this shock i- wvy variable —lasting 
 hut a lew minutes in most instances, and passing away 
 without medical assistance; in other cases persisting, 
 notwithstanding the internal use of stimuli and ex- 
 ternal application of warmth combined with stimu- 
 lating remedies. 
 
 When shock exists we try to ascertain the cause, 
 which a glance at the position of the wound will often 
 
IMMEDIATE ATTENDANCE IN GUNSHOT WOUNDS. 1G7 
 
 give us. If the cause appears trivial, the statement of 
 the fact, with a few cheering words, will reas- 
 sure the wounded man, and soon restore him to him- 
 self. Whore the depression is deeper and connected 
 with a serious injury, the course pursued is to admin- 
 ister a dose of morphine in a drink of brandy and 
 water. If conveniences are nt hand, it would be ad- 
 vantageous to administer the toddy hot. The patient 
 Bhould be, at the same time, covered with several 
 blankets or other warm clothing; pulverized mustard 
 or red pepper may be rubbed upon the legs and arms, 
 or plasters of the same substances extensively applied 
 upon the skin, or the limbs may be encircled with 
 bottles of hot water. The return of warmth to the 
 surface, and with it an improvement in the strength of 
 the pulse, is an indication that the heart will soon 
 have force enough to drive blood to the brain and all 
 parts of the body, to the relief of the patient and disap- 
 pearance of the symptoms of shock. 
 
 As the wounded soldier is always clamorous of hav- 
 ing his injuries attended to as early as possible, 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. Under such circumstances, wounds give 
 less trouble to the surgeon, less pain to the soldier, and 
 much better final results in treatment. All hasty 
 ags or examinations are to be deprecated, and 
 $ methodic pursued. The indications of treat- 
 
 ment, in all gunshot wounds, an — 1st. To control 
 hemorrhage; 2d. To cleanse the wound by removing 
 all foreign bodies; and, 3d. To apply such dressings, 
 and pursue such i rational course of treatment, as will 
 e.-t:iblish rapid cicatrisation. 
 
 lb morrhage, which product a such terror in the by- 
 
168 nKMunnnAOF. — now OONTRAOflD. 
 
 standera an<l anxiety in the patient, Bhould never un- 
 nerve the Burgeon, who requires all of his self]. 
 Bion and surgical tact to cope successfully with this 
 ebbing away of life. Fortunately, in gunshot wounds 
 serious hemorrhage is of rare occurrence; ami when 
 the largest arteries arc injured, as a rule they either 
 eease bleeding spontaneously, or the patient di 
 rapidly that art is of little avail, [n the Crimean war, 
 researches into the cause of death upon the battle-field 
 has given eighteen per cent, of the deaths to primary 
 hemorrhage from the large blood-vessels of the trunk. 
 If the case is not injuriously interfered with, the 
 natural haemostatics will often control the bleeding. 
 I n examining the table of ligation of arteries, it will be 
 seen how very few cases are reported as having been 
 operated upon for primary hemorrhage. In a con- 
 solidated table of all the ligations performed on tire 
 field, and reported by Burgoons to the surgeon-gen- 
 eral's office, during nearly three years of actual war- 
 fare, but two cases of primary ligation of the femoral 
 artery and one of the brachial artery are noted. The 
 ragged character of the wound, and the nervous shook 
 accompanying the injury, or brought on by the l< 
 blood, reacting upon the circulatory organs, so dimin- 
 ish the heart's impulse thai it drives little blood to 
 the extremities, which favors a stagnation of blood in 
 the wound. In those cases where the artery is Com- 
 pletely Bevered, the formation of a clot plugs up the 
 orifice in a bleeding vessel, and stops any further loss 
 
 ot hlo.nl. Where a large artery is but partially divid- 
 ed, the Vessel can not contract and retract, thereby 
 diminishing its canal, as is the case when the \ 
 is completely divided, and in such hemorrhage i.s 
 much more frequent ly fatal. 
 
 This spontaneous arrest of hemorrhage is usually per. 
 
ARREST OF HEMORRHAGE. 169 
 
 manent ; and, if the ordinary prophylactic couq^ is 
 pursued, of absolute rest and quiet, with the limb ele- 
 vated, no return shows itself. Should, on the conti-ary, 
 meddlesome surgery suggest the use of a tourniquet, 
 which cuts off the circulation, and especially the ve- 
 nous return, the limb soon swells, tissues become en- 
 gorged, excessive extravasation in the wound follows, 
 and a train is laid for future mischief. The field tour- 
 niquet, in former days, was so much in vogue that it 
 was considered indispensable on the battle-field, and 
 was, therefore, carried in large numbers, so as to be 
 applied to every limb from which blood was trick- 
 ling, or from which hemorrhage was feared. Now 
 they are nearly discarded from field service, and recent 
 experience, based upon the carelessness with which 
 they are used, recommends their abolition from the 
 field, as doing more harm than good to the wounded. 
 I'nless very tightly applied, they are of no service, as 
 they do not control the bleeding, and if firmly applied 
 they act as a general ligature around the extremity, 
 and can be used but for a short time without injury to 
 the limb. 
 
 lucent writers warn surgeons of the too hasty use 
 of haemostatics, and suggest that it is better for the 
 wounded t<> bleed, which will diminish the heart's pro- 
 pulsive force, than have the wounded tissues filled with 
 extravasated blood. 
 
 The free admission of air to the wound has also a 
 decided effect in hastening the clotting of blood, in 
 stimulating the open mouths of divided vessels to con- 
 traction, and thereby in controlling bleeding. In fact, 
 the free admission of air to a wound is classed among 
 our best hemostatics. Operating surgeons have fre- 
 quently noticed that when flaps are brought together 
 immediately after so operation, annoying hemorrhage 
 o 
 
170 ARREST OF HEMORRHAGE. 
 
 oc^^s within this sac. and, by its accumulation, 
 stretches the suturefl and makes tense the flaps. Tins 
 distension I »t-c-< > 1 1 1 i 1 1 ^r oxcessive, and threatening serious 
 consequences, the sutures are divided, the flaps opened, 
 and c-1' >ts of blood removed, when the bleeding vessel 
 will often so immediately close that it can noi be 
 found; nor will it again bleed. The same beneficial 
 effects are found in gunshot wounds. 
 
 If the hemorrhage be free, immediately after the 
 receipt of injury, the best mode of controlling it would 
 be the application of a ball of lint, a compress, or 
 sponge over the wound, secured by a bandage, which, 
 in closing the outer orifice, favors the formation of a 
 clot. If the hemorrhage is at all active, as from some 
 large artery, in addition to the compress on the wound, 
 the entire limb should be carefully enveloped in a 
 bandage, to some distance above the injury, so that the 
 pressure made upon the soft parts would diminish the 
 amount of circulating fluid in the limb, and prevent 
 the ingress of blood into the tissues. The haemostatic 
 properties of this dressing are very much increased by 
 soaking the sponge, or compress covering the wound, 
 
 with the porchlorido or persulphate of'ir which, as 
 
 a powerful astringent, when brought in contact with 
 fresh blood, will immediately form a clot. Either of 
 t hese preparations of iron poured into a wound, or the 
 injection of a solution of the perchloride of iron into 
 the wound, not using force enough to infiltrate the 
 tissues, is an excellent method of"establishing a solid 
 clot up to the very bleeding mouth <>f the injured 
 vessel. These preparal ions of iron are also used in the 
 form of powder, and are equally efficacious. A lump 
 of ice placed upon the compress will act with equal 
 vigor. A sponge or compress, tied on the bleeding 
 wound, with or without the iron styptic, is all that the 
 
ARREST OF HEMORRHAGE. 171 
 
 surgeon superintending the transportation of the 
 wounded is expected to do. 
 
 Unless the hemorrhage is very violent, threatening im- 
 mediate destruction of life J he tourniquet is rarely require,! . 
 All recent writers on military surgery recommend that 
 field tourniquets be dispensed with, as they are gener- 
 ally a useless, and often, when carelessly used, a dan- 
 gerous instrument, and our extensive experience has 
 not advancod their utility. They are still issued in 
 large numbers, and called for by army surgeons only 
 because they are upon the supply table for field ser- 
 vice ; but very few of them are ever removed from the 
 medical store-chest, where they remain as mementos 
 of a former practice. .Surgeons of large experience on 
 many bloody battle-fields have never seen it necessary 
 to apply them. The finger pressure of an intelligent 
 assistant is better than any tourniquet ever made, and 
 is a far preferable means of controlling excessive 
 hemorrhage, which (he compress and bandage may fail 
 to check. The femoral artery, for any injury to its 
 trunk or large branches, should bo compressed in the 
 groin where it runs over the pubic bone; the brachial, 
 where it pulsates against the head of the humerus, as 
 at this point its course is nearly subcutaneous. When 
 the position of these main trunks arc shown toany in- 
 telligent assistant, and he is made to recognize the 
 throbbing of the artery, he will have no difficulty 
 in keeping the vessel compressed during the transpor- 
 tation. Should the surgeon be doubtful of the exact 
 position of the vessel or the intelligence of his assist- 
 ant, the finger may be thrust into the depths of the 
 wound and be applied directly to the seat of injury in 
 the vessel, thus temporarily checking, and if sufficient- 
 ly long continue, i. often permanently controlling, the 
 bleeding. 
 
172 EXAMINATION OP Woiv 
 
 A- soon as the wounded arrive at the temporary 
 resting-place or field infirmary, where the Burgeons 
 are assembled, all bandages arc romovod, and the 
 wounds carefully examined. A glance at the wound/ 
 when tin- clothing has been previously inspected, will 
 often tell, when there an- two orifices differing in 
 appearance and in a direct line with each other, 
 whether foreign bodies have lodged or not. As the 
 patient is now taint from loss of blood ami from ner- 
 vous depression, the wound not yet being painful or 
 swollen, the surgeon, using his finger — which is the only 
 admissible />r<>hr. on such occasion* that the military 8Ufi> 
 gcon of experience recognizes — examines with it. if possi- 
 ble, the entire extent of the wound, searching tor 
 foreign bodies. Where the orifice is too small to admit 
 the index finger, the little finger will he found equally 
 serviceable, and by flattening the limb, by making 
 pressure upon the side opposite to and against the 
 finger, a much greater extent of the wound can ho 
 explored. 
 
 This examination is made without fear of reproduc- 
 ing hemorrhage, as the linger can not displace the 
 
 dots which hold firmly to the openings in tin' \ 
 Every surgeon has noticed how rudely a stump might 
 he sponged, and what force it requiroa to wipe away 
 clots which have formed over the far,' of a smooth, 
 incised, open wound. The adhesions are increased a 
 hundred fold by the irregularities of a concealed bullet 
 track. The finger finds no difficulty in entering a hole 
 through which a bullet has passed, if examined, as 
 every wound ought to be, before swelling has taken 
 plaec. 
 
 In examining fresh wounds, a silver probe will travel 
 in the direction given to it by the surgeon; and .08 
 
 most persons guide the probe instead of allowing the probe 
 
PROBING OF WOUNDS. 173 
 
 to guide them, the true course of a ball can only be de- 
 termined by it with great difficulty. It is but recently 
 that I saw a physician of experience, in seeking the 
 course of a. ball which had lodged in the thigh, pass the 
 probe, apparently without effort, among the muscles 
 quite across the limb, so that, the bullet wound being 
 on the outer side of the thigh, the end of the probe 
 could be felt under the skin on its inner side. When 
 the finger was introduced, it followed the track of the 
 ball at a very oblique course from the one which 
 the probe had taken. This example, which is only 
 one of the many of frequent occurrence, is sufficient to 
 show why military surgeons of expei-ience denounce 
 the silver probe, and distinguish by its use the tyro in 
 surgical practice. 
 
 In those cases only in which, from the small size of 
 the orifice made by pistol balls, the finger can not 
 be introduced, is a large bulbed ball probe, a female 
 catheter, or, lastly, an ordinary silver probe, used. 
 Elastic bougies have been recommended for the exami- 
 nation of extensive wounds, but they are apt to bend 
 should they meet an obstacle or irregularit}* in the 
 track, and when used for detecting foreign bodies do 
 not convey the same satisfactory information as do 
 metallic instruments. 
 
 The wound is examined from both sides, with the 
 double object of finding foreign bodies which may 
 have lodged, and seeing the proximity of the course of 
 the hall to the main arteries of the limb. It is a mat- 
 ter of importance to determine the condition of large 
 Vessels, whether they be injured or not, by examining 
 the degree of pulsation which they possess, as such an 
 injury would necessitate a morecareful after-treatment) 
 in order to prevent secondary hemorrhage. 
 
 In some cases the finger introduced into the opening, 
 
174 PROBING OP WOUNDS. 
 
 after passing through the skin and cellular tissue, finds 
 no further passage. This sudden arrest of the finger 
 would indicate either that the ball had been drawn oul 
 with the removal <>t the clothing, or thai the deep tis- 
 muscles, and aponeuroses have changed (heir re- 
 lations on account of changes in tin- position of the 
 limb. The track of ilie ball will not be discovered 
 until the former relations of the parts he resumed, by 
 placing the limb in the same position in which it had 
 received the injury, when the entire route of the hall 
 will he traced. 
 
 The inexperienced, readily deceived by the little re- 
 sistance met with in probing recent wounds, mistaking 
 muscular interstices for the trade of the hall, make 
 several false passages in their search for tin- foreign 
 body, and by their isolation or denudation of the parte 
 cause inflammation and add to the difficulties of further 
 examination. When the finger, buried in the wound, 
 shows that it is continued beyond reach, a hall probe 
 or silver catheter, introduced carefully and without force, 
 will often reach ami detect the foreign body. 
 
 In the examination of gunshot wounds, to detect the 
 presence of a hall, when, by the use of a silver hall 
 probe, a hard foreign body is discovered, but from the 
 depth of the wound and the little play of the bulb of 
 the probe, it is impossible to determine whether we 
 are feeling an exposed portion of bone or cartilage, 
 or have actually found the foreign body which we 
 are seeking, we can at once solve oar doubts and es- 
 tablish an accurate diagnosis by means of Nelaton's 
 probe, which differs from the ordinary hall probe in 
 having an unglazed porcelain bulb at its extremity. 
 When this bulb, buried in the depth of a gunshot 
 wound, reaches the suspected foreign body, it is only 
 isary to rotate it a few times against the hard 
 
PROBING OF WOUNDS. 175 
 
 mass and then withdraw it; when, if it has been 
 rubbed against a load ball, its surface will be blacked 
 by particles of the metal, which discoloration can 
 be produced by no other substance. This simple in- 
 strument is a triumph of surgical ingenuity. 
 
 Should but one opening exist, and the clothing 
 of the soldier covering the wound be torn, the proba- 
 bility is thai foreign bodies complicate the wound. 
 When two openings exist, indicating the escape. of a 
 ball, an examination should still be made, to detect, if 
 possible, the presence offoreign bodies, such as portions 
 of clothing, etc. 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 easily 
 mistaken for a clot of blood or the ragged lining of 
 the wound. This is particularly the ease when they 
 become saturated with the secretions. Forewarned 
 being forearmed, the surgeon, remembering these diffi- 
 culties, will examine with special care for these soft, 
 foreign complications. When found they should be 
 extracted, as their presence is certain to establish a 
 high degree of inflammatory excitement, with profuse 
 and long continued suppuration. 
 
 This effect was well shown in the case of a private 
 of the Second regiment of South Carolina volunteei'S, 
 who, during the attack on Fort Sumter, was shot by 
 the accidental discharge of a musket. The ball 
 entered the ch est at the anterior told of the armpit, 
 fractured the clavicle, and. after a course of nearly six 
 inches, was slopped by the tough skin over the poste- 
 rior portion oi the shoulder. The ball was readily de- 
 tected by the regimental surgeon, and. by an incision 
 through the skin, was easily removed. Inflammation 
 of a high grade having supervened upon the accident, 
 he was sent to the general hospital one week after the 
 
1 T « V PROBING OF WOURDB. 
 
 injury was received — at which time be was Losing from 
 
 three to four ounces of pus daily. On the day after 
 his admission, in examining the wound, I detected in 
 the shoulder wound sum*' substance resembling a 
 slough, and, upon extracting it, found a mass oi coal 
 pad, over two inches long and as thick as the finger, 
 which tent-like mass bad been driven into the wound, 
 and having been entangled by the irregular tissues 
 through which it had been driven, had been left 
 behind by the ball. An examination of his clothing, 
 made for the first time, showed a deficiency in the 
 lining of his coat, from which this mass had been torn. 
 The removal of this irritant diminished the discharge 
 immediately, so that, in the succeeding twenty-four 
 hours, the discharge diminished to one-sixth its former 
 quantity, and in four days was hardly sufficient to soil 
 the dressing. 
 
 The history of the case is of much importance in exam- 
 ining gunshot icounds, as often the course of the ball 
 can not be discovered without it. What surgeon, how- 
 ever great his experience, Seeing a wound made in the 
 arm by a ball, would think of looking in tin- opposite 
 thigh for its place of lodgement, did he not learn that 
 the injury was received from above, while mounting a 
 scaling-ladder, with arms raised above the patient's 
 head ? The ball entering the back of the arm near the 
 elbow, had passed down the arm under the shoulder- 
 blade, across the loin, and, traversing the buttock, had 
 lodged under the skin of the outer part of the opposite 
 thigh, where it was found and removed. 
 
 A ease in point was that of Private K\, 7th S. C. V. 
 regiment, who was shot in the neck at the Battle of 
 .Malvern Hill, June oO, 18C»2. J lis wound was consid- 
 ered trivial, and a furlough of thirty days granted, 
 lie came under my observation a lew days after the re- 
 
PROBING OP WOUNDS. 177 
 
 ccption of the injury with the neck very much swollen, 
 and a severe pharyngitis, with tonsilar enlargement 
 seriously obstructing respiration and deglutition. 
 The swelling on the back of the neck caused him to 
 cany the chin touching the sternum. A large orifice, 
 from apparently a minio ball, existed on the left 
 side of the neck, one and a half inches from, and on a 
 level with, the spine of the sixth cervical vertebra). 
 When the wound was probed it was found to traverse 
 the neck, running over without fracturing the spine of 
 the cervical vertebra?, and then to change its course 
 obliquely downward and outward. Profuse suppura- 
 tion soon came on, the pus burrowing under the right 
 scapula, caused, as was supposed, by some foreign body, 
 probably the ball, as there was but one orifice to the 
 wound. After some days of treatment an opening 
 was made on the right side of the back, above the upper 
 edge of the scapula, and the neighborhood thoroughly 
 explored. The subscapular region was found under- 
 mined and the neck of the scapula fractured, but 
 no foreign body could be discovered after the most 
 careful search. Suppuration continued profuse for 
 weeks, reducing the patient to the very last extremi- 
 ty, with extreme emaciation.* lie finall}' rallied, 
 thanks to a good constitution and good nursing, and 
 was at last sent home convalescent. In time an ab- 
 scess formed in the immediate vicinity of the elbow 
 joint, and a large ininie ball was extracted from this 
 situation. When he received his wound he was load- 
 ing his rifle, and was in the act of biting the cartridge, 
 with arm raised and face depressed. With this history 
 of the ease, the position of the ball could be readily 
 accounted for. 
 
 Knowing the direction from whence the ball came, 
 and the position in which the soldier was placed, you 
 
178 PROBING OF WOUNDS. 
 
 will auspecl the course whioh the ball would mosl 
 probabjy take; and your examinations in that direc- 
 tion will i k>! only save much time, but save the patient 
 much Buffering and annoyance. 
 
 The probing of wounds to find incarcerated kills 
 should be accompanied by a thorough and extensive 
 externa] examination of the surface, by running the 
 hand over the limb <>r trunk, pressing both lightly and 
 firmly, in order to detect any abnormal induration. 
 The position of balls is often discovered by palpation 
 alone, and in certain cases large masses of iron have 
 remained embedded in the soft parts unsuspected, 
 McLeod recorded a case from the Scutari hospitals, in 
 which a piece of shell, weighing three pounds, bad 
 buried itself in a soldier's leg, making so small an 
 opening that its presence was overlooked for three 
 months. Larrey reports a case in which a five-pound 
 hall buried itself in the thigh ; Begin a case of a nine- 
 pound ball; and Hennen one in which a twelve-pound 
 shot remained in the thigh, and was only discovered 
 alter death. Ae round shot are rarely used in modern 
 warfare, no such case has yet been reported from our 
 armies. For this examination the entire limb must 
 be exposed, and, in injuries of the trunk, the patient 
 should be stripped. Valuable assistance is often ob- 
 tained from the patient himself, who suggests, from 
 increased sensitiveness over a particular point, where 
 the ball might be found, or he may have detected the 
 ball by the sudden formation of a tumor where no hard 
 swelling had before existed. 
 
 Often the play of a muscle will shut oil' the track of 
 the ball. The relations of the soft parts vary with 
 vvrry position of the limb, and a passage made when 
 a limb was ilexed could not be followed when the 
 same limb is extended. Hence the necessity of plac- 
 
REMOVAL OF FOREIGN BODIES. 179 
 
 r 
 
 ing the limb in the same position in which it -was 
 when the injury was received. 
 
 The wound having been carefully examined by the 
 finger within and careful manipulations without, and 
 the foreign body detected, it should be at once re- 
 moved. This rule may nearly be considered absolute, 
 as all military surgeons place great weight upon its 
 accomplishment. The question is not so much wheth- 
 er balls can remain innocuous in the flesh, but do they f 
 Those who have had experience in the treatment of 
 gunshot wounds know how excessive is the irritability 
 caused by the presence of a ball in a wound; how 
 restless and irritable the patient is until it is removed ; 
 how profuse the suppuration and prolonged the period 
 of treatment in those cases in whidh it has been left ; 
 and how frequently the after-consequences aro so 
 distressing, the pain so permanent, and discharge so 
 constant, as to demand future interference, or make 
 life a burden. If such be the case with a ball, how 
 much more urgently is the extraction of other foreign 
 bodies indicated, especially fragments of shell, por- 
 tions of clothing, detached pieces of bone, etc. ? It is 
 only by carrying out this most urgent indication 
 in the commencement of the treatment that a number 
 of consecutive dangers, such as pain, inflammation, sup- 
 puration, gangrene, amputations, and even death, can 
 be avoided. 
 
 Balls may. in time, become encysted ; but even when 
 such occurs their presence, in after years, may set up 
 inflammation, which will mat together and bind dowti 
 important parts, whose usefulness depends upon frees 
 doin of motion. Repeated abscesses may form, press- 
 ure upon bones may give rise to ulceration and a 
 tedious exfoliation, blood-vessels may ulcerate, nerves 
 be painfully compressed, and life rendered miserable, 
 
180 DANQBR 01 INCARCERATED BALLS. 
 
 if not Jeoparded. Notwithstanding all that lias boon 
 written upon the innocuous character of balls embed- 
 ded in the flesh, for every instance in which they have 
 thus remained, without giving tr >uble, one hundred 
 (•an be exhibited Bhowing the great danger of foreign 
 bodies in the living tissues. Baron Larrey's experi- 
 ence showed that, as a rule, amputations are eventu< 
 ally necessary, after years of suffering, in those cases 
 in which halls have been left embedded in boneB. 
 [These remarks are equally applicable to all foreign 
 bodies, including spicube of bone. 
 
 In McLeod'fl Surgery of the Crimea, the report of 
 M. Hutin, chief surgeon of the Hotel des Invalides, is 
 given, which is a Btr iking commentary in favor of the 
 removal of all foreign bodies, lie reports that, of 
 four thousand cases examined by him, in which balls 
 bad remained embedded, ou\y twelve men suffered no 
 inconvenience; and the wounds of two hundred con- 
 tinued to open and close until the foreign body was 
 extracted. 
 
 The experience of the various hospital boards 
 throughout the Confederacy for the examination of 
 Wounded soldiers on furlough, will attest the impor- 
 tance of M. Hutin's remarks. Very rarely is a sol- 
 dier found returning to his regiment with a hall 1111- 
 extracted, and in those cases in which the position of 
 the foreign body escapes the careful examination of 
 the surgical stall', painful and often contracted limbs 
 are uniformly met with, rendering the patient totally 
 unlit for service. 
 
 When no doubt exists that a foreign body compli- 
 cates the wound, the Burgeon should neglect no pre- 
 caution to discover it. As a general rule, he will find 
 the examination facilitated by exposing the entire 
 limb. 
 
EXTRACTION OF BALLS. 181 
 
 It' the ball be felt loose in the soft parts, a bullet 
 forceps can be made to seize it; and it can be extract- 
 ed without difficulty, provided the disengaged hand of 
 the surgeon support the limb on the opposite side to th<tt at 
 which the forceps is introduced; otherwise, the ball glides 
 in front of the forceps and can not be seized. The or- 
 dinary bullet forceps, simulating the dressing forceps 
 of the pocket-case, was the instrument preferred by 
 Larrey, and is still in general use. Man}- changes 
 have been made in these, without advancing, to any 
 extent, the merits of' the instrument. An excellent 
 bullet forceps, which is the one now issued in the Con- 
 federate service, terminates with a sharp prong on 
 cither blade, at right angles to the blade, SO that, when 
 closed, the points are protected by the blades. These 
 ad as an axis upon which the ball may be rolled out 
 of the wound, instead of being drawn out, as with the 
 dressing forceps. 
 
 In my own experience, I havo found an ordinary 
 dissecting forceps, with toothed extremity, such as is 
 met with in all recent pocket-cases, the most conven- 
 ient instrument for extracting balls. The teeth, em- 
 bedding themselves in the lead, allow of firm traction 
 without fear of the instrument, slipping, which is so 
 constantly the ease when the common bullet forceps 
 is used. In removing a flattened ball, especially a 
 mashed minie ball, a good deal of force is often re- 
 quired to disengage and extract the irregular mass 
 from its bed in the soft parts. The long, ordinary 
 bullet forceps is an unnecessarily clumsy instrument) 
 made apparently with the belief that the ball will, in 
 every instance, be sought for through a long track of 
 Several inches, while rarely is this the case. The hall 
 i> usually found near the surface, and can he readily 
 removed by •■' Bhorl toothed forceps, which is much 
 more con\ unicntlv handled 
 
182 EXTRACTION OF BALLS. 
 
 Should the site of the foreign bod}^ be not at once 
 evident after the examination of the wound, the limb 
 should he carefully manipulated for some distance 
 
 from the wound. As the objeel of the examination is 
 to detect abnormal projections, the slightest elevation 
 should attract attention. When no projection is visi- 
 ble, palpation may detect a hard body at a great 
 depth in the tissues. The hand should, at first, be 
 run lightly over the surface, as light pressure would 
 expose the indurated spot, the site of a ball, when 
 well defined pressure would move the object, push the 
 ball back into its track, and cause its disappearance: 
 If the tissues are soft, the foreign body can be seized 
 between the fingers. If this be impossible, palpation 
 over the region, as for detecting fluctuation, will dis- 
 cover the hard, resisting, circumscribed body. Expe- 
 rience soon makes perfect in this kind of research, and 
 mistakes are rarely made. 
 
 In cases of long standing, when in doubt whether an 
 induration be a ball or a persistent deposit from pre- 
 viously existing inflammation, an enlarged lymphatic 
 gland, or a cartilaginous formation from an injured 
 and excited periosteum, I have found valuable aid to 
 diagnosis from the use of a fine cutting needle, such 
 as is used in couching or breaking up the lens in cases 
 of cataract. This very small sharp instrument can be 
 used upon any portion of the body, leaving no mark. 
 It gives little or no pain in transfixing the tissues, and 
 the sensation imparted by the point of the needle em- 
 bedding itself in lead is so peculiar that a surgeon,, 
 with experience in its use, can not be mistaken in the 
 diagnosis of an induration where the presence of a ball 
 is suspected. Should a ball have traversed a limb, as 
 it often docs, and its escape be resisted by the tough, 
 elastic skin which very often successfully inpedes (lie 
 further progress of the ball, it should be removed by 
 
EXTRACTION OF BALLS. 183 
 
 making an incision over its position, and not be BOUght 
 for, and drawn through, tin' entire length of the track 
 which it had traversed. 
 
 In removing subcutaneous foreign bodies, do not cut. 
 down directly upon them, as it will destroy the edge 
 of the knife — a sad accident in field practice, where no 
 conveniences exist lor putting instruments in order. 
 8teadv the skin over the supposed site by fixi&g the 
 prominence in situ between the thumb and index 
 finger of the left hand. A sharp-pointed straight bis- 
 toury held obliquely, the edge turned toward the 
 operator, is then thrust obliquely through the skin and 
 cellular tissue until it strikes the foreign body, when 
 the handle of the knife should hi' brought over toward 
 the operator, thus describing a segment of a circle, and 
 making a sufficient opening in the skin to allow of the 
 ready escape of the ball. 
 
 . If the ball is located in the vicinity of import ant 
 blood-vessels or nerves, and there is fear of injuring 
 important structures by a bold thrust, then the inci- 
 sion for its extraction must be made with more care by 
 a gradual dissection from without, dividing the tissues 
 layer by layer. 
 
 When a hall is firmly embedded in bone, it can be re- 
 moved by boring into it with a gimlet, which holds it 
 securel}-, and permits sufficient force being used for 
 dislodging it, or it may be cutout by using a trephine 
 or gouge. The latter instrument J have found par- 
 ticularly useful in opening a passage through bone, so 
 a- to permit the ready removal of an impacted ball. 
 
 After exposing a point of the foreign body, make the 
 incision to one side, or pass in a grooved director and 
 cut outward, when there will be no fear of doing harm 
 to the catting edge of the knife. 
 
 Biiudens, in noting the difficult}' of extracting these 
 

 l v l EXTRACTION OF BALLS. 
 
 subcutaneous Kails, ascribes it i<» a layer of cellular i la- 
 buo which lias been driven in front of the ball, and 
 which firmly and completely caps it. It is thin 
 enough to be nearly diaphanous, and yel tough enough 
 
 to clasp and hold firmly the Indict. This condensed cel- 
 lular tissue musi be completely divided. My own ex- 
 periencc corroborates thai of Guthrie, who says that 
 the diilicultics of extraction arc increased by tho Bur- 
 geon when fearful of making a tree incision. 
 in extracted with the least pain <m<l with great rapidity by 
 making </ bold incision. This course marks the differ- 
 ence bet ween civil and military surgeons ; half an inch 
 added to the incision does not increase its dangers, and 
 expedites materially the extraction. Be quite sure, 
 however, that yon are cutting upon a ball and not 
 upon some bony prominence, which comparison with 
 the opposite limb should warn you from. It is sulli- 
 cicnt to mention that such mistakes have happened to 
 military Burgeons. 
 
 By foreign bodies we mean halls, piecos of clothing, 
 Hjiicuhc of hone which have Keen broken off and are 
 in the wound, and any articles about the person 
 which may have boen driven before the ball. Those 
 should all bo removed immediately after the injury 
 has been received, and before swelling or infiltration 
 fenders the task difficult. When done early, the 
 
 wound will he found sufficiently largo to allow of easy 
 extraction without dilating. It is only when this 
 
 early a Mention 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. When a hall alone 
 
 complicates a wound, if it he nol readily found after a 
 careful and intelligent search, rather than continue 
 the examination from day to day, which can only be 
 
EXTRACTION OF BALLS. 1S5 
 
 prejudicial to the cage from the irritation and inflam- 
 mation which will be excited, it would save the sur- 
 geon much anxiety and the patient much annoyance 
 if the ball or other foreign body be left until suppura- 
 tion be well established. Then it will gradually expose 
 its situation, and can be much more readily removed 
 than during the height of reaction, when the parts are 
 very much swollen and very painful. The surgeon 
 will assist nature in the expulsion as soon as the swell- 
 ing baa subsided to such an extent that the finger or 
 the forceps can again be introduced into the wound. 
 
 The dilation of gunshot wounds, which was formerly 
 the constant rule of practice, is now altogether reject- 
 ed from military surgery, unless it be for the special 
 purpose of ligating a bleeding artery, or extracting 
 foreign bodies, including spicuhe, which could not be 
 otherwise readily removed without injury to the soft 
 pa lis. This old medical dogma was based neither 
 upon experience nor observation, and is now very 
 properly considered useless, injurious, and barbarous. 
 
 It often happens that, after repeated examinations, 
 the site of the ball can not be fixed, although we may 
 feel assured that it still remains embedded somewhere 
 in the tissues. Unless serious symptoms exist, as se- 
 vere and constant pain indicating pressure upon an 
 important nerve and leading us to suspect its position, 
 we are not justified in cutting down at random to look 
 for a ball. Unless we can locate with some certainty 
 the foreign body, it is a good rule not to attempt its 
 search. Tentative incisions usually fail of their 
 
 hould not be made. There i> no excuse lor grop- 
 ing about blindly, hoping to stumble upon a hall which 
 is hid away in the tissues. Unless we can feel the ball, 
 
 we niu-1 have \>vy strong iv;i > tor believing it lo- 
 
 : in any particular situation before resort is made 
 I 
 
180 HBMORaHAQK — HOW CO.NTHOLI.BD. 
 
 to the knife. Saving found a ball, it is equally our" 
 duty to remdve it. however important the parte anions 
 whirli it is located — as its presence, if left in the living 
 • b, always entails more Bertous trouble than the 
 dangers arising from the operation required for its re- 
 moval. At times su<h operations require all the -kill 
 of adepts in surgery toaocomplish Bafely the object; 
 hut this does not affect the established rulo: when a 
 /-./// can not be locaU </, nt m r opt rati for its r< moval unh bs 
 forced by the presence of serious symptoms, which map 
 tin-mien the life of the patient. Where a ball has, on the 
 contrary, been found, always extract it. 
 
 The above rules apply chiofly t<> gunshot wounds of 
 the extremities ; those of the trunk and head offer so 
 many exceptions to the above, and require, in a meas- 
 ure, Bnch Bpecial treatment, that the course to be pur- 
 sued in such wounds, complicated with foreign bodies, 
 will he specially dealt with in discussing special inju- 
 
 We have already Btated that fatal hemorrhage, from 
 tho large vessels of the extremities, does not often 
 OCCUr On the battle-fieldj and that when such arteries 
 
 are wounded, the hemorrhage is either so immediately 
 i'atal that no assistance can he rendered, or it ceases 
 spontaneously. The nervous depression so common 
 
 to seriOUS gnnshot wounds, with its tendency to -yn- 
 cope, and its control over the circulatory organs, 
 check- tie- impulse and supply of blood through the 
 injured vessel, and promotes the formation of clots. 
 Instances are reported in winch openings in arteries 
 have l»e. -ii temporarily closed by foreign bodies, and in 
 
 Buch oases hemorrhage had recurred when these had 
 been extracted. Cases are often met with in which 
 
 tin- largest arteries had heen wounded, and in which 
 
 bleeding ceased spontaneously. 
 
HEMORRHAGE — HOW CONTROLLED. 187 
 
 When hemorrhage ia not actually going on, or the 
 amount of blood lost has not been .Been, the only 
 means of detecting the injury of the large arteries of a 
 limb would be in examining carefully the strength of 
 pulsation in the vessel beyond the point of injury. 
 A diminution of its force when compared to that of 
 the corresponding vessel in the opposite limb, and 
 especially an absence of pulsation, shows conclusively 
 Bome hindrance to the circulation. The presence of 
 the pulse is, of course, no indication that injury has no! 
 been received. 
 
 Although from the course of the ball and the flow of 
 blood wo know that the main vessel of the limb has 
 born injured, if the bleeding has ceased spontaneously, 
 or by the pressure of the sponge or compress which 
 was tied over the wound, the artery should not be in- 
 terfered with. 7n by far the majority of cases, if proper 
 precautions be taken, there will be no recurrence of the 
 hemorrhage. The patient should bo kept perfectly 
 quiet, free from all causes of excitement, at perfect 
 rest, and, to ensure that the limb shall not be moved, 
 a bandage should be carefully applied from the ex- 
 tremity 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 sup- 
 port. Elevation of the limb will add much to the effi- 
 cacy of the preventive treatment. The accumulated 
 experience of field surgeons through all the campaigns 
 of this revolution, and their condensed reports of sur- 
 gery on the battle-field, will show how rarely is it 
 
 sary to ligato large vessels injured by the pa 
 of halls, and how successfully nature controls perma- 
 nently tin- hemorrhage from large artei 
 
 The ligation of an artery, which is the only sure pre- 
 caution again>1 the return of hemorrhage, is not only 
 
188 HEMORRHAGE — !lnW CONTROLLED 
 
 a difficult operati >n, requiring much skill for its 
 cessful performance. l>ut when necessary to control 
 the bleeding from a recent wound, becomes a very 
 dangerous one to the safety of the limb or lite of the 
 individual In casee of disease, nature, always on the 
 
 has enlarged oontiguoas blood-vessels, which are 
 ready to assume all the functions of the one requiring 
 obliteration. In a wound in a healthy person no such 
 preparation lias been made; and in cutting off the 
 main supply of blood through a limb, it becomes a 
 \<ry serious question, often answered by the 1"-- of 
 the. limb, and even life, whether the circulation will bo 
 
 ablished in time to save the member from morti- 
 fying. When a ligature is placed upon the main 
 artery of a limb for disease, previous developments in 
 the collateral circulation have been made to such an 
 extent that the extremity may not even lose tempera- 
 ture after the ligation, and as there is no diminution 
 of the nutrient supply there is no fear of mortification. 
 If placed on a healthy vessel for an injury, the limb at 
 oine becomes pale and cold, requiring the application 
 of artificial warmth and enveloping in flannels to sup- 
 port life in it until the circulation be re-established, 
 when the limb becomes actually warmer than its 
 colleague, because the supply of arterial blood is uow 
 disseminated in vessols much nearer to the surface, 
 while before its chief channel was deeply embedded in 
 i he i issues. 
 
 The rapidity of this collateral development in the 
 
 limit is well exhibited in primary and secondary am- 
 putations. When a thigh is amputated in a healthy 
 
 portion, xevy seldom are there more than three 01' four 
 
 Ligatures required to stop all oozing and lender the 
 stump quite dry. [f the amputation be necessary :it 
 
 ime point four or live days after an injury to the 
 
LIGATE BOTH BLEEDING ORIFICES. 189 
 
 main vessel has been received, the number is greatly 
 increased; as many as twenty-eight arteries having 
 been Ligated by Langenbeck after amputating a thigh 
 under similar circumstances, 
 
 Should active hemorrhage continue, and show no 
 disposition to cease, or the quantity of blood flowing 
 from the wound indicate speedy death unless the hem- 
 orrhage be slopped, the wound should be dilated, the 
 bleeding mouths of the artery found, and a ligature 
 applied both above and below the injury. This has be- 
 come the established 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 observation, but could be deter- 
 mined a priori from the physiology and anatomical dis- 
 tribution of arteries. 
 
 All surgeons are familiar with the anastomosis or 
 collateral circulation in blood-vessels. When the cur- 
 rent of blood, flowing through a main vessel, is stopped 
 at any one point, it will soon find its way, by retrac- 
 ing its steps through man}- circuitous routes, until it 
 comes in from below, and thus back to the very point 
 at which its direct course had been checked. When 
 an artery is divided, it it well known that, owing to its 
 muscular and elastic structure, that portion above the 
 wound at once contracts and retracts, so that the tube, 
 which was before cylindrical, now resembles, in form, 
 a claret bottle with a much constricted neck at the 
 point wounded. A clot of blood soon forms in this 
 mouth and neck-, and the further escape of blood 
 through lliis opening is intercepted. In the lower 
 port ion of the divided vessel similar changes are going 
 
 on, bui not to go great an extent. The contraction 
 (owing to the severing of the nerves which run upon 
 and between the coats of the vessel, and which give 
 
L1GATE BOTH BLEEDING ORIFICES. 
 
 tone to the arterial walls) is only partial, the walls be- 
 ing to a certain extent paralyzed, and so little blood 
 remains in the tube tbat 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 por- 
 tion remains patulous, inviting hemorrhage. As soon 
 as the blood-currents find their way by circuitous 
 channels to the lower portion of the injured vessel, it 
 wells up from the wound in a continuous purplish 
 Stream, all impulse having been lost, and also most of 
 the oxygen contained in the blood, by the long, round- 
 about way which the circulation now takes. The 
 darkness of the blood will depend upon the difficulties 
 of the circuitous passage; the rule, however, is : scar- 
 let or arterial blood from the upper end of the vessel, 
 blood more or less dark colored or venous from its 
 lower end. It must be remembered, however, from 
 what has been just said, that the color of the blood in 
 secondary hemorrhage is no criterion of the kind of 
 vessel from which it flows. 
 
 Guthrie lays down the two following rules as the 
 great principles of surgery, to be observed in the cases 
 of wounded arteries, and which ought never to be 
 absent from the mind of the surgeon : 
 
 1. That no operation ought to be performed upon a 
 wounded artery unless it bleeds. 
 
 2. That no operation is to be performed for a wounded 
 artery, in the first instance, but at the spot injured, unless 
 such operation not only appears to be, but really is, 
 impracticable. 
 
 These two aphorisms are the more particularly ap- 
 plicable to recent wounds of arteries, as we will have 
 occasion to mention exceptions to both of these rules 
 when discussing the modified conditions of the wound 
 
LIGATION OF BLEEDING VESSELS. 191 
 
 and wounded in reference to cases of secondary hem- 
 orrhage. 
 
 When it is necessary toligale ail artery, the surgeon 
 must be guided, in finding it, by his anatomical knowl- 
 edge, and also by the pulsation. Tn dilating the wound 
 so as to expose the bleeding mouths, the incisions 
 should be made parallel to the course of the vessel, and 
 Sufficiently free to facilitate the search. The dissec- 
 tion is carefully conducted, dividing layer by layer, 
 and avoiding the nerves and veins which always ac- 
 company the largo arteries. When the bleeding 
 mouth is so exposed that the origin of the jet of blood 
 is seen, the vessel is transfixed by a tenaculum, drawn 
 out, and secured as it would be in a stump after am- 
 putation. 
 
 Where it is impossible to ligatc the bleeding vessel 
 at the point wounded, a point should bo selected, at 
 which the vessel is comparatively isolated, easily dis- 
 covered, and free from large collateral branches. In 
 exposing it, make a free incision. The common error 
 that most surgeons commit is in making a small inci- 
 sion, which hampers the search. When we approach 
 the artery, use the grooved director to isolate those 
 cellular layers in which the vessel is always found. 
 The point of the knife should never be used for this 
 purpose. The lips of the wound should be drawn 
 asunder by an assistant, so as to give to the operator 
 the light necessary for accomplishing, speedily and 
 successfully, the ligation. In all cases requiring such 
 an operation, it is desirable to have the patient com- 
 pletely under control, and, therefore, chloroform 
 should be administered. 
 
 When the artery is found and the ligature passed 
 
 under it, before tying it be quite sure that it is the 
 
 I, and it alone, and not the nerve, that has been 
 
192 LOCAL TREATMENT OF WOUNDS. 
 
 seized. To be satisfied on this point it is only neces- 
 sary to draw slightly upon the thread, and examine 
 above and below it to see whether the pulsation has 
 altogether ceased below the ligature. Having deter- 
 mined that the thread is properly placed, it is then 
 firmly tied. The ends are brought out of the wound 
 and secured under a strip of adhesive plaster, attach- 
 ed to the immediate neighborhood of the wound. 
 This mode of disposing of the ligature will protect it 
 from becoming entangled in the ordinary dressing, and 
 from being drawn upon when those are daily removed. 
 Water dressings form the proper after- treatment. 
 The thread will come away spontaneousl}', by the 
 eighth, twelfth, or sixteenth day, according to the size 
 of the vessel ligated. 
 
 Local Treatment of Wounds. — Having removed all 
 foreign bodies, and hemorrhage having ceased, the 
 dressing now required should be of the simplest de- 
 scription. It is known that gunshot wounds, belong- 
 ing to the contused variety, show a constant disposition 
 to suppurate, and often to slough. This process of sup- 
 puration is not necessary to the healing of the wound, and 
 should be kept in subjection as much as possible. This is 
 effected by the continued application of cold water, 
 which, by keeping down excessive reaction, and keep- 
 ing out an excess of blood, diminishes the source of the 
 purulent supply, and thus hastens the cure. In former 
 times, suppuration was considered essential in the 
 healing of all wounds, by permitting the escape of 
 so much poisonous matter, which had accumulated in 
 the system, and which must either now find a vent, or, 
 if retained, would be considered the satisfactoiy cause 
 of any sickness from which the wounded man may 
 hereafter suffer. The wound was, therefore, under this 
 
WATER DRESSING! FOR WOUNDS'. 193 
 
 exploded belief, plugged with a tent, piles of greasy 
 lint in cushions were applied, and, after covering with 
 a sufficient number of compresses and bandages, a 
 forcing bed was formed, which supplied pus to the 
 satisfaction of all interested. It was common enough, 
 under such treatment, to sec life drain away from this 
 opening. 
 
 This smothering of wounds in hot poultices, ffhd the 
 smearing on of greasy ointments, which the wounded 
 formerly encountered, was a second enemy, far moro 
 fatal than the enemy on the battle-field — as in its 
 ranks were found exhausting suppuration, with its 
 hectic; pyeemia, with its vapid poisoning; hospital 
 gangrene, with its fatal collapse, and erysipelas, with 
 its thousands of victims ; broken-down constitutions, 
 tedious convalescence, and very protracted cures, with 
 endless pains and annoyances. 
 
 How much moro rational is the present practice! 
 Keep away all hot dressings, which invite blood to the 
 part. Vote poultices and greasy pledgets a curse, and 
 eject the dirty, troublesome applications. Guthrie 
 says poultices should not be permitted in a military 
 hospital ; they are generally cloaks for negligence, 
 and sure precursors of amputation in all serious inju- 
 ries. With more recent writers they even meet with 
 less favor, and the very extensive experience of the 
 Confederate hospitals confirms this opinion. 
 
 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 extend over a con- 
 siderable surface. If possible, cover this with a layer 
 of oiled silk, waxed cloth, or india-rubber tissue. A 
 second layer of cloth or a band secures the two former 
 layers in position, so that they will not be displaced by 
 Q 
 
194 WATER DRESSING FOR WOUNDS. 
 
 tho movements of the patient in sleeping. Then 
 either squeeze cold water frequently upon this outer 
 cloth, which will keep up the low temperature; or 
 adopt the much more convenient and less laborious 
 plan of suspending a bucket, or some vessel contain- 
 ing water, in the neighborhood of the wound, having a 
 narrow slip of cloth, or, what is better, a lamp wick 
 passing through a hole in the bottom of the suspended 
 vessel to the bandage upon the wounded limb. By ca- 
 pillary attraction, a constant stream of water is car- 
 ried from tho vessel to the dressing, and, by its evapo- 
 ration — robbing the skin of its animal temperature 
 to get a sufficient quantity of heat to convert the 
 Avater into aqueous vapor — refrigerates tho limb. Tho 
 wick must run freely through the hole, but not too 
 loosely, or tho water will flow out too rapidly. If 
 it passes through snugly, so as to block up the orifice, 
 capillary action will not draw oft' the water, and tho 
 parts will not be irrigated. The advantage of using 
 oiled silk, waxod cloth, or india-rubber tissue is, that 
 should the supply of water accidentally give out in the 
 suspended vessel, as it frequently would do, from inat- 
 tention of nurses, the picco of cloth beneath it remains 
 moist upon the wound. The wet cloth absorbs tho 
 discharges, and should bo changed two or three times 
 a day, it being well understood that they be disturbed 
 as seldom as possible, compatible with cleanliness. 
 
 At a very recont meeting of the society of army 
 surgeons, held at Richmond, the subject for discussion 
 being the use of cold water dressings in the treatment 
 of gunshot wounds, with but very few dissenting 
 voices, unanimous assent was given to the judicious 
 use of cold water as the only proper local application 
 for wounds. Tho past two years in the Confederate 
 hospitals have given more extensive opportunities for 
 
WATER DRESSING FOR WOUNDS. 195 
 
 testing the advantages of water dressings than had 
 ever previously been offered since the introduction of 
 this mothod as a remedial agent. The wounded who 
 have been brought under its happy influences can 
 be numbered by tens of thousands, and the magic 
 effects of this dressing, when judiciously used, and the 
 consequent high esteem in which it is deservedly held 
 by all army surgeons, has established, above all cavil, 
 its superiority over all other dressings. 
 
 Like all good remedies, it is capable of much abuse, 
 and yet it is so simple, and even when misused, doing 
 Comparatively but little mischief, that its application 
 has been put into the hands of every wounded patient. 
 In applying it judiciously, it is not necessary to have 
 the patient swimming in water. When the wound ex- 
 ists upon the limbs, the bod can be so arranged that tho 
 water as it is conveyed to the wounded will, when 
 it has refreshed the patient by its cool temperature, run 
 off into some receptacle, without spreading over tho 
 bed and wetting all the clothing of tho patient. A 
 piece of oiled or india-rubber cloth is usually placed 
 under the wounded limb to protect tho clothing of tho 
 bed and patient. When the wound is seated upon the 
 trunk, it would be dangerous as well as very annoying 
 to tho patient to have a stream of water running over 
 his person; therefore cloths, rinsed frequently in 
 cold water, to be changed as often as they becomo 
 warm, takes the place of irrigation, and is the proper 
 method of applying cold water dressings. Cold wa- 
 in- applications are advantageously applied to wounds 
 immediately after they have been received, and are 
 only contraindicatcd by oxisting shock. As long as 
 marked nervous depression is present, cold applica- 
 tions would tend to increase this serious complication ; 
 nor are there any indications for its use under these 
 
11)6 WATER DRESSING FOR WOUNDS. 
 
 circumstances, us there would be neither hemorrhage 
 to be checked, pain to be soothed, nor nervous irrita- 
 tion and vascular excitement to be controlled. It 
 is only when reaction is being established that the ad- 
 vantages of cold applications bocoine apparent. In 
 cases where nervous shock does not accompany the 
 injury, cold water can not be applied at too early a 
 period to wounds. 
 
 The surgeon should never be in haste to change t/tecoid 
 for warm applications. Should, however, in the course 
 of treatment, the virtues of a poultice bo called into 
 requisition, a soft, wet compress, covered with oiled 
 silk or india-rubber tissue, and secured by a flannel 
 roller or outer compress, will be found to combine, in 
 a simple form, all the properties of a poultice. It is 
 light, moist, soft, and is kept warm by absorbing ani- 
 mal heat, which the oiled silk and outer compress 
 retain. If wo add to these properties cleanliness, fa- 
 cility of medication, and the readiness with which an 
 impromptu dressing can be made, we find an array of 
 advantages which exclude all substitutes. 
 
 A more effectual mode of keeping down reaction is, 
 b} T using ice bladders, which are placed upon the india- 
 rubber, waxed, or oiled silk covering. These arc 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 compresses, which may be made suffi- 
 ciently thick to accommodate the application to the 
 sensitiveness of the patient. When possible, these 
 bladders should be of india-rubber or gutta-percha, as 
 such materials are impermeable to water and permit 
 of water applications for the reduction of temperature, 
 at tho same time keeping the body and bedclothing 
 dry — a very great desideratum. A large supply of 
 
ADVANTAGES OF WATER DRESSING. 197 
 
 those should always he 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 constantly wot, but the bladders soften 
 and decompose, becoming very offensive, and arc soon 
 destroyed. 
 
 Cold water is the only proper and universal antiphlo- 
 gistic that can be applied to wounds. It has the conven- 
 ience of always being at hand, it keeps up a uniform ac- 
 tion, is clean, simple, cheap, agreeable to the feelings 
 of the patient, easily obtained, easily applied, demands 
 least care from the nurses, who have their hands 
 usually full, and is withal effectual. With the judicious 
 application of cold water the surgeon can defy inflamma- 
 tion. Cold acts by keeping down temperature and 
 constringing vessels, thereby keeping blood from the 
 part injured; so that inflammation, which consists in 
 the engorgement of blood-vessels and an excessive 
 supply of blood, can not gel a foothold. Heat, redness, 
 pain, and swelling, all depend upon congestion ; con- 
 trol the supply of blood to a part, and inflammation is 
 kept in abeyance. It also acts directly upon the ner- 
 vous element of the tissues, by its local sedative effect, 
 blunting sensibility, allaying pain, removing irritation, 
 and thereby the excitement in the circulation. 
 
 As the advantages of cold water dressings are ob- 
 tained through the evaporating properties of water, 
 this action may bo increased by medicating it with sa- 
 line substances or alcoholic tinctures. Sugar of lead, 
 sulphate of zinc, tannin, muriate of ammonia, lauda- 
 num, spirits of camphor, and especially tincture of 
 arnica, would be useful adjuvants. Some surgeons 
 consider any addition as detrimental to the efficacy of 
 simple water; but. unfortunately, simplicity is but 
 little in accordance with the popular taste. 
 
198 ADVANTAGES OF WATER DRESSING. 
 
 While the irrigation is going on, the compresses 
 next the Bkin may bo moistened every three or four 
 hours with any of the above preparations. There arc a 
 few persons to whom the application of cold water is 
 inadmissible. In every ease the feelings of the patient 
 will 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, with tenden- 
 cies to chilliness, the irrigation must be superseded by 
 a wet compress, covered with oiled silk or a waxed 
 cloth. This will soon attain the temperature of the 
 body, and will keep the parts moist and soft. The 
 dressing requires to be changed three or four times in 
 twenty-four hours; not that the compress would get 
 dry, for the perspiration from the part, and discharges 
 from the wound, which are kept in by the oiled silk, 
 would bathe it in a continual and permanent moisture. 
 The object in renewing the wet cloths is to get rid of 
 these secretions, which, in decomposing, would irritate 
 the wound. 
 
 A question of great moment is, token should we desist 
 from water applications, and change for some more useful 
 or appropriate dressing? According to the present 
 rational views of surgeons, no other drossing is over 
 required, however serious the wound may be. As 
 long as inflammation threatens, so long is it necessary 
 to prevent engorgements. As long as suppuration is 
 kept up, so long will the efficacy of cold be required to 
 constringe the blood-vessels and control the source of 
 the purulent supply. 
 
 Pus, which we call a healthy fluid, is a heavy drain 
 upon the system. It is made from the richest ingredi- 
 ents of the blood, which were intended for the repair 
 of tissues. Once converted into pus, it is unfit for any 
 further useful purpose, and is, therefore, a waste of 
 
ABUSES IN COLD WATER DRESSING. 199 
 
 precious material. This discharge is not more neces- 
 sary to the healing of wounds than to the nutrition of 
 tho body. Extensive wounds, healing by the first 
 intention, do very well without its intervention. 
 Large subcutaneous wounds, when even their sides 
 are not kept in apposition, heal with rapidity without 
 the formation of pus. Under a scab we find tissues 
 form, by what has been called the remodelling process, 
 without it; and it should be our constant effort to 
 lieal all wounds, and I' would say, especially gunshot 
 wounds, with the least possiblo discharge. Hence the 
 water dressing can be continued beneficially for weeks, 
 or as long as the wound remains unhealed. Our ex- 
 perience in the treatment of gunshot wounds, which 
 accords with that of most army surgeons, is that the 
 wet cloth should be kept on until cicatrization is com- 
 pleted; and that no other application so protects and 
 promotes the formation of new skin. 
 
 I would, however, call attention to a general cause 
 of annoyance in the use of water dressing. The main 
 object of the cold water application is to prevent or 
 control inflammatory action in the wound and its vi- 
 cinity. Whenever all the sj-mptoms of inflammatory 
 excitement, viz: heat, redness, pain, and swelling — 
 have subsided, leaving a wound which suppurates but 
 little in a limb of normal size and appearanco, the ap- 
 plication of cold water, by irrigation, has fulfilled its 
 duty, and is no longer beneficial. If the entire sia*- 
 face of the limb should now be kept enveloped in wet 
 cloths the skin becomes irritable, tho sebacious folli- 
 cles take on suppurative inflammation, and crops of 
 very annoying boils, accompanied by interminable 
 itching, Bucceed each other with persistent regularity^ 
 until the dressing is changed. When the symptoms 
 of inflammatory excitement have disappeared from 
 
200 MEDICATED WATER DRESSING. 
 
 the wound, which i'n simple gunshot wounds is usual- 
 ly about the tenth day, instead of continuing tho 
 water dressing over a large surface of the limb, con- 
 fine its application to a small compress over and im- 
 mediately around the wound; cover this with a piece 
 of oiled silk, only a little larger than the compress, 
 and secure both in position by a bandage — the wet 
 cloth to be renewed two or three times a day. The 
 oiled silk keeps the cloth moist, preventing the secre- 
 tions from drying and forming a hard, painful crust 
 over the wound, which, by retaining the secretions, 
 would become the cause of pain. By retaining the 
 moisture it also prevents the cloth from adhering to 
 the edges of the wound, and thereby not only saves 
 the patient much pain at the renewal of the dressings, 
 but avoids the injury to the granulations. This is re- 
 cognized, after the removal of dressings carelessly 
 applied, by the bleeding from the surface, and more 
 particularly the edges of the wound, where the new, 
 delicate skin is forming, and which, if rudely torn day 
 after day by cloths adhering to the wound, will cause 
 it to take on an irritable or indolent condition which . % 
 is averse to healing. 
 
 There are a long list of ointments which have here- 
 tofore held universal sway in the treatment of wounds, 
 among which simple cerate is the most conspicuous. 
 Although this is a simple and innocent preparation, 
 as its name indicates, and is extensively used in the 
 army as an application to chronic wounds, even this 
 can be dispensed with for the more simple water 
 dressing. Should the wound require stimulation, the 
 nitrate of silver wash, grs. xx to the ounce, when 
 brushed over the part, will suffice; or tincture of 
 iodine, or iron, or some stimulating astringent, might 
 be equally applied in addition to the water dressing, 
 
DISTURBING INFLUENCES OF WOUNDS. 201 
 
 so that any imaginary condition of the wound might 
 be successfully met by the medicated wet cloth. 
 
 The disturbing influences in the healing process of 
 wounds are numerous, and most of them are capablo 
 of correction without much trouble. Among these 
 arc found imperfect transportation over rough roads 
 in improper vehicles ; bad attendance, including rough 
 or too frequent examinations; useless and excessive 
 bandaging, which promotes infiltration; too frequent 
 dressing; improper food; scorbutic, syphilitic, and 
 other diseases; the moral depression of defeat; and, 
 above all, imperfect ventilation and insufficient regard 
 to cleanliness, and over-crowding in the wards of mili- 
 tary hospitals. 
 
 We have already said that a surgeon is never war- 
 ranted in cutting down upon an artery and tying it 
 upon suspicion; he must be an e} T e-witness of the 
 hemorrhage, and see that it can not be controlled by 
 other means. The ligation of an artery is always a 
 troublesome operation, and, from the fear of subse- 
 quent mortification, always jeopards the limb, and 
 necessarily with it the life Of the patient. This is 
 especially the case in recent wounds, before nature 
 has prepared a collateral circulation; so that the rule 
 which we have laid down is imperative, as far as it 
 relates to recent wounds — never ligate an artery, how- 
 ever large, in which hemorrhage has spontaneously ceased. 
 Moreover, 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 
 vessel; and position, quiet, rest, and other prophylac- 
 tics, will most frequently prevent its return. 
 
 It has often happened that, after an injury had been 
 inflicted upon an artery of large size, the rapid flow of 
 blood from the wound had brought on syncope, which 
 
202 CONTROLLING PRIMARY HEMORRHAGE. 
 
 was more or less prolonged, followed by nervous .shock 
 and a depressed condition of the nervous system of 
 considerable duration. It is under such influences, 
 controlling all activity in the circulation, that the 
 bleeding ceases spontaneously and clots of blood form. 
 Should a person suffering from such an injury be not 
 disturbed by rough transportation, nor be too freely 
 stimulated, the blood forms firm clots, which may 
 close up the orifices in the injured vessel, and become 
 so blended with the tissues as not to be displaced, and 
 no further trouble ensues. It is on this account that 
 the unavoidable delay of removing the seriously 
 wounded from battle-fields becomes a blessing. In 
 running over the field after a severe battle, those 
 who, from loss of blood, have not the strength to cry 
 for help, are left as mortally wounded by the mem- 
 bers of the ambulance corps, who are busily engaged 
 in carrying to the infirmary those whom they think 
 require immediate attendance, and are likely to be 
 benefited by treatment. When all of these have 
 been removed, the battle-field is again gleaned for 
 such as may be found alive after, perhaps, an inter- 
 val of from twenty-four to forty-eight hours. The 
 quiet of the battle-field has supplied to the severelj- 
 wounded such treatment as they required, ami under 
 judicious care these cases often do well. Should such 
 wounded be disturbed soon after the flow of blood 
 had ceased, and be transported to the infirmary or 
 general hospital, and especially if brandy be freely 
 given to bring on reaction, the excitement which the 
 pulse would exhibit, and the increased force of the 
 heart's action, would displace the clots before they be- 
 came firmly established in the site of the wound, and 
 hemorrhage would reappear. 
 
 This renewal of the bleeding, as a variety of consec- 
 
SECONDARY HEMORRHAGE. 203 
 
 utive, is- called retarded hemorrhage, and is simply 
 a continuation of the primary hemorrhage, after an 
 interval of a few hours' suspension, before the artery 
 and surrounding tissues have undergone any material 
 changes. Although a ligature upon the bleeding 
 mouths of the vessel in the wound may be necessary 
 to arrest this bleeding, when excessive and threaten- 
 ing the life of the wounded man, as a rule judicious 
 pressure and the use of styptics are found adequate 
 for its control. 
 
 In the ordinary course of gunshot wounds, suppu- 
 ration is established about the fifth or sixth day, when 
 the track of the wound commences to be cleansed of 
 all those tissues which have been crushed and so 
 much injured as to bo no longer preserved among 
 the living tissues. During the elimination of these 
 destroyed parts, when the walls of blood-vessels are 
 implicated, and where the precaution of rest and abso- 
 lute quiet has not been enforced, hemorrhage, called 
 secondary, appears. All injuries to large arteries 
 threaten, sooner or later, to produce secondary hem- 
 orrhage. However large the artery reopened by this 
 process, the escape of blood seldom occurs with an 
 impulse, but usually flows away in a continuous 
 stream, which is supposed to indicate its escape from 
 the lower end of the vessel. 
 
 If hemorrhage has been arrested for a few hours, 
 when even from the femoral artery, the efforts of 
 nature are usually sufficient to prevent its return 
 from the upper portion of the artery, although not 
 from the lower end of the vessel; so that when the 
 main artery of a limb is divided by a ball, should 
 primary hemorrhage be controlled, the great fear is 
 either from subsequent bleeding through the lower 
 ond of tho vessel, or from mortification of the ex- 
 
204 CAUSES OF SECONDARY HEMORRHAGE. 
 
 tvcniity. Any hemorrhage, ufter forty-eight hours, 
 would be considered secondary, and would require 
 special treatment; prior to this it would be called 
 retarded or delayed primary hemorrhage. As long 
 as the wound remains unhealed, 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; and a case of un- 
 usual interest has recently been reported bj 7- Surgeon 
 S. E. Habersham, in the Confederate States Medical 
 and Surgical Journal, for January, 1804, in which ar- 
 terial hemorrhage destroyed life three hundred and 
 twenty-eight days after the receipt of wound. The 
 case was one of compound fracture of the upper third 
 of the thigh from gunshot woivfld, in which a detach- 
 ed fragment from the femur finally caused ulceration 
 in the femoral artery, and fatal hemorrhage occurred 
 through existing fistula 1 , which were still discharg- 
 ing. 
 
 Unless the causes of this hemorrhage be perfectly 
 understood, the rules laid down for treatment will 
 not bo duly appreciated. In speaking of the action 
 of the two ends of a divided artery, we have already 
 stated that the upper cud contracts vigorously, dimin- 
 ishes its calibre at the point divided, and for some 
 distance up the tube, until it simulates in its propor- 
 tions the neck and body of a claret bottle. The 
 blood, impeded in its outward course, allows a clot to 
 form, which, acting as a stopper, shuts up the open 
 mouth. The clot of blood, as a plug, is continued in 
 the contracted artery to the first collateral branch, 
 and nearly fills this cylinder. The lower portion of 
 the vessel, having been in a measure paralyzed by 
 
CAUSES OF SECONDARY HEMORRHAGE. 205 
 
 the division of its coats, which had cut off its supply 
 of nerves, acts with much less energy. The diminu- 
 tion of its calibre depends more upon the removal of 
 distension from its elastic walls than from the con- 
 traction of its muscular fibres. The result of this 
 paralysis is, a more or less patulous condition of the 
 lower portion of the vessel in the vicinity of the inju- 
 ry; and as the supply of blood from above is cut off, 
 there is but little arterial blood in it to clot and ping 
 it up. 
 
 As soon as this barrier or clot is placed upon tho 
 main thoroughfare, at the upper wound, preventing 
 the blood from following its accustomed channel, 
 nature is at oiu-c busy, opening and enlarging the cir- 
 cuitous by-ways and alle}-s of the circulation, so as to 
 restore the supply to the extremity threatened with 
 starvation, or, in surgical parlance, mortification. (Hoc 
 figure 4, plate 14.) As when upon a high-road abridge 
 spanning a stream is destroyed, travellers seek a ford 
 higher up by which they may return to the thorough- 
 fare beyond the impediment, so the blood, taking the 
 nearest by-roads above, soon gets around the obsta- 
 cle, and empties itself into the main channel below it. 
 The blood here changed in its direction, "and not 
 opposed by valves, passes up as well as down the 
 Hmb, and finding an open gate at the lower torn 
 mouth of the vessel, escapes. This fluid, moreover, in 
 its roundabout course, has lost much of its vivifying 
 properties; much of its oxygen is gone, and carbonic 
 acid, ammoniacal gases and the like, having taken its 
 place, mars its brilliant color, and diminishes its clot- 
 ting properties. No proper material, therefore, exists 
 for stopping rip the vessel, as in the upper end of the 
 divided artery, and the vosult is that secondary hem- 
 orrhage may readily occur from the lower end. 
 
2U6 LIOATE BOTH ORIFICES. 
 
 This being well understood, wo can now explain 
 why a ligature placed on the upper orifice alone, or on 
 the course of the artery above the injury, should not 
 always stop, but often only temporarily control, the 
 hemorrhage. As Boon as the collateral circulation above 
 the ligated point is re-established, should (he lower 
 opening in the vessel remain ae before, a sufficient in- 
 terval not having elapsed for the gradual contraction 
 and obliteration of the arterial tube, hemorrhage must 
 recur, or, if this collateral circulation be not establish- 
 ed, mortification must follow. The rule which experi- 
 ence has established from these physiological and patho- 
 logical/acts is: ligate both ends of the vessel at the point 
 wounded, as this is the safest course to pursue. 
 
 Another strong reason why the ligature should be 
 applied to the wounded ends of tho artery is, that there 
 is always some uncertainty as to the vessel injured, 
 whether it be the main trunk or only a branch. The 
 very serious and often fatal operation of ligating the 
 femoral artery has been performed for an injury to one 
 of its branches, which had not been suspected — a post- 
 mortem examination revealing the source of hemor- 
 rhage. When the ligature is applied to the bleeding 
 mouths'this accident can not happen. 
 
 A very interesting case in point, which brings the 
 propriety of the above rule strongly into view, was 
 that of Private 13. Creeey, Company E, 42d Virginia 
 regiment, who was wounded on tho 3d of .May, 1863, 
 by a minie ball, which, in its passage through the 
 larynx, above tho vocal cords, carried away the epi- 
 glottis. On the twelfth, nine days after the receipt of 
 injury, while under treatment in the Winder Hospital, 
 a severe secondaiy hemorrhage came on, to control 
 which tho left common carotid artery was ligated. 
 Tho hemorrhage ceased, to reappear on the eighteenth, 
 
TREATMENT OF SECONDARY HEMORRHAGE. 207 
 
 when the right common carotid artery was Iigated, 
 with the same effect of stopping the bleeding. The 
 
 patient lived thirty-six hours after the second opera- 
 tion. An autopsy revealed the tact that the lefthyoid 
 artery was the injured one, and the inference is that a 
 ligature to tho artery at the scat of injury might have 
 given a much more successful result, and obviated two 
 very serious operations. 
 
 The course which should be adopted in the ease of hem- 
 orrhage from an injured artery is as follows: After tho 
 hemorrhage has once been controlled, and through 
 either carelessness on the part of the surgeon, or rest- 
 lessness on the part of the patient, getting up to help 
 himself when he had strict orders to the contrary, or 
 perhaps from rough transportation over bad roads, or 
 the sloughing of the wound, or by enfeebled health 
 brought on by camp diseases or exposures in the field, 
 etc., hemorrhage reappears, the limb should be at once 
 bandaged from the extremity upward, making careful, 
 regular pressure, so as to diminish tho quantity of cir- 
 culating fluid. Over the course of the main artery, 
 and for somo little distance above and below the 
 wound, a compress, saturated or not with some of the 
 styptic preparations of iron, should be firmly secured, 
 the bandaging of tho limb extending to one or two 
 inches above the injury. The patient is then to be 
 placed upon his back, the limb elevated, and an Ice 
 bladdor applied over the wound. Absolute quiet 
 should be enjoined, and secured by the free adminis- 
 tration of opium. 
 
 In many cases this plan of treatment will bring 
 about the desired object if pei*sevcred in for some time, 
 and assisted by those internal remedies which control 
 the force of tho circulation, as veratium viride and 
 digitalis, in connection with such a course as will im- 
 
l!08 LIGATURE FOR SECONDARY HEMORRHAGE. 
 
 prove the plastic character of the blood, viz : tonics, 
 good food, etc. By the use of compresses saturated 
 with the perchloride of iron, in connection with abso- 
 lute rest, I have succeeded in checking secondary 
 hemorrhage from the carotid artery after tbe escape 
 of the ligature. 
 
 But should the parts be so situated that this press- 
 ure can not be applied for a sufficiently long time, or 
 should it not control the bleeding, or should the bleed- 
 ing recur, then the proper course is to attempt to save 
 the life of the patient by a surgical operation. Ligato 
 the mouths of the artery in the wound without further 
 delay, if it be possible. If the artery can not be found 
 at the point from which tho bleeding occurs, then 
 ligate it at some portion of its course above the seat of 
 injury. 
 
 No case of secondary hemorrhage should destroy 
 life by repeated recurrence j a surgeon is very culpa- 
 ble who thus permits life to ebb away from his grasp. 
 
 Surgeons can not be too much on their guard against 
 the delusive attempts at stopping the bleeding by 
 medication after the second recurrence of secondary 
 hemorrhage. If the case is not operated upon the 
 bleeding is sure to return, and as certain to destroy 
 life, as experience has repeatedly proved. Every fresh 
 hemorrhage increases the dangers and multiplies the 
 risks. A rare instance ma}' occur in which secondary 
 hemorrhage, even three or four times renewed, has 
 finally ceased, and the patient has recovered; but this 
 would be a very dangerous example upon which to 
 establish rules for treatment, as a very large majority 
 of similar cases would be sacrificed to this procrasti- 
 nation. The established rule, therefore, is never to neglect 
 the ligation of an artery after the second recurrence of 
 hemorrhage. 
 
HOW TO FIND BLEEDING VESSELS. 209 
 
 You must not be deterred from placing a ligature on 
 the open mouths of an artery in a suppurating wound, 
 on the deeply grounded but erroneous idea that the 
 artery has had its coats softened by this process. Prac- 
 tical surgery shows conclusively that but little press- 
 ure is required to close the vessel, and that the coats 
 are tough enough to sustain a ligature in a suppurat- 
 ing wound. Therefore the rule should have no ex- 
 ception on this account. When it is possible, ligate in 
 the wound under any circumstances. The swelling and 
 infiltration of tissues renders the search after the in- 
 jured artery difficult ; but the surgeon who, looking to 
 the side of humanity, considers it a sacred duty to do 
 everything for the interest of the wounded, must not 
 allow difficulties to interfere with his proper course. 
 Safety lies in this operation. When possible, the diffi- 
 culties must be met and overcome. 
 
 There are cases, however, in which these would be 
 nearly insurmountable, where the hemorrhage occurs 
 from an inaccessible artery located in parts which are 
 very much swollen, and in a subject much prostrated 
 by previous loss of blood. In such cases we are forced 
 to ligate the artery at some point above the site of 
 injury, where it can be found with facility and certain- 
 ty, and where the tissues have undergone no material 
 changes. 
 
 The following appearances will be observed in the 
 wound, and will assist in the search : After dividing 
 the infiltrated tissues, should the injury have been re- 
 ceived over forty-eight hours — particularly if ten or 
 fifteen days have intervened, which is the usual pe- 
 riod for the recurrence of secondary hemorrhage — the 
 ends of the vessel will be found incarcerated in the 
 midst of a mass of greenish yellow iibrine, with blood 
 clots of more or less recent origin. These indicate the 
 ■ 
 
210 HOW TO FIND BLEEDING VESSELS. 
 
 situation of the artery, the ('(Mitral being the softosl 
 portion of the clot corresponding to the orifice in the 
 vessel. Where post-mortem examinations are made, in 
 cases of death from secondary hemorrhage in which 
 the clots of former hemorrhage have had time to be 
 bleached by the absorption of the colored portions. 
 a probe introduced into the artery from below would 
 make its appearance at a point under the yellow fibri- 
 nous residuary clot, raising a thin portion as it pro- 
 trudes. Should the patient have been destroyed by 
 h hemorrhage, an opening will usually be found in 
 this pellicle. Through the upper portion of the artery 
 the probe would pass down with much more difficulty, 
 owing to a contracted tube plugged with cougula — 
 conditions which do not exist in the lower portion. 
 These lymphy, yellowish green fibrinous masses are 
 to be followed as our guides alter the wound has been 
 freely dilated. 
 
 The exact situation of the incision to seek the 
 bleeding vessel will depend much upon the position 
 of the wound. Should the ball have traversed in such 
 a way as to render the track of the wound a short 
 road to the vessel, the search would be made by dilat- 
 ing freely the wound. Where the ball has, however, 
 traversed the limb obliquely, and the orifice from 
 which the blood escaped is at some distance from the 
 vessel, requiring an unnecessarily extensive incision 
 to expose the artery, it would bo much preferable, 
 instead of dilating the existing wound, to pass a probe 
 through the track made by the ball until it reaches, 
 apparently, the immediate neighborhood of the bleed- 
 ing vessel, and then make an incision parallel with 
 and directly over the course of the artery at a point 
 where the vessel is most superficial, and where its 
 anatomical relations can be used as guides in the 
 
UUATliRE ABOVE THE INJURY. 211 
 
 search. If the incision be free, which it should al- 
 ways be. a healthy portion of the vessel, both above 
 and below the bleeding or injured portion, can bo ex- 
 posed, and the pulsation in its course above the in- 
 jury would materially assist the operator in finding 
 the torn or ulcerated portion. As this operation may 
 be called for in a case in which, should the search fail, 
 it would be impossible or inexpedient to ligatc the ar- 
 tery in its course above the seat of injury, the incision 
 may be made in such a direction as would permit oT 
 an amputation being performed as a dernier resort. 
 When the incision has exposed the vessel, a removal 
 of tho pressure from above, whether it be from a 
 tourniquet or the linger of an assistant, will allow the 
 blood to escape from the injured point. 
 
 In a surgical operation, especially in ligating arte- 
 ries, never be cramped from the fear of making too 
 large an opening; the error is always on tho other 
 side. Having found and ligatcd the orifices, the wa- 
 ter dressing should be continued as before — care be- 
 ing taken not to apply it should the limb become cool 
 and pale. This is not usually the case after ligations 
 for secondary hemorrhage, as the return of the bleed- 
 ing indicates a re 7 established circulation, which tho 
 ligature at the bleeding mouths can not now influence 
 to the injury of the limb. 
 
 Should it be impossible to find the bleeding mouths, 
 after a long and careful search, or should our experi- 
 ence teach us that, from the position of the wound, a 
 search after the vessel at its wounded portion would, 
 in all probability, be unsuccessful, then we will be re- 
 luctantly compelled to adopt the less satisfactory 
 operation of ligating the artery above the wound — 
 hoping it may obviate any further operation. Often 
 ihis course succeeds in checking permanently tho hem- 
 
21- AMPUTATION NECESSARY IN HEMORRHAGE. 
 
 orrhagc. The swelling and oedema of the limb rapidly 
 subsides, the wound takes on healthy action, granula- 
 tions spring up, and cicatrization marches steadily to 
 the complete healing of the wound. In many cases, 
 however, when this last plan has been adopted, a re- 
 turn of the hemorrhage necessitates a second ligature 
 upon some higher point; and should this fail, as is 
 often the case, amputation of the limb will be the 
 only resort to save life. Amputation must be equally 
 resorted to if. after the application of a ligature, the 
 circulation not being re-established, mortification of 
 the limb ensues. In either case amputate 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 when the 
 surgeon docs not adopt the only proper course to stop 
 the trouble at its commencement. Military 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. "When applied, it should not be interfered 
 with until it has either come away of its own accord, or 
 ten to fifteen days have elapsed, when cautious trac- 
 tions might be attempted to hasten its removal. 
 
 Silver wire has been spoken of as ligatures for arte- 
 ries. However well it may answer in fresh wounds, 
 where union by the first intention can be obtained, it 
 is quite out of place in suppurating wounds, when liga- 
 tures arc applied for controlling secondary hemorrhage. 
 
 Punctured wounds, made by the bayonet or sa- 
 bre, require similar treatment to gunshot wounds. If 
 the history and appearances clearly indicate the char- 
 
SABRK AND BAYONET WOUNDS. 213 
 
 acter of bho wound, there will be no need Of probing 
 for imaginary foreign bodies. Such wounds usually 
 bleed more freely than gunshot wounds, but the hem- 
 orrhage is susceptible of control by similar means. — 
 pressure being preferred to ligation of arteries. The 
 treatment should be cold water dressings — irrigation 
 preferred. Protect the wound from air, if possible, by 
 covering it with adhesive plaster or collodion, and 
 llres& it as seldom as possible, compatible u-ith cleanliness. 
 Once probing of such a wound should satisfy the curi- 
 osity of any surgeon. A frequent repetition of this 
 meddlesome surgery, besides the needless pain inflict- 
 ed upon the wounded man, must end in mischief. 
 
 Simple incised wounds, as sabre cuts, will be closed 
 by adhesive plaster (or sutures, which are preferable, 
 should there be any tendency to gaping), to be follow- 
 ed by the cold water dressing. Should the wound be 
 not of a serious character, it may be left even without 
 after-dressing — the little oozing from its edges, when 
 drawn together by straps or sutures, dries into a scab 
 along the line of wound, and excludes air with its per- 
 nicious influences. This permits of the remodelling 
 process, and cicatrization is effected without suppu- 
 ration. 
 
 Should a bayonet or sabre wound transfix one of 
 the natural cavities, the internal injury ma}' be rapid- 
 ly fatal from hemorrhage, or the injury inflicted upon 
 the contained organs may, sooner or later, lead to the 
 destruction of the patient by visceral inflammation. 
 Under ordinary conditions, when such wounds ex- 
 ist in the extremities, where no large vessels are im- 
 plicated, they require no special treatment. It is a 
 class of wounds not as frequently met with in military 
 Surgery as one would suppose. The Babre-baypnet, 
 when plunged into the body among the viscera, leaves 
 
214 PKOORKSS OF GUNSHOT WOUNDS. 
 
 i 
 
 but little work for the surgeon. Such cases seldom 
 leave the battle-field alive. 
 
 When the ordinary bayonet has buried itself deeply 
 in a limb, suppuration may appear in the course of* the 
 wound. Should pus be suspected, and fears exist that 
 it may be pent up under a fascia, it would be necessary 
 to dilate the wound to permit of its free escape. Un- 
 der no other condition should a punctured wound, 
 made by either sword or bayonet, be dilated, except 
 to remove foreign bodies or to control serious hemor- 
 rhage, where it is necessary to ligate the open mouths 
 of the bleeding vessel. 
 
 In gunshot wounds the swelling of the soft parts, 
 which commences a few hours after the injury has been 
 received, usually continues to increase until the com- 
 pletion of the fourth day, when it has attained its 
 acme, with commencing suppuration. Should slough- 
 ing occur, it will show itself by the sixth or seventh. 
 On the eighth or ninth day the slough has, in most 
 cases, separated itself from the edges of the track of 
 the ball, and in a few days more will have been disen- 
 gaged. With the cleansing of the wound, when no 
 complication with foreign bodies exist, the inflamma- 
 tion gradually subsides, the swelling diminishes, puru- 
 lent discharge lessens in quantity, and the'wound com- 
 mences to contract. The middle portion of the track 
 first closes, and with it most frequently 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. The wound 
 cicatrizes with a depression, marking distinctly the 
 nature of the injury which has been received. In the 
 experience of many army surgeons the most depend- 
 ant orifice heals last, without reference to the entrance 
 or exit of the ball. Should the orifices, however, be 
 
OENERAL TREATMENT OF GUNSHOT WOUNDS. 215 
 
 situate in the samo place, the orifice of exit is usually 
 tho first to close. This is the ordinary course which 
 gunshot wounds take when judiciously treated in good 
 constitutions. 
 
 In the general treatment of gunshot wounds, interfere 
 with the general health as little as possible. The 
 commonly prescribed antiphlogistic remedies are, with 
 but rare exceptions, not required. The endless list of 
 emetics, purgatives, diuretics, and diaphoretics, to 
 which somo European writers still cling with wonder- 
 ful tenacity, can, with decided benefit, be dispensed 
 with. 
 
 Guthrie, who represents this class, in speaking of 
 the inflamed stage of gunshot wounds, says that tho 
 treatment for subduing this should be active : "The pa- 
 tient, if robust, ought to be bled (if no endemic disease 
 prevails), vomited, purged, kept in the recumbent po- 
 sition, and cold applied as long as it shall be found 
 agreeable to his feelings ; when that ceases to be the 
 case, warm fomentations ought to be resorted to, but 
 they are to be abandoned the instant the inflamma- 
 tion is subdued and suppuration well established." 
 
 The experience of Confederate army surgeons is de- 
 cidedly averse to the use of any depleting agent. Ac- 
 tive purging and vomiting is incompatible with that 
 degree of quiet which we have laid down as a funda- 
 mental rule in the treatment of gunshot wounds. As 
 suppuration is usually long continued, and debility, 
 with a certain degree of emaciation, usually accom- 
 panies the progress of gunshot wounds, the disposi- 
 tion should rather be to harbor strength in order to 
 support this drain, than to despoil the system. The 
 modem practice of support rather than depletion hastens 
 convalescence, and is the only rational practice. 
 
 tieneral and local bloodletting are so soldom requir- 
 
lilG GENERAL TREATMENT OF GUNSHOT WOUNDS. 
 
 cd in the treatment of gunshot wounds, the patient 
 having, in most cases, lost more blood than the sys 
 tern could conveniently spare, that we need not lose 
 time by discussing these remedies as formerly used in 
 the treatment of all diseases and injuries. Suffice it 
 to say, that in military surgery we are rat called upon 
 to use either of them for the successful treatment of 
 gunshot wounds. 
 
 Kinetics, as such, are never required in the general 
 treatment of wounds. When very small doses of the 
 emetic preparations are given, they may bo useful in 
 inducing relaxation and for generalizing the circula- 
 tion, in this way deriving the excess of blood from the 
 wound. Small doses of tartar emetic may, with other 
 remedies, form a good proscription in cases of exces- 
 sive reaction. 
 
 Mild purgatives aro in constant rerpiisition, both for 
 their detergent as well as derivative effects, and may 
 be needed during the treatment of nearly every case 
 of gunshot wound. The most commonly prescribed 
 article is the compound cathartic pill of the pharma- 
 copoeia, although from tho large list of mild purgatives 
 ample opportunity is afforded for making a selection. 
 As a rule, where the object of the purgative is simply 
 to evacuate the bowels, without reference to exciting 
 the secretion of any of the abdominal organs, I have 
 always found that an enema which will act directly 
 upon the rectum, causing it to discharge its contents, 
 will give all the comfort desired. By its use we avoid 
 the delay accompanying the administration of medi- 
 cines, and the gastric disturbance always induced by 
 their irritating effect while passing through thirty 
 feet of intestine, before the desired evacuation can be 
 produced. As it is always desirable in the treatment 
 of wounds to impair the digestion as little as possible, 
 
GENERAL TREATMENT OF GUNSHOT WOUNDS. 217 
 
 the enema, whether of simple water, cold or warm, 
 or whether made more irritating by medication with 
 table salt, cpsom salts, soap-suds, etc., etc., will al- 
 ways be found a valuable substitute for purgative 
 medicines. 
 
 The granulations of a wound are said to be a better 
 index of the condition of the intestinal canal than the 
 tongue, as they arc much more readily influenced by 
 any cause which induces an irritable condition of the 
 system. Keeping watch over the digestive organs, 
 preventing, by proper diet, any indigestible food from 
 getting into them, while the excretions which empty 
 into this great sewer are not allowed to remain and 
 disturb the system, will be at all times judicious prac- 
 tice. 
 
 Diaphoretics and diuretics are the milder antiphlo- 
 gistic and derivative remedies, which may frequently 
 be required to quiet the pulse and equalize the cir- 
 culation. 
 
 The ordinary febrile reaction, which so frequently 
 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 largo. When, by 
 judicious local treatment, the nervous excitement 
 near the wound subsides, the pulse will pari passu 
 lose its frequency and irritability. It is not a disease 
 within itself, requiring to be especially treated. 
 
 In the general treatment of wounds, diet and rest 
 are the two great remedies which, in by far the ma- 
 jority of wounds, even the most serious, are all (hat 
 is required for successful treatment. Should there bo 
 an excess of general excitement, which a purge with 
 a diaphoretic or diuretic is not able to quiet, Ave 
 would administer to such ono of that class of modi- 
 s 
 
218 GENERAL TREATMENT OF GUNSHOT WOUNDS. 
 
 cincs which is known to control the excitement of tho 
 circulation, quiet tho, brain, and act as a sedative 
 upon the nervous system generally, viz: opium, hyos- 
 cyamus, eonium, belladonna, digitalis, veratrura viride, 
 gelseminum sempervirens, etc. 
 
 When local reaction is excessive, with great swell- 
 ing and heat, there is a class of general remedies 
 which might be given with advantage. They act by 
 increasing the tone of blood-vessels, and thereby 
 cause a contraction in their walls and diminution of 
 their calibre. This curtails necessarily the amount 
 of blood flowing through these temporarily diminished 
 vessels, and therefore relieves congestions. Upon such 
 remedies much reliance might be placed. Holding a 
 conspicuous position among these are the mur. tinct. 
 of iron, tinct. of belladonna, wine of ergot, etc. It 
 is by contracting the blood-vessels to such an oxtent 
 that a sufficient supply of blood can not be transmit- 
 ted for the nourishment of distant tissues, that morti- 
 fication follows the too liberal and long-continued use 
 of ergot. By this property of producing contraction 
 in blood-vessels uterine hemorrhages are checked, or 
 the action of the gravid womb, with its immensely 
 developed blood-vessels, excited. The entire profes- 
 sion have adopted the mur. tinct. of iron as Dearly a 
 specific against the fearful inflammatory reaction of 
 erysipelas, in which disease it causes a rapid and per- 
 manent contraction of the distended capillary vessels 
 involved. For stronger reasons, it is equally etficacious 
 in simple inflammatory engorgements. Belladonna 
 shows its general action by dilating the pupil — an 
 effect explained by the change in the circulation of 
 tho blood-vessels of the iris. Its advantages in re- 
 lieving injection of the blood-vessels of the eye are 
 well known and largely used. It is spoken of as tho 
 
GENERAL TREATMENT OP GUNSHOT WOUNDS. 219 
 
 remedy for the rapid relief of congestion of the spinal 
 cord. Although these are tho individual effects of 
 such remedies, the} r aro 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 arc offending, as there would bo 
 the widest field for the remedy to show its common 
 effects. 
 
 Inflammation is a perverted condition of tho blood 
 and blood-vessels of a part, which means a modified 
 state of nutrition. Whenever a cause of local irrita- 
 tion exists, which creates a disturbing influence in the 
 economy and depresses the vitality of a part, nature, 
 ever on the alert to ward off evil, pours its pabulum 
 of life into the injured portion, to counteract tho per- 
 nicious effects of the injury. The depressing effects 
 upon the nerves permit the relaxation of the blood- 
 vessels and invite in the circulating fluid. The 
 blood flows in, filling up all of the channels and inter- 
 rupting the healthy circulation through the part, and 
 by its accumulation produces still further depression. 
 
 There arc two diametrically opposed means of cor- 
 recting this condition and restoring health. One is, 
 by reducing the amount of blood carried to the part 
 which threatens to overwhelm the vital functions of 
 Bach an inflamed portion of the body. This is effect- 
 ed by bloodletting, vomiting, purgation, abstemious 
 diet, and the entire list of depletory or spoliative 
 remedies, which weaken the enemy to such an extent 
 as to allow of the part attacked successfully coping 
 with tin- disease. But when the disease is conquered, 
 tin- victory may l>c as disastrous as a defeat, a Long, 
 tedi'ius convalescence being required to restore tho 
 patient to Ins former Mate of health. Experience has 
 shown this destructive plan of treatment to bo inju- 
 
220 GENERAL TREAT MKNT OF GUNSHOT WOUNDS. 
 
 rious, and it lias been, therefore, properly discarded 
 for a much more preferable method. This consists in 
 increasing the tone, both of part and system, by sup- 
 porting agents, which strengthen the garrison, in- 
 crease the vital powers residing within the tissues fof 
 resisting the encroachments of disease, and thus are 
 enabled to drive out the enemy, however violently 
 the attack may be made. These successes are at- 
 tained with but little loss on the part of the system, 
 which comes out of the fire unscathed. Our object, 
 then, should always be to cure disease by using such 
 remedies as will cause the least possible loss to the 
 economy. 
 
 We have, therefore, abandoned the plan of starving 
 wounded men. or, by the mistaken policy of a rigor- 
 ous diet, to keep oft' inflammation. We look upon 
 inflammation as always depressing in its character — 
 nature requiring assistance from without to enable 
 her to cope successfully with disease. We do not 
 hesitate, therefore, as soon as the stage of reaction 
 has passed, to feed the wounded with strong, nour- 
 ishing diet, and also further to support the system 
 by the use of stimuli. Whiskey has been freely given 
 to our wounded, particularly during the suppurative 
 stage, and with decided benefit. As the irregularities 
 of camp life, especially during an active campaign, 
 have a depressing effect upon all soldiers, which, al- 
 though not apparent as lorn;- as they are capable of 
 performing duty, shows its influence immediately 
 when they are placed upon the sick-list, the above 
 course of supporting treatment is particularly appli- 
 cable to the wounded of armies. 
 
 In all injuries, were it not for an exquisitely sensitive 
 nervous system, we would have but little systemic 
 sympathy, and, therefore, but little personal annoy- 
 
OPIUM IN GUNSHOT WOUNDS. 221 
 
 ance. In the inferior animals, where the sensibilities 
 are of a low description, and where the various por- 
 tions of the body are more or less isolated and not 
 tied together by numerous cords of nervous sympa- 
 thy s, limbs can be torn off without deleterious effect 
 upon the rest of the body, and without producing in- 
 flammation. These inflammatory tendencies are only 
 observed as we advance in the scale of animal life, 
 until we find in man a perfection of a nervous system, 
 with its corresponding sympathies and susceptibilities 
 to physiological as well as pathological impressions. 
 If we could, by some metamorphosis in the nervous 
 sympathies of man, temporarily establish a condition 
 simulating the more primitive developments, Ave would 
 diminish the dangers of local trouble; or if we could 
 take possession, as it w r ere, of the nervous functions, 
 and reduce them to their lowest stage for extending 
 sympathies, we could equally keep down irritation, 
 and, to a great extent, jugulate the tendency to con- 
 gestion, and, subsequently, inflammation. 
 
 Opium, by which we can effect this subjection, will 
 ever be the greatest boon to the military surgeon. It 
 allays both local and general irritation, annuls pain, 
 soothes the mind, blunts the sensibility of the injured 
 nerves, and quiets the tumultuous action of the heart. 
 By its sedative influence upon the cerebrospinal sys- 
 tem it allows the sympathetic system of nerves to 
 act in unrestrained vigor, and through it tone is re- 
 stored to the muscular walls of blood-vessels. Under 
 its influence there is no longer a local irritation in- 
 ducing blood to the part, nor dilated and relaxed 
 blood-vessels, permitting an increased flow of blood; 
 and the result i^ that inflammation, which is inti- 
 mately cpnnected with a local congestion and a local 
 irritation, is kept in abeyance. It is, therefore, a 
 
222 ENDERMIC USE OF MORPHINE. 
 
 remedy which should never be absent from our reach. 
 Going on the field, the surgeon should have bis haver- 
 Back -well stored with it for immediate use; and 
 throughout the entire treatment of the wounded it 
 will ever hold a conspicuous place. Of all the pre- 
 parations of opium, morphine is, perhaps, the best 
 article for wounded men, as it has lost in preparation 
 some of those astringent properties which, as opium 
 or laudanum, would produce too great a tendency to 
 constipation. 
 
 The endermic method of using this remedy would 
 prevent endless suffering on the battle-field or in hos- 
 pital practice. When morphine is taken into the 
 stomach, it is dissolved in the fluids there found, and 
 then undergoes absorption. This takes place with 
 greater or less rapidity, according to the nervous ex- 
 citement under which the system is laboring. At 
 times its absorption is very slow, and its effects upon 
 the system, from the small quantity found in the 
 circulation at any one time, very indifferent. Under 
 other circumstances, when the absorbents of tho 
 stomach arc apparently in a condition of tempo- 
 rary paralysis, with complete suspension of their 
 function, very largo doses are administered in vain 
 to produce the soothing effects which naturally be- 
 long to the drug. It remains, perhaps, unchanged in 
 the stomach. Under the same condition, if a much; 
 smaller dose, in solution, be injected under the skin of 
 any portion of the body, the vessels seem to absorb 
 immediately the fluid, and its full effects are obtained 
 in a few minutes. The following cases will show tho 
 marked efficacy of the remedy when used l^-poder- 
 mically : 
 
 Mrs. C. had been operated upon for cataract by 
 division of the lens. Violent inflammation ensued, 
 
ENDERMIC USE OP MORPHINE. 223 
 
 ending in the destruction of the eye, and for three days 
 she sufferod agony. Day and night she rolled about 
 the bed in ceaseless torment, in spite of repeated doses 
 of morphine. Finding that one-half grain every two 
 or three hours produced no alleviation of her suffer- 
 ing, I tried the experiment of injecting one-third of 
 a grain, dissolved in two minims of water, under 
 the skin covering the sternum. A Wood's endermic 
 syringe was used. Absorption was immediate : in two 
 minutes she was relieved; in five, all pain had dis- 
 appeared, and in ten minutes from the timo of the 
 injection she was sleeping soundly, after seventy hours 
 of unmitigated torture. 
 
 Mr. T. had been suffering with articular inflamma- 
 tion of the right elbow joint, and for three weeks had 
 suffered so severely as to be robbed of all rest. He 
 visited Charleston, four hundred miles from his home, 
 to seek relief. An injection of one-third grain relieved 
 him of all pain in five minutes. After twelve hours' 
 sleep he awoke much refreshed ; and although a gen- 
 eral soreness continued for some days, no acute pain 
 was felt in the elbow from the time of injection. 
 
 Captain M. was accidental^ shot in the neck with a 
 Colt's pocket revolver. His head being turned, tho 
 ball entered the skin over the larynx, coursed down- 
 ward and backward through the posterior triangle of 
 tlic neck, and was found under the skin of the shoulder 
 over the spine of the scapula, and was removed. Con- 
 siih-rable swelling and extravasation followed, which, 
 diffusing itself, discolored that side of the neck. Some 
 branches of the brachial plexus of nerves must have 
 been injured by the ball, as the patient was seized with 
 violent pains shooting down the arm toward the fin- 
 gers, ami which, although never altogether absent, 
 would increase to torture as evening advanced. Tow- 
 
224 ENDERMIC USE OF MOBPIIINE. 
 
 arc! morning they would remit and allow of sleep, 
 after a restless and painful night. Gum opium and 
 morphine, in large doses, gave him no relief. The 
 arm was so sensitive that he would not permit its 
 being handled. One-fourth of a grain of morphine, 
 in three or four drops of water, was injected under 
 the skin of the shoulder; in five minutes all pain had 
 left him, and his arm could he examined rudely with- 
 out the slightest suffering. 
 
 Although other eases of gunshot wounds could be 
 detailed in which the endermic use of morphine gave 
 immediate and entire relief from pain, the above re- 
 cital will suffice as proof of its decided usefulness. 
 
 By the use of this simple process, a new and exten- 
 sive field for doing good is open to the humane mili- 
 tary surgeon, and he who is the fortunate possessor of 
 this talisman will receive daily the thanks and bless- 
 ings of his suffering patients. When chloroform can 
 not be obtained, I would suggest this mode of blunt- 
 ing sensibility, immediately before operations are per- 
 formed or painful and tedious dressings are made. It 
 will bo 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. Narcotizing the pa- 
 tient 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 
 rapidit}' of action when morphine is used endermi- 
 cally is a very great advantage on the field, where 
 every moment is of value. For complete narcotism, 
 where a sufficient quantity of morphine is used, five 
 minutes are all that is required; while with chloro- 
 form we all know that, when under excitement, its 
 inhalation is often extended to from twenty to thirty 
 
ENDERMIC USE OF MORPHINE. 225 
 
 minutes, and even longer — time which the surgeon in 
 the field can not well sparo. Judging from analogy, I 
 should say that, under the narcotizing influence of 
 morphine, operations should bo much more successful 
 than under chloroform — as the impression is more 
 lasting, and the inflammatory sequela) ought to be 
 correspondingly in abeyance. 
 
CHAPTER VII. 
 
 Complications which arise dubing the treatment of Gunshot 
 Wounds — Erysipelas, contagious and infectious character — 
 Constant tkndency to Debility — Treatment, General and Lo- 
 cal — Hospital Gangrene; its appearances; how recognized; 
 Causes giving rise to it — Thorough Ventilation necessary to 
 successful treatment — local applications, actual cauteby, 
 etc, — Pyemia a rare disease in our country; symptoms — The- 
 ory of Multiplied Abscesses — Great remedy; Prevention by 
 rigid observance of hygienic regulations — local and gener- 
 AL Treatment — Tetanus, characters; March — Rarity of curb 
 in Military Surgery — Local and General treatment upon 
 which most reliance can be placed — Woorara in Tetanus — 
 Hectic, from long-continued suppuration — Permanent and 
 Periodic Pains. 
 
 Erysipelas. — We have already examined, in detail, 
 the causes of secondary hemorrhage, which is one 
 of the most alarming complications that can befall 
 the wounded. A second, which is equal I j r alarming 
 to both surgeon and patient, is erysipelas. This dis- 
 ease appears to revel in tho depressing influences 
 which follow armies, and sometimes, as an epidemic, 
 attacks all wounds, ravages limbs, and makes a fright^ 
 fill list of victims. Although it frequently occurs as 
 an idiopathic disease, its most common exciting cause 
 in military hospitals is a wound. 
 
 Idiopathic erysipelas, which is often mot with in 
 isolated cases, and usually found attacking persons 
 without wounds, is a diffused inflammation of the 
 skin, most frequently seated upon the face, although it 
 may show itself upon any portion of tho body. A red, 
 
TRAUMATIC ERYSIPELAS. 227 
 
 swollen, glistening spot, accompanied by a sensation 
 of heat, weight, and fullness, seems to encroach rapid- 
 ly upon the contiguous surface, nearly visibly extending 
 its outline. Its appearance may have been preceded 
 by a chill, which is followed by lassitude, pain in the 
 limbs, back, and head, quick pulse and furred tongue, 
 loss of appetite, and nausea, often with vomiting. 
 During the secondary, in the simple form of the dis- 
 ease, a moderate effusion of serum escapes into the 
 subcutaneous tissue. Where this tissue is loose, as 
 about the eyelids, the swelling from serous effusion be- 
 comes excessive. The limit of the redness is at times 
 well defined, although usually it is gradually lost in 
 the surrounding healthy tissue. After a continuance 
 of a few days, if its tendency to spread is controlled 
 by judicious treatment, numerous vesicles, containing 
 a clear serum, appear upon the reddened surface, and 
 are considered an indication of returning health. These 
 burst, the fluid dries up, the skin flakes off, and with 
 these phenomena the general symptoms gradually 
 subside. 
 
 Gunshot wounds in patients debilitated by the many 
 depressing influences of camp life, are peculiarly prone 
 to attacks of erysipelas. The variety most frequently 
 met with among such is the phlegmonous, or, as it is 
 now called, the cellule-cutaneous variety. After a pre- 
 monitory chill it makes its appearance with violent 
 inflammatory symptoms, intense swelling, tension, 
 redness, pain, heat, and effusion, the affected part 
 pitting on pressure. It extends rapidly from the 
 wound as a centre, and soon covers a large area, ac- 
 companied by symptoms of inflammatory n-ww with 
 a dirty, foul tongue, and deranged gastrointestinal 
 secretion, generally constipation, although at times 
 diarrhoea, the urine being scanty, high-colored, and 
 
228 KFFECTS OF ERYSIPELAS. 
 
 acrid. It will be remarked that the pulse, although 
 frequent and full, has no strength ; and general pn 
 tration ensues at a very early day. Often by the 
 fourth day the hardened edematous tissue in the 
 
 neighborhood of the wound, although it is still highly 
 colored, presenting a glistening appearance, already 
 feels boggy when the fingers are pressed upon it, in- 
 dicating the extensive formation of pus and sloughs 
 under the skin. The wound usually gives outlet to 
 these pent-up secretions. 
 
 As the disposition of the disease is not to localize 
 itself, the effusion actively thrown out in the extent of 
 tissues undergoes a conversion into pus, which leaves 
 this matter disseminated in all the tissues where the 
 effusion had taken place. It is in this manner that 
 the extensive purulent dissection of limbs occurs; by 
 which muscles are isolated, blood-vessels separated 
 from the surrounding connections, bones exposed from 
 their periosteum, joints opened, and with these a gen- 
 eral destruction of cellular tissue, which may be pulled 
 out from the wound in shreds or layers resembling 
 strips of wet chamois leather. The extensive loss of 
 support to the skin from the undermining and destruc- 
 tion of the subcutaneous tissues causes it to breakdown 
 into sloughs, which make an opening for the escape of 
 this accumulating fluid. Nature in its weakened con- 
 dition can not stand this drain of its best nutrient 
 material ; and prostration, feeble, irregular pulse, dry 
 tongue, diarrhoea, delirium, and finally coma, ends the 
 scene. Or, .should judicious treatment check its in- 
 roads, a tedious convalescence and a shattered consti- 
 tution remain to the patient. 
 
 Erysipelas can always be recognized by its distinc- 
 tive characters of widely extended local inflammation, 
 with tendency to the rapid suppuration and sloughing 
 of the wound. 
 
PROPAGATION OF ERYSIPELAS. 22JJ 
 
 The prognosis of this complication, in military sur- 
 gery, is always serious, when it occurs after gunshot 
 wounds, as the constitutions of the patients have been 
 undermined to a certain extent by the hardships and 
 irregularities to which all soldiers in time of war 
 must submit. 
 
 In the treatment of gunshot wounds it must be re- 
 membered that erysipelas, which is a very serious 
 complication, is often produced by a careless disregard 
 of those hygienic regulations which are so essential 
 in the proper organization of a hospital. Over-crowd- 
 ing, bad ventilation, and a want of cleanliness — a com- 
 bination which produces a poisoned atmosphere — are 
 frequent causes for its production and propagation; al- 
 though it can not alwaj's be traced to the depressing 
 effect of bad food or a vitiated atmosphere, as cases occur 
 in private quarters where ventilation is perfect. As the 
 disease is clearly contagious as well as infectious, the 
 directors of military hospitals must be very careful 
 how they permit a case of er3 r sipelas to be introduced 
 int<> a ward with wounded men — for inoculation will 
 at once ensue; and when eiysipelas has taken posses- 
 sion 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 introduc- 
 tion of this focus of contamination, now take on erysi- 
 pelas. The system soon shows the depression under 
 which the patient is laboring. Some further compli- 
 cation, with low visceral inflammation of either the 
 membranes of the brain or lungs or intestinal surface 
 ensues, and life is overwhelmed bj' this combination. 
 
 Brichsen, in his Science and Art of Surgery, men- 
 tions the following case in proof of the contagion of 
 erysipelas, as having occurred in one'of his wards at 
 University Collego hospital : " The hospital had been 
 
-230 TREATMENT OF ERYSIPELAS. 
 
 free from any cases of this kind for ti considerable 
 time, when, on the 16th of January, 1851, at aboul 
 noon, a man was admitted under my care with gan- 
 grenous erysipelas of the legs, and placed in the ward. 
 On my visit, two hours after Ids admission, I ordered 
 
 him removed to a separate room, ami directed the 
 chlorides to be freely used in the ward from which he 
 had hcen taken. Notwithstanding these precautions, 
 however, two days after this a patient, from whom a 
 portion of necrosed ilium had been removed a few 
 week's previously, and who was lying in the adjoining 
 bed to that in winch the patient with the erysipelas 
 had been temporarily placed, was seized with erysipe- 
 las, of which he speedily died. The disease then 
 spread to almost every case in the ward, and proved 
 fatal to several patients who had been recently oper- 
 ated upon." If such he its tendency in civil hospitals, 
 how frightful is its march among the wounded in 
 military hospitals'.'' Such cases should be kept exclu- 
 sively to themselves, or they entail incalculable loss 
 upon the wounded. 
 
 The antiphlogistic treatment of erysipelas, especial- 
 ly the phlegmonous variety which we are now con- 
 sidering, has for many years hcen abandoned; and he 
 who attempts to cure erysipelas in military surgery 
 h} r depressing agents, will pay dearly for his rash- 
 ness. However violent arc its symptoms, the surgeon 
 must not he deceived. It is a disease of marked debil- 
 ity; the violence. of its inception is only a mask, 
 to he thrown off in a few days, and often in a few 
 hours. When the plan of attack is so well known as 
 it is in erysipelas, where a study of tin- natural histo- 
 ry of the disease has invariably shown, in its march, 
 certain and speedy prostration, the surgeon is highly 
 culpable who does not commence with the earliest 
 
TREATMENT OF ERYSIPELAS. 231 
 
 treatment to build np and Bupport the sj'stem, and 
 thus prepare it to withstand the depression which is 
 so sure to ensue, and which, if overlooked, will lead 
 to such serious consequences. 
 
 Prevention is always more judicious than cure, and, 
 therefore, our first care should be — by the strict ob- 
 servance of those hygienic regulations for ventilation 
 and cleanliness, and against over-crowding — to keep 
 the wards of a hospital with so pure an atmosphere 
 as to give no encouragement for this low class of dis- 
 eases to intrude. When a case appears, isolate it at 
 once; give it the advantage of a large airy room 
 with free ventilation, or, what is found still more sat- 
 isfactory, put the patient in a tent in which air can 
 be freely admitted, and use every precaution against 
 contagion. Tho use of sponges, bandages, etc., re- 
 quired by such a patient, must be restricted exclu- 
 sively to himself; for should the same sponge .be 
 used by a dozen woHnded men, they would all be as 
 surely inoculated. Fresh air is indispensable in the 
 successful treatment of this disease. Leave all the 
 windows open for thorough ventilation, even at the 
 risk of catarrhal affections, which arc trivial when 
 compared to the serious character of the disease under 
 discussion. 
 
 The treatment of phlegmonous erysipelas, ever hav- 
 ing in view the steady, onward march of the disease 
 to suppuration, sloughing, and prostration, unless a 
 barrier is thrown across its path, should be, from the 
 commencement, stimulating and supporting. This 
 tonic course, which is equally successful in simple 
 Idiopathic erysipelas, is prefaced by some mild cathar- 
 tic, t" oleanse the bowels of imparities which rapidly 
 accumulate in them, and to excite healthy secretions 
 from the digestive organs For this purpose, the 
 
 
232 TREATMENT OF ERYSIPELAS. 
 
 compound colocynth pill would he a good prescrip- 
 tion, although a dose of castor oil or sulphate of mag- 
 nesia would, in the majority of cases, fill every indi- 
 
 cation. "Without waiting the action of ("his cathartic, 
 from which only a moderate effect is desired, we at 
 
 once prescribe what is now called the specific by 
 many, and recognized as useful hy all — the tincture of 
 
 the muriate of iron, in doses of from twenty to thirty 
 drops, in a wineglass of water every three hours. 
 Besides acting as a general tonic, and also, through 
 iis mineral acid upon the liver, promoting the biliary 
 secretion, it appears to affect more immediately the 
 enfeebled and distended blood-vessels, producing a 
 permanent contraction of their muscular walls and a 
 diminution of their calibre, in this way relieving con- 
 gestion, and preventing, to a great extent, effusions. 
 I have seen it cut short a traumatic erysipelas of the 
 face, after an extensive operation for cheiloplasty, in 
 thirty-six hours from its appearance. The perchloride 
 or persulphate of iron, in from five to ten drop doses, 
 is preferred by some surgeons, while quinine as a 
 tonic is also found useful. 
 
 Jn connection with the mar. tincture of iron, ami 
 of equal importance with it, is the liberal use of alco- 
 holic stimuli and nourishing diet. Erichsen says : "I 
 have seen the best possible results follow the frco 
 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, 
 soften the tongue, and remove delirium. When the 
 skin is dry and harsh, mild diaphoretics should bo 
 used, and as anodynes are always required in the 
 treatment to allay pain and to give sleep, Dovers' 
 powders would be a valuable agent. By adopting 
 this course of attending to the secretions, keeping 
 
 
LOCAL TREATiMENT OF ERYSIPELAS. 233 
 
 the bowels soluble, and by generous diet and free 
 stimulation supporting the system, even from the very 
 commencement, against that prostration which is 
 certain, sooner or later, to show itself, this scourge 
 in military hospitals will be most successfully con- 
 trolled. 
 
 Considering the disease as one of 'marked debility, 
 most reliance should be placed upon the general treat- 
 ment. In the idiopathic form of the disease, the tinct- 
 ure of the muriate of iron, with attention to the diges- 
 tive organs, is now considered quite sufficient to check 
 the disease without the use of local remedies. The- 
 usual local treatment in simple erysipelas consists in 
 painting the part inflamed, as well as the contiguous 
 healthy surface, with tinct. iodine, or with a solution 
 of nitrate of silver (two drachms to one ounce of 
 water), or the part is kept bathed in a solution of sul- 
 phate of iron. Where it shows a disposition to 
 spread, the healthy skin around the inflamed spot is 
 covered with a narrow strip of blister plaster, or 
 painted with a saturated solution of nitrate of silver. 
 If the cuticle is destroyed by these applications, the 
 extension of the disease is checked. All local appli- 
 cations should tend to relieve engorgement. In the 
 early inflammatory stage of phlegmonous erysipelas, 
 before suppuration is established, painting the limb 
 with the pcrchloride of iron, or the tincture of iodine, or 
 using compresses soaked with tincture of arnica, etc., 
 would tend to promote healthy action. Cold water, 
 by irrigation, or iced applications, would be as useful 
 here as in any other engorgements, although their ir- 
 regular application, with the sudden and frequent 
 changes of temperature which accompany it, has 
 caused cold water dressings to be accused of inducing 
 erysipelatous inflammation. All of these applications 
 
 T 
 
234 LOCAL TREATMENT OF EKYSI I'ELAS. 
 
 may be accompanied with the methodically applied 
 
 roller, which will compress the limb, and, by its me- 
 chanical support, diminish infiltration and congestion, 
 and relieve tension and Bwelling. Sugar of lead 
 lotions arc highly lauded. Five incisions are reconv 
 mended by many Burgeons to relieve the engorged 
 vessels. They give great relief to the patient, but it 
 is a question whether they do not increase the irrita- 
 tion and hasten the suppurative stage — an effect not 
 to be desired, as the entire armamentarium of the 
 surgeon is directed against the formation of pus. 
 
 When pus has formed (which will be recognized by 
 the doughy condition of the parts, into which the 
 fingers sink when pressure is made, and, a little later, 
 by fluctuation), incisions should be made sufficiently 
 free to admit of the ready escape of pus at the same 
 time, parallel with the axis of tin- limit and also with 
 the course of the main blood-vessels, so that these 
 may be avoided. Stimulating water dressings should 
 be continued, to hasten the elimination of the sloughs 
 and diminish the amount of secretion. The tincture 
 of arnica, spirits of camphor, Labarraque's chloride of 
 soda, diluted with from six to ten parts of water, 
 diluted pyroligneous acid, diluted tincture of iodine, or 
 the persulphate or percbloride of iron, cither pure or. 
 diluted, make excellent stimulating applications, ex- 
 citing healthy action in the inflamed part, and check- 
 ing the tendency to continued suppuration. Wherever 
 pus shows a disposition to hag, it should bo let out hy 
 incisions. As the skin, largely undermined, is liable 
 to slough extensively, it should he supported hy prop- 
 erly applied bandages, which, by diminishing the 
 cavity within, will prevent the burrowing of pus, and 
 cause the skin to adhere to the deeper parts as soon 
 as adhesive action can he excited. 
 
HOSPITAL GANGRENE. • 235 
 
 Hospital Gangrene. — Still another fatal complica- 
 tion, to which gunshot wounds arc liable, is hospital 
 gangrene — the name being significant of the cause of 
 this pest, as it is rarely seen as an isolated disease 
 without the crowded wards of a hospital. It is 
 highly probable that, like the former diseases which 
 we have just considered, it is a blood poisoning, de- 
 pending upon a foul, infected atmosphere, operating 
 upon a depraved and enfeebled constitution. It most 
 frequently attacks those who have become debilitated 
 by exposure, disease, want of proper food, intemper- 
 ance, etc.; so that in a crowded hospital, when gan- 
 grene threatens to devastate the wards, you might 
 select, in advance, the cases which will most probably 
 be first attacked. At times, however, it engrafts 
 itself upon all wounds, whether trivial or serious; 
 whether in enfeebled or robust patients, and whether 
 recent or newly cicatrized, the presence of a wound 
 ensuring an attack. Many surgeons consider it a 
 constitutional disease, occurring from a strictly local 
 cause which is found within the walls of the hospital. 
 All surgeons recognize its contagious as well as infec- 
 tious character, and the facility of transmitting it by 
 sponges or dressings used in common by inmates of a 
 ward. 
 
 The facility with which the air of a ward, or even of 
 a hospital, becomes impregnated with this poison, 
 would show that animal exhalations, especially from 
 those suffering under this disease, possess the power of 
 diffusing it. Burgman reports that hospital gangrene 
 prevailed in one of tho low wards at Leyden, while 
 the ward or garret above it was free. The sin 
 made an opening in the ceiling between the two, in 
 order to ventilate the lower or affected ward, and in 
 thirty hours three patients hi the upper room, who 
 
236 CONTAGION OF HOSPITAL OANORENE. 
 
 lay next the opening, were attacked by the disease. 
 which soon spread through the whole ward. 
 
 Guthrie confirms the above by his experience, which, 
 he says, left no doubt upon the mind of any one who 
 had frequent opportunities of seeing the disease, that 
 one case of hospital gangrene was capable of infecting 
 not only every ulcer in the ward, but in every ward 
 near it, and, ultimately, throughout the hospital, how- 
 ever extensive it may be. 
 
 Both English and French surgeons in the Crimean 
 war recognized the atmosphere as clearly the vehicle 
 of its extension, and that its increase or diminution 
 depended upon the more or less crowded condition of 
 the wards, and the amount of ventilation. They also 
 observed the certainty with which it increased when 
 the same sponges were used indifferently for gangre- 
 nous and for healthy wounds. It may be considered a 
 thoroughly contagious disease. 
 
 Those who observe the march of the healing process 
 of wounds, without and within hospitals, know how 
 easily the one is cured, and with what difficulty a 
 tedious cure is obtained in the other. "Where the ex- 
 halations from many suppurating wounds are concen- 
 trated in a ward, the cicatrization of all wounds, even 
 the most simple, is retarded, and contagion of any 
 kind readily propagated. 
 
 There are certain conditions of the atmosphere in 
 cities under which hospital gangrene or sloughing 
 phagedcena shows itself, where its appearance can not 
 be attributed to over-crowding, want of caro or clean- 
 liness, nor to any appreciable cause. During the 
 year 1863 we passed through such an atmospheric 
 condition, when the phagedenic sloughing of wounds 
 was epidemic, and so general was this complication 
 that even the small prick in vaccination would, in 
 
SYMPTOMS OF HOSPITAL GANGRENE. 237 
 
 some instances, become frightful ulcers, and even lead 
 to the destruction of life. 
 
 In military hospitals, the hospital gangrene will be 
 recognized by the following appearances : Although the 
 patient may have recently shown feverish symptoms, 
 with loss of appetite, yellowish or pale skin, dirty 
 tongue, and deranged bowels, the first appearance of 
 the disease is recognized in the changes which the 
 wound undergoes, which has led many to believe it 
 to be, at first, a" local disease, in time infecting the 
 system. The granulating surface of a healthy sore, 
 about taking on this sloughing condition, becomes 
 comparatively dry and painful. The laudible pus, 
 which lip to this time was formed upon the surface, 
 disappears, and a thin, dirty, watery serum bathes the 
 ulcer. The florid hue of the granulations rapidly dis- 
 appears, and is replaced by a dirty gray or ash-colored 
 slough, which fills the wound, and forms a pultaceous 
 and adherent covering to the granulating surface. As 
 this gray slough increases in extent and depth, accom- 
 panied by a severe burning pain and a sensation of 
 weight in the part, the surrounding surface becomes 
 (edematous, swollen, 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, undermined, 
 ragged, and partially everted, assuming an irregularly 
 circular outline, irrespective of the form of the wound 
 prior to ijs invasion. The gray, tenacious mass, being 
 formed of the mortified tissue, and containing pieces 
 of dead, blackened matter, holds its place and can not 
 l>c wiped off, although it sways to and fro when any 
 attempt is made to cleanse the wound. 
 
 The liquefaction of these mortified tissues soon com- 
 mences, and a dirty, thick, highly offensive, irritating 
 
238 8YMPTOM8 or HOSPITAL QANGBINX. 
 
 fluid, produced from the putrefaction of tho Blough, 
 escapes from the wound, diffusing a peculiar odor, 
 which, when once smelt, will always be recognised. 
 This is the poison which |" such powers of in- 
 
 fection when brought in contact with healthy wounds) 
 and which, when inserted under the skin, as in vacci- 
 nation, will soon produce a similar ulcer t<> that from 
 which the fluid was taken. 
 
 Oner the disease has fairly rooted itself, its ravages 
 are extrusive and rapid. One can nearly Bee the ex- 
 tending line of slough, as if the poisonous fluid, 
 bathing the wound, possessed corrosive proper! ies ; and 
 often in twenty-four hours large portions of the skin, 
 Cellular tissue, and muscles will have mortified, exca- 
 vating immense, frightful, ragged cavities, from which 
 strings of dead membrane bang, and in the bottom of 
 which will soon he found destroyed ligaments ami ten- 
 dons, with exposed osseous surfaces. The areolarand 
 cutaneous structures are the mosl readily destroyed j 
 the muscular and fibrous tissues yielding more slowly, 
 the nerves offering the greatest resistance to destruc- 
 tion. These changes in the wound ;iml surrounding 
 - are accompanied by a severe burning, sting- 
 ing, lancinating pain. 
 
 Pari passu with this local destruction, the system is 
 gradually or rapidly showing the influence <>t the 
 poison. Although the symptoms may he at first of an 
 inflammatory character, accompanied by a high fever, 
 the pulse soon loses its strength but increases in 
 frequency, the mind becomes peevish, fretful, ami de- 
 sponding, the tongue becomes dry and brown, the skin 
 
 pale, and the countenance anxious. The pain accom- 
 panying these changes is often so Beverc as to deprive 
 tie- patient of Bleep and -rcatly depress his spirits. 
 The fobrile accompaniments of the disease rapidly as- 
 
SYMrTOMS OF HOSPITAL GANGRENE. 239 
 
 sumc a typhoid cast, with eve*y indication of phj^sical 
 and nervous prostration. Should the system becomo 
 overwhelmed by the virulence of the poison, delirium 
 ensues, and, with a tendency to coma, becomes a prom- 
 inent symptom. 
 
 Should the caso not terminate fatally before the 
 elimination of the sloughs commences, the separation 
 of these may open large vessels, from which hem- 
 orrhage will rapidly destroy life. The great nerves 
 and arteries appear to resist the gangrenous destruc- 
 tion longer than the muscular or cutaneous structures. 
 These, however, yield in the end, and repeated hem- 
 orrhages close the scene. 
 
 When, from judicious treatment or strength of con- 
 stitution, the disease assumes a favorable turn, the 
 sloughs are gradually thrown off, healthy pus making 
 its appearance over the face of -the wounds. When- 
 ever laudible pus is seen in a wound which had been 
 the seat of hospital gangrene, it may be considered as 
 the sign that the disease has been checked, and a very 
 strong indication of healthy action being resumed in 
 the part. Granulations readily spring up over the 
 entire surface of such cavities, pieces of dead tendon 
 slowly coming away. When not sobbed in pus they 
 become hard and black from exposure to air. The 
 blackened surfaces of exposed bones also arc slowly 
 thrown off, by exfoliation, from the surface, and, in 
 time, the most extensive excavations may till up and 
 cicatrize. With the local return to health is an im- 
 j rovement in the general symptoms, diminution and 
 final disappearance of fever, improvement in strength 
 of pulse, return of appetite, and, with it. color to the 
 cheeks, and, more gradually, restoration of strength, 
 p the live bloody battles around Richmond in 
 the summer of 1862 (the last days of June and first of 
 
240 EPIDEMIC HOSPITAL GANGRENE. 
 
 Jul}-), our wounded suffered fearfully from hospital 
 gangrene in the hospitals of Richmond. Previous pri- 
 vations and hardships had broken down the physique 
 of the army. Our soldiers had not yet hecome 
 veterans inured to want, hut were, on the contrary, 
 much enfeebled by camp diseases and very short 
 rations. Wounds from the Richmond battle-fields took 
 on a sloughing condition at an early period, and amidst 
 the destruction of tissue which followed more or less 
 rapidly, arteries were frequently opened, and fatal 
 cases of secondary hemorrhage were numerous. 
 
 I witnessed 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 hard- 
 ships, retreating daily before a victorious enemy, and 
 had, prior to the Battle of Solferino, tasted no food for 
 forty-eight hours. They had been deceived by their 
 leaders, who had taught them that certain death 
 awaited them should they fall into tho hands of the 
 Italians. With these impressions, the wounded hid 
 themselves in the ditches and underbrush of the ox- 
 tended battle-field, where many perished. Some, were 
 not discovered for two or three days after the battle, 
 when they were sent to the hospitals. The previous 
 hardships which the Austrian* had undergone, their 
 lymphatic tendencies, their irregular living, with tho 
 moral depression of repeated defeat, exposed them to 
 the ravages of the lowest forms of disease. Hospital 
 gangrene raged fearfully among them, destroying 
 numbers. Many of their wounds were frightful from 
 tho extended sloughing, and their worn frames and 
 gaunt visages indicated a fearful combat with disease. 
 1 was particularly struck with the mental depression 
 under which many of them were suffering — amounting 
 
EPIDEMIC HOSPITAL GANGRENE. 241 
 
 to despondency. This was farther increased by the 
 attendants and surgeons not speaking the German 
 language, so that neither could their wants be known 
 nor could sympathy be extended to them. From the 
 combination of these depressing causes, an epidemic of 
 sloughing phagedoena appeared, which was appalling 
 even to those accustomed to see disease in its most 
 fearful form. In some, the muscles forming the calves 
 of the legs had sloughed out, leaving frightful cavities; 
 while in others, such was the destruction among the 
 muscles of the thigh, that one could look through the t 
 limb. 
 
 McLeod tells us that, in the Crimea, during the 
 heat of the summer of 1855, not a few of those oper- 
 ated upon were lost by a gangrene of the most rapid 
 and fatal form. All of those attacked by it were car- 
 ried off. In the case of a few, who lived long enough 
 for the full development of the disease, gangrene in 
 its most marked features became established; but 
 most of them expired previous to any sphacelus of the 
 part, overwhelmed by the violent poison which seemed 
 to pervade and destroy the whole economy. " The 
 cases of all those who died in my wards seemed to be 
 doing perfectly well up to sixteen hours, at the fur- 
 thest, before death. Duringthe night previous todeath 
 the patient was restless, but did not complain of any 
 particular uneasiness. At the morning visit the ex- 
 pression seemed unaccountably anxious, and the pulse 
 very slightly raised, tin' skin moist, and the tongue 
 clean. Hy this time the stump felt, as the patient ex- 
 pressed it, heavy, like lead, and a burning, stinging 
 pain had begun to shoot through it. On removing 
 the dressing, the stump was found slightly swollen 
 and hard, and the discharges thin and gleety, colored 
 with blood, and having masses of matter, like gruel, 
 u 
 
242 TREATMENT OF H08PITAL QARQRRRS. 
 
 occasionally mixed will) it. A few hours afterward 
 
 the limb would Ik- greatly swollen, the skin tense and 
 white, and marked along its surface by prominent 
 veins. The cut edges of tbe Btump looked like pork. 
 Acute pain was tilt. The constitution by this time 
 had began to sympathize. A cold sweat covered tho 
 body, the Btomaoh was irritable, and the pulse weak 
 ami frequent. The respiration became short and hur- 
 ried, giving evidence of the great oppression of which 
 the patient so much complained. The heart'* action 
 gradually and surely got weaker, till, from fourteen 
 to sixteen hours from the first bad symptom, death 
 relieved his Bufferings." 
 
 In the treatment of hospital gangrene^ we must con- 
 sider it frequently a local disease, with rapid tenden- 
 cy, to constitutional poisoning. One of our early 
 duties would he to destroy the accumulating poisonous 
 ichor in the wound to prevent further infection, while, 
 at the same time, we correct those depressing causes 
 which predisposed to the disease. Guthrie says that 
 constitutional treatment, and every kind of simple, 
 mild, detergent applications, always failed unless ac- 
 companied by absolute separation, the utmost possi- 
 ble extent of ventilation, and the greatest possible 
 attention to cleanliness ; and not oven then, without 
 great loss of tissue in man)' instances. 
 
 Tho local remedies which are found most useful act 
 as caustics, and comprise tho most energetic of the 
 pharmacopoeia. Tho French and German military 
 surgeons prefer the actual cautery to all other appli- 
 cations to check tho encroachments of the disease, 
 although Arm and even speaks of this remedj r , upon 
 which much reliance was placed, as exceptionally 
 checking the progress of mortification. "After a thor- 
 ough cauterization the eschar separates rapidly, and 
 
TREATMENT OP HOSPITAL GANGRENE. 243 
 
 often exposes a second infected surface of greater ex- 
 tent." His individual experience gives the preference 
 to tincture of iodine as a local application. The best 
 results were obtained by him when a compress satu- 
 rated with this tincture was applied to the wound. 
 
 Guthrie recommends the liberal use of the concen- 
 trated mineral acids, especially the fuming nitricacid. 
 McLeod refers to the nitric acid as the most efficacious 
 means of stopping the sloughing process. 
 
 In our extensive expci'ienee we do not hesitate to 
 give preference to strong nitric acid, which, when thor- 
 oughly applied to every part of the wound, will 
 cheek tho advance of the sloughing process. As the 
 application, when properly done, is an exceedingly 
 painful operation, the patient should have previously 
 had a large dose of opium, or chloroform should be 
 inhaled. The entire surface of the wound should then 
 be thoroughly mopped with a dossil of lint saturated 
 with the strong acid, which should be allowed to run 
 in along the sinuosities of the wound, so that every 
 portion of the exposed surface might be converted into 
 an eschar, and all the existing fluids of the wound be 
 destroyed by the action of the acid. One thorough 
 application will suffice to control any case of hospital 
 gangrene, and. if accompanied by judicious treatment, 
 will not require repetition. Half-way measures, it 
 must be remembered, will be trifling with the life of 
 the patient. The surgeon must not be deterred, by the 
 tear of giving pain, from making a thorough applica- 
 tion of the caustic. The after-treatment of the wound 
 consists iu the use of charcoal, flaxseed, or meal poul- 
 tices, rendered stimulating by an admixture of pyro- 
 ligneoue acid, turpentine, or creosote, or, what is flu? 
 preferable, lint, raw cotton, or old soft cloth, saturated 
 with solutions of eitlier of these fluids, as it makes a 
 
211 TREATMENT OF HOSPITAL GANGRENE. 
 
 much cleaner, equally useful, and more convenient ap- 
 plication, When the sloughing tissues have separated 
 and granulations have froely sprung up, warm water 
 dressings can 1"- subs! ituted. 
 
 To show the confidence placed upon the judicious 
 application of strong nitric acid, I will quote a few 
 lines from one of many reports forwarded to the Sur- 
 geon-General's office by the chief surgeons of hospi- 
 tals. Burgeon < 'hamblis, of ( 'amp Winder hospital an 
 institution of three thousand beds), speaks as follows: 
 " Nitric acid has been applied in every case of hospi- 
 tal gangrene which has occurred in this hospital dur- 
 ing the past year — in every case with benefit, and in 
 most cases with prompt and decided success, which 
 may always be exj ted as the result, if properly ap- 
 plied." 
 
 In some hospitals the persulphate of iron, which is 
 a powerful acid astringenl and cauterizing fluid, ap- 
 plied with similar care, was found equally efficacious, 
 and is spoken of as establishing a slough which, when 
 thrown off, leaves a clean, nicely granulating surface; 
 It thoroughly destroys all the putrescent tissues, 
 making a dark, pultaceous, inodorous slough, which 
 can be removed by syringing, and which will separate 
 in thirty-six to forty-eight hours, leaving a healthy 
 surface. This application does not destroy or excite 
 
 Surrounding tissues, as is the case with the more vio- 
 lent nitric acid or actual cautery. Strong pyrol igne- 
 ous acid, when poured into the cavity of the wound, 
 was found, in many oases, to be followed by equally 
 satisfactory results, alt hough in a number of instances 
 it did not check the progress of the disease. 
 
 Labarraquc's chloride ol soda, creosote, perchloride 
 of iron, lemon juice, oil of turpentine, a combination of 
 quickdime and coal tar, etc., have been also used with 
 
TREATMENT OF HOSPITAL GANGRENE. 245 
 
 benefit; but general experience in military surgery 
 gives decided preference to the mineral acid prepara- 
 tions. These may be followed by irrigation or fre- 
 quent syringing, which wash away the ichorous dis- 
 charges as rapidly as they form, and prevents further 
 infection ; also, some soothing application should be 
 made, containing stramonium, conium, morphine, or 
 some anodyne preparation, in solution, to. allay the 
 agonizing pain in and around the wound. 
 
 The local treatment alone, without the constitu- 
 tional, would be followed by no good results. As 
 hospital gangrene appears pre-eminently to reside in 
 over crowding, the most important of all the constitutional 
 remedies is change of air. If the patient could be re- 
 moved from the atmospheric influences of the infected 
 ward, his chances for recovery would be greatly in- 
 creased. Baudens states that without isolation all 
 treatment will show itself powerless, and our experi- 
 ence has confirmed the importance of ventilation. An 
 established custom in the organization of a Confed- 
 erate military hospital is to have attached to the 
 same a number of tents, to be used especially for 
 the treatment of erysipelas and hospital gangrene. 
 Whenever hospital gangrene shows itself in a wound, 
 the patient is immediately removed from the ward to 
 an airy tent, where the thorough application of nitric 
 acid is made to tho wound, and, under the gonoral sup- 
 porting plan of treatment, improvement appears to 
 show itself immediately. Under this generally adopt- 
 ed coarse of treatment hospital gangrene, the fright- 
 ful Bconrge of European military hospitals, has been 
 robbed of all its terrors. Fresh air is the great remedy, 
 Every day. when the weather permits, the sides of the 
 tent are tucked Dp, BO as to allow the free circulation 
 of air. Cleanliness must he insisted upon. Quinine, 
 
246 I'V.v.mia. 
 
 or the muriated tincture of iron, is administered as :i 
 tonic — brandy or whiskey freely used — strong, nutri- 
 tious food given ad libitum, and we expect the patient 
 to recover. Barely are we disappointed in establish- 
 ing a cure. 
 
 Keeping the intestinal action free by a little blue 
 mass, or compound extract of* colocynth, will be re- 
 quire" i. 
 
 Opium is required in every stage of this dis< 
 and is administered in large and repeated doses to 
 allay the pain, irritability, ami sleeplessness which so 
 generally attend the severe cases of gangrene. The 
 diet throughout should be highly nutritious, ami should 
 be liberally prescribed. Although wounds, under the 
 influence of hospital gangrene, assume frightful ap- 
 pearances, the inexperienced surgeon can not be too 
 urgently warned against amputating limbs, unless 
 driven to it to save life, from the disastrous effects of 
 frequently recurring hemorrhages. The stump will 
 at once take a similar condition of sloughing, and 
 soon a more extensive ulcer than the one for which he 
 amputated will show him that he has risked the pa- 
 tient's life, by a serious operation, without having im- 
 proved his condition. 
 
 Pyjemia, a disease very common in Europe, and a 
 scourge of their military hospitals, was but seldom 
 met with in the Confederate States until it became 
 necessary to mass large numbers of wounded in crowd- 
 ed and badly ventilated wards, as after the many 
 bloody battles of the past three years. When it shows 
 itself in European hospitals, like its kindred disease, 
 erysipelas, it is not satisfied until it has swept off its 
 hundreds. After the battles of the Crimea those re- 
 quiring amputation were severely alllicted by pyajmia. 
 
PYEMIA. 247 
 
 nearly one-fourth of those operated upon being carried 
 off by this frightful scourge. In civil hospitals it is not 
 the less frequently met with, us we are informed by 
 European writers that it destroys forty-three per cent, 
 of all fatal primary amputations and twenty-five per 
 cent, of all fatal secondary amputations — ten per cent, 
 of all amputations dying from pyaemia. In some of our 
 militarj^ hospitals it has proved fatal to several of our 
 wounded ; at no period, however, has it appeared as an 
 epidemic, with its hundreds of victims. During the 
 years 1862 and 1863, before buildings were especially 
 erected for military hospitals, and when houses, how- 
 ever badl}* suited, were, from necessity, used as wards 
 for our wounded men, we find but fifty-two cases of 
 pyaemia reported by army surgeons. At the same 
 time fifteen hundred and seven amputations of large 
 limbs were reported as having been performed from 
 October, 18G2, to October, 1863 — only a portion of the 
 interval referred to above. Although this number is 
 not supposed to represent every case that occurred 
 during that period, it is, nevertheless, sufficiently near 
 the truth to show that, comparatively, it is a rare 
 disease in the Confederate army. Of these fifty-two 
 cases but one cure is reported, which also indicates 
 that it has lost none of its malignancy when con- 
 trasted with its European fac-simile. 
 
 The great similarity in causes, symptoms, and 
 effects, are sufficient grounds for associating this with 
 the huge class of aesthenic diseases, among which ery- 
 sipelas and hospital gangrene are prominent. It is 
 impossible to control the symptoms and prevent a fatal 
 issue, when, as acute pyaemia, it seizes upon the 
 wounded in military hospitals; it is, therefore, much 
 more to !"■ feared than its kindred diseases just men- 
 tioned. Although this disease is always associated 
 
248 SYMPTOMS OF PYiEMIA. 
 
 with injuries, no wound, however trivial or however 
 well advanced toward cicatrization, is safe from its 
 attack until completely healed. The disease is sup- 
 posed to be caused by a vitiated condition of the 
 atmosphere from over-crowding in badly ventilated 
 wards, and by the absorption of the ichorous fluids 
 decomposing in the wound, which produces a general 
 poisoning of the blood, rendering it unfit for sustain- 
 ing life. It has been called an acute decomposition 
 of the blood. 
 
 The most conspicuous phenomena which accompany 
 this affection are, great depression of the powers of 
 the system, and the formation of abscesses in various 
 parts of the body. In the incubative stage, which 
 may precede the explosion of the disease by twenty- 
 four or thirty-six hours, the patient is restless, anxious, 
 ill at ease, with forebodings of impending trouble. He 
 looks pale and sallow, has loss of appetite, and gener- 
 ally deranged secretions. The disease commences by 
 severe chills of long duration, which, in the acute 
 cases, are repeated with much irregularit}'. In the 
 subacute variety these chills appear at such regular 
 intervals, followed by high fever and terminating in 
 profuse sweats, as to induce the belief of the existence 
 of malarial-fever. In many cases the skin is hot, with 
 a pungent feel, irrespective of the chills; in others 
 the chilly and feverish sensations alternate, the skin 
 being at times clammy and often jaundiced. The 
 pulse is quick and feeble; face pale, with anxiety of 
 countenance; tongue foul, with a tendency to become 
 dry, and for sordos to collect upon the teeth ; the 
 stomach is uneasy, with bilious vomiting, and constant 
 thirst. The suspension of secretions gives a dull, yel- 
 lowish, icteric tint to the skin. 
 
 As the pulse becomes more and more enfeebled, the 
 
THEORY OF PUS FORMATION. 249 
 
 patient may complain of pains in his joints, simulating 
 rheumatism, and, simultaneous with these, a reddening 
 of the skin, with swelling of the joints. Collections of 
 a purulent character will soon after be detected, dis- 
 tending the synovial sacs. Collections also occur in 
 the cellular tissue, and even in the substance of organs. 
 These form rapidly and without much inconvenience. 
 Often the swelling alone — which has appeared during 
 the night, unaccompanied with pain, redness, or heat — 
 indicates that a large collection of pus has already 
 taken place. 
 
 While these symptoms progress, the wound usually 
 becomes foul and sloughy, ceasing to secrete pus. 
 This is not the invariable rule, as surgeons have noticed 
 cases in which the appearance of the wound was no 
 indication of the destructive disease which had laid its 
 relentless hand upon the injured. The disease may 
 even run its fatal course without material changes in 
 the wound. Certain injuries are more likely to be 
 followed by pyaemia; and those of bones and joints are 
 said to be peculiarly exposed to it. As in the kindred 
 diseases of low type, typhoid symptoms ensue at an 
 early day, and usually carry off the patient at the end 
 of the first week. Often' stupor comes on as early as 
 the fourth day, having been preceded by delirium. 
 An examination after death will reveal a rapidly ad- 
 vancing decomposition, with gas in the blood-vessels 
 and purulent collections in many organs, as the lungs, 
 liver, spleen, kidneys, heart, and brain. Similar col- 
 lections are found in most of the large joints, besides 
 the multiplied abscesses of the cellular tissue. 
 
 The theory of the metastatic character of the 
 abscesses, or the sudden change of place of such de- 
 posits, by absorption and redeposit, has long been 
 abandoned. Pus we now believe to be a modified 
 
 
250 THEORY OF PUS FORMATION. 
 
 nutrient fluid, which, from an impairment of its vital- 
 izing principle, falls short of its object of repairing 
 tissues. During the healthy action of living tissues 
 they arc constantly bathed in a plastic fluid which 
 they draw from the blood-vessels for their support. 
 Under ordinary acute inflammation this exudation of 
 plasma is freely drawn by excited tissues, which are 
 not able to consume the excess of nutriment which 
 they have taken from the circulation. This plastic 
 fluid, now at rest without the blood-vessels, and not 
 being used for the nourishment of the affected tissues, 
 attempts a formation of its own, developing cells in 
 this plasma which simulate closely the white cells in 
 the progressive development of the blood, and which 
 are supposed by some pathologists to be identical 
 with them. The effused fluid exhausts its developing 
 vitalizing power in this creation, and all further 
 changes in it are of a retrograde nature. This cellu- 
 lar fluid is pus. When, from some special cause, the 
 entire circulating fluid has become poisoned, its en- 
 tire plasma or liquor sanguinis is impaired. It is from 
 this plasma, under ordinary conditions, that the blood- 
 cells are to be generated. The usual process of devel- 
 opment is commenced, white cells form as colorless 
 blood corpuscles, and when the continued develop- 
 ment into the red or perfect cell is attempted, many 
 failures occur. There are, besides, many which had 
 exhausted their formative powers in attaining the de- 
 gree of development necessary to perfect the white 
 cell, and remaining as such, continuo in the circu- 
 lation. When the blood of a pyamiie patient is ex- 
 amined, a very large number of such colorless cells 
 are found in the blood, even in sufficient quantity to 
 modify its color, and it is in autopsies that the sepa- 
 ration of these white cells from the generating fluid 
 
HOW TO PREVENT PYyEMIA. 251 
 
 shows the appearance of pus in the blood or emboli 
 in the large vessels at the heart. 
 
 Blood in this condition, with an impaired liquor 
 sanguinis, is unfit for its duties as a life-supporting 
 fluid. The various tissues of the bod)', not receiving 
 the kind of nourishment appropriate for their healthy 
 function, become irritated. Nature tries to make up 
 the dcficienc}' in qualit}- by quantity. The irritated 
 parts are supplied with an excess of the impaired nu- 
 tritive fluid, which, being eliminated from the capil- 
 laries, is received into the tissues. This is rapidly 
 converted into pus, by the development of white or 
 colorless cells in it, which is the height of vitality in 
 such an exudate. 
 
 Experience, which helps to sustain this view, shows 
 the disease to be purely a blood poisoning — a general 
 disease, with its local manifestations. When the blood 
 has been thus thoroughly deteriorated, no remedy 
 which art possesses can restore it to its former health}' 
 condition, and the patient necessarily dies — there be- 
 ing no case of acute pyaemia which has ever been re- 
 ported cured. 
 
 As there is no course of treatment for acute pyaemia 
 which promises any good results, we must direct our 
 energies where they can really be useful. Our great 
 remedy lies in prevention. The hygienic precautions 
 of rigid cleanliness, thorough ventilation, good food, 
 and proper shelter, without over-crowding, will, if prop- 
 erly insisted upon, go far to keep away, if they do noo 
 altogether prevent, the occurrence of pyaemia. When 
 this disease threatens, too much attention can not bo 
 paid t<> I he detail of cleanliness in the wards. Theslop- 
 DUCketS, which are such a niusance, should be imme- 
 diately emptied, scoured daily with lime, and always 
 kepi covered, that the emanations arising from de- 
 
252 HOW TO PREVENT PYEMIA. 
 
 composing urine, which is very deleterious in hospi- 
 tal wards, can not escape. The bed and body linen 
 of the patients should be daily changed; doors and 
 windows must be kept open. If any difficult} 7 exists 
 in this respect, from the inattention of nurses or fears 
 of patients, it would be better to takeout the sashes, 
 so as to ensure continued renewal of the atmosphere 
 da}' and night. 
 
 There is a general dread of night air among our 
 people, 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 patient is 
 properly covered in bed, there is no fear of his taking 
 cold or contracting other injury from the continued re- 
 newal of pure air. Men who live in the open air, and 
 are protected by no other roof than the arched sky 
 above them, never have catarrhal affections. These 
 precautions must not be commenced when pyaemia 
 has already shown itself, but are those necessary to 
 be taken wherever the seriously wounded are treated) 
 or some low form of fatal disease will soon break out. 
 Any one who will visit, during the night, a ward 
 filled with suppurating wounds, will perceive the de- 
 gree of vitiated air which the patients are inhaling, 
 and see the necessity for free ventilation. 
 
 It is a bad principle to concentrate the seriously 
 wounded; always scatter them over a building, 
 mixing them in with , inmates from other diseases. 
 This increases the available space for tho seriously 
 wounded, and prevents a depressing effect, by diffus- 
 ing the emanations from so many extensive suppurat- 
 ing wounds. It is for a similar reason that we have 
 already recommended that rooms should not be kept 
 too long in use when occupied by tho severely wound- 
 ed. As the air becomes poisoned, the ward requires 
 
HOW TO PREVENT PYAEMIA. 25o 
 
 to be unoccupied, for purification, two weeks of every 
 two months, during which interval it is thoroughly 
 cleansed and whitewashed. 
 
 When pyaemia threatens to become general in a 
 military hospital, the seriously wounded should be put in 
 tents, or allowed double space in a constantly ventilated 
 room. Sixteen hundred cubic feet would not be too 
 much for every occupied bed. An additional quantity 
 of nourishing food should also be given out to all the 
 wounded ; besides which, whiskey or malt liquors 
 should be daily issued. Feeding the wounded on light 
 broths and other slops is paving the Avay to the de- 
 bility which is a precursor of pyaemia. At such times, 
 when pyaemia makes its appearance, all small opera- 
 tions should be avoided, 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. More 
 benefit will be derived from changing the patient into 
 fresh air than from any other remedy ; and, if he can 
 be saved, it^vill only be by putting him in a tent in 
 which he can be constantly surrounded by an ever- 
 changing atmosphere. Our entire reliance should 
 be placed upon the stimulating tonics. Strong, nutri- 
 tious, easily-digested food, the free use of stimuli, with 
 opium to allay pain and restlessness, are the remedies 
 indicated. The tendency to delirium should not [in- 
 vent the free use of this last remedy, for although it 
 would increase the difficulty if it be given in inflamma- 
 tion of the brain or meninges, it allaj-s pain, removes 
 restlessness, stops muttering, and induces quiet Bleep, 
 when given in cases of debility accompanied by de- 
 lirium. As in erysipelas, the acid preparations of 
 iron, as a blood tonic, may be administered with ad- 
 vantage. 
 
254 HOW TO PHKVENT PTiBMIA. 
 
 Although so little is to be expected in the actte form 
 of blood poisoning; in the Bnbacute or chronic pyemia 
 much benefit will be derived firom rigidly pursuing the 
 course of treatment just marked out. By the Bti mu- 
 tating and supporting plan, with change of air, many 
 patients, after a long struggle, ma}- be saved. 
 
 The important indication for local treatment in 
 pyemia is to prevent, by cleanliness, the accumulation 
 of putrescent fluids in the wound, and l>y the frequent 
 application of chlorinated washes, which also remove 
 foetor and stimulate the granulating surface. The 
 abscesses which form during the march of the disease 
 should not be too hastily opened, as this course, pur- 
 sued with the numerous collections, will induce rapid 
 prostration. 
 
 It is thus seen that the three most fatal complica- 
 tions to gunshot wounds are the three kindred dis- 
 eases — erysipelas, hospital gangrene, and pyemia — all 
 recognizing a common origin, viz: imperfect ventila- 
 tion, and want of proper attention to cleanliness, with 
 the abscenco of those h3 T gienic regulations necessary 
 for the healt h of an army. • 
 
 With proper care from the medical corps, these dis- 
 eases, which are the chief BCOUrgCS to the wounded, 
 
 and the causesofa large percentage of deaths, can bo 
 in a measure, if not altogether, prevented. 
 
 Once they have made their appearance iii a hospital, 
 they will never he got rid of until the building is 
 dosed, and the proper measures for purification re- 
 sorted to. Prevention, in this instance, as in all oth- 
 ers, will he found better than attempts at cure, as 
 many of these diseases, once they appear, are found 
 quite unmanageable, and tend naturally to a fatal is- 
 sue. All of these diseases are benefited by the isola- 
 tion <>f the patient in a pure atmosphere, when the 
 infectious character of the disease is counteracted,. 
 
HECTIC FEVER. 255 
 
 and the patient is in the host condition for successful 
 treatment. In all of them the antiphlogistic treatment 
 can not. be too severely condemned, 'flic support inn; plan, 
 with stimulating tonics and liberal diet, is the only 
 rational course that promises success, and should be 
 followed throughout the treatment. Attending to the 
 secretions with mild remedies, allaying pain, and in- 
 ducing refreshing sleep by means of opium, good, 
 strong, easily-digested food, and due regard to hygi- 
 enic regulations, will be the course of practice to bo 
 pursued. 
 
 Hectic Fever. — The not unfrequent sequela of se- 
 vere gunshot wounds is long-continued discharge, pro- 
 ducing emaciation and hectic, with its gradual disso- 
 lution of body and soul. It is not at all surprising 
 that the daily discharge from a wound, when at all 
 profuse, should cause debility, as we have already 
 characterized pus as the nutritive essence of the cir- 
 culating fluid. If the surgeon who has suppurating 
 wounds under his care overlooks the fact that he must 
 make allowance for this drain, and feed the wound as 
 well as the patient — the wound being more imperious 
 in its demands than the economy, deprives the latter 
 of its duo supply of nourishment, and progressive 
 starvation, which we call emaciation, must follow. 
 It is on this account that what is called the antiphlo- 
 gistic treatment, when fully carried out in the treat- 
 ment of suppurating wounds, is so injurious, and that 
 the supporting plan is required. 
 
 With diet, we have a powerful weapon for weal or 
 in surgical practice. Soon after injuries have 
 been received, when reaction runs high, by abstemi- 
 ousness we can do much to quiet excessive irritabil- 
 ity Bui as soon as this stage has passed, and sup- 
 
HECTIC NEVER. 
 
 paratloa has l>< me established, then the court 
 
 <lict Bhould be modified. Now liberal diet is necessa- 
 ry to prevent that febrile complication which, in t he 
 early stage of the wound, abstemiousness controlled. 
 
 The use of an abundance of strong, nutritions food, 
 with stimuli, by enriching the blood, will increase the 
 vital properties of the plasma, improve 1 1 1 » > tone of 
 tli«' tissues, Btop tln v excessive demands of the irritated 
 Wounded parts, ami diminish tht' drain. This t rest- 
 raint, with the liberal use of theastringent tonics, espe- 
 cially the preparations of iron, the use of cod liver oil, 
 and the injection of stimulating astringents into the 
 wound | a- nitrate of silver, ten grains to one ounce of 
 water, <>r tincture of iodine, or the acid tinctures of 
 iron diluted, or pyroligneous acid, one part to five of 
 water*), will gradually diminish a discharge which, un- 
 der less supporting treatment, would continue for a 
 much longer period. The economy can not withstand 
 this constanl drain of pus. A.s its nutrient fluid escapes 
 from the^ wound, the system becomes irritable in its 
 weakness In its efforts to throw oft* this yoke, it still 
 further enfeebles itself. Daily fevers, with their pro- 
 fuse sweats, reappear with fearful regularity. Finally 
 the blood becomes so poor that it deteriorates even 
 more rapidly. The effete matter or useless material 
 which is rapidly accumulating in nio blood, ami which 
 is ejected from the circulation, irrritates the organ* 
 through which it passes, causing diarrhesa, and also 
 copious deposits in the urine. This quadruple drain 
 from wound, skin, bowels, and kidueys, can not long 
 be resisted. Debility daily increases, the patient rapid. 
 lv wastes to a living skeleton, having literally melted 
 away, and at last dies from sheer exhaustion — the 
 conjoined result of malnutrition and wasting dis- 
 charges. Such is hectic fever. 
 
TETANUS. 257 
 
 Tetanus. — Another fatal complication of wounds, 
 depending, however, upon very different circum- 
 stances from those recently considered, is tetanus, or 
 lockjaw — a disease fearfully malignant under any cir- 
 cumstances, and, with very few exceptions, in military 
 surgery. Fortunately, this is never an epidemic, nor 
 can it infect a hospital, although pathologists have re- 
 cently attempted to prove its origin traceable to an 
 animal poison. This disease, although comparatively 
 common among our negro population, has but rarely. 
 been met with in military practice, and is not more 
 frequent among our wounded than it is in Europe, 
 where it is rarely met with. In the Crimean service 
 McLcod m-entions but thirteen cases as occurring in 
 camp and in the hospitals. 
 
 This disease, which does not depend upon the size 
 of the wound from which the patient is suffering, ap- 
 pears to be caused frequently by sudden atmospheric 
 changes in connection with dampness. Larrey, in his 
 experience both in Germany and Egj T pt, found it in 
 those wounded who, after sustaining great exertions 
 during the fight on a very hot day, were exposed to the 
 cold. dain]i night air on the field without shelter. After 
 the Battleof Bautzen, where the wounded wcrelefton 
 the field during the night, exposed to severe cold, Lar- 
 rey found on the following morning that more than 
 one hundred were affected by tetanus. No such effects 
 have followed the leaving of wounded soldiers upon 
 the battle-fields of the Confederacy. In the thickets 
 which cover the face of the country, and in which bat- 
 tle- often rage, some of those who fall escape the ob- 
 servation of those insearch of them, and remain two 
 and three day 8 exposed to the elements. Such wound- 
 ed we have not found more liable to tetanus than 
 those immediately eared for. In very hot climates it 
 v 
 
2.38 SYMPTOMS OF TETANl - 
 
 requires but little excitement to produce it — a trifling 
 
 puncture or scratch is, at times, sufficient to cause an 
 attack; and it has been noticed by military Burgeons 
 that the scraping of the skin by a ball, with bruising of 
 tho nerves, is more liable to tliis complication than 
 the more Bevere wounds. 
 
 Tho proximate cause appears to be some injury to 
 the nerves, not necessarily connected with an open 
 wound, as it has been known to follow the Mow of a 
 whip or a Bprain. Wounds in certain situations are 
 thought to favor its appearance, viz: injury to the 
 hands, feet, joints, etc. It may occur very speedily — 
 a few hours after the injury has been received — or it 
 may not occur for days. Rarely does it complicate 
 chronic wounds after the twentieth day. Its common 
 period for appearing is between the fifth and fifteenth 
 day, when, pei-hap-. thesimple wound has completely 
 cicatrized. 
 
 The premonition of anoasincsa on tho part of the 
 patient, with vague fears of impending trouble, dis- 
 turbed digestion, etc., are not often observed. Usu- 
 ally the first symptom which we recognize is a com- 
 plaint of soreness of the throat, which in ordinary 
 cases precedes, liy some hours, the contraction of the 
 muscles of the jaw and pinching of the features. This 
 
 symptom is often mistaken for a common son' throat 
 
 connected with some catarrhal affection, and is treated 
 
 accordingly — the true character of the symptom be- 
 ing usually overlooked. The spasm, instead of com- 
 mencing in the injured part, usually shows itself first 
 
 in those muscles supplied by the fifth pair of nerves; 
 and although, in sudden and violent cases, the spas- 
 modic contraction of the muscles generally may rapid- 
 ly follow the locking of tho jaws, or appear to be 
 even simultaneous with it, they are rarely found to 
 
SYMPTOMS OF TETANUS. 25 ( J 
 
 precedo it. The locking of the jaws; the contrac- 
 tion of the muscles of the neck, especially the sterno- 
 cleido-mastoids, which, b}~ bounding under the skin, 
 accurately defines the triangles of the neck; the pain- 
 ful sensation of tightness about the ensiform carti- 
 lage, as if the chest were in an iron coil ever contract- 
 ing; the hardened condition of the abdominal mus- 
 cles, with knots forming over the region of the recti 
 muscles during the paroxysm of spasm ; the stiffen- 
 ing of the muscles of the legs, while those of the 
 arms remain free ; the sardonic expression of the face, 
 with drawn mouth and pinched features; clear in- 
 tellect; sleeplessness; extreme restlessness; profuse 
 sweating; incessant desire to drink, and extreme diffi- 
 culty in accomplishing it; the occurrence of parox- 
 ysms of violent muscular contractions every few min- 
 utes, with loss of strength in the pulse, and rapid pros- 
 tration — define so accurately the disease that it is one 
 in ost easily recognized. 
 
 An} T one who has ever felt a cramp in the calf of 
 the leg. may have a faint appreciation of the intense 
 pain which a permanent and violent cramp of all the 
 muscles of the body must produce — a pain sufficient to 
 destroy life promptly, through nervous exhaustion. 
 
 The prognosis of this disease is so serious, and the 
 treatment, however conducted, so unsatisfactory, that 
 man}- surgeons of large experience have never had a 
 of traumatic tetanus to recover under their treat- 
 ment. That fruitful source of information, pathology, 
 gives ns no instruction in this disease. An autopsy 
 La to the eye nothing commensurate with tho 
 intensity of the symptoms. A slight congestion of the 
 spinal COrd and medulla oblongata is all that can he 
 ned. Prom the symptoms, we judge of the dis- 
 as one of intense nervous irritation. \l< cognising 
 
260 TREATMENT OF TETANUS. 
 
 the exhaustion which so soon and with such certainty 
 shows itself, the treatment, as laid down by the most 
 recent authors, and the one now generally adopted, is 
 one of support to both the nervous and muscular 
 systems. 
 
 Larrey lias cut short the disease, in its incipient 
 stage, by amputating the limb, or dividing the nerve; 
 which is supposed to he at fault. Other surgeons, by 
 isolating the irritation, have been equally successful. 
 Such results are, however, rarities in practice, the 
 operations nearly always failing even when performed 
 simultaneously with the very first symptoms, and 
 always when the disease becomes confirmed with gen- 
 eral spasms. At times, patients suffering from tetanus 
 get well under the mosl varied treatment. Nearly 
 every powerful remedy in the pharmacopoeia has been 
 recommended as a sovereign cure by those who may 
 have derived Borne benefit from sueh in the treatment 
 of tetanus. Disappointment is sure to follow the con- 
 fidence placed in any oi these articles. The most 
 judicious course is to disclaim all specific remedies, ami 
 be guided by the symptoms. Allay, if possible, the 
 intense nervous excitement, and the local cause of irri- 
 tation by which tic disease is occasioned, and support 
 the system against the ensuing exhaustion, both hy 
 sustaining the patient's Btrength with strong, easily- 
 digested food, and by procuring sleep, so as to allow the 
 nervous system an opportunity of regaining its wasted 
 powers. 
 
 The local treatment should consist in examining the 
 wound for fore ign bodies, and removing them, if pos- 
 sible, as they are frequently the exciting cause of 
 nervous irritation, under the presumption that unless 
 the local cause be removed we can expect hut little 
 abatement of the general tetanic excitement. .Should 
 
TREATMENT OF TETANUS. 261 
 
 no foreign body be found, if it be possible, an incision 
 should be made on the cardiac side of the wound, so as 
 to divide the nerves implicated, and paralyze their sen- 
 sibility. The powerful acids and the actual cautery 
 have been recommended for the similar purpose of de- 
 stroying the excited nerves at the seat of injury. 
 Although the}* may be at times useful, I have seen fatal 
 tetanus produced from ulcers under the cauterizing 
 treatment; and I have recently lost a case, after ampu- 
 tation of the leg, from gunshot fracture of the tibia, in 
 which mortification had attacked the entire stump. 
 In this instance, after arresting the sloughing by the 
 liberal use of fuming nitric acid, and succeeding in es- 
 tablishing a well defined line of demarcation, tetanic 
 symptoms appeared and destined tire patient in thir- 
 ty-six hours. A solution of morphine, atropine, aco- 
 nite, or kindred preparations, may be instilled into the 
 wound, for their sedative action, and the water dress- 
 ing, medicated with these remedies, continued. 
 
 If it be a E-mail member wounded, such as a finger or 
 toe, an early amputation may stop the spasm by 
 removing the irritating cause, and, therefore, 'should 
 be tried in all eases. This amputation should be per- 
 formed irrespective of the local appearances of the 
 .wound, and even if it be nearly cicatrized. .Should 
 tlic injured extremity be in a sloughy state, so as to 
 render its recovery doubtful, amputation should be 
 performed at any stago of the disease. When tetanus 
 supervenes upon an amputation, the surgeon would bo 
 justified in performing a second amputation upon tho 
 early establishment of the symptoms, as good results 
 mighl follow siieh ;i course. 
 
 The constitutional treatment will have for its object 
 tho removal of all those general and local causes winch 
 may keep up excitement. !i'< should constantly bear in 
 
262 TREATMENT OF TETANUS. 
 
 mind that tetanus is an affection of debility , and tbat the 
 violence of the spasmodic paroxysm gives & false ap- 
 pearance of strength to the patient, while the principal 
 source of danger and <l*:it li is from exhaustion, induoed 
 by the excessive energy of the muscular movements, 
 and the consequent want of rest. 
 
 Tn hospital practice, remove the patient at once 
 to a small room or tent, where he will be alone with 
 his single attendant. Ah the bowels are always con- 
 stipated and loaded with offensive foecal collections, 
 which might assist in sustaining the excitement of 
 the nervous system, the}'' should be at once emptied 
 by large doses of calomel, with gamboge, aloes, or 
 podophyllum. When a difficulty is found in adminis- 
 tering these, from the locked condition of the jaw, 
 two or three drops of croton oil can be placed within 
 the teeth, which, mingling with the saliva, will bo 
 swallowed. Three or four times the ordinary dose 
 will be required to relieve the torpid bowels. The 
 patient should then be kept perfectly quiet — if possi- 
 ble, by himself, as the stirring about of persons, noises, 
 draughts, etc., excite sudden and repeated paroxysms 
 of spasm. Ice bladders, blisters, or chloroform appli- 
 cations, may be made to the upper portion * » 1" the 
 spine to allay, if possible, the irritation of this nervous 
 centre. 
 
 Although opium is universally administered as an in- 
 ternal sedative, its good effects are not often obtained 
 even when given in largo doses. It is believed thai it 
 remains unabsorbed in the Btomach, and therefore ex- 
 hibits no action. The same of conium, hyoscyamus, 
 and the entire class of sedatives, when 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 slowly that their good effects are not 
 perceived. 
 
TREATMENT OP TETANUS. 263 
 
 .Recently, in two cases of traumatic tetanus, I havo 
 tried the endermic administration of morphine in one- 
 third grain doses, dissolved in a few drops of water, 
 and injected by means of a Wood's syringe. In a few 
 minutes the effect of the remedy was decided, but it 
 was not persistent. By its use partial relaxation of the 
 {jaws could always be effected, so that the taking of 
 nourishment was much facilitated; sleep could also be 
 induced. It is by far the preferable mode of using 
 opium, as its effects can be speedily and with certain- 
 ty obtained. In one case, in which I injected one- 
 tenth of a grain of atropine under the skin of the arm, 
 the effect upon the pulse was so immediate 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 secre- 
 tions, without, however, producing dilatation of the 
 pupils or causing relaxation of the muscles. As no 
 beneficial effect followed the atropine injection, mor- 
 phine had to be used, when relaxation to a certain 
 extont was immediately obtained. 
 
 The liberal use of belladonna has been recommend- 
 ed, and, from its great utility in relieving congestions 
 of the lower portion of the spinal cord, we might natu- 
 rally infer similar good effects upon the medulla ob- 
 longata. The tincture of cannabis indica has been 
 highly extolled. Some cases have recovered under its 
 use, but a very much larger number have died in spite 
 of its administration. The tinctures of vcratrum vir- 
 idis and golseminum sempervirens are also favorite 
 remedies with some, who speak <>f them as valuable 
 means for calming the excited action of the heart and 
 relaxing the stiffened muscles. Stimulating and nour- 
 ishing fluids must be liberally administered at regu- 
 lar intervals, and, notwithstanding the difficulty in 
 
264 TREATMENT 01 TKTAH 
 
 swallowing, the nurse should insist upon their being tak- 
 en. Many a fatal case can DC laid to tin- charge of care- 
 lessness in the attendance, where the wishes of the 
 patient are permitted to regulate the nurse's duties. 
 Beef lea,---;-, milk, custards, eggnog, and similar ar- 
 ticles of concentrated fluid nourishment, with wine, 
 brandy, or whiskey, must be frequently poured down th& 
 throat of the unwilling patient; ami if the mouth can 
 not be sufficiently opened, the inhalation of chloro- 
 form, or the endermic use of morphine, should be free- 
 ly used to effect it. I have seen excellent results from 
 either of these relaxing agents. I have found porter 
 an excellent tonic in such cases, as it combines both 
 sedative, nourishing, and stimulating or supporting 
 properties. The amourf! of stimulus to be adminis- 
 tered must not be measured by the health standard. 
 as I do not believe that intoxication can be induced 
 while the system is laboring under tetanus. 1 believe 
 that if inebriation could be brought about it would 
 mark, in many cases, the commencement of convales- 
 cence. Under the frequent inhalation of chloroform 
 the spasms can often he kept under control. 
 
 By pursuing the above course of keeping the pa- 
 tient <|iiiet, using nervous sedatives, with forced nour- 
 ishment, giving si iniulus freely. and relieving the loaded 
 intestines by croton oil, I have had the good fortune 
 of saving three tetanic patiertfS oul of six cases which 
 have come under ray personal observation. As the 
 three first cases which I treated were all restored to 
 health, although tiny were very Severe ca-es ( ,f trau- 
 matic tetanus, 1 imagined that I had found a success- 
 ful mode of treating this dreadful disease, and publish- 
 ed the same in the Charleston Medical Journal for 
 lsf>7. Since that time 1 have had throe cases under 
 Observation and lost them all, notwithstanding the 
 name course was pursued as in the successful cases. 
 
TREATMENT OF TETANUS. 265 
 
 When tho patient is able, constant smoking of 
 strong cigars may be useful in quieting the excited 
 nervous system. The impression among many ob- 
 serving surgeons is, that the patient is destroyed by 
 exhaustion — called by some staiwation. It is known 
 that if the patient can be kept alive to the sixth day 
 after the attack, there is a likelihood of his recovery, 
 and that by the tenth day he may even bo considered 
 convalescent. If the debilitating effects of the dis- 
 ease can be counteracted by the free administration 
 of very nutritious food, such as brandy, eggs, etc., 
 many surgeons believe that the nervous irritation 
 will wear itself out. It is based upon this belief, and 
 the known failures attending the spoliative plan of 
 treatment, that the above plan is urged. 
 
 Woorara poison has been recommended as an anti- 
 dote, from its known powerful sedative nervous ac- 
 tion, and its marked influence in counteracting the 
 effects of strychnia. When poisonous doses of these 
 substances are given conjointly, no poisonous effects 
 arc observed. The striking similarity betAveen the 
 spasms produced by strychnine and those of lock- 
 jaw suggested the use of woorara in this latter disoase. 
 As experiments proved it efficacious in the tetanus of 
 animals, its field of usefulness was enlarged to the hu- 
 man subject, and several cases of its successful adminis- 
 tration in chronic tetanus are reported. It was first 
 used by inoculation ; now it is given in the form of a 
 mixture: ten grains of the woorara to a six-ounce 
 mixture— a tablespoonful every half hour until perfect 
 relaxation is produced. Should poisonous effects, with 
 death-like symptoms, show themselves from an over- 
 dose, artificial respiration will support life and sus- 
 tain the action pf the heart until the poison is elimi- 
 nated from the circulation by the kidnoys. Tho 
 w 
 
PERIODIC PA1NI 
 
 rationale ol the remedy is to keep the spasms from 
 killing the patient by their violence, until the morbid 
 state calling thorn into play has exhausted itself. 
 
 Prom the known influence of quinine in diminishing 
 the pulse, and its tendency to mitigate Bpasms, many 
 consider it a useful drug in tetanus, and speak of h 
 remedy well worthy of trial. Cures have been effect- 
 ed under its liberal m 
 
 An expression which we frequently hear from a 
 lain class of surgeons is: "That the wounded under 
 their charge were threatened with tetanus, but the dis- 
 ease was kept off by judicious and timely treatment." 
 The community take uj> the refrain in resounding the 
 praise's of their skilful attendants. Although we have 
 had large experience in the treatment of wound-, we 
 are still at a loss to understand the above expression. 
 We do not believe that tetanus ever idly threatens, or 
 that there is any symptoms by which wecan l>e led to 
 suspect the probable occurrence of the disease. When 
 our Buspioions are aroused tetanus has already, by 
 unmistakable Bigns, laid its iron hand upon its victim. 
 and can not, by any treatment which we may insti- 
 tute, be suddenly checked in its well known pro 
 sive march. We do not know of any abortive treat- 
 ment for tetanus. 
 
 Periodic Pains. — Another Bcquela of gunshot 
 wounds is more or less permanent or periodicpain in the 
 injured limb, connected or not with paralysis of certain 
 muscles — the nervous supply to which has been im- 
 paired or destroyed by the ball in its passage. When 
 a nerve has been completely divided, permanent pa- 
 ralysis of the part supplied by it, and atrophy of the 
 muscles, ensue — the limb gradually dwindling, if the 
 muscles, indirectly destroyed, he important to the 
 
PERIODIC PAINS. 267 
 
 common movements of the extremity. A bruising of 
 the nerves, without division, is also followed by a 
 paralysis more or less persistent, which time, however, 
 and stimulating embrocations, will, to a certain extent, 
 remedy. 
 
 In sabre wounds, in which the nerve is neatly divided 
 and the tissues not displaced, the wound heals usually 
 throughout its entire extent without suppuration, and 
 sensibility and voluntary motion may slowly return. 
 Both experiments upon animals and experience in man 
 show that a reunion of the ends of the nerves may be 
 effected when divided by a sharp cutting instrument. 
 and nervous action restored to its former integrity. 
 
 When nerves are pricked, or in any other way 
 injured without complete division, very severe neural- 
 gic pains, with spasmodic action of the muscles of the 
 limb, may be occasioned. These pains, which are 
 often paroxysmal in their character, extend up and 
 down the injured limb, and, as in cases reported by 
 Guthrie, have, with irregular intermissions, annoyed 
 tin- patient for years. In one case, although the 
 severity of the symptoms subsided after six or seven 
 years, annoyance was, at times, experienced forty 
 years after the injury had been received. A coldness 
 of the parts supplied by the injured nerve is not an 
 uncommon effect, and is more or less persistent. Sud- 
 den changes in temperature, cold weather, or mental 
 excitement, an among the exciting causes of such 
 attacks. 
 
 The pains referred to are not such as are occa- 
 sioned by the presence of foreign bodies — as a hall 
 making injurious pressure upon a nerve at some por- 
 tion of if- -but are apparently caused by an 
 Irritation of the oerve trunk, extending a sympathetic 
 irritation through all branches distributed from the 
 
TRACK OF A QUN8HOT W01 ni> 
 
 From this cause, induced by a gunshot injury 
 in the groin, I have seen irregular periodic paii 
 great intensity, radiating from the groin and extend- 
 ing throughout the entire limb, In one case, although 
 the wound had healed up readily, still. :it the end of 
 two years, the periodic pains, in Bevere paroxysms; 
 jted, notwithstanding the most varied treatment. 
 An after-pain, which nearly all those wounded in the 
 inferior extremity experience, and which is mo 
 less persistent, accompanies ;i simple flesh wound. 
 
 When a ball traverses a limb, it- penetration is 
 effected by a combined movement which separates, 
 divides, and destroys the tissues, all of these effects 
 being more or less present in by far the majority of 
 cases, lip-'' effects are very evident in the skin, 
 which, in certain c;im s, appears as if its fibres had been 
 
 divided; at Other times, its fibres hive evidently been 
 
 torn, while, in the majority of cases, there is an actual 
 destruction of skin. The perforated cellular tissue 
 
 pr< B( nts a canal with contused walls, that firm in tin' 
 
 centre of the canal corresponding with the axis of the 
 ball, being destroyed and booh mortifying. The fibrous 
 li-sws may meet with a loss of substance, hut usually 
 present an irregular tearing, amounting, bo me times, 
 to a split or separation of the fibres, to give passi 
 the projectile. The muscular tissues yield readily to 
 the hall, which, by dividing and tearing, forms a canal, 
 the diameter of which will depend upon the degree of 
 tension of the muscles, [f relaxed when traversed bj 
 the hall, the subsequent contraction of the fibre will 
 give the appearance of much greater loss of substance 
 than it the muscle were in tension, when its relaxation 
 would elongate the fibre and tend to close the canal. 
 As all the muscles of the limb arc never in the same 
 condition of tension or relaxation, a ball, in perforat- 
 
TRACK OF A GUNSHOT WOUND. 209 
 
 in<;-, would find them in various stages of contraction, 
 which would result in an irregular canal ; at points so 
 constricted as to have its continuity nearly interrupted, 
 at other points widely dilated. In the healing of a 
 wound, the first effort of nature is so to arrange the 
 various tissues involved in the track of a ball as to 
 bring like tissues in contact, and then keep them at rest 
 until perfect union can be obtained. This is effected 
 by means of plastic lymph, which, as a natural glue, is 
 poured out freely among all the tissues. 
 
 When a ball perforates the limb and suppuration is 
 established, the wound, in healing, forms adhesions to 
 contiguous tissues, all of which, through the entire 
 thickness of the limb traversed by the ball, are more 
 or less matted together, the nerves being more or less 
 squeezed by this excessive effusion of solid matter. 
 The object of this free, plastic, interstitial deposit is to 
 prevent retraction or displacement in the injured tis- 
 sues, and enable nature to secrete her remodelling 
 material upon a firm basis, and, by degrees, reunite 
 the separated parts of similar structures. 
 
 After cicatrization there is a large amount of absorp- 
 tion of fibrinous adhesions necessary before the limb 
 can regain its former movements and the muscles of 
 the extremity play freely within their cellular envelope 
 without disturbing contiguous structures. Until this 
 absorption liberates the respective tissues, every action 
 of a muscle involved in the wound must draw upon 
 adherent and hypersensitive nerves, which, in turn, 
 produces pain. It is OH this account that a very large 
 
 number of wounded, for months alter their flesh 
 
 wounds have completely cicatrized. Miller more '>r less 
 
 ely whenever they attempl to use their injured 
 limbs, and are only at ease when at r< 
 In the latter class of cases, which are those con- 
 
270 TREATMENT OP PERIODIC PAINS. 
 
 stantly met with in hospital practice, the indications 
 for treatment are sufficiently obvious. Promote the 
 rapid absorption of the effused lymph ami liberate the 
 
 nerves from the traction, while at the same time the 
 irritation or increased sensitiveness of the nerve is 
 mitigated, and the pain complained of will gradually 
 disappear. The best means of meeting these indica- 
 tions are in the free use of stimulating narcotic em- 
 brocations. Any combination from the many arti< 
 of the materia medica, of stimulating and narcotic, or 
 anaesthetic ingredients, would, in most cases, give the 
 desired relief. An excellent and very efficient liniment 
 for rubbing such a painful limb could be made by dis- 
 solving two ounces of any of the essential oils of the 
 9u Pply table and one ounce of chloroform in five mm 
 of alcohol — frictions with this liniment to be made on 
 the limb twice daily. Camphorated soap liniment, 
 containing laudanum, forms also a highly useful appli- 
 cation. Each surgeon will, however, be guided by his 
 own experience in combining ingredients for the relief 
 of this class of cases. The internal use of quinine, 
 aconite, hyoscyamus, belladonna, or, more especially, 
 opium, will blunt sensibility, and will be required, 
 during the course of treatment, as constitutional 
 remedies. 
 
 In the treatment of every case, if possible, the 
 patient should obtain sleep at night, and, with this ob- 
 ject in view, opium, in some form, is constantly 
 administered at bedtime. 
 
 The endermic use of morphine in one-fourth grain 
 doses, or aconitine, one-sixteenth of a grain, dissolved i u 
 two or three drops of water, has given immediate relief 
 when all other anodynes, administered in large doses, 
 have failed to mitigate the pain. I place great con- 
 fidence in the endermic use of morphine, as I have 
 
TREATMENT OF PERIODIC PAINS. 271 
 
 never injected it without obtaining prompt and decided 
 relief. In some instances a permanent cure has fol- 
 lowed the first injection. Great reliance will hereafter 
 be placed upon this new method of treatment. In 
 some cases the persistent pain is found to depend upon 
 a diseased condition, with subsequent enlargement of 
 the nerve at the seat of injury. As, in such cases, the 
 treatment recommended above will only give tempo- 
 rary relief, a complete division of the nerve at fault has 
 been recommended and practiced with some good 
 results. But as we have already referred to the fact 
 that a nerve, divided with a sharp instrument, so«n 
 becomes reunited, and the pain, in many cases, return- 
 ing when union is perfected, it has been suggested, as 
 a more effective operation, to cut down upon the neu- 
 roma or nerve tumor, and remove all the enlarged 
 portion. In simple flesh wounds this proceeding is 
 very rarely called for — time, with stimulating anodjnie 
 embrocations, being usually sufficient to effect a per- 
 manent cure. 
 
 

 CHAPTER VIII. 
 
 TREATMENT OF WOUNDB OF THE DIFFERENT PARTS OF THE BODY, OR 
 
 Topical Surgery — Wounds or thb Bead — Concussion; its CHAR- 
 ACTERS AND TREATMENT — COMPRESSION J ITS SYMPTOMS — VARIETY 
 OF WolNDS OF THE HeAD; THEIR PROGNOSTIC VALUE — SlMPLE 
 
 Wound of the Scalp; Treatment — Fracture without Depres- 
 sion; COURSE TO BE PURSUED WHEN INFLAMMATION OF THE BllAIX 
 
 threatens — Fracture, with Depression, to be treated without 
 an Operation — Trephining very rarely called for — Compound 
 Fracture, with Depression and Compression; Trephining even- 
 here OF DOUBTFUL PROPRIETY — PERFORATING WOUNDS OF THE CRA- 
 NIUM complicated with Foreign Bodies. 
 
 Wounds of the head, when received in battle, require 
 a special treatment, which can not be engrossed in the 
 routine practice for wounds. Owing to the proximity 
 of the brain and membranes, and the facility with 
 which shocks or direct injury can be transmitted 
 through the protective envelopes, injuries of the head 
 possess a peculiar significance. All wounds of the 
 head are more or less serious, as the surgeon can never 
 know in advance whether the brain be injured, and 
 what amount of irritation or inflammation will ensue 
 upon such an occurrence. Hence the necessity of 
 caution in prognosis and treatment, which the experi- 
 enced surgeon will always exhibit, however trivial the 
 wound may appear. 
 
 Injuries of the head would divide themselves into 
 those produced from shot, small fragments of shell, or 
 from a bayonet thrust — those from large portions of 
 shell, or from clubbed musket — and those caused by 
 the blow of a sabre. Wounds are found of every grade 
 
WOUNDS OP THE HEAD. -<•> 
 
 of intensity, from a simple scratch to extensive de- 
 struction of the soft and bard parts, with or without 
 those phenomena recognized as concussion and com- 
 pression. As these terms will be continually referred 
 to in speaking of the treatment of head injuries, we 
 will, in brief, define the meaning which the surgeon 
 attaches to them. 
 
 Co?icussion, 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 
 injury to its structure, and with suspension of its 
 functions for a certain period. 
 
 Immediately as an injury upon the head has been 
 received, if at all severe, the patient is knocked sense- 
 less. He 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 contracted or 
 dilated; sphincters are relaxed, in common with the 
 entire voluntary muscular system, so that the con- 
 tents of the bladder and bowels often escape involun- 
 tarily. After continuing in this condition for a few 
 minutes, hours, or days, he gradually recovers consci- 
 ousness. The heart first regains its accustomed action, 
 the pulse gradually undergoes development, and the 
 skin becomes warmer. At this period vomiting usu- 
 allv 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 stimu- 
 lus to the general controlling organ, the patient rapidly 
 rallies. 
 
 This is the common picture of concussion as seen 
 in surgical practice, and the combination of its symp- 
 toms will be more familiarly recognized as those simi- 
 lating ordinary fainting or syncope. The extremes 
 
-7 1 PATHOLOGY OP I .\. 
 
 would be those cases in which the patient stag 
 Imt, after supporting himself for an instant against 
 some house, fence, or tree, recovers himself, and with- 
 out further annoyance continues his employment; or 
 those in which the patient is picked up apparently 
 dead, with relaxed muscles, pair surface, glassy eyes, 
 scarcely perceptible pulse, and very feeble and irregu- 
 lar respiration. The death-like appearance in such 
 
 Cases Of severe concussion becomos more and more 
 
 confirmed, the breathing gradually ceases, and the 
 
 pulse imperceptibly flitters away, without 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 substance, or extravasations of 
 blood in numerous or concentrated spots. In certain 
 instances the brain has apparently shrunk from the 
 excessive shaking or vibrations to which it has been 
 subjected, so that it no longer tills the cavity of the 
 skull. In some fatal eases, where the brain had been 
 fissured, the commotion among its particles had appa- 
 rently 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 some cases of nearly inslauta- 
 neous death from concussion or stunning, the brain. 
 Upon examination, appeared in every reaped healthy, 
 the lesion, in its Bubstance, not being perceptible to 
 the eye. On the other hand, in cases of perfect re- 
 covery alter concussion, where the patient had lived 
 \n\- a considerable period ( weeks or months) in the full 
 enjoyment of all his faculties, and had died from some 
 disease totally foreign to the former head injury, ex- 
 tensive lesions have been found in the brain, and traces 
 
TREATMENT OF CONCUSSION. Z(0 
 
 of largo and extended extravasations of blood, which 
 covered the hemispheres, as well as traces of blood 
 clots in the cerebral substance. The irritable condi- 
 tion of the brain in which the patient is often left, 
 after concussion of limited duration, with the impair- 
 ment of memory, or of some one of the special senses, 
 or even partial paralysis of the limbs, would be phys- 
 iological proof of cerebral injury. Although its 
 symptoms are usually transient, we may, doubtless, 
 Consider it a contusion or interstitial laceration of 
 brain substance. 
 
 As the appearances of a man stunned by a blow are 
 very alarming *o those not familiar with the march of 
 such lesions, those interested in the injured man are 
 always clamorous 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 termi- 
 nate fatally. The surgeon, under such circumstances, 
 requires all of his presence of mind to resist the im- 
 portunities of those who are urgent with their advice, 
 and with firmness should strictly pursue the non-inter- 
 ference plan of treatment. 
 
 The course which rational surgery now recom- 
 mends is to lay the patient horizontally, with his 
 head, perhaps, a little lower than his body, so that 
 the brain may have the benefit of gravitation to assist 
 in its supply of blood. He is wrapped in warm blank- 
 ets, bottles containing hot water are placed around 
 bis body, and >\vy frictions, with or without mustard, 
 used upon the extremities to excite the re-establish- 
 ment of the circulation ; but beyond this th< 
 should not interfere. In an ordinary case of cona 
 the safest pro* ! ists in doing as little as possible. 
 
 The indiscriminate use oj stimuli on the one hand, or 
 
276 TREATMENT OP CONCl 38ION. 
 
 bloodletting on the other, are to be especially and stu- 
 diously avoid,. I. 
 
 Only a few years since bleeding was the practice in 
 stunning, and the amount of mischief done by this 
 universal mania for bloodletting was often irrepa- 
 rable. We might as well Meed in a tainting fit and 
 expect good results. We find, as in syncope, that the 
 heart scarcely pulsates; and so little blood is driven 
 to the surface that it is pale and cold. A similar 
 condition exists in the brain, where so little blood cir- 
 culates that, from want of this natural stimulus, its 
 functions are temporaril}* suspended. Were it possible 
 to draw away much blood from this organ, the cessa* 
 tion of the nervous functions would become perma- 
 nent. 
 
 Modern surgery, in studying the natural history 
 of diseases and injuries, perceives now, what it should 
 long since have recognized, that nature, in her desire 
 to harbor the circulating fluid, tries to put a safeguard 
 against the rashness of surgeons, by shutting up the 
 bulk of this living, precious fluid in the inner recesses 
 of the body, where it can not be easily despoiled. On 
 account of this change in practice, we now seldom 
 hear of deaths from concussion, which was compara- 
 tively of common occurrence a few years back. 
 
 As regards stimulation, we must also desist as long 
 as it is possible, and give it with a most cautious, 
 sparing hand, only when its administration becomes 
 compulsory. Remember that the degree and dura- 
 tion of shock depends upon the extent of injury which 
 the brain has received, and that nature, always the 
 most skilful physician, accepts this concussion as a 
 safeguard to prevent further mischief. How are we 
 to know that the brain has not sustained severe 
 injury, extensive bruising or laceration, with more or 
 
TREATMENT OF CONCUSSION. 277 
 
 less extensive division of blood-vessols; and that this ex- 
 treme depression of the system, with consecutive con- 
 trol of the heart's action, is not especially indicated 
 to prevent hemorrhage within the brain substance, 
 and rapid death from compression induced by extrav- 
 asated blood? We know this, that after severe in- 
 jury to the brain, when, through officious meddling 
 and the free use of brand} 7 , the symptoms of concus- 
 sion early disappear, violent reaction is induced, and 
 internal hemorrhage or violent inflammation soon 
 shows itself; and that, for the doubtful gratification of 
 seeing the patient rapidly revive, we have the morti- 
 fication of seeing him as rapidly destroyed. 
 
 Cases of concussion, absolutely requiring stimulants, 
 are but seldom met with in practice. Even when of a 
 very severe form, all that is necessary, in the vast 
 majority of cases, is to apply warmth to the surface, 
 and to watch carefully the pulse. 
 
 Should it so happen — but this occurs 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, although the in- 
 sensibility last for hours or even days, desist from active 
 interference. After-trouble will be avoided by allow- 
 ing nature to take its own course unmolested. When, 
 from the great and long-continued depression, stimuli 
 are called for to prevent threatening dissolution, their 
 effects should be carefully watched, and, as soon as 
 reaction is apparent, with an improving pulse, at once 
 desist from the further use of stimuli. As is the state 
 of depression, so will he the state of reaction. When 
 the depression is extreme, the reaction will in time be 
 correspondingly excessive, and especially so if stimuli 
 have been freely administered 
 
278 COMPRESSION 
 
 When the patient, has recovered from the state of 
 insensibility, ho should be kept perfectly quiet; ex- 
 oitement of every kind Bhould be carefully avoided. 
 The diet should be simple, the head kept cool, and any 
 
 tendency to constipation corrected. Beyond this no 
 treatment is required until expressly called for by 
 excessive reaction, accompanied with symptoms of 
 congestion or inflammation of the brain. The pre- 
 cautionary bleeding, with repeated doses of calomel, 
 to ward off symptoms which, in far the majority of 
 cases, would not have occurred, was the routine prac- 
 tice of the old school, and can not be too severely con- 
 demned. The complications which might arise in 
 injuries of the head, after more or less serious concus- 
 sion, will be hereafter considered. 
 
 COMPRESSION. — Concussion is always simultaneous 
 with the blow, and gradually decreases, if death does 
 not carry off the patient at an early period. Com- 
 pression, the condition with which it is often allied, 
 usually comes on some little time after the reception 
 of injury, although it may appear either at the mo- 
 ment, or may not show itself tor days, or even weeks, 
 after the injury. The name explains the lesion ; com- 
 pression, referring to pressure upon the brain, made 
 either by a portion of the skull or some foreign body 
 driven into or upon the cerebral mass; or by an escape 
 of blood from some torn vessel, which, by forcing itself 
 into the unyielding skull, compresses its contents ; or 
 by an effusion of lymph or formation of pus, which 
 inflammation causes to bo deposited within the cavity 
 of the skull. 
 
 The symptoms by which this condition would be 
 recognized are as follows: The patient lies in a state 
 of coma, stupor, or lethargy — one side of the body 
 
SYMPTOMS OF COMPRESSION. 279 
 
 being paralyzed more or less completely, both as re- 
 gards motion and sensation. He is dull, drowsy, or 
 even insensible; at times answers mutteringly when 
 rudely shaken or loudly spoken to, but immediately*' 
 afterward is again breathing slowly, heavily, and la- 
 boriously, as if in deep sleep. Should his face be ex- 
 amined, the lips and cheek on one side will often bo 
 found to flap during expiration, producing a blowing 
 sound, as if smoke was being blown from the mouth 
 in the act of smoking. 'There is paralysis of that 
 side of the body opposite to the seat of injury, and, as 
 a necessary consequence, the air forced from the lung 
 in expiration puffs out that side of the face in which 
 the muscles have lost. tone. In attempts at speak- 
 ing, for the same reason, the corner of the mouth is 
 drawn over to the sound side. The countenance is 
 usually pale, cold, and ghastly, although it may be 
 flushed with a hot and perspiring skin; the eyelids, 
 particularly of the paral} T zed side, are partly or com- 
 pletely opened, with the pupils dilated and insensiblo 
 to light; the pulse is slow, the heart acting under 
 great oppression. There is usually constipation with 
 torpity of the bowels, and as the sphincter muscle of 
 the rectum is paralyzed, there exists usually involun- 
 tary discharges of the feces. From want of action 
 in the bladder the urine is retained, and, unless drawn 
 off, will decompose within the organ. If the urine is 
 not drawn off with a catheter, the accumulation of 
 fluid increases until the bladder is either ruptured, 
 causing a poisonous infiltration into the contiguous 
 t issues, or the blood becomes poisoned from the uIimu-])- 
 tion of decomposing urine. These symptoms are not 
 always equally marked — their extent depending upon 
 the Buddennesa and degree of compression. Unless 
 the causes of pressure be removed, the case usuallj* 
 
280 EXAMINATION OF HEAD INJURIES. 
 
 terminates fatally, although cases are not rare in 
 which, after days of unconsciousness, reason has grad- 
 ually been restored — the accompanying paralysis 
 slowly disappearing. 
 
 Having now explained the two conditions of con- 
 cussion and compression, which so commonly accom- 
 pany severe wounds of the head, we are better pre- 
 pared to study this special class of injuries. 
 
 The divisions which experience has proved of prac- 
 tical 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. 
 
 4. Compound depressed fracture of the skull, 
 with symptoms of compression of the brain. 
 
 5 Perforating wounds of the skull, complicated 
 with foreign bodies in the brain. 
 
 From the peculiar formation of the skull and the 
 resistance which it offers to blows, unless a shot strikes 
 it fairly at right angles, it does not perforate; but 
 whether it be a grape, musket, or pistol ball, it flics off 
 at a tangent, and running beneath tho skin upward, 
 downward, or laterally, escapes. The head has been 
 struck obliquely with even a round shot without seri- 
 ous injury. 
 
 The patient may, or may not, be knocked down by 
 the blow; severe pain is felt, and a puffing up of the 
 part instantly follows. When the hair is removed, 
 although there may be no discoloration of the skin, 
 there is abundant evidence of subcutaneous lesion, 
 which will soon develop inflammation and suppura- 
 tion in the scalp Tho severity of the blow upon the 
 
SIMPLE I1KAD WOUND. 281 
 
 head may have knocked the patient senseless, and in 
 this condition he is found by the litter-carriers. 
 
 The transportation of head injuries requires great 
 care, and the best transports should be devoted to this 
 service. When the patient ai-rives at the field infirm- 
 ary, where he should be kept for treatment and not 
 sent off" to a general hospital, he is laid down, with the 
 bead low, until he recovers himself. The restoration 
 is left to nature; cold water may be dashed into the face, 
 but all stimulation should be avoided unless the pulse 
 is found to flag, when a little brandy may be cautiously 
 given. The surgeon takes advantage of the insensi- 
 bility of the patient, shaves the head at the point of 
 injury, and gives the wound a thorough examination. 
 Using always the finger as a probe, he explores the track 
 of the ball, examining the condition of the skull to find 
 out whether it has been exposed, and whether, simply 
 grooved by the ball, the injury involving the outer 
 tablet only, or whether the skull is broken through. 
 When reaction has taken place and tho patient is re- 
 stored to consciousness, should the wound have been a 
 simple one of the soft parts, the cold water dressing is 
 all that will be required, and should be applied accord- 
 ing to general principles. The thin, wet compress, 
 covered with an oiled or waxed cloth, should cover the 
 wound and head for some distance around the injury; 
 and instead of tying these in place by the roll of band- 
 age, the better plan for keeping on the dressing 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, from either side, 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 temples. This is an admirable 
 x 
 
282 BiMPLk OsAn woi ND 
 
 dressing for all head injuries, which require light, cool, 
 and efficient applications. 
 
 A very useful, although not so eleganl a bandage, la 
 made from a piece of soft cloth, twelve to fourteen 
 inches wide, and from twenty-five to thirty inches .long. 
 This is slit, from each end, into three unequal parts, 
 leaving :i wide bandage between two narrow ones — the 
 three slits, of either end, being interrupted in the middle 
 of the bandage bv a bridge, four inches wide, where tin- 
 cloth has not been torn. In its application, place the 
 centre of this three-tailed bandage over the crown of 
 the head, encircling the temples from behind forward by 
 the two posterior ends, and in the same manner from 
 before backwai'd by the two anterior ends of small 
 bandage. The centre ends can either be tied under 
 the chin or can be carried hack over the head. If the 
 lateral bands secure it sufficiently, the centre ends 
 maybe cutoff on a level with the temples, and pinned 
 to the lateral bands. When firmly secured around 
 the head, the whole completes a "bonet de nuit" which 
 will retain securely an}- applications required in the 
 treatment of head injuries. 
 
 Should the soft parts have been much bruised, the 
 ice bladder, or continuous application of cold water. 
 may be required to keep down excessive suppuration. 
 To prevent mischief, and to avoid those complications 
 paused by irritation or inflammation of the brain, all 
 injuries of the head demand rest and quiet, avoidance 
 of stimulants, and abstemious diet. By adopting this 
 course in uncomplicated wounds, whether gunshot or 
 sabre, a speedy cure is usually obtained. 
 
 When free hemorrhage occurs in connection with 
 wounds of the head, and evidently from an artery of 
 the scalp, it is seldom necessary to apply a ligature, 
 
TREATMENT OF FRACTURED SKULL. 288 
 
 as pressure exercised upon the skull will readily 
 check the bleeding. Effusions of blood under the skin 
 should not be instrumen tally interfered with ; incisions 
 arc not required. If tbe effusions are allowed to re- 
 main excluded from air, the cold water dressing, ren- 
 dered stimulating by the addition of tincture of arnica, 
 will cause their rapid absorption. If the skin is punct- 
 ured and air admitted, suppuration will surely ensuo. 
 Should suppuration occur, and especially erysipelatous 
 inflammation, which so frequently accompanies injuries 
 of the seal]), as soon as pus can be clearly detected, 
 let it out by a small incision. If this operation be not 
 attended to at the proper time, the pent-up pus will 
 separate the periosteum from the skull and cause. 
 perhaps, a necrosis of tbe bones. Chronic disease of 
 the skull is often induced by a disregard of the fore- 
 going rule. When suppuration has been well estab- 
 lisbed. an oiled cloth is substituted for Avator dressings 
 by many surgeons, altbough the growing disposition 
 is to continue the wet cloth, to be renewed as often 
 as cleanliness requires, until cicatrization is completed. 
 When the skull has been fractured by a ball, sabre 
 blow, or fragment of shell, the treatment should in no 
 material respect differ from tbe course pursued in 
 simple seal]) wounds. A simple or compound 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, 
 however, that the brain is in near proximity, and may 
 have been injured, although no symptoms are present 
 for detecting such a lesion. If the patient is insensible, 
 we adopt the means already recommended for remov* 
 ing shock, viz: place the body in a horizontal posture, 
 ani leave the ease pretty much to nature — avoiding 
 everything tending to internal stimulation. While 
 
 J 
 
284 TREATMENT OF i'RACTURKD SKULL. 
 
 insensible, we examine the wound thoroughly, using 
 the finger as a probe; and if any Loose spicule of bone 
 or foreign body be felt quite free in the wound and 
 unconnected with the soft parts, they should be 
 removed. If attached, they should be left to escape 
 after suppuration is established. On rare occasions a 
 ball may be found embedded in the diploe without hav- 
 ing broken, to any extent, the inner tablet. If firmly 
 embedded, the easiest mode of removal, with least 
 damage to the skull, is to cut through the outer tablet 
 with the trephine. 
 
 Fractures caused by balls are usually distinctly 
 limited to the portion struck, and seldom ramify as 
 do fractures from diffused blows, such as those from 
 large fragments of shell, etc. It is this concentration 
 of the force within a small compass which renders 
 gunshot injuries of the head so serious. 
 
 When we are satished, from a careful examination 
 of the condition of the bones, that they remain in 
 their normal position without depression, no instru- 
 mental interference should be attempted. As soon as 
 the patient has re\ ived. and the symptoms of concus- 
 sion or shock have passed off, the cold water or ice 
 treatment should be at once instituted. Should there 
 have been but little shock from the injury, the head 
 should be shaved and wet applications should* be at 
 once applied. This treatment might be commenced 
 even on the battle-field. Such cases are always in- 
 juriously affected by a long, tedious transportation, 
 and therefore are included among those cases which 
 should be treated upon the battle-field, or at some farm* 
 house in the immediate vicinity of the field infirmary. 
 
 When the patient is put to bed (which should be 
 as soon as possible after reaction has taken place, for 
 early treatment is, at this stage, all-important) his 
 

 TREATMENT OF CEREBRAL INFLAMMATION. 285 
 
 head and shoulders should be elevated, and quiet, with 
 absolute rest, should be enjoined. The room should 
 be kept dark, and all stimuli, including light and noise, 
 should be, if possible, avoided. The bowels should 
 bo freely opened by a saline, mercurial, or aloetic 
 cathartic, and for a few daj^s abstemious diet pre- 
 scribed. These precautions are necessary to prevent 
 irritation of the brain, with subsequent congestion, in- 
 flammation, and effusion. If the patient appears irri- 
 table and peevish, without much heat of head or fulness 
 of pulSe, give opium to quiet him. 
 
 The case should be watched with care, and if symp- 
 toms of congestion of the brain threaten, with injec- 
 tion of the face, red eyes, hot skin, forcible throbbing 
 of the carotids, increasing headache, with an early 
 tendency to delirium, the patient might be at once 
 bled. The head should be shaved, and an ice bladder 
 or cloths wet with cold water, and frequently renewed, 
 be assiduously applied over the entire scalp. The in- 
 testines should be freely acted upon, so as to obtain 
 therevulsive effect of the purgative upon the brain, and. 
 for a similar reason, mustard should be applied to the 
 tegs and thighs. Should relief not be promptly obtain- 
 ed, leeches or cups might be applied to the temple or the 
 scalp behind the ears, or a large blister put upon the 
 back of the neck, extending down between the shoul- 
 ders. Calomel was formerly the universal prescrip- 
 tion for threatening cerebral inflammation. Salivation 
 was induced as early as possible, and when t lie system 
 wal brought under its influence the patient was con- 
 sidered comparatively sate. In modern surgery calo- 
 mel has lost its high position, and the dependence 
 Upon its salivating powers is annually diminishing. 
 .Many still use it, but not with the confidence of for- 
 mer times. 
 

 286 ABSCESS O.N THE BRAIN. 
 
 Should this threatened inflammation not subsidy 
 under this course of treatment, but, after a period of 
 high febrile excitement, the delirium becomes merged 
 into stupor, with noisy breathing, dilated pupils, slow, 
 labored pulse, relaxed sphincters, and paralysis, the 
 case indicates compression from effusions within or 
 upon the brain, and chances for life become very 
 doubtful. Perhaps a thick layer of lymph may have 
 formed upon the cerebral surface, or a quantity of 
 serous fluid collected in the ventricles, or a circum- 
 scribed or diffused abscess may have collected "m the 
 substance or upon the surface of the brain. This 
 lymphy effusion or collection of pus sometimes covers 
 the en tire surface of one or both hemispheres. In 
 such cases the arachnoidal membrane appears to he the 
 one chiefly inflamed. It is thickened, semi-opaque, 
 reddened in patches, and adherent to the brain surface 
 as well as to the reflected lining of the dura mater by 
 bands of newly deposited lymph. The pia mater and 
 brain substance is also highly injected. 
 
 If, -with the occurrence of these symptoms, the pa- 
 tient be seized with chills, the scalp wound becoming 
 dry and the tissues puffy, or a collection forms under 
 the periosteum, lifting this membrane from the bones, 
 which, when exposed, appear dry and yellow, it 
 would indicate, in many instances, a circumscribed 
 collection of pus within the skull. These symptoms 
 might be, but wry rarely are, relieved by the use of 
 the trephine, and. as a general rule, the case progresses 
 steadily to a fatal termination. I'nless an external 
 abscess, with the characteristic puffy scalp, defines 
 the collection of effusions within, the trephine should 
 not be used, as there would be little probability of 
 perforating the skull in the vicinity of the collection. 
 It often happens, after trephining, that these supposed 
 
HEMORRHAGE ON THE BRAIN. 287 
 
 collections have not been found, and it is only after the 
 irritating effects of the operation that the secretion 
 of pus has been established. When air is freely ad- 
 mitted to the meninges suppuration is highly proba- 
 ble, while, without the operation, the effusionsof blood, 
 lymph, etc., are known, in many instances, to have 
 been absorbed — the patient recovering after remain- 
 ing insensible, in one case, us long as twenty-^e days. 
 
 Cole, in his Military Surgery, mentions cases of 
 fracture of the skull from ball, without the -skin being- 
 torn. Such cases are very difficult of diagnosis. Unless 
 the bones are much displaced, as they were in one of 
 his cases, the condition would scarcely be suspected. 
 Such injuries must be treated under the antiphlogistic 
 expectant plan. Await symptoms of compression before, 
 active surgical interference is instituted, and we will never 
 regret it. 
 
 There arc a series of cases in which injury to the 
 skull is complicated with internal bleeding. The in- 
 sensibility which seized the patient at the moment of 
 injury will pass off, and the consciousness will be re- 
 gained, but only for a time. The patienj, after a 
 longer or shorter interval, feels heavy and dull, and 
 indisposed to exertion ; until, finally, a strong dispo- 
 sition to sleep comes over him, which, deepening into 
 coma, ends in all the symptoms of well marked com- 
 pression. This is an instance in which the surgeons of 
 twenty years since would have trephined, as the only 
 chance of saving the patient ; and should the collec- 
 tion of blood not have been found under the lirs! per- 
 foration in the skull a second, third, etc., would have 
 been made in search of the extravasated fluid until, in 
 some recorded cases of a former surgery, the head had 
 literally been sieved by twenty orifices. 
 
 Now we would lay down an equally broad rule, 
 
288 HEMORRHAGE ON THE BRAIN. 
 
 that his chances for recovery are increased by avoid- 
 ing the trephine. Pursue a rigidly antiphlogistic 
 course. Free venesection, when assisted by ice blad- 
 ders to the entire scalp, will stop further loss of blood. 
 Reduce the action of the heart by veratrum, gelsemi- 
 nura, or digitalis, and permit the effused blood to clot, 
 so as to close the openings in the torn blood-vessels. 
 Then, bjjkfrce purgation, act upon the bowels, both for 
 a derivative effect and to promote the absorption of 
 the effusion. If you can stop the further escape of 
 blood, that- which has been effused will gradually be 
 removed, and the symptoms of compression will as 
 gradually pass off, after having continued, perhaps, 
 for days, or even weeks. Trephine such a patient, 
 and what certainty have we that the point where 
 hemorrhage has taken place will be unmasked, or 
 that the blood is still fluid and can be removed — both 
 very improbable results. Blood-vessels may have 
 given way at any other portion of the brain than at 
 the portion corresponding to the point where the 
 skull is injured. The recoil of the contents of the 
 skull from the blow may have ruptured vessels dia- 
 metrically opposite to the injured point. Autopsies 
 not unusually reveal such conditions. 
 
 In gunshot wounds from musket-balls the fracture 
 of the bones of the skull is usually circumscribed, and 
 when situated over the course of a large meningeal ves- 
 sel, and these symptoms of internal hemorrhage super- 
 vene, there will be a probability that the injured 
 blood-vessel is in the immediate vicinity of the wound. 
 Usually, in such cases, the hemorrhage would show it- 
 self by the escape of blood externally. Under such 
 circumstances it would be necessary to remove the 
 portions of broken bone, either by the trephine, saw, or 
 forceps; and the bleeding vessel, if seen, should be se- 
 
FRACTURES, WITH DEPRESSION. 289 
 
 cared by ligation or by the pressure of a torsion forceps. 
 Those conditions, however, rarely exist, and the location 
 of hemorrhage is exceedingly doubtful. The operation 
 of trephining is always very serious per se, and is, in 
 many instances, sufficient of itself to cause cerebral 
 or meningeal inflammation, which will nearly always 
 terminate fatally. The operation is often as serious 
 as the condition for which it 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-eranial 
 hemorrhage, which have been unaccompanied by symp- 
 toms denoting such an accident; and the evidences of 
 such have only been found when the patient, recover- 
 ing from his head injury, had, at some subsequent 
 period, fallen a victim to a totally foreign disease. 
 Had such a condition been suspected, and the surgeon 
 used his instruments with the object of allowing the 
 effused blood to escape, most probably an autopsy, at 
 a much earlier day, would have revealed the condi- 
 tion. 
 
 The third variety of gunshot injury of the head, with 
 depressioti of the skull, belongs to a more serious class 
 of wounds. The complication is detected without 
 difficulty by examining the depth of the wound with 
 the finger, when the sinking of the bones is felt, the 
 extent of injury defined, and the oonditian of the de- 
 pressed portion, whether en masse or spiculated, deter- 
 mined. The depressed portion of bone, although 
 usually accompanied with symptoms of compression 
 or pressure upon the brain, may have no such compli- 
 cation. The mind may remain perfectly clear, and 
 the patient enjoy tho voluntary control of all of his 
 limbs. In certain cases of depressed bone, however, 
 there exists paralysis*of the limits on the opposite side 
 
 Y 
 
290 FRACTURES, WITH DEPRESSION. 
 
 of the body to thai side of the head injured. This 
 class of fractures of the head are considered very dan- 
 gerous, inasmuch as the depressed fragments of the 
 
 skull — -which usually has its inner tablel much more 
 extensively broken and displaced than the outer — 
 may have been driven through the membranes into 
 the Bubstance of the brain, and there establish such a 
 train of inflammatory symptoms as will destroy lifo. 
 A very large number, however, recover perfectly from 
 such injuries. 
 
 In simple fractures of the skull, even with depres- 
 sion of the fragments, but without a wound of the 
 soft parts, the rule to be followed is to avoid the use 
 of instruments, and exclude air from coming in '-.in- 
 tact with the broken bones through an incision made 
 by the surgeon. Eveu when symptoms of compres- 
 sion accompany the displacement, it is thought expe- 
 dient, by many Burgeons Of large experience, not to 
 operate, in gunshot fractures of the skull the case is 
 somewhat different, as there is always a wound con- 
 nected directly with the fracture. Still, as a rule, we 
 must avoid meddling with tho parts. If, upon exami- 
 nation, many spicuhe oi bone are found detached from 
 their connections, and lying loosely in the wound, t hey 
 should be carefully removed. This is done as soon 
 after the injury as possible, and often while the pa 
 tient is suffering from compression. Should tho symp- 
 toms of concussion have passed off, and no indications 
 exist of injurious pressure upon tho brain, nor of 
 loose fragments of bone in the wound, surgeons of 
 experience recommend that the ease be treated in 
 every respect as if no depressed fragments existed. 
 In such cases, unless we can clearly determine that 
 the bone is very much spiculated, and that sharp frag- 
 ments are probably piercing the meninges, wo should 
 
TREATMENT OF HEAP INJURIES. 201 
 
 avoid all instrumental interference, oven to dilating 
 the wound, for the purpose of facilitating a more 
 accurate diagnosis. 
 
 A rule which can not he impressed upon us too 
 early is, that we should never be anxious to see the 
 symptoms of concussion rapidly disappear in such 
 cases; let nature abide her time ; watch the case, and 
 see that the patient suffers no detriment. Examine 
 frequently the pulse, but not the head, and as long as it 
 sustains itself, everything is working to the advantage of 
 the wounded. With a rapid reaction, torn blood-ves- 
 Bels may not have had time to become plugged up, 
 and internal hemorrhage, which is always serious, 
 might ensue. Lay the patient in a horizontal posi- 
 tion, cover him with blankets, and, if required, use 
 external warmth. Internal stimulation would not be 
 required in the majority of cases. It is only when 
 the pulse evidently flags that it should be used. As 
 soon as the pulse indicates an improvement, we com- 
 mence cold applications to the scalp, which should be 
 continuously and assiduously applied. When inflam- 
 mation of the meninges, which may make its appear- 
 ance about the fifth day, threatens, revulsives, acting 
 by derivation to the intestines, as recommended in the 
 treatment of simple fractures, with ice or cold water 
 to the head, are the remedies upon which most re- 
 liance is to be placed. When severe headache or 
 exciting delirium is present, cold water may be fre- 
 quently poured over the head in douches with decided 
 benefit. Free purgation is not desirable, as the fre- 
 quent change <>f position would be injurious to the 
 patient. Should the integuments and pericranium 
 inflame, with much swelling, pain, tension, and with 
 febrile reaction, bring on the formation of pus, or if 
 the wound docs not give ready exit to the purulent 
 
292 IKlATMhNT OF DEPRESSED BONE. 
 
 secretion, a free incision must be made to releasi 
 pent-up fluids. 
 
 Surgeons are now becoming familar witb the Facl 
 that considerable depressioi mayexisl in the external 
 tablel of iIk' skull without the internal having been 
 fractured — the external layer being driven into and 
 condensed within the < 1 i i > 1 < »* ■ . Also, that both tablets 
 may be depressed, compressing the brain, without 
 causing harm at any subsequent period. Observation 
 h;ts multiplied those cases to such an extent as to mod? 
 ify the entire treatment of head injuries. Although 
 the crania! cavity is filled with brain, its contents are 
 continually undergoing changes, from the excessive 
 vascularity of the brain substance, ami also from the 
 free communication which exists between the fluid, 
 filling the ventricles ami the venous plexi which 
 abound in the brain. By diminishing tin' blood and 
 water in the brain, accommodation can lie made for 
 the depress* d hone. 
 
 As a general rule, in gunshot wounds of the skull, 
 with depression of fragments, no remarkable symp- 
 toms exhibit themselves until there is a determination 
 of blood to the head from reaction, brought on by 
 mental or bodily excitement. Rational practice would 
 had us to combat the tendency to congestion by rest} 
 quiet, cold, and revulsives, rather than by the tre- 
 phine, which experience has shown to he unprofitable. 
 
 Opium is now used with much greater freedom in the 
 treatment of injuries of the heal than formerly; and, 
 when administered with discretion, will, to a certain 
 extent, take the place of trephining. Whenever the 
 patient is restless, sleepless, and irritable, with deli- 
 rium, should the face not be red, nor head hot, opium, 
 or some of its preparations, can be used with safety 
 
 and hem-tit 
 
TREATMENT OP PERFORATED W0UND8 OP HEAD. 293 
 
 Those Burgeons wlio arc opposed to the use of in- 
 struments in cases of compound fracture of the skull 
 have been led, hy experience, to refrain from removing 
 the spicules until suppuration is well established. 
 
 In gunshot wounds of the head this will be found 
 the safest course to pursue, and is in opposition to the 
 rule laid down in gunshot rounds of the extremities, 
 where it was recommended to removo all loose por- 
 tions of the bone. 
 
 When granulations commence to form, those por- 
 tions of bone which can not be saved will gradually 
 become detached, and will escape. A tendency ,to 
 bleeding in the granulations of such a wound is an in- 
 dication 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, and by far the 
 most serious, is that in which a compound fracture, with 
 depressed fragments, is connected with symptoms of com- 
 pression and paralysis. This is the only variety of 
 complicated head wounds in which surgeons now con- 
 sider instrumental interference justifiable; and even in 
 this instance, although no doifbt exists that, in some 
 cases, immediate relief has followed the lifting of the 
 depressed bone, the propriety of trephining, as a rule, 
 is doubted by many army surgeons of large expe- 
 rience. The successful treatment of such injuries will 
 depend more upon the condition of the brain and 
 membranes than merely upon the depression. Should 
 these be lacerated, or in any way injured, inflamma- 
 tion will probably show itself, sooner or later. The 
 operation of trephining, under such circumstances, 
 would increase the local irritation, expose the injured 
 tissue- to injurious atmospheric influences, and hasten 
 on a violent, and usually fatal, inflammation. 
 
294 TREPHINING INJURIES OFTEN FATAL. 
 
 If the brain and membranes be not injured, expe- 
 rience teaches that the brain will soon become accus- 
 tomed to the pressure; and, although insensibility 
 
 may continue for hours, days, oi . as in many instances 
 of ultimate recovery, for weeks, the symptoms of com* 
 prossion and paralysis will gradually pass off. By not 
 using instruments, the Burgeon has the satisfaction of 
 knowing that he has not increased the local trouble 
 by a serious operation. When the depressed bone is 
 not raised, the removal of the symptoms of com- 
 pression, being very gradual, excessive reaction is 
 not likely to follow; and as no air has been admit- 
 ted to the effusions beneath the skull, the probability 
 of suppuration will be much diminished. When 
 effusions have taken place, the depressed bone arts 
 as a covering, excluding air, with its injurious chem- 
 ical influences; and autopsies at some distant period 
 show that fluids, uncontaminated by decomposition, 
 can be absorbed. When the skull is opened, and the 
 Tree admission of air is permitted, suppuration, with, 
 perhaps, pyemia, is prone to occur. 
 
 Stromyer, who is one of the highest authoritie 
 gunshot wounds of the head, and who, as surgcou-in- 
 chief of the Schles wig-Hols tein army, had cxwy 
 facility for studying his favorite branch of surgery, 
 gives us, as the result of hjs experience, observation^ 
 and study, that the trephine can be abandoned in 
 military surgery, in a supplement to his work on 
 Military Surgery, recentlj- published, he stales: " That 
 in military surgery trephining is never needed. When 
 the ease is so severe as to require the trephine in gun- 
 shot wounds, the patient will die in spite of it.'' In 
 the Last two campaigns, in which he had charge of the 
 army, he has not trephined. Loeffler, a distinguished 
 surgeon in the Prussian service, who has published 
 
TREPHINING INJURIES OFTEN FATAL. 295 
 
 one of the best books of instruction for military sur- 
 geons, after acknowledging Stronger as the master in 
 all relating to the treatment of gunshot wounds of the 
 head, endorses his views in opposition to trephining. 
 
 McLeod gives the following as the Crimean experi- 
 ence : "As to the use of the trephine — the cases and 
 time for its application — less difference of opinion, I 
 believe, exists among the experienced army surgeons 
 than among civilians; and I think the decided ten- 
 dency among them is to endorse the modern ' treatment 
 by expectancy,' and to avoid operating except in rare 
 cases. In this, 1 believe, they judge wisely ; for when 
 we examine the question carefully, we find that there 
 is not one single indication for having recourse to 
 Operations which can not, by the adduction of pertinent 
 cases, be shown to be often fallacious." Hewctt, in a 
 Series of lectures on injuries of the 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 dan- 
 gers of the trephine, and the great fatality accom- 
 panying 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 injured, only seven died — all the rest 
 recovered- In only one case was there any operative 
 interference, although si$ns of secondary compression <ij>- 
 1 in several. The antiphlogistic treatment, care* 
 fully carried out, was alone adhered to. 
 
 No Burgeon can doubt that the operation of trephin- 
 ing has cost many a man his lite; and although many 
 
ABE BRAIN. 
 
 cases have recovered after the operation, it i> a ques- 
 tion whether, in the majority of cases, more rapid 
 recovery would not have been obtained without it. 
 
 When symptoms of compression, accompanied with 
 paralysis, and, finally, stupor, ensue in the course of 
 
 treatment, continue the Steady, onward use of anti- 
 phlogistic remedies. At this juncture many Burgeons 
 recommend calomel pushed to salivation, which some 
 state to be synonymous with salvation. There is, 
 however, no unanimity on this head; the modern 
 practice is to treat such eases without the use of 
 mercury. 
 
 At this stage of the case, which is one of extreme 
 gravity, a successful course of treatment can hardly 
 be expected. Should the symptoms of compression 
 have been preceded by one or more severe chills, with 
 excitement of the pulse, pain in the head, divergence 
 of the eyes, protrusion of the tongue to one side, a dull, 
 pricking sensation in the arm and leg opposite to that 
 wounded, we might feel assured that pus, or some 
 effused fluid, has been thrown out upon the brain, and, 
 usually, that the substance of this organ has heeomo 
 more or less softened. As such cases are exceedingly 
 fatal, the operation of trephining is usually performed] 
 hoping that the collection of pus may he found and 
 discharged, and that, by the relief of pressure, the 
 serious symptoms may ho also removed. Very rare 
 instances of such successes are upon record, hut in by 
 far the majority of eases the symptoms continue una- 
 bated, even when the abscess has heen opene/1. 
 
 The following case is pertinent to the subject under 
 discussion : 
 
 Private I>. Shumpert, Company F, 20th regiment S. 
 C V.. aged eighteen, was stunned by the explosion of 
 a shell during the bombardment of Battery Wagner, 
 
ABSCESS ON BRAIN. L H .»7 
 
 July 18, ISO:. He soon revived, and was sent to a 
 hospital in Charleston on the following day. Upon 
 examination a small shell wound was found in the 
 scalp behind the left ear, but was, apparently, of a 
 very trivial character. He was transferred to a hos- 
 pital in Columbia on the 23d of July, 1863. The ex- 
 ternal ear had been perforated by a small fragment of 
 shell, and, in connection with sensitiveness of the scalp, 
 there was contusion of the tissues behind the left ear. 
 Under the usual cold water dressing the wound rap- 
 idly healed, the sensitiveness disappeared, and only a 
 small orifice in the scalp behind the left ear remained 
 open — all swelling having subsided. 
 
 Since his admission he had been considered a con- 
 valescent, and had associated freely Avith the inmates 
 of the hospital, lie was now nearly ready to return 
 to his regiment, when, on the 30th, he complained of 
 feeling his eyes filling with tears when spoken to, 
 which was attributed to his anxiety to get home. On 
 the 31st he complained of great weakness, left eye suf- 
 fused, and orbicular muscles slightly paralyzed, with 
 inability to turn his head to the left side. 
 
 August 1. — He had fever, pulse one hundred, tongue 
 coated, bowels costive, spirits depressed. As these fe- 
 brile sj^mptoms continued, he was treated for continued 
 fever. On the 7th he had a severe chill, which 
 Was repeated during the day, with tendency to sleep. 
 When roused, he complains of pain in the back. The 
 chills appeared again on the following day, with grad- 
 ually increasing stupor. As he had. at DO time, com- 
 plained of his head, the presence of the wound was 
 altogether overlooked. On the !Mh a purulent dis- 
 charge was noticed from the ear, which attracted sus- 
 picion to the head, and suggested the probability of an 
 abscess upon the brain. 
 
_!'." s AB8CE88 ON IlllAIN. 
 
 Coma being well established by the lOthj and a 
 probe, passed into the small wound behind the ear, 
 having come in contaot with denuded bone, ii wus de- 
 cided i" dilate freely the wound, expose the hone, ami, 
 should any fracture and depression of fragments be 
 found, to trephine. A.a the mastoid portion of the left 
 temporal was found denuded, with a depressed fragment 
 of skull at the junction of this bone with the ocoipital, 
 the trephine was used, and several fragments of the 
 inner table, which were Pound detached, were rem ■ 
 The trephine had been applied directly over the lat- 
 eral sinus, and the anterior edge of the orifice corres- 
 ponded with the line of attachment of the tentorium 
 cerebelli. No pus was found. No amelioration of 
 symptoms followed the operation, and the patient died 
 
 twelve hours alter it. 
 
 An autopsy revealed a fracture of the skull, which 
 had completely separated the squamous from the 
 petrus portions of the left temporal bone, the fissure 
 extending in front of the ear to the base of the skull. 
 Inflammation had been excited in the membranes aa 
 well as in the substance of the brain at the base of the 
 skull, and a large accumulation of foetid pus, about feuu 
 ounces, had collected in the arachnoidal cavity, and 
 had so compressed the hemisphere of the brain that 
 
 there was a space fully an inch in depth between the 
 
 flattened hemisphere and the skull — the pus covering 
 the entire surface of the hemisphere from the tentori- 
 um cerebelli to the falx cerebri. The base of the brain, 
 corresponding with the broken hone, was softened, 
 and of oreamy consistency. Had the trephine been 
 placed one quarter of an inch more anteriorly, it 
 would have allowed the escape of pus, although the 
 emptying of the abscess could not have saved life, as 
 experience shows injuries to the base of the braiu, 
 
FOREIGN BODIES IN BRAIN. 299 
 
 followed by inflammation and coma, to be always 
 fatal. The caso is of much interest in many respects, 
 but more especially shows that an injury of the head, 
 of the most serious character, may be inflicted with- 
 out creating even a suspicion of its existence; and as 
 this may frequently occur, it should teach us to con- 
 sider all cases of head injury serious. 
 
 When balls penetrate or perforate the cranium, the 
 detached pieces of bone are driven before the ball into 
 the substance of the brain, leaving an orifice in the 
 skull larger than the missile which made it. The 
 resistance which the ball meets may change 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 instantane- 
 ous, or soon follows the receipt of this injury. In 
 such cases it sometimes happens that the patient has 
 survived the shock, and has been, to all appearances, 
 recovering rapidly, when he is suddenly seized with 
 COma, and rapidly dies. There are, nevertheless, a 
 few exceptions to this rule, in which the patient, 
 recovering from the shock and sequela 1 , although he 
 may have lost a quantity of brain substance, has car- 
 ried the ball or other missile within his cranium for 
 years. Eventually dying of some disease unconnected 
 with the head, an autopsy has revealed the ball em- 
 bedded in the brain, and surrounded by a ma- 
 lymph. Of ninety -one cases of ponetrating and per- 
 forating gunshot wounds of the head which were 
 admitted into hospital in the Crimea, all, without 
 option, proved fatal. 
 
 When the openings are examined, it will he found 
 
 that the hole made in the outer tablet is more or less 
 
 smooth, while the orifice in the inner tablet is mnch 
 
300 FOREIGN BODIES IN BRAIN. 
 
 more extensively fractured, and usually much Bpicu- 
 lated. This condition of the orifices is owing more to 
 the direction of the blow than from any Bupposed brit" 
 tieness in the inner tablet — for, ahould the ball traverse 
 from within outward, the reversed condition is ibund. 
 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, in by far 
 the majority of cases, ensure a fatal issue, whatever 
 bope of recovery might have been previously enter- 
 tained.* 
 
 Cole, in his Indian Reports, mentions -'That there 
 arc many soldiers now doing duty in our ranks for 
 whom (having been wounded in their heads during the 
 late war) the medical oflicers 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 
 wounds with a metallic probe, to satisfy the curiosity 
 of a surgeon, would soon have destroyed all bope, 
 with the life of the patienl ; ami yet I have seen ignorant 
 and careless surgeons rooting into the brain with a 
 silver probe as if they wore determined to find a 
 foreign body, cost what it may. It is needless to say 
 that such practice is criminal, and in no possible ease 
 called for. 
 
 The general treatment of SUCh cases should in no- 
 wise differ from that laid down for the treatment of 
 head injuries in general. The symptoms of concussion 
 and compression, which arc well marked and always 
 
 * On one occusiun. by the use of a gum bougie, Baron narroy disoov- 
 cred a ball which had penetrated the foreboad, Bnd, travelling along iho 
 dura mater, had lodged at and under the occipital protuberance, 
 whence it was successfully removed by trephining. — Sedillot Medicine 
 Uj» ratoire. Paris : 1868. 
 
OSTITIS OF SKULL. 301 
 
 present, must be combated by rising all the precau- 
 tions which have boon already pointed out 
 
 We might now sum up, in a few words, the rational 
 and successful treatment of gunshot wounds of the 
 head. In concussion, unless there is evident sinking, 
 leave the case to nature, and avoid both stimulation 
 and venesection. When the patient is restored to 
 consciousness, should inflammation of the brain threat- 
 en, if there be no congestion of the face, give opium to 
 allay irritation. Should congestion be evident, use 
 the antiphlogistic treatment, locally and generally, 
 with ice applications to the head. In every case abso- 
 lute quiet and rest are essential to successful treat- 
 ment. All injuries of the head are serious, however 
 trivial they may seem, inasmuch as violent inflamma- 
 tion often follows apparently slight wounds. All, 
 therefore, should be carefully watched for some time even 
 after the wound has cicatrized. 
 
 Chronic ostitis, or periostitis, resulting from gunshot 
 wounds of the head, are of frequent occurrence, but 
 possess no peculiar interest. Where the bones have 
 been much denuded, either by the instrument inflicting 
 the injury or by subsequent inflammation and suppura- 
 tion, extensive exfoliations occur. I havo seen cases 
 in which, as sequclre of erysipelas engrafted upon a 
 gtinshot wound of the head, the frontal or parietal 
 bone was gradually isolated and removed. Such cases 
 must clearly be left to nature, and the system suit- 
 ported by tonics and nutritious food when debility is 
 present . 
 

 CHAPTER IX. 
 
 Wounds op the Faoi — Fractures <>f thb Upper and Lowed Jaw — 
 
 Wounds of the Netk — Large Vessels avoid the perforating 
 ball — When large Arteries in the neck are divided, the ne- 
 cessity OF LIGATING THE BLEEDING .MOLTnS IS URGENT. 
 
 Wounds of the fack, when they do not implicate the 
 brain, are not usually of a serious character. On ac- 
 count of the vascularity of the tissues, the severe cuts 
 ahout the face, made by the sabre or by pieces of shell, 
 heal very readily by the first intention, if the lips be 
 kept in apposition by sutures or strips of adhesive 
 plaster. The application of cold water for a few 
 days will usually effect a cure. The excessive swelling 
 which accompanies many injuries of the face, espe- 
 cially gunshot wounds and burns from explosion of 
 powder, is readily controlled by cold water dressings. 
 Although its appearances are so frightful, effacing tem- 
 porarily the features, and exciting much alarm in the 
 uninitiated, it runs its harmless course, moderated 
 by the cold applications, and subsides at the end of a 
 few days. The rapidity with which all wounds of the 
 face heal has often been remarked, and the large num- 
 ber of such wounds make them, as a class, familiar to 
 our arnvy surgeons. 
 
 The most common injuries to the face from gunshot, 
 wounds are fractures of the upper and lower jaws 
 from perforating shot. Round balls often become em- 
 bedded in the soft, spongy bones of the face, but minie 
 balls usually traverse the face and escape. When the 
 bones of the face are struck by a grapeshot or a flat- 
 
WOUNDS OF PACE. 303 
 
 tened conical ball there may bo great destruction of 
 the features, followed by shocking deformity. But 
 even when the bones are speculated, exfoliation is not 
 so general as in other portions of the skeleton — a few 
 small pieces of bone escape from time to time, but 
 such fragments as are firmly connected with the soft 
 parts are permanently retained. 
 
 One or more of the senses are not unfrequently 
 destroyed after gunshot injuries — sight or smell being 
 often impaired, if not completely lost. Where the 
 wound involves the orbit, the loss of vision is not 
 only very probable, but there is great fear that the 
 cause producing the injury, whether it be a ball, bay- 
 onet, or a sword point, may have perforated the thin 
 plate of the skull, and, entering the brain, may induce 
 fatal cerebral inflammation. Many cases of appar- 
 ently trivial wounds of the eyelids have terminated 
 fatally, and an autopsy revealed serious injury to the 
 anterior lobes of the brain and its enveloping mem- 
 branes. Such cases should be carefully watched, and 
 any cerebral symptoms which maj T arise should be ac- 
 tively met by the antiphlogistic treatment, with abso- 
 lute quiet. 
 
 From the great vascularity of all the structures 
 composing the face, we would expect to have serious 
 hemorrhage accompanying all injuries. For control- 
 ling this the astringent preparations of iron may be 
 required, although, in by far the majority of cases, the 
 bleeding ceases spontaneously. Should the carotids 
 and other largo arteries have escaped injury, the iron 
 styptic will control the most annoying hemorrhage. 
 The vessels are small and so numerous that the direct 
 application of ligatures can not be made. 
 
 In fractures of the upper jaw the bones are always 
 more or less spiculated, with one or more teeth loos- 
 
304 TREATMENT OF FACE WOUNDS. 
 
 ened or completely detached. Sometimes the teeth 
 are separated from the gums, and, driven in front of 
 the ball, are buried in the soft parts about the mouth, 
 and are only detected after the formation of a fistula. 
 As all portions are frecl} T supplied with blood-vesstls, 
 union will take place among the fragments, even after 
 considerable shattering of the bones. Unless the frag- 
 ments are either completely detached or but slightly 
 adherent, the} r should not be taken away, 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 wa- 
 ter dressings, with an occasional dose of salts to re- 
 lieve the excessive swelling, is the onty medication re- 
 quired. The wound in the face, after a careful adjust- 
 ment of the movable fragments, should be closed Avith 
 adhesive plaster, and, with the use of coid water 
 dressings for a few days, the case is left pretty much 
 to nature. 
 
 When the soft parts, as well as the bones, are crush- 
 ed, secondary hemorrhage may occur, should slough- 
 ing tissues come away. Formerly, the difficulty of 
 restraining this loss of blood was so great as to 
 require, in many eases, the ligation of the main ves- 
 sels in the neck. We now find the local application 
 of the perchlorido or persulphate of iron an efficient 
 remedy. Should necrosis follow injuries to the bones 
 of the face, the dead pieces of bone should bo 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 accident 
 on the battle field, whether caused bj 7 shot wounds or 
 
TREATMENT OF FACE WOUND*?. 305 
 
 other casualties. The complicated character of the 
 fracture does not prevent consolidation, which is 
 effected in all cases, although usually connected with 
 some slight deformity from displacement of the frag- 
 ments. At times the entire jaw may be swept off by 
 a round shot, leaving the mouth and throat exposed. 
 One of the most fearful cases on record of such an in- 
 jury is one in which the entire face was carried away ■ 
 by a cannon-ball, leaving nothing but the skull prop- 
 er appended to the vertebral column. The opened 
 gullet marked the former site of the features. The 
 patient lived ten houi'S, and from the frequent change 
 of position, and the squeezing of the hand when his 
 was taken, it was thought that consciousness re- 
 mained up to the time of death. Legouest reports a 
 case in which the entire face was carried away by a 
 cannon-ball, the eyes alone remaining of all the fea- 
 tures. This patient survived the accident. 
 
 The surgeon accompanying the transports usually 
 sends injuries of the face to the field infirmary un- 
 touched, or, should the lower jaw be broken, applies a 
 folded handkerchief or band under it to support it. 
 This fracture is permanently put up at the field infirm- 
 ary in a pasteboard splint, well padded with carded 
 cotton, and secured by a folded cloth or double-tailed 
 bandage. One band passes over the vertex, support- 
 ing the jaws, while the other passes from the front of 
 the chin behind the head, and then around the fore- 
 head, where it is secured by pins. Before the dress- 
 ings are applied the wounds should have been exam- 
 ined carefully with the finger, and all perfectly 
 detachcQ spicule of bone shoitld have been removed. 
 From the excessive vascularity of all the tissues of 
 this region the bones do not necrose as extensively 
 as in other portions of the body, and portions of bono 
 z 
 
306 TREATMENT OF FACE WOUNDS. 
 
 which are attached to the soft parts very often con- 
 solidate. The surgeon must be prepared to meet much 
 swelling and profuse salivation. 
 
 All gunshot injuries to the hones of the face being 
 compound, suppuration is soon established, and the 
 secretion of pus is copious. When (lie hall has per- 
 forated the buccal cavity, causing inflammation and 
 salivation, it will add much to the comfort of the 
 patient if his mouth be swabbed out daily with a 
 piece of soft rag or sponge attached to a thin piece of 
 wood. From the difficulty in swallowing, fluid nour- 
 ishment must be prescribed. The constant thirst of 
 those wounded will be relieved by small doses of mor- 
 phine, or by acidulated drinks, made either with dilut- 
 ed nitric acid or vinegar. Injuries about the face 
 are very liable to erysipelatous attacks, which, how- 
 ever, are readily controlled by the free use of the 
 muriated tincture of iron — thirty drops every three 
 hours often checking the progress of the disease by 
 the end of the first day of treatment. 
 
 The most distressing injuries of the face are those 
 involving vision. When a minie ball traverses the 
 temporal regions, emptying both eyes, there is, of 
 course, no remedy. The case is equally hopeless whew 
 injury to the optic nerve or optic ganglion occurs in 
 the passage of a ball, although the globe of the eye 
 may not have been touched. The general optbalmia 
 induced will, by disorganizing all the tissues, dcstroj' 
 vision, in spite of treatment. When balls embed 
 themselves about the face, they are found, often with 
 difficulty. Time may develop their situation, as the 
 weight of the metal may cause them gradually to shift 
 their position and approach one of the open cavities. 
 When a ball crushes through the roof of the mouth, 
 throwing the nasal and buccal cavities into one, and 
 
WOUNDS OF NK.CK. 307 
 
 affecting both articulation and deglutition, the serious 
 annoyance can be corrected by adapting a gutta-percha 
 plate to the roof of* the mouth, which will restore the 
 continuity of the cavities, and, with it, other respective 
 functions. Should a ball in its passage injure the facial 
 nerve, a permanent paralysis follows of all the muscles 
 of the face supplied by it. 
 
 Wounds of the neck, with injury to the numerous 
 large vessels which course through this constricted re- 
 gion, are among the serious accidents in battle. Prom 
 the anatomy of this region we would suppose that a 
 missile could not traverse the neck in any direction 
 without destroying some important part. We find 
 among the wounded, after every great battle, cases in 
 which the neck has been perforated by balls traversing 
 in every direction. Some of these are accompanied 
 by violent hemorrhage, showing that, from the course 
 of the ball, large vessels must have been injured; yet, 
 should the patient rally from the first fainting brought 
 on from shock and loss of blood, we find, usually, a 
 spontaneous cessation of the bleeding, and the onward 
 progress of the case becomes one of continued conva- 
 lescence. I have seen conical balls perforate the neck 
 antero-posteriorly, entering just above the sterno-cla- 
 vicular junction, and passing in the midst, if not 
 through, the largest vessels of the body, without pro- 
 ducing a fatal hemorrhage. I have also seen them 
 perforate the throat laterally, on a level with and just 
 behind the angle of the lower jaw, and a cure equally 
 follow. It is wonderful low the great vessels escape, 
 or the rapidity with which clots form and the wounds 
 of sueli vessels close. McLeod reports one hundred 
 ami twenty-eight cases, more or less severely injured 
 in the neek, with hut four deaths. Many, to he sure, 
 die on the battle-field in a few moments after receiving 
 
308 TREATMENT OK NECK WOUNDS. 
 
 a serious injury to the large arteries; but, undoubt- 
 edly, many also recover. 
 
 The powerful ii*on styptics, with methodically ap- 
 plied compresses and bandages, are the only local 
 remedies applicable on the battle-field, as the assistant 
 surgeon, following the troops, has neither the time nor 
 conveniences for ligating the bleeding mouths of the 
 divided vessel, however urgently it may be needed. 
 A finger thrust into the wound and retained for some 
 time, has been successful in stopping the bleeding from 
 apparently large vessels. Should the field infirmary 
 be at no distance it may be possible, by pressure in 
 the wound, to control the bleeding until the soldier 
 can bo conveyed to this point of safety, when, if the 
 hemorrhage continue, an operation may be performed; 
 but so seldom is thi* at a convenient distance, that if 
 the bleeding does not soon cease spontaneously or be 
 rapidly checked by the stypties used, the patient dies 
 — no case of ligation of the large vessels of the neck 
 having been yet reported from our battle-fields. 
 
 The precautions which were urged in discussing the 
 means of arresting hemorrhage in wounds generally, 
 must here be carefully applied; and should secondary 
 hemorrhage occur, notwithstanding the careful appli- 
 cation of the iron styptic, the safety of the patient will 
 then lie only in the ligation of both bleeding orifices. The 
 anastomosis of the blood-vessels in the neck are so free, 
 and the vessels so numerous, that there would be much 
 difficult}' in diagnosis; and as the rule is to determine, 
 if possible, the precise seat of hemorrhage, it can only 
 be verified by the dilatation of the wound. A ligature 
 upon the carotid artery, at a short distance both above 
 and below the wound, has been reported a failure in 
 controlling a hemorrhage, which was only checked by 
 dilating the wound and ligating the artery at the point 
 
TREATMENT OF NKCK WOUNDS. 309 
 
 injured. And at page 206 will be found the report of a 
 case in which both common carotids were ligated for 
 the injury of a comparatively small branch — the hyoid 
 artery. The patient died. Had the rule of dilating 
 the wound and of ligating both orifices of the bleeding- 
 vessel been followed, which is more imperative in neck 
 injuries than in those of any other portion of the 
 body, the patient would, most probably, have been 
 saved. Should the large veins, when injured, persist 
 in bleeding, they should be also ligated. In enlarging 
 the wound, the incision will always be made parallel 
 with the axis of the neck, so as to avoid injuring im- 
 portant nerves or blood-vessels. 
 
 Several instances have occurred in the Confederate 
 campaigns where the trachea has been perforated by a 
 shot or the larynx carried awa}'. Such contraction 
 of the air passage and difficulty of breathing follows 
 upon this accident, as to force the patient to wear, 
 permanently, a trachial tube, to protect him from 
 attacks threatening suffocation. In such cases the 
 voice is reduced to a whisper. 
 
OHAPTBB X. 
 
 Wounds of the Cbbst — Fi iss Wounds — Bffi bionb within the 
 CAVITY WHEN the Plei ra is injured — Wounds of the Heart or 
 
 Lis*. A TBAH8FIXED ClIEST DOES NOT N E( 'ESSARILY IMPLY A Pk.R- 
 
 forated Lung — Diagnostic value of the various Symptoms — 
 Ho Moi'TYsis, Dyspnosa, Collapse, Emphysema — Treatment or 
 Chest Wouhos — How inflammatory complications are to be 
 combated — the treatment of a fractured rlb — contusions and 
 injuries of the Spine. 
 
 Wounds of thk chest, when taken as a class, arc, 
 perhaps, the most fatal of -gunshot wounds. 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. Era- 
 ser, in an excellent treatise on chest wounds, based 
 upon data obtained in the Crimea, states the mortality 
 to have been twenty-eight per cent, of all chest wounds, 
 and seventy-nine per cent, of those in which the lung 
 had been injured. The Russian Crimean reports give! 
 as their mortality in chesl wounds ninety-eight per 
 cent., which is sufficient proof of the serious character 
 of this lesion. The danger in wounds of the thorax is 
 from visceral complications. Should the lung be se- 
 verely injured, the ease usually terminates fatally. 
 
 From the peculiar formation of the thoracic box 
 and the curve of the ribs, halls, in striking, are often 
 deflected from the straight line, and, alter a longer or 
 shorter course, escape without having penetrated tho 
 chest. Often the two openings correspond so accu- 
 rately in direction as to establish a strong conviction 
 of a direct passage through or across the thorax, 
 
WOUNDS OF C1IKST. oil 
 
 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 as if it had traversed the thorax; its entire 
 course having been subcutaneous, no inconvenience 
 was experienced. This tortuous track can only be 
 made by a ball striking at a considerable obliquity. 
 Its direction is generally indicated by a reddish or 
 purplish line under the 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 little treat- 
 ment. The eold water dressing fills every indication, 
 and its applieation for a few days usuall3 T effects a 
 cure. 
 
 A great amount of nervous shock often accompanies 
 very trivial injuries of the chest. Many instances aro 
 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 soldier's coat — and had fallen to the 
 ground without even touching the skin, yet the sol- 
 dier had been knocked down breathless, and. in some 
 eases, did not recover completely from the shock for 
 days. In some of the cases the lungs are so much 
 concussed by the blow that blood escapes from the 
 mouth as in perforating wounds. 
 
 Where a ball traverses the out* r side of the chesl 
 antcro-posteriorly, although the cavity may not have 
 been opened, there may be the very serious complica- 
 tion of injury to the axillary artery as it courses un- 
 der the ({reat pectoral muscle. Pressure with the 
 thumb upon the subclavian vessel above the middle 
 of the clavicle as it passes over the first rib, will con- 
 
'61- PERFORATING WOUNDS 01 Cfll 
 
 trol the bleeding sufficiently to allow the wound to bo 
 dilated, when both bleeding orifices should be secured. 
 
 Should the ball have penetrated the chest, it may 
 course for some distance between the ribs and their 
 lining membrane, 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 
 ausculation, will detect, and an antiphlogistic course, 
 accompanied with the free use of opium, will readily 
 subdue. Opium, when used in large and frequently 
 repeated doses, possesses other virtues than merely 
 allaying pain and quieting nervous symptoms. It 
 combats, directly, inflammation, and, by the great 
 control which it exercises over the brain and circula- 
 tion, becomes, in the treatment of the serious sequehe 
 of wounds, one of the most, if not the most, valuable 
 remedy of the materia medica. When given in com- 
 bination with nitrate or carbonate of soda, its nau- 
 seating effects are counteracted. 
 
 The evil which the surgeon fears from perforating 
 wounds, followed by inflammation, is that a serous or 
 sero-purulent effusion may rapidly accumulate in the 
 thoracic cavity, and destroy the patient. So rapidly 
 is this fluid formed, that the chest has been known to 
 fill in twenty-four or forty-eight hours — the fluid com- 
 pressing and condensing the lung against the verte- 
 bral 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 disappear when the cavity is filled. 
 At the same time respiration becomes much embar- 
 rassed, with marked dyspnoea. Percussing the side 
 will now give a dull, heavy sound, instead of the ordi- 
 
PERFORATING WOUNDS OF CTIE6T. 313 
 
 nary clear, sonorous one of health ; and the position 
 of the patient must vary the sound by the gravitation 
 of the serous collection unless the cavity is filled with 
 fluid. The lung is condensed and flattened against 
 the vertebral column, and is temporarily impervious 
 to air; under a long continuance of the pressure, it 
 will become permanently consolidated. The increase 
 in the circumference of the chest, and the fulness of 
 the intercostal spaces, with the absence, to a great ex- 
 tent, of respiratory movements upon the affected side, 
 the displacement of the heart from its usual posi- 
 tion — being found on the right side, whei*c the effu- 
 sion fills the left pleural cavity, and vice versa — and 
 great oppression of the breathing, with inability to 
 lie upon the healthy side, are conspicuous symptoms 
 of a distended cavity. 
 
 The quantity of fluid thrown out varies from a few 
 ounces to several pints. When the natural dimen- 
 sions of the cavity are not sufficiently extensive to 
 accommodate it, it forces the mediastinum over to 
 the sound side, interfering with the action of the 
 healthy lung, while an encroachment may be equally 
 made upon the abdomen. 
 
 When, after gunshot wounds, accompanied by dis- 
 tressing symptoms of dyspnoea, the surgeon recog- 
 nizes such collections as rapidly forming in the chest, 
 an earl} 7 evacuation will be required. Should the col- 
 lection 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, the broad intercostal space, be- 
 tween the sixth and eighth ribs on the right, or be- 
 tween the seventh and ninth on the left, might be 
 the point selected. The instrument, usually a trocar 
 and canula, should bo introduced at right angles to 
 Aa 
 
81 I WOUNDS OF HEART. 
 
 Ihe chest and near the upper edge of the rib, toward 
 its angle, in a line continuous with the posterior bor- 
 der of the armpit. As this puncture corresponds 
 with the lowesl portion of the cavity, the chesl ran 
 be perfectly drained through it. 
 
 In all gunshot, injuries of the chest, the most serious 
 complication is injury to the lungs or heart, and it is 
 often difficult to detect at first Buch lesions. Notwith- 
 standing the many infallible signs laid down by an 
 thors, experience teaches us that Yio one symptom is 
 sufficient for establishing a diagnosis. When the heart 
 is injured, although instantaneous death does not take 
 place as a general rule, the wounded man lives but a 
 short period. The pericardium soon becomes tilled 
 with blood j the action of the heart is mechanically 
 
 impeded, and, sooner or later, depending upon the 
 size of the wound and i he facility for letting out blood, 
 it erases its pulsation. As reports of cases arc not 
 very rare in which small, oblique, incised wounds of 
 the heart have been recovered from — and even gun- 
 shot wounds of this organ, perforating its cavities, 
 have escaped with life — a wound of the heart is not 
 considered necessarily a fatal accident. When the 
 pericardium is perforated and the heart not injured, a 
 successful result may readily he obtained by a judicious 
 course of treatment, which will keep down inflamma- 
 tion, with its effusions of lymph and serum. Close 
 carefully the outer wound, so as to induce healing by 
 the first intention, but otherwise Leave the case to 
 the vis medicatrix natura, avoiding all excitants, keep- 
 ing the patient quiet, and instituting a non-stimulating 
 diet. 
 
 The lung often escapes injury when, from the po- 
 sition of the wounds of entrance and of exit, with the 
 certainty of the cavity being transfixed, the natural 
 
luno wouNns. 315 
 
 belief would lead to a perforation of the organ. A 
 straight line between the wounds passes evidently 
 through the substance of the lung, but the ball, in per- 
 forating the rib, may have been deflected from its 
 straight course, and following, perhaps, the inner curve 
 of the chest, and meeting with some resistance, had" 
 forced its way through the chest — either appearing 
 under the tough, elastic skin, or cutting its way out 
 Without having touched the contained organs. 
 
 The lung may, on the other hand, be severely injured 
 when no perforating wound exists. A blow by a spent 
 ball or a fragment of shell may make a very superfi- 
 cial wound or bruise in the skin, and yet may shatter 
 one or more ribs, driving the spicule into tho lung, 
 lacerating, to a greater or less extent, its substance. 
 Even without fracture of the ribs, the concussion or 
 blow may have been sufficiently great to have caused 
 irreparable injury. 
 
 The following cases, extracted from a Memoir on 
 Amputations, by Baron Larrey, will exhibit the extent 
 of internal injury from a spent ball without external 
 indications of mischief: 
 
 "At the Siege of Roses there were brought from tho 
 trenches to the ambulance that 1 had established at 
 the Village of Palace, two gunners, having nearly the 
 same kind of wound j they had been struck by a ball 
 of large calibre, which, when nearly spent, had grazed 
 posteriorly their two shoulders. In the first I dis- 
 covered a slight ecchj'mosis over tho whole posterior 
 part of the trunk, without anj- apparent solution of 
 continuity, lie was hardly able to breathe, and sjiit 
 up :i great quantity of vermilion and frothy blood, 
 The pulse was small and intermitting, and the extremi- 
 ties cold ; in short, lie died an hoar after the accident, 
 :t- 1 had prognosticated \ opened the body in the 
 
316 HEMORRHAGE IN 0HES1 WOUNDS 
 
 presence of M. Dubois, inspector of military bospitala 
 
 The skin was unhurt; the muscles, the aponeuroe 
 the nervea and vessels of the 'shoulder, were broken 
 
 and torn, the scapula- fractured, the spinous proccs 
 of the corresponding vertebrae of the hack and the 
 
 posterior extremities of the neighboring ribs Tract ored ; 
 the Bpinal marrow was distended, the parenchyma of 
 the lungs toward the corresponding points were lacer- 
 ated, and a considerable effusion had taken place into 
 both cavities of the thorax. The second gunner died. 
 with the same symptoms, three-quarters of an hour 
 after his entrance into the hospital. On opening the 
 body the same mischief was perceived as in the first." 
 
 The severity of the Bymptoms will depend upon the 
 portion of the lung injured, and also the depth of the 
 wound in the lung. Where a hall traverses the peri- 
 pheral substance of the lung, whether it be at the apex 
 or base, where the vessels are broken up into their 
 minute ramifications, the case is usually less serious, 
 and much more likely to recover, than when the root 
 of the lung is perforated. The injury in this case 
 would implicate the large vessels passing to and from 
 the heart, and hemorrhage may be so rapid and ex- 
 cessive as to be immediately fatal. It is on account «>t' 
 the loss of blood that the most conspicuous symptoms 
 arise, viz: hemorrhage, collapse, cough, and dyspnoea, 
 or oppressive breathing. 
 
 The patient may be at once suffocated by a large 
 quantity of blood filling up the thorax and pre- 
 venting the ingress of air into the lungs. Usually 
 blood passes from both the mouth and the wound. 
 When the smaller vessels are injured, thai from the 
 mouth is froth}- and florid, and is brought up by a 
 short, tickling, harassing cough. Where the vessels 
 injured are of larger sizo, the blood comes up from tho 
 
HEMORRHAGE IN CHEST WOUNDS. 317 
 
 chest in a purer condition and in larger quantity, at 
 times in nearly a stream, filling the mouth as rapidly 
 as it could be spit out, and threatening suffocation. 
 The size of the dark-colored stream pouring from the 
 wound depends upon the position of the orifice. 
 Where the orifice is situated low upon the chest, and is 
 large and direct, the effusion into the cavity escapes 
 freely — the symptoms of collapse may soon appear, 
 but suffocation is prevented; while from an injury 
 in the upper portion of the chest, particularly if small 
 and oblique, the thorax may fiLl with blood, and suffo- 
 cation becomes imminent, without much external loss. 
 The danger from hemorrhage is greatest during the 
 first twelve hours, and is pretty well over by the sec- 
 ond day. The bleeding may, however, continue for 
 eight or ten days. graduall} T diminishing in quantity. 
 With the flow of blood from the wound air often 
 escapes, and the two symptoms are considered unequiv- 
 ocal proof that the lungs have been injured — their ab- 
 sence does not prove the contrary. We meet with 
 cases of perforation of the lung terminating fatally at 
 the end of thirty-six or forty-eight hours, in which 
 collapse had been the only conspicuous sympfom — 
 no hemorrhage may have been present either from 
 mouth or wound — }-et an autopsy will reveal the 
 chest filled with blood. 
 
 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 arises from a sudden concussion of tho or- 
 gan. Eraser, in his recent work on gunshot wounds 
 of the chest, places less value on hemoptysis than do 
 Other military Burgeons. Guthrie considers it a proof 
 of lung wound; so do Baudens, licLeod, Stromyer, 
 Ballingall, and others. Eraser's experience in the Cri- 
 
319 DYSPNOSA IN 0HE8T W01 N 
 
 gives, in nine t':it:il 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 spitting of blood. In twelve cases of n 
 ery, three had hemoptysis, Prom our large experi- 
 ence of perforating chest wounds we would infer that 
 the Bpitting of blood is :i very deceptive diagnostic 
 Btgn of lung wound. When it is rapidly brought up 
 by moutlifuls, it hecomes an important symptom. 
 
 The discharge of blood from the wound is Borne- 
 times occasioned by injury to the intercostal vessel; 
 hut this is so rarely the case thai McLeod states that 
 he neither saw nor heard of an instance during the 
 Crimean war. 
 
 The most distressing symptom is dyspnoea, which 
 uia\ 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 
 been present at any time. This symptom is some- 
 times \<ry intense — from moral or other causee 
 when the lung is not wounded, and it may be bull 
 slightly marked, or even altogether absent, when the 
 lung is seriously implicated. This difficulty in breath- 
 ing depends, in some instances, upon the direct press- 
 ure and condensation of the lung by air or by fluids. 
 When the chest has been opened by a ball the lung 
 does not oollapse, as is generally supposed, but, if the 
 opening is sufficiently large, can be seen moving to 
 and fro against the thoracic walls simultaneously 
 with respiration ; and. as a proof of the continued ac- 
 tion of the lung, and its inflation with air, it is BO me- 
 times found protruding from the orifice, forming a 
 hernia of the organ. Even when the lung has been 
 Completely perforated, it does not necessarily collapse ; 
 hut as blood escapes into the pleural cavity, the lung 
 
DTSPNOSA IN CHEST WOUNDS. 319 
 
 maybe gradually pushed back and condensed against 
 the vertebral column, with all the accompanying symp- 
 toms of dyspnoea. From injury to the lung and con- 
 tinued pumping of air into the pleural sac, when an 
 opening exists in the chest for its ready escape, we 
 sometimes find similar difficulties in respiration in- 
 duced. 
 
 Emphysema is a symptom Of injury to the lung upon 
 which much importance has been placed, and yet is a 
 sign which our extrusive experience shows to be rare- 
 ly present. It ma}' be occasioned by any circum- 
 stance which admits air 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. Should 
 a ready exit not be offered for its escape, or should any 
 Obstacle exist in the form, size, or direction of the 
 wound, the air would be forced into the cellular tissue. 
 Owing to the free communication in the interstices of 
 areolar tissues, it diffuses itself widely and rapidly. 
 Should a perforated wound from a ball or other weap- 
 on allow air to enter the pleural cavity, whether the 
 lung be injured or not, emphysema might appear. It 
 is not bo frequently met with after gunshot wounds, 
 because the large orifice of entrance offers a free 
 exit to the contents of the cavity. It is a much 
 more common accompaniment of oblique punctured 
 wounds, and is also met with in cases of fractured 
 vilis. when sharp spieulao of bone have abraded the 
 Surface of the lung and allowed air to escape from 
 the air tubes into the cavity. As it is found either 
 with or without lung injury, it can not be of much 
 value in diagnosis. The injured lung, in gunshot 
 
 wounds, do.s not often permit air to escape for any 
 
 ,i of time from its wounded surface, ;^ an imme- 
 
320 COLLAPSE IN OHEST WOUNDS. 
 
 diate extravasation of bloo i into the braised tissae 
 closes up the small air tabes, and shuts off oommu> 
 nication with the cavity. 
 
 Another Bymptom of great value is collapse, depend* 
 ing upon loss of blood. It is well known thai all the 
 blood of the body must continually pass through the 
 lungs j and Bhould the vessels composing tin- Daren* 
 ehyma «»t' this organ be extensively opened, the loss 
 in even a short period must be excessive. It is not 
 surprising, therefore, that the patient should soon !"■- 
 come cold, pale, and faint — with feehle, small, and ir- 
 regular pulse, ami with rapid tendency to syncope. 
 This is nature's efforl to chock further 1>>ss; ami al- 
 though sometimes successful, often gives hut tempora- 
 ry security. The surgeon tries to induce this condu 
 
 tion for a similar purpose. 
 
 Prom the consideration of the above symptoms, we 
 are induced t<> believe that no one symptom is pathog- 
 nomonic of injury to the lung; it is rather from a 
 combination of phenomena that any certainty in 
 diagnosis is attained. The immediate danger and in- 
 tensity of the symptoms will depend upon the depth <>f 
 the penetration. Wherethe chest is only superficially 
 
 WOUIlded, although the force of the Mow may he Buffi- 
 Oienl to pro. line an amount of shock of shorter . r 
 longer duration, and blood may he expectorated from 
 the COnCUSSiOC of the lungs, the symptom-, will he 
 
 trivial. The pain of the bruised tissues will pass off in 
 
 a few days, ami with it all the accompanying svmp- 
 toms. When the chest has heen Opened without inju- 
 ry to the long, heart, or intercostal vessels, the 
 symptoms are also trivia] ; and unless inflammation of 
 the pleura, and subsequenl effusions of serum or pus 
 should ynsue, the case will equally require hut little 
 
sYMl'ToMs OF LUNG WOUNDS. 821 
 
 treatment. When the hi 1 1 <^ is implicated, and especially 
 when severely 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 quantify, as in haemoptysis, while, at the same 
 time, it flows from the external wound in the side. 
 If the openings in both lung and chest be free, the 
 blood escaping, both by the wound and the mouth, 
 is mingled with air when the patient coughs. The 
 air is forced from the chest wound in such a blast 
 as to extinguish a lighted candle. With the loss of 
 blood, the surface becomes cold and bedewed with a 
 cold perspiration; the pulse is weak and tremulous, 
 becoming more and more enfeebled until syncope 
 comes on, which temporarily checks the excessive 
 bleeding. Should the orifice in the side offer an im- 
 perfect escape to the blood, and the vessels injured be 
 large, it collects in the pleural cavity, rapidly en- 
 croaches upon the lung, which is forced back against 
 the spinal column, and, by compressing the opposite 
 side of the chest through the mediastinum, threatens 
 suffocation. The eyes protrude, nostrils expand to 
 their utmost, the arms are thrown about in every di- 
 rection, and frightful struggles for breath appear in 
 every feature. These are the cases which, if not re- 
 lieved by the free escape of blood externally, will, in a 
 few moments, terminate fatally b} r suffocation. Where 
 the bleeding occurs from small vessels the pressure is 
 so gradually increased that the above symptoms are 
 not observed. 
 
 The simple cases of chest wound, requiring no imme- 
 diate attendance, will be sent on to th«- field infirmary, 
 
TRKATMK.NT IN CHE8T WOl N 
 
 and although the woand lias evidently transfixed the 
 chest, if no argent Bymptoms exist, the case requires 
 no treatment from the ambulance surgeon. The sur- 
 geon at the field infirmary removes any rough field 
 dressing, and. where foreign bodiea arc suspected, 
 examines the wound wiih the finger. It the orifice be 
 aol sufficiently large to permit a thorough search, he 
 dilates it with a probe-pointed bistoury. 
 
 In perforating chest wounds, unless urgent symp- 
 toms of dyspnoea are present, the general treatment is 
 purely of the expeotant plan. The wound having 
 been carefully closed with a strip of diachylon plaster, 
 
 the patient lies on the wounded Bide, 80 as to throw 
 
 the lung against the orifice, hoping that it may adhere 
 to the chest at that point, and so close permanently 
 the cavityj he also finds this the most comfortable 
 
 position. He i^ kept quiet ; all excitants are avoided; 
 
 abstemious diet is instituted; vcratrum viride or digi- 
 talis may lie given to control the action of the heart ; 
 opium is freely administered to quiet the constant 
 backing, tickling cough, and cold water dressings are 
 
 applied to the chest. With >iieh treatment and Care- 
 ful watching, Beeing the patient, if possible, every one 
 
 or two hours, we await the development of symp- 
 t s. The accurate cl08Ure of the wound excludes 
 
 the admission of air, to a certain extent prevents 
 emphysema, and also the rapid decomposition of the 
 escaped, fluids in the cavity, which indirectly prevents 
 inflammation. 
 
 [f it be a shot wound, with a single orifice, and 
 
 portions of the clothing he foond wanting, the wound 
 
 should he examined for foreign hodies. If found, 
 
 extiaet them; if not detected, then close the wound 
 carefully with a strip of diachylon, and apply the 
 
 water 01' ICO dressing. 
 
TREATMENT IN CHEST WOUNDS. I!'-.'! 
 
 The search for foreign bodies must always be made 
 with the finger, and should never he protracted. 
 Should nothing be found after a moderate, intelligent 
 Bearch, close the wound and await developments. 
 This examination should be made before reaction 
 (•nines on. Should we not see the patient until he is 
 Feverish, all examinations must be absolutely forbid- 
 den until reaction has subsided and suppuration be 
 well established. 
 
 it is well known that balls, etc., — even pieces of 
 clothing— have often been found encysted in the lungs 
 years after they had been deposited; and in some in- 
 stances these articles have been expectorated, during 
 a severe spell of coughing, after a long interval from 
 the receipt of the injury. Although always desir- 
 able to remove these, a prolonged search may entail 
 such an amount of injury as to destroy all hope 
 of saving the patient, when the presence of the for- 
 eign body would not have been necessarily incom- 
 patible with life, or even health. Besides, when sup- 
 puration is well established, we have a second and 
 much better opportunity for a careful examination, 
 without much fear of doing injury. 
 
 A case in point was reported to the association of 
 array surgeons al their meeting in February, l^:i}. by 
 Surgeon Tliom. as communicated to him by Surgeons 
 Seldcn and Moore : 
 
 "The patient, of scrofulous habits, t wenty-two years 
 of age, was leaning on his gun, the muzzle in contact 
 with his left side, when it exploded, tearing a hole in 
 the chot of three Or four inches in diameter, carrying 
 
 with the load of shot fragments of tic third, fourth, 
 
 and fifth l-il's, ami the whole of a very heavy English 
 gold patent-lcvei- watch, exoepl the ring to which the 
 chain was attached — which, singular to say, was found 
 
:524 TKKATMKNT in 0HE8T WOt nds. 
 
 in the Lining of his waistcoat, on tbe right side. Dr. 
 
 .Seidell found the patient apparently about t<» expire, 
 
 and. from the impending suffocation upon the ingress 
 of air within bo Large an opening, he could make do 
 
 exploration of the wound. Closing the wound with 
 
 a large compress and bandage, opium and stimulants 
 were freely administered. Reaction took place, and 
 in a fortnight sufficient adhesions were established to 
 permit exposure of the cavity of the wound, and to 
 recognize and to remove the metal face of the watch, 
 from some six inches at the bottom of the wound. 
 For several weeks fragments of the watch continued 
 
 to present themselves and were extracted — sonic from 
 
 the diaphragm, others below the clavicle. The lung 
 
 Collapsing was not torn to pieces, though wounded iii 
 several points. Both the heart covered hy the peri- 
 cardium and the aorta were exposed to view and to 
 touch. Suppuration was enormous — hemorrhages fre- 
 quent. The collapsed lung became hound down by 
 adhesions; the whole side of the thorax sunk. Sus- 
 tained by every article of nutritious food calculated to 
 supply an inordinate appetite, the patient's recovery 
 was slow until the wound, progressively reduoed, 
 could only admit a female catheter. Fragments of 
 the watch and hone, together with shot and other 
 extraneous matters, continued for some time to he 
 ejected by expect orat ion, with sputa. The patient 
 now possesses every part of the watch except the 
 hands, a considerable portion of the small works hav- 
 ing been expectorated. The openings into the lung 
 were of sufficient Bise to allow a current of air to es* 
 cape, and, if directed against the flame of a candle, to 
 extinguish it. The patient's health continues feeble, 
 but is as robust as it had been during the past live 
 year- " 
 
TREATMENT IN CHEST WOUNDS. 325- 
 
 When active hemorrhage occurs within the cavity, 
 two diametrically opposite courses are recommended 
 by military surgeons of experience. Many advise 
 that the wound should be kept open, so as to allow 
 the free ingress of cold air into the cavity, which, as a 
 haemostatic of great value, may be influential in con- 
 stringing the injured blood-vessels and stopping the 
 hemorrhage. Other surgeons recommend that, in 
 such cases, the orifice be closed with extreme care, even 
 paring the edges of the wound and bringing the parts 
 together by silver sutures, so as to ensure union by the 
 first intention. The object of this course being to re- 
 tain the blood within the cavity of the pleura, allow- 
 ing it to fill this space, compress the lung, and with it 
 the bleeding vessel, so as to stop the further loss of 
 blood. Should the rapid accumulation of blood in the 
 cavity of the chest cause serious dyspnoea, the orifice 
 may require opening to allow the fluid to escape, and 
 thereby relieve the pressure upon the lung. 
 
 The effect of this escape of blood from the cavity 
 of the chest was exemplified in the case of Major 
 Wheat, who was shot through the chest at the first 
 Battle of Manassas, the hall entering in atone armpit 
 and escaping from the other on a level with the nip- 
 ple. Soon hemorrhage caused great oppression and, 
 finally, fainting. When he partially recovered his 
 consciousness he found himself surrounded by his men. 
 who, believing him dead, had Btripped his body of 
 every vestige of rank, so as to prevent recognition by 
 the enemy. One of his men (a powerful sergeant |, 
 determined to save the body from indignities, had 
 seized the major's arms at the wrists, and, with the 
 assistance of a comrade, had slung the body over ids 
 back, drawing the arms of the supposed dead man over 
 each shoulder, and in this position started off from 
 
.;_'•'» TREATMENT IN OH EST WOUNDS. 
 
 the battle-field. Major Wheat was himself a power- 
 ful man, and his weight, in addition to his chest being 
 
 drawn forcibly against the broad back of bis sergeant, 
 80 increased the pressure upon his lungs as nearly to 
 extinguish the flickering spark <>t' remaining life, when 
 ho suddenly felt a gush of blood and air from, both 
 armpits, followed by sueli immediate relief that he 
 found his breath returning, and when lie reached the 
 ambulance wagon he could stand up. Arriving at the 
 hospital, he found that he had so far recovered, under 
 this rough treatment, that he could walk with assist- 
 ance. Quiet, with but little medication, soon com- 
 pleted the cure, and, in course of time, enabled the 
 major to resume his command. 
 
 In drawing off the contents of the chest, should 
 syncope threaten we should close the opening ami 
 await another opportunity. The collection is retained 
 in certain cases, when no marked dyspnoea exists, for 
 the purpose of retarding and finally controlling the 
 bleeding, by the pressure which the pent-up fluid 
 exercises upon the lung and its injured blood-ves- 
 sels. After the third or fourth day, the tendency to 
 hemorrhage having ceased, and the wound having al- 
 ready commenced to suppurate, t he adhesive plaster is 
 removed ami 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, for the first few days, a copious and very 
 offensive discharge. Gradually the escaping fluid 
 loses its dark color and offensive smell, and assumes 
 the appearance of healthy pus. Formerly much care 
 was taken to favor the flow of fluids from the chest, 
 and dilation of the wound was the recognized rule; 
 now, unless serious oppression of breathing exists, 
 threatening suffocation, the opposite treatment is the 
 
TREATMENT IN CHEST WOUNDS. 327 
 
 one urged, to exclude air, and, if possible, retard de- 
 composition — as this deterioration of the effused fluids 
 is more injurious to the sj'stem than the advantages 
 obtained by their ready escape. From this time on- 
 ward, simple water dressing will be the only local 
 treatment required for the wound," 
 
 If the orifice from a punctured wound has healed, 
 with escaped blood remaining within the chest, the 
 collection, if small, should be ignored, as it will gradu- 
 ally be absorbed. If the extravasation be very ex- 
 tensive, particularly if air had previously entered the 
 cavity, it may be necessary, in a few rare instances, 
 to withdraw the effusion by making a puncture at 
 the most dependent portion of the chest. This opera- 
 tion, unless called for by urgent or distressing symp- 
 toms, should, in no ease, be hastily performed, but 
 should, on the contrary, be delayed as long as possible. 
 
 In collapse we have already recognized a valuable 
 aid for cheeking hemorrhage, and its remediable ad- 
 vantages should be appreciated. As a S} T mptom it 
 must be carefully watched, and should it threaten to 
 stop the action of the heart, external stimulation must 
 be freely used; but the internal stimuli must be admin- 
 istered only in small quantity, and with caution. 
 
 European writers on the subject of chesl wounds 
 agree that the lancet is the only safe reliance in eases 
 of dyspnoea, or internal hemorrhage, and they urge 
 that, in the incipient treatment, before the patient is 
 borne from the battle-field by the litter-carriers, the 
 veins of both arms should be opened and blood be al- 
 lowed to run off freely, which they consider as the bes| 
 means of Stopping the effusion within the thoracic cav- 
 ity. This venesection they do nut hesitate to repeal 
 whenever dyspnoea -hows itself, and recommend that, 
 to obtain its beef results, il should be carried to syncope. 
 
TREATMENT IN CHE8T WOUNDS. 
 
 In connection with this, the most active antiphlogistic 
 treatment is instituted. The results reported by them 
 indicate that tins injury is among the most fatal of 
 gunshot wounds. Of four hundred and seventy-four 
 
 cases reported by Mel d of injuries to the chest, one 
 
 hundred and twenty-six died, which is a frightful mor- 
 tality, when it is taken into consideration that all 
 wounds about this region were included, only a small 
 proportion being perforating wounds with injury t<> 
 the lungs. Among the officers there were fifty-four 
 cases of chest wounds, of which twenty-one had ap- 
 parently perforated the cavity. Of those latter fifteen 
 died — a mortality of 71 per cent. In our expedience 
 perforating wounds of the chest, even those in which 
 
 the ball had clearly travelled the lung, are. by no 
 
 means, so fatal an injury a-< ganshot wounds of other 
 regions of the trunk. Under the expectant plan, 
 
 which consists of little more than careful nursing, 
 avoiding all active treatment, more especially hlood- 
 Letting, we have succeeded in Bavin g the majority of 
 our wounded. Burgeon Thoin, in a recent report to 
 the association of army ami navy surgeons, gives a 
 list of seventy. i'mim- cases of ganshot wounds perforat- 
 ing the chest and transfixing the lungs, as reported 
 by Confederate army surgeons. Of these twenty died 
 — a mortality of 25 per cent., — which indicate- clearly 
 
 the advantages of the expectant course of treatment 
 
 for this as well as for all gunshot wounds, over the 
 heroic and fatal treatment of former years. As far 
 as could he ascertained, bloodletting had beon resorted 
 
 to in hut one case of perforated chest wound. 
 
 When the immediate dangers have passed, the next 
 
 in order is inflammation of the lungs and pleura. 
 Neither of these conditions differ in any very material 
 respect from the idiopathic varieties of tho disease. 
 
TREATMENT IN CHEST WOUNDS. 320 
 
 except that traumatic pneumonia is usually circum- 
 scribed to narrow limits. As the cause of pleuritis is 
 a direct injury to the membrane, and, in the majority 
 of instances, as air has been admitted within the cavity, 
 the effusions which accompany the inflammation soon 
 become purulent, and, in time, false membranes of con- 
 siderable thickness line the inner surface of the ribs. 
 
 Thp 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, ac- 
 tive, and repeated bleedings, with cool drinks and ab- 
 stemious diet, recognizing, at the same time, however, 
 that many excellent recoveries have been mado with- 
 out recourse to the lancet. Guthrie uses the lancet, 
 which he designates the first and most essential remedy, 
 and which he says should be resorted to in every case. 
 The venesection, which he repeats whenever the in- 
 flammatory symptoms sIioav an increase, is vigorously 
 followed by large doses of tartar emetic in pneumonia, 
 and calomel in pleurisy — the object being to affect the 
 gums as soon as possible. This is the treatment of the 
 old school, which recent experience does not uphold. 
 Guthrie states "That in the Crimea bloodletting had 
 not been so favorably viewed, nor found so serviceable, 
 nor so neoessary." Fraser, from Crimean experience, 
 states that, in the prevention and reduction of inflam- 
 matory action, in perforating wounds of the chest, 
 venesection is not demanded. He advises its use only 
 when the pulse is full, strong, and labored — a condition 
 not often met with. When the heart and pulse are 
 both weak — a common condition after severe wounds 
 — in our experience the abstraction of blood will 
 sion a complete prostration of strength, and may be 
 fatal 
 
 Bb 
 
TREATMENT IN CHEST WOUNDS. 
 
 There is no reason for changing the plan of treat- 
 ment, already discussed in detail, for combating inflam- 
 mation following gnnshol wounds, and which is equally 
 applicable to chest wounds. Even when the lung is 
 inflamed, we prefer the mild, antiphlogistio and ex- 
 pectant treatment i<> tin' spoliative. The large suc- 
 i) the treatment of perforating chest wounds in 
 the Confederate hospitals puts forth, in a Btrong light, 
 the powers of nature to heal all wounds when least 
 interfered with by meddlesome Burgery. Absolute 
 rest, cooling beverages, moderate nourishment, avoid- 
 ing over-stimulation, with small doses of tartar emetio, 
 veratrum, or digitalis, the liberal use of opium, and at- 
 tention to the intestinal Becretions, will be required in 
 all cases, and in most will compose the entire treat- 
 ment. 
 
 A certain degree of pleuritis is expected and d< - 
 in penetrating lung wound.-, to establish adhesions 
 
 between the injured lung and thoracic wall, which will 
 at once isolate the injured part, and prevent inflam- 
 matory sequela). As gunshot wounds do not usually 
 close rapidly, but suppurate, often permitting the ac- 
 cess of air within the thorax, the suppuration may he 
 profuse and long-continued. We must remember this 
 in the treatment, and not use depressing agents. 
 When the pleuritis is excessive and general, both false 
 membranes and the rapid accumulation of fluid are to 
 be anticipated. If the external wound isstill open, the 
 position in which the body is placed is very important, 
 as it will allow of the ready escape of the effusion, 
 which is, at first, serous, but Boon becomes purulent. 
 
 Position and constitutional support will form the basis 
 of treatment. lithe pus could have a constant outlet 
 for escape, and accumulation within the cavity could 
 be prevented, the false membranes would tie the lung 
 
TREATMENT OF FRACTUftEfc RIBS. 331 
 
 to the thoracic Avail at an early period, and, by oblit- 
 erating the affected portion of the pleural cavity, pre- 
 vent further discharge. Should the wound from which 
 pus pours daily be in the upper portion of the chest, 
 and auscultation and percussion indicate that the entire 
 cavity is filled with fluid, it would hasten the cure to 
 establish a counter-opening from the most dependent 
 portion of the cavity, by which the drain would be 
 facilitated. 
 
 The chapter on the treatment of suppurating wounds 
 lays down general laws for counteracting the inju- 
 rious influences of long-continued suppuration. 
 
 Penetrating wounds of the thorax occasionally re- 
 main fistulous for an almost indefinite period — which 
 is caused by a failure of general adhesion between the 
 costal and pulmonary pleura*. A kind of pouch is 
 found, lined by a false membrane, from which a puru- 
 lent lymph is continually secreted. After empj^ema 
 the chest contracts, the walls sink in, the diaphragm 
 rises high on the affected side, the spine becomes con- 
 torted, air enters indifferently into the lung, ausculta- 
 tion indicates no respiratory murmur, little or no 
 respiratory movements are seen in the chest, and a 
 portion of the respiratory apparatus is rendered useless 
 to the economy. Usually this long train of symptoms 
 terminate fatally in phthisis, although in the progress 
 of ordinary gunshot wounds of the chest and lungs 
 perfect health is regained in the majority of cases. 
 
 In cases of fractured ribs, from gunshot injuries, 
 which is a very frequenl complication of perforating 
 wounds of the chest, the bone is usually spiculated, 
 and some of the fragments may accompany the ball in 
 its onward course. Upon examination with the finger 
 irregular fragments can bo detected, and should 
 be removed. If necessary, the outer wound might be 
 
TRKATMF.NT OF FRACTURED U 
 
 enlarged, to facilitate this importanl step. The danger 
 i< do( bo much from the breaking of the bone, bat from 
 the displaced, sharp fragments seriously injuring the 
 pleura and Lang. Where the ball has fractured the rib 
 without perforating the cavity, the digital examina- 
 tion should be made With extreme caution, so as not to 
 force Bharp spiculaj through the pleural lining, thereby 
 converting a simple into a serious accident. When these 
 are removed the wound should be closed with a wide 
 adhesive strap, and cold water dressings applied. 
 Whether symptoms indicate injury to the lung or not, 
 a broad band must be applied and firmly drawn 
 around the chest, in order to control the thoracic 
 movements and allay the pain. This pain is caused 
 chiefly by the movements of the broken ribs driving 
 the sharp fragments into the sensitive tissue. < iontrol 
 the movement by a broad bandage, and pain is at 
 once relieved. An opening is made in the broad hand 
 to correspond with the wound, so that the discharge 
 can esoape freely without interfering with the fracture 
 dressing. Where the spiculaj are not displaced, a 
 broad adhesive strap is the only local apparatus re- 
 quired. Necrosis of the rib commonly follows a gun- 
 shot fracture, and may require a subsequent operation 
 for its removal. 
 
 When an intercostal artery is divided the bleeding 
 point will be discovered bydrawingoul the lips of the 
 wound with a tenaculum, when the vessel should he 
 
 secured. All military Rurgeons agree thai this is an 
 operation more frequently spoken of than performed, 
 many of extensive experience having never seen a 
 
 case. 
 
 When foreign bodies, as halls, pieces of hone, cloth, 
 wadding, etc., are driven into the pleural cavity, unless 
 remoYed, they may produce fatal results by inflamma- 
 
GUNSHOT WOUNDS OF SPINE. 333 
 
 tion and exhausting discharges. A loose ball can bo 
 sometimes felt by the patient, and its movements often 
 detected by the stethescope. Through an opening, 
 made at the most dependent portion of the chest, the 
 foreign body has been successfully removed. 
 
 Among the most fatal injuries are found gunshot 
 wounds of the spine, whether inflicted by shot or por- 
 tions of shell. A concussion of the spinal cord, pro- 
 duced by the explosion of a shell in the immediate 
 vicinity of the back, is an injury not unfrequently 
 met with in field practice, having, as its most con- 
 spicuous symptom, pain in the vicinity of the injured 
 part, accompanied by impairment of mobility and 
 sensation of the lower limbs, amounting at times to 
 paralysis. These annoying conditions are very per- 
 sistent — patients thus afflicted being often the in- 
 mates of military hospitals for months. As the re- 
 sult of such a concussion, blood may be effused within 
 the sheath of the cord, causing a similar paralysis from 
 pressure as was seen in hemorrhage within the skull. 
 A chronic and eventually fatal myelitis may supervene 
 upon this extravasation, increasing and extending 
 the paralysis so as to include the bladder and rectum, 
 With involuntary escape of feces and retention of 
 urine. The inflammation may run on to complete dis- 
 organization of the cords. The treatment from which 
 relief will be obtained is in keeping the patient per- 
 fectly quiet in the recumbent position, using blisters 
 or cups to the back, and applying stimulating embro- 
 cations to the spine. The urine should be drawn off 
 twice daily. When the bladder is paralyzed and the 
 rectum emptied daily by an enema, so as to prevent 
 the continued escape Of small quantities of fecal mat- 
 te!', extrad of belladonna, in half-grain doses, is sup- 
 posed to exercise's decided influence in controlling 
 
kIPTOMS OS WOUNDS 01 SPINK. 
 
 stions of the spinal cord, and may be used with 
 benefit. When the Bymptoms ai*e slowly (subsiding, 
 the only remaining evidence of injury being the de- 
 bility of the lower limbs, convalescence can be hast- 
 ened by the internal use of sulphate of strychnia. 
 
 'L'li' ,u which balls embed themselves in the 
 
 bodies of the vertebra without injury to the cord are 
 not bo dangerous, although a weakness of the baok, 
 with severe pains similating rheumatism, torment the 
 
 patient, and may eventuate in serious derangement of 
 the economy. 
 
 All gunshot wounds of the spinal column do not 
 destroy life with the same rapidity, although they are 
 all considered necessarily fatal. By examining the 
 anatomical distribution of the many nerves which take 
 their origin from this nervous centre, we will find that 
 
 many of the important Organs Of the trunk are Mip- 
 
 plied from this source. I lommencing from above, after 
 the muscles of the neck are supplied, arc the phrenic 
 nerves, which give motion to the diaphragm. They 
 arise from the vicinity of the third cervical vertebra. 
 Prom the lower cervical region originate the nen 
 the upper extremity ; from the dorsal region the inter- 
 costal muscles receive their nervous supply j ami from 
 the lumbar region, besides the muscles of the lower 
 pari of the trunk and those of the lower limbs, the 
 bladder ami rectum are dependent for their powers of 
 action upon nerves originating here. 
 
 Should a fragmonl of -hell or a hall lay open the 
 lower portion of the .spinal column, the immediate 
 
 symptoms would he paralysis of the lower limbs, 
 
 with retention of urine and involuntary discharges 
 
 of feces, inasmuch as there is no power in the sphinc- 
 ter muscles Of the anus to retain the contents of the 
 
 rectum. The surface of the lower portion of the body 
 
SYMPTOMS OF WOUNDS OF SPINE. 335 
 
 and extremities loses temperature, and with it a 
 gradual impairment of nutritive activity, in which 
 the entire economy in time sympathizes. The skin 
 of the paralyzed portion assumes a cadaveric hue, 
 with tendency to congestion at different points, even- 
 tuating in a lifting of the cuticle and a gangrenous 
 condition. Should the patient survive sufficiently long, 
 mortification attacks all thoso paralyzed portions of 
 the body compressed in the attitude of lying, and im- 
 mense sloughing bed sores assist to exhaust the patient. 
 While these changes are going on, some of tho con- 
 tents of the over-distended bladder, filled with decom- 
 posed urine, is constantly escaping — there being no 
 power in the paralyzed neck of the bladder to retain 
 it. The urine becomes alkaline and ammoniacal, irritat- 
 ing the mucus lining of the bladder, which assumes 
 a condition of chronic inflammation, with thick, ropy 
 discharges. Should not inflammation and disorganiza- 
 tion of the spinal cord occur to destroy life more rap- 
 idly, the patient may live for weeks or months, but is 
 graduall}' worn out. 
 
 Where the injur}' to the spine is located in the 
 dorsal region, there are present, besides the symptoms 
 just enumerated, paralysis of the abdominal muscles, 
 and all those intercostal muscles situated below the 
 seat of injury. This complication interferes more or 
 less seriously with respiration, which meets with no 
 assistance from the abdominal and intercostal muscles, 
 but must be carried on solely' by mean- ->t the dia- 
 phragm, the thoracic cavity h.inu- contracted by the 
 depressed ribs. In consequence of this paralysis, res- 
 piration and the artrrializat i<>n of the blood is \<vy 
 indifferently performed. Congestion of the* lungs is 
 gradually induced, and tho patient rarely survived 
 this accident more than from two to three weeks, 
 
33(5 TREATMENT Of SPINAL INJURIES. 
 
 although he is usually carried ofl'a few days after the 
 reeeipt of the wound. As. the point of injury ascends, 
 the spinal cord involving the upper extremities, the 
 respiratory movements are more embarrassed, and 
 should tho injury be Located in the vicinity of the 
 third cervical vertebra, and at the origin of the nerves 
 supplying the diaphragm, death is immediate from 
 asphyxia, as all respiratory movements are completely 
 paralyzed. 
 
 In any case of gunshot injury of the spinal column, 
 even in its lower portion, should inflammation of the 
 cord and its meninges be established, which, when it 
 occurs, ordinarilj' makes its appearance four or five 
 days after the receipt of injur}-, death occurs speedily 
 from the disorganizing effects of this inflammation. 
 Where the spinal cord has been injured by a ball <>r 
 portion of shell, the patient dies, no course of treat- 
 ment offering any prospects of success. The course 
 to be pursued is altogether palliative — keeping the. 
 bowels and bladder emptied, and allaying pain by 
 administering some of tho preparations of opium. 
 This class of injuries is by far the most fatal of all 
 gunshot wounds. 
 
CHAPTER XI. 
 
 Wounds or Abdomen — Flesh Wounds — Never probe perforating 
 Wounds of the Abdomen, and, especially, never attempt to 
 BBARCH for Foreign Bodies which have passed beyond the Ab- 
 dominal Walls — Sew up Intestinal Wounds — Dilate Wound in 
 Abdomen when necessary to relieve strangulation and to fa- 
 cilitate reduction — AVhere the larger Viscera are injured, 
 recovery is rare — Avoid using Purgatives when the Intestine 
 is wounded — Peritonitis a common causeof 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 ab- 
 dominal wounds boi-c a fair relative proportion toother 
 wounds, immediately after a battle, a few days suf- 
 ficed to remove them — so that, by the end of the first 
 Week, there was scarcely one to be seen. This rule is 
 only partially verified in modern surgical experience, 
 as many cases of intestinal wounds recover. In cases 
 of perforating wounds of the abdomen, those Avho have 
 received wounds of the large abdominal viscera, such 
 as the liver, stomach, kidneys, and bladder, are most 
 frequently lost — t he exceptions of restoration to health 
 being not very numerous. Like wounds of the chest, 
 where the abdominal walls are not perforated, bu1 the 
 entire traek of the hall lies in the thickness of the 
 muscles, the wound is simply a flesh wound, of a com- 
 paratively trivial character, and should be treated ac- 
 cordingly. Tin- track Of the hall may not always he 
 in a straight coane, as the muscles, or their ten' 1 ' 
 
338 ABDOMINAL WOUNDS. 
 
 portions, when in action, offer sufficient resistance to 
 divert the ball. 
 
 A perforating wound of the abdomen is equally dan- 
 gerous with those of the chest, as peritonitis 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 
 incised abdominal wound, many recommend that the 
 needle should not pass deeper than the superficial 
 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 contrac- 
 tion, while, if the peritoneum be also included, perito- 
 nitis is likely to occur from the irritation of the 
 thread. Although this may hold good in theory, it 
 is not verified by experience. There is no reason 
 why attempts should not be made to cause union 
 throughout the entire thickness of the abdominal 
 wall, and, therefore, all the tissues should be included 
 in the suture. When this is done, the cicatrix will be 
 firmer, and there will be less probability of secondary 
 hernia — a very common accident after injury to the 
 abdominal walls. 
 
 In probing abdominal wounds, the only object to be 
 sought by the examination is, whether the wound has 
 perforated the cavity or not ? From the direction of 
 the track, this can nearly always be determined. In 
 this, as in any other gunshot wound, the use of the 
 silver probe would be very dangerous, as it may con- 
 vert a simple into a perforating wound. By means of 
 the finger, or a gum bougie, the course of the wound 
 can be traced, and also the existence of foreign bodies 
 detected. Should we find that the opening transfixes 
 the abdominal wall, our examination should go no 
 
RETURN PROTRUDING VISCERA. 339 
 
 further. It is a dangerous amusement to satisfy curi- 
 osity at the expense of such irreparable mischief as 
 may destroy the life of the patient. 
 
 If the wound be a large one, as when made by a 
 bayonet, fragment of a shell, or minie ball, a portion 
 of the abdominal contents may protrude from the 
 wound. This is not a serious complication if the 
 viscera be not injured. When the ambulance 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 or 
 other extraneous substances by pouring water upon 
 it; and, carefully returning it within the abdomen, 
 closes the wound by sutures, if it be an incised wound, 
 or a broad strip of diachylon plaster, if a gunshot 
 wound. He then administers a dose of morphine, and 
 sees that the wounded man is properly transported to 
 the field infirmary. 
 
 To facilitate the return of the protrusion, whether 
 it be intestinal or omental, the patient is placed upon 
 his back, with the thighs drawn up and the abdominal 
 muscles relaxed, when the surgeon makes steady 
 pressure upon the protrusion 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 inflam- 
 mation of the protruding organ. The better plan 
 would be to encircle the protrusion by the fingers 
 clustered together as a funnel or cone, which will 
 diminish the bulk at the opening in the abdomen, 
 and facilitate its return. 
 
 If it be found that the mass is so constricted, by the 
 small size of the orifice, that the return within the 
 abdominal cavity is impossible without inflicting in- 
 jury upon the bowel, the intestine should be drawn to 
 
340 RETURN PROTRUDING VISCERA. 
 
 one side, arid, using great caution, the wound should 
 be enlarged a quarter or half an inch, as the injury in- 
 flicted in the abdominal walls by the knife would be 
 of small moment, when compared to the bruising of 
 tho protruding viscera from the force necessary to 
 push it through the small opening. 
 
 Cutting upon a grooved director, or using a probe- 
 pointed bistoury, while enlarging the wound, will 
 diminish the dangers of injuring some important part 
 within. The return of the bowel should always be 
 effected by the ambulance surgeon before the case is 
 transported to tho field infirmary, inasmuch as the 
 crowding of the wounded at the infirmary may be such, 
 that several hours might elapse between the receipt 
 of injury and the hospital examination — quite long 
 enough to cause strangulation of the intestine, and 
 sufficient to excite cither inflammation or mortification 
 of the protrusion, usually a fatal complication in ab- 
 dominal wounds. 
 
 The early return of the protruding intestine makes 
 the case one for simple and successful treatment. Bo 
 satisfied that the intestine has been returned within 
 tho abdominal cavit} r and not forced under the sheaths 
 of the abdominal muscles, where it would strangulate 
 and rapidly destroy life. 
 
 Should the case not bo seen until several hours had 
 elapsed, the intestine should be equally returned, 
 whether it be blackened by congestion or be inflamed; 
 but when gangrenous, which is recognized by its 
 greenish ash color, loss of polish, its flaccid condition, 
 with already a disposition to separation in its various 
 coats, it should remain without the wound, and be laid 
 open so as to allow its fecal contents to bo evacuated. 
 Adhesions rapidly form, uniting the protruded intes- 
 tine to the peritoneum at the inner orifice of the wound. 
 
TREATMENT OF PUNCTURED INTESTINES. 341 
 
 This shuts off all connection with the peritoneal cavity, 
 and prevents extravasation of fecal matter 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 Avould be ex- 
 cited. 
 
 Should the intestine be punctured, it should be 
 closed with one, two, or more points of interrupted 
 suture, according to the size of the opening — a stitch 
 being placed for every one-sixth of an inch of intestinal 
 wound. The ends of the suture are cut off close to 
 the knot, and the bowel is returned with care into the 
 abdomen. A fine cambric needle will be the best in- 
 strument for sewing up intestinal wounds, as the small 
 puncture and fine thread produce but little irritation. 
 
 It would be better to avoid perforating the mucus 
 lining of the bowel in passing the sutures 5 but should 
 the entire thickness of intestinal wall be transfixed by 
 the needle, the pouting mucus surface must be pushed 
 in from between the lips of the intestinal opening, so 
 that, in drawing the noose of the suture, the perito- 
 neal surfaces will be turned in and brought in contact 
 upon each side of the wound, when rapid adhesion will 
 take place. As the mucus surface is lined by an epith- 
 lium, its presence between the lips of the wound would 
 prevent union. During the process of healing, an ex- 
 cess of lymph is deposited, which accumulates over the 
 suture, incarcerating the knot. Finally the thread is 
 thrown off into the bowel, having disengaged itself by 
 ulcerating through the mucus membrane. This is a 
 very beautiful provision of nature, for, should the 
 thread escape into the peritoneal cavity, fatal inflam- 
 mation would most probably ensue. 
 
 If a large dose of opium had been administered on 
 the battle-field, or as soon as the patient had arrived 
 
•°.1_' TREATMENT OF PUNOTUBED iv, 
 
 at the infirmary, while awaiting his turn t<> be dre 
 the peristaltic action of the bowels would have been 
 suspended, and the wounded portion of the bowel, 
 which, when the hernia ie extensive, should always be 
 the last portion returned, remains within the abdomi- 
 nal cavity, in immediate contact with the wound ; and 
 to this point it soon becomes attached throhgh adhe- 
 sive inflammation. Should, from any oau8e,thesu1 ores 
 give way. or the bowel slough from the injury which 
 it had received, its Contents, instead of being thrown 
 into the peritoneal cavity where it would produce fatal 
 inflammation, would, on account of the adhesions of 
 
 the bowel near an external outlet, escape externally, 
 
 which diminishes materially the risk run by the patient. 
 The threads used in closing the opening in the intes- 
 tine, under these circumstances, either escape through 
 the bowel by stool, or are discharged through the 
 abdominal wound. 
 
 In examining the external wound when no protru- 
 sion exists, should we find an escape of fecal matter — 
 which proves that the bowel has been perforated — 
 some surgeons recommen'd that the abdominal wound 
 be enlarged, and the wound in the intestine closed by 
 suture. This tiny consider the only expedient for 
 saving life — for, should the contents of the bowel be 
 allowed to escape, into the peritoneal cavity, a fatal 
 Issue must be expected. The dilatation of the wound, 
 they believe, diminishes the risks. 
 
 In such eases I would prefer paralysing the vermi- 
 cular motions of the intestine by large and repeated 
 doses of opium — the first dose being administered as 
 soon as the condition of the wound is perceived, and the 
 effects kept up for several days until the bowel becomes 
 adherent to the abdominal wall, or the orifice in it be- 
 comes closed. With the cessation of peristaltic mo! ion 
 
TREATMENT OF PUNCTURED INTESTINES. 843 
 
 the escape of intestinal contents will also cease, and the 
 dangers of inflammation, from a foreign substance in 
 the peritoneal cavity, diminish. Should the discharge 
 continue, it would likely escape through the abdomi- 
 nal wound. 
 
 Should the intestine be extensively injured beyond 
 the possibility of saving it, rather than return a por- 
 tion of bowel within the abdomen to mortify and 
 destroy the patient, it should be left hanging out of the 
 wound. All of the sound portion of the protrusion 
 having been returned, the crushed portion is enveloped 
 in a wet or oiled cloth. The peritoneal coat of the 
 bowel will form adhesions to the peritoneal edge of the 
 abdominal wound, the outer portion sloughs, ami an 
 artificial anus forms, which gives constant escape to 
 the fecal contents. In time this artificial outlet grad- 
 ually closes b% T a spontaneous effort of nature, the feces 
 seeking their normal passage. In nearly every case 
 of artificial anus from gunshot wound, the restoration 
 of the continuity of the bowel, with closure of the 
 wound, is effected by nature, although the cure may be 
 delayed for even twelve months. Rarely is it neces- 
 sary to interfere, by an operation, to remove the de- 
 formity. 
 
 In examining the archives of surgery we find cases 
 in which portions of the intestines have been cut off, 
 the cylinder of the bowels reunited by sutures, and 
 excellent recoveries obtained. These experiments 
 have been tried successfully upon animals, and in- 
 stances are met with where the human subject has been 
 saved by a similar operation. I have recently had 
 under my care a lunatic, who, some months since, at- 
 tempted suicide by opening Ins abdomen, drawing out 
 hi- bowels, ami completely severing two feet of in- 
 testine. Dr. Gaston, of Columbia, S. <"., who had the 
 
.; I 1 PERFORATING ABDOMINAL WOUNDS. 
 
 case under charge, brought the two open ends of the 
 intestine together, and, securing them l>v carefully-ar- 
 ranged sutures, returned them within the cavity. 
 The patient made a perfeel recovery. Tins accident, 
 which terminated so successfully for the lunatic, sug- 
 gests an operation for a crushed intestine, which may 
 offer bettor prospects than Leaving the bowel to slough 
 and form an artificial anus. In such eases the hest 
 rule for treatment would consist in removing the in- 
 jured portion, securing the bleeding vessels, and re- 
 closing the intestine by sutures, and treating the case 
 as if a simple incised wound of the bowel had alone 
 existed. 
 
 In all .perforating wounds of the abdomen, as we 
 can not 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 the double 
 object, viz: of controlling the peristaltic action, which 
 alone can prevent extravasation of the contents into 
 the peritoneal eavity, and for its antiphlogistic effeet, 
 to equalize the circulation, allay pain, suspend nervous 
 irritability, and prevent inflammation. 
 
 2. Avoid the use of purgatives, and enforce abste- 
 mious or even absolute diet. 
 
 In our hospital experience, gunshot wounds, impli- 
 cating the intestines, give a mortality of about 25 per 
 cent., — the average duration of treatment for the suc- 
 cessful eases being thirty-eight days. The large num- 
 ber, proportionably, of cures, depends upon the class of 
 wounds, as many of the more serious die on the field 
 before they could bo conveyed to a general hospital. 
 
PERFORATING ABDOMINAL WOUNDS. 345 
 
 When all perforating abdominal wounds, with injury 
 to intestines, are included, the experience of field 
 surgeons gives a mortality of 75 per cent. The for- 
 mation of an artificial anus in the progress of the case 
 should not be considered a serious complication, as 
 they usually heal even when the bowel has been 
 wounded in two or three places, with the formation of 
 as many artificial ani. 
 
 With the majority of physicians, who have had but 
 little experience in the - treatment of abdominal 
 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 
 progress of the case will soon show them. This is a 
 fatal error, which the utmost after-care can not remedy. 
 For three or four clays at least after the receipt of in- 
 jury, in which the intestines are known or are supposed 
 to be wounded, absolute rest, the most abstemious diet, 
 and the liberal use of opium (one grain of gum opium, 
 or its equivalent in laudanum, every six hours), in 
 connection with cold water or iced dressing, will com- 
 pose the entire treatment. If the patient feels uneasy, 
 an enema will relieve the large intestines and add 
 much to his comfort. By the fourth day the wound 
 in the intestines will have closed by lymphy effusion, 
 and the dangers of exciting inflammation will, to a 
 certain extent, have subsided. 
 
 If peritoneal inflammation be excited, with febrile 
 reaction, pain greatly increased by pressure over the 
 abdomen, and more particularly in the neighborhood 
 of the wound, with tympanitis, 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 
 
846 PERFORATING ABDOMINAL WOUNDS. 
 
 and filling the abdominal cavity with fluid. To check 
 this rapidly fatal disorganisation, leeches or cupa 
 
 sliouhi be applied to the abdomen, to be followed by 
 hot narcotic or turpentine stupes, by blisters, or by 
 ice bladders, which arc now preferred, while opium 
 should be given in large doses and at short intervals. 
 J f the patienl he young and plel boric, and the inflam- 
 matory symptoms are early recognised, the lancet 
 might be used; but as a rule, in military Burgery, this 
 remedy is badl}' borne, and has been generally dis- 
 carded. Calomel was formerly used with the opium, 
 and was considered tlte main dependence, hut is now 
 dispensed with, as all the advantages gained are ac- 
 credited to the opium. 
 
 Sometimes in a lew 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 baa experienced from the peritonea] 
 inflammation, and marks rapidly-approaching dissolu- 
 tion. It is rare that the liberal use of brandy, with 
 carbonate of ammonia, external warmth, and sin- 
 apisms, rescue the patient at. this advanced stage; 
 although, it' given when debility commences to show 
 itself, they may supp >rt the patient, and be the means 
 Of saving life. When the swelling of the ahdomen, 
 and the dull sound which percussion elicits, shows ex- 
 tensive eil'usion. the abdominal wound should be ro- 
 opened, and, by placing the patient in a proper position, 
 the eil'usion he allowed to escape. It is a desperate 
 operation, but has been known to save a few cases, 
 which, if left alone, would have certainly perished, as 
 those do upon whom this operation is not performed. 
 
 In gunshot wounds of the ahdomen, if the missile 
 has perforated, it would he madness to probe the ab- 
 dominal cavity. We must imagine the worst, give 
 
PERFORATING ABDOMINAL WOUNDS. 347 
 
 the patient the benefit of these doubts, and by ex- 
 treme care hope to counteract the baneful influences 
 which foreign bodies, when remaining in the abdomi- 
 nal cavity, always exercise. The ball may have trav- 
 ersed the cavity and embedded itself in the fleshy 
 walls beyond, or even in the body of a vertebra, 
 without having injured any organ of importance in 
 its course. The absence of serious symptoms, as the 
 case progresses, can alone inform us on this head. 
 From the physiological effects following a gunshot 
 wound we might, at times, trace the resting-place of 
 the ball : e. g., when paralysis of the lower limbs fol- 
 lows au abdominal gunshot wound, we might infer 
 tin.' burying of the ball in the vertebral column, with 
 pressure upon the spinal cord, 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, either 
 from division of some large vessel or from injured vis- 
 cera ; or may be caused by the division of the epigas- 
 tric artery while coursing in the abdominal walls. 
 Should the orifice made by the ball lie directly over the 
 course of this vessel, and external hemorrhage be ex- 
 cessive, t lie wound should be dilated, the bleeding orU 
 ■light for, and, when found, ligated. When, from 
 the former source, but little can be done, venesection 
 to syncope might check the flow, and the formation of 
 a clot may plug up the injured vessel. Some sur- 
 gOons, knowing tin' desperate condition brought on 
 by internal hemorrhage, recommend dilating the 
 wound; and, should it be found that hemorrhage 
 conies from one of the mesenteric vessels, the artery 
 should be ligated. The position of the external wound 
 
348 PERFORATING ABDOMINAL WOUNDS. 
 
 will assist us in forming a diagnosis us to the proba- 
 ble source of the hemorrhage. Cases of recovery are 
 recorded where the wound was diluted, and the bleed- 
 ing vessel in the omentum sough 1 for and secured. 
 
 Where some of the large viscera or blood-vessels 
 are injured in perforating abdominal wounds, the 
 Symptoms are mnoh 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 battle-field; or, should they be 
 alive, they are pale and cold, with anxious counte- 
 nances, and intense longing for water. This insatiable 
 thirst is not peculiar to visceral wound or to nervous 
 .shock, but is an indication of serious hemorrhage. 
 Should the wound be extensive, they never rally from 
 this collapse. In other cases-the shock may permit the 
 clogging of injured blood- vessel 8, and may 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 nil' 
 the patient after a period of intense suffering. 
 
 On account of the hemorrhage and subsequent in- 
 flammation which accompany these injuries, all gun- 
 shot wounds of the larger abdominal viscera are con- 
 sidered nearly necessarily mortal, and exceptional 
 cures are rare. Punctured wounds of the liver, stom- 
 ach, or kidneys are often saved, and even gunshot 
 wounds of these viscera are at times recovered from. 
 AVhen the external orifice is small, the position and 
 direction of the wound will lead us to suspect the 
 special injury, and, in connection with persistent vom- 
 iting, the ejection of blood by tho mouth, by stool, or 
 with the urine ; the escape of special secretions, as 
 
WOUNDS OF STOMACH." 340 
 
 bile, urine, or feces by the wound; and the peculiar 
 pain or sensations experienced by the patient — will be 
 our chief indications in locating the injury. 
 
 In gunshot wounds of the stomach the contents es- 
 cape externally, and also into the peritoneal cavity, 
 where, as extraneous substances, they light up gen- 
 eral and, usually, fatal peritonitis. As soldiers most 
 frequently go into battle without previously having 
 had a meal, the flaccid condition of the stomach, with- 
 out contents to escape from this organ, is a great 
 safeguard in case of wounds, and hence perforating 
 wounds of this viscus more frequently recover under 
 t hese circumstances than when gunshot injuries are 
 received under other conditions. The location of the 
 wound is often, in the army, the only basis for diagno- 
 sis, as the escape of contents and vomiting of blood 
 are not constant sjnnptoms, and shock, which is usual- 
 ly present, is common to all wounds of the abdominal 
 viscera. When the patient survives the reactionary 
 state from the effects of gunshot wounds of the liver, 
 bile continues to flow from the wound, often in largo 
 quantity, the patient gradually becoming emaciated. 
 He is rendered more feeble by diarrhoea, induced from 
 the absence of the biliary secretion in the intestines, 
 where its antiseptic properties are required to prevent 
 decomposition of thcinjesta, and continued irritation. 
 In kidney mounds the most fatal complication de- 
 pends upon the infiltration of urine in the contiguous 
 cellular tissue, creating extensive sloughs, poisoning 
 the blood, and usually rapidly destroying life. Great 
 pain in the lumbar region, frequent micturition, with 
 bloody urine, retraction of the testicle, nausea, vomit- 
 ing, indicate the injury. These cases usually do bad- 
 ly, and, in the experience of many army surgeons, 
 arc always fatal. \Y< now and then hear of wounds 
 
3o0 ' KIDNEY WOUNDS. 
 
 of the kidneys recovering, but their rarity only bring 
 the fatal character <>( the lesion more prominently 
 forward. It' the exit for urine from the wound be 
 free, then infiltration may no1 occur, and in these 
 pare instances the siee and location of the wound may 
 be instrumental in effecting a cure. This is more 
 especially the case where the injury is an oblique one, 
 which has not implicated the abdomen. 
 
 The treatment of these serious wounds, which, on 
 the whole, is so unsatisfactory, is similar to that re- 
 quired for perforating wounds of the chest, with in- 
 jury to the lungs. Opium internally, and cold locally, 
 with absolute diet, should become the basis of treat- 
 ment. A little water or small jiieees of ice is all that 
 
 the patient requires during the first two or three days. 
 
 In injuries to the bladder, bloody urine, or rather the 
 passage of clots as well as pure blood through the 
 penis, is the diagnostic sign. Should urine escape 
 from the wound, it is equally pathognomonic. In ad- 
 dition to the course -already laid down for internal 
 abdominal injuries, the introduction, by the penis, of 
 a large gum catheter into the bladder, through which 
 urine is allowed to drain away as fast as it is secret- 
 ed, will assist in preventing urinous infiltration, which 
 is one of the most fatal complications connected with 
 a wounded bladder. The catheter should be intro- 
 duced as soon as possible after the reception of the 
 wound, 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. Should the 
 injury be at the neck of the bladder, the catheter 
 will also be required when the sloughs are separat-* 
 ing, as swelling of the parts often obstructs the 
 ready flow of urine. The gum catheter may even be 
 
"if" / 
 
 WOUNDS OF BLADDER. 351 
 
 kept in from the commencement of the treatment un- 
 til the wound is well advanced in healing, unless it 
 excites much irritation,*when it may be temporarily 
 withdrawn. This precaution will prevent many cases 
 of urinous infiltration, and save many lives. 
 
 Although this is clearly the course to be pursued, 
 it is often impossible of attainment, as, even in the 
 hands of a skilful manipulator, the instrument can not 
 be introduced when the neck of the bladder, or the 
 prostatic part of the urethra, has been divided. Jf 
 the catheter can not be passed into the bladder a free 
 incision should be made through the perineum for 
 the evacuation of urine and the discharges from the 
 wound. 
 
 The following case is pertinent to the subject, as it 
 clearly demanded a perineal incision; the surgeon 
 having failed to make it, nature in time eifected it, 
 but too late for the salvation of the patient. 
 
 Private T. Young, Company (x, 7th New Hamp- 
 shire regiment, was shot, on the 18th of July, at the 
 assault upon Battery Wagner, Morris island. The 
 ball entered the outer and posterior side of the left 
 hip, about two inches below the great trochanter. 
 Its range was slightly upward. Having passed under 
 the skin of the perineum, cutting the urethra in the 
 vicinity of its membraneous portion, the ball was de- 
 flected downward from its straight course, making its 
 exit on the outer and posterior side of the right thigh, 
 four inches below the great trochanter. When 
 brought into hospital, the day after the assault, at- 
 tempts were in vain made by the surgeon in attend- 
 ance to introduce a catheter. Urine flowed from both 
 wounds in the thighs, at first involuntarily. After 
 a few days the patient gained control of his bladder, 
 but could not direct the stream of urine, which still 
 
352 W01 ND8 01 BLADDER. 
 
 ™ 
 
 l out of ill" thigh wounds whenever he mictu- 
 rated. An abscess oventually formed in the perineum, 
 which, when opened three weeks after the injury, also 
 gave vent to urine. The patient died with extreme 
 emaciation* 
 
 One of the chief points of interest in this case is 
 the long track through which the urine found its way 
 immediately after the injury, and by which it con- 
 tinued t<> escape. None was at any time passed 
 through the penis, although the patient bad a perfect 
 contro] over the bladder. 
 
 Fortunate it is for men going into battle thai the 
 excitement under which the troops -are at thai lime 
 Laboring causes a continual dropping from the ranks 
 
 to urinate. BO that rarely does a soldier go into battle 
 
 with his bladder full. In this physiological fact lies 
 the safety of many a man, as the contracted bladder, 
 concealed behind the pubis, in the cavity of the pelvis, 
 often escapes injury from the passage of a ball, which, 
 were the organ distended, would assuredly traverse it. 
 Our hospital reports give several eases of vesical in- 
 jury successfully treated. Among these is one of 
 special interest, in which the ball, in traversing the 
 pelvic region antero-posteriorly, transfixed bladder 
 
 and rectum, anterior abdominal wall, and saeruin. lis 
 extent was reeo^ni/.ed by the escape of urine ante- 
 riorly, and urine with I'ecal matter through the sacral 
 orifice, as well as urine running off h\ the rectum. In 
 
 time these orifices closed, and the patient was dis- 
 charged cured. 
 
 On May ."». l^t'..;. I removed an encysted calculus 
 from the bladder of Private R. S. Moore, Company K, 
 
 Palmetto Sharp-shooters, who was shot at the Battle 
 
 of Prazer's Farm, June 29, 1862. 'The ball passed 
 obliquely, entering at the right Bide of the abdomen, 
 
WOUNDS OP BLADDER. 353 
 
 on a level with the crest of the pubic hone, crushing 
 its outer surface, then traversing the bladder, and es- 
 caping through the left buttock, between the tuberosity 
 of the ischium and base of coccj'-x. For several days 
 after the injury the bladder emptied itself through 
 both of these orifices, no urine escaping by the penis. 
 After discharging urine for several weeks, the wound 
 in the buttock closed, the abdominal wound continu- 
 ing to discharge urine up to the day of operation for 
 lithotomy — nearly eleven months. During this period 
 he has passed by the penis pieces of bone as well as 
 fragments of calculus. For four months he had been 
 aware of the presence of a stone, which he felt rolling 
 in his bladder. He had been confined to his bed for ten 
 months, and was exceedingly emaciated, with hectic, 
 when he presented himself for operation. So direct 
 was the communication of the anterior fistula with the 
 bladder; that, when this viscus was injected, prior to 
 the operation, the water escaped so rapidly from the 
 fistula as to empty the bladder before it could be 
 opened. A round stone an inch in diameter was found 
 encysted over the pubic region, and was removed with 
 much difficulty. The case recovered verj^ rapidly. 
 The abdominal opening closed up at once, no urine 
 escaping from it after the operation. The nucleus of 
 the calculus was paste-like, with no trace of a foreign 
 body which I expected to find. Among the many 
 points of interest which the case possesses, is the one of 
 the orifice of exit healing tir>t. although urine was 
 discharged through it as the most dependent orifice. 
 
 Injur}/ to the large intestines, when not involving the 
 peritoneal cavity, arc not so serious as perforations of 
 the small. As the large bowel is bound down in the 
 greater pari of it- course, extravasations of their con- 
 tern- do not necessarily take place into the i bdominal 
 Dd 
 
354 RUPTURE OV AHl.cMINAL VI8CERA. 
 
 cavity j and although fecal matter escapes externally 
 from the wound, and high inflammation, with profuse 
 suppuration, usually follows, many of the wounded 
 eventually do well. 
 
 Cases not unusually occur on the battle-field in 
 which the abdominal contents might be severely crush- 
 ed without apparent external injury. It is the tough- 
 ness and elasticity of the skin which gives rise to the 
 exploded theory of the wind of a ball destroying life ; 
 and such cases as those we are now considering were 
 formerly brought forward as instances of the fatal 
 effects of the vacuum following the wake of a cannon- 
 ball. 
 
 Observation has shown that a knapsack might be 
 torn from the back, a hat struck from the head, an 
 epaulet from the shoulder, or a pipe from the mouth, 
 without leaving a trace of injury; while, on the other 
 hand, viscera might be reduced to a jelly, or bones 
 crushed, without a visible bruising of the skin. It is 
 tho ball itself, and not the wind, which produces these 
 disorganizations. From the blow.of a spent cannon- 
 ball or fragment of a shell the liver might be lacerated, 
 intestines torn, blood-vessels opened, spleen fissured, or 
 kidney ruptured, without an external wound. Severe 
 shock and collapse mark the extent of injury received ; 
 and should the patient rally from this condition, which 
 is rare, violent inflammation will soon destroy life. 
 Although we follow vigorously the treatment laid down 
 above, we very seldom have tho satisfaction of saving 
 a patient. 
 
 Sergeant E. L. Davis, Company < ', 7th battalion S. 
 C. V., was injured, on the 10th of July, during the bom- 
 bardment of Battery Wagner, by the explosion of a 
 shell. Two days afterward, when he entei-ed the gen- 
 eral hospital, he complained of pain in the left lumbar 
 
EFFECT OF SPENT BALLS. o55 
 
 region, where he had been struck. There was no 
 eschimosis present, although there existed some tume- 
 faction — not, however, sufficient to excite any appre- 
 hension. There was slight abrasion about his face and 
 right side. Six days after the injury, he having suf- 
 fered much with pain, fluctuation was detected in the 
 lumbar region. A puncture was made, which dis- 
 charged a large quantity of pus, and, with it, fecal 
 matter. Some of this escaping into the cellular tissue 
 of the loin and buttock induced a phlegmonous con- 
 dition, with rapid sloughing of cellular tissue. Al- 
 though free incisions were made, the sloughing could 
 not be checked. It extended in every direction, until 
 one vast sloughing cavity occupied half the trunk, from 
 the ribs to the trochanter, and from the vertebral col- 
 umn to the pubis. An autopsy revealed a double rup- 
 ture in the descending colon, with openings parallel to 
 the circular fibres, which had permitted the free escape 
 of fecal matter into the cellular tissue, between the 
 bowel and quadratus lumborum muscle. Collecting 
 in quantity, it had separated and disorganized the tis- 
 sues as low as Poussart's ligament, forming a large sac 
 distinct from the peritoneal cavity, and separated from 
 it only by the peritoneum. In this the iliac artery was 
 lyitig bare. Had the feces not escaped in the loin it 
 would have dissected to the groin, as the fecal cavity 
 was hounded below by Poussart's ligament. 
 
 The amount of destruction effected by a spent ball 
 is often surprising. The uninitiated on tin- battle-field 
 will attempt to Stop, with the foot, a cannon-ball roll- 
 ing on the ground, and which is just about exhausting 
 its force, perhaps with only momentum sufficient to 
 Carry it one or two feel further, yet it crushes the 
 limb pu1 out to oppose it. Baudens.in warning persons 
 to avoirl cannon-balls, however slowly they may he 
 
BALLS IN PBLVIO OAYD I. 
 
 rolling, mentions the case of m grenadier of the guard, 
 Bleeping on bis Bide on the gronnd, who was instantly 
 killed by :» spenl 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 overcoat, where it was found. Lt was just 
 about to slop when it struck. Oneor two feel further, 
 an<l its entire force would have been exhausted. 
 
 Balls nearly spent, in perforating the pelvic cavity, 
 expend all of their force in passing through the bones, 
 and then remain embedded in the cellular tissue. As 
 such wounds do not readily heal, on account of spicules 
 of bone keeping up a discharge, a probe can he passed 
 
 through the orifice in the hone to the hall beyond it. 
 
 In the ease of Private B. •' Mm thews, of the 26th Ala- 
 bama regiment, a youth of fourteen years, who, when 
 returning from a tilth charge against :i Yankee bat- 
 tery during one of the Battles of Richmond, was shot 
 in the hack; the hall entered through the sacrum an 
 
 inch from its BpinOUS processes, and one inch below the 
 level of the crest of the ilium. Eight months after the 
 
 reception of the wound he applied to me for relief, as 
 
 he had a constant discharge of pus from both the 
 wound in the hack and a fistulous passage in the left 
 groin. Upon examination with a probe, which passed 
 
 in four inches, traversing the sacrum, the foreign body 
 
 was detected, the bulb of the prohe entering the cup 
 of the- minie hall. Uy using a gouge, the orifice 
 through the sacrum was enlarged sufficiently to allow 
 the hall being drawn from the pelvic cavity. The case 
 
 recovered. 
 
CHAPTEE XII. 
 
 Injuries of the Extremities — Compound Fractures — Difference 
 of treatment in tiie Utter 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 best means of saving 
 Life — -How Resections are to be performed — Special Resec- 
 tions of Shoulder, Elbow, Wrist — Resections and Amputations 
 of the inferior extremity — Primary and Consecutive Amputa- 
 tion — When, and under what circumstances, Amputations 
 should be performed — modes of operating and of dressing 
 
 STUMPS. 
 
 As the major portion of the injuries of the extremi- 
 ties are merely flesh wounds, these will not require to 
 be now noticed, but the effects of such wounds in im- 
 pairing the uses of a limb will be hereafter considered. 
 Those which we will now discuss are such as involve 
 the bones, joints, or important vessels, and which may 
 call for special treatment. It is in this department 
 that conservative SUrgerj lias made the greatest ad- 
 vances, and has accomplished so much in diminishing 
 mortality and mutilation. Not that amputations will 
 ever be abolished, tor many lives can be saved in no 
 
 Other way than by the sacrifice Of limbs ; but conserva- 
 tive BUrgery lias shown that the constant flourish <>f 
 the amputating knife is not the way to obtain the 
 greatest number of BUrgical Victories in tines of war. 
 Amputations must, however, ever remain a surgical 
 
358 0UN8H0T rRACTUB*. 
 
 jsity ; :ui<l be who removes crashed limbs with 
 the greatest skill, and saves the patient*by successful 
 after-treatment, will ever deserve the high position 
 which humanity :i!i<l philanthropy will bestow upon 
 him. 
 
 In gunshot wounds of the extremities we find a 
 mnch greater vitality and resistance to injuries in the 
 upper than in the lower limbs, which would modify the 
 treatment of similar injuries located in these two por- 
 tions of the body. This depends upon the greater 
 vascularity and freer anastomosis in the arm than in 
 the leic- I" the more liberal supply of blood-vessels 
 and nerves we find the source of safety which enables 
 
 US l" sivr an arm, when, for a similar injury, a leg 
 
 would be generally condemned. 
 
 The most common accidents to the extremities 
 whioh give Burgeons the greatest annoyance, and re- 
 quire the most careful diagnosis, prognosis, and treat- 
 ment, are compound fractures. These have always 
 made a numerous and important class in military sur- 
 gery, but have become doubly so in modern warfare, 
 from the substitution of conical shot for the round 
 musket-ball. This projectile Beldom impinges upon a 
 
 hoic without leaving frightful traces of devastation. 
 
 Such a conioal ball rarely remains embedded, but, 
 acting on the principle of 6 wedgo, splits and commi- 
 nutes the bone, driving the loose spicules in every di- 
 rect ion before it . 
 
 When a hone is crushed by a ball, the patient i- con- 
 veyed very carefully to the field infirmary; or, if it 
 can be done without delay, to the general hospital, 
 
 where the treatment commences. < >n the field the 
 
 ambulance surgeon can do nothing but administer a 
 dose of morphine, ami secure the limb t<» a rough 
 
 splint, to facilitate transportation. for a fractured 
 
PROGRESS OF GUNSHOT FRACTURE. 359 
 
 clavicle, scapula, or humerus, the arm is bandaged to 
 the chest, which, on the battle-field, answers the pur- 
 pose of a temporary splint; for a crushing of the 
 forearm or hand, the arm PS laid upon a board splint, 
 and slung from the neck. If the splint is not at hand, 
 the sling made of a handkerchief must answer until 
 the wounded man can be better attended to — it being 
 understood that a wet or greased cloth is always put 
 over the wound for its protection during the transpor- 
 tation. 
 
 When he arrives at the hospital the limb is care- 
 fully examined. The external wound may give no 
 indication of the extent of internal injury. When 
 the finger is introduced and the wound carefully 
 explored, the degree of crushing will be ascertained, 
 and the question at once proposes itself: what course 
 shall we pursue? Shall we attempt to save the limb ; 
 or does its condition, with the want of proper facili- 
 ties for its successful treatment, necessitate its con- 
 demnation? If we have had experience in the care 
 of gunshot fractures, we should anticipate the dan- 
 gers, and, with Sir Charles Bell, contemplate what 
 will be the condition of the parts in thirty-six hours, 
 in twelve days, or in three months. In thirty-six 
 hours the inflammation, pain, and tension of the whole 
 limb, the anxious countenance, the brilliant eye, the 
 BleepldBfl an 1 restless condition, declare the impression 
 the injury is making on the limb and on the constitu- 
 tional powers. In twelve days ihe affected limb is swol- 
 len t<> sometimes half the size of the body ; a violent 
 
 phlegmonous inflammation may pervade the whole; 
 
 seronB effusion lias taken place in the limb, and ab- 
 
 ea are forming in the great beds of cellular texture 
 
 through which the hall has- passed; from the wound 
 pus is escaping in large quantities, impoverishing the 
 
riU.MAKV AMPUTATION PRKKBABLK. 
 
 blood, and rendering the Bystem irritable. In throe 
 months, if the patienl has labored through tins length- 
 ened agony, the bones are carious; the abscesses are 
 interminable Binnses, from*which are kept up a con- 
 tinued discharge j the patienl is pale and emaciated, 
 with hectic flushes and diarrhoea, and the constitu- 
 t i • • 1 1 :i 1 strength ebbs to the lowesl degree. All these 
 conditions must be rapidly considered, ami with them 
 the more immediate dangers "f mortification, ami the 
 remote dangers <>f erysipelas, pyemia, and hectic, ami 
 the questionable utility of the limb, when, after sever- 
 al months of continued trials, the wound has been 
 healed, hut the limb remains weak, shrunken, stiff) 
 
 painful, and nearly useless. 
 
 Our conclusions must be made and acted upon 
 within twenty-four hours, or before reaction sets in, 
 while tlu- patient has bis sensibilities depressed by the 
 Bhock. Success of treatment depends upon prompt 
 
 action — the delay of a few days has destroyed thou- 
 sands of wounded. Should amputation he required, 
 
 there is no period in the progress of the case so favor- 
 able for the performance of this operation as the first 
 four-and-l wenty hours. Should an injudicious at temp! 
 
 he made to save the limit, until suppurative act ion has 
 
 been well established an amputation can not he resort- 
 ed to with a- good prospects of success as prior to the 
 
 development of the inflammatory stage. Should ery- 
 sipelas attack the wound, an amputation is impracti- 
 cable; ami when gangrene has supervened, during the 
 
 Stage "I' reactionary excitement, we are driven t<> an 
 operation under the most unfavorable circumstance-. 
 
rniMARY AMPUTATIONS rilEFKRAKLE. 
 
 361 
 
 Consolidated Tabic of Amputations, from June 1, 1862, to February 1, 
 1864, collated from reports in the Surgeon-General's office. 
 
 Primary. 
 
 Secondary. 
 
 Thigh 
 
 Log 
 
 Arm 
 
 Forearm 
 
 Shoulder-joint. 
 Elbow-joint . . . 
 Wrist-joint. . . . 
 
 Hip-joint 
 
 Knee-joint 
 Ankle-joint . . . 
 Tar8al-joint . . . 
 
 Total 
 
 345 
 
 213 
 
 132 
 
 1 
 38 
 
 162 
 
 43 
 
 119 
 
 314 
 
 219 
 
 95 
 
 30 
 
 150 
 
 76 
 
 74 
 
 294 
 
 252 
 
 42 
 
 14 
 
 140 
 
 87 
 
 53 
 
 69 
 
 61 
 
 8 
 
 12 
 
 4ft 
 
 3ft 
 
 10 
 
 79 
 
 54 
 
 25 
 
 31 
 
 28 
 
 B 
 
 20 
 
 4 
 
 3 
 
 1 
 
 25 
 
 8 
 
 2 
 
 1 
 
 7 
 
 ft 
 
 2 
 
 28 
 
 
 . . • 
 
 
 3 
 
 1 
 
 2 
 
 66 
 
 • . . 
 
 • . . 
 
 
 5 
 
 2 
 
 3 
 
 60 
 
 6 
 
 
 6 
 
 6 
 
 4 
 
 2 
 
 33 
 
 4 
 
 
 
 16 
 
 13 
 
 3 
 
 19 
 
 27 
 
 8 
 546 
 
 262 
 
 1 
 
 284 
 
 1,149 
 
 827 
 
 31ft 
 
 49 
 
 37 
 
 ■22 
 
 n 
 
 100 
 12 
 
 The report of a much larger number of amputa- 
 tions have been received at the Surgeon-General's 
 office, but as the results of treatment in many cases 
 have not been given, these doubtful successes have 
 been purposely omitted from this table. 
 
 There are numerous compound fractures upon which 
 judgment can be immediately passed: with some, there 
 is every probability that the limb can be saved; while, 
 there are others in which the limb is condemned at a 
 glance — our prognosis being based upon the following 
 circumstances: As the upper extremity can sustain 
 a much more serious injury than the lower, we may 
 lay it down as a rule that a compound fracture of any 
 of the long bones of the arm, when not complicated 
 With excessive crushing of tho soft parts, or injury to 
 blood-vessels and nerves, can and should be saved. 
 An arm i> rarely t<> l>c amputated for recent gunshot 
 injuries, except from tho effects of' balls breaking up 
 Be 
 
862 TREATMENT OF COMPOUND FRACTURES. 
 
 extensively the shaft, with long tissuivs extending into 
 
 joints, or where cannon-shot or fragment's of shell, he- 
 sides crashing the hones, makes frightful lacerations 
 of the soft tissues, tearing away muscles, nerves, and 
 blood-vessels, and even at times carrying off the limb— 
 the Burgeon's services being required only to give a 
 better form to the stum]). 
 
 For a gunshot wound from a musket or minie ball, 
 which has fractured the hones of the arm without 
 implicating a joint, the following is the course to be 
 pursued: At the field infirmary the wound is care- 
 fully probed with the tingcr, and its spiculated condi- 
 tion noted. All loose fragments are to be remov 
 this first examination, before reaction ensues, for it will 
 be very injurious to the wound, as well a- excessively 
 
 painful to the soldier, to continue such examinations 
 
 from day to day. The first examination should al- 
 ways he effectual. The patient is then suffering from 
 shock, with sensibility temporarily blunted, and is, 
 
 therefore, in the host condition to be operated upon. 
 To render this first examination complete, should the 
 Shock have passed oft' and the patient complain of 
 much pain, it would be better to give him largo doses 
 of opium, or administer chloroform, rather than desist 
 from this important portion of the treatment. Make 
 a thorough exploration with the finger passed into 
 both orifices, and should the bone he found much 
 crushed, and the orifice^ made bythe ball not sufii- 
 ciently large to permit of their easy extraction, dilate 
 the opening and remove all detached fragments. 
 Should we omit to bring away all spicuhe. the further 
 removal should not he attempted during the stage of 
 excitement and febrile reaction, which will come on 
 after twenty-four hours, and which will run its course 
 in six or eight days. When this BUbsides, then, and 
 
REMOVAL OF FRAGMENTS. .'W3 
 
 not before, we make the second examination, and, by 
 the use of instruments, remove any loose fragment 
 which we may now detect. Wo will simply mention, 
 in this connection, that as there is not the slightest 
 probability, or even possibility, of the wound closing 
 by the first intention, the insertion of tents and pieces 
 of lint is a relic of barbarous surgery, which being 
 useless, injurious, and very painful, can not be too 
 severely condemned. 
 
 Modern surgery recommends that all spiculae, 
 whether detached or not, should be removed, but this 
 practice, unfortunately, is not carried out b}- surgeons 
 generally; and, as the result of this negligence, our 
 country and hospitals arc filled with cases of necrosis 
 of one and two years' standing — men who add mate- 
 rially to the numbers and expense of an army, without 
 in any way increasing its efficiency. .Experience and 
 observation has, in a few instances, shown that, 
 although large fragments ma}* be detached from the 
 shaft of the bone, they may still be adherent to the 
 periosteum, which may effect a reunion and consolida- 
 tion.. On the other hand, experience and observation 
 continually show that, from the force with which coni- 
 cal shot strike a bone, the spicules, which may be very 
 numerous, are driven in every direction, but generally 
 toward the opening <>f escape of the ball. At other 
 times the bone is broken in larger pieces and is split, 
 fissures extending upon the Bhafl for some distance, 
 even perhaps to t he adjacenl articulation. 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, mor- 
 tification, or tetanus. Or inflammation of the lining 
 membrane and periostial envelope, with profuse dis- 
 charge, may entail rapid prostration and intense 
 
364 KKMovAL OF FRAGMKNT8. 
 
 suffering. No surgeon doubts the propriety of re- 
 moving all such fragments on tho spot, or at the 
 earliest possible moment. As the opening of exit, 
 around which the Larger number of tin* fragments are 
 found, may be too oontraoted 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 coin- 
 pound fractures with crushing of the bone, be dilated, 
 so as to facilitate the detection and removal of every 
 spiculse. In enlarging this orifice, injury to the im- 
 portant blood-vessels and nerves will, of course, be 
 avoided by incising parallel to the axis of the limb. 
 
 <)n the subject of removing 'ill fragments, whether 
 detached or not, there appears to be no longer a diver- 
 sity of opinion. The older surgeons, who base their 
 treatment on the effects of round balls, believe that 
 often the connection of the fragments to the soft parts 
 and to tho periosteum will guarantee a consolidation 
 of the fragments. The round hall simply breaks the 
 bone without usually scattering the fragments, and. 
 therefore, their relations to the surrounding tissues 
 will not be so materially changed. But, not withstand- 
 ing this impression, which mayor may not be correot, 
 what does actual experience prove, when reduced to 
 facts ? 
 
 Take tho experience given by the inmates of the 
 Hotel des Invali.des, as recordod by M. I In tin, tho sur- 
 geon of the institution. lie states that those spicuhe 
 which had been attachod to the soft parts, and which 
 were allowed to remain 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 retained 
 
REMOVAL OP FRAGMENTS. ,'5t)5 
 
 fragments, sooner or latei', set up an elimi native action, 
 which is always painful, often dangerous, and at times 
 fatal. M. Ilutin refers chiefly to the effects of round 
 or musket balls. Baudens gives, as his Crimean ex- 
 perience, " That whether adherent or not, it is better 
 to remove all spicule, and thus simplify the wound. 
 If these be retained, endless suppuration, continued 
 suffering, with exacerbations of all the S3'mptoms at 
 the escape of each small fragment, will gradually ex- 
 haust the vital forces, and entail its sequelae of 
 marasmus, diarrhoea, and hectic." Suppuration will 
 eventually bring all of the fragments to the surface, but 
 at what a sacrifice ! 
 
 McLeod, after quoting the experience of Roux, 
 Baudens, Guthrie, Hutin, Dupuytren, Curling, Begin, 
 and others, on the dangers of allowing movable fras:- 
 merits to remain, and the necessity of extracting every 
 piece which is not extensively attached to the soft 
 parts, gives his experience as decidedly in favor of the 
 modern practice of removing all movable spiculce as the 
 best mode of hastening a cure and diminishing mor- 
 tality, " As the removal must tend immensely to sim- 
 plify the wound." 
 
 Again, he sa}*s: " The extensive comminution of the 
 bone by a conical ball makes the indications with re- 
 gard to the management of the sequestra more evident 
 than it is commonly considered. I do not think that 
 %ve paid sufficient attention to their removal in the 
 Bast. It may be true, as some tell us, that in fract- 
 ures with the old ball it was desirable to meddle as 
 little as possible with the fragments; but this is the 
 teaching of only a few. However, t6 my mind, the 
 question assumes a totally different light when viewed 
 by the pathological results which we had occasion to 
 witness." 
 
3(J0 00NDTTT0N OF COMPO • I URFJ. 
 
 Some sargeona go farther, and recommend thai not 
 only should all apiculsB be removed, but that the sharp, 
 irregular ends of the bones should be sawed off. 'This 
 suggestion has not met with general approval, and is 
 spoken of by Stromyer and Locfller us no improve- 
 ment. Their experience gave a larger mortuary list 
 when this practice was attempted. 
 
 There is no doubt that the removal of all fragments 
 will expedite the cure. In Burgery, whenever we are 
 in doubt, we should always give the patient the bene- 
 fit of it; and in thesubject under consideration, know- 
 ing that the removal of the attached fragments, which 
 might eventually become consolidated, can do no 
 harm, while leaving them in, should union not be 
 obtained, would not only be followed by serious .lun- 
 ger, much annoyance, and Buffering, but would event- 
 ually require removal, we should, without hesitation, 
 give the patient the benefit of the doubt, and remove 
 all of them ai the tirst examination. 
 
 If a compound comminuted fracture from a gunshot 
 
 WOUnd be examined three weeks after its occurrence, 
 
 it will be found that the limb will always be enlarged, 
 the tissues oedematous, the muscles softened, orifices 
 pouting, from which laudihlc pus in quantity is daily 
 discharged, and ai the bottom of the wound the probe 
 comes in contact with denuded pieces of bone, which 
 appear movable and isolated as if in a pouch. If an 
 incision is made bo as to expose- the injured hone, a 
 oavity will be entered, lined with a granulating pus- 
 secreting surface, in which the broken pieces Of hone 
 lie denuded of their periosteum, isolated from all con- 
 nection with the soli paii-. and perfectly bleached as 
 ir they had undergone a long process of maceration. 
 Some fragments which .-till remain connected with 
 the soft surrounding tissues will he blanched upon 
 
TREATMENT OF COMPOUND FRACTURE. 367 
 
 then* free side. The periosteum which attaches them 
 to the contiguous tissuos is soft, thick, and very vas- 
 eular, adhering closely to an intermediary substance 
 of spongy texture — evidently new bone in process of 
 formation. In other fragments this new deposit from 
 the thickened periosteum has so nearly enveloped the 
 piece of bone broken from the shaft, that the partially 
 isolated white bone can not be separated without 
 breaking through this newly-formed shell. The white 
 fragments are those pieces which had become isolated 
 from the soft parts by the force of the projectile, and, 
 as is always the case, have been killed, as it wore, 
 from that moment and until removed, either slowly by 
 nature, or by a surgeon, irritate the soft parts as for- 
 eign bodies, and excite the copious discharge of pus 
 from the wounds. 
 
 The incarcerated fragments are such as were still 
 adhering to the soft parts by their peviostial surface, 
 but had met with such destruction of their interstitial 
 nutrient vessels, by the abrupture of the shaft and 
 the tearing of the medullary membrane, as to be 
 incapable of living. They remain adherent only for a 
 time; new bone is formed over them; gradually they 
 are isolated from the new structure, and form, as do 
 the movable fragments, sequestra. From these path- 
 ological developments it would appear that the de- 
 tached fragments are at once destroyed, and those still 
 connected to the soft parts have their nutrition so im- 
 paired that they also die and become foreign bodies. 
 
 The course of treatment based upon pathology is. 
 then, clearly defined. If the chief cause of death in 
 compound gunshot fractures is from irritation of the 
 system, and from the profuse discharge of pus drain- 
 ing off the life's blood, both of which are caused by 
 these foreign bodies, the army surgeon is culpable 
 
368 TREATMENT OF COMPOUND FRACTURE. 
 
 who attempts to treat a compound fracture without 
 removing all such fragments of bone broken off from 
 the shaft i > \ the ball in its passage, whether they arc 
 loose or not. Besides the immense number of victims 
 which the grave conceals, the Dumber of necrosed 
 limbs daily appearing before our examining boards 
 for furloughs and discharges show sufficiently the neg- 
 lect of this principle. The country is now filled with 
 men upon whose arms and legs Buppurating fistula- 
 lead to exfoliated fragments, incarcerated in a shell 
 of new bone, or embedded in the soft parts, and 
 which years of suffering and annoyance have not 
 been able to eliminate. These living testimonials 
 of a bad practice establish a rule of treatment which 
 we should never swerve from except when it is im- 
 possible of performance, viz: in gunshot fracture of 
 the long bones remove, without fail, and as soon after the 
 accident as possible, all fragments of bone. Experience 
 shows that, where this course is rigorously pursued, 
 the duration of treatment is very much shortened, and 
 the mortality decidedly diminished. Our marked suc- 
 cess in the treatment of compound fracture, as shown 
 by the reports from the Surgeon^ leneral's office, can 
 be attributed, in a measure, to the general adoption of 
 this rule of practice. 
 
 While recommending so urgently that all fragments 
 be removed, 1 am averse to the operation of cutting 
 off the sharp ends of fractured hones, as these, not 
 
 having their circulation materially disturbed, are not 
 
 liable to the same dangers of necrosis as are the frag- 
 ments. Their nutrition is well Supported, and such 
 ends usually consolidate. Even when the periosteum 
 has been stripped from the ends for some distance, de- 
 struction docs not necessarily follow — as the bone, 
 through its immediate vascularity, may become soft- 
 
TREATMENT OF COMPOUND FRACTURE. liG'J 
 
 oncd, its blood-vessels enlarged, and granulations for 
 
 the formation of new bone appear upon and cover the 
 surface. 
 
 Feeling secure that we have removed every foreign 
 body, and having left nothing in the wound which is 
 likely to retard the cure, we should ignore the pres- 
 ence of the wound as much as possible, and treat the 
 case as one of simple fracture. Inflammation and 
 suppuration we expect; they generally accompany 
 compound fractures, and especially those connected 
 With gunshot wounds; and remembering the long- 
 continued and profuse drain which will establish itself 
 after four or five days, we should be careful how we 
 make use of active antiphlogistic treatment. For the 
 first week or ten days the limb may be stretched 
 upon a pillow, or loosely secured to a broad, long 
 splint, which will support the entire extremity, and 
 prevent all movements between the broken ends. Dur- 
 ing this period we confine the treatment to cold wa- 
 ter dressings, either by iced bladders, applied over 
 compresses, in order to remove the injurious effects of 
 its direct application, or by the process of irrigation — 
 either of which, when judiciously applied, is better than 
 the continued renewal of wet cloths. 
 
 When we speak of the advantages of irrigation 
 above all other methods of treatment for keeping 
 down inflammatory action, we do not refer to the 
 abusive mode of application common in the army, of 
 deluging the body and bedclothing of the patient, and 
 keeping him for days in this saturated state, fre- 
 quently chilled by the evaporation going on from 
 the entire surface of his body, whenever the bed- 
 clothes are thrown from his person. Under this proc- 
 ess we have not been surprised to hear surgeons com- 
 plain that pneumonia has frequently developed in the 
 
JOINT 1N.li BLIE8 
 
 course of treatment, and thai erysipelas is more Lia- 
 ble to appear in auch patients. All tl> Sects 
 are only obtained when the water dressing is strictly 
 confined t<> the vicinity of the wound. 
 
 The general treatment, for the tirst few days, or 
 
 during this period of inflammatory excitement, con- 
 
 ■ !' simple diet, rest, quiet, and the administration 
 
 of mild diaphoretics, with the Liberal use <>t' opium. 
 
 Tain we do not consider, in any sense, necessary 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 active cathartics 
 will be at once evident from the movements made nec- 
 essary by their action. Bloodletting, emetics, and 
 
 the use of mercury we absolutely discard, as always 
 useless and injurious in the treatment of any Staj 
 compound fractures. A.s Boon as the period of inflam- 
 matory reaction lias subsided, we then apply Buch 
 splints and bandages to the limb as will secure quiet 
 and rest, while at the same time a \'i\>i- vent is allow- 
 ed in the apparatus for the escape of discharges from 
 the wound. This opening also permits the application 
 Of water dressings t<. the wound. 
 
 The most dangerous fractures of the extremities 
 are those extending into a joint, and involving the 
 heads of the hones. The synovial injury adds great- 
 ly to the danger of the oase, and in former tunes was 
 considered nearly a fatal oomplioation, as it net 
 tated an amputation which, under the ordinary cir- 
 cumstances attending hospital treatment, was not far 
 removed from a fatal termination. 
 
 The severity vt' the Bymptoms of articular injuries 
 
 depends upon the size of the joint and the character 
 
, JOINT INJURIES. 871 
 
 of. the wound. The dangers are, at times, serious 
 enough with even the smallest puncture, but when 
 the wound is large and lacerated, and often even 
 when it is apparently trifling, extensive local mischief 
 and constitutional disturbance ensues, leading with 
 certainty to the destruction of the joint, and usually 
 destroying the patient. Hence, in the days of John 
 Bell, the united experience of surgeons considered 
 wounds of joints mortal. Crimean experience corrob- 
 orates John Bell's conclusions, as no serious injury 
 to the large joints recovered unless the limbs were 
 amputated or joints resected. The great danger is 
 not in the serious injuries, as these cases are at once 
 operated upon. It is in the apparently trivial case, 
 where, from the very small size of the wound, we 
 hope that no trouble will supervene, that violent 
 inflammation shows itself, and life is sacrificed. 
 
 The cold water treatment of wounds, so universally 
 adopted in the Confederate army, both in field and 
 hospital practice, shows its great advantages over every 
 Other dressing, even in this hitherto fatal class of 
 injuries. In examining the reports in the Surgeon- 
 General's office we find that a fair proportion of gun- 
 shot wounds of joints have recovered, where no 
 operation was attempted. In knee-joint injuries, 
 which, when not operated upon, have heretofore been 
 considered as always fatal, we can show nearly fifty 
 per cent, of cures. Quiet, rest, immobility of the 
 injured joint, cold water dressing by irrigation pre- 
 ferred, and opium, comprise the elements of success- 
 ful treat nient 
 
:172 
 
 JOINT INJURIES. 
 
 CoiiKolitiatfii Tabi* of fnjurii <•/ Joint*} trrrxt.,1 without Amputntiqii, 
 
 III .Inn, I . 
 miry 1, 1864— J N ■ • ■ • //• />'<!' r. 
 
 Kumarka. 
 
 = 
 
 I 
 
 - B 
 
 i. 
 
 j 
 
 ■ 3 
 
 W 1 < 1 
 
 Oanea of guiD-lint injurv .... IT 
 
 '. 11 
 
 km byloaii 
 
 imb 4 1 
 
 
 
 Percentage of mortality 86 00 07 100 
 
 period of death 10 88 
 
 Greatest 
 
 Leaet " " " o »; 
 
 Average period of recovery 132 l"l OS 
 
 ■I 21 I ■-Tii 240 
 
 u a 32 -j s a: , 
 
 I6« 71 
 
 286 lb' 
 
 Of il I with 
 
 able limt'H. and Jj 
 with anctaj l"*»--i jointa; 
 remainder no! - 
 
 Iii comparing the table of injured jointa not oper- 
 ated upon with the table of resections, it must be 
 remembered thai the more Berious cases were operated 
 upon. If these lia<l been treated without resection or 
 amputation, the mortality among such would have 
 been very heavy. In many of the cases above report- 
 ed, the joint was simply opened withoul injury to the 
 bones, while in all cases of resection halls had entered 
 the joint, tearing up the capsule and, in mosl instan- 
 pushing the arti tulating surfaces, and, therefore, 
 making the prognosis much more serious. 
 
 A wounded joint, under the ordinary hospital treat- 
 ment, will exhibit the following symptoms: When a 
 ball has perforated the joint, the period of reaction ia 
 not long absent. In extensive wounds a great degree 
 of nervous shock accompanies the injury, the pationt 
 lying deadly pale, cold, and faint. In from twenty-four 
 to forty-eight hours the tissues around the articulation 
 become hot, swollen, and painful; inflammation lias 
 ahvady sid/.t'd upon the synovial membrane, and will 
 
 soon involve all the structures. All these symptoms 
 
JOINT INJURIES. 373 
 
 r 
 
 rapidly increase until they become excessive. There 
 is no rest for the weary sufferer, who, often in spite of 
 iced applications and the free use of morphine, with the 
 entire arcana of antiphlogistic remedies, writhes about 
 in unmitigated agony. If the aperture leading into 
 the joint be made by a ball or piece of shell, tho 
 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 tho pain, which is 
 increased by the irregular spasmodic contractions of 
 the surrounding muscles. 
 
 Accompanying these local symptoms will be found 
 a high grade of inflammatory fever, with rigors, great 
 gastric distress, intense thirst, excessive restlessness, 
 and with such an amount of constitutional disturbance 
 as sometimes to destroy life in a few days. As the 
 disease advances, abscesses form in the surrounding 
 tissues by extension of the inflammatory process, and 
 in a few days open continuous passages to the joint, 
 from which a constant discharge of purulent matter ' 
 escapes. Should the patient have an iron constitu- 
 tion, ami the case terminates successfully, it will only 
 bo at the expense of time. After many weeks, or 
 even months of suffering, emaciation, and hectic, the 
 discharge will gradually cease ; but as the preceding 
 inflammation lias drstroyed the cartilaginous surfaces 
 of the joints, and also the character of the sjmovial 
 membrane, lymphy deposits will so mat the extremi- 
 ties <>t' the bones together as to permit of but little 
 motion, and an interstitial deposit in the tissues sur- 
 rounding tin' articulation will restrain all motions of 
 the tendons and inuseles passing in this neighborhood, 
 
 anchylosis being the usual sequela; of a suppurating 
 joint. In dome cases, where mechanical means arc 
 
pIAGNOSIS 01 ARTICULAR IN.MRV. 
 
 to break up those bands i as the inflam- 
 
 matory stage baa paased, movable joints have been 
 saved ; a-< a rule, however, b stiff join! follows articu- 
 lar injury. 
 
 [f the patient be not destroyed in the early Bti 
 of the disease by nervous exhaustion from the intense 
 and constant pain, or by erysipelas and pyemia, in 
 connection with the irritative fever to whioh Buch 
 joint wounds are particularly liable, lie Calls a prey to 
 hectic, caused by the continued drain from the disor- 
 ganized joint — synovial membrane, cartilages, and 
 bones forming one mass of disease. In severe gunshot 
 wounds of large joints, in military hospitals, rarely 
 does the patient escape with life. In private practice 
 he sometimes recovers, bul even under the most ad- 
 vantageous Circumstances for treatment a BUCCi 
 
 case is rarely Been, and then usually with a destroyed 
 and anchylosed articulation. As the results in injured 
 joints are so fatal, Burgeons had, at an early day. 
 adopted amputations as giving the only chance for re- 
 covery. In recenl years conservative Burgery has 
 introduced the operation of resection as affording not 
 only the means nt' preserving life, but also of saving a 
 useful limb. 
 
 The diagnosis of articular injury is usually evident 
 from the direction of the wound and from the escape 
 
 Of synovia; at times, however, when the Orifice is 
 small and the wound circuitous, a successful diagnosis 
 
 requires much ezperienceand close observation. When 
 possible, a consultation should always be had over 
 
 these eases; as it is often in these very cas< - of appar- 
 ently trivial injury that the most violent reactionary 
 symptoms are met with, and that a fatal issue occurs, 
 [f left nn Operated Upon, the apparently trilling won ml. 
 perforating the Joint, might lead to severe crushing 
 
RESECTION OF .SHOULDER-JOINT. 375 
 
 of the bones, which, if left unrecognized, might nearly 
 be considered mortal ; while, if the joint be not impli- 
 cated, the operation 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 injury to the heads of bones forming the 
 joints in the upper extremity resection is particularly 
 applicable, and this operation 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 gunshot wound, whether 
 the joint has been largely opened, or the heads of 
 the bones forming the articulation crushed, as soon as 
 the excessive shock under which the patient may he 
 suffering passes off, we proceed at once to operate. A 
 primary resection is as much called for as a primary 
 amputation, and is followed by as successful results. 
 It should, be performed within twenty-four or thirty- 
 six hours, or before reaction sets in. Such cases would 
 do much better if the patient could be transferred to 
 the general hospital prior to an operation, as trans- 
 portation is difficult and dangerous immediately after 
 the resection, from the difficulty of securing the limb 
 from movements. Experience has so establisbed tbis 
 fact that, in eases necessitating a long and tedious 
 transportation, the rule is to amputate rather than to 
 resect, inasmuch as the gravity of the resection is very 
 much increased by the transportation. Should the 
 • ■a-" col come under observation until reaction hi 
 in, then, by general, mild, antiphlogistic treatment. 
 and ice bladders or cold water dressings locally, we 
 await the establishment of suppuration — after which 
 
:;7»> RKiSEOTION OF BHOULDKR-JOINT. 
 
 the operation might be attempted with good prospects 
 
 Of SlU'i'os. 
 
 The results of the primary resection, are more BU0- 
 cessfal than the secondary ; and these are, in turn, 
 much more likely to Buooeed than when the operation 
 is performed daring the stage of febrile excitement. 
 
 There arc three or lour rules necessary in all cases 
 of resection, and which should not be forgotten daring 
 the operation, viz: Make the incisions 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 possiblo, make 
 the existing wound lio in the line of operations, and 
 place the incisions in such a way as to permit a con- 
 tinued drain from the joint. Make these incisions 
 free, so as not to cramp the operator in turning out 
 the heads of the hones. An inch added to the incision 
 does not increase its serious character, and hastens 
 the operation. Remove most of the synovial mem- 
 brane, and save as much periosteum as possible; the 
 one is prone to take on inflammation — the other 
 makes, and will, to a certain extent, reproduce the 
 bone. In performing secondary resections, the re- 
 moval of all the diseased synovial membrane bocomes 
 one of the first elements for success. 
 
 More successes are obtained from resections of the 
 shoulder-joint than from an operation upon any other 
 articulation — the statistical tables of the final results 
 of operations in favor of resection being conclusive 
 over amputations. 
 
 In examining these tables take into consideration 
 that primary operations are performed upon the most 
 serious injuries; the cases of apparently trivial injury 
 are kept, and resection found necessary during the 
 progress of the case. 
 
RESECTION OF SHOULDER-JOINT. 
 
 377 
 
 CmiKnlidated Tabic of Resections) collated from records in the Surgeon- 
 General'* office, from June 1, 1862, to February 1, 1864— prepared 
 by Surgeon H. Bacr, P. A. C. S. 
 
 PllIMAUY. 
 
 Bucoessful . . . 
 Unsuccessful., 
 
 Secondary. 
 Sucoessfal 
 
 In successful.. . . 
 
 Useful Joints. 
 
 c 
 
 
 
 
 
 to 
 
 
 
 
 
 13 
 
 * 
 
 «Jj 
 
 
 CD 
 
 o 
 
 5 
 
 hi 
 
 P. 
 
 H 
 
 a 
 
 Total 68 
 
 28 
 
 22 
 
 2 
 
 
 
 13 
 
 3 
 
 •• 
 
 
 2 
 
 20 
 
 23 
 
 1 
 
 1 
 
 1 
 
 7 
 
 6 
 
 •• 
 
 1 
 
 1 
 
 2 
 
 7 
 
 
 
 •• 
 
 68 
 
 54 
 
 3 
 
 2 
 
 4 
 
 131 
 
 Consolidated Tabic of Disarticulations, made up from records in the 
 Surgeon-General' s office, from June 1, 1862, to February 1, 1864 — pre- 
 pared, by Surgeon H. Baer. 
 
 c 
 
 
 
 
 
 s 
 
 
 
 
 
 -d 
 
 5s 
 
 J 
 
 
 . 
 
 S 
 
 
 00 
 
 
 
 o 
 A 
 CO 
 
 3 
 
 hi 
 
 » 
 
 
 Primary. 
 
 Cures 
 
 Deaths 
 
 Secondary. 
 
 Cures 
 
 Deaths 
 
 Total*.... 
 
 54 
 
 3 
 
 5 
 
 ' 1 
 
 2 
 
 25 
 
 1 
 
 2 
 
 2 
 
 3 
 
 9 
 
 2 
 
 
 
 
 20 
 
 1 
 
 •• 
 
 •• 
 
 6 
 
 108 
 
 7 
 
 7 
 
 3 
 
 11 
 
 136 
 
 * Sixty-five additional cases had been reported, but, as the results 
 had not been determined, they have been omitted from this table. 
 
 When the ball litis entered directly within a joint, 
 only the surface may require excision ; but should the 
 head of tin* bone be extensively spiculatod, we must 
 Pi 
 
TREATMENT IN EM 
 
 «ui Lack to the sound bone, bVen if wo are compelled 
 to remove four or five inches of the shaft of a bone, as 
 was successfully done firsl by Stromyer for a gunshot 
 
 injury, .and several times in the Confederate service. 
 Should the receiving cavity be equally Injured, the 
 fractured portion Bhould be removed. The rule is, 
 never to remove more of the hone than is absolutely 
 called for, and not to open the medullary cavity if it 
 can in any way he avoided. 
 
 When the wound has been cleansed of all foreign 
 hodies, the flap is replaced and secured with one or 
 two. points of suture. As adhesion by the first inten- 
 tion is not usually expected, and gives no advantage 
 pver the final result by granulation, nice adjustment 
 along the entire line of the incision is not necessary. 
 An opening must be left at the si dependent por- 
 tion of the wound for drainage. The patient is then 
 put to bed, and cold water dressings applied. Intlam- 
 Diation at first runs high, the parts around .the joint 
 arc much swollen, and a collection soon forms within 
 the Cavity from which the hones have heen removed. 
 
 'I'hc escape <>t this decomposed blood ami pas from 
 the wound'gives great relief. When kept in by the 
 
 too nice adjust me nt of t he (lap, the collection inci 
 
 the swelling, osdema, and pain, which is diffused ove* 
 
 the neighboring parts, involving the chest as well as 
 arm. When suppuration becomes established the 
 swelling and pain subside, granulations spring up, 
 and eventually close the wound. In tin- meantime, 
 the divided muscles have formed new relations. By 
 means of the lymphy exudation they become more or 
 less incorporated with the surrounding tissues, and, 
 by attaching themselves around the cut portion of the 
 
 bone form, in time, a dosed capsule. A head to the 
 bone is SOmetimeB, in a measure, formed; in other 
 
TREATMENT IN RESECTION. 379 
 
 cases the end of the bone becomes attached to the 
 cavity by fibrinous bands. 
 
 As suppuration will bo excessive and often long- 
 continued, nourishment and stimuli will be required 
 during the treatment. "When abscesses form in the 
 surrounding cellular tissue they should be opened. 
 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 uneasi- 
 ness and irritation which the splints and bandages 
 give, do much to prevent success. In the upper ex- 
 tremity it matters little what length of limb the pa- 
 tient has, provided his life be saved and the convales- 
 cence be speedy. A shortened arm does not affect its 
 usefulness, and a slightly changed direction can bo 
 corrected in the after-stages of the treatment. The 
 most effectual management is the simplest, and tedi- 
 ous daily dressings are to be discouraged. Straight- 
 ening the limb upon the bed, a pillow, or a long, broad 
 splint, without complicated or elaborate bandaging, is 
 the best and most comfortable dressing for any resec- 
 tion. The patient is kept in bed until the suppu- 
 rative stage is established, when he will be permitted 
 to get up. His arm is then placed in a sling, and the 
 water dressings are continued until a complete cure 
 is effected. When the parts are nearly eicatriaed it 
 will be time enough t<> apply the tumefaction hand- 
 age for removing the oedema of the limb. Anchylosis 
 rarely follows this operation in the shoulder-joint. 
 
 Of the cases of resection of the shoulder performed 
 
 in the Crimea DUl few died; and all those saved re- 
 gained a useful limb, possessing all the motions, with 
 the exception of those of the deltoid, Which III U - 
 
 Certain extent, paralyzed from the division of its 
 
 nerve-, which can not altogether he avoided in ex- 
 
380 RESECTION OF SHOULDER-JOINT. 
 
 posing the head of the bone. As a proof of the 
 efficacy of resection, Stronger excised nineteen shoul- 
 der-joints with a loss of seven, chiefly from pysemia. 
 Of eight cases in which the operation was required, 
 but, from some mitigating circumstances, was not 
 performed, five died. 
 
 Sixty-eight cases of resection of the shoulder-joint 
 have been reported to the Surgeon-General's office, of 
 which forty-eight were successfully treated, the pa- 
 tients regaining very useful arms, the forearm and 
 hand possessing all of their former movements. 
 
 Comparative Table of Resections of the Shoulder-joint. 
 
 
 QQ 
 
 
 J3 
 
 a 
 
 a 
 
 rt 
 
 
 O 
 
 ft 
 
 English in Crimea 16 3 I H> 
 
 French in Crimea 38 21 55 
 
 Confederate service 67 20 30 
 
 This operation was not performed as frequently as 
 necessity required. Many cases of necrosed joints 
 from gunshot wounds of the shoulder are daily apply- 
 ing to examining boards for extension of furlough, in 
 which an anchylosed joint, with useless and impov- 
 erished limb, exists, and also fistuhe of many months, 
 and even two and three years' duration, from which 
 is kept up a thin, ichorous discharge, with the period- 
 ical escape of pieces of bone. 
 
 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. In- 
 flammatory reaction runs high, as in all cases in 
 which joints have been opened by a ball. Collections 
 
RESECTION OF SHOULDER-JOINT. 381 
 
 soon form, and the excessive swelling stretches the 
 softened capsule, which, giving way, allows of the 
 burrowing of pus and final discharge through open 
 abscesses. After running a tedious, painful, and dan- 
 .gcrous course, if the patient escapes with a shattered 
 constitution and an anehylosed limb, it is as much as 
 he can expect. When the bones forming the elbow 
 are not involved, the treatment consists in repose, 
 keeping the joint immovable, with the free applica- 
 tion of cold water, and the* administration of opium 
 to allay pain and quiet nervous excitement. 
 
 Should the wound be of such a character as would 
 probably be followed by disastrous inflammation, then 
 a primary resection offers a diminution of the risks 
 to life, a rapid convalescence, and a movable joint. 
 In the Schleswig-Holstein army, of fifty-four amputa- 
 tions of the arm, nineteen died; while of fort} T resec- 
 tions, under similar circumstances, only six died. In 
 the Confederate service, of two hundred and fifty casos 
 of amputation of the arm there were sixty-five deaths, 
 while in forty-five resections of the elbow there were 
 nine deaths. The results of the operations were also 
 modified by the period at which the resection was 
 performed. Of eleven cases excised within twenty- 
 four hours before reaction ensued, but one died ; of 
 twenty cases between the second and fourth day, or 
 during the stage of irritation or excitement, four died ; 
 and of nine cases operated upon between the eighth 
 and thirty-seventh day. only one died — an exemplifi- 
 cation of a general rule laid down in the commence- 
 ment of this chapter, that the wounded bear opera- 
 tions before the Btage of reaction, or after the estab- 
 lishment of suppuration, much better than they do 
 while suffering under high inflammatory excitement. 
 This shows the necessity of deferring secondary opera- 
 
382 TREATMENT OF EUACTUUED ARMS. 
 
 tions until the proper time has arrived which experi- 
 ence has determined. 
 
 It can not he expected that an arm, after a serious 
 gunshot injury to the bones, will be cured without 
 deformity. The arm will always be shortened, where i 
 many spicuhe have been removed. We acknowledge 
 this fact in anticipation, and never attempt, by trac- 
 tion and counter-extension, to i*estore it to its former 
 length. AVe simpty place the arm in an easy position, 
 and allow the muscles to •approach the broken ends. 
 This course is opposed to that adopted in the treat- 
 ment of simple fractui'es, where the main object is 
 to prevent deformity, and, especially, shortening of 
 the limb. As this object is discarded in compound 
 fractures of the upper extremity, the treatment is 
 thereby much simplified, and the patient is saved much 
 annoyance and suffering. 
 
 In simple fractures of the arm, the pasteboard splints 
 are to be preferred ; while, for the forearm, wooden 
 splints, made'of light material, and wider than the diam- 
 eter of the arm, will make the best application. The 
 tumefaction bandage is not required, and in gunshot 
 fractures is altogether discarded. In gunshot injuries, 
 where we have an open wound to dress daily, our 
 mechanical applications should be of such a character 
 as to permit of easy inspection, and also the ready- 
 readjustment of the apparatus when disarranged, 
 while, at the same time, the splints are kept secure. 
 The serious objection to bandaging compound fract- 
 ures is in the abundant discharge saturating the 
 dressing, and in summer rendering it necessary to 
 renew it daily, if not twice a day. Every movement 
 of the broken limb being very painful, but little hand- 
 aging should be used, so that the wound is open to 
 inspection, and the limb can be daily dressed without 
 
TREATMENT OF FRACTURED ARMS. 383 
 
 disturbing its position. Diachylon plaster is now 
 extensively used to secure splints to fractured limbs 
 three or four bands encircling tbe limb will always 
 retain the supporting apparatus, While the limb, at 
 its wounded portion, remains uncovered. 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 condition. The erect position 
 •will have the additional advantage of permitting the 
 ready discharge of pus and prevent the bagging of 
 this fluid, and will obviate the necessity for the estab- 
 lishment of counter-openings. In all simple fractures 
 the excess of callus depends upon the degree of mo- 
 bility between the broken ends. In compound fract- 
 ures 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 at rest. Fortu- 
 nately this does not interfere with the final results, as 
 false joints are not more frequently met with in com- 
 pound than in simple fractures. Experience shows 
 us that there is not that necessity, winch many prac- 
 tice, of frequently tightening the apparatus, to the 
 very great annoyance of the patient. If the consti- 
 tution be strong, a considerable degree of relaxation 
 may be permitted, and be found not incompatible with 
 perfect consolidation. In animals with compound 
 fractures we Bee continual exemplifications of this 
 fact — their broken bones becoming united, notwith- 
 standing the continued motions of the limb, in the 
 absence of all retentive apparatus. 
 
 The local and general treatment of the wound will, 
 
384 TREATMENT OF FRACTURED ARMS. 
 
 in no respect, be modified on account of the fracture. 
 Water dressings, until cicatrization is completed, med- 
 icated with aBtringents to allay profuse discharges, or 
 with antiseptics to remove fetor, or with stimuli to 
 promote granulations, will be the proper course, while 
 the general health is watched, retarded secretions 
 promoted, and debility guarded against. If fragments 
 of bone have remained and have become necrosed, 
 the Burgeon must assist nature in their expulsion, 
 otherwise they will be surrounded by new formations, 
 and, as sequestra, incarcerated in an involucrum, will 
 only be expelled after much time and trouble. When 
 spiculae are suspected, the wound should be examined 
 from time to time, and especially about the eighth or 
 tenth day from the receipt of injury, when the swell- 
 ing has subsided to such an extent that the finger can 
 l>e introduced. During the excitement of reaction all 
 examinations of the wound should he interdicted. As 
 soon as we conclude that all fragments have been 
 removed, we desist from further probing, as it can not 
 hut he injurious to the delicate granulations. 
 
 Cleanliness is necessary to successful hospital prac- 
 tice in the treatment of suppurating wounds, but, 
 when excessive, becomes a serious obstacle to rapid 
 cicatrization. It is a common error for surgeons to 
 place a wounded limb over a basin of water, and 
 sponge and rub it as if they were cleansing a piece of 
 porcelain. I have seen others cleanse gunshot wounds 
 by the free use of a powerful syringe, with which 
 they poured a stream of water into the wound until 
 the granulations were bleached and the water re- 
 turned discolored with blood, and this repeated with 
 great regularity at the morning and evening visit. 
 It was not surprising that wounds, treated with this 
 ovor-care, took a very long time to heal. 
 
TREATMENT OF FRACTURED ARMS. 385 
 
 This too liberal use of the syringe is a very common 
 error with surgeons, who overlook the protective in- 
 fluence of healthy pus in their over-estimate of exces- 
 sive cleanliness. I have seen a surgeon, in a case of 
 resection of the shoulder-joint which promised a 
 speedy and successful cure, put the beak of a syringe 
 into one of two or three fistulous tracks by which the 
 ligatures had escaped, and distend the cavity until jets 
 d'eau spouted from the opposite orifices, the perp si ra- 
 tion streaming from the lace of the patient, and the 
 distorted countenance indicating the unnecessary tort- 
 ure which the surgeon Avas inflicting. Was it singular 
 that the case retrograded from the time this rude and 
 ignorant practice was instituted ? and could any other 
 result have been reasonably expected? 
 
 If the wound be gangrenous, and the object be to 
 remove ichorous decomposing fluids, to diminish or 
 prevent absorption and general poisoning, then the 
 syringing is desirable; but under no other conditions 
 should the granulating surface of a Avound be washed. 
 Wipe around the edges and' remove an} secretions 
 which might have collected upon the skin, but leave 
 the pus, as the best covering which healthy granula- 
 tions can have. Under its protection the plasma, 
 which is thrown out from the blood-vessels, Avill rapidly 
 form tissues ; but rub or wash away this covering, and 
 the exposure to the baneful influences of the atmos- 
 phere Avill 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 besl conditions, 
 are tedious cases, and in gunshol injuries our patience 
 will often be taxed to the utmost. Despondency should 
 Ga 
 
METI10D FOB RESECTING ELBOW-JOINT. 
 
 not be an element in the character of a military Bur- 
 on. We must expect to have a compound fracture 
 under treatment at least twice it' not three times 
 long as would bo required to consolidate a simple fract- 
 ure. 
 
 Should the main vessel be injured, in connection 
 with the fractured bones, weliavo m»t sufficient cause 
 to sacrifice the limb; but, ligating the artery at its 
 bleeding mouths, we treat the fracture as if this com- 
 plication had not existed. Owing to the free anasto- 
 mosis of the blood-vessels 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 nourishment to the parts beyond. Should the 
 neivi b as well as the artery be injured, or the principal 
 nerves be divided with the bones, then the limb, even 
 when saved, would bo a useless, paralyzed extremity) 
 and its immediate removal will sa\ e the patient a long, 
 
 h di0U8, and dangerous convalescence. We pursue a 
 similar course when the soft parts are extensively 
 lacerated. In euch cases it is our duty to sacrifice the 
 limb to diminish the risks to life, 
 
 The elbow-joint, for gunshot wounds, transfixing its 
 capsule and fracturing the bones, is best rosocted from 
 the back of the joint, the patient lying upon his abdo- 
 men. There are no important vessols 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. W 1 1 * • 1 1 tho posterior liga- 
 ments aro divided and the joint exposed, only remove 
 the fractured head and all foreign bodies, and do not 
 interfere with that bone which has not been injured. 
 The lips of the wound are cloi od by sutures, and cold 
 ngs be< ome the pi incipal treatment. The 
 
RESECTION OF WRIST-JOINT. 387 
 
 limb is placed upon a pillow, and not disturbed, if 
 possible, until suppuration is established. "When the 
 soft parts are cicatrizing, and healing is nearly com- 
 pleted, passive motions in the joint will prevent anch- 
 ylosis, and a tumefaction bandage will removo the 
 oedema of the limb. 
 
 Instances of successful resections are recorded for 
 injuries at the wrist-joint, where the spiculated ends 
 of both radius and ulna have been satisfactorily re- 
 moved ; also, instances in which either of these bones 
 have been removed entire, for chronic ostitis and 
 necrosis brought on from gunshot injuries. Similar 
 incisions to those recommended for the resection of 
 (he elbow-joint will expose the heads of the wrist 
 bones, and permit of the ready removal of any injured 
 portion. In this, as in all other cases, we must save 
 all tendons passing over a joint to supply distant 
 bones; and in the wrist, particularly, many of tho 
 muscles which supply the fingers can be drawn out of 
 the way, and thus escape section. 
 
 When a ball perforates a wrist-joint, although in- 
 flammation will run high, with much persistent swell- 
 ing, pouting orifices, and profuse discharge, such cases, 
 with patience and cold water dressings, will event- 
 ually do well. This is an instance of gunshot wound 
 of a joint, with fracture of the bones, which rarely _ 
 requires amputation. In such injuries the hand aid 
 forearm is carried upon a straight splint until the 
 inflammation and swelling subside, when great care 
 must he taken to avoid the contraction of the fingers 
 and hand by using daily passive motion's and by rub- 
 bing with su<h stimulating embrocations as will pro- 
 tie- absorption of deposits in and around the 
 sheaths of the tendon-. 
 
 Sow "i frightful an injur) involves the band, li is 
 
3S8 SAVE ALL PARTS OF HAND. 
 
 very seldom that it is so mangled as to 1"' beyond the 
 pale of surgical skill, and unless it is literally ground 
 up it should not bo amputated. In certain cases 
 fingers may have been already torn off, or may be 
 hanging by a fragment of skin, when they should be 
 removed ; but for ordinary gunshot lacerations of the 
 hand, amputation of the entire hand is very rarely 
 required. 
 
 Different bones of the hand and wrist are to be re- 
 moved when irrevocably injured, with or without the 
 metacarpal bones of the fingers or the thumb. Any 
 fingers which can he saved will be better than the 
 West artificial limb. In eases of lacerated hands, in 
 military surgery, when attempts are made to save the 
 limb under cold water dressings, the inflammation 
 which comes on makes a shocking limit to those- unac- 
 customed to treat lacerations of this extremity; but 
 at the end of eight or ten days, when suppuration has 
 hern well established and granulations are forming, 
 the swelling subsides, the torn portions are drawn 
 together, cicatrization advances rapidly, and often hut 
 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, how- 
 ever frightful the injury to it may appear; and there 
 is much truth in the assertion. 
 
 In the inferior extremity wo find the treatment of 
 gunshot injuries somewhat different from those of the 
 Upper limb, on account of the minor degree of vascu- 
 larity, and the much greater tendoncy to mortification, 
 so that the rule to which we called attention, of ampu- 
 tations being rarely required for the superior ex- 
 tremity, is reversed for the leg, where it is often the 
 Only way of escape left to save the life of the wounded. 
 
 We have elsewhere stated that when balls embedded 
 
THIGH FRACTURES. 889 
 
 themselves in the pelvic bones, and their position 
 could be discovered, provided a serious operation is 
 not needed, they should be removed, as their presence 
 will, sooner or later, give rise to trouble. All loose 
 spicuhe should also be taken away, and, as sequestra, 
 frequently show themselves from time to time during 
 the treatment, they should be withdrawn. 
 
 When the ball strikes lower down, in the neighbor- 
 hood of the trochanters, it usually splinters the bone, 
 and frequently involves the ilio-femoral articulation. 
 Such injuries are of the most serious character, and 
 are usually considered fatal. It is a question of much 
 moment to inquire how can modern surgery, with all 
 of its appliances, improvements, and experience, as- 
 sist in saving the life and limb of such seriously 
 wounded ? Within a few years the rule for all com- 
 pound fractures of the femur was amputation of the 
 limb; but the statistics from military hospitals in time 
 of war are so frightful — but few successes for the num- 
 bers treated — that it was naturally suggested that the 
 risks could not be materially increased by letting the 
 patient take the chances with his limb on; when, if 
 his life were saved, it would be with and not without 
 his leg. This hag settled down into a conviction for 
 fractures of the upper third of the femur, which are 
 now treated without amputation, inasmuch as nearly 
 every amputation in the neighborhood of the trochan- 
 ter, and, with very rare exceptions, all at the hip-joint, 
 are fatal. 
 
 It' we are assured that the ball has crushed the head 
 of the bone, then the operation of resection offers the 
 best prospects of success for the patient; but it does 
 not always follow that this diagnosis can be clearly 
 made out, if the signs of intracapsular fracture be Q01 
 at. -Military surgical experience shows that a 
 
RESECTION OP HIP-JOINT. 
 
 fracture of the upper portion of the shaft of a hone 
 does not necessarily extend into the head, and vice 
 versa. Unless the junction of the epiphysis with the 
 shaft is struck', the fracture is more likely to be con- 
 fined to a centre of ossification — so that in the thigh, 
 as in the arm, a blow just below the trochanter will 
 not usually fracture the head of the femur. When 
 the joint is opened and the head of the bone fractured, 
 the wound should be enlarged, or an opening made 
 into the joint from the outer side of the hip. by which 
 the fractured head might be removed. 
 
 If any success is hoped for, those cases alone should 
 be selected in which neither blood-vessels or nerves 
 are injured, nor the soft parts extensively torn. If all 
 or any of such are involved, where experience teaches 
 us that the chances for successful resection are more 
 than doubtful, do not have recourse to amputation, 
 which is so certainly fatal, but let the patient live his 
 few remaining hours or days without being haunted 
 by the ghost of a useless operation. Should he revive 
 the reactionary stage, and still retain a good pulse and 
 comparatively unshattered constitution, then a second- 
 ary operation might give a chance of success. In the 
 Crimean service no amputation in the vicinity of the 
 hip-joint was successful — every individual case died. 
 In the Confederate service but one successful case of 
 primary amputation at the hip-joint is reported. This 
 only corroborates the experience of other campaigns, 
 and also 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 
 to the patient the benefit of the chances which experi- 
 ence teaches us are nugatory. 
 
 As regards resections in suitable cases, the report is 
 a little more satisfactory. Of six resections performed 
 
RESECTION OF HIP-JOINT. 391 
 
 by the English Burgeons in the Crimea one was suc- 
 cessful, and the condition of all operated upon was 
 made more comfortable. Had the conveniences for 
 treatment been greater, and the general sanitary con- 
 dition of the troops better, with less pyaemia, hospital 
 gangrene, cholera, and scurvy, much better results 
 might have been obtained. Some of the cases were 
 doing well, with every prospect of final success, when 
 they were swept off by one of the above diseases. Ln 
 amputations at the hip-joint all the cases died speedily. 
 
 In cases of resection, the greatest difficulty lies in 
 the after-treatment. As it is not expected to restore a 
 perfect limb, no good result can be obtained by using 
 violent extension. The leg, however, must be fixed, to 
 facilitate those movements in the changing of position, 
 Which are necessary to the patient's comfort. A long, 
 straight splint is used for this purpose by some sur- 
 geons, while the inclined piano, or Smith's anterior 
 splint, which I would much prefer, is depended upon 
 b}' others. Some have bandaged the limb to the 
 sound one, and speak of it as a good mode of support. 
 Water dressings compose the local treatment. 
 
 Baudens succeeded in saving both limb and life in 
 -cases in which compound fractures of the upper half 
 of the thigh were treated without operation. Consoli- 
 dated and useful limbs, with but little deformity, are 
 reported as having been saved. By the use of the 
 fracture-box and inclined plane he succeeded in curing 
 a compound fracture on a level with the trochanter — 
 saving a useful limb, although he had extracted two 
 inches of the shaft of the femur. His experience 
 proves that compound comminute 1 fractures of the 
 upper half of the thigh are not so fatal when attempts 
 are made to save the limb as when the thigh is ampu- 
 tated. The experience of surgeons, derived from the 
 
392 BESKCTION OF HIP .MUM'. 
 
 wounded of the Confederate campaigns, would estab- 
 lish a similar course of treatment, as excellent limbs 
 were saved where fractures had occurred in the upper 
 third of the femur, while amputations in the immedi- 
 ate neighborhood of the trochanters mol with the usual 
 fatality. ^ 
 
 As the resection of the hip is so much more success- 
 ful when performed fur disease than for injury, it has 
 been suggested, by surgeons of experience, that an ex- 
 ception to the rule of immediate resections be made 
 for the hip-joint, and that such eases, even the most 
 suitable for the operation, be deferred until suppura- 
 tion is well established. For hip-joint resections it is 
 said that nothing is lost by this delay, while, on I lie 
 contrary, there may be a chance of saving the limb 
 without an operation. Larrey, in 1S12, reported six 
 eases of gunshot fractures of the neck of the femur, 
 with three cures — showing that the prospects are not 
 altogether hopeless. "When the patient is, in a meas- 
 ure, placed in a similar condition to those affected 
 with diseases of the bones, his prospect for a success- 
 ful resection appears to be improved. Baudens says 
 that, as the resection of the hip-joint only succeeds as 
 a secondary operation, attempts should first be made 
 to save the limb. 
 
 "We preface the following table, taken from Ar- 
 mand's Jlistuire Medico- Chiruryica I e Je la Guerre </<■ 
 Crimee, with the suggestion that any surgeon who has 
 ever had a successful case of resection at the hip-joint 
 has always been eager to publish it, while many have 
 been disposed to hide their misfortunes from the pub- 
 lic — so that the tables, showing the relative advan- 
 tages of primary and secondary resections, appear in 
 their very best light. 
 
RESECTION OF Hll'-. HUNT. 
 
 393 
 
 Primary Resections after Gunshot Wounds. 
 
 Suiiu eons. 
 
 Operated n 
 
 Cur 
 upon. 
 
 Deaths. 
 
 Larrey. (Volume 3, Clinique) 
 
 J. Cooper. (Dictionary) 
 
 Leteillo. (Relatione du Siege d'Anvcrs par 
 
 M. II. Larrey) 
 
 IIu^u. (Memoircs dc Medicine et de Chi- 
 
 rnrgie Mil it aires) 
 
 Esedillot. (Annates de la Chirurgic Fran- 
 
 oaise el Etrangere) 
 
 Duyon. (Expedition de Churchill, Algere 
 
 Ruehct. (Journees de Juin. 1848) 
 
 Gubiot. (These de Montpellier, 1840) 
 
 French Crimean Service 
 
 McLcod. (Crimean War) 
 
 Stromycr 
 
 1* 
 
 5 
 1 
 1 
 3 
 9 
 4 
 1 
 
 36 
 
 * 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. 
 
 Secondary Resections after Gunshot Wounds. 
 
 Surgeons. 
 
 Operated 
 upon. 
 
 Cures. Deaths. 
 
 Larrey. (Clinique, volume 5) 
 
 Guthrie. (Clinic, volume 5) 
 
 Baudens. (Traite des Plaice d'Armes a feu) 
 Ferussac. (Bulletin des Science Medical es, 
 
 volume 3) 
 
 Robert. (Journees dc Juin, 1848) 
 
 GuersanL (Journees de Juin, 1848) 
 
 Vidal. (Traite de Chirurgie) 
 
 Mounier. (Constantinople, 1854) 
 
 Legouest. i Constantinople, 1854 ) 
 
 McLcod. ( Crimean War) 
 
 12 
 
 The reports of hip-joint resections at the Surgeon- 
 General's office are exceedingly meagre. I know of 
 several unsuccessful cases of primary resection, and 
 two oases of successful operation, in one of which the 
 
394 
 
 I DRE IN I'l'I'KIt THIRD. 
 
 patient could walk well by using a cane. The num- 
 ber of eases is not known, however, with sufficient 
 certainty to offer any percentage of coxes. 
 
 It lias been suggested that, it' the patient who lias 
 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 
 should be treated, in every respect, as if in tin- arm. 
 Unless the leg is so mangled that an amputation is an 
 act of necessity, it should not be thought of. We have 
 already said that, in field military surgery, amputa- 
 tion of the thigh in the immediate vicinity of the 
 trunk is nearly synonymous with death, while many 
 gunshot fractures in this region are saved. The fol- 
 lowing tal-les will throw much light on this subject. 
 
 Contolidated Table of Compound Fracture of th>> Thigh, treated without 
 amputation, made iip from records in Surgeon-General's office, from 
 Junt 1, 1862, to February 1, 1804 — prepared by Surgeon II. liner, P. 
 A. C S. . 
 
 
 .2 
 o 
 o 
 q 
 
 a 
 
 ft 
 
 & 
 ft 
 
 XI 
 o 
 
 a 
 
 M 
 
 Remarks. 
 
 
 116 
 
 105 
 
 
 
 Besides the fore- 
 
 Average period of recovery. . . 
 
 
 ... 
 
 HU 
 
 
 going, there aro 
 
 t period of recovery . • • 
 
 
 
 266 
 
 .... 
 
 forty-seven un- 
 
 
 
 
 41 
 
 — 
 
 decided cases. 
 
 A verage period of death 
 
 
 
 52 
 
 .... 
 
 
 <; reatesl period of death 
 
 
 
 IS., 
 
 .... 
 
 
 
 
 
 1 
 
 — 
 
 
 Average amount of shortening. 
 
 
 
 
 l.'.l 
 
 
 Greatest amount of shortening. 
 
 
 
 
 5 
 
 
 
 
 
 
 .5 
 
 
FRACTURE IN UPPER THIRD. 
 
 395 
 
 Consolidated Table of Amputations of the Thigh, collated frdm records in 
 the Surgeon- General' a <\(fiee, from June ], 1802. /<> February 1, 1SGI — • 
 prepared by Surgeon If. Baer, P. A. C. S. 
 
 Upper 
 
 Middle 
 
 Lower 
 
 third. 
 
 third. 
 
 third. 
 
 
 A 
 
 
 J3 
 
 
 J 
 
 
 
 
 
 
 
 M 
 
 
 
 
 M 
 
 
 a 
 
 s 
 
 
 <u 
 
 s 
 
 
 o 
 
 ft 
 
 O 
 
 p 
 
 t> 
 
 
 
 Circular. 
 
 Primary 
 
 Secondary 
 
 Flap. 
 
 Primary 
 
 Secondary 
 
 Method not stated. 
 
 Primary 
 
 Secondary 
 
 Total. 
 
 19 
 
 11 
 
 33 
 
 14 
 
 42 
 
 27 
 
 3 
 
 7 
 
 7 
 
 14 
 
 12 
 
 21 
 
 6 
 
 4 
 
 15 
 
 10 
 
 35 
 
 11 
 
 3 
 
 1 
 
 3 
 
 9 
 
 5 
 
 5 
 
 15 
 
 22 
 
 24 
 
 21 
 
 35 
 
 27 
 
 4 
 
 16 
 
 5 
 
 19 
 
 14 
 
 35 
 
 50 
 
 61 
 
 87 
 
 87 
 
 143 
 
 126 
 
 140 
 64 
 
 81 
 26 
 
 144 
 93 
 
 554 
 
 Besides the foregoing, there are ninety-seven cases of amputation 
 of the thigh recorded, but the result not being ascertained, they 
 were excluded from this table. The mortality appears graver on this, 
 and all other tables of capital operations, than truth would warrant, 
 inasmuch as many of these deaths occur within the first few days after 
 a battle, before the patient has passed out of the hands of his regimen- 
 tal surgeon, or while still at the field infirmary. Those who do not 
 die. there are sent off to hospitals, and some taken off to private quar- 
 ters by their friends, and never again heard of — while all who die, as 
 above stated, are recorded. This will, perhaps, not only account for 
 the large percentage of deaths, but also, in a measure, for the want of 
 a better correspondence with tables made under more favorable auspices. 
 
 The treatment must commence on the battle-field 
 by proper transportation; the judicious removal of 
 fractured limits 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 of 
 having his life saved We will carefully remove till 
 spicule, dilating the wound, if necessary, by a bold 
 incision, to facilitate the thorough removal of all for- 
 
396 TREATMENT IN THIGH FRACTURES. 
 
 eign bodies. Until suppuration is well established, 
 the limb is kept in an easy position and surrounded 
 with cold applications. All tight, retentive ban dag' 
 are to be rejeeted, as they interfere with topical anti- 
 phlogistic applications. Dispense with bandages. 
 Should the case not have been carefully examined 
 soon after its occurrence, and every fragment of bone 
 removed, whether detached or not. a careful examina- 
 tion for foreign bodies will be necessary on the eighth 
 or tenth day, when the reactionary stage has passed, 
 when all portions of bone found in the wound should 
 be removed. If not, as sequestra, they will become in- 
 corporated in the new osseous formations, and be the 
 cause of much trouble and suffering. 
 
 In all compound fractures, with much loss of bone, 
 it is always injurious to attempt to obtain a limb of 
 equal length with the sound one. It can not be done, 
 and the chafing ami annoyance of splints and tight 
 bandaging may react very seriously, if not fatall}', 
 upon the constitution. The first thing to be attended 
 to is to prepare facilities for treating such a fracture. 
 ll' 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 prop- 
 er bed and a good firm mattress, prepared with a bed- 
 pan hole for facilitating nature's daily wants without 
 the necessity of moving him. 
 
 Upon this the patient is placed, lying on his hack', 
 with the leg extended. Two long straps of diachylon 
 plaster are attached to the sides of his leg from the 
 knee to the ankle (see figure 3, plate 24); 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 cxten- 
 
smith's anterior splint. 397 
 
 sion; oi' the limb might be loosely attached to a long 
 thigh-splint. The tumefaction roller is inadmissible, 
 and strips of adhesive plaster or stripe 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 ap- 
 paratus needed. As the case advances and inflamma- 
 tion subsides, with a diminution of purulent discharge 
 from tho wound, splints may be more methodically ap- 
 plied by using long inner and outer splints of light 
 board, well padded with loose cotton, and secured in 
 position by hands of adhesive plaster or with tapes. 
 The extending hands are made by adhesive strips, at- 
 tached to the sides of the leg and carried under the 
 foot, where they are secured to the end of the splint. 
 Allow the ends of the bones to fill up the void made 
 by the extraction* of the spicule, as this hastens con- 
 solidation. 
 
 A better method of treating fractures of the thigh 
 is in the use of Smith's anterior splint, or Mayor's 
 posterior wire splint (see plate 25), by which the limb 
 is. suspended. Smith's anterior splint is formed of a 
 strong iron wire (three-sixteenths of an inch) bent 
 in the form of a parallelogram, as long as the limb, and 
 five inches wide. Cross-pieces of the iron prevent the 
 sides from collapsing, and are also used for suspending 
 the limb. This wire splint is placed upgn the anterior 
 surface of the limb. While traction is being made 
 npon the foot by an assistant, which removes all 
 shortening, tho splint is secured by enveloping the en- 
 tire limb in a roll of bandage, omitting the banda 
 the points where the ball has perforated. "When this 
 
 Bandage is nicely adjusted it should be covered with a 
 
 thick- sol ut ion of Starch, which wid glue all of the hands 
 together, and form a mould for the limb, which sup- 
 
398 mayor's posterior splint. 
 
 ports it equally throughoul its entire extent, and 
 gives great relief. When properly applied, the patient 
 should be altogether free from pain. The limb is then 
 
 suspended two or three inches above tho bed, by 
 passing cords from the upper and lower cross-wires 
 of the splint, all of which, uniting in a single cord, is 
 attached to the ceiling or top of the bedstead. With 
 the limh thus suspended, the patient may move about 
 in the bed at pleasure, without tear of disturbing the 
 adjustment or giving himself pain. As the roll of 
 bandage has been omitted at tho site of the -wound, 
 local applications can be daily made and the parts 
 duly inspected. This has become the favorite method 
 of treating compound fracture of the lower extremity 
 in the Confederate service; although the anterior 
 splint is better adapted to compound fractures of the 
 leg, where it offers every desirable facility for success- 
 ful treatment. The very great advantage which i4 
 possesses is in allowing the patient to shift his position 
 without moving the hones at the seat of fracture, and 
 this assists in preventing bed-sores. It also uses the 
 body for counter-extension, and in this way overcomes 
 muscular contraction and excessive shortening. Tho 
 greatest objection to its uso is that, as the splint re- 
 quires nice adjustment, careless manipulators find in 
 it a very troublcsomo appliance, with constantly shitt- 
 ing bandages„badly supporting the limb, and inducing 
 the bagging of pus. When carefully applied, it always 
 gives satisfaction. 
 
 Mayor's posterior splint, although a much older 
 apparatuses still used with great advantage in com- 
 pound fractures of the lower extremity. The principle 
 of action is the same, viz: suspending the limb so astjjj 
 ensure rest of the broken ends; while, at the same 
 time, the patient is permitted to shift his position, and 
 
TREATMENT OF FRACTURED THIGH. 399 
 
 avoid bed-soros from continued pressure! In Mayor's 
 posterior splint tbe injured limb receives a firm, regu- 
 hu* support from tbe unyielding splint. Smith's splint, 
 on the contrary, supports the limb only by tbe band- 
 age, which, in successive turns, passes around the leg 
 and the splint. The comfort of the apparatus will de- 
 pend altogether upon the care and regularity with 
 which this bandage is applied. If some bands are 
 drawn tighter than otbcrs, instead of presenting a 
 smooth plane, moulded upon the limb for its perfect 
 and painless support, the irregular adjustment will 
 suspend the sensitive extremity by a few cords or 
 tight bands, which, by their irregular support, can not 
 but produce much suffering. In the hands of a nice 
 manipulator, Smith's anterior splint is the perfection 
 of a fracture apparatus; for general use, Mayor's pos- 
 terior splint is decidedly preferable. Another decided 
 advantage which Mayor's splint possesses is, that as 
 the limb is only secured at a few points, nearly the 
 entire extremity is exposed for* inspection or the ap- 
 plication of remedies. (See plate 25.) 
 
 With tbe exception of the mechanical appliances for 
 the broken bone, the case is treated as for a long-con- 
 tinued suppurating wound, by avoiding, in all cases. 
 depiction, and by giving liberal diet. Man}* of these 
 Cases will die; but if we have facilities in a well-venti- 
 lated and well-organized hospital, we will bave tho 
 satisfaction of saving nearly half of the patients sub- 
 mitted to our care. Of 221 cases of compound fract- 
 ure of the femur reported by Confederate surgeons us 
 treated in military hospitals from June 1, 1862, to 
 February 1. l^m, 116 wen: successful; while of 554 
 thighs amputated, 280 recovered. 
 
 In fractures of the middle and lower third of the 
 thigh, not implicating the knee-joint, the question 
 
400 TREATMENT OF FRACTURED THIGH. 
 
 will again recur, what course is to bo pursued with 
 such 1 These arc still very serious cases, and are 
 classed with those of the upper third. Where attempts 
 are made to save them, as recommended by Guthrie, 
 the fatality will not be very dissimilar to fractures 
 nearer the trunk, and the successes will depend upon 
 the state of health of the sufferer and the conveniences 
 for treatment. 
 
 There are cases which often appear so trivial — only 
 a small bullet-hole leading to the crushed bone — that 
 it seems barbarous surgery to condemn the limb with- 
 out an attempt at saving it. The young military Bur- 
 geon expects much from conservative surgery in such 
 cases. We are informed by the experienced that this 
 Striving after conservatism is the main cause of the 
 heavy mortality. 
 
 Surgeons from civil life are not prepared to believe 
 bow dangerous compound fractures of the thigh are in 
 military surgery, until the unwelcome truth is forced 
 upon them by an ever-recurring experience that many 
 lives are sacrificed to attempts at saving these broken 
 limbs. In civil surgery, or with every facility in mili- 
 tary hospitals, wo should attempt to save the limb — it 
 is the proper course to pursue — but on the battle-field, 
 with the deteriorated material upon which we an- 
 operating, and the poisoned atmosphere of the wards 
 into which the patient is to be carried, and the rough 
 transportation to which he must be submitted, it is 
 often a fatal error. Military surgeons are often forced 
 to abandon their conservative intentions to expedi- 
 ency. It is for such cases that primary amputation 
 offers the best chances for life. In rejecting amputa- 
 tions we lose more lives than we save limbs. As a 
 rule, amputations are less hazardous the greater dis- 
 tance we operate from the trunk; and the reason why 
 
TREATMENT OF FRACTURED THIGH. 401 
 
 amputations are usually urged for compound fractures 
 of the lower and not upper portions of the femur is, 
 that the chances being similar without it, amputa- 
 tions are much less fatal in the lower than in the 
 upper half of the thigh. 
 
 With the light of recent experience, and the advan- 
 tages found in removing all fragments which, as thorns 
 in the flesh, are the direct cause of much of the suffer- 
 ing, suppuration, and fatal accompanying symptoms, 
 the urgency for amputation is not so great as in 
 former wars, and many lives and limbs can now be 
 saved by adopting this rule of practice. 
 
 Surgeons in the Crimea often had cause to regret 
 attempts at saving fractured thighs, but never regret- 
 ted an early amputation. The improvements in more 
 recent practice warrant us in adopting a more conserv- 
 ative surgery. 
 
 Resection, or the cutting off of the sharp spiculated 
 ends from the shaft of the femur, for a compound fract- 
 ure of the bone, has been frequently recommended, 
 and often practised j but the experience of lattor years 
 discourages its pei-formance, as the operation is as 
 serious as the condition for which the remedy is used. 
 When the splinters of bone are removed, there is 
 considerable space for the play of the rough remaining 
 edges, which, therefore, give but little trouble. 
 
 Should we attempt to save a fractured thigh in its 
 lower third, which we should do in many instances, 
 where the soft parts are not extensively torn, or im- 
 portant vessels and nerves injured, the first and essen- 
 tial step to success consists in a careful exploration 
 of tho wound, and the removal of all fragments of the 
 bone crushed by the ball, whether these fragments be loose 
 or not. Even should the shaft for three or four inches 
 be found broken up, remove all of it. It is these 
 lln 
 
IQ2 TREATMENT OF FRACTURED THIGH. 
 
 fragments which cause the irritation and profuse sup- 
 puration which, in most instances, destroy life in gun- 
 shot fractures. The}' all have their nutrient vessels 
 so injured that they rarely consolidate; they nearly 
 always die; and it is in attempts to throw off these 
 that nature exhausts herself. 
 
 Should the orifico not he sufficiently largo to permit 
 the thorough cleansing of the wound, enlarge the 
 opening. It would be woll should this operation bo 
 performed at tho first dressing. If unavoidably de- 
 ferred until tho reactionary stage has passed, it would 
 be of decided advantage to perform it at any time 
 after the first week. Tho earlier it is accomplished the 
 sooner irritation is allayed, and tho more rapidly a 
 cure is effected. The after-treatment consists in keep- 
 ing the leg extended upon the bed, and the wound 
 under the influence of cold water dressing. As short- 
 ening must occur from the loss of bone, putting the 
 leg immediately. in retentive apparatus, so as to keep 
 it to its former length, will be a causo of irritation 
 which would bo injurious, and the free discharge of 
 pus would so soil tho dressing as to necessitate its re- 
 application daily, which would be very trying to the 
 patient. 
 
 For tho first fortnight, succossful results are best 
 promoted by keeping tho limb in an easy position, 
 with a wet cloth over and around the wound, which 
 can bo frequently renewed without disturbing the leg. 
 When tho period of excitement has passed, the limb 
 may be then kept quiet or stiffened, by using cither a 
 straight splint with the starch bandage, leaving an 
 opening corresponding with tho Avound, or tho log 
 can be comfortably secured upon an inclined plane, as 
 seen in plate 24, figure 5, which represents a very 
 convenient form of apparatus. Tho treatment in all 
 
REMOVE ALL FRAGMENTS OF BONE. 403 
 
 of these cases will be very tedious — the average of 
 cure, as collected from reports to the Surgeon-General, 
 being 104 days ; the longest period being 255, and the 
 most speedy cure 41 days. This, however, we may 
 lay down as a rule : that recovery is expedited for 
 every fragment of bone that we remove, the most 
 satisfactory results being connected with their early 
 and thorough removal. 
 
 The following case, from the Soldiers' Relief Hospi- 
 tal, Charleston, under Surgeon W. H. Huger, will 
 exhibit the advantages of the course which has been 
 so strongly recommended above. Private R. A. 
 Howell, Company H, 21st South Carolina regiment, 
 was wounded by a minie ball at an assault upon 
 Fort Wagner, 10th of July, 1863. lie was taken 
 prisoner by tbe Federalists, and after two weeks 
 exchanged, when he entered the hospital. The ball 
 had traversed the limb antero- posteriorly, at a 
 junction of the middle and upper third, crushing the 
 femur for a distance of from four to five inches. 
 When received, the suppuration was excessive and ex- 
 hausting. Large pouches containing pus bagged in his 
 thigh, and hectic fever, with its accompanying emacia- 
 tion, had already made marked inroads upon him. 
 When motion was imparted to the thigh, the broken 
 fragments could be moved about so freely as to impart 
 the sensation of foreign bodies in a bag. The finger 
 passed into the wound detected also denuded ami 
 movable fragments. Upon consultation, it was de- 
 termined to lay open the limb and remove all frag- 
 ments, as the only course offering any prospects of 
 saving life, as hisdaily increasing debility admonished 
 us that he could not hold out much longer in his 
 present condition; and the wound was so near the 
 
 trunk, and large abscesses had so dissected the soft 
 
404 TREATMENT OF FRACTURED THIOH 
 
 parts, as to render an amputation Dear the trochanters 
 extremely hazardous. Under chloroform the opera- 
 tion was very protracted. After removing all the 
 loose and dead portions of bono, it was found that large 
 masses firmly connected to the sofl parts by a thick- 
 ened periosteum, and still firmly adherent by an inter- 
 mediary deposit of new bone, were perfectly denuded 
 upon their free surface, and when removed showed 
 dearly the process of death in Buch fragments, and 
 their incarceration by new osseous formations. All 
 such fragments, however firmly connected with the 
 soft parts, were taken away, comprising very nearly 
 five inches of the shaft of the femur. The patient ral- 
 lied from the operation, and an improvement in his 
 case commenced from that moment. Under liberal and 
 stimulating diet the suppuration gradually diminished, 
 and he became cheerful, with good appetite, lie was 
 furloughcd on November :; — the wound baving com- 
 pletely healed, and perfect osseous union effected, with, 
 however, a slight angular deformity at the site- of 
 union — it having been found impossible to avoid the 
 displacement of the upper fragment, as no devised 
 splints seemed to meet the requirements of the ease. 
 Had this case not been operated upon, there was every 
 
 prospect of a speedy death ; and in similar fractures. 
 
 where life had been spared, necrosis, suppuration, and 
 Buffering remain permanent companions of the 
 wounded. 
 
 In compound fractures of the lower portion of the 
 thigh, the inclined plane is found the mo8l convenient; 
 apparatus, as it oilers the most comfortable position 
 to the patient, hut has the disadvantage of promoting 
 
 the burrowing of pus, which, in working its way down. 
 the limb, may dissect passages for itself as far as the 
 buttock, and, by its multiplied openings, unless cor- 
 
KNEE-JOINT INJURIES. 405 
 
 rected by a firmly-applied roll of bandage, causes 
 much annoyance, as well as destruction to bones and 
 muscles. 
 
 Mayor's patent wire splint, which combines the ad- 
 vantages of the inclined plane, will be found a very 
 comfortable mode of dressing. 
 
 The anterior wire splint of Smith is found also 
 useful in these fractures, although a straight, long 
 splint, so attached as to keep the broken ends of the 
 bone quiet, and so stiffen the limb that it can be lifted 
 without pain, forms a most serviceable apparatus*. 
 Whatever be the appliance, the wounds must, be allowed 
 free vent for their discharges. 
 
 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 appear, 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 
 lever, will come on after twenty-four or thirty-six 
 hours. Should the patient survive the inflammatory 
 stage, erysipelas, pyaemia, or hectic will ultimately 
 destroy life; and although, on the other hand, the, 
 effusions may be absorbed, and an anchylosed but use- 
 ful limb saved, it is a very rare occurrence. If the 
 soft parts are nut much lacerated, or the blood-vessels 
 and nerves behind the joint injured, such eases are 
 well adapted for resection, and excellent results are 
 obtained in practice. 
 
 A straight or elliptical incision over tin- anterior 
 portion of the joint, across its entire diameter, will ex- 
 DOSe the interior and enable the surgeon (o remove 
 the foreign bodies, whatever they may he, and with 
 them the head of the injured hones. The section of 
 
!<"'> KNEE-JOINT INJURIES. 
 
 the bones should be made in such a way that the sur- 
 u ill adapt themselves to each other — usually the 
 patella is removed. When the external wound is 
 ! by SO.tures, union by the first intention may, to 
 a certain extent, be obtained. In the Buccessful oases 
 the bones eventually heroine firmly united, and, with 
 an anchylosed joint, the patient retains a useful limb. 
 
 After the resection, a long splint upon the hack of 
 the [eg, reaching from the buttock to the heel, is all 
 the apparatus required, while cold water dressings 
 alone are applied around the joint. In cases of resec- 
 tion the surgeon must not expect quick union in the 
 wound, as that docs not often occur in military sur- 
 gery. A tedious suppuration, the formation of numer- 
 ous abscesses, and often the exfoliation of portions a£ 
 bone, is the rule, requiring care ami judicious manage- 
 ment to obtain a final success — many of those operated 
 Upon being lost by the action of those deleterious 
 causes winch affect injuriously all wounds in military 
 hospitals. 
 
 When attempts are made to save the limb in what 
 we suppose to be a trivial or doubtful case of knee- 
 joint injury, we should follow the routine of the anti- 
 phlogistic treatment. Jn a single puncture of the cap- 
 8U le, even when synovia has escaped, the orifice may heal 
 by quick union. When local inflammation ensues, and 
 runs Such an acute course that the \'wc application of 
 leeches — twenty to forty to a limb — the continued use 
 of cold water or ice dressing, with the general treat- 
 ment of opium and small doses of antimony, etc., 
 does not quell the inflammation, and w e are led to inter 
 that pus has formed within the joint, the articulation 
 shouldbe (<ir</< ly opt /<<</. .nu/ the joint thoroughly cleansed, 
 whether we resect the heads of the hones or not. 
 There is no longer injury from the admission of air, 
 
COMPOUND FRACTURE OP THIGH. 407 
 
 while there is serious fear of destruction of the carti- 
 lages should the collection of pus be retained. This 
 free opening of the articulation may, in some cases, 
 obviate the necessity for secondary resections and am- 
 putation, as excellent results have been obtained by 
 this apparently bold surgery — the patient saving his 
 life and limb. The effect of this incision into the joint, 
 in allaying the general irritation, is marked. 
 
 As a rule, gunshot wounds of the knee-joint are so 
 fatal that the experience of military surgeons confirm 
 the necessity for amputating all such eases. In the 
 reports from many military hospitals every case of per- 
 forating wound of the knee, in which no operation was 
 performed, proved fatal; and of all tho cases reported 
 from the army to the Surgeon-General's office, wc find 
 but 50 successful cases out of 103 cases treated. 
 
 Tho course which will be pursued with a fracture 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 wc mast be very guarded how 
 we jeopard the one to save the other. It is in this re- 
 spect that military surgery is so very different from 
 civil practice. We are continually compelled to sacri- 
 fice limbs to expediency, when, under more favorable 
 conditions, w T e would not hesitate to practice conserva- 
 tive surgery. To introduce a single example: where 
 a long and tedious transportation becomes necessary 
 after a battle, it would be expedient to amputate 
 much more freely than we would do were there hos- 
 pitals in the immediate neighborhood of the battle-field 
 where the wounded could be treated. How, for in- 
 stance, COUld we transport, with any chance of BUCC6SS, 
 a resected joint, such as the shoulder, or a gunshot- 
 
408 INJURIES TO ANKLE-JOINT. 
 
 fractured thigh or leg ? Under such circumstances 
 an amputation would give the patient a much better 
 chance for life, which should always bo the main 
 object. 
 
 When facilities offer for attempting the preservation 
 of a fractured leg, the same precautions are taken as 
 in other fractures, for removing immediately all loose 
 or very movable fragments of bone. The limb is 
 placed in a fracture-box, or upon the double inclined 
 plane, and by the constant application of cold water, 
 while we use those remedies already suggested for 
 kc oping down an excessive reaction, we watch the pro? 
 gress of the case, and meet the various complications 
 as they arise, by the rules of practice which have been 
 already frequently discussed. 
 
 It is in this class of fractures that Smith's anterior 
 splint, or Mayor's posterior splint, will exhibit a long 
 list of splendid triumphs — cures without doformity, and 
 with the smallest amount of shortening ; a painless 
 treatment, allowing the patient to move about at will, 
 and even leave his bed the first week after the recep- 
 tion of injury. Should mortification appear in the 
 wound a few days after the injury, we will find in 
 early amputation the only moans of safety. 
 
 Resections of the ankle-joint have not been follow- 
 ed by that success which has characterized operations 
 upon the larger joints, especially the knee and the 
 elbow. It is recommended as a conservative meas- 
 ure, but is seldom practised. When gunshot injuries 
 occur about the ankle, crushing the bones, excision 
 offers but a meagre resource. Mortification often 
 follows such injuries, and amputation holds out strong- 
 er inducements for immediate ami subsequent benefit. 
 
 Gunshot wounds of the foot, with extensive crush- 
 ing of the tarsal and metatarsal bones, frequently 
 
_^ . . NECESSITY FOR AMPUTATIONS. 409 
 
 require amputation in these joints. In ordinary per- 
 forations of the foot by balls, even with injury to the 
 bone, a cui-e is eventually effected ; but such cases are 
 always tedious, months elapsing before the patient 
 can support his body upon the foot, and much pain 
 attends pressure. The treatment differs in no respect 
 from that laid down in general rules. Removal of 
 osseous fragments and cold water dressings comprise 
 the treatment. When the foot is so mangled that an v 
 amputation is considered best for the patient, the 
 foot can be removed at airy of its articulations. 
 
 We have often referred to the fact that amputations 
 will ever be a necessit}* in military surgery ; and, ac- 
 cording to McLeod, had they been more freely practised 
 in the Crimea, a large number of lives would have 
 been saved. 
 
 Among a certain class of surgeons, on the contrary, 
 however, amputations have often been performed when 
 limbs could have been saved, and the amputating knifo 
 has been often brandished, by inexperienced surgeons, 
 over simple flesh wounds. In the beginning of the war 
 the desire for operating was so great among the large 
 number of medical officers recently from the schools, 
 and who were for the first time in a position to indulge 
 this extravagant propensity, that the limbs of soldiers 
 were in as much danger from the ardor of young sur- 
 geons as from the missiles of the enemy. 
 
 It was for that reason that, in the distribution of la- 
 bor in the field infirmaries, it was recommended that 
 the surgeon who had the greatest experience, and upon 
 whose judgment most reliance could bo placed, should 
 officiate as examiner, and his decision be carried out by 
 those who may possess a greater facility or desire for 
 the operative manual. 
 
 As a general rule, the following conditions necessi- 
 Ii 
 
Jin WHEN TO AMPUTATE. .. ^._ 
 
 t at o the I08S of a limli, viz: When an entire limb is 
 carried off by a cannon-ball, leaving a ragged stump, 
 or when a limb is literally crushed up, although still 
 attached t<> the body, it will be necessary to amputate 
 to form a good si ump ; also, if the principal vessels and 
 nerves are extensively torn, even without injury to 
 the hone; or if the soft parts are much lacerated; or 
 in cases of extensive destruction of the skin — as such 
 'cases offer very tedious cures, if cicatrization is ever 
 obtained. Again, in severe compound fractures, and 
 often in apparently simple compound fractures, where 
 experience teaches us that, although the wound may 
 appear trilling to-day, in attempting to save it we will 
 sacrifice lite a lew days hence. Amputation is com- 
 pulsory when mortification of the limb rapidly follows 
 upon an injury; also when, in compound fractures or 
 perforated joints, the profuse discharge or the con- 
 tinued irritation threatens a fatal issue; again, where 
 joints are crushed, and where resections are not ad- 
 missible; or where a fracture of the shaft of a bono 
 extends into a joint ; also in cases where secondary 
 hemorrhage can not he controlled by the ligature, or 
 by any other hemastatic. Knowing that in such < 
 sooner or later, the life will be jeoparded, we must, an- 
 ticipate these troubles by amputation. 
 
 .Military surgeons have long made the important 
 division of amputations into primary and secondary — 
 a division of great practical importance, and which 
 forces itself upon our notice by the relative mortality 
 following the two operations. A mputations for direct 
 injuiy, which are performed after the shock has passed 
 off, but before inflammatory symptoms make their 
 appearance, are styled primary; those required for 
 cases of mortification, profuse suppuration, secondary 
 hemorrhage, or for necrosis, are called seeondaiy or 
 
TIME FOR AMPUTATIONS. 411 
 
 mediate, and comprise all amputations performed after 
 the first twenty-four or forty-eight hours, when reac- 
 tion has set in. A third division of intermediary 
 amputation is a subdivision of the secondary, and re- 
 fers to cases amputated from the second to sixth day. 
 An examination of the following table will show, 
 satisfactorily, the advantages of operating early. 
 
 
412 
 
 TI.MK FOR AMPUTATIONS. 
 
 h3 
 
 < 
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 w 
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SUCCESS OP AMPUTATIONS. 
 
 413 
 
 • The very large number of results not stated is ac- 
 counted for by those amputated upon the field, some of 
 whom fall into the enemy's hands; others are sent to 
 private hospitals, or arc treated in private families by 
 physicians who are not in the army, and who, there- 
 fore, make no report of the case. While in many cases 
 only the number of operations are reported, but as the 
 cases are still under treatment the final results can not 
 be given. If we be permitted to divide the list of 
 unknown results proportionately between the cures 
 and deaths, which would give us even a larger propor- 
 tion of deaths than occur, as the cases scattered through 
 the country usually recover, it will exhibit the most 
 successful army practice of modern times. 
 
 I here insert a comparative table of amputations 
 from recent wars, showing the result of practice 
 among those whom we are accustomed to consider the 
 best surgeons, and to whom we are indebted for most 
 of our medical and surgical knowledge. When it is 
 remembered that the French and English include all 
 OaBes of minor amputations, viz: of fingers and toes, 
 in their report, while the Confederate report for one 
 of the three years of the war comprises capital ampu- 
 tations only, our great success will be appreciated. 
 
 COMPAKATIVE REPORT OF ARMY AMPUTATIONS. 
 
 English in Crimea.. 
 French in Crimea. . 
 
 (''•ii li-ilcrntc army. , 
 
 
 
 
 
 
 a 
 
 
 A 
 
 
 I 
 
 
 
 s 
 
 
 
 si 
 
 m 
 
 
 u 
 
 n 
 
 t~ 
 
 998 
 
 27a 
 
 ■::■ 
 
 1,464! 
 
 8,181 
 
 70 
 
 l.oss 
 
 631 
 
 37 . 
 
 Remarks. 
 
 Includes all minor am 
 tut ions of fingers, toes, etc 
 
 apu- 
 
 * Capital amputations alone performed iu Confederate arniv from 
 June 1, 1S62, to February 1, 1864. 
 
II I 
 
 'I [ME FOB AMITTATlliNS. 
 
 The relative success will be more conspicuously 
 brought out by comparing the results in any one 
 amputation, viz : that of i he thigh, which is considered 
 by far the most fatal in military Burgery. 
 
 COMPARATIVE .STATISTICS OF AMPUTATION OF THIGH. 
 
 Crimean war 
 
 Confederate war, June 1, 1802, to Feb. 1, 
 1864 
 
 
 
 n 
 
 
 
 -a 
 
 
 
 
 
 M 
 
 
 cS 
 
 3 
 
 
 O 
 
 o 
 
 fi 
 
 1,664 
 
 123 
 
 l,5«| 
 
 507 
 
 256 
 
 251j 
 
 a, a 
 
 I ii amputations of superior half of thigh the Crimean 
 mortality was ninety-four in every one hundred oper- 
 ated on, while our reports for the year L863 give a 
 mortality of fifty-seven in every one hundred, or the 
 recovery of nearly half of our cases. 
 
 The experience of every battle-field shows thai the 
 mortality following the amputation of limbs which, re- 
 quire immediate operation is always less than those 
 performed some days after the infliction of the wound 
 — although the milder oases were those retained, and 
 
 the most severe those selected for immediate opera* 
 tion. As all military surgeons recognize the propriety 
 of amputating condemned limbs within twenty-four or 
 thirty-six hours after the injury, before inflammatory 
 reaction has sel in. the aubjeel requires no discussion. 
 The rule in military surgery is absolute, viz : That the 
 amputating knife should immediately follow the condemna- 
 tion of the limb. These are operations for the battle- 
 field, and should he performed at the tield infirmary. 
 When this golden opportunity, before reaction, is lost, 
 it can never be compensated for. 
 
 The rule in performing primary amputations is to 
 
MORTIFICATION OP STUMP. 415 
 
 operate as far as possible from the trunk, as every 
 inch diminishes the risk to life. This rule is so general, 
 that when an amputation can be performed at a joint, 
 never amputate higher up. The only exception made 
 to this rule is in the knee-joint disarticulation, which, 
 on account of its large synovial surface and inflamma- 
 tion which follows, gives very bad results. In examin- 
 ing our statistics for disarticulations, it will be found 
 that of eleven cases of amputation through the knee- 
 joint nine died; while of sixty-seven amputations in 
 the lower third of thigh, forty-three died. 
 
 In secondary amputations it may not be expedient 
 to follow this rule; necessitj', or the desire to save life, 
 which is always paramount, may compel us to ampu- 
 tate at a distance from the injury, as in cases of mor- 
 tification. If the rules for primary amputation be 
 followed, viz: of removing, at once, all limbs in which 
 the blood-vessels and nerves are extensively injured in 
 connection with the crushing of the bones, there would 
 be seldom gangrene to require a secondary amputation. 
 
 When mortification attacks a limb, it will be known 
 by change of color in the skin. When it occurs in the 
 tag, which is its common seat, the foot changes from 
 the natural flesh color to a tallowy or mottled white; 
 the tissues in a measure liquefy, are cold, and become 
 offensive — breaking up into more or less extended 
 sloughs, saturated with an ichorous fluid. This gan- 
 grenous condition may stop at the ankle, either above 
 or below it, depending upon the seat of injury; or it 
 may creep up to the knee, where it equally shows a 
 disposition to limit its extension. When the ankle 
 limits 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 
 
416 * MODI RATING. 
 
 days, sometimes in a few hours, as if by a continua- 
 tion of the same gangrene. 
 
 In mortification of the stump, upon tho upper por- 
 tion of a limb, a second amputation is inadmissible. 
 
 By the local use of pure nitric acid to the mortified 
 surface, or the concentrated Labarraque's chloride of 
 soda, or pyroligneous acid, we strive to limit the ex- 
 tent of the slough; while, with carbonate of ammo* 
 
 nia, quinine, brandy, and strong food, we support the 
 system until some improvement makes its appear- 
 ance in the stum]!. When all the sloughs have been 
 eliminated, and the stump has commenced to cica- 
 trize, let time remodel the old amputation. 
 
 Having condemned a limb, we should wait until the 
 nervous shock — from which most of the wounded suf- 
 fer — subsides, and then give chloroform. Should we 
 not have the time for its proper inhalation, we may 
 inject a half grain or more of morphine under the skin, 
 which will produce a rapid blunting of nervous sensi- 
 bility ; and in fivo minutes, or even in less time, the 
 patient will be in a lit condition to stand the operation 
 with the least degree of constitutional shock. 
 
 In tin' performance of all serious operations, when 
 possible, there should be three assistants. One aid 
 gives the chloroform; a second compresses the main 
 artery, which is much better than using the tourniquet 
 — an instrument which is now, in a great measure, 
 discarded from practice — and a third holds the limb 
 and supports the flap during the section. The aid who 
 administered the chloroform during the incisions, can 
 assist in ligating the arteries. -Military surgeons pre- 
 fer the circular operation to the flap, which they only 
 use in the exceptional cases. With the circular stump, 
 covered only by skin, there is less soft tissue to sup- 
 purate and slough, and a much more rapid cicatriza- 
 
MODE OF OPERATING. 417 
 
 tion is effected. Experience, which has long recog- 
 nized the utility of the circular operation for the leg, 
 has now generalized it as tho most useful amputation 
 for the thigh or arm. 
 
 As tjhe soft parts, muscles, etc., are divided perpen- 
 dicularly to the hone in the circular method, there 
 w r ould be fewer blood-vessels severed, and those would 
 he cut across at right angles; wdiile in flap amputations 
 a large artery coursing through the flap, after passing 
 the point where the circular incision would have divid- 
 ed it, might give off several branches, all of which would 
 be cut, and then so obliquely that they would require 
 much more care in ligation. Small vessels, when cut 
 obliquely, do not contract to occlusion as readil}' as 
 when divided perpendicularly to their axis. Moreover, 
 as t he vessels are much more numerous, secondary 
 hemorrhage is more likely to occur in flap than in cir- 
 cular amputations. Another objection urged against 
 flap operations is that the nerves run through the en- 
 tire flap, and their divided ends are exposed at the ex- 
 trem ity which forms the cicatrix. The pressure upon 
 these ends by the indurated cicatricial tissue, is a fre- 
 quent cause of painful stumps. In circular amputa- 
 tions, the flap being formed of 'skin alone, and the 
 nerves being divided on a level with the bone, there is 
 no fear of like incarceration. 
 
 The rapidity of making flaps, which is often offered 
 as an inducement for adopting this method, should not 
 influence the- surgeon in his choice — as, under chloro- 
 form, a lew Beconds, or even minutes, more or less, is of 
 no moment either to operator or patient, nor does it 
 affect in any possible way the final result. When we 
 
 hear of surgeons boasting thai they can take oil' a leg 
 in so many seconds, we always attach to them a desire 
 to gain the applause of spectators at the exp< □ 
 
U8 MODS OF OPERATING. 
 
 the patient's Bafety. I have seen operators belonging 
 to this class who would make a frightful gash in peri- 
 neum and bladder, so as to ensure the extraction of a 
 calculus in the shortest possible time, to the wonder 
 and astonishment of a large assemblage of professional 
 men, while a tew dayi of fatal Buffering would disclose 
 the price at which tin- false reputation ha- been pur- 
 chased. The spectators) however, who lose Bight of 
 the case, know nothing of this natural consequence. 
 Safety to the patient is of the first moment, rapitli ty 
 in performing an operation being altogether of sec- 
 ondary consideration. The reputation of a surgeon 
 should be measured by his successful cases, ami not by 
 the number of seconds he takes to slay his patients. 
 
 Saving assigned the aids to their posts, and seen 
 
 that all the DOCeSSary instruments which may he need- 
 ed are at hand — for a surgeon should never commence 
 an operation until he has satisfied himself on this score 
 — the Burgeon removes the limb, ligates the vessels, ami, 
 when all OOzing has ceased, secures the stum]) hy 
 points of suture placed at intervals of an inch, or a 
 little less, along the entire line of wound. 
 
 In dividing the shin, the surgeon can not be too careful 
 to leave <ni ample tl<i/> t<> cover the /i<;i</s of the bones. 
 
 This is the first and most important rule in amputat ion. 
 You can not well leave too much skin, ami can very 
 easily commit the opposite error. The surplus of skin 
 will he absorbed} a deficiency can in no way be sup- 
 plied. The rule is, to have the flaps so ample that no 
 tension he necessary in closing the wound. One of 
 the most constant, as well as one of the most frightful, 
 
 exhibitions in those military hospitals where the sur- 
 geons have not yet gained experience, is the protrusion 
 of the hones from the Btumps of amputated legs, m- 
 oessitating a second operation should the patient Bur- 
 
MODE OF OPERATING. 419 
 
 vivo the first. A little care will obviate this (rouble, 
 and Bave the surgeon much mortification. Any omis- 
 sion in this respect must be corrected before the stump 
 is dressed ; unci if the hone is found so long that the 
 skin can not be made to cover it without traction, re- 
 move a section of bone Avith the saw, and not attempt, 
 through want of honesty, to conceal a badly-perform- 
 ed operation, and make the innocent patient the victim 
 of our misplaced pride. In ll.gating the vessels, tie every 
 artery which bleeds, or is likely to bleed. It is not deroga- 
 tory for a surgeon to apply ten, fifteen, or even twenty 
 ligatures to a stump; it shows that he understands 
 his profession; experience has taught him the great 
 trouble and annoyance of reopening a stump to find a 
 bleeding vessel, when ho has but little time to attend 
 to the urgent demands of the wounded. The rule is, 
 neglect no small artery. 
 
 As adhesive straps for supporting and sustaining the 
 flaps arc antagonistic to water dressings, they are 
 useless in amputations, and are not used. Only a small 
 strap is necessary to secure the ligatures upon the limb 
 at one angle of the wound, and prevent these threads 
 from being unintentionally pulled off from the vessels, 
 before the processes necessary for obliterating perma- 
 nently the arteries have been completed. Sutures are 
 recommended in all operations, and, in amputations, 
 should be sufficiently numerous to keep the Haps in 
 perfect apposition. As they arc not removed for four 
 or five days, they obviate much after-dressing. A sin- 
 gle layer of wot cloth is applied to the stump ; this, in 
 turn, is covered by a piece of waxed cloth or oiled silk 
 t" keep in the moisture, and either an ice bladder or 
 water by irrigation is continuously applied over this 
 outer cloth. The <ase should now he looked upon ;i s H 
 wound, and should be treated accordingly. The course 
 
IJo TREATMENT OF AMPUTATIO 
 
 laid down for wonnds is here strictly applicable, and 
 
 should be closely followed. 
 
 hi certain eases of amputation, as in the circular, 
 ■where the skin alone forms the flap, the dressing may 
 !><• changed, as follows: After applying suture- to the 
 entire Length of the wound, draw the intervening 
 sp.-ucs accurately together by means of strips of isin- 
 glaSS-plaster, and cover, also, the length of the wound 
 with a folded strip of the same, only leaving uncov- 
 ered the most dependent angle where the ligatures 
 escape, and where drainage from within is permitted. 
 The ohject of the dressing is to convert the wound 
 into a suheutancous one, excluding the air and hasten- 
 ing union. To the stump no Other dressing is applied 
 than a wet (doth, frequently renewed or kept moist by 
 irrigation. At the expiration of a week, the removal 
 of the straps will show complete cicatrization along 
 the line of incision. In healthy patients, and in a pure 
 atmosphere, a rapid healing of stumps may in this 
 way he obtained. The isinglass-plaster will alone 
 answer for this dressing — the diachylon being too 
 irritating, and not sufficiently pliant to seal, hermeti- 
 cally, the wound. We 6nd hut little use for ointments 
 
 in dressing recent stumps — the wet cloth being much 
 simpler, not irritating, and, therefore, more efficient. 
 
 Dining the treatment of all wounds in military hos- 
 pitals, previous want and exposure, which belongs to 
 every army, however well organized, will show their 
 influence; and if, from misguided views of the pathol- 
 ogy of inflammation, the plan of abstemious or anti- 
 phlogistic diet he adopted for those operated upon, 
 the mortality will be heavy. Liberal feeding shows 
 its good effects in the after-treatment of amputations; 
 and the great difference in the surgical statistics of 
 the French and English depends more, perhaps, upon 
 
ACCIDENTS TO STUMPS. 421 
 
 the diet in their hospital practice than upon an}' one 
 other cause. Tisanes can not support a person in or- 
 dinary health, and certainly can not support him un- 
 der the additional drain of an exhausting suppuration. 
 If patients are placed under identically similar condi- 
 tions, the successful treatment of amputations will he 
 found to lean to the side of those who are the most lib- 
 erally supported. Slops are out of place in a surgical 
 hospital, and good cooking will be found as useful as 
 good nursing. Let nature be our guide. For the first 
 one or two days after a serious operation, there is but 
 little disposition to eat. Under such conditions, 1 
 would not advise food to be forced ; but, as soon as 
 the patient expresses a desire to cat, foster his appe- 
 tite with good, strong, nourishing, easily-digested 
 food, and let his supply be liberal. Any attempt at 
 starvation will be highly injurious. 
 
 If the patient escapes the ordinary diseases inci- 
 dent to hospitals, viz: erysipelas, gangrene, pyaemia, 
 etc., — we must be extremely careful of him about the 
 tenth or twelfth day. When the ligatures are escap- 
 ing from the arteries, absolute rest should be insisted 
 upon, and the patient should not be allowed to exert 
 himself in any way until this fear of secondaiy hem- 
 orrhage is passed. We have elsewhere stated how 
 this complication is to be met. 
 
 Among the accidents to which recent stumps are 
 exposed, we find hemorrhages, spasmodic twitchings, 
 excessive sensitiveness, often amounting to severe 
 pain, and protrusion of bone, with necrosis. When, 
 upon examination, a few hours after a stump has 
 been dressed, it is found hard, enlarged, and glisten- 
 ing,- with the sntuies drawn, and apparently burying 
 themselves in the skin, the patient complaining of the 
 pain of tension, the cause will be found in internal 
 
\22 Aft ll> I M> TO BTUMT8. 
 
 hemorrhage. Under the sedative action of lot 
 blood, or the depressing effects of pain, etc., the heart's 
 action had Itch bo lowered that a condition approach- 
 ing syncope had been brought about, accompanied by ■ 
 tardy and feeble circulation. Such vessels which bled 
 freely when firsl divided, under this loss of vis a tcrgo 
 fbroe, ceased to bleed. The stump looked dry, and was 
 closed by suture. As Boon as the patienl gets warm un- 
 der reaction, blood is driven with more force through 
 
 open-mouthed vessels, the small clot which tem- 
 porarily plugged them is dislodged, and the cavity of 
 the stump, made complete by the close apposition <>1 
 the flaps, is gradually tilled with blood. If there- be no 
 outward escape for the blood, it clots, and thus stop- 
 ping the orifice Of the vessel, permits the more per- 
 manent clots to form within the divided calibre — so 
 that often, when the Butures are cut, the stump freely 
 opened, and theclotted blood emptied out, no bleeding 
 
 1 can be found. Should the bleeding point be 
 discovered, a ligature, which should have been used 
 during the operation, must now be applied. It is the 
 frequent occurrence of such accidents, necessitating a 
 reopening of stumps, thai teaches an experienced 
 surgeon t<> negleol no bleeding vessel, [f there arc 
 too many small oozing points, and the surgeon is de- 
 sirous of leaving as few ligatures in the wound as 
 possible, I have found that forcibly breaking a thread 
 around these small vessels will, by cutting through 
 their inner contractile coats, crush their walls to the 
 obliteration of their calibre, and thus put a Btop to 
 the bleeding, without the necessity of leaving the 
 thread in the wound. When such hemorrhages occur 
 after a stump has been dressed, it is necessary to re- 
 move the clot from the cavity of the stump, so as to 
 obtain, if possible, direct union between the flaps. 
 
OOZING FROM FACE OF STUMP. 423 
 
 Under certain conditions there is a general oozing 
 from the entire surface of the stump, which is very 
 difficult to control, and Which depends upon a hemor- 
 rhagic diathesis induced by the depressing influences 
 of camp life. Legouest, in his Crimean experience, 
 mentions many instances of this capillary oozing. 
 Direct pressure upon the bleeding surface, the eleva- 
 tion of the stump, cold applications, the local applica- 
 tion of the persulphate of iron, and indirect pressure 
 upon the main vessel, will suffice to stop this drain. 
 As this condition will likely induce an unhealthy ac- 
 tion in the stump, and probably sloughing, with secon- 
 dary hemorrhage, the general system of the patient 
 must be improved by liberal diet. Secondary hemor- 
 rhage, which comes on from the eighth to the fifteenth 
 day, about the period of separation of the thread from 
 the main vessel, will be met by ligating the artery in 
 the stump, if possible, or above it, according to the 
 rules laid down so fully in page 207. 
 
 "We sometimes observe, after amputation, that an 
 irregular action is excited in the divided muscles, with 
 a tendency t<> contraction or twitching, which causes 
 the stump to be disturbed, moving it from its position, 
 or even lilting it from the bed upou which it is lying. 
 As every movement of the sensitive extremity is very 
 painful, this spasmodic muscular action in the stump 
 becomes an annoying complication, which demands 
 control from medicines. A bandage applied around 
 the limb is often used to allay these twitchings, and is 
 supposed to be beneficial by the pressure and support 
 which it affords t<> the divided muscles. Mosl frequents 
 ly, however, some one of the nervous sedativ. 
 which opium is the chief, i> oecessary to quiel this 
 ilar, painfUl action. This spasmodic action of 
 the muscles accompanies recent amputation, :md i- 
 
l'_'4 PAINFUL BTDMP. '^^^^.^M 
 
 rardy scon whori the operation has been performed 
 0v< r ten or fifteen da; 
 
 When cicatrization has commenced, a Bocond acci- 
 dent may appear, consisting in a severe pain locating 
 itself in the end of the stamp, and often radiating up 
 the lim!>. The pain is one of pressure or tension, and 
 is at times very severe. It is accounted for by an 
 incarceration of the ends «>t' the divided nerves in the 
 cicatricial tissue, which, in hardening, exercises pain- 
 ful pressure upon them. This condition is not so like- 
 ly 1" occur in circular as in flap amputations, as the 
 cicatricial lino in one case is formed of skin alone, 
 while in flap operations the nerves extend to the very 
 extremity of the (lap, ami arc often incorporated in 
 icatrix. ruder certain circumstances a morbid 
 action is Bel up in the extremity of the divided q< 
 with exudation among the nerve filaments, resulting 
 in the formation of a tumor which incorporates ami 
 compresses painfully the extremity of the nerve trunk. 
 Whenever persistent pain exists in a healed stump 
 which anodynes can not remove, some such patholog- 
 ical condition must he suspected, and the compressed 
 nerve be liberated, <>r its diseased extremity exoised. 
 
 The mosl important accident to which a stump is 
 liable is from exposed bone, called usually a conical 
 stum] i, the pathology of which is not generally under- 
 stood. This condition has been very frequently at- 
 tributed to carelessness in operating, and by many is 
 always traced to a deficiency of flap. Experienced 
 surgeons, however, meet with this condition of pro- 
 truding hone where every care had been taken during 
 the amputation to leave even a superabundance of 
 
 soft parts, and where the end of the hone was amply 
 
 covered. Again, its presence has been attributed to an 
 irritability of the muscular envelopes of a stump which, 
 
CONICAL STUMPS. 42. r > 
 
 by their excessive retraction, expose the end of the 
 bone. There is no doubt that the muscles do retract, 
 but instead of the cause, it is rather as the effect of a 
 previously existing disease. The true cause of conical 
 stumps is found in an inflammation of the lining en- 
 velopes of the bone, both periostial and medullary, but 
 more especially the latter. Either from some peculiar 
 condition of the patient or atmosphere, or from the 
 direct injury which these nutrient membranes of the 
 bone receive from the saw, an inflammation is excited. 
 The medullary membrane takes on the general suppu- 
 rative inflammation with all the tissues of the stump. 
 It becomes red, swollen, and thickened, soon filling up 
 the entire medullary canal, and even protruding, 
 fungus-like, from the smoothly cut end of the bone. 
 In connection with this inflammation, the nutrition of 
 the bone becomes impaired, the periosteum as well as 
 the medullary membrane separates from the exposed 
 end, which leaves a white, denuded, osseous rim. The 
 soft parts of the stump will not unite over this fungoid 
 mass from the medullary cavity, but, gradually re- 
 ceding on all sides, leaves it eventually the most 
 prominent portion of the surface. From exposure the 
 bone is darkened, and the medullary granulations 
 desiccate into a hard, black, greasy crust, intimately 
 attached to the end of the bone. In the progress of 
 the case, under Long-oontinued suppuration, with the 
 formation of sinuses and fistulous openings, the en- 
 velopes of the bone still further separate from the ex- 
 tremity of the shaft, so thai a probe can pa-- up. for 
 some distance, alongside of the bone. 
 
 In the meantime nature has set up her eli mi native 
 action, and by slow steps is isolating the denuded, ne- 
 crosed portion. After many weeks Borne motion can 
 be imparted to the blackened protruding prominence 
 J j 
 
420 OAL STL KPB. 
 
 ■ in-. .-Hid soon after it is round s<> detached that it 
 can be palled off, coming away as an irregular cylin- 
 der, Bmoothlycut where the -aw had traversed it. bul 
 very apioalated in the direction of the Bhaft. These 
 prolongations are eometimea four and five inches long, 
 showing to what a distance th<' disease had extended 
 in the medullary cavity. 
 
 As the pathology of conical stumps eau be clearly 
 traced to a destructive inflammation of the medullary 
 and periostial membranes, the plan oftreatmonl can be 
 as clearly laid down. No benefit can bo derived from 
 a course recommended of making traction upon the 
 soft parts by means of bandages and plasters, bo as to 
 draw the muscles of the stump over its extremity. 
 The result would be the incarceration of a necrosed 
 bone. Nor is the risk of a Becond amputation justifia- 
 ble, as no Burgeon can foretell the extentof the inflam- 
 mation, and to what beight the disease lias involved 
 the Bhaft. In cutting off an inch of the bone we may 
 leave two or three inches of sequestra behind. The 
 only judicious course to pursue in the accident of 
 conical st u in] >>, is. to await patiently the elimination of 
 the dead hone, knowing that, in time, the entire extent 
 of diseased bone will become detached, and can bo 
 readily removed, when the stump will heal rapidly. 
 The history of this war has given us interesting cases 
 in which medullary necrosis, following upon amputa- 
 tions in the middle of the thigh, had exfoliated the Bhaft 
 of the bone as high up as the trochanter. JtB the rule 
 
 of treatment for conical st umps with necrosed bone is to 
 
 await patiently the separation, any instrumental in- 
 terferenoe is meddlesome surgery, and always injurious. 
 
 Whenever operations are to be performed in mili- 
 tary surgery, Chloroform should be administered. It is 
 a remedy which the surgeon should never be without, 
 
TJSE OP CHLOROFORM. 
 
 427 
 
 and which might be used on all occasions with advan- 
 tage, whether for operations or for dressing painful 
 wounds, as in the cleansing of compound fractures. 
 The effects of chloroform are wonderful in mitigating 
 the suffering of the wounded, and it is often instru- 
 mental in the cure of wounds, from the rest and tran- 
 quillity of mind which follows its inhalation. It also 
 prevents excessive reaction in the paroxyms of trau- 
 ma lie fever. During the performance of capital oper- 
 ations on the battle-field, death sometimes ensues 
 from nervous exhaustion, produced by excess of suf- 
 fering; the use of chloroform relieves the patient at 
 least from this risk. 
 
 The universal use of chloroform to allay the pain of 
 surgical operations, is a complete vindication of the 
 utility of the remedy, and proof of its necessity. For 
 ourselves, we place unlimited confidence in itsjudicious 
 administration, arrd use it without hesitation under any 
 circumstances. We l*ope that the humanizing tenden- 
 cies of the age, in introducing this invaluable comfort, 
 has banished that dread of being cut as an item to be 
 considered when operations are necessary; and we 
 hope to see anaesthetics used as liberally in allaying the 
 pain of surgical affections as cold water is now used 
 for keeping down inflammation. We do not hesitate to 
 say, that it should be given to every patient requiring a se- 
 rious or painful operation. We may hear, now and then, 
 Of an accident from its administration; but who can tell 
 us of the immense number who would have sunk from 
 operations, had ii not been administered? 
 
 In iis administration we must use the following pre- 
 cautions: The besl apparatus is a folded cloth, in the 
 form of a cone, in tin' apex of which a small piece of 
 Sponge is placed. This, is at first held a! some distance 
 from the nose ami mouth of the patient, 80 that tlu- 
 
428 USE OF CHLOROFORM. 
 
 first inhalation may be well diluted with air. As the 
 exhilarating Btage is reached, the cloth should be ap- 
 proached to the nose, so that a more concentrated 
 ether may be inhaled, which will rapidly produce the 
 desired insensibilit} 7 . Noisy breathing is the sign that 
 the anaesthetic effect is produced, when the inhalation 
 should be suspended, and the operation commenced. 
 Unless the operation is very tedious, do not renew the 
 inhalation. 
 
 Ingenious inhalors are more or less complicated, and 
 are, on that account, more or less inefficient. The 
 great perfection of the above-mentioned apparatus is 
 its simplicity. Finding that much chloroform is wasted 
 by evaporation from the handkerchief, I have for some 
 years used a common funnel as my inhalor, which pro- 
 tects the hands of the person administering the chlo- 
 roform, and prevents the loss from general evaporation. 
 If a piece of heavy wire, or a small" bar of tin, be at- 
 tached across the interior of the tkinnel, about half-way 
 toward its throat, the sponge containing the chloro- 
 form can be supported between 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 bo 
 large enough to coyer the lower half of the face, in- 
 
 eluding the 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 ex- 
 cluded from the apparatus, are not annoyed by the 
 evaporation of chloroform. As the tunnel does not tit 
 accurately to the lower outline of the face, there will 
 be ample spaces on either side of the chin to admit air 
 for diluting the vapor. 
 
 Besides a great saving of chloroform, which is no 
 
USE OF CHLOROFORM. 429 
 
 small recommendation, the use of this instrument ob- 
 viates the fear of suffocation, which is always present 
 to my mind when I see chloroform carelessly adminis- 
 tered. When the cloth is used, should the patient 
 struggle — a very common occurrence — or should the 
 assistant administering the anaesthetic be at all inter- 
 ested in the operation, the cloth is thrust down upon 
 the face of the patient, respiration is impeded, and suf- 
 focation is imminent. Suppose the patient has already 
 been influenced to such an extent that he has lost the 
 voluntary control of his muscles, and can not pull 
 away the cloth, he is in a very dangerous condition, 
 and the continued 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 largcl}' increased. In 
 times of hurry, confusion, and excitement, as after a 
 battle, we can not surround the safety and well-being 
 of the wounded with too many guards for their pro- 
 tection. 
 
 Of the many thousand instances of its administra- 
 tion since the war between the Confederate States and 
 United States began, but two fatal cases from chlo- 
 roform inhalation have been reported. In one, the 
 patient 'lied in a few minutes after inhalation was com- 
 menced. In the other, the patient did not die for sev- 
 eral hours. The case was that of a healthy young 
 soldier, who bad a minie hall embedded under the 
 scapula, and who, while > n /out, to rejoin his command, 
 Btopped at a hospital, ami desired its removal. The 
 
 Operation was very tedious, and he was kept under the 
 
 influence of chloroform for one and a half hours. Al- 
 
430 STIFF JOINTS FROM GUNSHOT WOUNDS. 
 
 though he regained his consciousness when the admin- 
 istration was stopped, his pulse never reacted, notwith- 
 standing the liberal use of brandy. A few hours alter 
 the operation was completed there appeared an in- 
 creasing disposition to sleep, which gradually ended 
 in coma, the pulse becoming more and more feeble. 
 He died thirty-two hours after the inhalation. As the 
 operation affected no vital part, and as the health of 
 the patient was good, his death could be attributed to 
 no other cause than the inhalation of chloroform. 
 
 Stiff Joints and Deformed Limbs. — I have had my 
 attention frequently called to the number of anchylosed 
 limbs, resulting from gunshot fractures of the shaft of 
 a bone, or even from simple flesh wounds. These de- 
 formities are caused, in most instances, b} r the misap- 
 plication of splints and bandages. Nothing is more 
 common, in army experience, than to see a sling worn 
 for months for a gunshot wound of the arm or forearm. 
 The injury, usually a compound fracture, or perhaps 
 only a flesh wound, after some days' treatment in a 
 hospital, may have been found so rapidly improving 
 that, with the prospects of an early cure, the patient 
 was given thirty days' furlough, and sent home. From 
 neglect, or injudicious treatment, the process of the 
 cure was retarded; and, after an extension of furlough 
 of thirty days, he reports to a hospital or examining 
 board with wound healed, but with a stiff joint. Wounds 
 of the forearm frequently leave, as sequelae, when they 
 are not properly watched, contracted fingers and stif- 
 fened wrists. Anchylosis of the elbow is also afrequent 
 accompaniment of such injuries, as well as of injuries 
 of the arm. 
 
 During the treatment of every gunshot wound of the 
 upper extremity, when it is necessary to carry the 
 
STIFF JOINTS- FROM GUNSHOT WOUNDS. 431 
 
 forearm and hand upon a board, or the arm in a sling, 
 it is the common custom to wear the apparatus until 
 the wound is perfectly healed. When this is accom- 
 plished, the patient throws aside the sling; but finding 
 that the limb, after being carried for a long time in an 
 elevated position, is congested immediately when it is 
 allowed to hang, ho becomes alarmed at its swollen, 
 discolored, ^md painful, or rather benumbed, condition. 
 After a few minutes' trial he elevates the limb, and as 
 he finds in it immediate relief from these disagreeable 
 sensations, he reapplies' the apparatus, with the inten- 
 tion of wearing it until his arm becomes strong enough 
 to bear the depression. In this opinion he is often 
 sustained by his physician, who tells him that, eventu- 
 ally, all will get right. After frequent attempts at al- 
 lowing the limb to hang, with the same results as at 
 first, he gives up all hope of ever getting the use of his 
 arm, and carries if day and night in a sling. Unless he 
 is exceedingly fond of the excitement of an active cam- 
 paign, he rather cajoles himself with the frequent re- 
 newal of his furlough. Eventually he finds that he has 
 lost all power of movement in the clbow r -joint, which 
 has become anchyloscd. In gunshot wounds of the 
 thigh and leg a similar stiffening of the knee-joint often 
 results from the position in which the leg is for a long 
 time carried — semiflexed, to relieve the painful tension 
 of the muscles. 
 
 When a limb has been supported for even a few da ys, 
 the veins appear to lose their tonicity, and are easily 
 distended b}- the weight of a column of blood; so that, 
 when the arm or leg is lnmg downward, the blood stag- 
 nating in the veins distends all of these vessels, con- 
 gesting the limb, and producing a painful exaggeration 
 of numbness. Should there be an ulcer upon the ex- 
 tremity, venous blood will at once trickle from its but- 
 
432 STIFF JOINTS FROM GUNSHOT WOUNDS. 
 
 face — having burst through the attenuated walls of the 
 vessels, as the column of blood exercises more pressure 
 than these feeble vessels can bear. This loss of tone 
 is readily restored after a few days' use of the limb. 
 
 In cases where the arm has required support for 
 some time, as in compound fractures, when a cure has 
 been perfected, and the necessity for using a sling has 
 passed, tbe following course has been found, beneficial : 
 After dropping the arm for even a few minutes, as soon 
 as it becomes painfully congested it should be raised, 
 and supported by thrusting the thumb or hand in the 
 buttoned coat or vest. When the arm has rested suffi- 
 ciently, allow it again to hang down; and, by fre- 
 quently repeating this manoeuvre, in a few days tone 
 will be restored to the vessels, and the painful disten- 
 sion from position corrected. If the medical attendant 
 does not urge the patient to this course, and explain to 
 him the pathological condition, so that he can intelli- 
 gently assist himself, the tonicity of the vessels will 
 be daily deteriorating, instead of the arm gaining 
 strength. Frictions over the limb with a stimulating 
 embrocation will assist materially the member, and 
 even dry rubbing is found very strengthening to the 
 vessels by stimulating the nerves, which, in turn, con- 
 trol and restore .action in the blood-vessels. The 
 splints, and especially the sling, should be discarded, as 
 soon as they have fulfilled their usefulness. Cases of 
 neglect of tliis important rule are so numerous, when 
 wounded men are allowed to be treated at home on 
 furlough, that the propriety is very questionable of al- 
 lowing them to leave the hospital, until a cure is so far 
 progressed as to enable them to dispense with all ap- 
 paratus. 
 
 When stiff joints are presented for correction, it is 
 important to know whether the anchylosis is false or 
 
. STIFFENING} WITHOUT A JOINT. loo 
 
 true; whether produced from a permanent contrac- 
 tion of the muscles around a joint, or from fibrinous and 
 osseous formations within fhe articulation and between 
 the heads of the bones, ultimately joining these, or 
 even blending them. When a wound has occurred at 
 some distance from a joint, which has become stiff 
 during a tedious course of treatment, the presumption 
 is that the anchylosis is spurious, or resulting from 
 contracted muscles and shortened ligaments, the effect 
 of a long-continued and restrained position. If, when 
 an attempt is made to straighten such a limb, strong, 
 hard tendons, as cords or stays, are felt prominently 
 under the skin, preventing extension, the most speedy 
 and certain relief is found in the subcutaneous section of 
 such cords. Chloroform is administered, and the limb 
 extended forcibly until the contracted tendons become 
 prominent. A delicate tenotomy knife is then passed 
 under them, and, by turning the sharp edge of the 
 blade outward, exercising, at the same time, a sawing 
 motion, the tendons will suddenly yield, and the limb 
 can then be readily extended. It would be bad policy, 
 however, to straighten the limb at once, inasmuch as 
 the divided extremities of the tendons would be so sepa- 
 rated from each other that a very indifferent bond of 
 union would be formed between them. The better 
 course is to replace the limb immediately in its contract- 
 ed position, and support it in the same by a splint and 
 bandage. At the end of a week the ends of the divided 
 tendon will have been glued together by an abundance 
 of plastic material, which will be found so yielding in 
 its* character that, if a splint, with a movable joint, 
 as seen in figure 1, plate 24, be now attached to the 
 limb, and by means of the screw be gradually straight- 
 ened out a little everyday, at the end of three or four 
 weeks the tendons will have become so much elon- 
 Kk 
 
134 BTIfFENlIfp WITHIN A JOINT. . 
 
 gated by the yielding of this plastic deposit as to 
 permit the ready straightening of the limb, and the 
 removal of all contracting deformity. 
 
 Plate 24. figure 1. shows tin 1 kind of angular splint 
 best adapted to false anchylosis of the elbow, which is 
 a very common accident after a compound fracture of 
 the arm or forearm. Figure 4, plate 24, gives the de- 
 sign of a similar apparatus for straightening the knee- 
 joint. Where no tendons become prominent or require 
 division, the angular splint alone will suffice for re- 
 moving the contraction. The biceps tendon at tho 
 elbow-joint, and the hamstring muscles at the knee, 
 are the tendons requiring division. After section the 
 limb should not be immediately, hut gradually, 
 
 straightened. With ordinary care, and a little ana- 
 tomical knowledge, the operation of tenotomy becomes 
 a simple and usually very successful expedient. Per- 
 manently Hexed fingers and toes, when caused by in- 
 jury to the muscles of the arm or leg, are veiy easily 
 straightened by division of the contracted tendon. 
 
 When inflammation has occurred within, or in I he 
 immediate vicinity of, an articulation, the cause of 
 stiffening is found in a deposit of lymph, which ties the 
 heads of the bones more or less intimately together, 
 restricting all movements in the joint. Such cases re- 
 quire a different treatment. These muscles may not 
 he immediately at fault, and, therefore, would not re- 
 quire division. The proper mode of proceeding is, under 
 chloroform, to flex forcibly the limb, breaking up bands 
 of adhesion. They can be felt to give way under the 
 hand, at times, with an audible noise. In the elbow, as 
 well as in the knee, the limb is straightened by first flexing 
 it. Bend the .forearm until if lies upon the arm, and 
 the knee until the heel touches the buttock. By this 
 tbrcible flexion the main vessels of the extremity, all 
 
OSSEOUS UNION IN ANCHYLOSIS. 435 
 
 o? which pass over the flexed portion of the limb, are 
 relaxed and not stretched, and, therefore, injury to 
 them is avoided. 
 
 After complete flexion is effected, attempts may then 
 be made to straighten the limb, without, however, using 
 an excessive amount of force. An angular splint is ap- 
 plied, so as to retain the degree of extension and pre- 
 vent recontraction. Inflammation and pain in and 
 about the joint will likely arise, which will be controlled 
 by the use of water dressings, either cold or warm, as 
 most acceptable to the patient- At the end of a week 
 or ten days, when the redness and swelling has disap- 
 peared, the splint should be removed, and the limb 
 flexed and extended, in order to destroy any adhesions 
 which may have reformed. This manoeuvre is re- 
 peated daily, and continued until the limb is straight- 
 ened — the angular splint being reapplied after it, and 
 straightened a little more than on the preceding day. 
 The splint must be worn day and night; otherwise the 
 contraction of the muscles, by giving the most comfort- 
 able position to the limb, will restore the deformity. 
 
 When osseous union has taken place between the 
 extremities of the bones, forming a joint, much more 
 force is required to flex the limb; and often the fusion 
 between the bones is so complete that it is found im- 
 possible, by a warrantable degree of force, to restore 
 motion to the joint. Too much violence is not justifi- 
 able. If, b} r a moderate application of force, the bony 
 union can be broken up, motion can be eventually re- 
 stored to the joint. Inflammation will ensue, requir- 
 ing local applications as well as general treatment for 
 its control. When this subsides, passive motions of 
 the joint should be daily made. 
 
 When, upon careful examination, in anchylosis of the 
 knee-joint, the patella H found intimately attached t" 
 
186 FROST-BITK. 
 
 the anterior faco of the femur, no benefit Can accrue, 
 from restoring motion between the extremities of the 
 femur and tibia, as the attachment of the patella pre- 
 vents all use of the quadmceps-extensor muscle, 
 which is the anterior support and motive powerofthe 
 leg. Such cases should not, therefore. I>e interfered 
 \v ith . 
 
 FROST-BITE. 
 
 Among the affections of the extremities which sur- 
 geons in the field are called upon to treat, daring the 
 inclemency of the winter's campaign, are those oc- 
 casioned by exposure to oold and moisture. During 
 the winter months an army usually sutlers from these 
 accidents in proportion to the privations which they 
 are compelled to undergo — for well-fed and well- 
 clothed troops do not readily yield to the injurious 
 influences of exposure. 
 
 During the Crimean war. the two winters whioh the 
 allied army spent before SebastOpol were very ditl'er- 
 cnt in character. The winter of 1864—66 was not 
 very cold, but was a season of continued rain; the 
 soldiers were literally living in the mud, with wet 
 clothes, which, for weeks, they had no means of dry- 
 ing; at the same time, the difficulty of procuring 
 supplies was so great that their means of subsistence 
 kept them just above starvation. Sleeping in wet 
 boots as long as the boots were whole enough to 
 remain on, and the continued maceration of the feet 
 in snow and ice-water, caused a gradual diminution of 
 the circulation and vitality *©f th< toes and feet 
 
FROST-BITE. 437 
 
 Very short allowance, unusual exposure, and very 
 indifferent shelter, more than counterbalanced the 
 absence of a very low temperature; and the result 
 was that extremities, which could barely be kept 
 alive. would be given over to disease under a temper- 
 ature which would, under other conditions, be innocu- 
 ous. The feet and toes would become swollen and 
 cedematous, with a feeling of tension which gave 
 much uneasiness during the day, with such an increase 
 of pain toward night as, in many instances, to pre- 
 vent sleep; the parts would be discolored of a brown- 
 ish-red hue. In more serious cases, blisters would 
 form upon the discolored surfaces, beneath which 
 blood would extravasate. The drying and blacken- 
 ing of this would simulate mortification so closely as 
 to be mistaken by the careless observer; the peeling 
 off of this blackened pellicle would, however, expose 
 either a new skin or an ulcerated surface. In feeble 
 constitutions the parts attacked by this low inflam- 
 mation break down into sloughing ulcers, character- 
 ized, in their future march, by chronicity, and an 
 inactivity in the formation of healthy granulations; 
 also an excessive secretion of a highly offensive, ichor- 
 ous pus, with pale, greyish, exuberant, irritable, very 
 painful, and bleeding granulations. 
 
 Like- hums, the effects of cold show various degrees 
 of gravity — from the redness and puffiness of a toe, 
 through blistering of the surface and the formation of 
 superticial ulcers, to the complete mortification of 
 extremities and putrescent liquefaction of the soft 
 parts — with the usual systemic irritation, general 
 depression, and intestinal complications. 
 
 A second variely of frost-bite was well exemplified 
 in the Crimea daring the winter of 1855-56.. At this 
 period the soldiers were better clothed and fed, all 
 
l:;^ FROST-BITE. 
 
 the comforts of army Life were at their disposal, and 
 the hygiene of the camp was in every respect good. 
 
 The temperature of tliis winter was so extreme 
 that warm clothing could not retain the degree of 
 heat necessary to support life in the extremities. 
 Those who wci-i' in in 1 1 exposed tir>t lost all sensation 
 in their feet, so that no feeling would be imparted to 
 the foot upon touching the ground, and then found 
 some difficulty in walking, or even in supporting the 
 erect posture. The feet, upon examination, would be 
 found cold, livid, mottled, slightly swollen, hard, 
 cedematous, and without sensation. The continued 
 influence of cold would destroy the limb, causing it to 
 shrivel and become dark. In time a lino of demar- 
 cation would form, and the slow process of separation 
 commence, leaving a chronic, fungus, sensitive ulcer, 
 from which a fetid pus would be continuously dis- 
 charged for months. As the fibrous tissues resist 
 mortification they retain dead, blackened bones, 
 which protrude from the face of the ulcer — a source 
 of much annoyance, keeping up irritation, causing 
 abscesses in the vicinity, and extending the mischief 
 to contiguous bones. Should any attempt be made to 
 remove these protruding and hanging phalanges, con- 
 stitutional irritation, with increased pain, and a fungus 
 condition of the ulcer, if not gangrene, were sure to 
 follow. 
 
 The treatment which is found most useful in cases 
 of frost-bite would be of a stimulating character, 
 avoiding studiously the application of heat in any 
 
 form. 
 
 » 
 
 Cold water and ice play an important part in the 
 treatment of the local injuries induced by intense cold. 
 Where the parts are swollen, painful, and discolored, 
 frictions, with snow or ice water, is the popular mode 
 
TREATMENT OF FROST-BITE. 439 
 
 of treatment in arctic climates, where experience dur- 
 ing the winter months verify its advantages. The 
 frictions stimulate the tissues in which vitality has 
 been depressed, while the continued application of cold 
 prevents an cxeUed action from overwhelming the 
 weakened tissues and crushing out the little life re- 
 maining. These cold applications must be persever- 
 ingty continued for several days. Even when insuffi- 
 cient in themselves, they seem to increase the remedial 
 power of other remedies. Similar results are obtained 
 by local applications of spirits of camphor, tux-pentine, 
 or sugar of lead and laudanum, or by painting the parts 
 with tincture of iodine or a solution of nitrate of 
 silver, or diluted nitric acid. Tannic acid, dissolved in 
 glj-cerine, is highly extolled in chilblains, even who n 
 accompanied with ulceration. Under such applica- 
 tions the local symptoms will gradually disappear. 
 For the more serious grades, with ulceration, stimu- 
 lating and narcotic applications will be found the 
 most useful, although a tedious cicatrization will 
 accompany the most judicious treatment. 
 
 When mortification threatens, never use warm poul- 
 tices, which I have seen applied in such cases — a cer- 
 tain means of ensuring an extensive destruction — but 
 by frictions with cold, stimulating substances, try to 
 excite new action in the parts; and, should the general 
 system have been much depressed, stimuli and nourish- 
 ing food, with the tonic preparations of iron, should 
 be administered. Until the line of separation between 
 the 'lead and Living parts is well established, and the 
 neighboring tissues have lost their discoloration, swell- 
 ing, and induration, no amputation should be perform- 
 ed, as gangrene is likely to follow the irritation pro- 
 duced by the knife in such diseased tie Ls,how- 
 ever, these slowly decomposing masses would poison 
 
110 TREATMENT OF IMtOST-IMTE. 
 
 tlir atmosphere of a hospital by putrefactive emana- 
 tions, the course which was round most successful WB8 
 to cut away the dead masses, and remove-the sloughs, 
 hut without touching the living tissues. 
 
 In the majority of eases those surgeons who cut off 
 the bones at tin- face of the stump, leaving nature to 
 complote the cure, had the must satisfactory results. 
 Experience, however, shows the process of cicatrization 
 to be so slow, and the cicatrix remains so long sensi- 
 tive, that a preferable mode is to amputate in healthy 
 tissues, at some little distance above the well-defined 
 line of separation. When the patient is in good health, 
 or bis sj'stcm has been prepared by good food and 
 stimuli, and when no gastro-intestinal complications 
 are engrafted upon the local injury, this secondary 
 amputation hastens the cure. 
 
 It may be necessary to modify the form of amputa- 
 tion in such cases. Where the toes have all been de- 
 str03 T ed, the line of mortification is usually found as 
 extensive in the sole as upon the back of the foot, which 
 prevents the usual flap from being taken from the 
 plantar surface. In such cases it is better to perform 
 the circular amputation, making" perpendicular in- 
 cisions on the sides of the foot to facilitate the section 
 of the bones; and as the bones of the inner side oft lie 
 foot are much more extensive than those of the outer 
 side, the line of circular incision should be oblique, to 
 allow of a greater extent of soft parts on the inner 
 side of the foot. It is not necessary to follow the con- 
 tour of the joints in making these amputations. The 
 much simpler plan is to use the saw rather than to 
 disarticulate — which is at all times a tedious and 
 troublesome operation, especially when, with the mor- 
 tification of the anterior portion of the foot, the lever 
 is destroyed, which assists so materially in exposing 
 
MALINGERING. 441 
 
 the articular interspaces for the passage of the knife. 
 General treatment must not. be overlooked in frost- 
 bite. It is a depressed system which predisposes to 
 the affection, and which, by its injurious influence, re- 
 tards the cure. 'The internal use of iron, barks, good 
 food, etc., will be necessary in most cases. 
 
 MALINGERING. 
 
 In closing this Manual, experience induces mo to 
 offer to army surgeons a few suggestions regarding the 
 frauds daily practised upon medical officers by im- 
 postors, who feign disease to escape military dut} r . 
 Malingering, or the feigning of disease, has ever been, 
 and will continue to be, popular with soldiers, irre- 
 spective of the material of which an army is composed. 
 Honesty of purpose and patriotic motives are not the 
 only incentives to enlistment, even against such an in- 
 vasion as our enemies are now carrying on for the 
 destruction of all our most sacred and cherished rights. 
 
 The odium heaped upon those who would remain at 
 home, has forced many into the ranks who were but 
 little disposed to give up their comforts and their 
 habitual idleness for the active and laborious duties of 
 camp lite. Such soldiers are always ready to use every 
 subterfuge for escaping from what is irksome and dis- 
 tasteful to them; and as complaints of indisposition 
 offer an easy release, it is the plan usually adopted. 
 Moreover, where large bounties are offered for enlist- 
 ment, many are found who would enlist, obtain the 
 bounty, and a suit of clothes, and, by feigning disease, 
 successfully impose upon their medical officers, be dis- 
 
U2 MAI.INCKIUN 
 
 charged from service, to re-enlist in a few 'lavs, di- 
 stances arc known in which this coarse has been 
 --fully pursued several times in a ahort period. 
 Hence it is thai the study of feigned diseases bee 
 an important branch of military Burgery, both for the 
 protection of the service and the detection of frand. 
 Unless medical officers are aware of impostors, and are 
 
 always on the alert to detect and punish such imposi- 
 tions, the service suffers seriously, and the willing 
 soldier is over-taxed with double duty. 
 
 Among the varieties of sickness classified as ma- 
 lingering, are slight indispositions much exaggerated ; 
 or the symptoms of disease may be purely fictitious, 
 while diseased conditions, such as ophthalmias, ulcers, 
 wounds, etc., may bo either intentionally produced 
 or aggravated by the malingerer. 
 
 Greneral experience shows that, at times, one may 
 he more or less depressed, with uneasy, nervous feel- 
 ings, foreboding Bickness. These are transient con- 
 ditions, depending, perhaps, upon a disturbed diges- 
 tion, and will disappear spontaneously at the end of a 
 lew hours, having us in our accustomed health. Ig- 
 norant or infatuated is that phj(|ician who believes 
 medicine n 38arv for every Mich temporary indis- 
 position, and who adopts the rule of prescribing drugs 
 for every person who presents himself for treatment. 
 This constant drugging is detrimental to the service, 
 in making oases, and diminishing the effective si rengt h 
 of a command, while it squanders mfdioines which are 
 only replaced with trouble and expense. A little 
 moral courage on the part of the medical officer to re- 
 fuse the applicant as a patient, and a word to the 
 commanding officer to overlook his call for guard 
 duty, will gain him the confidence and the rospect of 
 the soldier. The surgeon should not act hastily in his 
 
MALINGERING. 443 
 
 diagnosis, but should pass judgment only after a careful 
 study of the case; for it is hard to force a sick man to 
 duty, but, on the other hand, feigned diseases, which 
 escape detection, are rewards granted to fraud. 
 
 Among the diseases most readily and frequently 
 feigned, are pain, rheumatism, deafness, impaired 
 vision, etc. ; all erf these are as difficult of detection as 
 their simulation is easy, and hence the readiness with 
 which such complaints are feigned. When we are 
 called upon to investigate these suspected cases, we 
 must carefully weigh the moral and physical condition 
 of the patient — his habits, his probable motives, with 
 the presence or absence of pathognomonic symptoms. 
 During the examination we mustniai'k the disposition 
 of such malingerers to overact their part, their anxiety 
 to impress us with the reality and severity of their 
 sufferings, and also the readiness with which they can 
 be led on to acknowledge the presence of incompatible 
 and preposterous symptoms. 
 
 When pain is feigned, as this may really exist as a 
 disease without external manifestation, it is the most 
 difficult of all symptoms to detect. By close observa- 
 tion and constant watching the fraud may be detect- 
 ed, although the malingerer may continue his com- 
 plaints until he attains his object— a discharge from 
 the service. In studying out this imposition, we must 
 examine into the nature and cause of this pain — its 
 duration and intensity— its character, whether fixed 
 or wandering, whether persistent, remitting, or inter- 
 mitting, und whether increased or diminished by pr< 
 ore — for no part can be exquisitely sensitive under 
 pressure, which will not show other indications of lo- 
 , ;1 | trouble. If the patient complains of an internal 
 pain, we should examine whether it be accompanied 
 
I I I MAl.IM.riMNC. 
 
 by those symptoms which it is impossible to assume, 
 and the absence of which would lead to suspicion. 
 
 Much may also be Learned from the treatment pur- 
 sued. In real diseases painful remedies will not bo 
 objected to, while in the feigned a decided aversion is 
 shown when the use of these remedies is threatened. 
 1 have cured a pain of six months' standing in a ma- 
 lingerer by the use of the actual cautery, and the 
 promise that, if the first application did not remove 
 all the [tain, a second would most certainly effect it 
 Even the prospect of a severe application on the fol- 
 lowing day, if the patient does not feel better, has 
 brought its fruit. This, however, docs not always 
 succeed, as malingerers have withstood the repeated 
 application of the most powerful remedies, and have 
 confessed their imposition only after exhausting the 
 resources of the suspecting surgeon, or after obtain- 
 ing their dismissal. A simple mode of testing the 
 sensitiveness of what the patient complains of as an 
 intense pain, is by making pressure upon the part 
 when the patient sleeps. Sleep, in itself, may lead to 
 detection — as quiet, placid sleep at night, with intense 
 pain during the day, without loss of flesh or genera] 
 i in pa i mi en t of the digestive organs, are a combination 
 
 which belongs to no known disease. 
 
 The pains complained of by malingerers usually 
 
 assume the form of a rheumatism, which withstands 
 
 all treatment. Notwithstanding the Liberal use of 
 remedies, this pain continues unmitigated-— the pa- 
 tient at all times suffering severely j while the true 
 
 disease is mostly affected by changes in the weather. 
 Catechising in the feigned disease will readily mislead 
 
 the patient into acknowledging inconsistent and con- 
 tradictory symptoms, which, in many eases, will lead 
 
MALINGERING. 445 
 
 to detection. Intense and long-continued pain in a 
 joint can not exist as an isolated symptom. Walking 
 with a stick, which patients, think necessary to influ- 
 ence the medical officer, is an expedient common to 
 all those whose indispositions are less serious than 
 they would have the medical officer believe. Being 
 stunned by a bomb is a piece of good fortune to many, 
 who prefer hospital life to the exposures and priva- 
 tions of the field ; and as long as the war lasts there 
 will be some who will have partially-paralyzed limbs 
 and painful spines from this cause. To be " stung by 
 a hung," and be demoralized, is a condition which hos- 
 pital surgeons classify among the most intractable of 
 diseases. 
 
 A feigned paralysis of the arm — a disease at times 
 
 •assumed — can be readily detected during sleep, by 
 
 tying the sound arm to the body and tickling the nose 
 
 or lips, when the palsied arm will innocently move to 
 
 the face to brush away the offending body. 
 
 Deafness comes next in order as a disease difficult 
 of detection, and, therefore, frequently assumed. 
 Those familiar with this disease will often notice a pe- 
 culiar manner, which belongs to such only as have 
 difficulty in hearing. The surgeon must exercise his 
 ingenuity in devising means for exposing the imposi- 
 tion. Among these would be making, suddenly, loud 
 noises, such as discharging a pistol near the car of the 
 unsuspecting person! Very few have such control 
 over themselves as to withstand this trial, although 
 instances are known where impOStorfl remained un- 
 moved, notwithstanding this tot. Relating a conver- 
 sation in which the patient is deeply interested^ and 
 watching Clandestinely the play of his features, will, 
 at times, lead to detection. 
 
 Chloroform is found :i valuable aid in detecting 
 
146 MALINGERING. 
 
 fraud in those who feign being dumb. An instance 
 has come to my notice of a malingerer who had suc- 
 ceeded repeatedly in rinding the enrolling officer. 
 At last, coming under the inspection of one alive to 
 the frauds practised upon conscripting officers, chloro- 
 form was administered, when, under its intoxicating 
 influence, Ins tongue soon became loose, to the aston- 
 ishment of his wife, who had not heard the sound of 
 hi 8 voice for several years. The loss of voice, when 
 the effects of chloroform had passed off, was readily 
 restored under the bucking process — this severe treat- 
 ment establishing a complete and permanent cure. 
 
 Like impairment in hearing, so is impaired sight a 
 very common complaint among those who desire to 
 escape duty. Night or day blindness is a complaint 
 which may have foundation under certain eireum- • 
 stances, but is rarely met with. When suspicion is 
 aroused, compulsoiy duty is the best remedy. Un- 
 der the plea that, for sentinel duty, and especially for 
 night duty, hearing is even more important than Boe- 
 ing — and as four ears are always better than two — a 
 double guard, of which the malingerer is one. should 
 be placed at the post. At the same time, a low diet 
 will show the impostor that his complainl does nol 
 meet with much sympathy. A soldier may appear 
 before the medical officer with an excessively dilated 
 pupil, and with a complaint of impaired vision. It 
 must be remembered that, as' a disease, this symptom 
 seldom appears alone, and that a drop of a solution of 
 bolladonna will, at any time, induce it. Where such a 
 case excites suspicion, searching the patient and lock- 
 ing him up, under guard, will, in a few days, solve the 
 doubts by the return of the pupil to its normal dimen- 
 sions. 
 
 Epilepsy is another disease ofti d attempted. To 
 
MALINGERING. 447 
 
 have fits is thought by the public to be the acme of an 
 incurable condition, deserving the commiseration of a 
 community; and the soldier necessarily infers that a 
 man who can have a fit while in camp, surrounded by 
 his companions, may have a similar one while on guard 
 duty, and is, therefore, not a proper person to be en- 
 trusted with the protection of a camp. These fits 
 are brought on at will. Should the surgeon of a hos- 
 pital express a desire, in the hearing of the patient, 
 to see him during an attack, he will most likely be 
 accommodated during the day. This disease has been 
 so frequently feigned, both in civil as well as mili- 
 tary life, and the symptoms of the disease have been 
 so carefully studied, that mo,st surgeons will be on 
 their guard against such impostors. A drop of tur- 
 pentine or alcohol in the eye of such an one will, with- 
 out doing harm, bring his acting to a speedy close. 
 Very tew impostors can stand this innocent test. It 
 is, perhaps, as well to state that, during the epileptic 
 fit, all sensibility is for the time suspended, which is 
 not the case, of course, when the disease is feigned. 
 
 A feverish skin may also be simulated by the liberal 
 use of a flesh brush, while the foulest coat upon the 
 tongue can be manufactured at will by a local applica- 
 tion of chalk, clay, ashes, brick-dust, flour, soap, etc. 
 Deformities and contortions of the limbs, which are 
 never drawn up during sleep, or under the influence of 
 chloroform, are also feigned by malingerers, and will 
 require the most careful scrutiny. In order to deceive, 
 the mouth is scarified to permit the spitting of blood, 
 ulcerations on the legs are made by the pressure of 
 bard substances, and swollen arms and legs by ligating 
 
 the extremities near the trunk. Frequent micturition 
 
 or diarrhoea may easily be complained of, and dysen- 
 t. ri< Btoola have been actually stolen from neighboring 
 
448 MALINGERING. 
 
 patients to assist in carrying out the deception. It is 
 only necessary for surgeons to know to what extent 
 diseases may be feigned, to be prepared to meet the 
 impostors; and by using all the means, both morally 
 ami medically, which their ingenuity would suggest, to 
 detect and punish the malingerer. 
 
 Maiming, or self-mutilation, is occasionally practised 
 in every army by craven, cowardly men, who, in this 
 way, try to escape the dangers or privations of the 
 field. In the English service every soldier maimed by 
 the discharge of his own musket, and who thereby bo- 
 comes unfit for service, whether the injury occurred 
 on or off duty, or whether accidental or intentional, is, 
 in evciy case, tried by a, distinct court-martial as soon 
 after the event as possihle. The soldier's claim to a 
 discharge, or even his exemption from punishment, 
 will depend upon the decision of the court. 
 

 APPENDIX. 
 
 Li, 
 
A FEW PRACTICAL RULES USEFUL IN PERFORM- 
 ING THE VARIOUS OPERATIONS REQUIRED IN 
 MILITARY SURGERY. 
 
 AMPUTATION OF THE FINGER. 
 
 
 Owing to the size of the phalangeal bones composing the fiuger 
 (plate 2, fig. 1), amputations are usually performed in the joints for 
 any injury which the bones may have sustained, although, under cer- 
 tain circumstances, it may be preferable, when a good flap can be 
 made from the soft parts around the wound, to remove the finger at 
 the point of injury, cutting off the sharp ends of the bone with a bone 
 forceps. This proceeding gives an equally good result with disarticu- 
 lation. In gunshot wounds of the fingers, as the bone as well as soft 
 parts are usually much crushed by the missile, disarticulations through 
 the joint above the injury arc to be preferred. 
 
 In examining fig. 1, of plate 2, it will be seen that the phalangeal 
 bones have their extremities enlarged, but, at the same time, so round- 
 ed off that when brought in contact with each other a ring of depres- 
 sion exists at the point of apposition. The lateral surfaces of these 
 enlarged heads are roughened and nodulated for the attachment of the 
 lateral ligaments of the joint. These are so proiniuent, that when the 
 index finger and thumb of the surgeon are made to glide with pressure 
 over the lateral surfaces of a finger from its extremity upward, the 
 contracted shaft of the phalangeal bone is felt enlarging as the joint 
 is approached. Surmounting the first elevation is a line of depression, 
 followed immediately by a second elevation, from which the fingers 
 gradually descend upon the constricted shaft of the superimposed 
 phalanx. Between the two hillocks is the depressed line of the articu- 
 lation. Another mode of determining the articulating surface is by 
 traction upon the inferior portion of the finger — when, the ends of the 
 bones being drawn apart, the surgeon can insert the nail of his index 
 finger between the separated articulating ends ot^tho dorsal surface of 
 the finder. If much delay has occurred, however, i" the presentation 
 of the wounded loldier, the finger may have become so much swollen 
 M to have obaoarod these prominences end depn lions. The natural 
 folds upon the palmar face of tho fuigrr c;i]i alwayi be I 
 
152 A.Mii TATION OF A PHALANX. 
 
 fnllible guide to the position of tin- :irticulating surfaces — plate '.'. 
 and 2. Of the three folds, the middle one corre*pond« alwayt with the 
 junction of the oral and second phalanges] bones. The Fold nearest the 
 end of the finger lies one-eighth of an inch behind the joint of tin- 
 second and third phalanges, while the upper fold lies half an inch in 
 front of the articulation of the Anger with the palm •if the hand. If it 
 he remembered, in connection with these landmarks, that when any of 
 
 the hinge-joints are Hexed at right angles, the antcro-posterior diame- 
 ter lit the lower head of the upper bone forms tlie prominent angle, and, 
 it allowances be made for its width, the articulating surfaces anterior to 
 it will be readily found. In performing amputations of the fingers, 
 the sharp-pointed bistoury, found in all pocket-eases of instrument", 
 is the knife preferred. 
 
 Amputation of a part of a FiNniiR. — In amputating at the sec- 
 ond or third phalangeal articulation, either the circular or flap operation 
 may be used, and the latter either by transfixion <>r by cutting the 
 flaps from without. The plan generally adopted is thai of making an 
 anterior Hap from the palmar surface, as in plate 2, fig. 5, by trans- 
 fixing, with a sharp-pointed bistoury, the finger on a level with the 
 articulation, including in the (lap about being formed half the soft parts 
 comprising the finger. 'Ibis is accomplished by entering the point of 
 the knife from the side of the finger in such a way as to strike the 
 lateral surface of the phalanx; the handle being now depressed, 
 allows the point to glide over the bone, when it should be in turn ele- 
 vated so that the point will protrude opposite to its place of entrance. 
 The blade is now, by a sawing motion, made to graze the bono in its 
 descent for the distance ■ I ball or three quarters of an inch, when the 
 blade is made t" cut dinctl\ out at right angles to its former course, 
 which completes the Hap. The bund is now turned over to its dorsal 
 as]. cct, and the skin of the linger upon which the amputation is being 
 performed being well drawn upward by an assistant, the position of the. 
 joint having been satisfactorily located, an incision is made at right 
 angles to the flap, which will join the incisions on each side of the fin- 
 ger, a*id, ut the same time, expose the articulation. The lateral liga- 
 ments form the key to the joint, and keep the extremities of the pha- 
 langes in close apposition. Until these arc divided, which should be 
 effected by the point of the knife, the articulation can not he traversed. 
 
 This amputation may be modified in the following way: After mak- 
 ing the palmar flap, this might be raised bj an assistant (plate 11, fig. 
 6), and the joint entered from the palmar surface. Unless the operator 
 is well skilled in anatomy and in the operative manual, the articulation 
 will not be easily found, as the configuration of the parts will most proba- 
 bly throw I he knife above the joint upon the shall of the superior jdia- 
 
AMPUTATION OF A FINGER. 453 
 
 lanx. The steps of this amputation may be reversed — the articulation^n- 
 tered from the dorsal surface, as seen in plate 2, fig. 3, and, after the 
 division of the dorsal and lateral ligaments, the finger being bent, the 
 blade traverses the joint, and then has its position changed to one of 
 right angles to its former course — fig. 4. The finger is now extended, 
 and the palmar flap cut as before directed. The arteries being very small, 
 do not require/ usually, a ligature; twisting them with a torsion forceps 
 will, as a rule, prevent hemorrhage. Should they bleed, however, they 
 should be ligated. The flap, which should be made always long enough 
 to cover completely the exposed articulating surface, will be adjusted 
 by two or three points of suture, and the application of a single thick- 
 ness of wet cloth completes the dressing. The adhesive plaster dressing, 
 which was the old method of putting up stumps before water dressing 
 came into vogue, would, when wet, become detached, and permit the 
 wound to gape, which, in itself, would destroy all hope of union by the 
 first intention. The sutures should be removed on the fifth day. The 
 wet cloth will be continued for a few days longer, when simple cerate 
 dressing should be substituted. All the advantages of cold water dress- 
 ing, which are chiefly to prevent inflammation and promote quick 
 union, will be obtained within ten days, when its use should be dis- 
 continued. When used it should be applied to the stump alone, and 
 not to the entire extremity. Cold water dressing, although essential 
 in the treatment of wounds, like every good remedy, is liable to much 
 abuse. Its diffused application, and the extravagant waste of cloth, 
 extending over an entire limb for a circumscribed wound, can not be 
 too severely ojxiticised. 
 
 During the inflammatory stage of reaction, extending over the first 
 five or six days succeeding an amputation, cold water should be freely 
 used ; but when this period has passed, a damp cloth, renewed before it 
 becomes dry, is the proper dressing: otherwise, an inflammation of the 
 skin is set up, with the formation of itching pustules, which are more an- 
 noying to the patient than the wound for which the water treatment 
 is used. 
 
 Amittation of a Finger. — In removing an entire finger at the mcta- 
 carpo-phalangeal articulation, one of two methods are usually adopted: 
 either by the oval method, or by lateral flaps — plate 2, fig. 7. The 
 urticulating surface will be located as directed above for the ]>balangeal 
 joints, but more especially by traction upon the finger, which v 
 ar&te the extremities of the bones to a considerable t stent. The in- 
 cision must be commenced upon the back of the hand, over and ujiun 
 the metacarpal bone, and at least half an inch above its inferior ex- 
 tremity. This is continued parallel with the bone until it reaches tho 
 articulation, when ilt direction is obliquely changed, puling midway 
 
454 AMPUTATION OF ALL THE FINGERS 
 
 D the fingers to the extremity of the webbed portion of skin. II 
 the oval method has been Selected, the knife is now made to encircle the 
 palmar face of the finger in the upper Fold of skin indicating the junc- 
 tion "f the finger and hand, and is then brought up upon the opposite 
 side of the finger; when reaching the web of skin its direction is changed 
 to make an oblique incision similar to the one first traced, and which 
 will meet this on a level with the joint — not, therefore, where the in- 
 cision started from, Imt half an iuch below it If the incision was con- 
 tinued upwards to end where it was commenced, a V flap of skin would 
 be removed, which would leave a deficiency of soft parts for covering 
 the exposed end of the metacarpal bone. 
 
 If the flap operation has been preferred, the direction of the knifo is 
 changed after reaching the webbed portion of skin before spoken of, and 
 instead of encircling the palmar surface of the finger, it follows an oblique 
 course in the palm corresponding to and directly under the oblique 
 dorsal incision. When the point of the knife roaches the palmar site of 
 the joint, which will make an incision three-quarters of an inch in length 
 and terminating one-third of an inch from the transverse fold in the 
 palm of the hand, its direction is changed, so as in cutting out to mnke 
 an equally oblique incision, passing through the webbed skin upon the 
 opposite side of the finger to bo amputated, and continuing obliquely 
 upon the back of the hand to meet the first incision over the articulat- 
 ing surface. 
 
 The flaps are now dissected upward, in order to isolato them from the 
 finger, which is drawn upon and flexed at right angles, so as to facilitate 
 the disarticulation, which can now be readily effected by dividing the 
 r tendon and dorsal ligament, then the lateral ligaments which 
 form the key to the joint, and finally the palmar ligament with flexor 
 tendons. In all hinge joints the bones are kept in close apposition by 
 these lateral ligaments, and to facilitate their division it is necessary 
 to put them upon the stretch by flexing tho bone laterally. The two 
 small arteries which run parallel on either side of the head of the meta- 
 carpal bone will require ligation, otherwise annoying hemorrhage will 
 probably occur, necessitating tho opening of the stump. To avoid com- 
 plicating the wound with too many foreign bodies, one end of tho liga- 
 ture should be cut off near the knot, and the other, drawn out from tho 
 most convenient portion of the wound, la confined about one inch above 
 the stump, under a strip of adhesive plaster. Thrco or four stitches will 
 keep the flaps in close apposition, and a single thickness of wet cloth 
 completes the dressing. 
 
 Amputation ok all thk Fingkrs. — When a gunshot wound has so 
 crushed all of the fingers as to necessitate the removal of all of them, 
 the flap to cover the heads of the metacarpal bones must be made from 
 
AMPUTATION OF METACARPAL BONE. 455 
 
 tho palm, and also a small flap from the dorsal skin to assist in covering 
 over these large bones. Tho site of the articulations being readily de- 
 termined, the operator commences the palmar incision, if he is operating 
 upon the right hand, by inserting the point of the knife through tho 
 skin upon the lateral surface of the joint of the index finger, midway 
 between the palmar fold and the fold at the base of the finger. From 
 this point he traces a curved incision across the junction of the fingers 
 with the palm, extending to a similar point upon the outer side of the 
 little finger, having traversed the palm one line above the intcrdigital 
 web. The object, at this step of the amputation, being simply to trace 
 out the form of the flap, the knife only traverses the thickness of the 
 skin. 
 
 The hand is now reversed; and while an assistant retracts the skin, 
 as seen in plate 3, fig. 2, a similar incision is marked out on the dor- 
 sal surface, extending also in an elliptic form from the outer to the in- 
 ner termini of the palmar flap, and from one-fourth to one-third of an 
 inch below tho joints — which is as deep as a regularly delineated flap 
 can be made, owing to the skin dipping down between tho fingers. 
 This anterior flap, which is the least vascular, is now rapidly dissected 
 up, the joints opened from their dorsal surface, the long-bladed knife 
 passed through and under them, and a flap cut out, following the line 
 which was marked out in the palm. The arteries having been ligated 
 as they are exposed between each metacarpal bone, the flaps are 
 brought together by means of five or six points of suture, which, by 
 their nice adjustment, will give an excellent result. 
 
 The assistant who holds the hand for the surgeon can assist materi- 
 ally in the successful accomplishment of the amputation by handling 
 the limb in the following manner: The hand to be operated upon be- 
 ing pronatcd with the dorsal surface upwards, the assistant places his 
 two hands on each side, with the ends of the second, third, and fourth 
 fingers of each hand resting over the course of and compressing the 
 radial and ulgar vessels ; the patient's wrist is clasped by the balls of the 
 assistant's thumbs — which are the supporting power upon the back of 
 the wrist, and against which pressure is made by the fingers resting over 
 the arteries. The two index fingers make tense the skin of the palm of 
 the hand, while the thumbs of the assistant make traction upon the 
 skin of the dorsal surface, which enables the surgeon to include all the 
 skin possible in the posterior flap. Without shifting his grasp the as- 
 sistant can pronate or supinate the hand as the surgeon requires, in the 
 various steps of the amputation. This is a good method of securing 
 the hand during all operations upon this extremity. 
 
 Amputation ok Fin<;i,k. with METACARPAL Hose. — When neces- 
 sary to remove a port ion of, or the entire metacarpal I , similar meth- 
 
1 .'•'*• AMPUTATION 01 MKTACARPAL BONE. 
 
 ode of operation may be adopted ta In the removal of n finger, selecting 
 either the ovol method, 0* lateral flap, according to the character of 
 
 the injury or the faney of the surgeon. Plate 2. fig. 8, Indioatee 
 how the oral method should be 6arried oot When the entire An 
 quires remoTal, the point of the knife ihonld eommenee to traoe (he inci- 
 sion oreT the carpal bone to which the finger is attached. For the thumb 
 the incision, soanmencing over and npon t hi- trapezium bone, 
 donnmurdl npon ami ]>arallel with the metacarpal hone for half its 
 length, when its direction if changed obtf ojucly, so as to pass around 
 the finger, as in plate 2. fig. B. When the soft parts arc separated 
 from the bona, an in plate 2, fig. 9, the thumb is forcibly Hexed into 
 the palm, which makes prominent the head of the bone and stretches 
 the ligaments With the point of the knife both the posterior and lat- 
 eral ligaments are divided, which allows the bone to be lifted up, the 
 knife passed under it. and the finger detached. The stump is well 
 shown in plate 2, fig. 10. 
 
 The only difference between removing one of the middle fingers, or 
 with it the metacarpal hone in part or in whole, is in the length of the 
 perpendicular inoiaion. In the Bap operation, which is preferred by 
 many for the little finger or thumb, the lateral Bap ii defined by plan* 
 inL' the point of the knife (plate •"•. fig. Ii over the articulation of the 
 oarpne with the meta ca rpal bone on the back of the band, tracing an 
 
 incision npon and parallel with the metacarpal bone over itl entire 
 length. \\ hen it has passed the level of the metacarpo-digital articu- 
 lation it turns off obliquely to the outer Bide of the finger, continuing 
 downward! to the middle of the first phalanx, or to a level with the ex- 
 tremity of the interdigital web; the point of the knife is then reversed, 
 
 und an incision, Cones] ling exactly to that upon the back of the 
 
 hand, is traced in the palm. In these lines a broad outer flap is dis- 
 
 Bectod up. 
 
 The skin of the hand being DOW drawn inwards by an assistant, the 
 knife, with its edge against the web, is placed between the linger to bo 
 operated upon nnd its neighbor, and. by a .-awing movement, is made 
 t0 traverse fn ■ below upwards, the intermetacarpal space meeting the 
 first incisions where the metacarpal hone joins the carpus. The linger 
 
 is now forcibly drawn outward, which puts the carpo-metacarpal liga- 
 ments upon the' stretch, and facilitate! their division from within out- 
 wards. When the load of the bone is liberated the knife is passed upon 
 its ■.uter side, and, by cutting from above downwards, the Boft pu 
 
 severed from the metacarpal bone in the lines of incision, and the llap 
 completed. When the arteries are ligated and the flap socured in its 
 position by several points of suture, very little deformity will be ob- 
 bi 1-. ed. 
 
PARTIAL AMPUTATION OF HAND. 457 
 
 AMPUTATION OF THE HAND. 
 
 Partial AMPUTATION of hand. — In injuries to the hand the surgeon 
 must ever remember that every portion of this extremity which can be 
 saved ean be made useful ; and the thumb alone, when opposed to oven 
 a portion of the palmar surface, will prove far more useful than tho 
 most elaborate artificial limb. Therefore, should tho hand bo over so 
 much crushed by shell or shot, if the thumb and one or more fingers 
 cau be retained, it is the duty of the surgeon so to improvise an opera- 
 tion as to remove only those portions which extended experience has 
 shown can not be saved. Experience has established the fact that 
 frightful mutilations arc not incompatible with the restoration of a use- 
 ful member; therefore we must not be guided by appearances in con- 
 demning a hand. If two or three fingers, with thoir metacarpal bones, 
 have been crushed, with soft parts torn, and bones protruding, sueh 
 fingers alone should be amputatod. If all the metacarpal bones of the 
 palm have been crushed, with frightful laceration of tho soft parts, it 
 may still be possible to saw through the metacarpal bones immediately 
 above their broken, spiculated surfaces, which is a better operation, when 
 we have the choice, than disarticulating in the carpo-mctacarpal joint — 
 plate 3, fig. 5. In performing this amputation the flap is made, as 
 usual, from the palmar surface,* either by marking with the point of tho 
 knife the form and size of the flap desired, and then dissecting it from 
 without inwards, or, having mapped out its extent, cutting it up rapidly 
 by transfixion — plate 3, fig. 6. 
 
 In amputating the right hand, the point of the knife perforates over 
 the unciform bone, and, after traversing the entire palm, appears at the 
 root of the thumb at a point where its web joins tho lateral surfaco 
 of the hand. 'With a sawing motion the heel of the knife cuts out the 
 flap by following the line which had been previously traced, c ba, in plate 
 3, fig. 6. The hand is then reversed (figure 5) and an incision made 
 on a level with the oarpo-metaoarpal joint, extending on the back of tho 
 band from its outer border to the head of the metacarpal bone of the 
 thumb, " to 6 — then obliquely downwards through the interspace b c, 
 between the metacarpal bones of the thumb and index finger, to meet 
 the commencement ol the palmar incision. Th#hand is thcti forcibly 
 Bexed, the point of the knife dividing the posterior carpal ligaments and 
 Opening the joints, the line of which can bo determined by per land- 
 marks—one, the head of the metacarpal bone of the thumb, and the other 
 the prominence of the cuneiform bone on the outer border of th<' band; 
 • low this prominence is the articulation of the fourth and fifth 
 with the unciform bone of the carpus. Af- the large 
 supplying the hand run through the palm, the low of much blood 
 during the amputation can be aroidt d by making f> erii r In- 
 
458 AMPUTATION AT THE WRIST-JOINT. 
 
 cisions, then completing the division of the ligaments, and opening the 
 joint before the palmar flap is dissected up. Complete the operation by 
 ligating every bleeding vessel, ami retain the flap in thorough apposi- 
 tion by using a sufficient number of sutures. 
 
 Ampvtation at tiik wrist-joint. — The hand is, however. BO muti- 
 lated at times, from the effect of shot or shell H onnds, that it is impi 
 ble to save it, and its entire removal is demanded. Under such cir r 
 cumstances disarticulation at the radio-carpal joint may l>e performed, 
 either by dissecting up a circular flap of skin, or b} - making a palmar 
 flap. Commencing the circular incision an inch below the styloid proc- 
 esses of the radius and ulna, which form easily-felt prominences on 
 each side of the wrist-joint, dissecting up the skin alone, a flap is 
 made, which is turned up over the lower part of the arm as the cuff to 
 a sleeve. When dissected up to the level of the joint, which is rccog- 
 • nized by the styloid processes, the tendons on the back of the hand are 
 divided by a sawing motion of the knife, also tin- capsule, which, is 
 very thin, and the joint is thus opened from behind. The division of 
 the lateral ligaments and flexor tendons complete the operation. The 
 prominent ends of the radius and ulna should be removed with the saw 
 before the flap is closed by suture; as, otherwise, these projections of 
 bono, compressing the sensitive skin of the flap, leave >'>ro points for 
 some time after the wound has complete!] cicatrized, or, by their pi 
 urc, may cause ulceration through the skin. The radial and ulnar 
 arteries, which will require ligation after this amputation, will be found 
 on the outer and upper sides of their respective bones. 
 
 The flap operation which gives the most perfect adaptation of the 
 soft parts over the ends of the bones, is performed as follows : With tho 
 palm of the hand upwards, the point of the knife is made to perforate 
 the skin on the lateral surface of the band immediately tinder tho sty- 
 loid process of the radius; from which point (plate 3, fig. v i an inci- 
 sion descends for three-quarters of an inch, then sweeps n a semicircu- 
 lar diroction across the palm one and a half inches be ow the joint, 
 to terminate in a perpendicular incision of three-quarters of an inch 
 
 under tho styloid process of tho ulna. Tho styloid pi ss of the 
 
 radius is felt as a pro#incnce on the outer side of the wri t-joint and 
 continuous with the shaft of the radius, the styloid process of tho ulna 
 being on the inner side and continuous with the ulna bone. A slightlv 
 concave incision (concavity looking toward the hand), into which 
 the convexity of the palmar flap will bo nicely adjusted, is now made 
 over the back of the joint (plate 3, fig. 8), connecting the styloid 
 incisions. With a sawing movement of the knife the tendous on, the 
 back of the hand are divided, and the articulation widely opened. The 
 lateral ligaments being sovcrcd, the amputation is completed by push- 
 
AMPUTATION OF THE FOREARM. 450 
 
 ing the blade of The knife through the joint and under the honey, when 
 a palmar flap is dissoctod out in the line of incision previously traced. 
 
 AMPUTATION OF THE "FOREARM. 
 
 Several, methods of amputating the arm may be adopted where tbo 
 radius and ulna have been crushed, with extensive injurj r of the soft 
 parts, viz: the circular amputation, a double flap, or a long anterior 
 flap, sufficient to form a good stump — the rule in this, as in all amputa- 
 tions, being to leave the greatest length of limb possible. 
 
 Circular method. — Although the circular amputation can be applied 
 to every portion of both extremities, thero are certain portions of the 
 limb where other methods_are preferable. Such is the case where an 
 amputation is demanded upon the lower portion of the arm, where, the 
 limb being conical, the lower border of the flap is everted over the 
 larger portion of the limb. As the skin is, however, very elastic, this 
 can be effected withoutmuch effort. A circular incision is made around 
 the arm, extending alone through the skin (plate 5, fig. 2) — the object 
 being to avoid injuring the deep vessels of the limb at this stage of the 
 amputation, and thus save the patient the loss of blood which he would 
 otherwise incur. This skin is then dissected up from the muscles, and, 
 when separated sufficiently, is turned over as the cuff of a coat would 
 be, when its isolation can be the more readily effected by drawing 
 the sharp edge of tho knife upon the bands of cellular tissue which 
 tie down the *kin to the deeper tissues, until a sufficiency of flap is ob- 
 tained. The incision through tho skin is always located in reference 
 to the point where it is desired to divide the bones, the proper allow- 
 ance being made for tho size of the limb. If the limb is to be removed 
 a few inches above the wrist, the circular incision through the skill 
 would be located one and a half inches bolow the point at which the 
 bones are to be sawed. In the more fleshy portions of tho arm, nean r 
 the elboWj^rom two to two and a half inches of skin would be re- 
 quired. 
 
 The circular flap being well drawn upwards by an assistant, the knife 
 is made to encircle tho limb immediately below the fold of turncd-up skin, 
 and, cutting to the bone, divides all of tho muscles. The point ol the 
 knife i.« then thru.-t between the radio- and ulna to divide the hit 
 on- ligameni and such muscular fibres as may have previously escaped 
 the knife. When ilio bones arc isolated, a retractor, made by slitting 
 three tails in a band eight inches wide, i- applied for the protection of 
 the sot' : ','■ middle tail if plated between tl 'he lat- 
 
460 IMPUTATION OF THB FOREARM. 
 
 < nil and broadest tail "ti each aide of the bones, and aft drawn f 
 upwards, retracting and protecting tb< soft parts f"r the formation of 
 the stamp (plate 1, fig. 1). Tin- saw is applied t «. t h<- bonei Just be- 
 low the rhtraotor. In Its application, place the heel of the saw upon 
 ill. nl 1 1 :t (which is the Immovable bone "f the forearm), and fixing it 
 in position between the stamp and the thumb nail of the left band 
 
 iperator, he draw- the saw baokwnrds, which at onoe makes a 
 proovo for itself, and pit ven1 - the Instrument wandering about the limb, 
 
 tiling the fingers of surgeon and assistant. As a i as ; 
 
 r itself, ItS position IS - I as t" make it emn- 
 
 plete the section of the radius (the rotating, movable bone) before the. 
 sootion of the ulna is finished. Ligate the vessels, usually two in num- 
 ber, the radial and ulnar artery— although, at times, two others, the an- 
 terior and posterior interosseous, may require ligation. < !ul off one end 
 of each ligature near the Knot, and bring the other carefully from the 
 wound, securing all the remaining ends under s piece o< adhesive plaster 
 
 Upon the arm: then apply SO many points of suture as will keep the 
 
 opposing edges of tl iroular flap in perfect apposition. A wel olotb 
 
 the stump completes the dressing. 
 
 Flap operation Bg. •'!.) — Amputating the arm by 
 
 more flaps is an operation at times preferred, from the rapidity of Its 
 execution; or when, from extensive injur)- to the soft (■int.- upon one 
 
 : the frao tared 1 es, without wound on the other, a single flap 
 
 made upon the uninjured side of the arm would enable the operator t<> 
 amputate loner down, thus Baving more of the extremity. Trans- 
 fixion is the preferable mode of forming the flaps. The arm having 
 been supinated - i that the radio- and ulna lie parallel to eaob other - 
 b \er;, itep, to av lid passing the knife between the hones, 
 
 which would be a most awkward acoidonl for the surgeon who values 
 hi- reputation the operator, it operating upon the Left arm, Beises all 
 
 i parts in fronl of the bones with hi- left hand, while h 
 the point o[ the knife through the skin on the outer side of the arm 
 down to the outer edge of the radius, whioh itruok by Its 
 
 point; the handle of the knife is then depressed, so as to ejpvate the 
 
 point and allow it to glide upwards over the uppi redge of the 1 •• A- 
 
 soon as the point of the Knife escapes beyond the margin of the radius 
 its handle is brought to the first position, so as to allow the blade of the 
 knife to glide over t he an tori' ■ ; bol h radius and ulna, gracing 
 
 When over the ulna, the handle of the knife should he 
 elevated, whioh will depress the point; the sofl tissues over the blade 
 
 are drawn upwards, and the knife now made to transfix the skin on the 
 inner Bide of the arm, on a level with the inner border of the ulna, BO 
 
 thai at Least one-half the thi knees •■> the soft parts of the arm will lie 
 
AMPUTATION OF THE FOREARM. 461 
 
 over the blade. The knife is now made to graze the bones in its 
 descent for two inches, when the nitre is turned directly upwards nearly 
 at ri^rht angles with its former course, and, by a §auring motion, onts 
 it > way outwards through the tendons and skin. The anterior flap 
 being thus formed, the knife is made to transfix the limb at the point 
 where the operation was commenced (plate 5, fig. .'!). Passing now he- 
 hind the bones, the soft parts on the back of the arm being drawn back- 
 wards, so that the blade may readily transfix the arm without cutting 
 again the skin, the kuife is made to graze the posterior surface of the 
 bones for the space of two inches in its descent, and cuts out again at 
 right angles, with a sawing motion, to form the; posterior flap. 
 
 The two flaps are now elevated by an assistant, while the surgeon 
 passes the knife around the limb on a level with the base of the flaps, 
 which enables him to divide the remaining muscular fibres directly 
 npon the bones. He also passes the knife between the bones for the pur- 
 pose of dividing the interosseous membrane and the muscles attached 
 to it. To perform this step of the operation successfully, the point of 
 the knife must he thrust from below upwards, and the edge, in turn, he 
 brought, with a sawing motion, against both radius and ulna. When 
 withdrawn, the point of the kuife is. in a similar manner, inserted from 
 
 with the same object in view. The flaps are now well drawn 
 back by an assistant, who clasps the arm and everted flaps with both 
 hands near the point where the bones are to be divided. If the assist- 
 ant is unskilled the soft parts can be well protected from injury while 
 sawing, by using a retractor or piece of cloth fifteen inches- long and 
 twelve inches wide. One end of this is torn, half-way down, into three 
 strips, the central one of which is but one and a half inches wide. This 
 Central strip is thrust between the bones, the broad pieces are brought 
 up on either side and drawn obliquely over the anterior face of the 
 Bapi and forearm, which, when drawn firmly up, encloses all of the 
 soft parts in a kind of bag, thus protecting them from being injured 
 by the 
 
 The soft parts which are to compose the stump being now well pro- 
 tected, t! perator places the heel of the saw upon the ulna, fix> 
 
 ; ion by the nail of his thumb, which restri against the side of the 
 it from wandering, and drawing the saw backwards 
 nearly the entire length of the blade, makes ■ groove for its reception. 
 When this groove i.- sufficiently deepened by the to and fro movements 
 of the saw, which is permitted to cut chiefly by it.- on D weight and with 
 but little pp . the handle in so depn 
 
 , as, which, .1- :i movable bone, ihould be 
 
 the ulna i [f the arm, both above and he- 
 
 point of amputation, is firmly held, and the saw allowed to mn 
 
 ritfa hut little pressure, the bones will be smoothly cut 
 
AM1M DATION AT ELBOW-JOINT. 
 
 motions allowed la the arm. particularly if one portion of the arm is 
 tilted upwards, or overpressure made upon the Baw, will oanse the blade 
 to be oaught between the bone?, or eanae the bone-- to Bnap before the 
 
 i by the bbm has been completed, leaving an ugly, Bbarp spiou* 
 lam projecting from the extremity ol the bone, which must be re- 
 moved by the bone forceps. If this -sharp point be left it will irritate 
 the Baps, may cause ulceration, and, protruding through the soft parts, 
 be the aouroe of long-continued pain to the Btump. Two large arteries 
 will require ligation In the anterior flap — plate 6, fig. I lying re- 
 
 ely over the radius and ulna bones. A third, and even a fourth) 
 mil -h smaller vessel, which sometimes requires tying, will be found be- 
 tween the bones and upon either side of the interosseous membrane. 
 All the vessels are secured by the assistance of a tenaculum or a bull-dog 
 forceps. This foroeps differs from the torsion or dissecting forceps in 
 having the ends shaped like the beak of a sparrow, and so conical that 
 it is impossible for the noose of the ligature to remain upon it. When 
 the ligature is drawn upon, it must slip off the instrument uptfn the artery 
 held between its points. One end of the ligatures is oul off near the knol : 
 the other is brought out of one of the angles of the wound, and secured 
 npon the arm by a strip of adhesive plaster. The flaps are brought to- 
 gether by Beveral points of interrupted suture. 
 
 One of the established rales in surgery is always to operate as far 
 from the trunk as possible) compatible with the removal of all of the dis* 
 eased tissues. A- military surgery offers no exception to this rule, 
 cases frequently occur requiring amputation in whiob the injury is con- 
 fined altogether to one side of a limb. In Bucb cases, if the crushing of 
 ; Des does uol extend beyond the immediate seat of injury, it is 
 
 urgery to oul a long flap from the uninjured Bide of the member 
 and amputate jusl above the fracture, making upon the injured Bide of 
 the limb a semioiroular Lnoision, joining the Hap a) righl angles. 1 1 will 
 be most convenient to make this Hap by transfixion, taking the precau- 
 tion, as related above, of including half the thickness of the soft parts 
 of the limb in the Hap. 
 
 AMPUTATION AT BLBOW-JOINT. 
 
 In diinrlirii/dliii,/ ill tin tlbote joint, the anatomy of the osseous sili- 
 Qtering into the Eormation of ibis articulation must be familiarly 
 
 known, otherwise great difficulty will be found in getting between the 
 
 In examining plate i. fig's 1 . -'. 3, the forms of the heads of the 
 
 radius, ulna, and humerus oan be studied in detail, isolated as well 
 
 as in juxtaposition, with their lateral as well as antero-posterior rcla- 
 
AMPUTATION AT ELBOW-JOINT. 463 
 
 tions. It must be remembered that the shaft of the humerus, as it be- 
 comes developed to form the head, not only expands its"*surface, but is 
 also surrounded by important prominences placed laterally upon en- 
 largements which are called condyles. The outer elevation, called epi- 
 condyle, is the conspicuous prominence visible on the outside of the 
 elbow, and separated from the articulation of the radius with the exter- 
 nal condyle about half an inch — plate 4, fig. 3. The external lateral 
 ligament which assists in forming the elbow-joint, is attached above 
 to this epicondyle, below to the head of the radius, or rather to the an- 
 nular ligament which binds together the radius and ulna. The epitroch- 
 loea, a larger and more prominent elevation, situated upon the lateral 
 surface of the internal condyle, is in a similar way related to the ulna, 
 giving attachment to the powerful internal lateral ligament which 
 connects this epitrochloea to the inner face of the head of the ulna, 
 and distant from the articular face about three-quarters of an inch. 
 
 The articular face of the humerus (plate 4, fig. 1) presents two un- 
 equal prominences ; upon the smaller or outer one rotates the cupped 
 head of the radius, while upon the largor or inner one tho head of the 
 ulna, with its antorior sharp coranoid and long posterior olecranon 
 processes, moves as upon a pulley. To receive these prominent proc- 
 esses of the head of the ulna are two depressions upon the anterior 
 and posterior surfaces of this extremity of the humerus, called sigmoid 
 fossae, which permit the extended movements of flexion and extension . 
 When the bones are placed in their proper position it will be found 
 that, although the epicondyle and epitrochloea are upon tho same plane, 
 the line of the articulation runs obliquely inward and downward 
 (plate 4, fig. 3); the anterior line of articulation being overhung 
 by the coranoid process of the ulna (plate 4, fig. 2), while the pos- 
 terior surface is completely covered in by the projecting olecranon proc- 
 ess of tho same bone. The main artery runs in front of the joint. 
 In amputating by the antorior flap, which is preferred by some to the 
 circular operation, the arm is supinated and slightly flexed (plate 4, 
 fig. 4) ; the surgeon, standing upon tho inner side of tho limb, and 
 u.-ing a long narrow-bladed knife, transfixes the limb by introducing 
 the point on the inner side of the arm, one and a half inchos below tho 
 epitrochloea or prominence on tho inner condyle of tho humerus. In 
 sage forwards the point of the knife strikes tho side of the ulna. 
 Ihe handle it now depressed to allow the blade to glide over the an- 
 terior face nf the bones, when the handle is again elevated to allow the 
 point to protrude OK t lie outer side of the arm, one inch below the 
 epicondyle "r prominence on the outer condyle of the humerus. A 
 made by a sawing motion id the descent of the knife, tho blad e 
 grazing the bones in Its downward movements, until four inches is trav- 
 ersed, when it is turnod directly outward? and the flap completed. In 
 
\>\\ AMPUTATION AT BLTKW-JOTNT, 
 
 ling ilic arm for this flap, unless the bonca arc kept parallel by 
 placing ili>' ffircarm in supination, the point of the knife may 1 
 tween the bone*— ft very awkward accident. 
 
 tlii- flap, he at the same time compresses the main arteries which trav- 
 erse it, controlling the hemorrhage, [f the -Kin bo properly r< tracted by 
 an assistant, the points at which the knife transfixed the arm will havo 
 beon drawn up, corresponding closely to the articulating surfaoea 
 (plate . r >, fig. 5), viz: half an inch below tin- epicondyle and threes 
 quarters of an inch below the epitroohloea. The round head of the 
 radius being dearly distinguished, the operator, stooping, with his 
 hand under the arm t" be removed, places the heel of the knife at the 
 outer angle of the incision, and with a sawing motion makes a semi- 
 circular cut around the back of the arm, terminating at the point! 
 of transfixion. In dividing tho skin at this step of the operation, if 
 the surgeon has marked well the osseous prominences, tin; blade of 
 tho knife should be made to glide betweon tho head of the radius 
 and the condyle of the humerus. The articulation of the ulna with 
 humerus is now attacked from in front, by the division of the re- 
 maining muscular fibres tot .-. rered in making the flap, and also by 
 the division of the internal and anterior ligaments, which arc put 
 upon the stretch by extending foroibly the forearm. Should there 
 be any difficulty in finding the situation of these ligaments, it is only 
 necessary to refer to the epitrochlcea; three-quarters of an inch be- 
 low it the articulation will always be found. The articulation hav- 
 ing beon largely opened in front, continued forced extension will 
 luxate the olecranon process from its deep sigmoid fossa, when tho 
 triceps muscle attached to this prominence should he out oil' close to 
 tho bone, ami the forearm removed in the line of inoision already 
 i on the back of the arm. The radial and ulna arteries and, per- 
 baps, also tie- interosseous, will require ligation, 'flu- ligatui 
 brought out at one of the angles of the wound, and the (lap secured in 
 its position by several points of suture. A single thickness of wet 
 oloth over the stump completes the dressing. 
 
 The circular amputation at the elbow-joint is an operation which 
 gives equally good results with that of the anterior (lap. Tho ar.n is 
 held in supination and slightly flexed, and the brachial or axillary 
 artery secured by pressure with the fingers, either in the axillary space 
 at the junction of the anterior with the mi. Idle third of this space, in 
 
 which line the axillary artery can always he found running directly 
 over tho head of tho humerus, and at which point, owing to its super- 
 ficial seat being covered only by skin and cellular tissue, and lying 
 upon hone, tho circulation through it can be most readily controlled] 
 or, as tho vessel courses through the arm on the inner side of the biceps 
 
AMPUTATION OF THE ARiM. 165 
 
 muscle, where it is readily felt, surrounded by its reins and accompa- 
 nying nerves. If an intelligent assistant is at hand, the artery can bo 
 readily secured in cither position. Should it be necessary, however, to 
 use the tourniquet, this can only be "applied upon the arm about its 
 middle and over the inner border of the biceps muscle. The test of 
 the proper application of the tourniquet will be the complete control of 
 the circulation, with cessation of the pulse at the wrist. As the tour- 
 niquet in general use clasps the entire limb so tightly as to stop both 
 arterial aud venous circulation, deep-seated as well as superficial, 
 much blood is usually removed in the limb. The fingers of a good 
 assistant, which is in every case to be preferred, will only compress 
 the limb at two points : one over the seat of the vessel, and a point of 
 counter-pressure upon the opposite side of the limb. As this methodi- 
 cal pressure does not embarrass to any great extent the venous circu- 
 lation, the blood, which otherwise would be incarcerated in the con- 
 demned member, has an opportunity to escape, and the imputation will 
 be effected with very little loss. 
 
 The circular operation is commenced by the surgeon in a kneeling 
 posture, passing the knife under the arm, so as to make an incision on 
 the outer and upper part of 'the arm, three fingers' breadth from the 
 fold of the elbow. I?y a sawing motion a circular line is traced on 
 the outer, under, and inner side of the arm, the operator rising from 
 the kneeling posture, which enables him to watch the heel of the 
 blade, and direct properly the line of incision. As it would strain the 
 wrist to perfect the incision on the upper surface of the arm, it Is pref- 
 erable, although not so brilliant a step in the process, to change now 
 the position of the knife, and, placing the blade over the arm in the 
 incision where first commenced, complete it by cutting toward the 
 operator, thus joining the two terminations of the first incision. 
 
 Although this incision should extend solely through the skin and 
 cellular tissue, however sharp the Made may be, unless the operati i ap- 
 plies a sawing motion to the knife the skin will be very irregularly 
 divi ded, and at points not cut at all. As the vessels are deeply seated, 
 an d the skin alone i.- required to form i be flap, the incision should he only 
 skin -dee) i, so u to avoid the loss of blood during the tedious pn 
 dissecting up the circular flap. When the circular incision hi 
 completed the operator Beizee the upper < dge of the incision with a for- 
 ceps, and by trokei of the knife — using a scalpel, if he pre- 
 fers it to the amputating Unite — di llular bands uniting the 
 skin to the d( -. When the ,-i.in baa been sufficiently under- 
 i and rapidly dissected upwards until sufficient 
 skin is obtained to cover the head of tie humerus, which « ill bring the 
 
 fl;ip on a hvel with the articulation. By a bold Sweep of the knife 
 (plate 4, fig. 6) all the muscles are divided, the blade panting 1 
 
46G AMPUTATION 01 THE ABM. 
 
 i of the humerus and radius, the artioulation opened from t lie 
 front and the oper.-ition oomplel • 1 by is ilating the ole iran in. 
 
 AMPUTATION OP THE ARM. 
 
 In amputating the arm in either its upper, middle, or lower third, 
 
 any one of the various described methods may be used with equally 
 
 suits. It would be useless here to describe again the circular 
 
 operation, or dissecting up of a circular flap of skin with which to 
 
 form a stump, as this operation upon the arm would differ in no res] t, 
 
 except in situation, from that performed upon the forearm, aud which 
 has been already so minutely detailed. The circular amputation, 
 upon whatever portion of a limb performed, presents a striking uni- 
 formity in its procedure. The skin should always be divided suffi- 
 ciently below the point where it is designed to saw the hones, so as to 
 allow an ample covering of soft tissues for the extremity. A good 
 rule would be to make the distance bet w. ten the incision in the skin and 
 the point of division in the bone, or removal at the joint, equivalent to 
 half the diameter of the Limb, allowing, in addition, from one-half to one 
 Inch for retraction of the -kin : e. /., if an arm is four inches in diame- 
 ter, the incision through the skin should be from two and a half to 
 three inches below the point where the bone will be divided. Aooord- 
 this rule, if a thigh is six inches in diameter the skin will be 
 divided four inches below the point of amputation. By following this 
 rule a Buffioienoy of skin will be had for covering the stump, permitting 
 ready adjustment without traction upon the sutures used in closing the 
 wound. 
 
 A modification of the circular operation, well adapted to the arm or 
 thigh, where a single bone is surrounded on all Bides by muscular en- 
 velopes, has for its object the formation of a muscular cushion for the 
 Immediate covering of the sawed surface of the bone, and is thought 
 by many operators I" form u more symmetrical stump than where the 
 bone is covered solely by skin. Heforo chloroform was used, an addi- 
 tional reoommendation was rapidity in its performance; but as a nur- 
 geoo should never operate against time, a few second- more or loss in 
 completing an amputation, under chloroform, la an item not worthy of 
 
 ( Bideration. The arm being drawn ouf al right angles to the body, 
 
 .■in assistant compresses fl"' axillary artery as it ooursos over the head 
 of the humeral, and another olaspc the arm above the point where the 
 incision is to be made, at the same time retracting evenly the skin. The 
 surgeon, placed upon the inner si le of the arm if he is operatic 
 the right arm, or on the du(i ( lids it the left, stooping or kneeling, ns 
 
AMPUTATION OF THE ARM. 467 
 
 most convenient, with his arm passed under the arm to be removed, 
 places the heel of the knife on the upper surface of the arm, its point 
 reaching over his shoulder, and with a rapid sawing motion sweeps 
 around the arm, completing a circular incision which extends through 
 the entire thickness of skin. 
 
 The watchful assistant at once retracts evenly the skin to the extent 
 of nearly an inch, ami the surgeon, placing the heel of the knife in the 
 position where he commenced the operation on the upper surface of the 
 arm and at the edge of the retracted skin, makes a second Circular 
 swe'ep over the Hmb, passing now through all of the tissues down to 
 the bone. The assistant, placing his fingers deeper into the wound, re- 
 tracts to B much greater extent the skin, with superficial muscles, when 
 the surgeon places, for the third time, the heel of the knife on the upper 
 side of the arm, upon the level of the retracted edge of the skin (plate 
 5, fig. 5), and incises again the muscles directly to the bone, dividing 
 carefully all the muscular fibres. A retractor, or piece of cloth twelve 
 inches wide, slit from one* end half-way down, so as to make a double- 
 tail bandage, is passed around the'bone, the soft parts retracted by it, 
 so as to avoid any laceration of these muscles with the saw, and the 
 bone sawed off as near the retractod soft parts as possible. 
 
 Plate 5, tig. 6. shows the relation which the end of the bone bears 
 to the soft envelopes forming the stump, and shows how well and per- 
 fectly it is embedded in the muscular layer, and how completely the 
 flap of skin is protected from the sharp edges of the bono. In the am- 
 putation of the arm the brachial artery is the only large vessel requir- 
 ing a ligature, and is found always on the inner side of the humerus, 
 lying obliquely inward and upward. 
 
 In amputating the arm by the double flap, the surgeon reverses his 
 position, so that lie can seize with his left hand the tissues from which 
 he designs cutting the flap, and, by drawing upward the soft pi 
 the arm, he can so transfix the limb with the knife as to have fully 
 one-half the thickness of the limb in the first flap. The limb U BO 
 transfixed as to form an outer flap, and thus avoid the humeral artery, 
 the division of which should be left for the second or inner flap. The 
 left hanl of the operator retains its position, holding upward the 
 part of the arm, until he baa made an incision parallel with the arm. as 
 long as half the diameter of the limb, when he cuts directly outward^ 
 lib-rating the flap. He now, with his left hand, draws tin? remaining 
 tissues downward, so that the knifejnay readily pass uuder the bone* 
 through the I the point where the awn was first tran 
 
 without notching or in nny way involving a second time the -kin. An 
 la made, in the descent of the knife, of similar length to thai 
 on the npper side of the bone, when t he edge of the knife la turned out- 
 ward, and the skin divided to complete the lower or Inner flap. 
 
468 AMPUTATION AT SHOTJLDEIt-JOINT. 
 
 flaps are now drawn backward by an assistant; the surgeon sweeps the 
 knife around the bone at th<' base of the Haps, so as to divide all the 
 remaining muscular fibres which had not beeu included in the former 
 incisions. While the Hups are now carefully drawn backward, being 
 clasped by both the hands of an assistant, >>r a retractor with two tails 
 nsed for the protection of the flaps, the surgeon divides the hone with 
 the saw. having fixed the blade upon the humerus by supporting it 
 with the nail of his thumb. When the limb has been removed, any 
 gpicula of bone left protruding from the humerus must be nipped off 
 with the bone pliers. The brachial artery is drawn^uit by the tenacu- 
 lum or forceps, isolated from its accompanying veins and nervi 
 tied with a well-waxed thread, before the assistant relaxes pressure 
 upon the axillary vessel. Any vosscls which throw a jet of blood, how- 
 ever small, should be ligated, one end of the ligature cut off, and t he 
 other brought out of one of the angles of the wound, and secured 
 from injury two inches above the incision, under a piece of adhesive 
 plaster. The wound is closed, -as in all stftnips. by several points of 
 suture, which should include the entire thickness of skin, but not the 
 muscles. Plate 5, fig. 7, shows the formation of the outer and inner 
 11 ap s, with the relative position of the bone, forming the apex of a tri- 
 angle. 
 
 AMPUTATION AT THE SHOULDER-JOINT. 
 
 In cases where the humerus has been shattered within two in 
 the glenoid cavity, without involving the head of the hone in the injury, 
 or in any way implicating the joint, Burgeons prefer amputating the limn 
 without retno\ ing the head of the bone. By sawing through the humerus 
 just above Its fraotured Beat, the amputation is simplified, both as to the 
 
 operation and its results, while the rotundity and symmetry of the shoul- 
 der is retained. W. however, the injury to the bone extends into the joint, 
 while al the same time the soft parts are so lacerated as to preclude the 
 possibility of reseoting the head of the humerus, then disarticulation must 
 be resorted to, in order to save life at the expense of the limb. The shoul- 
 der-joint is formed by the scapula and humerus, and protected above hy 
 the clavicle. Plate 6, Bg. 1, indicates how the round head of the hume- 
 rus is reoeived lato th« flat, Baucer-sbaped head of the Bcapula, in con- 
 tact with which it is retained more by the scapula muscle, attached to the 
 greater and le.-.-cr tuberosities of the humerus, than by the capsular liga- 
 ment. The B/Coromial process of the scapula, with claviole attached 
 (plate 5, Bg. 2). protects the articulation from above, while the coranoid 
 process, jutting from the base of the glenoid cavity, protects the joint 
 from within. 
 
AMPUTATION AT SHOULDER-JOINT. 469 
 
 Two methods arc equally applicable for this disarticulation ! a double 
 flap operation, generally known as Lisfrane's, and the oval mothod, or 
 Larrey's process. 
 
 Lisfrane's, or the lateral flap amputation at the shoulder-joint, — Tbc 
 
 patient having been chloroformed and brought to the edge of the bed, 
 the surgeon, having located with care the space between the coranoid 
 and accromial processes, seizes the arm firmly in his left hand, and car- 
 rying it upward and outward, if it bo tho left arm requiring' removal, 
 passes the point of a long, narrow, sharp knife (plate 6, fig. 3) into the 
 middle of the posterior fold of the axilla, and pressing it obliquely up- 
 ward, makes it strike fairly the head of the humerus. By depress- 
 ing the handle of the knife, the point of the blade is made to glide over 
 the head of the humerus, cutting through the capsulo, and continuing 
 onward, between the head and the accromial process, perforates the 
 akin upon the anterior portion of the arm, through the^paoc bounded by 
 the clavicle with coranoid and accromial processes of the scapula. 
 Should it be the right arm requiring removal, this step of the operation 
 is reversed — the knife entering in this triangular space, and after pass- 
 ing through the capsule and over the anterior face of the head of the 
 bone, appears through the posterior fold of the axilla. Tho deltoid 
 muscle being still relaxed, the point of the knife descends in the line, 
 a b, until the blade is brought to a horizontal position, when it com- 
 pletes an outer flap from four to five inches long, in the line of incision 
 a L c. This Hup is at once drawn up by the assistant ; and as there 
 are no important vessels in it, but little bleeding occurs. 
 
 The position of the arm is now changed, as it is brought down and 
 carried forcibly across the chest, which throws the head of the hu- 
 merus backward and upward, making tense the capsular ligament, and 
 shows the opening made into the joint by tho passage of the knife. Tho 
 point of the knife is now drawn firmly across the capsule, and as the 
 arm is rotated forcibly inwards and then outwards, all of the muscles 
 attached to the greater and lo.-ser tuberosity of the humerus are, in turn, 
 divided by this incision, which opens the joint largely, and allows the 
 I tin- humerus to .-lip out from its covering. The blade of the 
 knifeis then passed on the inner side of the head of the bone, completes 
 the section of the capsular ligament where it is attached to the neck of 
 the humerus, and grazing the bone for tho distance of three inehes, 
 allow- ample room for the assistant to follow the knife with the thumb 
 of bis right band buried in the wound, ami to seize the pulsating brach- 
 ial artery between the thumb within the wound and the fingers of the 
 right hand in the axillary space. As BOOS a- the artery is firmly se- 
 cured in the fingers of the assistant, tin- operator completes the ■ 
 of the inn-r flap ' iv outward to the Burface (plate 5, 
 
170 AMPUTATION AT BIIOULDER-JOINI 
 
 forming a flap of similar length ; 
 tho arm. The objeot in grrwir.p the- humerus in i lie descent of the 
 
 knife is to avoid catting any vessel, and < >i [ally the axillary artew, 
 
 until it could lie secured in the Bap by an assistant, If thi.- step of the 
 operation la properly performed, there is no necessity in attempting to 
 compress the Bubol avian artery above the claviole, which i.- ti ■ • t only a 
 difficult manoeuvre, owing to the positions into which the arm most be 
 placed, bat cramps thi operator. When the am]iutati<in is completed] 
 the large brachial artery it carefully seoared by ligature before the 
 assistant loosens bis hold upon the vessel. The ciroumfh i 
 
 [aire tying- If the amputation be porformed for disease, the 
 glenoid cavity must be oarefully examined, ami any necrosed portion 
 be removed l>y the pliers or gouge : several points of suture close tho 
 wound, the ligatoi al at the superior portion of the wound. 
 
 A small opening is allowed at the inferior portion of the flaps for drain- 
 ago from the cavity of the stamp. 
 
 Lam if'* operation, or the oval method. — The steps of this operation 
 follows: The limb being placed parallel with the trunk, the 
 g the arm by passing his Dngera In the axilla and 
 thumli on the outer side. -.. as t" force outward the head of the hum cms 
 (plate 6, Bg. 5), throats thi point of a Btrong, stout knife into the 
 shoulder, immediately below the aocromial process, and makes a longi- 
 tudinal incision of two inches in length, extending down to the bone. 
 From the extremity of this be makes an incision on each side of the 
 joint, passing obliquely downward and outward, forming an open V« 
 
 rectly tO the bone, and tWO flaps are disserted boldly 
 up. BO ^ t.. . xpi -' the articulation. Wit bthe point "I the knife care- 
 fully guided by the surgeon, so that it can not wander al t In the 
 
 depth of the incision to woand Important vessels, the anterior portion 
 of the capsule is Largely opened, the muscles attached I 
 
 ter t ni iitj divided, and the head of tbe humerus fori ed out, 
 
 by using the arm as s lever, or i>\ tbe fingers in the armpit The 
 blade ol the knife is then passed behind the humerus, grating the 
 bone downward for nearly three inohes. Tho assistant follows the 
 knife in thewonnd to secure tbe humeral artery between his flngt 
 prevent bleeding, when the Hap is cut directly outward toward the 
 
 axilla, ipleting such a dap as Is seen In plate 6, fig. 6. During 
 
 this amputation the olrcumfli in divided in the fust step of 
 
 ration, and arc seonred by the fing< r ol an a -si -taut compressing 
 
 in th<' wound. Is the brachial artery is in the inferior portion of the 
 
 flap, it c.in be readily Beoured by an assistant before dn ided. All bleed- 
 
 are tied, and the opposing surfaces of the flap retained in 
 
 by a sufficient nambi r I sutures, 
 
AMPUTATION OF TOES. 471 
 
 The disarticulation of the shoulder can he equally effected by an 
 anterior and posterior flap, or by a single long anterior Hap formed of 
 "the dcltojjj muscle — Dupuytren's method. 
 
 AMPUTATIONS UPON THE INFERIOR EXTREMITY. 
 
 In amputation of a toe (plate 7, fig. 8), either by the double lateral 
 flap or the oval method, identically similar steps arc followed as for 
 the amputation of a finger, and, therefore, the minute detail of this 
 operation need not to be repeated. The same rule holds good for am- 
 putation 6T alhVthe toes, as seen in plate 7, fig. 5. A double flap is 
 made, with convexity downward, including all of the soft parts extend- 
 ing to the intcrdipit.il web, both upon the back of the foot and from 
 the sole. It requires all of these soft parts to cover the heads of the 
 metatarsal bones without making traction on the flaps. 
 
 The tarso -metatarsal amputation, or Lisfrane's, is an operation per- 
 formed much more frequently than required. The articulation between 
 the tarsal and metatarsal bones is an intricate one, requiring much an- 
 att mical knowledge to open with facility the line of joint, while a saw 
 run through the metatarsal bones, an inch more or less from the joint, 
 would simplify wonderfully this troublesome operation. In gunshot 
 injuries to the anterior portion of the foot, in advance of the tarsal 
 bones, where amputation is necessary, the transverse section of the 
 tarsal bones is one always to be preferred, and should be the method 
 regularly adopted in army surgery. 'When, as the result of diseased 
 action from gunshot injuries, the heads of the metatarsal bones be- 
 coTiie involved, Lisfrane's amputation may become necessary. In all 
 amputations through the foot, whether it be by section of bonos or 
 isolation at joints, the flap to cover the end of the stump is formed 
 from the sole of the foot. 
 
 If we examine plate 7, fig. 1, we wilj see that four irregular bones, 
 01 mprisiog the anterior row of. the tarsus, arc opposed to the heads of 
 the metatarsal bones of the five toei - all of these bones being intimate- 
 ly bound together by ligaments. If the index finger of the operator 
 runs over the inner face of the big toe. and continues upward upon 
 the inner side of the foot, after passing over the shaft of the metatar- 
 sal bone "t" the big toe it meeti with a prominence, then n slight de- 
 
 ii. and immediately a second elevation. The first of tl 
 the prominent head of the metatarsal bone, the second an eli 
 upon the inner face of the internal cuneiform, <j. and the depression be- 
 tween them marks the articulation. In passing the finger over the 
 outer side of the little toe at junction with metatarsal bone, a decide'! 
 
472 TARfi \MITTAT! 
 
 prominence is felt a little beyond the middle of the f<">t. which i 
 ponds with the projecting head of the fifth metatarsal bone,/. Imme- 
 diately behiflid it is ita articulating surface with the cuhafd 
 Should utiy diffioaltj exist in determining the articaiation of the big 
 thia head of the little toe i- always very prominent, one inch in 
 front of n line drawn from tlii- prominenoe directly act 
 will correapond with the articulation of the tir-t metatarsal and inter- 
 nal cuneiform. 
 
 ring been determined, the fool to be removed ii 
 drawn down until the heel rests npon the edgi or resisting 
 
 The palm oi the left hand of the operator ia applied t.« the 
 able of the foot, the thumb marking the head of the metatarsal < 
 the little toe, if it be the right fool to be amputated, ami the index 
 plate 7. fig. l) marking the site of the corresponding artionla 
 Hon of the external cuneiform with the first metatarsal. Tl • 
 npon the dorsum "f the foot having been drawn backward by an aa- 
 inoiaion is made a little below, but terminating at 
 the points indicated by the thumb and index linger.-. Saving i i 
 well the bones by dividing all the tendons passing over the baok "i 
 the foot, the point of the knife is paaaed around the promint 
 the head <>f tin- tilth metatarsal bone, when it at once enters the 
 joint between this bone and the ouboid, and, following a slightly oun ad 
 
 line downward and inward, pauses between the fourth and third meta- 
 tarsal -n one .-id'' (plate 7. Ii-- ■ 'he cuboid and external 
 cuneiform, / i, on the niher. Its further progress is now haired by 
 sond metacarpal hone, 2. which, passing further hack- 
 ward than anj other of the five hones, is received in a box formed be- 
 tween 'he internal and externa] cuneiform bones, t g. It is here inti- 
 mately seemed in place by strong Interosseous ligaments, whioh can 
 only be severed by adopting the course exhibited In plate 7. 
 The heel of the foot. being firmly kept upon the e I ible by 
 listant, the surgeon, drawing the portion of the foot to be re- 
 moved firmly downward, thrusts the point of the knife very obliquely 
 hetwi ■ d the upper portion of the Intermuscular Bpaoe between the first 
 
 metatarsal b s, until he feels that the point has 
 
 beyond the depth of the artloulation, when, by raising the handle of 
 the knife, the end of the blade divides the Interosseous ligaments, as 
 seen >" the figure, a similar procedure is effected between the heads 
 
 Of the s,e. ,nd and third metatarsal hone to divide the ligaments 
 
 uniting the head of the seoon i metatarsal bones with the middle and 
 
 external OUnelform. If the anterior portion of the loot he now drawn 
 forcibly downward, ami the point of the knife he drawn over the back of 
 the foot aorOSS the suppO 'he articulation, between the second 
 
 metatarsal .md middle cuneiform, 2, •. it will op^n. and also cause 
 
chopart's amputation of the foot. 473 
 
 the ligaments binding the head of the first metatarsal to the internal 
 cuneiform to yield, when the section of all the anterior ligaments will 
 be completed, and the joints widely opened, as in plate 7, fig. 7. As 
 soon as the blade passes into the sole beyond the articulating faces of 
 the bones the blade is placed horizontally, the toes elevated, and a flap 
 is cut parallel with and grazing the inferior face of the metatarsal 
 bones. When the knife has traversed nearly the entire length of th'o 
 of the foot, the toes are again depressed, the portion of the foot to 
 be removed held perpendicularly to the flap, and the knife, also held 
 perpendicularly, carves out a regular termination for the. flap, and 
 separates it from the foot, as in plate 7, fig. 8. It requires the entire 
 length of tho sole of the foot to form a flap sufficiently long to cover 
 readily', without traction, the exposed surfaces of the tarsus — plate 8, 
 fig. 1, a a a. The sesamoid bones, at the ball of the big toe, will inter- 
 fere with the formation of the flap if their presence is not recognized and 
 the knife made to glide over them. Ligation of the plantar and dorsal 
 arteries, and closing the wound by attaching the flap to the anterior 
 incision upon the dorsum by means of a sufficient number of sutures, 
 completes the amputation. 
 
 Chopart's amputation, or the medio-tarsal, between tho scaphoid and 
 cuboid in front (plate 7, fig. 1, e f) and the astragalus and os calcis 
 behind, c d, is performed in a similar manner to Lisfrano's, the flap 
 being taken altogether from the sole — plate 8, fig. I, b b b. The me- 
 dio-tarsal joint is found by the following laudmarks: In examining 
 plate 7, fig. 1, the outer surface of the scaphoid bone forms quite a 
 prominence, which can readily be felt by running the index finger 
 upward upon the inner face of the foot. The first projection felt is 
 the head of the metatarsal bone of the big toe, 1; then the promi- 
 nence of the internal cuneiform, g ; and the third knob felt as tho 
 finger passes toward the heel on a line with the extremity of the inner 
 malleolus, is upon the scaphoid bone, e. Immediately behind this 
 third knob is the articulation between the scaphoid and astragalus. 
 aid the foot be examined from behind, three-quarters of an inch 
 in front of the inner malleolus will bo found the prominence upon the 
 scaphoid bone, behind which is the articulation. On the outside of the 
 foot the articulation of the cuboid with the anterior face of the 08 
 calcis is found with equal facility. The prominent head of tho meta- 
 tarsal bone oT tho little too can always be felt; one inch behind this is 
 the articulating surface: or immediately in front of the external mal- 
 leolus is a tubcrHc upon the outer face of tho os calcis, and fa front 
 of this is the joint. 
 
 In operating upon the left foot, it i^ seised in the left palm of the 
 surgeon, with the prominent landmarks for the joint marked by the 
 
 * 
 
• 17 1 BYME'e AMPUTATION OF THE FOOT. 
 
 thumb upon t he tubercle of the scaphoid and index finger of the loft 
 hand, one inch behind the tarsal end of the metatarsal bone, as in 
 plate 7, fig. 4. The surgeon makes a slightly convex incision across the 
 hack of the foot from one landmark to the other, or one and a half inches 
 in front of the malleoli. This incision dividing all of tin soft parts to 
 the bones, the heel being fixed upon the tabic, the Burgeon draws the 
 foot forcibly downward, which puts the anterior ligaments upon the 
 stretch, allows the knife to divide them, and enter readily between the 
 articulating surfaces — plate 7, fig. 9. Care must be taken to keep tho 
 knife behind the tubercle upon the Bcaphoid : if it passes in front of 
 this, the joint between the scaphoid and cuneiform bones is opened, 
 and the scaphoid bone is left on the wrong side of the stump. When 
 the knife has passed through the joint tho blade is placed horizontal, 
 as in tho second part of Lisfranc's amputation; and whilo grazing the 
 bones, a flap is formed of the sole, and completed, as in \\^. 8. Fig. 10 
 shows the appearance of the stump alter section of the plantar flap, 
 also tho position of the dorsal and plantar vessels which will require 
 ligatures. Sutures in sufficient number attach the flap to tho anterior 
 wound, and are especially required in foot amputations. 
 
 Sgme'a amputation of the foot, ox the tibio-tanal disarticulation. It 
 
 is sometimes found that a ball in its passage has so crushed the tarsal 
 bones, including the anterior portions of the astragalus and os calei.-, 
 that the removal of the whole foot is required. In examining plate 7, 
 fig. 1, we find that the styloid processes of tho tibia, -<. and fibula, l>, 
 project downward below the level of the articulating face of the tibia, 
 forming a box or groove in which the rounded head of the astragalus, c, 
 plays, making a hinge-joint of this articulation. Powerful internal and 
 external lateral ligaments bind the malleolus to the astragalus and os 
 calcis. The anterior and posterior ligaments partake of the capsular va- 
 riety, but do not give strength to the joint. To amputate by the method 
 of Syme, after administering chloroform the circulation through the 
 limb i's secured either by compressing the femoral artery in the groin, 
 or by an assistant placing one thumb over the anterior tibial artery as 
 itruns over the ankle, midway between the malleoli (plate 17, fig. 3, a), 
 and tho fingers of the other hand over the course of the posterior 
 tibial artery (plate 18, fig. 2), as it runs on the inner side of the leg 
 and midway between the inner edge of the tibia and the tendo achillis. 
 Two incisions are then made in tho direction of the lines, c c c, plate 
 8, fig. 1. The ends of the malleoli being clearly ascertained, an inci- 
 sion through the skin and tendons is made on the instep, extending 
 from one malleolus to tho other. The direotion of the knife is then 
 changed: the heel of the blade is placed at tho termination of the dorsal 
 incision under the tip of thecxtcrnal malleolus, and passing obliquely 
 
TIROGOFF's AMI'I f ATION OP THE FOOT. 475 
 
 backward under the sole, is continued obliquely upward and forward, 
 fig. 1, c c c, to meet the termination of the dorsal incision under the 
 inner malleolus. The foot beiug forced downward, using the heel 
 upon the end of the table as a fulcrum, the tibial joint is largely 
 opened upon the anterior face, the lateral ligaments next divided 
 with the point of the knife, which allows the head of the astragalus 
 to glido forward (plate 8, fig. 2), leaving the articulating face of the 
 tibia folly exposed. The foot if still further depressed, the posterior 
 ligament divided, and the attachment of the tendo aehillis very carefully 
 separated from the foot by cutting it away from the posterior surface 
 of the os Calais. The dissection of the sole in the line of flap is com- 
 pleted by thrusting the thumb into the inferior incision, and applying 
 the point of the knife between the thumb-nail and the inferior and 
 lateral surfaces of the os calcis. When the foot is removed it will be 
 found that, however closely the posterior surface of the os calcis is 
 grazed, the skin in the flap corresponding to this portion is always 
 very thin. If the dissection be attempted without care, the flap will 
 be perforated during this step of the amputation. When the foot is 
 removed, the malleoli are sawed off smoothly on a level with the articu- 
 lating face of the tibia: the dorsal and plantar arteries, two in number, 
 secured, and the flnp brought forward and retained by sutures. The 
 objection to this opera I ion is that the flap forms a cup from that por- 
 tion of the heel which covered the calcis, and as such can not be 
 brought in perfect apposition with the opposing surface, but remains 
 separated, a receptacle for blood, pus, etc. The leg is shortened two 
 inches by this amputation. 
 
 A modification of the tibio-tarsal disarticulation, introduced to the pro- 
 fession by a Russian surgeon, Pirogoff, is a decided improvement upon 
 the plan adopted by Syrue. The anterior incision extends from one mal- 
 leolus to the other, ami is joined by an incision extending obliquely 
 backward and downward under the sole. The joint is largely opened 
 from the anterior surface by the division of the anterior and lateral liga- 
 ments. To this point of the operation it has differed in no respect from 
 that of Syme, except thai the plantar inoision, runs more obliquely back- 
 ward j from this point the differences of the operations become apparent. 
 After the astragalus has been freed from the tibia, instead of dissecting 
 the tendo aehillis from the her], the >:nv is plaoed directly behind the 
 head of th ■ .-»r-t r:itr:ilu.-. and the os calcis is divided in the oblique line of 
 the plantar incision. The malleoli and articulating face of the tibia are 
 then sawed off obliquely, so that when the flap is brought upward the 
 oblique face of the calcis will be brought in nice apposition with the ob. 
 liquelycuf tibia, and retained in immediate juxtaposition by 
 
 sutures. When tl me united, which they soon do, a g 1 
 
 solid .-tump is formed, which readily bean the weight of the body, and 
 
478 AMPUTATION OF THE LBO. 
 
 tho leg is found very little shortened when compared with tho sound 
 limb. The very great advantages of this modification is the moro rapid 
 performance of the operation, ohviating the tedious dissection of the 
 plantar flap, and isolation of the os calcis. with division of the tendo 
 achillis. It also loaves no cupped flap for the collection of secretions, 
 and, moreover, tho portion of the r»? cab-is retained adds from one to 
 two inches to the limb. Piste B, fig. 3, shows the appearance of die 
 wound after amputation with solid inferior flap, and fig. 1 indicates the 
 appearance of the stump after cicatrisation in Pirogoff's amputation. 
 in the after-treatment of this amputation it must not be forgotten that 
 until the skin has firmly cicatrized, and the bones have, in a measure, 
 bi come united, the leg should be kept somewhat flexed upon the thbgh; 
 otherwise the constant contraction of the tendo achillis would displace 
 the remaining portion of the 08 ealeis from its apposition with the tibia, 
 and prevent immediate consolidation. After all amputations of the foot, 
 should tho stump, when cicatrization is complete, be found too much 
 drawn backward, and its usefulness thereby interfered with, a subeuta- 
 neous section of the tendo achillis will be required to correct the position 
 of the tarsal bones. 
 
 AMPUTATIONS OF THE LEO. 
 
 
 In theBe days of mechanical ingenuity and perfect artificial limbs, it 
 is matter of moment to leave as long a stump as possible For the bitter 
 support of an artificial leg. Formerly the seat of election for amputat- 
 leg was four fingers' breadth below the inferior border of the 
 patella. Now we operate at any available point of the limb The cir- 
 cular operation is the one usually preferred upon the leg. In amputat- 
 ing immediately above the ankle some difficulty is found in turning up 
 the onff of skin over the larger ciroumference of the conical leg. To 
 facilitate the dissection of tho flap, a perpendicular incision, two inches 
 long, is made upon the anterior surface of the tibia, commencing over 
 the point where it is intended to divide the bono. At the lower extremi- 
 ty of this incision a oirculat cut is made round the leg, and the skin 
 rapidly dissected from the musolee by lifting the two anterior naps aa 
 high as tho perpendicular incision will allow. These flaps are well 
 drawn back, and the knitv, held obliquely from above downward and 
 backward, cuts up a Hap of mn toles from the bach of the leg. This pos- 
 terior flap is dissected upward until it reaches the level of the com- 
 mencement of the perpendicular incision, when the remaining and Inter- 
 osseous muscular fibres are divided by passing the knife first circularly 
 around the bones at the base of the flap, and then between the two 
 bones, cutting with a sawing motion, first upon tho tibia, then upon tho 
 
AMPUTATION OF THE LEG. 477 
 
 fibula. To complete the figure of 8 movernont between and around the 
 bones, so as to divide all of the muscles, the knife must be first thrust 
 between the bones from above downward, then from below upward. A 
 broad, three-tailed retractor is placed between and around the bones for 
 the protection of the flaps, while the bones are divided by the saw. 
 Plate S, fig. 5, shows the appearance of the open stump after the removal 
 of the leg through its lower third, by the method of Lenoir, above de- 
 scribed : a, I), the two-pointed flaps dissected upward. /, the anterior 
 tibial vessels lying upon the anterior surface of the interosseous mem- 
 brane; d, the posterior tibial, and, e, the peroneal arteries, will all re- 
 quire ligation. In closing the flap apply points of suture, first to the 
 perpendicular incision, and then close the circular portion of the 
 wound. 
 
 Amputation, four fingers' breadth below tho patella, is the common 
 site chosen for amputating the leg — having this great advantage among 
 the poor laboring classes who can not procure an expensive artificial 
 limb : that when the wooden pin is worn (plate 24, fig. 6), a long stump 
 docs not protrude behind, much to tho inconvenience of the wearer. 
 The best results arc obtained from tho circular amputation. Chloroform 
 is administered, and the lower portion of the body of the patient stripped, 
 so that an assistant can secure the circulation through the limb by com- 
 pressing the femoral artery at tho groin, under the middle of Poupart's 
 ligament, where its pulsation can be readily felt, as the vessel courses 
 over the ridge forming the acetabulum — plate 14, fig. 6. Should there 
 not be sufficient help present, the pad of a screw tourniquet is applied 
 over the course and pulsation of the femoral artery, and tightened suf- 
 ficiently to stop pulsation iu the vessel below the tourniquet. The sur- 
 geon, in the meantime, Bees that all the instruments which he may have 
 Deed for daring the operation are at hand, viz : an amputating knife, 
 sufficiently narrow toward the point of the blade to pass between the 
 tibia and fibula; a stout scalpel, for facilitating the dissection of the 
 circular flap of skin (in the hands of a careful surgeon, the skin can be 
 as well dissected up by the amputating knife — in the hands of oue not 
 familiar with the use of a long knife, the hands of the assistant will 
 be in serious danger, hence the scalpel is recommended for this step 
 of the operation); a saw, tenaculum, artery forceps, and bone-pliers, 
 which, with a three-tailed retractor, ligatures, and a surgeon's needle, 
 completes the necessary instruments. Two assistant! d: on- 
 
 to compress the artery iu the groin : the other to elevate aud retract 
 the flaps, and support the upper portion of the leg. 
 
 The point of Bection of the bones having been determined, the sur- 
 geon kneeling, with right hand holding the knife passed under the limb 
 to be removed, places the heel of the knife on the anterior surface of 
 the leg, reaches three inches below the point" where the bones arc to bo 
 
I, B C1R< I I All AMl'l 1ATIHN Of I 1 
 
 divided, the ]><-iiit of the knit'.' toward lii.-* shoulder, end, by ■ ssiring 
 motion, watching the heel of the knife and raising himself n« he onto, 
 makes h circular incision around the lim ndi the wri.-t t>. ■ 
 
 straining posture t" oomplete » 1 1 «- circle > p of the knife, it is 
 
 oompleting three-quarters of Lb< section, to ■ 
 sition of the knife, and placing th<' heel ol the blade al the point when 
 the incision iras commenood, cut in s saw ing i n ■ ■ t j ■ ■ : i acr >ss the anterior 
 surface of the leg t" Join the tiret incision where left off. The skin is 
 now drawn upby thefingers of the left hand, or by a forceps, when, with 
 
 i ir.'in its cellular 
 tions with tin' muscles, so that the surgeon can turn it up, cuff- 
 like. Onoe rolled over, it i.- only neoessary to apply the e<t^«- of the 
 scalpel to the cellular tissue at the fold of the everted .-kin. as the 
 ■ iii draws it upwards, when it can be rapidly d the rc- 
 
 quired height The long knife now being resumed, the operator places 
 himself, with bended knee, in the tir.-t position (plate B, ti^'. 8), 
 and commencing n second incision on a level with tlio cuff-like Hap, 
 cuts boldly throngh tlie muscles to the bone in passing around tlio 
 entire limb, :<< before. The soft parts t»'in^ drawn backward by the 
 
 1 1 1 j ir < r - of an Msistaol thrust i 1 1 1 • • the WOUnd, the Itching 
 
 i the tin . 'i-r.- of the assistant, rtion of 
 
 the blade, which i.- osually double-edged, throngh th< inter 
 space from below upward, cutting with s ition on es 
 
 in tarn. When all of the muscular Bbres on the inferior portion of the 
 limb have been divided, the knife Is withdrawn, to be thrust b 
 
 in above, to oomplete the section of the muscles which had, 
 t ■ j • to this time, escaped. When the bones are completely bared, o three- 
 tailed retractor plate B, Bg. 7, ■< a) is applied to the stump, the centre 
 tail passed betw< en the bones, the outer strips folded on the outer and 
 inner side ol the stump, and the whole retracted so that the soft parti 
 will be protected from the sen - 
 
 mmencing the division of the bones, Bi the heel of the saw upon 
 the anterior surface of the tibia, by enoloaing it between the Btump and 
 the left thumb-nail of the operator, and tan very obliquely for a few 
 strokes, cutting the ores! of the tibia obliquely for three quarto i 
 inch ; the heel ol the saw Is then placed el right angles to the bone, 
 one-quarter of an Inch below the firs) section, and, fixed In position by 
 the thumb-nail, oommenoei i" groove anew the tibia. After entering the 
 BubBtanoe of the tibia, the saw Is so elevated "r depressed, depending 
 
 upon the limb operated upon, as t ipleto the division of the fibula 
 
 first, and then finishing the section of the tibia. The object of making 
 pine of the tibia was to remoi e t hi> sharp 
 
 prominence of l , and prevet I ulceration through the 
 
 flap. An examination of plate 6, ii lt. 8, will how the position and aum- 
 
FLAP AMrUTATION OF LEG. 479 
 
 bcr of tbe vessels requiring ligation, viz : anterior and posterior tibial, 
 peroneal, aud sural arteries. At times tbe section of tbe bones is made SO 
 near the head of the tibia, or the popliteal runs so low down before it bi- 
 furcates, that but one artery requires ligation — the inferior portion of the 
 popliteal, above the origin of tibial and sural vessels. One end of each 
 ligature is cut off, and the remaining thread secured upon the outside 
 of the leg by a piece of adhesive plaster, and the lips of the skin flap 
 kept in apposition by means of a sufficient number of sutures. A cold 
 wet cloth, frequently renewed, is all the dressing required. 
 
 The flap amputation, when preferred, is performed as follows : The 
 point where the bones are to be sawed having been determined, and 
 similar arrangements having been made as in the circular amputa- 
 tion for controlling the circulation through the femoral artery, a 
 convex incision is made upon the anterior surface, extending from 
 the outer border of the fibula to the inner border of the tibia, about 
 half an inch below the point of section in the bone. As the tibia 
 lies very superficially upon the anterior portion of the leg, the incision 
 is only skin-deep — plate 9, fig. 2, g h k. As soon as this small anterior 
 flap is traced, the surgeon, standing on the inner side of the leg, if he 
 is operating upon the right limb, thrusts along, sharp, narrow kuife 
 iDto the calf, directly under the inner border of the tibia, at the termi- 
 nation of the anterior incision, and passing horizontally through the 
 limb, taking care to keep the knife immediately behind both bones, 
 makes the point protrude at the commencement of the anterior in- 
 cision on a level with the posterior face of the "fibula — plate 9, fig. 1. 
 Fig. 4, d t <j, defines the position of the two incisions. The surgeon 
 cuts down, parallel with the two bones, for a defame of three 
 . when the edge of the blade is turned obliquely backward, and 
 cuts out the long posterior Bap. The anterior flap is separated from 
 its deeper parts For half an inch, and the knife is then thrust between 
 the bones both from above downward and from below upward, cutting 
 alternately upon each bone, and then making a circular incision 
 around tbe bone-, in order to divide the interosseous ligament and 
 all remaining muscular fibres* not included in the flaps. The two 
 flaps arc then well drawn back by an assistant, who uses cither 
 his hands clasping the stamp, or I three-tailed retractor, and the 
 inrgeon applying the heel of the saw held obliquely to the bono, 
 and fixing it between bit thumb-nail and the anterior flap, cuts to the 
 depth of half an inch. IK- then places the heel of the saw one-third 
 of aii inch lower down, at right angles to the bone, and with rapid 
 to and Iro motion-, without bearing too heavily upon the saw. divides 
 
 partially the tibia, and completes the section of the smaller bone, the 
 fibuln, before the tibia is completely divided. Four arteries usually re- 
 
480 H.A1' AMPUTATION OF LI 
 
 quire ligation : the anterior tibial, between the tibia and fibula, upon the 
 anterior surface of the interosseous membrane, and three vessel? in the 
 posterior flap, viz : the posterior tibial) peroneal, and sural vessels. 
 When the heavy, voluminous posterior flap is brought over the surface 
 of the bone t" be covered, it is always found s.i thick that it has 
 to be puckered and even stuffed into the cavity of the stump, to make 
 the rounded margin adapt itself to the small cutaneous anterior flap. 
 The irregular adaptation is often the oause of a failure in obtaining 
 qniok union, and the stump heals usually by the slow process of granu- 
 lation and suppuration. As the size of the posterior flap is tho only sori- 
 ous objeol ion to this otherwise good operation, il can be readily overcome 
 by laying the flap upon the palm of the left hand before the arteries 
 are tied, which will make the mass of muscles rise in a ridge in the 
 centre of the flap, when, with a sharp knife, a heavy steak is taken 
 from the face of the flap, which reduces it to a thin layer of muscular 
 tissue and skin. In this condition all objections to the posterior flap 
 from size and weight are removed, as it will now adapt itself perfectly 
 to the anterior flap, and make, in every respect, a creditable stump. 
 
 Sutures and a wet cloth complete the dressing. 
 
 In using an artificial limb, after an amputation of the l< 
 
 ure of the false limb u nol allowed up m the cicatrix. l>ut is borne 
 chii-Uy by the lower border of the patella and condyles of the femur, 
 the support being extended upon the thigh, and in some ine 
 
 to the trunk. In the use of the oo mm in wooden pin, as seeu in plate 
 21, fig. (>. the stump is ben) at ri-Jit angles to the thigh, and the entire 
 re is applied to the knee — the stump, untrammelled, jetting be- 
 hind the apparatus. 
 
 In amputating at the knee-joint, one of two methods may be adopted. 
 In one, the knife is drawn directly across the knee below the patella 
 | plate 9, li::. I |, the incision : L t once passes through skin, lie-amentum, pa- 
 
 tollsB, and capsule, entering boldly into the knee-joint, and, severing the 
 
 strong internal and external lateral ligaments, travei-c- the entire ar- 
 ticular surface. As soon as the head of the tibia can be luxated for- 
 ward, the blade is placed behind this bono, and grazing its posterior 
 surface in its desoent, cuts a posterior flap — plate 9, fig. 4, « b <•. While 
 the perpendicular portion of the posterior flap is being made, which 
 should be about three inches long, the assistant might thrust his hand 
 into the wonnd and secure the popliteal artery. Alter ligation of all 
 bleedin most of which will be found in the posterior flap, the 
 
 Boft coverings for the head of the femur will be retained in position by 
 a. sufficient number of sutures. 
 
 As this posterior flap operation has the same objection which was 
 urged to the posterior flap In amputations in the upper third of I 
 surgeons have reversed the position of the flap, taking it solely from 
 
AMPUTATION OF THIGH. 481 
 
 the skin upon the anterior surface of the leg — plate 9, fig. 5. The land- 
 marks about tho knee-joint having been determined, an incision is com- 
 menced upon the outer face of the tibia, just below tho centre of tho 
 external condylo of the femur. After descending vertically for three 
 inchos, the knife sweeps in a convex incision across tho anterior surface 
 of the log, and is continued 'upward on the inner side of the leg, in a 
 similar perpendicular incision of equal length, terminating below tho 
 centre of the inner condyle — plate 9, fig. b, a b c. This flap of skin is 
 dissected up from the face of the tibia, t, and everted, cuff-like, is drawn 
 over tho lower anterior extremity of tho femur, until the base of the 
 fold exposes tho anterior ligament of the kneo-joint, when tho knife 
 cuts directly into and through it, completing tho removal of tbo log by 
 making a circular incision directly backward in the Hue of the joint. 
 
 This is the bettor operation of tho two flap disarticulations, as the 
 oioatricial line is placed behind the limb, whoro it will ho comparative- 
 ly protected. When the cicatricial lino lies on tho anterior faco of tho 
 stump, it is liable to frequeut and painful injury. 
 
 AMPUTATION OF THIGH. 
 
 In the thigh, as in the amputation of every portion of either limb, 
 the surgeon has the choice of oithor circular or flap methods — the flaps 
 being mado in au astero-posterior, lateral, or obliquo direction, as the 
 iv require iw the fancy of the surgeon suggest. As has been be- 
 fore stated, the circular method is nowgeucrally preferred by most opera- 
 tors, especially those who have not had much experience in the removal 
 of limbs, inasmuch as the circular flap of skin is much more likely to bo 
 ample tha n where flaps are cut, which, in the hands of the inexperi- 
 enced, arc always made too short. In examining tho reported lists 
 from tho Surgeon- General's office it is found that of 917 capital ampu- 
 tation! where the method adopted was reported, 562 woroby the circular 
 method, an'l 355 were flap amputations. Of 233 amputations of the 
 thigh, 131 were by tho circular method. These figures .-how clearly 
 the preference given to the circular oVer the flap operation. 
 
 Fl'ip amputation. — Where the surgeon shows a preference for the flap 
 ni( t bod, he stands in such a way that he can seize the muscles upon the 
 anterior portion of the thigh with his left hand, and while a careful Assist- 
 ant compresses the femoral artery in the groin where it courses over the 
 pubic bono, ■ long, narrow, sharp-pointed knife i? plunged into the 
 lateral surface of the leg. and oonthiuot its onward progress nn'il it 
 00 
 
182 i IRCl LAB AMPUTA1 [ON OJ I BIOH 
 
 strikes tbc centre of the lateral surface of the femur. Depressing the 
 handle, he continues the onward movement of the knife until it glides 
 over the anterior face of the hone, when i • igbtly the handle, 
 
 and pushing the knife directly forward across the limb, the point 
 appears through the skin on the 0] • of the thigh, when tho 
 
 knife will have fully one-half the thickness of the limb u i>'«n the blade. 
 Grazing the femur, the operator outs, directly downward until ho has 
 sufficient length of 1 1 n j > . when he turns the edge of the blade outward and 
 completes tho flap. The flap being now held up l.y an assistant, the point 
 of the knife is again entered a little lower down than before, through 
 the cut muscular surface, and parsing under the femur, appears again 
 through the cut muscular surface on the opposite side of tho limb — 
 plate 10, fig. 1. The object of passing the kuifo through the muscles El 
 to avoid cutting the skin irregularly at the point of trausli.xion. The 
 posterior surface of the femur is grazed, as vas its anterior in the tirst 
 stop of tho amputation, and when a sufficient length of flap Iim* been 
 formed, cuts directly outward. The two flaps are drawn hack bjf an 
 assistant, the Burgeon sweeps the knife around the bono at tin ; 
 the Haps to divide all muscular fibres oot se?< n d in the cutting of the 
 ii;i] is, and then applies the saw to the femur as high up as possible, 
 fixes the heel of the blade between the nail of bis left thumb and the 
 base of the flap, and drawing it Bteadily toward him, readily groove^ 
 a passage for it upon tho bone. Should the limb not be steadily held 
 during the sawing, any sharp spioula of bone left by tho snapping of 
 the femur must be removed by the bone forceps. 
 
 In locating tho flaps, the knife should be BO directed that the femoral 
 artery escapes the first section, and is found at the base of the second 
 or posterior flap — plate 10, fig. 2. The length of the Haps must depend 
 
 upon the size of the limb. A g 1 rule is to make them ample, eveij 
 
 larger than may be required : retraction and contraction of the Map 
 will soon remove all excess, when a too closely fitting flap, by II 
 ening, may bo so drawn over the eud of the bone as eventually to 
 cause its exposure and protrusion. One-fourth the circumference of 
 tho limb would make a sufficiently ample flap — if the thigh be twenty 
 inches in circumference, the flaps should be five inches long. When 
 nicoly cut and properly attached hy sutures, they adjust themselves as 
 porfcotly as the two valved shells of an oyster. 
 
 In the circular amputation many methods may also bo adopted. 
 The circular flap of skin may either be 'li IBOOted up, cufT-like, for four 
 or live inches, when all of the remaining soft parts are severed perpen- 
 dicularly to tho bone; or the following course may be adopted: Having 
 chloroformed the patient and secured the circulation through the 
 femoral artery, either by preBBuro at the groin or by means of a tour- 
 
AMPUTATION AT HIP-JOINT. 
 
 483 
 
 niquet, a circular incision is mndo around the thigh from four t° f ,ve 
 inches below the point at which it is designed to saw the boue. To 
 effect this circular incision the surgeon kneels, and passing his arm 
 undor the limb to bo amputated, bends tho wrist so as to place the heel 
 of the blade on tho anterior face of the limb, the point of the knife 
 nearly touching tho right shoulder of the surgeon. With a sawing 
 motion ho commences the incision, and, watching the heel of tho knifo 
 as he rises, may, by flexing forcibly tho wrist, complete the circuit of 
 the member. This position being a forced one, however, it is prefer- 
 able, after cutting three-fourths of tho cireumferenco of the limb, to 
 change the position of the knife. Placo the blado over the member 
 with tho point looking away from the operator, and commencing tho 
 second incision in tho line traced at first by the knife, complete tho 
 circle by ending where the first incision left off. The skin being equal- 
 ly retracted by an apt assistant, will cause the gaping of the wound for 
 nearly an iuch. The knife, placed again in the same position as at first, 
 follows the upper lino of the retracted skin, cutting through all of tlio 
 muscles. This enables tho assistant to retract the soft parts, leaving 
 from two and a half to threo inches of gaping. A third incision, fol- 
 lowing as before the upper contour of tho cutaneous incision, dividos 
 for a third time the muscles, permits of ample retraction of tho soft 
 parts to make a large conical flap, and at the same time isolates tho 
 shaft of the femur, preparing it for the saw— plate 10, fig. 3. A ro- 
 tractor, in this figure, composed of a slit piece of cloth, protects the 
 soft parts from being injured by the saw. The flap, before it is closed, 
 represents an inverted cone, the cut surfaco of tho bone forming the 
 truncated apex, while the retracted muscles form the sides of the cone 
 (plate 10, fig. l), having the skin as a base. This is one of the best 
 methods of amputating, giving excellent results, as the circular flap, tho 
 edges of which arc composed solely of skin, shows a strong disposition to 
 heal by quick union. The bono is so well covered that a conical stump 
 rarely results from this operation, while at the same time there is no 
 excess of muscle in the flap to induce suppurative inflammation. 
 
 Amputation at the hip-joint is an operation so serious in its re. 
 nearly every case being fatal — that it is a question whether its per- 
 formance should not be confined to the amphitheatre Military .-ur- 
 geons have at times thought the operation called for. and have per- 
 formed it with invariably the same fatal result ; so that the question is 
 often forced upon them whether ii would not be preferable t<i leave t ht- 
 patient to bis fate, which, under no condition, can be mure serious than 
 the operation. There is an unfortunate ambition — we might even use a 
 ■tronger term for it — a criminal desire to have an amputation at. the 
 hip-joint in the lis) F o| rfurmed, which misleads many sur 
 
1M . AMPUTATION AT HIP-JOINT. 
 
 gcons to perform this disarticulation, when their bolter judgment tench- 
 es them that it must be a useless mutilation. Most that can be said in 
 its favor is that i' relieves the wounded of a lingering death, as it 
 hastens this issue. As one ease of primary amputation at the hip-joint 
 during this war has recovered, and as a limb may be so torn off or exten- 
 sively mutilated that the operation may be justifiable— even as a very 
 temporary measure — to relieve the wounded man of a mangled limb, 
 the method of performing the disarticulation will be given. 
 
 Plate 10, fig. 5, indicates the relative position of tho pelvic bone- with 
 the femur, and shows where the head of the thigh-bono hides itself in 
 the deep acetabulum. Amputating by tho double flap is found the most 
 convenient method. To form the anterior flap, if tho amputatiou be 
 performed upon the left thigh, the limb being slightly flexed and ab- 
 ducted, a long, sharp, narrow knife is entered from the outer side of the 
 thigh immediately above the upper and outer border of the great tro- 
 chanter, and is carried directly inward until it strikes the neck of the 
 lemur. The handle of the knife is then slightly depressod to allow the 
 point to glide over the junction of the head with the neck, cutting 
 through the capsule. The direction of the knife must now be changed, 
 otherwise the point would pass into the abdi minal cavity. The handle 
 should bo carried upward and forward, whioh depresses the point and 
 allows it to make its appearance on the inner side of the thigh, one 
 inch iu front of and below the ischial tuberosity — plate 10, fig. 5. Tho 
 heel of the knife cuts downward in the direction of c b, grazing tho 
 hone, and is followed by the hand of an assistant thrust into tho 
 wound and securing the femoral artery. Tho flap is completed by 
 cutting out in the direction n /,. This flap is then drawn upward upon 
 the abdomen 1>.\ the assistant, who secures the vessels by pressure; tho 
 thigh is carried downward, backward, and outward, which causes the 
 head of tho femur to stretch the anterior portion of the capsule ; an 
 incision directly across this releases the bead, which, as the ligamen- 
 tum teres, the round ligament attaching the head of the femur to tho 
 cotyloid cavity, is severed, escapes from the acetabulum, with a strik- 
 ing noise. 
 
 The amputation is completed either by passing tho knife behind the 
 neck of the femur and cutting a flap obliquely downward and back- 
 Ward, corresponding to the line of anterior incision, or this flap can bo 
 made by cutting from without inwards, as follows : the operator, kneel- 
 ing, passes the heel of the amputating knife on tho inner sido of tho 
 thigh, and, commencing an incision from the inner angle of tho ante- 
 rior flap, cuts obliquely downward and outward until a flap of suffi- 
 cient length is made, when he brings tho heel of the knife, with a 
 sawing motion, across the limb, then upward and outward to terminate 
 the incision at the point of transfixion. The capsular ligament and 
 
RULES FOR RESECTION. 485 
 
 remaining muscles in the vicinity of tlic joint, attaching tbo thigh to 
 the trunk, arc divided from above backward. The large arteries re- 
 quiring ligation arc the femoral and its profunda branch, which are 
 on the inner side of the anterior flap, accompanied by their veins,// 
 (plate 10, fig. 7). The bleeding vessels in the posterior flap are com- 
 paratively small muscular branches. As the patient, during this oper- 
 ation, often dies from the loss of blood, it has been recommended to 
 ligato all bleeding vessels in the anterior flap before the section of the 
 posterior flap is commenced. The closure of the wound by sutures, 
 and the subsequent cold water dressing, is common to all amputations. 
 
 RESECTIONS. 
 
 i?e*eo/?'o»s of the heads of bones are offered as a substitute for ampu- 
 tations. Experience in military surgery has shown that when a ball 
 pasnes through a large joint, crushing the heads of the bones, it pro- 
 duces a very serious lesion, which, without an operation, would be 
 classed among the mortal wounds. Attempts at treatment, without the 
 use of tho knife, would in most cases terminate fatally; and even 
 where the life was saved, the limb would be a stiff and useless one. So 
 aware were surgeons of the little success following the treatment of 
 such joint injuries, that they had established the rule, of amputating 
 in all such wounds. Conservative surgery has introduced resections as 
 a very decided improvement over amputations, inasmuch as it not only 
 saves the limb, thus protecting the patient from the fatality of ampu- 
 tation, but leaves him with a very useful extremity. 
 
 Although the resection of each joint has its peculiarities, there are 
 certain rules in the performance of the operation common to all resee- 
 One of these is, that the joint should always be opened iu such 
 away as to avoid all of the large: vessels and nerves. As these 
 always run over one face of the articulation, the incisions necessary to 
 expose the heads of the bones should always be made upon the oppo- 
 site surface. Straight incisions are usually preferable to flaps, as the 
 s are not cut up, and therefore their action not paralysed, as is 
 usually the case in flap operations. The perpendicular incision should 
 always be made ample, to expose perfectly' the heads of tbo bones, and 
 give room for manipulation: a free incision expedites the reBCCtion, fa- 
 cilitating every step of the operation. When this incision is loo short 
 the movements of the operator are very mnoh cramped, especially as 
 regards the ligation of divided vessels, the isolation of tho bones, and 
 the eversion of their extremities. This straight incision should pass 
 
186 ItKSl CTTON OP l lir. r.OWI i: .TAW. 
 
 >- to the bone by a single stroke of the knife, and the head of the 
 bones isolated by dissecting up from the bone all the muscles :md peri- 
 osteum also with it. if possible. By keeping the point of the knit'«' grts> 
 ing the bone, the main blood-vessels and nerves running through the 
 soft parts are not disturbed. All tendons running over the joint t" sup- 
 plj distant parts must be carefully drawn aside, and not divided. 
 Usually it is found most convenient to torn the head of the bone out of 
 its socket before the saw is used. To effect this, all of the musoles and 
 ligaments whieh are attached around the neck of the bone must bo di- 
 vided, which can only be safely accomplished by rotating forcibly the 
 shaft inwards, then outwards, which will bring the various muscles into 
 the straight incision and under the point of the knife. In isolating the 
 head of the bone, and releasing it from its cavity, the point of the knife 
 should never get out of sight, as important parts may very easily be 
 injured by the point buried in the wound. When the bead of the bone 
 has all of its connections severed, and is thrust out of the wound, we 
 should place behind it a guard, composed of a strip of wood, the handle 
 of a knife, or the blade of a spatula, to protect the soft parts while the 
 saw is dividing the neck of the bone. 
 
 In gunshot wounds, as the head is often crushed from the shaft, the 
 portion remaining in the articulating cavity must be seized with a 
 strong tooth forceps, so as to obtain a leverage upon it, and by rotating 
 the extremity the capsule and muscles can bo divided, and the head 
 withdrawn. The section of the shaft should always be horizontal, so as 
 to offer a smooth, broad surface to the articulating surface above. 
 Where the head of a bone has been fractured, the extremity of the 
 shaft must be cut so as to leave a smooth surface. All small vessels 
 divided during the operation must be ligated, and the wound closed by 
 sutures, the limb placed in an easy position, ami cold water dressings 
 applied. 
 
 Union by the first intention is not expected for the entire wound. 
 A portion of it will heal rapidly, leaving an opening for the escape of 
 the secretions from within the cavity. During the treatment the inner 
 surface of the wound will usually suppurate profusely, and small par- 
 ticles of bono may become detached from I he sawed extremities. Fi- 
 nally, ligamentous bauds unite the opposing surfaces of the bones ; and 
 while all of the movements of that portion of the extremity beyond 
 the part resected arc preserved, the now' joint regains in time many 
 useful movements. 
 
 Rbbbction of tiik LOWBB jaw is commenced by drawing out the 
 incisor, or canine tooth, corresponding t" that portion of the jaw to 
 which the saw is to be applied. With a sharp-pointed bistoury an 
 incision is made along the base of the jaw, extending from its angle to 
 
RESECTTON OF TI1F. LOWftR JAW. 487 
 
 the point of section of the bone, which is usually within a half-inch of 
 the symphysis menti, or median line of the chin. This incision ex- 
 tends to the bone, and as it divides the facial artery, in its course over 
 the face, in front of the massoter muscle, this vessel should be ;it once 
 tied. The next step of the operation consists in isolating the gums and 
 floor of the mouth from the maxillary bone at. the point where the sec- 
 tion is to be made. When the finger, from the outer wound, can be 
 passed readily into the mouth, both above aud below the bone, the low- 
 er jaw is to be divided, either by passing a chain-saw around the bone 
 and with steady traction sawing it through, or by using a strong Lis- 
 ton forceps, which requires more strength in the hand than surgeons 
 usually possess: or by placing a spatula under the bone for the protec- 
 tion of the soft, parts, and using a small saw. As soon as the section 
 is completed, the portion of the lower jaw to be removed is drawu forci- 
 bly outward, dividing the muscular floor of the mouth attached to the 
 mylo-hyoidean ridge. The pterogoid muscles attached to the inner 
 face of the ramus are divided ; next in order the tendon of the tempo- 
 ral and masseter muscles attached to the outer face of the ramus and 
 coranoid process. Using still more force upjn the lever, the head of 
 the lower jaw is wrenched from its glenoid cavity (plate 11, fig. 1), 
 leaving a few ligamentous bands to be divided. This is much better 
 than burying the point of the bistoury in the depth of the wound 
 for the purpose of dividing the internal ligaments of the joint, when 
 it will be nearly impossible to avoid injuring the internal maxillary 
 artery, and cause annoying hemorrhage. Should this artery, which 
 runs in very close proximity with the neck of the jaw-bone, be cut, it 
 must be secured by ligature. When this vessel is avoided the facial 
 artery is the only one severed. Should thero be much oozing from the 
 depth of the wound in the vicinity of the glenoid cavity, the surface 
 should be painted with the liquid persulphate of iron. When the (lap 
 resumes its position, and is kept in place by a sufficient number of 
 sutures, healing rapidly takes place, and very little deformity ensues. 
 If the operation be performed upon a man, his beard will conceal all 
 traces of the operation. 
 
 Although the lateral portion of the inferior maxillary is most liable 
 to disease, the anterior portion, or arch at the symphysis menti, may 
 become carious and require removal. The bone is readily exposed by 
 an incision upon the median line of the chin and throat, extending 
 from the lip, which is divided, to the hyoid bone. Two flaps are dis- 
 sected up, laying bare the portion of bone to be removed — plate 11, fig. 
 2. One tooth is drawn from each m le of the mouth corresponding to 
 the points of notion, and the bo severed either by the use of the 
 saw or Liston's heavy bone foroeps. In the removal of the anterior 
 ji irtion of the lower jaw, a" the muscles which protrade t' 1 
 
. hi: i PPKR JAW. 
 
 ; from their points of attachment on the inner face of ti. 
 
 menti. the retractor muscles, having no antagonistic 
 
 tend to draw the tengue backward, whore, recoiling upon the larynx, 
 
 and pushing down the epiglottis upon the laryngeal opening) it tbrcat- 
 
 Sboation. To obviate thia the tot aculun 
 
 and drawn forward. When the flapa ar< 
 
 ed through the phrenum <>r the tongne, trhioh causes it to ad- 
 the cicatricial line, and the teudoncj ire retraction 
 
 is corrected. 
 
 I\ Tin: bbbbctiom OP Tii i: i I'i'i.it .? a w, a somewhat similar proced- 
 adopted. The relutii.nn of the superior maxillary bone are M 
 follows: Upon the median line it meets the opposite superior jaw-bon«j 
 forming with it the roof of the month: its ascending | Lttaohed 
 
 to the oh frontis, 08 unguis, and ethmoid; externally it meets with the 
 malar bone, posteriorly with the palate bone and pteregoid plates of the 
 sphenoid. To isolate the bone it must be separated from all of these 
 
 A simple plan "f operation consists in making a curved incision 
 
 ctending through the entire thickness of the oheat 
 
 from the sygoma to the angle of the month. By dissecting up this 
 
 nppor flap from the face of the upper jaw, the entire extent of tin- bona 
 
 can be readily exposed- -plate 11, fig. 9. Having separated the nasal 
 
 cartilage from the oreseentie louder of the nasal pi to open 
 
 tl cavity through the wound, one of the incisive teeth is drawn 
 
 out. and a heavy Listen foroeps is applied to the jaw to sever the hard 
 
 palate or roof of the month. One blade is placed, as in fig. 3, Into the 
 
 mouth in th icatod by the extracted tooth; the othei 
 
 under the everted flap into the nostrils, and the anterior and lateral 
 
 oonneotion of the bone is readily cut through. The fo 
 
 applied so as to divide the nasal process with the attachment to the 
 
 all and ethmoid. To effeof thia the flap ia dl lected upward an 
 
 as to expose tl rbital eavily. One blade of the forceps ii plaot l In 
 
 the upper part of the nostril, the other into the inferior portion of the 
 orbital oavity, and with one stroke the superior connections of the jaw 
 are severed. Again, one blade of the foroeps is placed in the outer and 
 inferior portion of the orbit, the other in the temporal fossa behiQd the 
 miliar bone, when the malar oonnectiona are destroyed. Should the 
 malar hone be also diseasi d, it .-In. old be remov* d by passing the blade 
 
 Of the foioepa first into ihe outer portion of tl rbit and the temporal 
 
 tbove tin: malar bone, and afterward severing the sygomatio arch. 
 
 The Isolation of the bone la completed by putting a chisel upon the 
 
 floor of the orbit, and driving it With ■ mallet, force it downward and 
 
 backward, cutting through al tha Ural blow the floor of the orbit and 
 
 the superior maxillary nerve coursing upon it. The chisel ia forced, 
 
RESECTIONS UPON TIIF. UPPER EXTREMITY. l v '' 
 
 without much diflicnlty, through the posterior portion of antrum until 
 it reaches the posterior wall of the maxilla, and finds an obstacle in 
 the ptercgoid plates. Using these plates as a fulcrum or bose, the 
 chisel as a lever, it is only necessary to depress the handle, when the 
 maxillary bone will at once yield and be luxated from its position. 
 The soft palate alone keeps it attached to the skull, and this can be 
 severed either by using a eurved scissors, or by thrusting a .-harp- 
 pointed bistoury into the mouth, cutting first in the median line of the 
 roof of the mouth, and then making a transverse incision extending 
 half-way across the posterior superior wall of the buccal cavity, two 
 lines in advance of the pendulous portion of tbe soft palate. Thebone 
 is then grasped in a strong foreepB, and, being turned upon its axis, ex- 
 poses any remaining soft parts for division. 
 
 There is but little hemorrhage from such an operation. The superior 
 maxillary bone, although freely supplied by many small vessels, has no 
 large artery running upon it . ; and, moreover, by the use of the chisel and 
 bone forceps the vessels have their coats so crushed that they partake of 
 the character of contused and lacerated vessels, which do not bleed. 
 Any oozing of blood soon ceases upon exposure of the cavity to air. 
 The application of the liquid persulphate of iron will at once dry the 
 surface. Although the cavity looks frightful immediately after the 
 operation, the closure of the flap leaves but little deformity — plate 11, 
 fig. 4. From the vascularity of the soft parts quick union is, without 
 difficulty, obtained under cold water dressings. The sutures are removed 
 by the fifth day, and the patient is nearly well by the end of the first 
 week. It is a practice with some surgeons to stuff the cavity, imme- 
 diately after the operation, with a piece of sponge or lint. No such 
 stuffing is required ; on the contrary, any foreign bodies in the wound 
 arc detrimental. Pus is secreted from the cavity, and is spit up some 
 time after the outer wound bas completely cicatrised. 
 
 SECTIONS l PON Till, l I'l'Kl: t:\tkemity. 
 
 Tin- i i avi' i i may require resection, in whole or in part, from dis- 
 MMd action in the bone, brought ,uela of gunshot injury. 
 
 iries may supervene, accompanied by pain and a constant 
 and annoying discharge of pns from fistulous orifices at the rool of the 
 neck "r on the upper portion of the chest. The chief danger of the 
 n of this bone, particularly its inner half, which most frequently 
 requires operation, is in the near proximity of very large vessels, which, 
 if injured, would destroy the patient. Fortunately for the operator, 
 
190 RESECTIONS UPON I HI. I I'l'l'.lt EXTREMITY 
 
 nature in attempting to get rid of the old diseased bone, has usually 
 i hi ed i around the clavicle as to separate th< 
 
 portent b certain distance, whi in bo more readily 
 
 avoided. A. now deposit of bone has usually taken place around the 
 necrosis, and it i; 1 only oeoessary to cm Into this involucrum <n 
 of new bone, to enable one tn ron the diseased portion. 
 
 At times, however, it is aeeessary t" remove the entire thickness of 
 the bone for one-half of it* length An Inoision is made parallel 
 with and directly upon the bone, sufficiently elongated to expose 
 freely the diseased portion which is to be removed. If it lie the sternal 
 portion of the bone, great care must be used in detaching the gr< 
 toral muscle below and the sterno-cleido mastoid above from the sur- 
 face of the clavicle. Using the back or handle of the knife, or the 
 point of a grooved director, the entire circumference of the bone is 
 isolated, when a chain-saw is placed around tho external portion to be 
 divided, and by cutting forward the shaft is severed. Should an ordi- 
 nary saw bo used, the flat handle of a scalpel or the blade of a small 
 spatula is passed under the clavicle, which pro too is the important soft 
 parts beyond, and prevents any injury from the saw. When the 
 of the bone is divided, the cut end is drawn directly forward to 
 rate it, as fur as possible, from the blood-vessels al the rout of the neeki 
 By grazing the posterior face of the b >ne with the edge of the knife 
 it is denuded of all soft tissue, and a careful section of the liga- 
 ments at the sterno-elavioular junction isolates completely the b , 
 
 As the internal-mammary, subclavian, and transverse cervical arteries, 
 
 with ;n mpanying veins, and also the upper portion of tho pleuraj 
 
 with apex of the lung, have immediate relations with tho po 
 border of the claviole, this operation will not be undertaken except 
 by those familiar with the a tatomy of this region, and fully aw i 
 the dangers to be avoided. With similar care in isolating the bond 
 from the soft parts, the outer half of the clavicle, or even the entire 
 bone, may be successfully rcui"\ ■ 1. 
 
 ■ HOH oK THE SCAPULO HUMERAL ARTICULATION.— When 
 
 tion of the shoulder-joint has been deemed advisable, one of two meth- 
 ods might be adopted : One prooedurt nsiste in outting up an anterior 
 
 and outer flap formed of the deltoid musole, which exposes freely the 
 lead of the bone, and facilitates exoision, The other mathod, a per- 
 pendicular inoision upon the anterior fa f the joint, exposes the head 
 
 of the bone with more difficulty ; but as this plan does not out up the 
 entire attachment of the deltoid, it has its advantages. Plate 12, ti.u r - 
 1, explains the method of reseoting by making a deltoid flap. The arm 
 being drawn upward and inward, the point of the knife enters the arm 
 isterior portion, just in front of the posterior fold of the arm- 
 
RESECTION or THE SHOULDER-JOINT. A { .)\ 
 
 pit, and a little in advance <>f the point of perforation for Lisfrano's 
 
 flap amputation. The blade glides forward over the head of the hume- 
 rus, opens the capsule, and perforates the skin on the upper and anterior 
 portion of the arm, immediately below the accromial process of the 
 SCapala; by cutting downward and outward an external flap is-made of 
 the deltoid muscle. If the head of the bone has not been altogether de- 
 tached from the shaft, carrying the elbow across the chest and rotating 
 the arm will force the head against the outqr portion of the capsule, 
 and by successive strokes of the knife, cutting through the capsular 
 ligament and rotatory muscles attached to the tubercles of the hume- 
 rus, the head will be turned out from its synovial cavity. As the elbow 
 of the arm upon which the operation is being performed is carried up- 
 ward over the chest, the head of the humerus projects from the cavity, 
 and allows the kuife to graze its inner surface and isolate it for a suffi- 
 cient distance from all soft parts. A chain-saw is then passed around 
 the bono, and by steady traction on each handle, alternately, the neck 
 or shaft of the humerus is smoothly and rapidly divided. When an 
 ordinary saw is used, the flat handle of a scalpel or the blade of a spat- 
 ula will be placed behind the neck of the bone, to protect the soft parts 
 while the saw is being applied. As the nervous supply of the deltoid, 
 and also in part its nutrition, is destroyed by this flap section, atrophy 
 and paralysis of the muscle ensue. It was on account of this sequela 
 of resection by a deltoid flap, that a modification of the operation was 
 suggested. 
 
 Plate 12, fig. 2, represents the method of resecting the shoulder-joint 
 by a perpendicular incision of five or six inches iu length on the ante- 
 rior surface of the shoulder, commencing immediately below the accro- 
 mial process and extending down to the bone, parallel with the arm, 
 cutting through the middle of the deltoid muscle. The anterior cir- 
 cumflex artery, supplying the deltoid and clasping the surgical neck of 
 the humerus, is divided in the first incision, and should be ligated. A 
 retractor or dilator is put in the wound, and each lip of the incision 
 drawn forcibly outward so as to expose, as much as possible, the deep- 
 er parts. If tho head of the bone has beencrushod. the fragments arc 
 seized with a heavy dressing or tooth forceps, and removed by isolat- 
 ing them from their muscular connections. As the head of the hu- 
 merus is nourished solely by the vessels running through the shaft, 
 the severing of the head from the shaft converts it into a foreign body 
 within the joint, which must be removed. If the ball has traversed the 
 articulation, perforating without severing the head, the length of tho 
 arm can be used as a lever, and, by rotating the head within its capsule, 
 the rarloui rotatory muscles attached about the anatomical neck of tho 
 bone are brought under the knifo. These are cut aorosi aa • tpoaed, the 
 capsule widely opened by a transverse incision, and by carrying the 
 
492 [ON <T THE SHOULDER- JOINT. 
 
 elbow backward, pushing it nt the same time upward, the heail of the 
 will be dislodged. As soon as Lhe head is freed the knife is pass- 
 ed behind it. and the neck isolated to the extent of the pat- 
 ula is placed behind it to protect the Boft parts, and the head of the 
 bone is reran b4> 
 
 In the operation by a horizontal anterior incision, the wound is usu- 
 ally made over and parallel with the long head of the biceps muscle, 
 which tendon should be carefully lifted from it? lied in the bicipital 
 
 groove and drown to the inner side of the wound. It" this tendon he di- 
 vided, it impairs the usefulness of the forearm by injuring one of the 
 principal muscles of pronation. By the anterior horizontal incision, the 
 large posterior circumflex artery, the chief source of nutrition tor the 
 deltoid muscle, and the circumflex ucrve, which also supplies it, escape 
 injury, as they both pass under the humerus and supply the muscle 
 from its posterior portion. 
 
 In military surgery, as resection is most frequently performed for fract- 
 ures of the head and upper portion of the shaft extending into the seap- 
 ulo-humeral joint, the resection consists usually in removing all spioulsa 
 or fragments of bone, including the head, and in sawing off the BpioU- 
 lated extremity of the shaft smoothly. ,\s much as lire inches of the 
 shaft and head have been removed, leaving a useful forearm and hand, 
 and often somo useful movements in the arm. In these eases in which 
 the crushing of the neck has isolated the head, mueh difficulty will be 
 found in removing this portion from the glenoid cavity, unless the pro- 
 truding portion be seized with a heavy forceps resembling a straight 
 tooth forceps, by the assistance of which the head can be rotated and 
 its ligamentous and teiidiiioit.- attachments divided. 
 
 It the resection l" performed for caries or necrosis, the lip of the 
 
 glenoid cavity may bave become involved in the disease, and. the • 1 i s - 
 
 d portions must be removed bj a gouge or cutting bone-pliers. W Ion 
 
 all fragments hai e been renxn ed and bleeding \ esscls ligated, the wound 
 
 is closed by a BUfficienl number of BUtUTOS, having a small portil of 
 the wound open for drainage. A large portion of the wound will unite 
 by the fust intention, bul a- the secretion of pus from the cavity is usu- 
 ally large and persists for some linn', the opening left at the inferior 
 portion of the wound discharges freely for sometime. If the entire 
 wound be brought in apposition, the collection of pus within the cavity 
 having no mean- of esoape, will. by internal pressure, cause agonizing 
 pain, until it breaks through the skin, fold water dressing and the 
 of diluted pyroligneous acid to oorreel the fostor from the profuse dis- 
 charge, prises the Local treatment After the operation the arm is 
 
 secured firmly to the trunk, so as to restriot all movements in it, inas- 
 much as any motion in the cut < ictrt mity of the hone produces severe 
 pain. This bandage should only be removed when it becomes loosened 
 
RESECTION OF THE ELBOW-JOINT. 493 
 
 or much soiled with pus, and when renewed the arm must bo held 
 firmly while the bandage is taken off and reapplied. Tho general treat- 
 ment will differ in no respect from that recommended for all exten- 
 sive .suppurating wounds, viz : opium to allay pain, and good strong 
 food, with stimuli, to support the system. 
 
 Resection OF the elbow-JOINT is considered a preferable operation 
 to amputation of the arm, as it is less fatal in its results, and saves a 
 useful extremity. This operation la applicable in military surgery to all 
 fractures involving the joint, the portion of bone removed being con- 
 linod to that injured. It must be remembered that the elbow-joint is 
 composed chiefly ef the two bones, humerus and ulna, the radius enter- 
 ing but- little into the formation of this articulation. When the arm is 
 extended the olecranon process of the ulna, playing around the trochlea 
 of the humerus, closes in the back of the joint. The bones are held in 
 apposition by strong lateral ligaments, the strength of the articulation 
 in front depending upon the tendinous fibres of the biceps and coraco- 
 brachial muscle, while the attachment of the triceps muscle to the 
 olecranon process of the ulna protects the joint from the back. The ar- 
 teries which course over the posterior surface of the joint are all small 
 muscular branches, the brachial artery lying in front of tho arm. A 
 large nerve, the ulna, lies upon the posterior surface of the internal 
 condyle of the humerus, and is the only important structure liable to 
 injury. 
 
 Two methods aro recommended for resecting this joint. In one. a 
 straight longitudinal incision, parallel with the limb and five inches in 
 length, is made over the back of the joint, extending directly to tho 
 bono. The Lips of this incision arc dissected up from the soft parts, cut- 
 ting always on a level with tho bone. By so doing the ulna nerve will 
 bo lifted, with the soft parts, over the internal condyle, and as it will 
 not be exposed, will escape injury. When the lips of the wound can bo 
 sufficiently drawn apart so M to expose the entire width of the joint, tho 
 tendinous attachments of tho triceps muscle arc cut transversely, the. 
 postorior ligament divided, and t lie joint largely opened by cutting off 
 the olecranon process. This is effected by applying the saw to its 
 base where this process of bone meets the anterior or coranoid \ 
 Tho lateral ligaments arc now cnl through with the point of the knife, 
 which, in connection with the bending of the joint, liberates all of the 
 bones. 
 
 If the injury U confined to the lower portion of the humerus alone, 
 only its irregular, broken surface is removed with the saw. in con- 
 nection with the olecranon process of the ulna — the Boft par! 
 protected bythebladeof a spatula, placed between tho Lend t>> be re- 
 moved and t: hould the humeral < 
 
104 BE whim roiK 
 
 and ulna all •] ..r fractured, their broken oust Im> 
 
 i with tin- saW| mootb cat ends upon nil the 
 
 iculse whii h resulted from tl 
 tho ball. After the resection and liga'ion of bleeding vessels, the 
 wound is closed by sutures. The arm, secured upon an anterior angular 
 splint, long enough to support the extremity from the upper third ol the 
 humerus to the fin • t ;ii ■ ri^lit angle, is laid upon a pillow. 
 
 In securing this splint the posterior f ,] ' i"t> of the elbow-joint Is nol 
 .,.\cr'.l by the b thai ii remaini i inspection 
 
 and the application of appropriate dressing. Ligamentous union in 
 time forms between the ends of the bono, and a very useful limb is 
 
 : > cd. 
 
 The other method of exposing the joint from its posterior surface, is by 
 ninking s longitudinal incision on the onter "r inner side of the baek Of 
 the arm, which, oommenchtg three inches above the joint, terminates 
 opposite t'i the base of the olecranon process. The inferior termination 
 of the inoision is me I by a trant verse inoision extending across the joint, 
 L-sbaped. [f mort space is n quLn d, o second inoision on the inner ride 
 
 of the arm, and parallel with the first, forms a i l-sbaped flap, whioh, 
 
 when dissected op, will expose sufficiently the Inferior extremity of the 
 
 humerus. Should the heads "I the radius ami ulna lie found di 
 
 the perpendicular incisions can be prolonged, H-like, and two square flaps 
 
 ed up — plate 12, fig. i. In making the in tenia I inoision oare musl 
 
 be taken not to injure the ulna nerve, whioh must be sought for and 
 
 drawn to the outer Bide of the wound. Although the combination of 
 
 litates tl" exposure and resection of the articulating 
 
 . ill the bones, yet i' leav< s a muoh Larger wound than where the 
 
 median incision is made; nor dees the soft parts Upon liiel.aek 
 
 of the aim give as much support to the resected joint. In securing the 
 limb after the r< section, som< prt fers straight splint on theanteri 
 tion of the arm, as exeroising less tension on the wound. An angular 
 splint is, however, found the most convenient. It requires many months, 
 aftei cicatrization is completed, heiuie the limh regains strongth and 
 use ful i 
 
 I: i - 1 - tion or Tin. w rib i-.ioint is one not often called for in gunshot 
 wounds, and, as a primary operation, gives so little success that the op- 
 eration is discouraged. Asa secondary i peration, for necrosis of either 
 the oarpeJ extremity of the radius or ulna, good results are obtained. 
 The diseased bone can usually * by a horizontal incision over 
 
 t lie joint and pa nil lei with the bone to be removed. If the one incision 
 is found to restrict too muoh the manipulation of the surgeon, its inferior 
 portion may he extended at right angles across the joint. When the 
 oarpal extremitiee of both bon md require i\m- ■ 
 
RESECTION OF Tin; INFERIOR EXTREMITY. 495 
 
 pcndicular incisions should be made (plate 12, fig. 6) over the outer 
 and posterior edge of each bone. The tendons of su«h muscles as lie 
 in the way are carefully drawn to one side, and the bone, having been 
 isolated of soft parts by careful dissection, is divided by a chain-saw, 
 bone-pliers, or ordinary saw. As the main vessels lie upon the anterior 
 face of the arm, they escape division. If the longitudinal incisions aro 
 sufficiently long, the ends of the bones can bo readily removed. Should 
 more room be required, however, a transverse incision across the back 
 of the wrist, uniting the longitudinal incisions, will permit of a largo 
 square flap of skin being turned up. The flap should be but skin-deep, 
 inasmuch as the tendons on the back of the wrist-joint are to be protect- 
 ed. All of these must be drawn asido and not divided; otherwise, the 
 ubc of the hand and fingers will be destroyed. The closure of the 
 wound, securing rest and quiet to the hand 'and forearm, by attaching 
 it to a broad splint placed upon its anterior surface from the elbow to 
 beyond the fingers, and the local treatment, are similar for all resections. 
 
 RESECTIONS OF INFERIOR EXTREMITY. 
 
 Resections of the lower extremity do not. give such flattering results 
 as similar operations upon the upper; yet, when we take into consider- 
 ation the more serious operations for which these arc offered, we must 
 consider their adoption as a material advance in conservative surgery. 
 In speaking of amputations at the hip-joint, wo discouraged the ampu- 
 tation as one nearly invariably fatal. Resections, on the contrary, for 
 gunshot injury to thehead of the femur, where the bone enclosed by the 
 capsule and within the cotyloid cavity is fractured, with, perhaps, inju- 
 ry to the acetabulum, arc sometimes successful, saving a useful limb as 
 presenri ng the life of the wounded. Some surgeons recommend 
 that this resection be performed always as a secondary operation — the 
 a of a successful result being greater than when the operation is 
 performed immediately after the injury. Two methods are offered for 
 Dg t/ir hip-joint. It must be remembered thai the bead of thi 
 .ved into the acetabulum, where it is held firmly by tho ligamen- 
 tum teres and thick capsular ligament) surrounded by powerful muscles. 
 The prominent portion of the femnr on the outer side of the thi^h is 
 the great trochanter ( from which the neek and head of the bone runs 
 inward and upward, more or less obliquely. The gluteus m&ximus and 
 muscles run o-,,r and are attached to the OBter and upper side 
 of the groat trochanter. The ors and abductors, including 
 
 the gluteus minimus, pyriformis, gtmelli, internal obturator, etc., aro 
 
IN OE niK INFERIOB EXTREMITY. 
 
 ■i to the inner face of the trochanter, and into the fossa at its 
 base. No reasons or nerves of importance run on the outer Mile of the 
 hip-joint. The large arteries, veins, and nerves all pass on the inner 
 and anterior side of the joint, ami are only injured from carelessness 
 in manipulating. 
 
 By one method, a straight Incision is ma<le upon the outer side of the 
 thigh, six inches long, and parallel with the limb ; a short, sharp- 
 pointed knife is thrust into the upper part of the thigh, on a level with 
 and one inch behind the anterior superior spine of the ilium. Cutting 
 directly to the bono, tho Incision is extended downward over the tro. 
 ohanter sufficiently long not to embarrass the operator— plate 13, fig. 1. 
 The thigh being now forcibly abducted so as to put the rotatory and 
 abductor muscles upon the stretch, they are divided by the point of tho 
 knife, and the capsule largely opened from the outer side of the joint. 
 By rotating the thigh a much larger surface of the capsule is brought 
 under the knife, which facilitates tho oscapo of the head of the hone. 
 Tho ligumentum teres is now divided ; tho soft pans in front of the 
 neck carefully divided s6 as to avoid important vessels, a chain -saw 
 passed around the neck to bo removed, and, by steady, alternal 
 tion upon the handles, the afieeted portion of the bono is sawed through. 
 When a chain-saw is not at hand, the Boft parts are protected by means 
 of a slip of wood or a spatula, and an ordinary saw applied. In com- 
 pound fractures from gunshot wounds, all of the crushed portion of tho 
 bone must bo removed, if it involves as much as even three or four 
 inches of tho neck and shaft. Should the acetabulum bo also d 
 or fractured, all the affected portion must bo removed — a gouge or bouo 
 
 aged. After the completion of tho resection and : 
 of tin- bleedin ; vei sols the wound is olosed by sutures, leaving its in- 
 ferior portion open lor the escape of all from the cavity. 
 Alter the operation, the I, ml, i- seoured upon a straight, long Splint J 
 
 although many surgeons prefer that the limb be brouj hi into a straight 
 
 position, and lie upon tho bed or cushions, without being trammelled 
 by splints or bandagt of any kind. The progress of the ease is mofe 
 or less slow. Suppuration from the wound is at first prof uso, and un- 
 cus has a free vent, infiltration may take place. By degrees 
 tlii; discharge diminishes, the wound heals, the patient is allowed to 
 
 use crutches, and, finally, may possess JO .-Iron- a limb that, with the 
 use of a high-heel boot and a stick, he can walk very satisfactorily. 
 
 An objection having been made by some operators to tho difficulty of 
 exposing and liberating the head of the femur from its cavity by the 
 straight inoision, they have suggested many methods by which thi? 
 tedious step of the operation could fie facilitated. A convex flap, cut 
 upward by transfixion, the base resting upon the outer portion of the 
 thigh .nifit below the great trochanter, is ooneidered "iit> of the most 
 
RESECTION OP THE KNEE-JOINT. 497 
 
 desirable. This flap can be formed by cutting around the margin 
 of the groat trochanter horsoshoe-like, the convex portion of tho flap 
 extending two inches above the trochanter. If tho knife bo passed 
 down deep enough, this wound would expose the head of tho femur. 
 In milking a transfixion, a narrow, sharp-pointed knife may bo thrust 
 through the outer portion of the thigh on a level with the uppor part 
 of the trochanter, the point of the kuife passing from behind forward, 
 under the gluteus medius muscle, and through the trochanteric fossa, 
 between the great trochanter and the neck. When the knife has trans- 
 fixed the outor portion of the limb a flap is made upward, which will, 
 in cutting out, sever all the rotatory and abductor tendons attached 
 to the great trochanter. By carrying the thigh across tho sound one 
 and rotating the knee forcibly inward, the capsule can be largely di- 
 vided, the head of the bono turned out of its cavity (plate 13, fig. 2), 
 and the saw applied. Or, the neck of the femur can bo isolated and 
 divided by a chain-saw passed around it, or by the ordinary saw, be- 
 fore the head is turned out of the acetabulum. The neck can then be 
 seized with a strong, straight tooth forceps, and rotated so that tho 
 capsule and contiguous muscles can be easily divided. Should the neck 
 of the femur have been fractured, the part protruding from the ace- 
 tabulum is firmly seized by a strong forceps and rotated during the 
 division of the ligaments. This flap incision is preferred by some 
 surgeons, as it offers a ready escape for those secretions which will 
 form freely in the wound. Any diseased portion of the acetabulum 
 must be removed by the gouge. 
 
 Resbction of the knee-joint. — This joint is formed by the ex- 
 panded extremity of the femur above and the tibia below, the anterior 
 face of the articulation being closed in by tho patella. The lateral 
 and crucial ligaments keep tho bones in apposition, and give strength 
 to the joint. All important vessels and nerves pass behind the joint 
 through the popliteal space. In resecting this joint for perforating 
 wounds followed by suppurative synovitis, or in cases of compound 
 fracture involving the heads of tho bones entering into the formation 
 of the articulation, the patient is put under the influence of chloro- 
 form, which is now in universal use whenever operations of any kind 
 are to be performed. With the leg flexed upon the thigh, tho surgeon 
 makes a convex incision extending across the entire anterior portion of 
 the joint from one condyle of the femur to the other, encircling the 
 upper border of the patella. Another curved incision of similar dimen- 
 sions passes below the patella, which encloses this bono between two 
 elliptical Incisions. These incisions are contiuued through the entire 
 thickness of the sofl parts, and the patella isolated and removed. This 
 exposes the entire anterior portion of the knee-joint, and by cuttiDg 
 
498 RESECTION OF THE ANKLE-JOINT. 
 
 across the crucial ligaments in the centre of the articulation, between 
 t he cupped cavities of the tibia and condyle of the femur, and also 
 dividing the internal and external ligaments, the joint is widely opened, 
 and either the extremity of the femur or tibia can be turned out of the 
 wound and resected. Either or both bones, if diseased or injured, 
 are resected. They are isolated from the soft parts posteriorly as 
 well as anteriorly ; a guard is placed behind the bono for the protec- 
 tion of the soft parts and important vessel* (plate IS, fig. 3), while the 
 affected portion of the head and shaft is sawed. In this resection it is 
 considered advisable to remove as much of the Bynovial surface a- pos- 
 sible, and when it is not necessary to resect the tibia, the semilunar 
 cartilages, with their free synovial surfaces, lying upon the upper sur- 
 face of the bone, to deepen the cups for the better reception of the con- 
 dyles of the femur, should be removed. When it is remembered that 
 the degree of deformity and shortening of the limb will depend upon 
 the extent of the bone resected, only the crushed portion in injury, or 
 the ulcerated surface in disease, should be removed. When a Bection 
 of either or both bones is required, the saw should be so applied that 
 the cut surface will be brought in uniform apposition to "the opposing 
 bone. After the section of the bones the soft parts are adjusted by 
 points of suture, and the usual water dressing instituted. As rest and 
 quiet in the limb are essential to a successful issue, a straight, broad, 
 splint is secured to the back of the log, reaching from the buttock to 
 the heel, and is retained until consolidation of the joint is effected. It 
 is expected, in the successful cases, that the joint remain permanently 
 stiffened by fusion of tho tibia and femur. 
 
 Resection of the ankle-joint, like that of the wrist, is an opera- 
 tion sometimes required for gunshot injuries to the bones forming this 
 articulation. Straight incisions on tho lateral surface of the leg, par- 
 allel with the tibia or fibula, and extending to the inferior border of 
 the malleoli, will give ample space for isolating tho diseased or fractur- 
 ed extremity of either of these bones. Should more space be needed 
 the inferior end of the incision may be extended at right angles across 
 the anterior surface of the bone. These soft parts being protected by 
 a guard, a saw or chisel, as in plate 13, fig. 4, will divide the bone, when 
 the lower fragment should be seized by a strong, straight tooth forceps, 
 and while rotating it, the ligaments holdiug it to the tarsal bones can 
 be severed. 
 
LIGATION OJT ARTERIES. 4 ( J9 
 
 LIGATION OF ARTERIES. 
 
 Arteries, as they oourse through limbs, seldom perforate muscles, but 
 usually lie in the intermuscular spaces, accompanied by veins and nerves 
 — the veins and arteries being enveloped in a layer of condensed cellu- 
 lar tissue, called the sheath of the vessels. All arteries of the largest 
 size, such as the carotid, subclavian, and femoral, have but one vein ac- 
 companying them, which is always larger than the artery, and usually 
 lies upon tho inner or most protected side of the vessel. Arteries of 
 the second class, as brachial, radial, ulnar, and tibial, are accompanied 
 by two veins, one lying on cither side of the vessel. A large nerve or- 
 dinarily accompanies the artery; more especially those of the second 
 and third magnitude. It usually courses upon the outer or more ex- 
 posed .<ide of the artery, and without the sheath of the vessels ; so that, 
 in cutting down to expose an artery, when the immediate vicinity of 
 the vessel is reached, the nerve is first found upon the outer side of tho 
 sheath, and this, as an important landmark, determines whero the arte- 
 ry should be sought. The superficial landmarks are the muscles be- 
 tween which the arteries lie; also the direction of the vessels in relation 
 to bony prominences; and their pulsation. 
 
 In the ligation of arteries, the rule is to make an incision parallel 
 with their course, as one least likely to injure the vossel sought for. 
 When, however, the position of the artery is doubtful from tho obscuri- 
 ty of the landmarks, which is the case with one or two very deeply-seat- 
 ed vessels, viz : the glutial — it is preferable to make the incision 
 across the course of the artery. 
 
 The exact position and direction of the artery having beeu determin- 
 ed, the skin of the limb where the incision is to bo made is rendered 
 tense by the surgeon, either by stretching it between the thumb and in- 
 dex finger of his left hand, or by putting the four fingers of his left 
 hand iu a straight line over the course of the vessel and making a 
 straight incision of sufficient length, immediately in front of his finger- 
 nails. If the artery be deep-seated, the incision should extend through 
 skin, cellular tissue, and fascia, directly to the muscles. As most arte- 
 ries are comparatively superficial, this incision should not extend deep- 
 er than the skin. The proper form of knife for making the incision is 
 a Bharp-pointed, straight bistoury : and to make a clean, neat wound, 
 the point of the knife should pass perpendicularly through the thick- 
 ness of ihe sljin, then depress the blade, making the length of incision 
 necessary, and again elevate the blade perpendicularly before the inci- 
 sion is terminated, so that the skin is perfectly divided throughout its 
 
 entire extent, t lie incision Dot ending in Bcratohei OpoO the surface. The 
 superficial layers of cellular tissue may now be carefully divided by the 
 
500 
 
 l-IOATION ol AKT1 
 
 point of (he knife, or the tissue may be drawn upward by seizing il with 
 :.e of the angles of the wound. Make a hole in 
 ii by outting horizontally, insert the point of a grooved director in this 
 opening, slide the instrument under the cellular tissue for the entire 
 length of the wound, and holding the knife with the i dgi turned up- 
 ward, run ii.- point through the entire length of the groove, which will 
 divide oompletely the layer of tissue. With the point <>f the gi 
 lireotor the cellular tissue around U tore up, which i 
 
 the sheath of the artery. As this is usually a Umgh lay < r of membrane, 
 
 iting i" be torn, it is ought np with the foroepi as before, an 
 
 opening made horizontally in it, and by inserting the grooved d 
 through this orifice the sheath can be divided opwu he cel- 
 
 lular ti 
 
 Arteries are not nourished by the blood which runs through them, 
 but by a distinct set of vessels called \ small 
 
 size, which ramify in the outer coat of arteries, and which are furnish- 
 ed from tlmse small branch, s which pass in from the sheath of the 
 This sheath, from which these small vessels aro supplied, 
 must not !"• torn up to too great an extent, or the artery requiring a 
 ligature is Isolated too extensively from it- oellular envelopes, and the 
 destruction of these nutrient vessel- may cause sloughing of the ar- 
 tery and secondary h e morr h age. A- a rule, only a sufficient i] 
 made between the sheath and the artery to allow the passage of the 
 
 in needle armed with the ligature. The point of the aneurism 
 i- always, entered between the vein and the artery, so as to avoid 
 
 injuring the thin and delicate structure of the vein : and a< the vein is 
 usually placed upon the inner side of the artery, the needle is always 
 Inserted from within outward. When the thread is passed under what 
 we suppose to be the artery, it should be drawn upon, so as to raise the 
 vessel and obliterate it- calibre, while the index anger of the - 
 is thrust Into the wound to determine whether the vessel still pulsates 
 
 below the thread. If the pulsation Is confined to thai p rti"n above 
 
 the ligature only when the thread is drawn upward, with DO pulsation 
 below it, while this latter pulsation i.- resumed as soon as the traelion 
 Upon the artery is released, we may feel assured that the propel 
 
 i secured. This preoautl y, inasmuoh as veins and 
 
 nerves, instead of arteries, ha\ < I.e. Q tied by operators of sonic expe- 
 
 rienoe who aegleoted to make use of this expedient 
 Having passed the ligature under the artery and any strong thread, 
 
 whether <d" cotton, tlas. or silk, will answer. QaZ being the most com- 
 monly used — the thread is tied in a single loop, and drawn firmly upon 
 -el. with the intention of cutting through the two inner cats of 
 
 the artery, as it is by the puokeringin and final union of these ooats that 
 the artery is to be obliterated — plate 14, tig's 1, 2, 8. As the outer or 
 
LIGATION OF ARTERIES. 501 
 
 cellular coat is very tough and resisting, there is no fear of tearing this 
 through, provided the fingers are placed in the depth of the wound bo- 
 fore the traction upon the thread is made. The vessel should not bo 
 lifted from its bed during (be ligation. The thread having been well 
 waxed, after making one twist upon it to form the first noose, the ends 
 of the ligature are wrapped around the little fingers of both hands until 
 the thread is made so short that, when the index fingers of both hands 
 are thrust into the depth of the wound, with the back of the fingers 
 placed against each other, using the knuckles as a fulcrum, the extremi- 
 ties of the fingers are forced outward, and as the thread is drawn tight- 
 ly over them, the noose will be firmly tied. The wax prevents the thread 
 from Blipping and relaxing its firm pressure upon the vessel. When 
 the operator feels that he has exorcised sufficient traction to obliterate 
 the tube and sever the inner coats, he draws a second noose, which knots 
 firmly the thread. In tying arteries, an ordinary knot suffices, provided 
 the ligature has been well waxed: there is no necessity for twisting the 
 ends of the thread twice, as formerly recommended by surgeons — "the 
 surgeon's knot." One end of the thread is cut off close to the knot ; 
 the other is brought out of the wound and secured on the outer side of 
 the limb by a piece of adhesive plaster. The wound is then closed by 
 a sufficient number of sutures. If nicely brought together, the lips 
 usually unite by the first intention, leaving but a small fistulous passage 
 for the thread. 
 
 From the eighth to the sixteenth day, depending upon the size of thfl 
 artery ligated, the degree of force used in cutting through the inner 
 coats and compressing the outer, and the more or less perfect isolation 
 of the vessel, the thread comes away, having, by its pressure, killed 
 and softened, and caused to slough, in the line of pressure only, the coat 
 of the artery encircled by the noose of the thread. This liniary 
 (toughing i.^ essential to the escape of the ligature. It is only when 
 the sloughing is more extensive, so as to involve the inner coats which 
 have recoiled away from the thread, that secondary heinorrli 
 sues — plate 14, fig. 3. When the ligature remains on longer than the 
 period above stated, slight traction may be daily made upon it, which 
 will hasten its escape by increasing the irritation and ulceration in the 
 line of ligation. The retention of the thread U often due to the want 
 of sufficient traction upon the thread in tying the artery — not sufficient 
 to cause the thread to cut through the inner coats and strangulate the 
 outer one — or it may be oaused by some of the neighboring tissue being 
 included with the artery in the noose. The only plan for it.-^ 
 
 moral, where it remains for a more or lees protracted period in the 
 wound, is to wait patiently upon it. making moderate traction upon the 
 thread daily. Sometimes the wound heals up, hugging the thi 
 
 that ii re |uirei moderate traction to draw the kn 't through the 
 
502 
 
 LIGATION OF ARTERIE8. 
 
 fistulous passage left for thread. Unless this moderate force was used, 
 the ligature would be thought still connected with the artery. 
 
 LIGATION OF ARTERIES OP Till: SI PERIOR EXTREMITY. 
 
 Coneolidated Tublr ,,f Ligation of Art- run, made up fro* 
 Surge* "* Office, from June 1, 1862, t<i February 1, 18 
 
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 Remarks. 
 
 Primary. 
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 Average period at which hem- 
 oi i hage sel In, foi which ar- 
 
 days. 
 
 
 
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 In li^atinp; :irteries in their course, as the surgeon can most frequent - 
 lj' select the point at which the vessel is to be tied, he Bhould always 
 the operation upon the artery as far as possible from Large 
 bran ob os. Immediately after the ligation, a clot of blood forma within 
 the upper i >< > r t i< >n of the vessel, between the ligature and the fn>t col- 
 lateral branch given off from the artery. This clot prevents the weak 
 portion of the vessel, whore its Coats had been cut through by the liga- 
 ture, being disturbed during the cicatrization or union of these ooats. 
 Should the ligature have been applied in the vicinity of a large branch, 
 the lymph thrown out by the •■ ■ ra to close up the puckered end 
 
 of the tube is washed away by the current of blood; no clot forms, 
 
 and - ndary hemorrhage will probably occur when the ligature es- 
 
 i rmii the vessel. 
 
 To ligate arteries in their course certain locations are [.referred, and 
 these regions must be carefully studied, so that all the relations of the 
 arteries bo clearly understood. In the upper extremity, the points of 
 • Ii ction for lighting the arteries are in the lower third of the axilla for 
 the axillary artery, the middle uf the arm for the brachial) and near the 
 
LIGATION OF ULNA ARTERY. 503 
 
 wrist for the radial and ulna, although sometimes it is necessary to li- 
 gate either of these in the middle of the forearm, or to secure them after 
 they have passed into the hand. 
 
 After the subclavian artery has passed under the clavicle, it is called 
 axillary artery. It then continues through the armpit and upon the 
 inner side of the arm as brachial vessel, until it roaches the anterior pur- 
 face of the bend of the elbow; here it bifurcates into two vessels, the 
 radial and ulna arteries, running parallel with their respective bones. 
 When approaching the wrist the ulna vessel passes under the annular 
 iit on tin inner side of the pisiform bone, and, afler a perpendicu- 
 lar course of one and a half inches, forms an irregular curve in the palm, 
 called the superficial arch, from the convexity of which (plate 15, fig. 3) 
 branches arc given off to supply the fingers, while the continuation of 
 the vessel turns upward to meet a branch from the radial artery, and 
 thus completes the palmar arch. . 
 
 Should an injury to the inner portion of the palm cause annoying and 
 persistent hemorrhage, the ulna artery can be secured by making an in- 
 cision an inch in length on the inner side of the pisiform bone, cutting 
 through skin, cellular tissue, o.ud annular ligament, when the artery, 
 lined by two veins, will be found lying upon the tendons passing over 
 the anterior surface of the wrist-joint, and having the ulna nerve upon 
 its outer or pisiform border. It should be carefully isolated from its 
 accompanying veins, and secured. As the ligation at this point has no 
 special advantage, it is much preferable to secure the artery above the 
 wrist, where the pulse is usually felt. In this region the pulsation of 
 the artery is so easily found that there can be no difficulty in determin- 
 ing its position. From the middle of the bend of the elbow (plate 15, 
 fig. 3) the ulna artery, g, k, accompanied by two veins, takes a curved 
 course. It is deeply buried in the arm, lying upon the deep flexors, and 
 covered by the superficial layer of flexors. After traversing one-third 
 the length of the arm in this obliquely curved course, it changes its di- 
 rect ion to run in a straight course downward and parallel with the ulna. 
 For the inferior two-thirds of its length it lies upon the deep flexor- .f 
 the fingers, between tho flexor carpi ulnaris tendon, f, on its outer or 
 more exposed side, and the flexor sublimis digitorum, j, on its inner 
 side. The ulna nerve lies upon the outer side of the vessel, partly cov- 
 ered by the tendon of the flexor carpi ulnaris muscle. When the arm 
 is so swollen or fat that these muscular tendons can not be felt under 
 the skin, nor the pulsation of the artery perceived, a simple rule for find- 
 ing the vessel in the inferior half of the forearm Would be to ilraw a line 
 from the epitrocbleea to the inner face of the pisiform bone. Under 
 this line the artery will be found. An incision from one and a half to 
 two inehes in length is made in this line, pasnng through the skin 
 and cellular tissue. The fascia, which i- now exposed, U pinched op at 
 
LIGATION 01 HAI'IAI, ARTERY. 
 
 one end of the wound) and a small orifice is made into it fur the passage 
 of the grooved director, upon which the fascia is divided. The tendon 
 of the flexor carpi ulnaris is then drawn outward, and the :irt • 
 found lined by it- . baring the ulna nerve upon its outer 
 
 border. 
 
 When it becomes neOOISfcry to li.'ate the ulna artery in its upper half, 
 as its pulsation OU not he felt, the course of the vcs.-el can always be 
 determined l>y drawing a line from a point midway between the con- 
 dyles of the humeral .1 of the elbow, to ■ point on tho inner 
 side of the forearm where the middle third joint the upper third of the 
 ulnu. It is at this point that the artery hi usually sought. It can bo 
 found nearer the elbow joint, but ai the artery is very deeply seated, and 
 at its exposure requires the division of the superficial flexors, it Is con- 
 sidered preferable to li^ate the humeral artery on the inner side of the 
 
 bioept muscle. Where the middle and upper third of the inner border 
 of the forearm meet, the artery, lined by its veins, has already escaped 
 from beneath the flexor sublimis digitorum, and can he found in the in- 
 termuscular space between the flexor sublimis and flexor carpi alnaris. 
 An incision three inches Long is made, aa in plate L5, fig. I. Bj 
 
 live layers the skin, cellular tissue, uiid superficial fas oil are divided. 
 A- the artery is deeply seated, these tissues can be divided without cut- 
 ting upon a grooved dlreotor. By planing the index finger In tho 
 
 WOUnd upon the inner la f the ulna, and drawing it. with pressure, 
 
 toward the interior oi* the arm. the finger will mount over the belly of 
 the Bezor ulnaris muscle, and suddenly sink into a depression, which 
 marks the intermuscular space between this muscle and the flexor sub- 
 limis. With the point oi" the grooved director held firmly, the cellular 
 -ue of this intermuscular space is torn up, the inner border of the 
 
 flexor alnaris is drawn aside, and the artery is found beneath it. 
 
 The radial art* ry runs a rnuoh straighter course. Prom the centre of 
 the bend of the elbow il follows nearly a straight course downward, 
 parallel with the radius, lying in an intermuscular space, having (pints 
 16, fig's 8, 9) the supinator longus muscle on its outer side, and on its in- 
 ner side the pronator radii teres for its upper third, and theflexor carpi 
 radlalis, », for the lower two-thirds of its course. In the upper half of 
 
 the arm the artery, '/', lined by its two veins, randy-, is deeply seated, 
 . aa it lies in an intermuscular space, its pulsation oan be felt In 
 
 the lower half of its ir-e it i- - • inperfioial that at the wrist it is 
 
 only SUbOUtaneOUS. In ligating this artery, an incision made in any 
 portion of the arm parallel with and over the inner holder of the supi- 
 nator longus muscle, will alwaj the vessel. Tho 
 
 pulsation of the artery is another guide j and a third, useful at all times, 
 
 Is to draw a line from the middle of the lend of the elbow to the inner 
 surface of the styloid ■■ the rudius. An incision in this line, 
 
LIGATION OF BRACHIAL ARTERY. 505 
 
 one and a half inches in length if the operation is performed in the vicin- 
 ity of the wrist, or from two and a half to three inches if in the upper 
 portion of the forearm (plate 15, fig. 4), extending through the skin 
 and superficial fascia, will always expose the artery, with its veins. In 
 the uppor portion of the arm the artery is covered by the inner border 
 of the spinator longus muscle, which overhangs it, and must, there- 
 fore, be drawn aside in the search. 
 
 From the insertion of the great pectoral to the bicipital ridge of the 
 humerus, to the bend of the elbow, the main artery of the arm is called 
 brachial or humeral — plate 16, tig. 11, A. It lies on the inner side of 
 the biceps muscle, D, and corico-brachialis, C, lying upon the triceps 
 and brachialis anticus, and surrounded by a number of largo veins and 
 nerves, all being enveloped in a loose cellular tissue. The median nerve, 
 G, which is found in the upper portion of the arm, botween it and the 
 coraco-bracbialis muscle, crosses the course of the artery in the middle 
 of the arm, usually in front, sometimes behind the vessel, and is found 
 upon its inner Bide at the bend of the elbow. F, the brachial vein, 
 with b, the basilic vein, accompany the artery. A', the ulna nerve, 
 which lies in juxtaposition with the inner surface of the artery in the 
 upper portion of the arm, runs obliquely from it in its descent. The 
 artery gives off but two large branches in its omirM. the superiorand in- 
 ferior profunda branches, both from the upper half of the vessel. If 
 the arm is not very stout, the pulsation of the artery can bo felt upon 
 the inner border of the biceps muscle throughout its entire extent. 
 When the arm is extended the median nerve lifts the skin, forming a 
 prominent cord, which mark* out the position of the vessel, and cau bo 
 used as the guide to the artery. The inner border of the coraco-brachia- 
 lis and biceps muscles are the satellites of the artery. In ligating the 
 brachial artery, an incision from two to three inches in length, is made 
 upon the inner border of these muscles (plate 10, fig. 2), cutting through 
 the skin, cellular tissue, and exposing the muscular fibres. The fascia 
 is divided upon a grooved director, and the search for the artery com- 
 menced i'roin the fibres of the biceps muscle. Looking inward from this 
 muscle, a large nerve is met, which is recognized ns the median, and 
 immediately within and behind il will be found the artery. If the inci- 
 lion be made upon the inner border ol the biceps muscle, in the vicinity 
 of the elbow, the artery maj be found upon the muscular aide ol the 
 iii i re, or din rtlv behind it 
 
 Iron tin clavicle to the insertion of tin great pectoral muscle, the 
 continuation of the brachial artery upward is called axillary. ] 
 t«i v liei "0 tin- ;mt. ri'.r portion "I ill'' armpit, running under the pec- 
 major and minor muscles (plate 16, fig. 4 — 1, 2), surrounded by 
 veins and nerves ; the chief vein, h, being upon its under and anterior 
 surface, while the • 
 
 Qg 
 
506 LIGATION OF AXILLARY ARTERY. 
 
 \ « r:il large branches are given off from the main trunk to 
 ■apply the shoulder, back, and efaeat Tbe inferior third of tho art* rj 
 below the peotoralla minor nuuele i- tin- only portion upon wbi 
 
 ligation ie attempted. When the arm is carried outward from 
 the body, the artery ka found lying npon the inner border of tbe i 
 braehJadu muaele, '*. having two nerves upon 
 
 external cutaneouo, e, and the median, d. If tbe space between the 
 : the great pectoral and gn at dorsal muscles be dh ided int<> 
 three parte, tbe axillary arterj « ill be fonnd oouraing over the ju notion 
 of the anterior and middle third, wben an incision, of three inches in 
 length, after cutting through >k in and superficial fascia, will And it. 
 The ineiaion baring bean made (plate 18, the fasoia divided 
 
 upon tbe grooved director, the inner border of the ooraoo-braohialls is 
 sought. From 1 1 1 i ^ herder aa u landmark, the oollnlar tissue la torn by 
 tho point of the grooved director. Searching inward, the fir.-t white 
 cord which makes i t ^ appearance i.- the external ontaneous nerve : v< rj 
 near this appears, the second nerve, the median: further inward we 
 would find the ulna nerve; then the internal cutaneous. It is after the 
 second nerve, or between and behind the median and ulna, that the ar- 
 tery will be found. 
 
 There is an opcrattVi laid down in tbe books for securing the axillary 
 artery on the inner 6ide of the peetoralia major muscle. Just before the 
 vessel passes under the clavicle to beoome subclavian, the arterj is ao 
 covered by it."- very large v< in, and gives off such large branches, thai 
 
 the result! "f ligation are D8Ually fatal, and therefore the operative 
 
 procedure need not be deacribed. In plate 20, fig. -1 — 1, is seen an in- 
 cision, four inches in length, under and parallel with the clavicle, ex 
 tending outward from the vicinity of the Bterno-olavioular junction. 
 Tho .-kin, cellular tiwoi peotoral muaele are divided, when 
 
 ■ell will be fonnd beneath the great pectoral muaele with ita 
 lar^e vein upon it:- anterior surface, both embedded in loose cellular 
 tissue. 
 
 Through tho lower region of the neck passes the largo aubelaoicui 
 
 artery. <»n the right side, this veaael is of the bifurcating 
 
 branches of the arteria innominataj on the left side >t arises as an m- 
 
 dopendant branch fi the aroh of the aorta. The arterj m 
 
 oorve through the neck, running fi tbe att r Navicular junction to 
 
 the middle ol the cla \ ieh-, w here It pfl In.- bone to beOOBM 
 
 axillary, and henoe the name "t aubclai to it. The artery, 
 
 about five inches in length, forma a bow, ol which the claviole forms tbe 
 cord. It lies deeply at the root of the in ek, covered in by skin, platysma- 
 myoid, aterno-oleido-maatoid, omo-hyoid, Chii 
 
 last muscle, the Boalenui antiot tohmenl to tbe tu- 
 
 ■ the middle thud ol the 
 
LIGATION OF SUBCLAVIAN ARTERY. - r i07 
 
 subclavian artery, thus dividing it into three portions — a p;irt within the 
 muscle, between its inner border and the sterno-clavicular junction ; a 
 second portion behind the scalenus muscle; and a third, or longer por- 
 tion, between the scalenus muscle and the upper border of the clavicle. 
 From the inner and middle portions so many large branches are given 
 off that it is impossible to obtain a sufficient space between the scat of 
 ligature aud one of these branches to obtain a successful result after 
 ligation. It will not be neeessary, therefore, to study the relations of 
 tbese portions of the subclavian artery. It is upon the outer portion of 
 the vessel, after it has escaped from between the two scalcni muscles, 
 that successful ligations are practised. Usually no branches arise from 
 this outer third of the vessel. The subclavian vein (plate 20, fig. 8, B) 
 accompanies A, the subclavian artery, being upon its anterior face, 
 and separated from it by the anterior scalenus muscle — the artery 
 passing behind the vein, which lies in front of this muscle. No 
 nerve accompanies immediately this artery, although the entire brach- 
 ial plexus of nerves, I), issuing from the four inferior cervical foramina* 
 pass to the arm at a short distance from the outer border of this 
 vessel. Both artery, vein, and nerves are found in a deep triangular 
 space bounded below by the clavicle, and on the inuer side by the 
 external border of the stcrno-cleido-mastoid, 4, or the anterior scalenus 
 muscle. The upper and outer boundary is formed by the omo-byoid 
 muscle, 5; the outer directly by the trapezius muscle. The immediate 
 guide for finding the artery is the tubercle upon the upper .face of the 
 first rib, upon which prominence is attached the scalenus auticus muscle. 
 Iu ligating the subclavian artery at its outer third, which is the only 
 practicable portion, the shoulder to be operated upon must be depress- 
 ed, the face being turned away from it. The skin of the neck is drawn 
 down, parallel with the clavicle, for half an inch, and an incision out- 
 ward, three inches in length, is made on the upper edge, and parallel 
 with the clavicle, extending from the external border of the sterno- 
 lid muscle to tin anterior border of the trapezius muscle. 
 The incision at first passes through the skin alone. At its inner angle 
 is seen the external jugular vein, passing down on the outer border of 
 the Bterno-cleido-mastoid muscle to empty into tho subclavian vein. This 
 vessel, when exposed, ii drawn to the inner aide of the wound. Should 
 it have bean injured in the first incision, two ligatures arc applied to it, 
 and the vessel divided between them. The next tissue divided is the pla 
 tysma-myoid; then the cervical fascia, divided upon a grooved direotor. 
 
 As all of the resistant tissues have now been divided, n grooved direct. »r 
 ir substituted for the knife, and by holding it firmly near its point, the 
 cellular tissue is torn by the to and fro movemi nts which isolate the ves- 
 
 I he index I. • ry well effect this tearing of the c. llular 
 
 tissue. Should the km: r thit purpose, the supra-scapular 
 
508 LIGATION <>!■' CAROTID AKTKUY. 
 
 artery, which runs from the inner half of the subclavian outward, parallel 
 with the upper border of the clavicle, may be injured. Having now free 
 access to the depth of the wound, the left indei 6nger of the Burgeon is 
 thrust into the wound, tli>' pulsation in the artery found, nn-l the tubercle 
 upon the upper face of the first rili sought When found, the finger is kept 
 upon it tn mark its situation, while an aneurism needle is guided by it 
 to the depth <if the wound, and by placing the blunt point of this needle 
 in front of the outer border of this tubercle and scraping it upon the rib 
 immediately from before backward, the artery is hooked up, as it is the 
 only structure lying upon the rih upon the outer Bide of the tub 
 plate 20, fig. -1 — 2. The vein is separated from the artery by the thick- 
 the Boalenus musole, and therefore can no) be included in the 
 ligature. Should the point of the needle not be retained in contact 
 with the tubcrdc of the rib, but be allowed to wander about the wound, 
 niic of the brachial plexus of nerves will must probably be hooked up. 
 The aneurism needle having been threaded before it was appli 
 end of the thread is drawn out of the eve upon the outer side of the l es- 
 sel, and )>\ drawing the instrument backward, the exposed thread being 
 held, the other end is drawn out of the wound with the needle, leaving 
 the ligature under the artery. By drawing slightly upon this it can be 
 readily determined whether the artery ii over the thread or not, as the 
 pulsation in it would in- stopped by tin- pressure. Peeling assured 
 that the artery alone bs tred, the Ligature is firmly tied by 
 
 thrusting Uie fingers deeply into the wound. One end of the ligature 
 
 is cut (iff close to the knot, the other brought out of the wound, and the 
 
 inei.-ion closed by But u 
 
 I.ioation OF THB COMMON CAROTID. In examining the outer surface 
 of the neck, when the Bhoulder is drawn downward, the jaw thrown up- 
 ward, with the faoe toward the opposite Bhoulder, a muscular ridge la 
 Been running diagonally across the Deck from the sternum below to be- 
 hind the ear above. This ridge is the storno oleido-mastoid muscle, 
 whioh, from its position, divides the Deck into two triangles. <>nc, 
 
 bounded by this ridge, the anterior median line, and the lower border 
 ot the jaw, is I lie anterior cervical triangle, which contains the eat -lid 
 artery and all of its important branches. In the outer triangle bound- 
 ed by this ridge, the Clavicle, and the anterior border of the trapc/.ius 
 
 . lies the Bubolaviari vessels. It the neck be dissected, 
 
 by the removal of the skin, cellular tissue, plat\sina- 
 myoid muscle, and cervical fascia, the lower portion of the sterno- 
 
 oleido-mastoid musole will lie fonnd to cover all of the vessels, the 
 
 oommon carotid artery being deeply seated at tho root of the nock. 
 
 About the middle of the neck the carotid vessel appears from beneath 
 
 rder of the muscle, lying in a groove between the trachea 
 
LIGATION OF CAROTID ARTERY. 509 
 
 and larynx in front and the vertebral column behind, having, in the 
 cellular sheath which envelopes the vessel, the large internal jugular 
 vein upon its outer and anterior surface, and the important pneumogas- 
 tric nerve between and behind the artery and the vein. A branch of 
 the hypo-glossal nerve, called the descendens noni, lies in front and 
 upon the sheath of the vessel, while behind the sheath is the sympa- 
 thetic nerve. If the sterno-cleido-mastoid (plate 20, fig. 1 — 3) be re- 
 moved, this anterior trianglo of the neck is found subdivided by the 
 oblique position of the omo-hyoid, 2, forming an inferior and a 
 superior triangle. In the lower triangle the common carotid vessel, 
 A, plate 20, fig. 1, is deeply seated, accompanied by the internal 
 jugular vein, B, and pneumogastric nerve, C. No branches are 
 given off from it. In the upper triangle it becomes more superficial. 
 Here its pulsation can readily be felt, and, as the vessel is nearly 
 subcutaneous, can also be seen. When the common carotid reaches 
 the level of the thyroid cartilage it bifurcates into two vessels, 
 the internal and external carotid. The internal becomes again 
 deeply seated, entering the skull through the temporal bone. The ex- 
 ternal commences at once to give off branches, the first of which, the 
 superior thyroid, runs obliquely downward and forward, to be spent upon 
 the thyroid gland, on the anterior surface of the trachea. A second, 
 the lingual, runs outward, parallel with the hyoid bone, to be spent in 
 and about the tongue. A third, the facial, E, runs an obliquely upward 
 and forward course over the lower-jaw, to be distributed upon the face. 
 The continuation of the external carotid upward terminates finally into 
 two branches, the internal maxillary, which passes on the inner side of 
 the head of the lower jaw, and is the artery often injured in the re- 
 moval of this bone; and the temporal artery, coursing upward, in 
 front of the ear, to be distributed to tho anterior portion of the scalp. 
 
 In ligating the common carotid artery, the storno-cleido-uiastoid 
 muscle is used as a guide to find the artery. The vessel, at its origin, lies 
 under this muscle, but always escapes from beneath its inner border at 
 the middle of the neck, and then courses upwards to the lower jaw, in 
 the direction of and nearly parallel with its inner border. The chest 
 being raised by a pillow placed between the shoulders, head depressed, 
 and face turned toward tin- opposite shoulder, with angle of jaw turned 
 upward, so that a Btrong light falls upon the neek. an incision, three 
 inches in length, is made upon and parallel with the inner border of 
 the ido-mastoid muscle (plate 20, fig. 2, a). It passes 
 
 through the skin, cellular tissue, platysma-myoid muscle, and superficial 
 ia, exposing the fibres of the Bterno-cleido mastoid muscle, which 
 :ir , ,,t . . they run always in an oblique direction, 
 
 upward "»</ bat I he only otl rhiota may confuse the 
 
 ratoi i- the platysma-myoid, the fibres of which run always npi 
 
BIO T.ldATloN OF ARTERIES. 
 
 and forward. It is always preferable to cul down upon rather than at 
 the inner side of the Bterno-cleido-mastoid muscle, as, when exposed, 
 it can be used as a sure guide; and also, by it- thickness, protects the 
 vessels, etc., beyond it. When the deep layer of cervical fascia is 
 divided upon the grooved director, the inner border of the muscle is 
 drawn outward by an assistant, when, with the linger, the pulsation <>f 
 the artery can be felt under its sheath, upon which can now bo. 
 seen a small white thread — the deseendens mini nerve. The cellular 
 tissue forming the sheath is carefully picked up by a forceps, 
 and opened by the poiut of tut; knife held horizontally ; great 
 care being taken not to mistake the structure of the vein for the 
 sheath — the latter will be known by its dark appearance when filled 
 with blood — nor should the small nerve upon the sheath bo injured. 
 Upon a grooved director, carefully inserted, the sheath is divided. 
 With the point of the director the vein is separated from the artery, 
 using a forceps, upon the contiguous sheath and not upon the vein, to 
 steady the parts while the cellular connections between the vessels are 
 torn. An aneurism needle, threaded, is now passed from without 
 inwards around the artery — care being taken not to include the pneii- 
 inogutrio nerve, which lies between and behind the vessels, imr the 
 deseendens noni, which runs on the anterior surface of the sheath. 
 The needle should always bo entered between the vein and artery, 
 and by a winding or worming movement is made to work its way 
 through the cellular tissue forming the bod of the vessel. After the 
 thread is passed under the vessel it must be drawn upon, to determine 
 whether it has been applied to the artery, which is proved by the pul- 
 sation ceasing below it. The vessel is then tied firmly by thrusting 
 the tinkers into the wound and making traction Ogainsl the pulps of 
 the two index lingers. One end of the ligature is cut oil" near the knot, 
 the other secured to the surrounding skin of Hie neck under a piece of 
 adhesive plaster, and the wound closed by sutures. 
 
 When it is necessary to ligate the external carotid artery, a similar 
 incision, extending upward, but still upon the inner border of the 
 Hterno-cloido-inastoid muscle, will equally expose the vessel in the 
 vicinity of the posterior extremity of the hyoid bone, where either the 
 common trunk, the internal, or external carotid can bo liguted. 
 
 Some of the branches of the external carotid sometimes require 
 ligation, either from the direct effects of injury, or from secondary 
 hemorrhage. 
 
 The superior thyroid artery, the first branch given off from the ex- 
 ternal carotid, can be exposed in the wound for the ligation of the 
 common carotid at its bifurcation. The artery lies between the sheath 
 Of the carotid vessel and the lateral lobe of the thyroid gland, where 
 it can be found. 
 
LIGATION OP ARTERIES. 511 
 
 The lingual artery is so deeply seated, covered by Uio hyoid and 
 lingual muscles, that its pulsation can not be felt. The guide for 
 this vessel is the upper border of the hyoid bone, parallel to which, 
 and half an inch above it, an incision of one anil a half inches Bhould 
 bo made. This incision exteuds through the skin, platysma-myoid, and 
 cervical fascia, which exposes the tendon of the digastricus muscle — 
 plate 20, fig. b — a. The incision is continued above this tendon through 
 the hyo-glossus muscle, uudor whicli the artery is found resting upon 
 the gcnio-hyo-glossns muscle, and accompanied by tho hypo-gloss:il 
 nerve. The facial artery, as it runs over the lower jaw in front of the 
 masseter muscle, cau be readily felt and secured by making an incision 
 parallel with the anterior border of the masseter muscle, the vessel 
 lying very superficially. In front of the ear the temporal artery can 
 be roadily felt, where its courso is subcutaneous over the posterior and 
 outer edge of the zygomatic arch. An incision of one inch in length, 
 passing through the skin, will expose the artery embedded in a con- 
 densed cellular tissue. 
 
 In cases where persistent hemorrhage occurs from the passage of a 
 ball implicating any of these vosscls, it is preferable at all times to 
 enlarge the wound, seek the bleeding vessel, and ligate it in situ, 
 rather than ligate the main vessel, which should always be considered 
 a dernier resort. 
 
 LIGATION OF ARTERIES OF TTIE INFERIOR EXTREMITY. 
 
 In the inferior extremity we find a similar distribution of blood - 
 to that of the superior limb. The artery which passes through 
 the pelvis as iliac, becomes femoral as it courses through the thigh, 
 then popliteal behind the knee, where it divides into two main trunks. 
 Ono perforates the upper portion of the interosseous membrane between 
 the tibia and fibula, to become anterior tibial, running down to the foot 
 as dorsalis pedis: the other passes through the back of the leg as 
 posterior tibial vessel, and running behind the inner malleolus supplies 
 the plantar muscle as plantar artery. Soon after its origin the poste- 
 rior tibial artery gives off a large branch — the peroneal artery — which 
 runs down the limb on the inner and posterior border of tho fibula, 
 passing into tho sole behind the external malleolus. 
 
 In examining plate 17, fig. 1, the d Malta pedis artery, the continua- 
 tio i of tlie anterior tibial vessel, A. is seen running superficially upon tho 
 back of the foot, having passed bauoath, 1, the annular ligament. Its 
 Course is a straight one from the mi Idle of the space between the two 
 malleoli to the IntermetatarsaJ space between the first and second toes 
 
512 LIGATION OF TIBIAL ARTERY. 
 
 The artery, accompanied, U usual, by two veins ami a nerve, lies in ;m 
 intermuscular spare upon the deep extensors of the toes, 1. havii 
 
 iii8or of the toes, 3, upon its outer border, and the 
 proper extensor of the big toe, 2, upon its inner side. The guide for 
 ligating this artery is either in make an incision (plate 17, fig. 2) upon 
 the outer side of and parallel with the tendon "f the extensor propria! 
 poliiois — which tendon, when pat in action, forms a cord under the 
 skin, upon the anterior and inner Side of the foot— or in a line 'Irawn 
 from the middle of the instep to tin- Interspace between the big and 
 second toe. An incision through the skin and cellular tissue at onod 
 ezpoBBS the vessel. Should any doubt arise as to its exact locality, by 
 searching from the outer edge of the tendon of the proper extensor •!" 
 the big toe the artery can always he found. 
 
 The anterior tibial artery (plate 17, fig. 3, A), accompanied by its 
 veins, B B, runs nearly a straight course upon the anterior surface of 
 the interosseous membrane, being very deeply seated above, but becom- 
 ing more superficial as it descends, until at the instep its position over 
 the anterior face of the inferior extremity of the tibia is nearly subcu- 
 taneous. In the upper half of the leg the anterior tibial artery. .1. 
 eeply in the intermuscular space formed by the body of the 
 tibialis anticus muscle, 4, upon the inner side, and the extensor commu- 
 nis digitorum pedis, 6, upon the outer side. The tibial nerve, '', here 
 lies upon the outer side of the artery. In its lower half the artery is 
 placed between the tibialis anticus mUBCle, Land the extensor pollicis 
 pedis, S, the anterior tibial nerve, c, lying often upon the anterior face 
 Of the artery, and, at times, even gaining its inner border. 
 
 In ligating the anterior tibial artery in any portion of its extent, sev- 
 eral guides can be used. One of these is the tendon of the tibialis ami- 
 cus muscle, which, when put upon the stretch, tonus a prominence un- 
 der I he skin of the leg ; an incision made upon the outer b irder of this 
 cord-like prominence will always find the artery. Another guide is to 
 allow a certain thickness for the belly and tendon of the tibialis anticus 
 muscle, and make tin' incision correspondingly, which allowance, in a 
 lleshy Bubjeot, should be three fingers' breadth from the anterior edge 
 of the tibia in the upper third of the leg; two fingers' breadth in the 
 middle, and one finger breadth in tin' lower third of the leg, where the 
 tendon alone separates it from the tibia. Still a third guide is a straight 
 line drawn from a point midwa\ between the head of the fibula and an- 
 terior spine of the tibia, and a point midway betweon the malleoli. An 
 inoi8ion made in any portion of this line will expose the artery. I sing 
 any of these guides (for they all correspond with each other), an inci- 
 sion is made (plate 17. flg, 1 — 2) lour inches in length, in the upper 
 part of the leg. extending through the skin, cellular tissue, and 
 aponeurotic fascia which binds down the muscles. As the longitu- 
 
LIGATION OF TIBIAL ARTERY. 513 
 
 dinal incision through this Fascia is usually not sufficient to allow 
 of a free search, a cross incision is made into it, extending' from the 
 spine of the tibia outwards, one inch in length. The intermuscular 
 space not being clearly defined in the upper portion of the leg, 
 is readily determined by placing the index finger in the wound with 
 the tip resting upon the spine of the tibia. As the finger is drawn 
 outward, pressing at the same time upon the muscle, a mass of muscu- 
 lar tissue, the belly of the tibialis anticus, is felt to roll away from the 
 tinker, which at once sinks into a depression or groove corresponding to 
 the intermuscular space between this and thecomniou extensor muscle. 
 With the grooved director or index finger the two muscles arc separated 
 in this gutter, and after passing to the depth of nearly two inches, the 
 artery, with veins and nerve, are found lying upon and intimately con- 
 nected to the interosseous ligament. With the point of the grooved 
 director the artery is isolated from the accompanying veins for a suffi- 
 cient distance, one or two lines, to allow the passage of the aneurism 
 needle, armed with a ligature. A3 there are no vessels of any size to 
 be divided in this operation, the incision can be bold, and the opera- 
 tion is comparatively a dry one, without loss of blood. In the lower 
 portion of the leg the operation is conducted in the same way. After 
 an incision of two to three inches in length through the skin and (plate 
 17, fig. 4 — 1) superficial fascia, the finger is placed upon the spine of 
 the tibia and drawn outwards. When one cord escapes, we know that 
 it is the first and only muscle intervening between the bone and the 
 artery, and, therefore, upon its outer side we will invariably find the 
 resseL 
 
 The potterior tibial arttry also runs a straight course upon the back 
 of the leg, lying deeply embedded in the upper half of the limb, between 
 the deep and superficial layers of muscles. Approaching the surface &e 1; 
 descends, when near the ankle, it lies under the. skin and fascia, without 
 muscular covering. From its origin in the inferior portion of the popli- 
 teal space, the posterior tibial artery (plate 1 B, fig. 1, A) lies under the 
 calf muscles, ... composed of the gastrocnemii and soleus, uniting to form 
 below the tendo achillis, 6. The artery, accompanied by two reins, />. 
 one on cither side, and the posterior tibial nerve, c, lies beneath the 
 deep fascia, ami upon the deep flexor muscles of the foot and leg To 
 expose the artery in the upper half of the leg. the soleus muse], 
 detached from the inner hordcr of the tibia and drawn outward with a 
 hook, as in fig. 1, 5. As the artery in its descent appears from i 11 
 the inner border of the soleus muscle, becoming comparatively -nper- 
 ficial. it lies in the inierinus -nlar spaot between tin' tendo aehilli.-, fi. 
 and the flexor communis digitorum, 8, the tendon .>f which mat 
 
 reachinj 1 f the foot, passes through .1 .^heatii behind the inner 
 
 malleolus, 2. 
 
:.| 1 LIGATION 01 FIBULAR AUTKUY. 
 
 To Ligate this rend, the leg is placed on Ita oater side, with knee 
 flexed, and .-in Incision i< made parallol with and one inch from the in- 
 nor and posterior border ol the tibia, it' the ligation la performed In 
 the npper half of the leg; and midway between the tibia and tendo 
 achillls, if in the lower. A.- the posterior tibial art< i nto tho 
 
 foot, it can be found midway between tho internal malleolus and the 
 bony prominence upon the Inner border < ■ f the oaealcis, in thooentn of 
 the hollow of the heeL In the lower portion of the leg the inoision 
 should be two and a half inehea in length ; plate 18, Bg 2- 1 1, extending 
 through tin- skin, oellulat tissue, end faula. When the d 
 divided upon the grooved direotor, and the finger thrust into the wound 
 i position of the vessel ean be discovered by its pulsation, and 
 by means of the end of the grooved director it ean he suflieiently iso- 
 lated for the passage of tho aneurism needle, bom its oontiguona veins 
 and posterior tibial nerve, which lie- upon its outer side. 
 
 In the Upper half of the leg the artery is niueh deeper seated, lying 
 
 between the deep and superficial Layers of musolos, under th 
 
 faSCis Ol tlie leg and under the middle of the calf. As from the depth of 
 the around and the inconveniences of cutting through the centre of the 
 
 call, both from injury to the muscles and from the accompanying 
 orrhage, it would he improper to cut down directly upon the course of 
 
 ■ ■!. an incision of four inches, or even more, ill extent, la made 
 
 upon the Inner side of the lag (plate 18, fig. - -3), parallel with and 
 one inch from the posterior border of the tibia. The incision is made 
 boldly through the skin and cellular tissue to the musoular fibres of 
 the toleua musolo. Detach this muscle from ita eonnectiona with the 
 tibia, and have it- border drawn backwards (plate is, tig. i— 5). if 
 the ironnd be thoroughly oleansed, the vessels con bo seen aa well as 
 the pulsation in the artery felt, under the deep fascia, having a vein 
 . ii each side, and the tibial nerve upon it., cater border. Thi 
 fascia is divided upon a grooved director, the vessel Isolated, and the 
 
 in needle, armed with a ligature, passed. This operation, owing 
 
 to the depth of the wound, la one of the most troublesome and tedious 
 
 of the ligation-. 
 
 The fibular or peroneal artery, an external and posterior bifurcation 
 of the posterior tibial, descends vertically along the posterior and inter- 
 nal horder of the til ml a, throughout its entire length, being deeply 
 
 covered in by the aoleua console above and by the tibialis posticua and 
 
 proper llexor of the great toe in the lower half of its course. To ligate 
 
 -.1 the leg i- placet upon its Inner surface, and an inoisi 't 
 
 four Inohea in length la made parallel With and one-fourth of an inch 
 from tin' externa! horder of the fibula. This incision extends through 
 tin- Integumentary tissm the masole. If the operation is 
 
 performed in the upper half of the leg. I he Boleua muscle must I 
 
LIGATION OF FEMORAL ARTERY. 515 
 
 tached from its fibula connection and drawn outwards, which exposes 
 the flexor longus pollicis. Detach this muscle from the fibula and draw 
 it outwards, when the peroneal artery will be found at its inner border, 
 lying upon tbc bone near the attachment of the interosseous membrane 
 (plate 17, fig. 4—3). 
 
 The femoral artery requires from us particular attention, as its liga- 
 tion is more frequently required, both in civil and military surgery, 
 than that of any other artery. The main artery running through tbo 
 thigh is called femoral from the groin to the knee. The abdominal 
 aorta, opposite to the body of the fourth lumbar vertebra, bifurcates 
 into two large vessels, which run off obliquely from the main trunk. 
 Those are the common iliacs, which, after a course of two inches, 
 when they reach the vicinity of the sacro-iliac symphysis, subdivide 
 into two other vessels, the external and internal iliacs. The external 
 iliac continues onward around tho brim of the pelvis until it passes 
 from the abdomen, beneath Poupart's ligament, when it is known as the 
 femoral artery. Its course is still a straightone, shooting down the limb, 
 leaning to the inner bonier of the thigh, and finally winding around 
 and behind the femur, where, as popliteal artery, it is found behind the 
 knee-joint. Throughout its entire course it is accompanied by a very 
 large vein, the femoral vein, which is always placed upon its inner 
 border, and by a nerve, which lies on its outer side. 
 
 In examining more particularly the relations of the femoral artery, 
 we find that the vessel, with the femoral vein upon its inner side, and a 
 large plexus of femoral nerves upon its outer side, passes out from be- 
 neath the femoral arch, midway between the anterior superior spinous 
 process of the ilium and the symphysis pubis. At this point the pulsa- 
 tion of the artery can be distinctly felt, as it lies upon the pelvic bones, 
 separated from them only by the psoas and iliacus muscles, which form a 
 soft bed for the vessel. Thcartery is here quite superficial, covered only 
 by skin, cellular tissue, and the fascia lata of the thigh. No muscular 
 pad covers the vessel ; hence the facility of arresting the circulation 
 through the thigh by pressure at this point whenever operations In- 
 volving the vessels are practised upon tho inferior extremity, Plate 14, 
 fig. 6. shows how pressure in to be made by applying both thumbs to 
 the pulsating vessel, Al't'T its esoape from beneath Poupart' 
 mi nt, the femoral artery, throughout its oouree through the thigh, It 
 placed in certain relations with the thigh muscles. Thesartorius mus- 
 cle, running obliquely from the outer portion of the hip to the inner 
 pari of the knee, where ii i- attached to the inner face of the head of 
 the tibia, is called the satellite of thcartery. In tho upper fourth of 
 thethigfa the artery lies on the Inner side of the muscle, In the second 
 fourth, a? themueeie runs much moreobliquely inwards than the artery, 
 ■ r the vessel, which, in this part of the thigh, lies under the 
 
516 LIGATION or FEMORAL ARTERY. 
 
 muscle. In the third portion of the thigh the artery is actually placed 
 upon the (niter side nf the muscle, inasmuch as the sartorial has run 
 over the arteryj and is now found apon the inner side of the vessel. In 
 
 10, lig. 2, the Bartorias muscle is 1 ked up and drawn outwards, 
 
 to sIkiw the vessels running under it. 
 
 In the upper third of the thigh, as the femoral artery is must super- 
 ficial, this position is mosl frequently selected for the application of the 
 
 ligature. The Space IS called the triangle of Scarpa, and has long) D 
 
 the sent of election fur tying the femoral artery. The boundaries of this 
 space are the sartorius muscle, which forms a prominent ridge upon the 
 (inter and anterior border of the triangle. The inner border i.- formed 
 by the adductor longus muscle, which is attached above to the pubis, 
 and below, upon the middle of the rough line of the femur. The base 
 of the triangle is formed by Pouparfs ligament, 1. Even before the 
 skin is dissected off from the upper part of the thigh, the outline- of the 
 triangle can bo well discerned. The line of the groin forms the base : the 
 oblique ridgo upon the anterior portion of the thigh the outer 1. order of 
 the triangle] t he inner ridge of the thigh the inner boundary; and 
 where these two ridges intersect inch other is the apex. If a line be 
 let fall from this apex, perpendicularly to Ponpart's ligament, it will 
 lie, throughout its entire extent, over the course of the femoral artery. 
 The artery, A, will he accompanied on its inner side by the femora] 
 vein, <\ which adhere- more or less intimately to the artery, being 
 separated from it by a prolongation of the fascia lata : and separate. 1 
 from the artery also by a prolongation of the fascia lata, is a large 
 package of anterior femoral nerves. A'. From one to two inches below 
 the fold of the groin the femoral artery gives oil' a very large branch) 
 the profunda femoris, which at on.e Lories itself in the muscles of the 
 
 thigh to supply them With nutrition. The femoral vessel proper, alter 
 
 this bifurcation, passes onward to the knee, giving "if no branches of 
 
 importance until it beoomes popliteal, when it commences through the 
 terminal branches, which we have already studied, a- tibial vessels, to 
 supply the leg and foot. 
 
 In ligating the femoral artery in Scarpa's triangle the position of the 
 profunda must lie remembered, as the ligature should he applied at 
 either some little distance above or below this vessel, and not at the 
 bifurcation. The outlines of the triangle must he clearly mapped out, 
 and the perpendicular drawn from the apei of the triangle to the centre 
 of Pouparfs ligament, which line will correspond to the pulsation of 
 the artery, and also to a line which will mark out the course of the ar- 
 tery when the limb may lie so swollen or fat that the muscular promi- 
 nences may not he discernible. Thi* line, which lies over the entire 
 course of the femoral artery, is one drawn from the middle of Pouparfs 
 ligament, or from midway between the anterior superior supinous process 
 
LIGATION OF FEMORAL ARTERY. 517 
 
 of the ilium and the symphysis pubis, to a point midway between the 
 condyles of the femur behind tbe knee, the line encircling obliquely the 
 inner portiou of the thigh. An incision from three to four inches in 
 length is made upon this line as it passes through the centre of Scarpa's 
 triangle — plate 19, fig. 3. This incision, after passing through tho skin 
 and cellular tissue, exposes a superficial vein called the interna] saphe- 
 nous (plate 19. fig. 2, d), which, running up from tho foot and leg, 
 curses upon the inner surface of the thigh, and one and a half inches 
 below the fold of the groin enters an orifice in the fascia lata, the saphe- 
 nous opening, to empty directly into the femoral vein. This vein must 
 not be injured. The fascia lata, upon its outer side, is pinched up and 
 divided upon a grooved director, which exposes at once tho sheath of 
 the vessel. With blunt hooks the lips of the wound are drawn asunder 
 by an assistant, when the surgeon, feeling the pulsation and seeing tho 
 vein and artery, by the careful use of the end of the grooved direotor 
 separates the vein from the artery for a sufficient extent to pass the 
 threaded aneurism needle between tho vein and artery, with point 
 directed outward, and hooks up the artery. Isolating the artery from 
 all nerves, and feeling assured that tho ligature passes under it, the 
 thread is tied, and the case treated as usual, by closing the wound by su- 
 tures, and applying water dressing to ensure quick union. 
 
 Whether that portion above or below the origin of the profunda re- 
 quires a ligature, the only difference in the operation consists in the 
 position of the wound upon the line indicated — the envelopes of the ar- 
 tery, and its relation, both to the femoral vein and crucial nerves, being 
 practically the same in both situations. 
 
 When we are called upon to tic the femoral artery at the junction of 
 the upper and middle thirds of the thigh, we either cut in the imaginary 
 line drawn from the middle of the groin to the middle of the back of 
 the knee, or it the sartorius muscle is sufficiently prominent, an in- 
 cision of from three to four inches in length is made directly upon this 
 muscle, exposing its fibres by cutting through skin, cellular tissue, and 
 fascia. We recognize the musclo immediately by tho direction of iis 
 as in. other superficial musole of the thigh has fibres running 
 obliquely downward and inward. Knowing exactly where we are by 
 the direction of these fibres, they are all drawn to the outer Bide of the 
 wound, when the femoral artery, vein, and two accompanying nerves, 
 will be found under its inner border, covered over by a lay< r l ; 
 lata and the propel sin nth of the vessels. 
 
 The two Berret which accompany the artery are the internal cuta- 
 
 ind the lonj,' saphenous. When the artery passes through the 
 
 tendon of the adductor muscle, at the junction of the middle and interior 
 
 thirds of tb< thigh, it is still accompanied by the long 
 
 saphenous nerve, which i ridge with if, while 
 
518 LIGATION OF ILIAC ARTERY 
 
 the internal cutaneous passes over the bridge, and, as its name implies, 
 is distributed to the skin of the inner portion of the leg. 
 
 Although Beldom required, there are instances in our military ex- 
 perience where, from injury to the femoral vessels in the groin, a liga- 
 ture to the ttiae artery is deemed necessary. Plate 19, fig. 1. will 
 exhibit to us the relations which the external iliac artery bears t" its 
 surroundings. The entire length of the external iliac is not over five 
 inches, extending along the rim of the pelvis from the Bacro-iliao 
 symphysis to Poupart's ligament. As it approaches its termination 
 it gives off two large branches, the epigastric and the circumflex arte- 
 ries. On its inner side lies the iliac vein, and without a number of 
 crural nerves. All of these structures lie upon the psoas and iliac 
 muscles, covered by transversalis fascia and peritoneum. In exposing 
 the artery, an incision three to four inches in length is commenced 
 over the point where the pulsation of the art* ry is distinguished as it 
 runs over the brim of the pelvis, being parallel with and half an inch 
 above Poupart's ligament, and terminates two inches above the anterior 
 superior spine of the ilium. The incision extending through the skin. 
 Superficial fascia, the tendon of the external oblique muscle, and the in- 
 ternal and transversalis muscles, all of which are incised upon the 
 grooved director for safety, exposes the traus\ crsalis fascia. 
 
 The wound is now dilated with the two index fingers of the surgeon 
 separating the cellular tissue, and pushing inward ami upward the 
 peritoneum, which he dissects by tearing it from the transversalis fas- 
 cia. AVhen the separation is carried sufficiently far, the operator, keep 
 ing back the peritoneum with the index finger of the left hand, thrusts 
 the forefinger of the right hand into the. wound, feeling for the brim of 
 the pelvis and the pulsation of the iliac artery. As soon as permit- 
 ted, the wound being well dilated, the operator scratches through the 
 loose cellular sheath id' the vessels, ami passes the threaded aneurism 
 needle from within outward, the point being first inserted between the 
 vein and the artery, to avoid injuring the delicate coats of the former. 
 Ono end of the thread is drawn out of the wound ; the withdrawal of 
 the needle with the other end of tho thread encircles the vessel. Being 
 quite sure that the artery alone is surrounded, the thread is tied bj 
 passing Hie forefingers deeply into the wound, and making traction 
 upon the noose without lifting the artery from its bed. One end of the 
 thread is cut off olose to the knot, the othor drawn out and secured 
 safely upon the abdominal wall, the wound being closed by sutures, as 
 in all instances, and (he usual oold water dressing applied. 
 
OPERATION OF TREPHINING 519 
 
 TREPHINING. 
 
 In compound fractures of the skull, where the bones are much spec- 
 ulated, it, has lu'i'ii already recommended to remove all loose fragments 
 at the first dressing. Should the skull have been driven in, depressed, 
 with accompanying symptoms of stupor, resulting apparently from the 
 direct pressure of the fragments upon the brain, it is sometimes thought 
 expedient to lift the depressed portion of bone and relieve, if possible, 
 Hie symptoms of compression. This operation is effected by enlarging 
 the wound of the scalp. A crucial incision — two lines crossing each 
 other at right angles — is made over and directly to the depressed bone, 
 and the four corners are dissected up as in plate 21, fig. 2, a a a ", 
 which exposes the skull covered by periosteum. An incision is made 
 into this membrane, which is so intimately attached to the bone that it 
 must be scraped off from a sufficient space to allow the application of 
 the trephine. This instrument is a circular saw, a section of a cylinder 
 with the saw-teeth arranged upon its free end, working upon a, central 
 movable pivot. An improvement, which consists in making the body 
 of the instrument a truncated cone, with teeth npon the side as well as 
 upon the end, has been attributed to Mr. Gait, of Virginia ; but draw- 
 ings strikingly similar can be found in Heistcr's Surgery, published in 
 London, 1757, which Heister in the text speaks of as "the trephine 
 which I use." The advantages which the conical trephine possesses 
 over the cylindrical is. that the pressure in cutting is borne mostly 
 upon the rim of the skull and not upon the fragment which is being 
 removed, and therefore there is much less danger of wounding tho 
 membranes and brain. 
 
 When we have a choice in the position, we would not place the tre- 
 phine over the anterior inferior angle of the parietal bone, for fear of 
 injuring the meningeal arteries, a a a (plate 21, fig. 1 ), which often lio 
 deeply embedded in grooves traced upon the inner face of this bono ; nor 
 over the lateral and longitudinal sinuses, which arc seen in the same 
 figure — c d, and b b b. 
 
 When the trephine is used to relieve accumulations of fluid within the 
 skull, it should be applied directly over the supposed Beat of the fluid. 
 When used to assist in the elevation and restoration of depressed bone, 
 
 the point or axis of the saw is placid upon the contiguous edge of un- 
 injured bone, so that the circular saw, in its rotary movements, will cut 
 out a small segment of the depressed bone and a much larger picco of 
 
 the healthy skull. 
 
 Tin- e urgeon, holding the handle of the instrument firmly, as in plate 21 , 
 Bg. 2, with i i." laced upon the crown of the instrument to steady 
 
 it, and point or axis protruding a twelfth of an inch, commencei by rotating 
 
BTDROCJ 
 
 ft ui'li it the instrument, so as to bore into the skull and bury 
 the pivot Upon this as an axi eth revolve, cuttii 
 
 the bone. When this gro ently deep to oonfino the instrument 
 
 and allow it t" oontinae its rotatory motion without the nse of the nxis, 
 the pivot la drawn within the oyllnder, 10 that .ill injury to the mens* 
 brane by this perforating point "ill be avoided. After cutting 
 into the skull, the bottom of the groove should be examined by ■ probe 
 
 or (piili, to determine which porti i the hone bas been cut through* 
 
 The sensation Imparted through the quill can readily detect the hardj 
 nndlvi led bom from t li c- mambraoes beyond the out portion. When the 
 trephine is reapplied, pressure must he only made by the rim ol I 
 upon thai portion of the bone not yel out through. When it Is found that 
 nearly the entire crown bas been eut through, the trephine is removed and 
 
 the end of a lever placed in the groove, I which the round 
 
 piece of bone is lifted from it.- position. Through the opening I 
 end of the lever can be easily applied beneath tl 
 hear in;: down upon the long arm of the lever, using the rim of th< 
 ing in the uninjured bone as a fulcrum, the depressed fragmei 
 priced ap into place— plate SI, li^ r . I. Should largi found 
 
 quite detached they should be rem< as they will die, having 
 
 had their nutrition destroyed. Should the dura mater and brain be- 
 neath be in a healthy condition, the dura mater will retain its natural 
 level, the pulsating of the brain being clearly seen. If the operation 
 has been performed to relieve the afieots of pressure produced by the 
 accumulation nf fluid under this membrane, it will at once rise up. flll- 
 
 ■ trephine hole, when the poind pice ■ .1 bone is removed, and no 
 pulsation will he transmitted through it. Under these circumstances 
 
 it will he necessary to inolse the dura mater, to allow the pent up fluids 
 compressing the brain to aaoape. w hen the operation ha- been pom? 
 pleted, the Baps in the scalp are olosed bj suture, and cold water dress- 
 piled. 
 
 in !>]:■>< BLE 
 
 Hydrocele, s di tmmon in tho army, < n°i8ts in an accu- 
 
 mulation of fluid in the scrotum, being contained in the cavity of the 
 tunica vaginalis. Tho enlargement formed of the scrotum is round or 
 oval, uniformly hard, yet ah. -inc. fluctuation. It 
 
 iroin hernia by being < lined altogether to Ve soro* 
 
 turn, the cord where it passei into tin- abdomen being soft and of Its 
 usual size. As all hern] | m the abdomen, SUOO tumors always 
 
 gradually •> me • must 
 
HYDROCELE. 521 
 
 always hare thoir enlarged, stout neelc loading directly into tho ab- 
 domen. 
 
 Hydrocele is distinguished from diseases of tho body of tho testicle, by 
 tho latter being irregularly hard and inelastic, also feeling hoavy when 
 the mass of the swelling is supported in tho hand. In hydrocele tho skin 
 is seldom involved, while in diseased and enlarged testicles the skin is 
 usually red and quite sensitive. Tests, to detect fluctuation in painless, 
 uniformly enlarged scrota, in which tho increase in size has been slow, 
 without symptoms of inflammation, I have found best applied as follows: 
 I usually seize the body of the swelling between the index finger and 
 thumb of the right hand, while tho upper portion of tho swelling is held 
 firmly between the index finger and thumb of the left hand. By alter- 
 nately squeezing with the right hand, then with the left, the fluid dis- 
 placed by one hand will be felt to force asunder the fingers of the other. 
 I have found this a very simple and successful test fur hydrocele. In 
 the posterior portion of the swelling will always bo felt a hard mass, 
 which is the testicle. The tunica vaginalis, as it is reflected from the 
 scrotum to the testicle proper, leaves in front of it a sac in which the se- 
 rous fluid collects. As it accumulates it forces the testiclo away from the 
 anterior wall of the scrotum, and removes the dangers of injuring tho 
 testicle during the operation for tapping the sac and drawing off the fluid 
 accumulation. 
 
 The method for tapping a hydrocele is as follows : The left hand of 
 the surgeon seizes the upper portion of the enlarged scrotum, grasp- 
 ing (plate 22, fig. 1) the entire circumference of the tumor, forcing the 
 fluid into the lower portion of the sac, and stretching the skin of the 
 scrotum over the tumor. This position, by forcing the fluid between 
 the testicle and the anterior wall of the sac, renders the puncture of the 
 testicle impossible, if the instrument be properly directed. With a small 
 sharp trocar and canula, held between the thumb and second finger, the 
 handle butting against the base of the thumb, and with index finger upon 
 the stem, guarding the depth to which the instrument should be. thrust 
 into tho scrotum, the point of tho trocar is placed upon that portion of tho 
 anterior and inferior portion of the tumor devoid of large veins, and, by 
 a forward and sudden movement of the wrist, the instrument is thrust 
 obliquely backward and upward, in a direction somewhat oblique to the 
 long axis of the swelling. As soon as the surgeon feels the resistance 
 r that the point of the trocar has passed through the walls of the 
 scrotum and lies in the cavity >•! the tunica vaginalis, he draws out tho 
 trocar, while the canula is pushed forward well into the cavity. As 
 soon a» the trocar is drawn oul :i clear serum escapee in n stream, the 
 cavity is rapidly emptied, and the swelling disappears. 
 
 This tapping of tho sac is only a palliative remedy: for, although tho 
 fluid may not rcaccumulate, it most frequently ted, Hid after 
 
 Rb 
 
522 \ MUCOCELE. 
 
 a few months the scrotum will attain its former enlarged size. This 
 tupping can be renewed from time to time, without inconvenience or 
 danger. No treatment is necessary after this puncture the patient 
 usually attending to his ordinary duties, without laying up an hour. 
 The use of a suspensory bag is the onlj' clement of treatment neces- 
 sary. Where the patient desires security from the recurrence of the ac- 
 cumulation, he can obtain it by the injecting of the tincture of iodine 
 into the sac, wbich so inflames the lining surface of the sac as to cause 
 it's two opposing surfaces to adhere to each other, and by thus obliterat- 
 ing the cavity prevent any further secretion. In some instances, 
 although this adhesion does not occur, the lining surface has its func- 
 tions so modified that it ceases to secrete this excess of fluid. A long 
 list of irritating substances have, from time to time, been used as an in- 
 jection. The profession at large have now adopted the tincture of 
 iodine, as it gives the largest number of cures, accompanied with the 
 smallest number of accidents. After the fluid has been drawn off, one 
 drachm of tincture of iodine, diluted with two drachms of water, is in- 
 jocted through the canula into the sac, and is left in, the instrument 
 being withdrawn. After the injection pain is soon experienced, of a 
 very sickening and painful character, extending in the direction of the 
 cord to the origin of the spermatic nerves in the spine, which may in- 
 crease to such intensity as to require the free use of morphine. In- 
 flammation attacks the lining membrane of the sac, extending to the skin 
 of the scrotum — the tumor becoming, in forty-eight hours, red, hot, swol- 
 len, and painful. As the sac rapidly redistends with fluid, it is the prac- 
 tice of many surgeons to puncture at the end of the third or fourth day, 
 and draw off the accumulation, when the inflammation, under the cold 
 water troatment, subsides, and the scrotum in time nearly resumes its 
 healthy dimensions. As the inflammation in the tunica vaginalis has 
 thickened both the testicular and scrotal membranes, there remains for 
 a long time apparently a slight enlargement of the testicles. If the 
 fluid bo not drawn off, absorption gradually reduces the tumor, and the 
 final result is equally satisfactory, although the cure is more protracted. 
 After the disappearance of the more acute inflammatory symptoms, 
 painting the scrotum with the tincture of iodine will hasten the ab- 
 sorption of the fluid. 
 
 VARICOCELE. 
 
 Varicocele is an affection very frequently encountered by a military 
 surgeon, and one for which too many efficient men are put upon light 
 duty, or discharged from the army. It consists of a relaxation and eu- 
 
VARICOCELE. 523 
 
 largoment of the spermatic veins, a varicose condition in which the 
 vessels become much enlarged and tortuous. The left spermatic veins 
 are far more frequently affected than the right, which is aooounted for 
 by fecal accumulations in the sygmoid flexure of the colon oomprcssing 
 the vessels, and preventing the ready return of blood from them; and 
 also to tho absence of a valvular formation at the extremity of the left 
 spermatic vein, where it empties into the vena cava, ami which permits 
 regurgitation of blood. The rarity of varicocele upon tho right sido 
 is accounted for by the presence of this valve at the termination of tho 
 vein. 
 
 Varicocele is recognized by an enlargement of the spermatic cord, 
 extending to the scrotum, and varying at times in size. When in the 
 recumbent posture, and at rest, the swelling nearly disappears. In this 
 respect it siinilatcs hernia. If pressure be made upon the upper part of 
 tho cord, and the patient resume the erect position, the veins accumu- 
 late blood, which the pressure prevents from returning into tho circu- 
 lation, and the tumor reappears. In this respect it differs from hernia, 
 which could not reappear as long as the pressure is continued, as tho 
 linger prevents the bowel from protruding through the abdominal open- 
 ing. When the cord is felt, the sensation of a large number of soft 
 vessels is transmitted, resembling earth worms — plate 22, fig. 6. The 
 tortuous condition of the veins is often easily recognized on the surface 
 of the scrotum. Under exercise the swelling enlarges, accompanied 
 by a sensation of weight, and often of acute pain of a neuralgic char- 
 acter, extending to the groin and loins. This pain is often so severe as 
 to prevent the patient from walking or riding, and therefore attending 
 to active service. 
 
 The treatment of varicocele will depend upon its extent. In mild 
 supporting the testicle in a suspensory bag, and thus relieving 
 all traction upon the cord, is found a sufficiently palliative remedy. In 
 cases where tho vessels are tortuous, and in which the suspensory bag 
 does not remove the symptoms to such an extent as to permit the 
 patient to attend to his daily duties, an operation is called for, which 
 has for its object tho obliteration of the enlarged veins by ligation. 
 Plate 22 gives three methods for effecting this result. In fig. 2 an 
 incision is made from one and a half to two inches in length, parallel 
 with and directly over the spermatic oord, carefully dividing upon a 
 grooved director each layer of cellular tissue uutil the elements of tho 
 cord are clearly exposed. By feeling the mass of enlarged vessels, 
 one will be felt much harder than the rest. This is the vas deferens, or 
 excretory duct of the testicle, and is the only element of the cord which 
 must Ik- omitted in tying the vessels. This hard tube being carefully 
 avoided (plate 22, tig. 2), all of the remaining vessels are surrounded by 
 a ligature, which, in time, will cause their obliteration. As the spcr- 
 
524 VARICOCELE. 
 
 niatic nerves are always included in the noose of the ligature, tho pain 
 of the operatiou is very severe. 
 
 The vessels can be as readily secured without an incision by passing 
 a pin behind them, and twisting a ligature in figure of 8 over the ends 
 of the pin. The cord being seized between the thumb and index 
 finger, its elements arc felt, and the hard cord or vas deferens, which is 
 easily distinguished, is separated from the soft vessels and pushed 
 backward. The remaining vessels are drawn as far forward as pos- 
 sible, stretching the skin over them, when a piu is thrust through tho 
 skin, from within outward, passing behind the mass, and its point reap- 
 pears again through the skin upon the opposite side. A thread is then 
 firmly twisted around the protruding extremities of the pin, which 
 causes sufficient pressure upon the vessels to effect their permanent 
 obliteration in six or eight days. Plate 22, fig. fi, shows the position of 
 the pin behind the tortuous veins; and in fig. 7 is exhibited the appear- 
 ance of the pin with thread firmly twisted in figure of 8 around the 
 protruding extremities. The point of the pin should be cut off after 
 the operation is completed, to avoid its pricking the surrounding soft 
 parts. The pin is withdrawn at the end of the sixth or eighth day. 
 
 A second method for obliterating these vessels is by the use of a sub- 
 cutaneous ligature, applied as shown in plate 22, fig's 3, 4, and 5. In 
 fig. 4 is seen two doubled threads, with looped extremities, each double 
 thread passing through the loop of the other. When they are firmly 
 drawn, as in fig. 5, it is seen how they compress firmly the vessels. 
 The mode of application is as follows : Both ends of a piece of strong 
 flax or silk thread are passed through the eye of a needle, which leaves 
 a loop at one extremity of the double thread. The cord being seized 
 between the thumb and index finger of the surgeon, is drawn forward, 
 the hard cord of vas deferens distinguished and pushed behind and 
 away from tho mass, which is drawn forward. The needle is then in- 
 serted behind the fingers, and drawn through upon the opposite side, so 
 as to have in front of the thread all of the vessels of the cord oxcept 
 the vas deferens, which was pushed out of tho way. Fig. 3 gives the 
 position of the double ligature and loop. A second needle is now 
 taken, with a similar ligature, and the skin of the scrotum over the 
 cord alone drawn forward. The point of the needle is entered through 
 the orifice from which the first one escaped, and passing superficially 
 under the skin and over the vessels, escapes out of the first puncture, 
 so that a loop remains on each side of the cord. The corresponding 
 ends of the threads are passed through tha loops (fig. 4), and the 
 threads drawn upon as in fig. 5, when the loops at once bury themselves 
 in the punctures and compress the vessels. When firmly drawn, they 
 should be tied over the cords. A single ligaturo can be applied in the 
 same way, and will give better results. First pass the needle, armed 
 
FISTULA IN ANO. 525 
 
 with a single thread, behind the vessels, and, drawing tho skiu forward, 
 pass it back through the sumo openings in front of tho vessels, and tie 
 as usual. The knot at once buries itself in tho puncture, aud disappears 
 from view. 
 
 FISTULA IN ANO. 
 
 Fistula in nno is a very common affection, particularly in the cavalry 
 arm of the service. It is caused by the formation of abscesses in the vicin- 
 ity of the rectum, which, after discharging their purulent contents either 
 into the rectum or externally upon tho buttock or porinaium, refuse to 
 heal. They become chronic, contracted, tortuous passages, called fistula;, 
 from which a inuco-purulent discharge continues, much to the annoyance 
 of the patient so afflicted. There are three forms in which this disease 
 shows itself. Plate 23, fig's 1 and 2, indicate varieties of incomplete fis- 
 tulas. In fig. 1 the fistulous passage passes from a cul de sac and empties 
 its secretion into the rectum, r, just above the internal sphincter, leaving 
 no opening upon the outer surface through which the purulent contents 
 of tho fistula can be discharged externally. In this case pus would be 
 discharged per an urn during defecation. In fig. 2 is seen a much more 
 common variety of incomplete fistula — b, the tortuous blind cul de sac, 
 with its neck, o, ending externally upon the inner face of the buttock. 
 The cavity having no communication with the rectum, tho purulent dis- 
 charge would uot be thrown into this cavity, but would be poured out 
 continually upon the external surface within the fold of the buttock. Fig. 
 3 represents also a common variety called a complete fistula in ano, inas- 
 much as the fistula, b b, has an inner connection with the rectum at a, 
 and also an external orifice upon the buttock at/. The contents of this 
 secreting passage can either be emptied into the bowel or be poured upon 
 the outer surface of the anal region. Owing to the free communication 
 between the cavity of the rectum and tho external surface, small parti- 
 cles of fecal matter escape through the fistula, giving an offensive odor 
 to the secretion. Gases also escape from the rectum by this passage. 
 The opening into the rectum is usually found immediately above tho 
 sphincter muscle, from one to one and a half inches from tho outer sur- 
 face of the anus; rarely over this depth. When wo hear of cases in 
 which the passage of a probe oxtended for three and four inches along- 
 side of tho bowel it can be readily understood, for the previously existing 
 abscess may have been a large one, and have dissected the tissues for a 
 considerable distance; but when we hear of an opening in tho bowel 
 from three to four inches from the orifice, it means that the operator, 
 in passing the probe, had missed the lower opening in the bowel just 
 
I int" the bowel, m it only by « thin mu- 
 
 cus membrane, bad (breed the. probe tbrongb it. making a second and 
 artificial opening from tin- extremity ol tl ae i > 1 1 - • the rectum. 
 
 ■ . irbetheT complete "i- othern ise, usually run up 
 leaving only the thickness of the muc 
 
 camlning a patient suspected of having an anal Batuln, I 
 
 Che buttock draw i 
 by mi assistant, or the buttock being drawn aside with the left hand "f 
 i - 1 1 1 ; i II papule or conical elevation, resembling 
 a granulation, in the centre of whiob "ill be found a small orifice. Bj 
 pressure upon the buttock this orifice is by the appearance 
 
 of a drop of pus Bqueesed from the Interior of the fistula It' the bulb 
 of ;i silver probe is introduced into this orifice and very flight pi 
 ii . ,], it will find its own way tbrongb the fistula, and will usually take 
 up ••! direction inward and apward toward the bowel. Should it be neo- 
 i Mary the probe should be slightly bent, t" enable it to follow mora 
 readily the irregularities of the pa thould b< d 
 
 amination, and when 1.1 1 is drawn it ind 
 
 rongh and painfnl exploration. If the index finger be passed into the 
 rectum above the sphincter muscle of the anus, the end <d" the probe 
 oan be readily fell separated fr< m the finger bj a thin mucus mem- 
 brane, which gives the impression of the bulb being covered by a thin 
 film. Often the probe wtll find its way through an opening in this ut- 
 tenuated mucus membrane, and pass into the bowel in contact with tho 
 ben ihc mil •!< xii, ■ continues apward along the bowel for 
 r three inches. 
 
 Dstulse show so little disposition to heal by the usi 
 
 or local applications, thai no other treatment is worth} of isideration 
 
 but an operation whioh bai foi its objeet the radical cure, Bxp< 
 shows that the anatomy of the parte bas muoh to do with the difficulty 
 ol closing up these secreting | bief obstacle to healing 
 
 to reside in the continued action of the Bphincter muscle of tho 
 anus, whioh, by keeping the wall.- of the abscess in constant motion, 
 draw the opposing sides away from each other and prevent aniot 
 perienoe Bbows thai unless the sphinoler muscle is divided, a cure of 
 rectal fistulas is nearly Impossible, and also that there is never a neoes* 
 Bity for cutting the bowel above the sphincter musole. Winn Burgeons 
 report oaaas in which an incision i-ur inobea deep was made through 
 the bowel, it is an indication of hold and dangerous surgery from ig- 
 norai 
 The mode of procedure in operating for fistula in ano is as follows: 
 
FISTULA IN ANO. 527 
 
 Tho bowels having been well emptied by a purgative dose, the patient 
 lying upon his side, us in plate 23, fig. 6, and under tho influence of 
 chloroform, a small silver grooved director, terminating in a probe, has 
 its probe extremity entered into the fistula, and passing upward through 
 the sinus toward tho bowel, is fell by the index finger of the left hand 
 passed into the anus. As soon as the finger feels that the probe reaches 
 the mucus membrane of the rectum, immediately above the internal 
 sphincter, and about one inch from the external surface of the anus, an 
 effort is made to find B passage into the bowel. Should none he found, 
 tho surgeon turns the end of the probe against the thin mucus mem- 
 brane just above the sphincter, "and without hesitation forces a pas- 
 sage into the rectal cavity, thus rendering the sinus a complete fistula. 
 The probe is now thrust forward and upward sufficiently to onablo the 
 bulb of the index finger to hook the end of the probe, as in fig. 4, and, 
 drawing it downward and outward, draw its extremity through the rec- 
 tum and anus until it rests upon the opposite but lock, both ends of tho 
 probe, being risible, the grooved portion remaining in the fistula — fig. 
 5. The sphincter muscle, the enemy to the healing of the fistula, is 
 now clearly on the outside of the probe. The blade of a sharp-pointed 
 bistoury is now run through the groove in the director, and in cutting 
 its way out cuts out the probe and divides completely the sphincter 
 muscle. As soon as the probe is cut out blood wells up freely from the 
 wound, as the hemorrhoidal arteries ramifying around the anus are 
 divided in the incision. A sponge is thrust into the wound to dry the 
 surface of the incision, while the surgeon saturates a piece of soft lint 
 with the liquid persulphate of iron. Removing the Sponge, the lint is 
 i lmi- 1 to the bottom of the wound, a compress applied, and secured by a 
 T bandage. One band passes around the waist, the other passes be- 
 livoii the buttocks, around the peiinseum, with the anterior portion of 
 the band slit so as to allow one strip to pass on each side of the scro- 
 tum and across each groin, to be secured to the abdominal band. Opium 
 is freely given to allay pain and to keep tin' bowelfl quiet. When sup- 
 puration is established, which is usually at the end of the second or 
 third day. the dressings are removed, which will expose a clean, granu- 
 lating wound. A daily dressing of a little simple cerate upon a soft 
 doth, secured in place by the T bandage, i.- all the dressing required. 
 ;iiis simple treatment the wound will granulate from the bottom 
 and sides, and gradually becoming more superficial, will, in the course 
 of two or three w< i mpletely cicatrised — a radical cure of the 
 
 annoying fistula. 'I be upper portion of the ml ih toe, above the point 
 where the probe was forced into the tectum, usually heals -itnultanc- 
 onsly « itli the res! of the sit u>. and gh < - no trouble. 
 
 binary ni' tbod of dressing Dstulse after an o] I be ap- 
 
 lint, which is forced up the rectum daily: 
 
528 FISTULA IN ANO. 
 
 • depth as the bottom of the wound fill? up with granulations, 
 until the dressing becomes a superficial one. The object of this treat- 
 ment is based upon tin- desire t" prevent tin' wound healing by quiok 
 
 union. The incision being performed by ;i ibarp instrument, leaves 
 two nicely cut surfaces in apposition t" each other, which would unite, 
 together in twenty-four hours, leaving the fistulous passage lined by its 
 hard, secreting membrane, unohlitcrated. Tbo consolidation of tin- 
 sinus can only be secured by keeping the lips of the wound asunder, 
 so as to force granulations to form along the lining membrane of the 
 fistula, and thus force the wound to heal from the very bottom. 
 
 Although the daily application of the tent of lint, thrust between the 
 lips of the wound, prevents any union, it is a very painful operation — 
 even more so than the cutting — as it forces a large roll of lint against 
 a very sensitive, inflamed surface: it is also a very troublesome appli- 
 cation. The use of the persulphate of iron, either upon a camel's hair 
 brush or a soft piece of lint, is in every way a preferable remedy. 
 When the entire surface of the wound is carefully swabbed with this 
 stroug fluid, its immediate action is to form a hard, crusted clot of 
 blood over the surface, which checks the bleeding, and placing a foreign 
 body between every portion of the opposing surfaces precludes tin- pos- 
 sibility of adhesion by the first intention. Again, the application of the 
 persulphate or perchloride of iron acts as a cau.-iie. produoing a super- 
 ficial Blongh from the entire surface of the wound, including the pyo- 
 genic membrane with which the fistula was lined, which, in itself, would 
 prevent any quick union. It, inoreo\er. stimulates the surface iu such 
 a way as to cause the rapid formation of granulations; and theu has 
 the very decided advantage over all other applications that no further 
 dressing is required. 
 
 Surgeons who use the greased lint tent lay grea' Btress upon the daily 
 dressing, as a very important element in the successful treatment. 
 With the thorough application of the persulphate of iron I have no 
 
 further fear for the patient, nor oven is it necessary for the BurgOOfl to 
 see him again. Should he have come from a distance to bo operated 
 upon, he can return to his friends the same day, a few hours after the 
 operation has been performed, the Burgeon giving the assurance, which 
 experience with this remedy will permit him to do, that the case will 
 now cure itself without further treatment. I have used this remedy for 
 ten years, in every instance with success. It is a perfect method, which 
 leaves nothing to be desired. The case is a very rare one which require! 
 the patient to keep bis room more than twenty- four hours. 
 
 The use of opium is kept np for four or five days, when the bowels are 
 emptied by a dose of Castor oil, citrate of magnesia, or any simple medi- 
 cine, mild in its action, which will produce fluid evacuations : after which 
 tbo case is left to nature. Although the sphincter is or nkould /"■ divided 
 
FISTULA IN ANO. 529 
 
 completely in every case, no fear should be felt that the muscle will not 
 unite again, and control over the contents of the bowel be resumed. It 
 may bo, however, one or two weeks before the patient will have the 
 perfect control of the sphincter muscle, but it will assuredly be regained 
 in every case in which the operation has been properly performed, as 
 directed above, and where the bowel has not been ignorantly divided to 
 too great a depth. 
 
 A ligature passed through the fistula and bowel, with the intention 
 of cutting slowly and very painfully through the same structures which 
 the knife divides, is a remedy extensively used by itinerant specialists, 
 who take advantage of the suffering community by depicting the hor- 
 rors of the knife to nervous, timid patients, and extolling the certain 
 success of a simple thread. This application will, at times, cure fistula 
 in ano, but always at the expense of much suffering. The ecrascur, or 
 more rapid ligature, is troublesome of application, and possesses no 
 advantage. 
 
 Ss 
 
 
Plate 1. 
 
 Fig. 1. — A Confederate army litter for transporting wounded men 
 To secure the heavy duck-cloth or sacking to the frame, n ^r'"-\ e three- 
 quarters of an inch wide and foe-eighths of an inch deep u out out in 
 the length of the frame. The cloth is tacki-d in this, and Beoured by a 
 lath which fits accurately the groove, and which is nailed in, covering 
 the cloth. The tension upon the cloth is not borne by the tacks, but is 
 uniformly supported by the entire lath, and therefore never rips off. 
 
 fi, h 2. — A Confederate four-wheeled field ambulance wagon. In 
 the Confederate army there are two kinds of ambulance wagons — one 
 with two wheels, and the one represented in the figure. The four- 
 wheeled is the most convenient, and is the one in general use. 
 

 
FIG 4 
 
 r I t 
 
 r i c a 
 
 . [Yot.< L CefTandly CcJwnJh^S 
 
Platk 2. 
 
 Fig. 1. — Vertical section of a finger, showing the relations of the 
 phalangeal bones with the soft parts ; also the relations which the artic- 
 ular surfaces bear to the natural folds on the palmar surfaco of the 
 finger. 
 
 Fig. 2. — A finger flexed to show that the articulating surfaces are 
 not to be found at the apices of the angles which the bent finger makes. 
 
 Fig. 3. — Amputation of a finger in second phalangeal joint. The 
 position of the finger while the knifo enters between the articulating 
 surfaces on tho back of the finger. 
 
 Fig. 4 shows the horizontal position of tho knife after having trav- 
 ersed the joint from behind. 
 
 Fig. 5. — Flap operation — shows the knife transfixing the finger at 
 the second digital fold, so as to make the palmar flap, a b c marks 
 the form and size of the flap, or the line in which the knife will cut 
 from within outward. 
 
 Fig. 6. — Continuation of the same amputation. Flap turned back — 
 the knife placed perpendicularly, dividing the anterior and lateral liga- 
 ments, and passing into the joint. 
 
 Fig. 7 exhibits two methods of amputating an entire finger, a d c 
 b shows the flap after the oval method, the palmar incision following 
 tho palmar fold at the web of the finger ; a c b the method by two later- 
 al flaps, the incision cutting across the palmar digital fold, and passing 
 up obliquely in the palm nearly to the transverse fold. 
 
 Fig. 8. — Tho hand, with relation of bones and joints to the soft parts. 
 a b c, showing the extent and direction of incisions in amputating the 
 thumb, with its metacarpal bone, at its articulation with tho trapezium. 
 
 Fig. 9 shows the position of the thumb, and also how the knife is 
 held while the point of the blade divides the ligaments, and opens freely 
 tho joint. 
 
 Fig. 10. — The appearance of the wound and hand after removal of 
 th« thumb. 
 
Plate 3. 
 
 Fig. 1 represent? the line of incision for amputating the little finger 
 with metacarpal bone. A similar line, traced upon the back of tho 
 hand, defines the extent of the flap. 
 
 Fig. 2. — Position in which the hand is held in amputation of the fin- 
 gers, a b c shows the line of incision for opening the metacarpopha- 
 langeal joints ; after traversing which, the direction of tho knife is 
 changed, as in the figure, so as to make a flap from the palmar surface. 
 
 Fig, 3. — a b c marks out the extent of the flap, and shows the rela- 
 tion of the heads of the metacarpal bones to the soft parts. 
 
 Fig. 4.— Anatomy of the hand. «, carpal extremity of ulna; b, ex- 
 tremity of radius ; c, semilunar bone ; d, scaphoid ; <•. cuneiform : /, 
 unciform ; g, os magnum ; h, trapezoid ; i", trapezium ; 1, 2, 3, 4, 5, heads 
 of metacarpal bones of the thumb and fingers. 
 
 Fig. 5. — Amputation of the four lingers, with their metacarpal bones. 
 a b, showing the carpo-metacarpal articulation between the trapezoid, 
 os magnum, and unciform for the carpus, and the four metacarpal bones 
 of the fingers ; 6 c, the line of incision extending through the muscu- 
 lar septum, between the thumb and index finger. 
 
 Fig. 6. — The completion of the amputation, a b c, showing the ex- 
 tent of the flap from the palmar surface: <•, on ■ level with the unciform 
 bone, and a, near the root of tho thumb, Indicating the two points 
 through which the palm is transfixed in cutting out the flap, a b c. 
 
 Fig, 7 indicates position of hand and lino of incision in amputa- 
 tion at tho wrist-joint, with palmar flap. 
 
 Fig. 8 shows the flexed position of the hand, and also the position 
 of the knife while opening tho radio-carpal articulation from the back 
 of the wrist, and completing the operation commenced in fig. 7. 
 
FIG % 
 
 F.ra/u umiruy 
 

 fcuu S Cegt—^i, ' , 
 
Plate 4. 
 
 Fig. 1. — Delineations of the prominences upon the heads of the 
 bones forming the elbow-joint. A, humerus ; B, radius ; C, ulna. 
 
 Fig. 2.— Lateral view of the elbow-joint. A, humerus, with internal 
 condyle and epitrochloea ; B, he,ad of radius concealed by C, the head 
 of ulna, with olecranon and coranoid processes— showing the curved 
 line marking out the articulating surfaces of humerus and ulna. 
 
 Fig. 3.— Anterior view of the elbow-joint. A, humerus ; B, radius ; 
 C, ulna, with line of articulating surfaces between the three bones. 
 
 Fig. 4.— The outlines of the bones of the arm and forearm, a c, the 
 points at which the knife transfixes the forearm, and a b c, the outline 
 of the anterior flap for covering the head of the humerus in amputation 
 at the elbow-joint. 
 
 Fig. b.—A B C, the flap delineated fig. 4, turned up, so as to ex- 
 pose the line of articulation as seen in fig. 3, and the position of the 
 knife as it completes the section of the skin on the back of the elbow- 
 joint. 
 
 Fig. 6. — Circular amputation at the elbow-joint, a a, flap of skin 
 dissected up and turned over upon the arm as the cuflF to a coat-sleeve. 
 The edge of the knife, placed behind the arm and looking toward the 
 operator, completing the section of the retentive ligaments. 
 
 Fi '.h 7.— The appearance of the stump after the amputation. B, the 
 head of the humerus, covered with cartilage, with remains of the 
 fibrous capsule, a, the position of the brachial artery in front of the 
 bone. 
 
Plate 5. 
 
 Fig. 2. — Circular amputation of the forearm, the position of the 
 arm to be operated upon, and also the position of the hands of the 
 operator. The first black line above the wrist indicates the line of 
 circular incision through the skin ; b, flap separated from the cellular 
 tissue, and turned up, cuff-like. The second line marks the root of the 
 fold of skin, turned up, and is the litre of section for all the muscles 
 down to the bone. The distance between the second and third line 
 indicates the width of the turned-up flap. 
 
 Fiy. 1 shows the retractor, a piece of cloth thrust between the bones, 
 and drawn backward, to protect the soft parts of the stump from bein^ 
 injured by the saw. 
 
 Fiy. 3. — Flap amputation of the forearm, c e d shows the anterior 
 flap cut up by transfixion, and exposing at b a the radial and ulna 
 arteries in the anterior flap ; c d shows the points at which the knife is 
 again thrust through the arm behind the bones, so as to complete the 
 severing of the muscles by making a posterior flap. 
 
 fig, 4. — The appearance of the stump after amputation of the fore- 
 arm by anterior and posterior flaps; c, cut end of radius; d, of ulna: 
 a, position of the ulna artery ; b, radial artery. 
 
 fig, 5. — Circular amputation of arm. rc, the first circle made through 
 the skin; b, second incision made through the musoles to permit of free 
 retraction; c, third line of incision to the bone, dividing all soft parts. 
 
 Pig, 6. — Appearance of the stump after circular amputation of tho 
 arm. 1, Biceps muscle ; 2, humerus; a, brachial vessels on inner side 
 of stump; b, superior profunda branch of brachial artery. 
 
 Fig. 7. — Outline of stump after amputation by internal and external 
 flaps, showing position of the bono at angle of flaps. 
 
f. i 
 
 r i g 7 
 
F I C. I 
 
 '10. «. 
 
 -&«x/i« if Caysve-u, ^Zt^mhcb, S.C 
 
Plate 6. 
 
 Fig. 1 represents the scapulo-humeral joint ; 6, clavicle attached to c, 
 the accromial process of d, the scapula : c, the head of the humerus 
 secured to the glenoid cavity by the capsular ligament. 
 
 Fig. 2 shows the position of the glenoid cavity, a, in relation to the 
 coracoid process, c, and accromial process, 6. 
 
 Fig. 3 shows the position of the bones of the shoulder in relation 
 to the soft parts, and also the position in which the limb is held by the 
 surgeon while he commences an amputation at the shoulder-joint by 
 external and internal lateral flaps — Lisfranc's method. The point of 
 the knife outers the arm from behind at c, corresponding to the poste- 
 rior of the axillary space or border of the latissimus dorsi muscle, 
 passes obliquely upward, grazing the head of the humerus, and ap- 
 pears at a, which corresponds to an interspace between the coranoid 
 arid accromial processes of the scapula. The lino a b c marks the extent 
 and direction of the flap. 
 
 Wig. 4. — Cutting the internal flap in Lisfranc's amputation, a b e, 
 external flap raised ; d, head of the humerus freed from the glenoid 
 cavity, with capsule divided. The knife has passed through the joint 
 to the inner side of the humerus, and is now cutting out the inner flap. 
 
 Fig. 5. — Larrey's method of disarticulating at the shoulder-joint. 
 a c b, a short perpendicular incision upon the head of the humerus ; 
 c d and c c, two lateral incisions passing obliquely downward, and 
 dividing all the muscles, isolating the joint. 
 
 Fig. 6. — a bed shows the outline of the incision when the arm has 
 been removed by the oval, or Larrey's method ; e, the glenoid cavity, 
 with remnants of capsular ligament ; c, axillary or brachial vessels. 
 The completion of the operation of fig. 5 is seen to be a circular incision 
 passing around the axillary portion of tho arm on a level with the infe- 
 rior boundary of the axillary space. 
 
Plate 7. 
 
 Fig. 1. — Bones of the foot. «. inferior extremity of tibia; b, inferior 
 extremity of fibula; <■, articulating face of astragalus: d, external 
 prominence of os calcis; e, scaphoid ; /, cuboid; y, internal cuneiform; 
 h, middle cuneiform ; t, external cuneiform ; 1, 2, 3, 4, 5, the metatarsal 
 bones, with formation of tarso-metatarsal articulation. Upon this 
 figure the direction of all the articulating surfaces can be studied. 
 
 Fig. 2. — Lateral outline of the bone*, with relation to the soft parts. 
 a d c b traces the line necessary in amputating the big toe, with its 
 metatarsal bone. 
 
 Fig. 3. — A foot, showing the appearance of the flap, abed, after an 
 oval amputation of the big toe; e, head of metatarsal bone ; / h y rep- 
 resent an amputation, with two lateral flaps. 
 
 Fig. 4. — The relation of the bones of the foot with the soft parts, with 
 transverse lines marking the various dorsal incisions necessary in per- 
 forming all disarticulations of the foot. a a, the line of dorsal incision 
 required in amputating the toes ; b b, incision in the tarso-metatarsal 
 amputation, or Lisfranc's ; c c, line of themedio-tarsal, or Chopart's am- 
 putation ; d d, the dorsal incision for Syme's or Pirogoff's amputation, 
 viz : tibio-tarsal amputation. 
 
 Fig. 5. — a b c, amputation of all the toes. The knife has passed 
 through the joints and behind the phalangeal bones to complete the flap 
 from the sole of the foot. 
 
 Fig. 6. — Lisfranc's amputation. Dorsal flap dissected up, exposing 
 the line of articulations, a, the head of the second metatarsal bone, 
 boxed in between the external and internal cuneiform. The figure 
 represents the mode of dividing the lateral ligaments; a b c, the curve 
 which the knife makes. 
 
 Fig. 7. — All the tarso-metatarsal joints opened, and blade of knife 
 passed behind metatarsal bones to make the posterior flap. 
 
 Fig. 8. — The completion of the plantar flap in Lisfranc's amputa- 
 tion. /, the anterior portion of the foot drawn upward ; b, the plantar 
 flap ; d, the mode of holding the knife in rounding off the end of the 
 flap. 
 
 Fig. 9. — Chopart's amputation, or the medio-tarsal, showing how the 
 foot is grasped in the left hand of the surgeon, and depressed while the 
 knife opens the joint formed by the astragalus and os calcis posteriorly, 
 and the scaphoid and cuboid anteriorly; a, dorsal vessels of the foot. 
 
 Fig. 10. — Chopart's amputation completed, ad, dorsal vessels ; e, 
 plantar vessels, on under and inner side of flap; a b c d, size and form 
 of fl;ip fro n sole of foot. 
 

f i o e 
 
Plate 8. 
 
 Fig. 1. — Lateral sketch of foot, with relative position of the bones. 
 The lines traced across the foot showing the direction of the plantar 
 incisions for performing the various disarticulations upon this extrem- 
 ity. This figure should be studied in connection with plate 7, fig. J. 
 a a. a a, the line of the tarso-metatarsal incision in Lisfranc's oper- 
 ation; b b b b. the incisions for effecting the medio-tarsal or Cho- 
 part's amputation : c c c, the incisions for the tibio-tarsal or Synie's am- 
 putation at the ankle-joint. If the incision, c c, from the end of the 
 tibia to the plantar surface of the heel, ran a little more obliquely 
 backwards, it would trace out the incision for Pirogoff's amputation at 
 the ankle-joint. 
 
 Fig. 2. — Syme's tibio-farsal disarticulation. The completion of the 
 operation by separating the tendo achillis from the os calcis. 
 
 Fig. 3. — Completion of Pirogoff's amputation. The inferior extrem- 
 ities of the tibia and fibula removed, exhibiting the general outline of 
 the plantar flap, with a portion of the os calcis embedded in its centre. 
 
 Fig. 4. — The appearance of the stump after Pirogoff's amputation. 
 
 Fig. 5. — Amputation of the leg in lower third, a b, the extremities 
 of the flap formed by a union of the vertical incision with the circular; 
 d, position of posterior vessel; e, peroneal artery ; /, anterior tibial 
 vessels. Lenoir's method. 
 
 Fig. 6. — Circular amputation at the seat of election, the upper third. 
 a b c, the line of incision through the skin for circular flap; d, circular 
 flap of skin turned up like cuff of sleeve, being from two and a half 
 to three inches in length — the knife dividing the muscles to the bone 
 at the base of the flap. 
 
 Fig. 7. — a a, retractor of cloth placed between the bones to protect 
 the stump ; the position of the saw. 
 
 Fig. 8. — Appearance of stump before closed, h, tibia; g, fibula; b, 
 anterior tibial artery and veins in front of interosseous ligament and 
 between the bones; r, posterior tibial vessels behind the tibia; d, pero- 
 neal artery and two veins behind the fibula; /, sural vessels for calf 
 muscles. 
 
Plate 9. 
 
 Fig. 1. — Amputation of leg in upper third by posterior flap, a b c, 
 line in which the flap will be cut by the knife transfixing the calf at a 
 c — the hand of the surgeon drawing back the muscles. The objection 
 to this operation is the size and weight of the posterior flap. After sec- 
 tion of the bones and removal of the limb, a more useful and lighter flap 
 is made by holding the flap upon the palm of the hand, and slicing off 
 a thick layer of muscle from its anterior face. 
 
 Fig, 2 gives the anterior transverse lines for tracing incisions in 
 amputations about the knee-joint, n, fibula; m, tibia; p, patella; o, 
 femur; g h k, circular amputation of leg; d e f, anterior lino of inci- 
 sion, where the amputation is performed with a large posterior flap, as 
 in fig. 1; ab c, anterior incision for disarticulation at knee-joint, as 
 seen in fig. 4. 
 
 Fig. 3. — Anatomy of knee-joint, a, inferior extremity of femur ; b, 
 head of tibia; c, patella enveloped in the anterior ligament or tendon 
 of the quadruceps extensor muscle, called ligamentum patella; ; d, 
 crucial ligaments; e, popliteal artery, lying immediately upon and 
 behind the joint. 
 
 Fig. 4. — Amputation at knee-joint by posterior flap. The operation 
 commenced by a circular incision into the joint just below the patella, 
 which extends through half the circumference of the knee, a b c, form 
 and extent of flap; p, patella; /, femur; d t g, line of incisions in 
 performing the posterior flap amputation of the leg in uppor third or 
 seat of election. 
 
 Fig. 5. — Amputation at knee-joint by anterior flap, a b c, line of 
 anterior flap; t, anterior surface of tibia exposed ; ;>, patella; /, femur; 
 d, anterior flap turned up. The knife is passing through tho joint 
 between the heads of the bones. 
 
rf ,FI 5 
 
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/ 
 
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Pl.ATB 10. 
 
 Fig. 1. — Anterior and posterior flap amputation of the thigh in mid- 
 dle third, cf, line of anterior flap ; b, anterior flap held up by hand of 
 an assistant. In perforating for the anterior flap the operator, with hi? 
 left hand, draws the soft parts on the anterior surface of the leg as much 
 forward as possible, so that the anterior flap will comprise half of the 
 circumference of the thigh. The knife has been again thrust through 
 the thigh and behind the femur, so as to cut out the posterior flap, d. 
 
 Fig. 2. — Appearance of stump after double flap amputation, e, ante- 
 rior flap ; /, posterior flap, separated to show the extremity of the femur 
 deeply embedded in the muscles; g, femoral artery and vein on inner 
 side of flap. 
 
 Fig. 3. — Circular amputation at middle of thigh, c, first incision 
 through the skin ; d, incision through the muscles ; e, final incision to 
 the bone ; f, section of the femur ; a a, retractor around the bone to 
 protect the upper flap, b. 
 
 Fig. 4. — Appearance of stump after circular amputation, a, femur ; 
 b, femoral artery and vein ; c, muscular vessels. 
 
 Fig. 5. — Amputation at hip-joint. Anatomy of the parts, c, point 
 of entrance of knife above great trochanter ; a, exit of the point near 
 inner fold of the groin, the blade in its passage over the anterior sur- 
 face of the hip-joint and head of the femur having divided freely the 
 capsule of the articulation ; a b c, size and form of anterior flap. 
 
 Fig. 6. — Amputation at hip-joint, a, hand of assistant lifting the 
 anterior flap; c c, femoral artery and profunda branch; b, head of 
 femur turned out of the cotyloid cavity, the knife behind the femur 
 cutting out posterior flap. 
 
 Fig. 7. — Double flap amputation at hip-joint completed. Size, form, 
 and direction of flaps. / /, the femoral artery and the profunda 
 branch. 
 
Plate 11. 
 
 Fig. 1. — Resection of the lower jaw. The incision for removing 
 half of the bone from its symphysis to the glenoid cavity, runs along 
 the base of the jaw. a b c, the flap dissected up and held over the tem- 
 ple by an assistant; d, the symphysis of the lower jaw, where the bone 
 has been divided by the saw; e, the lower jaw forcibly drawn out- 
 wards so as to expose for section the pterygoid and temporal muscles, 
 and render disarticulation, of the jaw easy. 
 
 Fig. 2. — Removal of the anterior portion of the jaw, including the 
 symphysis, d, the incision passed through tho middle of the lower lip 
 in the median line, extending under the chin to the hyoid bone ; a b, 
 the ends of the flaps dissected up and drawn aside. The saw is applied 
 to the lower jaw at the canine fossa. 
 
 Fig. 3. — Removal of upper maxillary. The line of incision through 
 the cheek is seen in fig. 4. The flap is dissected up from the bone, and 
 the nasal cartilages separated from the nasal process of the maxilla : 
 the bone is readily isolated from its intimate attachment by passing 
 one blade of a strong Liston's forceps through the mouth, the other 
 through the anterior nares, thereby dividing the roof of the mouth or 
 palate process of the superior maxillary bone. One blade of the for- 
 ceps can again be placed in the upper part of the nares ; the other in 
 the orbit to divide the floor of the orbit. Tho malar connection can be 
 divided with the saw or by the bone forceps, by placing one blade in 
 the orbit, the other in the temporal fossa. 
 
 Fig. 4 shows the curved line of incision from tho zygomatic arch to 
 the angle of the mouth ; also, how the wound is dressed by several 
 points of interrupted suture, and how little deformity results from this 
 resection. 
 
F I 4 
 
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Fit I 
 
 r i c ^ 
 
 F I Q . 4-. 
 
 FIG. S 
 
 
 I 
 
 FIG. 3. 
 
 
 .'<•«. X /.■ 
 
Plate 12. 
 
 Fig. 1. — Resection of the shoulder by a deltoid flap, d, tho flap 
 made from the deltoid muscle turned up upon the shoulder; /;, head of 
 humerus isolated from the glenoid cavity: /, chain-saw passed behind 
 the head of the bone in the act of resecting. 
 
 Fig, 2. — Resection of the shoulder by the straight incision. /, posi- 
 tion of the clavicle; c, accromial process of the scapula; a perpen- 
 dicular incision of five inches in length passing down to the bone, com- 
 mencing at the accromial process ; d d, two retractors or hooks for 
 drawing aside tho soft parts, exposing clearly, a, tho head of the hu- 
 merus ;/, resection of tho sternal end of tho clavicle, the soft parts 
 divided by an incision upon and parallel with the clavicle — the soft 
 parts retracted to expose the bone. 
 
 Fig. 3. — Resection of the elbow-joint. 1, 2, 3, 4, of fig. 4, marks 
 out extent and direction of the incisions; 1, hand of assistant raising 
 the posterior flap; 2, joint exposed; 3, saw applied to, 4, the inferior 
 extremity of the humerus. 
 
 Fig. \. — The H incision, generally used in exposing the elbow-joint 
 forjresoction of the heads of the bones. The method of closing the 
 same by suture when the section of the bones is completed. 
 
 Fig. 5. — Resection at the wrist-joint, removing the styloid process of 
 the ulna. 1, the flap; 2, carpal extremity of the ulna; 3, the blade 
 of a spatula placed under the bone to be divided, so that the saw, 4, 
 cutting against this, can not injure the soft parts. 
 
 Fig. 6. — A hand, with delineations of the bones of tho forearm and 
 carpus. 1, 2, 3, 4, form and extent of an incision which will expose 
 the posterior surface of the radio-carpal joint, and facilitate the remov- 
 al of the carpal extremity of both radius and ulna. 
 
Plate 13. 
 
 Fig. 1. — Resection of the hip-joint; a straight incision, six inches in 
 length, on the outer side of the joint, upon and parallel with the femur, 
 commencing about two inches above the great trochanter, or on a level 
 with the anterior superior spinous process of the ilium. The soft parts 
 drawn aside to expose — a, the femur; b, the great trochanter; d, the 
 head of the femur. 
 
 Fig. 2. — Resection of the hip-joint by means of an external flap, cut 
 from below upwards, by transfixion. 1, the head of the femur dis- 
 lodged from the acetabulum and turned outward, so that a guard can 
 be placed behind the head for the protection of the soft parts from the 
 saw; 3, a chain-saw, placed around the neck of the femur for its re- 
 section. 
 
 Fig. 3. — Resection of the knee-joint. The articulation exposed by 
 making two elliptical incisions from one condyle to the other, including 
 the patella, which is removed. 1, a retractor or piece of cloth passed 
 around the inferior extremity of the femur to retract the soft parts; 2, 
 a guard placed behind the bono to protect them from the saw ; S, 
 the extremity of the femur being removed by, 4, the saw. The t#o 
 round dark surfaces, surrounded by white rings, are the articulating 
 cups upon the head of the tibia. 
 
 Fig. 4. — Resection of the ankle-joint. Tho extremity of the bone is 
 exposed by an L incision, made parallel with the outer border of the 
 bone, and then at right angles across its head ; 2, a chisel, and 3, mal- 
 let, which are the instruments used for dividing the bone. When the 
 section of the bone is effected, a knife divides the ligaments and com- 
 pletes the isolation. 
 
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J 
 
 
 
 
Platb 14. 
 
 Fig. l.—Strnotn re of arteries. «. external or cellular coat, the (ongh, 
 resisting coat of arteries dissected up ; 6, thick elastic muscular or mid- 
 dle coat, also dissected from c, the inner or serous coat. Both the coats, 
 B and C, are divided by the thread in the application of the ligature. 
 
 Fig. 2. — The appearance of an artery after the application of a lig- 
 ature, c d, a ligature applied so as to cut through the inner and middle, 
 which are the brittle coats of the artery. These coats are seen pucker- 
 ed in, have become united, and are continuous on each side of the ves- 
 sel ; 6, clot of blood formed in the upper portion of the vessel ; no 
 clot is seen below tho ligature ; a, the first collateral branch, which leads 
 the blood through a circuitous route, and will take the place of the 
 main channel obliterated by the ligature. 
 
 Fig. 3. — An artery obliterated by a ligature, c, a fibrous band form- 
 ed in the former site of the ligature; b b, fibrinous clots in ends of the 
 artery for the permanent occlusion of the vessel. 
 
 Fig. 4. — Occlusion of the popliteal artery, a, showing how the 
 branches, 6 6 6, given off both above and below the obliterated portion, 
 enlarge and communicate, so as to carry on the collateral circulation, 
 and restore it to the natural channel below the obstruction. Also ex- 
 plains bow the collateral circulation, bringing blood to the lower por- 
 tion of a divided artery, induces secondary hemorrhage. 
 
 Fig. 5. — Mode of securing an artery after amputations, by using a 
 tenaculum, r, loop of ligature upon the instrument ready to be applied 
 to the vessel. 
 
 Fig 6 shows how the femoral artery should be compressed by the 
 thumbs of an assistant in amputations of the inferior extremity. The 
 limb is grasped by both hands, and one thumb placed upon the other. 
 Pressure is only made by one thumb at a time: when the lower one be- 
 comes fatigued, pressure is made by the upper upon the lower; in this 
 way they relieve each other. 
 
 Fig. 7. — The use of the simplest form of field tourniquet, composed 
 of a bandage or folded handkerchief with a knot in it. The knot is 
 placed over the course of the femoral artery, and the bandage tight- 
 ened by twisting it with a piece of stick 
 
 Fig. 8. — The mode of applying the icrew tourniquet 
 
Plate 15. 
 
 Fig. 1. — Anatomy of the hand, showing the course and relations of 
 the termination of the radial artery. 1, band of annular fascia, which 
 binds down the tendons at the wrist; 2, extensor ossis metacarpi pol- 
 licis; 3, extensor primi internodii pollicis; 4, extensor secundi inter- 
 nodii pollicis muscle; a, radial artery in the depression between the 
 tendons upon the back of the thumb. 
 
 Fig. 2. — The incision, an inch long, made in a line parallel with the 
 index finger, and necessary for exposing the radial artery on the back 
 of the hand, a, the artery ; 6, the ligature passed behind it. 
 
 Fig. 3. — Anatomy of the forearm and hand, showing the course and 
 relations of the radial and ulna vessels, a, brachial artery, accompa- 
 nied by b, median nerve ; c, median basilic vein at the bend of the 
 elbow, used in phlebotomy; d, aponeurotic expansion of the tendon 
 of the biceps muscle, under which passes the brachial artery, and over 
 which lies the median basilic vein. As this vein is separated from the 
 brachial artery at the bend of the elbow only by the aponeurotic expan- 
 sion of the biceps tendon, the artery may be readily injured by blood- 
 ing carelessly in this vein. Under this tendon the brachial artery bi- 
 furcates into radial and ulna, g, k, curved course of the ulna artery, 
 accompanied by two veins, and h, the ulna nerve; I, the continuation 
 of the ulna artery under the annular ligament, to form the superficial 
 palmar arch, with branches passing to each finger ; i, tendon of the 
 flexor carpi ulnaris muscle upon its outer side ; j, the tendon of the 
 flexor sublimis digitorum upon the inner sido of the vessel, the artery 
 always lying between these two muscles, being more or less covered 
 by the flexor carpi ulnares ; p t, radial artery, running a straight course, 
 and accompanied by r *, two veins ; q, tendon of the supinator longus 
 muscle upon its outer side; on its inner sido is the flexor carpi radialis 
 muscle. Either of those tendons are used as a guido for finding the 
 artery. 
 
 Fig. 4. — Tracing of the brachial artery with its branches, the radial 
 and ulna, through the arm, forearm, and hand, with size and direction 
 of the incisions required in ligating these arteries in the lower and 
 uppor part of the forearm, a, skin; b, cellular tissue;, c, ulna norve; 
 d, accompanying vein ; a, ulna artery elevated upon the aneurism 
 needle. 
 
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 w 
 
 
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 P- I' 
 
 i.* « Cofavtt.ll, Coti 
 
Plate 16. 
 
 Fig. 1. — Position and relations of the brachial vessels in the arm. 
 A, brachial artery as it appears from the axilla to the elbow ; /•'. the 
 large brachial vein which accompanies it ; B, the basilic vein, also ac- 
 companying the artery; E, the median nerve lying above upon the 
 outer side of tho artery, crossing its course in the middle of the arm, to 
 run upon its inner side, near the elbow; H, inferior profunda branch of 
 the humeral artery, accompanied by A', the ulna nerve; C, coraco- 
 braohialis muscle; T>, biceps muscle, the package containing the brach- 
 ial vessels and nerves always found on the inner border of this mus 
 cle; a, aponuerotic fascia from the tendon of this muscle, forming a 
 bridge at the elbow under which the brachial artery passes. 
 
 Fig. 2. — The direction of the brachial artery traced upon tho inner 
 side of the biceps muscle, with the incision for its ligation, both in upper 
 and lower portion of the arm. a, the artery elevated upon c, tho 
 grooved director ; b, the sheath of the vessel. 
 
 Fig. 3. — Exposure of the axillary space. 1, the pectoralis muscle, 
 forming the anterior boundary of tho space; 3, the latissimus dorsi 
 muscle, forming the posterior wall ; 4, biceps and coraco-brachialis mus- 
 cles on the outer side of the arm ; 5, the origin of the triceps muscle ; 6, 
 superficial fascia which covers and binds down all of the structures of 
 arm ; k, the axillary artery, appearing between the median nerve, (I, 
 and/', the ulna nerve; r, scapula branches of the axillary artery; g t 
 axillary vein; e, the internal cutaneous nerve. 
 
 Fig, 4. — The position of the incision for securing the axillary artery, 
 being in a line with the inner border of the coraco-brachialis and biceps 
 muscles, and corresponding to the junction of the anterior and middle 
 thirds of the axillary space, b, the axillary artery upon the grooved 
 director ; d, axillary vein ; o, median ner\ v ; < , ulna nerve. 
 
 Tt 
 
Plate 17. 
 
 Fig. 1. — Anatomy of the dorsum of the foot, with course of the dor- 
 salis pedis artery, the continuation of tho anterior tibial artery. A, 
 dorsalis pedis artery accompanied by its vein bound down by 1, the an- 
 nular ligament, having, 2, the tendon of the extensor pollieis pedis on 
 its inner side, and 4, 3, the extensor communis digitorum upon its outer 
 side. 
 
 Fig. 2. — Incision upon the ankle for securing the dorsalis pedis arto- 
 ry in a line drawn from midway between the malleoli to the space be- 
 tween big toe and second toe. 
 
 Fig. 3. — Relations of the anterior and posterior tibial arteries. 4, 
 tibialis anticus muscle, hooked forward ; 5, flexor communis digitorum, 
 drawn outward ; A, anterior tibial artery, with B, accompanying vein> 
 lying deeply upon the interosseous membrane between these muscles; 
 8, the extensor pollieis pedis assuming the same position on the outer 
 side of the inferior half of the anterior tibial artery as the flexor com- 
 munis did in the upper half of the leg; c, anterior tibial nerve on the 
 outer side of the artery; 9, posterior tibial artery drawn out from beneath 
 the gastrocnemius and soleus muscles. 
 
 Fig. 4. — 1, 2, incisions made in a line drawn from midway between the 
 head of tibia and fibula above, to a point on the back of the foot between 
 the malleoli; A, the artery hooked up ; 3, incision made upon the inner 
 border of the muscles of the calf, for securing the posterior tibial arte- 
 ry ; A, the artery ; b, the posterior tibial nerve. 
 

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 FIG 2 
 
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Plate 18. 
 
 Fig. 1. — Relations of the posterior tibial artery, A, lying between tho 
 superficial and deep layers of muscles upon the back of the leg, covered 
 in the upper half of its course by 9, the gastrocnemius and soleus mus- 
 cles, and lying upon 8, the common flexor of the toes. In the lower 
 part of the leg the posterior tibial artery lies between 6, the tendo achil- 
 lis, and 7, the common flexor of the toes, which separate the vessel from 
 the face of the tibia; C, the posterior tibial nerve which follows the 
 course of the arter} r ; B, the tibial veins, two of which accompany the 
 vessel 
 
 Fij. 2. — The position of incisions for exposing the posterior tibial 
 artery in its upper, middle, or lower third, in a line drawn from the 
 inner and posterior edge of the head of the tibia to a point midway be- 
 tween the tendo achillis and inner malleolus; 3, an incision through the 
 skin ; 6, the superficial fascia ; d, the inner bordor of the soleus muscle, 
 separated from its attachment to the tibia and drawn outward ; A, the 
 posterior tibial artery, accompanied by two veins, and having the pos- 
 terior tibial nerve in its immediate neighborhood. 
 
Plate 19. 
 
 Fig. 1. — The relations of the iliac arteries, passing through the up- 
 per edge of the pelvic cavity to be continuous, as femoral artery, upon 
 the thigh. 1, portion of abdominal walls ; 2, anterior superior spinous 
 process of the ilium; 3, sartorius muscle; 4, psoas magnus muscle; 5, 
 iliacus internus muscle, upon the lower portion of which, as a bed. lies 
 the iliac vessels and nerves ; A, inferior portion of the aorta bifurcat- 
 ing into E, common iliac artery, which in turn bifurcates, after a course 
 of two and a half inches, into D, the internal, and //, the external iliac 
 arteries. Just before reaching Poupart's ligament the external iliac ar- 
 tey gives off two branches — c, epigastric artery, and e, the circumflex 
 ilii ; G, anterior plexus of femoral nerves lying upon the outer side of 
 the artery ; F, the common iliac vein, passing under the iliac artery to 
 take up a position upon its inner side; K, spermatic cord, with testicle 
 appended. 
 
 Fig. 2. — Continuation of fig. 1, showing the course of the femoral 
 artery A, through the thigh, accompanied by C, the femoral vein, and 
 F, the internal cutaneous nerves : one of these, in immediate juxtaposi- 
 tion with the femoral vessels, passes under the tendinous bridge, 2, in the 
 adduotor magnue muscle — the other runs over the bridge, to become sub- 
 cutaneous and supply the skin on the inner and anterior face of the log 
 and foot ; tho sartorious muscle is drawn upward and outward, so as 
 to expose the femoral vessel running under it; </, the saphenous Vein, 
 emptying into the femoral vein, through the saphenous opening in tho 
 fascia lata, and ou a level with the origin of the profunda femoris arte- 
 ry; 1, Poupart's ligament, forming the base of Scarpa's triangle. 
 
 Fiij. 8 traces the course of the femoral artery, and the direotion of 
 incisions necessary for exposing it in any part of its course. These in- 
 cisions will be found in a line drawn from the middle of Poupart's liga- 
 ment to the inner and posterior edge of the inner condyle of the femur. 
 The three incisions upon the thigh lie in such a line; on tho groin, tho 
 incision is at right angles to the course of the artery ; a, incision in 
 skin; b, superficial fascia; <•, sheath of tho vessels; d, femoral m in M 
 inner side of artery ; A, femoral artery, raised upon the grooved di- 
 rector. 
 
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 F I C 3 
 
 
 
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 VKUU tf Uf :f I .. ■' 
 
 tL 
 
 
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 j 
 
 ft * 
 
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 L 
 
Plate 20. 
 
 Fig. 1. — Anatomy of the nock. 1, the sternohyoid and thyroid mus 
 cles, covering the trachea; 2, the oino-hyoid muscle, running obliquely 
 across tho neck from the scapula to the hyoid bone, and forming two 
 triangles of the deep cervical region — the superior and inferior cervi- 
 cal triangles : 3, the sterno-cleido-mastoid muscle, severed in its lower 
 third — a portion drawn over the clavicle, the upper portion drawn aside 
 by a hook, in order to expose the deep region of the neck which is 
 covered in by this muscle ; 4, the masseter muscle, attached to the lower 
 jaw ; A, common carotid artery, deeply seated below where covered by 
 the clavicle and stemo-clcido-rnastoid muscle, and becoming more super- 
 ficial after passing beneath the omo-hyoid muscle. This artery bifur- 
 cates On a level with the upper border of the thyroid cartilage into inter- 
 nal and external carotid, tho external branch coursing upward in front 
 of the ear; B, the internal jugular vein, running along the outer and 
 posterior surface of the artery, and being much larger than the carotid 
 vessel, it oarers it when distended with blood : V, pneumogastric 
 nerve, running in the BheaiD of the vessels between and behind them ; 
 D, bifurcation of the internal jugular vein, with branches correspond- 
 ing to the bifurcations of the carotid vessel : E, facial vessels ; F, su- 
 perior thyroid artery, the first branch from the external carotid; H, lin- 
 gual artery. 
 
 Fig. 2 represents course of the common carotid and some of the 
 branches of the external carotid artery, a, incision for ligating the com- 
 mon carotid artery in the middle of the neck ; b, incision for exposing 
 the lingual artery: e, incision exposing the facial artery as it runs over 
 the lower jaw, immediately in front of the insertion of the masseter 
 muscle: d, ligation of the temporal artery or terminal branch of the 
 external carotid, in front of the ear. 
 
 /'/■/. 3. — Anatomy of the lower portion of the neck and upper portion 
 of the chest. 1, the clavicle: 2, the great pectoral mUBcle attached to the 
 clavicle; -1, stern-cleido-mastoid muscle; 6, deltoid muscle ; 7, c< ranoid 
 ]M.rti<>n of the pectoralis minor- A. subclavian artery, arching through 
 the subclavicular region, to be continuous as axillary; It, axillary vein, 
 continuous as subclavian, lying upon the inferior and outer side of the 
 artery, and receiving the cephalic vein, (', from the arm ; />, brachial 
 plexat of nerves running behind and posterior to the artery : n, scapu- 
 lar I. ranch of the subclavian artery, running across the root of the neck; 
 rior thyroid artery, ascending from the subclavian. 
 
 />■!. L— -The two fcnoMomi reejuirud in exposing the subclavian and 
 axillary arteries. 2, incision four inches long, parallel with and just 
 above the clavicle : a. subclavian artery: h, the subclavian vein on in- 
 ner sH> r, the brachial | ■ outer side of ar- 
 tcrx 1. incision below and parallel with the clavicle for exposing tlie 
 axillary artery; a, artery ; /-, axillary voin upon it- Utsjssr and ■ 
 
 sci. . 
 
Plate 21. 
 
 Fig. 1. — Anatomy of the head. The scalp and skull removed from 
 the outer half of the head, exposing the brain enveloped in its menin- 
 ges — the thickness of the scalp and skull is distinctly seen ; b b b is the 
 prolongation of the dura mater, called the falx cerebri, between the 
 folds of which is contained the superior longitudinal sinus ; G D, large 
 lateral sinus of the brain which, upon its exit from the skull at the fora- 
 men lascerum posterius, forms the origin of the internal jugular ; a a a, 
 branches of the arteria meningia media, ramifying over the surface of 
 the brain, being partially lodged in grooves in the inner face of the 
 temporal bone. 
 
 Fig. 2 shows the application of the trephine in depressed fractures of 
 the skull, a a a a, the four corners of the crucial flap dissected up and 
 turned out so as to expose the skull. The crown of the trephine is 
 applied to the bone, and the hand of the operator grasps the handle in 
 such a way as to permit of rotation, while the index finger steadies the 
 instrument. 
 
 Fig. 3.— A fracture of the skull, with isolated fragment. A four- 
 sided flap has been dissected up so as to expose the injury, and the loose 
 fragment has been seized by a strong forceps, and is being extracted. 
 
 Fig. 4 shows the stellated fracture produced by a concentration of 
 the force causing the injury. A small portion of the bone has been re- 
 moved to facilitate the application of the lever, so as to elevate the 
 depressed fragments and restore them to their proper position. 
 
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 X 
 
 
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Pi.ati: 22. 
 
 Fig. 1 represents the uianncr of holding t lie Bcrotum in operating for 
 hydrocele, so as to make the sac tense by forcing all tho scrum to the 
 most dependent portion of the scrotal sac. As the testicle is adherent 
 to the back of the sac, the forcing of the fluid in front throws a thick layer 
 of serum in front of the testicle, shielding it from injury when the sac 
 is punctured by tho trocar. This figure also shows how the trocar 
 should be held by the surgeon. 
 
 The following plates show the various methods used in obliterating 
 the enlarged veins in the disease called varicocele: 
 
 Fig. 2. — Incision over the spermatic cord at the junction of the scro- 
 tum with the groin, and isolation of the spermatic artery for ligation in 
 varicocele. The incision extends through the skin, cellular tissue, su- 
 perficial fascia, and proper fascia of the cord, separating the elements 
 of the spermatic cord and permitting the spermatic artery to be secured. 
 
 Fig. 3 shows tho operation of applying a ligature to the spermatic 
 vessels subcutaneously. c, scrotum; b, enlarged cord, under which a 
 double thread has been passed, leaving out the noose, a. 
 
 Fig. 4 shows the subcutaneous application of a double ligature. One 
 double thread passes under the other over the cord, the ends of one 
 passing respectively through the noose of the other, so that, when firm 
 traction is made, as in fig. 5, all the vessels are compressed, and will be 
 finally obliterated. In fig. 4 the vas deferens, b, or spermatic tube from 
 the testicle, is not included in the ligature. 
 
 Fig. 6 exhibits the enlarged convoluted condition of the spermatic 
 veins in varicocele. A pin, a, has been passed behind these enlarged 
 vessels, b. 
 
 Fig. 1 shows the position of the pin, a, transfixing the scrotum, with 
 6 6, a strong thread wound tightly in figure of 8 around the pin, and 
 compressing the vessels between the pin and the thread. 
 
Pi am 
 
 l'i-tula in ano, with method of operating for obtaining a radical cure. 
 
 Fig. I exhibits the appearances of internal ii Btpleti fistula, r, 
 
 rectum : /, fistulous sac in the surrounding cellular tissue, with an ori- 
 fice discharging the secretion of the fistula into the bowel, above the 
 sphincter muscle. 
 
 2 indicates an incomplete external fistula, r, cavity of rectum ; 
 >'. the irregular sac of a chronic abscess, located in the loose cellular 
 tissue around the rectum, having ;in external orifice, O, from which a 
 thin discharge daily escapes. Although the fundus of this sac Lies in 
 juxtaposition with the bowel, and may he separated from it only by the 
 thickness of the mucus membrane, it has no communication with the 
 bowel. 
 
 Fig. '■'< shows how ■ complete tistula in ano has an orifice, a, commu- 
 nicating with the cavity of the bowel, by which pus or the M ration 
 from the fistula is not only thrown into the bowel to oscape by stool, 
 but gases, and even fecal matter, can escape by it and through the fistu- 
 la, to appear at b. the outer orifice or exit upon the buttock. 
 
 Fi<j. 4 shows how the silver flexible probo is pastel into the bowel 
 during the operation for fistula in ano. ,-, oavitj of rectum, with the in- 
 dex linger of the lefl hand of the surgeon passed up into it; », a silver 
 probo entered :it /., the outer orifice, and passed along tho fistula through 
 ((, the inner orifice, until it is forced well into the bowel, when readily 
 felt by the linger; «, the interval of tissue to be divided by the knife, 
 which lies between the probe and the finger. 
 
 / ig. 5. — The parts as above. The finger has been hooked over the end 
 of tho probe, and has drawn the bulb out of the anus and lodged it 
 upon the opposite bnttook. A sharp-pointed bistoury. < . is now run into 
 the groove of the probe in order to >U\ i.i<- t, the Lnton ening tisau< 
 tainingthe sphincter muscle, which is the important structure requiring 
 division. 
 
 Fig. 6. — Tho position of the patient during the operation for fistula 
 in ano. Tin- hand of an assistant separates the buttook, and . 
 perfectly the fistula, with the anus: the surgeon either passes the probe 
 as in fig. 5, and ante upon it, or passes the index linger of the left hand 
 in the anus, and pushing a probe-pointed bistoury through the fistula 
 into tho bowel, keeps his linger upon the extremity of the blade, while 
 ho makes it cut through the intervening septum. 
 
FIG I 
 
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 FIG 3 
 
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Mode afmahn/f tatenam,viA adhesive jihuter 
 
 
 f i c . a . 
 
 I?va/i* § Csasn'M* triwffcfrm, S- C 
 
Plate 24. 
 
 Fig. 1. — An angular splint for the arm, with screw for flexing and 
 extending the splint — an excellent form of splint for straightening con- 
 tracted limbs, or stiffened elbow-joints. 
 
 Fig. 2. — A straight splint for treating fractures of the inferior ex- 
 tremity. 1, 2, bands of adhesive plaster applied around the upper part 
 of thigh, and secured in position bj- S, a circular band of adhesive plas- 
 ter ; counter-extension is made by means of these strips; 4, broad strips 
 of adhesive plaster, to be attached to each side of the leg from the foot 
 to the knee, and tied under the foot; 5, the screw, for drawing the leg 
 downward, and making extension by traction upon the adhesive bands. 
 
 Fig. 3 shows more satisfactorily how the adhesive plaster is applied 
 for making extension in fractures — two broad strips attached to the in 
 ner and outer face of the leg, and secured by two or three circular 
 bands. 
 
 Fig. 4. — Amesbu'ry's splint, or inclined plane, for treating fractures 
 of the leg or thigh, showing also the mode of application. By means 
 of the screw behind the knee, which flexes or extends the splint, the 
 apparatus becomes very useful in correcting deformities from contracted 
 limbs. 
 
 Fig. 5. — An excellent form of double inclined plane for treating all 
 cases of fracture of the lower extremity. 
 
 Fig. 6. — Two simple forms of wooden stumps to be worn after auipu- 
 tatiou of the inferior extremity. 
 
 l'i 
 
Plate 25. 
 
 Fig. 3. — Posterior wire splint of Mayor. M, foot-piece ; j, support 
 for the leg ; D, for thigh ; C, the joint behind the knee. This splint is 
 made of stout wire, with a fine wire passed from side to side, forming 
 an open platform for supporting the limb. 
 
 Fig. 2. — The application of Mayor's posterior wire splint, secured 
 to the limb by bands or soft handkerchiefs, folded in form of cravat. 
 One passing around the ankle, K L M, secures the foot to the foot-piece 
 of the splint : one, H f, attaches the leg firmly to the wire ; the handker- 
 chief,^, secures the thigh firmly to the splint, while B B C passes around 
 the loins and attaches the upper portion of the apparatus to the trunk 
 — a very necessary band for the comfort of the patient and the suc- 
 cessful treatment of the case. N N, 0, the two suspending cords 
 which, uniting in one, allows the limb to be suspended from the ceiling 
 or top of the bedstead. The advantage of this splint is its easy and 
 rapid application, giving but little pain, as it requires but little manip- 
 ulation of the fractured limb. It also exposes the entire surface for 
 inspection, or any wound for treatment, while at the same time it gives 
 a steady support to the entire member. 
 
 Fig. 1. — The application of Mayor's posterior wire splint to a fract- 
 ure of the leg, permitting the patient to get out of bed, and to amuse 
 himself in many ways, without suffering pain or interfering with the 
 progress of the cure. 
 
Pi zs