'•(HUll/bl >^«Jg 3AN TARY COMMISSION /i' >:*t- REPORT MILITARY HYGIE-SE THERAPEUTICS Report of Committee on Militeinj Surgery to the Surf/ical Sec- tion of the New York Aivdemy of Medicine. PRINTED FOR CIRCULATION liY THE SANITARY COMMISSION. Your Committee begs leave respectfully to report that it has directed its attention chiefly to matters of practical interest Avhieh are not discussed in the ordinary books on surgery. The duties of a military surgeon hrvolvc a high degree of responsibility, and upon their skillful and faith- ful performance the efficiency and success of armies is largely dependent. The ancient poet took a correct but altogether too limited view of the usefulness of military surgeons, when he uttered the sentiment— '' A wise physician skilled our wounds to heal Is more than armies to the public weal." The principal duties of the medical staff of the army are ,j A • '// 4. " ■•" . ^. 2 comprehended in the two classes of military hygiene and military therapeutics. The former of these two classes, although it attracts much less popular attention than the latter, is by no means inferior to it in practical importance. The statistics of armies clearly reveal the fact, that a much larger number of soldiers die from disease, resulting from unfavorable hygienic circumstances, than from Avounds in- flicted in battle. Even the dreadful slaughter of Waterloo and Solferino has been exceeded in its desolating poAver by the pestilential diseases, by Avhieh large armies have some- times been invaded. A few examples will suffice to shoAV the extent to which armies have been scourged by disease. Sir David SteAvart mentions " that the 92d regiment lost more officers and men in four months from the climate of Jamaica, than by the hand of the enemy in an active war of 22 years, in the progress of which it was 26 times in battle." Sir James McGrigor, in his account of the diseases of the Peninsular army in 1812, 1813, and a part of 1814, says "that there Avere 68,894 cases of fever, of which 6,703 died, equal to 9.7 per cent.; and 7,526 cases of dysentery, of Avhieh 4,717 died, equal to 62.5 per cent." Sir John Pringle says, "that of the troops stationed during 1747, in South Beviland and the Island of Walcheren, some of the corps were so sickly as not to have more than one hundred men fit for duty, Avhieh was less than the seventh part of a complete battalion." In a paper by Mr. Edmonds compiled from returns in the Adjutant General's Office, it is stated that "in the Peninsular army, averaging a strength of 64,227, including officers and men, the annual ratio of mortality, from the 25th December, 1810, to 25th May, 1813, Avas 10 per cent, of the officers, and 16 per cent, of the men, and that this army had during the above period 3 22^ per cent, constantly sick." In the report of the Brit- ish Sanitary Commission despatched to the seat of Avar in the East in 1856, it is stated that "on the Aveek ending- April 7th, the sick and Avounded amounted to.124 in every thousand, or nearly an eighth part of the army. The Avounded were only five per cent, of this proportion. The force amounted to 31,610 men." After the attack on the Redan, the Avounds amounted to 40 per cent, of the admis- sions, the remaining 60 per cent, being sick. During ten weeks, the admissions from Avounds amounted to 3,858, or 10 per cent, of the force ; and the deaths from wounds to 334 0.37 per cent, of the force. During the same period, the admissions for disease amounted to 18,683=48.7 per cent, of the force, and deaths from disease to 1,309 = .'). 04 per cent, of the force, or at the rate of 17.6 per cent, per annum. Only 17 per cent, of the total admissions, and 20 per cent, of the total deaths, were due to Avounds exclusive of deaths on the field. Bazancourt, in his account of the Expedition to the Crimea, speaking of the operations in the Dobrudscha, says that " General Yusuf had resolved by a night march to fall suddenly upon the body of troops assem- bled around Babadagh, but at the moment Avhen (at about 6 o'clock in the evening) the order for departure Avas given, 500 men lay stretched upon the earth unable to rise. The cholera had fallen like a thunder-bolt upon the expedition- ary column. At 8 o'clock, there Avere already 150 dead, and 350 dying." The pestilence continued its ravages, and the expedition to the Dobrudscha Avas consequently given up. The Avhole number of officers and men sent to the East by the French government, during the period of two years. was 309,268. Of this number 200,000 Avere under treat- 4 ment at the ambulances and hospitals, viz: 50,000 for Avounds, and 150,000 for diseases. The medical officers of the French army arranged their plans for taking care of their sick and Avounded on the basis of the calculation that 10 per cent. would be under treatment at one time. So at the period when the number of their troops was limited to 40,000 they made provision for 4 000 to 5,000 patients. In the attacks of cholera during the Dobrudscha expedition, the propor- tion of deaths to attacks Avas as 1 to 1TV More than 8,000 French soldiers Avere placed hors du comhat by the cholera in the epidemic of Varna and Dobrudscha. At the end of February of the first Avinter in the Crimea, there Avere 3,000 cases of scurvy in the French army, averaging 100 for each old regiment, and 25 for each new one. At the same period the Avounds presented an unhealthy appearance, the granu- lations Avere flabby, and traumatic gangrene Avas frequently observed. In the month of June, 1855, there were 4,000 cases of cholera, and more than six thousand wounds. The medical officers suffered greatly in health from their inces- sant and exhausting labors, about one-third of their number being sick. After the battle of Traktir Bridge in August, 1855, the French surgeons performed 300 amputations and resections. A number of them Avere obliged to Avalk a great distance to the field of action; they Avere occupied Avith dress- ing wounds nearly the whole day, exposed to the heat of the sun, and then returned in the afternoon to the stationary ambulances, to perform urgent operations, Avhieh Avere not completed before midnight. The Malakoff Avas taken in Sep- tember, 1855, after 316 days of hard Avork and fighting in the trenches. A million of sand-bags and 80,000 gabions had been employed. There had been 600,000 discharges of cannon and mortars. Twenty leagues of trenches had been i) opened. After the taking of the Malakoff, the French sur- geons had the care of 5,000 Avounded persons, including many of the Russians. The Avhole number of patients under treatment at that time in the French ambulances was 10,520. In one division three surgeons and an apothecary had the entire care of 900 patients. The number of the Avounded after the battle of the Tchernaia was 2,474. viz: 810 French and 1,664 Russians coming under the care of the French sur- geons. T}Tphus fever broke out in the French army in De- cember, 1*55; in that month there Avere 734 cases. In Jan- uary there Avere 1,523 cases. During the tAvo months, 787 cases terminated fatally. In February there Avere 3,402 cases, of which 1,435 Avere fatal. The disease attacked large numbers of persons Avho had been previously sick Avith other diseases. Every other disease seemed to be transformed into this terrible scourge. Seventy-five French surgeons in the Crimea Avere sick Avith typhus, and thirty-one died of it. Scrive says, that "the losses occasioned by the most mur- derous battles do not equal one-fourth of the total losses to which an army is ordinarily subjected." Scrive. in report- ing the sanitary condition of the army in February, 1856, makes the folloAving remarks: "The regiments were not all attacked in the same degree. The proportion of the sick bears a close relation to the energy of the exciting causes. Thus, but few patients were found in the 17th battalion of chasseurs—10 out of 450 men. This battalion is comfort- ably quartered in barracks of good elevation: the ground is carefully paved: each soldier has a bed raised thirty centi- metres, or about twelve inches, from the ground. Perfect cleanliness is obsen^ed throughout. The sea of mud of the adjoining streets is replaced by a stone pavement. Great care is taken as to diet, and vegetables are never Avanting. 6 The chasseurs are a chosen body of robust and intelligent men, and the site of their encampment is a very healthy one. The 85th regiment is the worst treated of all; it counts about 200 patients, waiting until places can be found for them in the hospitals. This regiment is badly sheltered, and presents all the causes of disease in an exaggerated state. Among the other regiments, the 57th has nearly 200 sick, the 10th has 150, the 61st 200, the 6th dragoons 40, 7th dragoons 30, 4th hussars 50, infantry of marine 20, engi- neers 13, artillery 100. In all these regiments there is not a single ease of sickness among the officers, Avho are better lodged and fed." The Avhole number of French troops sent to the army of the East, as already mentioned, Avas 309,268; the whole number of deaths Avas 69,229. Of this number there Avere 7,500 Avho were killed on the battle-field, or not afterwards heard from. The total attacks of cholera in the French army of the East amounted to 18,400. Of this num- ber 11,000 Avere fatal. Attacks 1 to 15 of the army; deaths 1 to lT6dths of the cases. The total attacks of typhus Avere about 35,000; total deaths from the same disease 17,515. The AAdiole number of cases of diarrhoea Avas 19,339, of dys- entery 6,105. Scurvy prevailed to a great extent during the severe cold of Avinter, and during the sultry heat of sum- mer, but almost disappeared during the spring and autumn. Scrive says that '' the single efficient cause of scurvy Avas the absence of fresh vegetables." He adds, "Scurvy, like typhus, can be created at Avill." A considerable number of French soldiers died from exposure to cold, frosted limbs, etc. Most of these wrere intemperate persons. Among the wounded in battle, 1 in 5 died on the field, the proportion being the same in the three battles of Alma, Inkerman, and Traktir bridge. The proportion of amputations was about 7 1 out of 6 Avounded. During the first five or six Aveeks of the siege, the health of the troops Avas good, and the wounds pursued a favorable course; at a later period the wounds did not do as Avell. From the facts Avhieh have been presented, it is very evident that the lives of military men are much more en- dangered by disease than by Avounds received in battle. It is then one of the highest duties of an army surgeon to make himself well acquainted Avith the correct principles of military hygiene, and to exert his influence to the great- est possible extent in promoting the health and physical energy of the soldiers Avho are entrusted to his care. Your Committee proposes to consider the subject of military hy- giene in some of its most important details. I. The selection of a ground for encampment. It is a matter of the utmost importance, AArhenever it is practicable, to avoid encamping in a malarious district. The camping ground should be dry, moderately elevated, and Avith a sufficient slope to prevent Avater from stagnating when it rains. It should be in the vicinity of pure water for drinking and Avashing, and there should be an abundant supply of fuel for cooking. The Avant of Avater in the vicinity of an encampment is a very formidable evil. When the French army, after the battle of Alma, encamped near the village of Mackenzie, they found but tA\To or three Avells. which Avere soon exhausted. The soldiers called the camp "the camp of thirst." They endured great suffering in consequence of the Avant of Avater. In selecting a site for encampment on the banks of a river, care should be taken to guard against the danger of inundation by a rapid rise of the water, from melting of snoAAT, or from a sudden fall of 8 rain. If military necessity should require an encampment in the neighborhood of an extensive marsh, the ground should always, if possible, be selected on the Avindward side, so that the prevailing Avinds should carry aAvay the noxious emanations from the soil. When soldiers are ex- posed to cold an,d damp air without suitable protection, the injurious effects of such exposure Avill be diminished by the judicious use of camp fires. In malarious districts, the protectiAe use of the sulphate of quinine is to be highly commended. Each man may take three to ten grains daily, according to the intensity of the malarious influence. It may be taken in one dose at bedtime. II. The construction and arrangement of tents, and other means ichich are employed to protect the soldiers from the weather. Tents should be made of a. strong material and of close texture, so as to perfectly exclude the rain. The ground on Avhieh the soldier lies should be covered with boards, with straAv, Avith twigs of pine, hemlock, or cedar, or with India-rubber cloth, to exclude the moisture from beneath. In hot Aveather, where there arc no shade trees, the tents should be double to exclude the solar heat, and ventilation should be afforded on the shady side. There should also be openings for ventilation at the upper part of the tents to carry off the heated gasses which accumulate in those re- gions. A sufficient number of tents should be provided to preArent overcrowding, and if, in any emergency, it should be necessary to crowd an unusual number of persons in a tent, the evil should be counterbalanced, as far as circum- stances Avill permit, by increased ventilation. The tents should not be allowed to remain many days in the same position, as the ground which they cover absorbs the eman- 0 ations from the body and thus vitiates the air. In fine weather the tents should frequently be taken doAvn in the morning and put up again in the afternoon or eA^ening. Every fine day the clothing and bedding should be freely exposed to the outer air. A sufficient space should be alloAvcd between the tents to admit free ventilation. When the tents have been removed to a neAV ground, unless it be to a great distance from their former site, the ground from which they have been removed, should be purified by sprinkling it freely with charcoal, lime, or other disin- fecting agents. When circumstances forbid the removal of the tents, the ground may be purified by a similar use of antiseptic agents. The French army surgeons in the Crimea used sulphate of iron as a disinfecting agent. It avrs dis- solved in fifteen times its weight of Avater. Three litres were used to disinfect a square metre of ground. It was also poured on collections of filth, faeces, Ac. A litre is a little more than a quart ; a metre is about thirty-nine inches. When soldiers are making forced marches, and means of rapid transportation arc insufficient, as they usually are on such occasions, it is better to dispense Avith the use of tents. and to sleep in the open air, as a more abundant supply of food, clothing, blankets, and other articles which are more indispensable to the health and comfort of the troops, may thus be transported. When an army is to be encamped during the Avinter, wooden huts are to be preferred to tents, as affording better protection to their inmates. In the con- struction of these huts, it is very important to make ample provision for efficient ventilation, and to avoid overcroAvding. There should be openings for ventilation at the ends, sides, and ridge of each hut. They should also have projecting eaves—boards to protect the sides from the heat of the sun, 10 and to prevent the entrance of rain or snow through the openings Avhieh are left for ventilation. They should be whiteAvashed with lime Avithin and Avithout. Care should be taken to prevent accumulations of Avater about tents or huts. The ground should be sloping, and Avhenever it is necessary, trenches should be dug to carry off the Avater. When an encampment is to remain long in one place, and the ground is tenacious of moisture, the streets betAveen the tents or huts should be paved. III. The disposition of excrements and offal. Pits should be dug on the leeAvard side of the camp, and ordinarily at a distance of not less than two hundred yards. They should be at least four feet in depth, and the bottom should be covered with charcoal. Such offal as cannot be consumed by fire should be throAvn into the pits each day, and then covered Avith charcoal and a feAv inches of earth. When the matter reaches within two feet of the surface, cover Avith charcoal, and fill up with earth a little above the level of the adjacent surface. No pit should be dug for such purposes near any source from Avhieh Avater is supplied to the camp. Dead animals and offensive offal should be buried immediately, at such a depth that at least three feet should intervene between their upper surface and the level of the ground. Before the pit is filled in, the carcass or offal should be covered with charcoal. Similar precautions should be observed in the interment of human bodies. After a severe engagement, attended Avith great loss of life, the bodies should be interred in trenches eight or ten feet in depth. When offensive emanations arise from the ground, in conse- quence of the decomposition of organized substances, the surface should be covered with deodorizing materials. The British sanitary inspectors in the Crimea recommended for 11 this purpose a compound consisting of one part of peat char- coal, one part of quicklime, and four parts of sand or gravel. M. Scrive, medical inspector of the French army in the Crimea, recommended a solution of chloride of lime for the same purpose. He sometimes directed the solution of sul- phate of iron to accomplish this object. He also directed the bodies of men and animals to be covered Avith a thick stratum of lime, after being buried at a proper depth. IV. Clothing. Flannel should be Avorn next to the skin. The clothing should be light, and should be so adjusted as not to interfere with the most perfect freedom of muscular action. Each soldier should be provided Avith one or more blankets, for protection during the night. The clothing should be washed and thoroughly dried as often as circumstances Avill permit. From the first of October to the end of May, each soldier should be provided with a thick overcoat to protect him from cold and stormy Aveather. The feet should be covered with stockings and stout shoes, Avith broad soles and Ioav heels. The shoes should not be tight so as to pinch the feet, but they should not be excessively loose. Great care is re- quired Avith fresh recruits, to prevent the feet from becom- ing sore. If the heel becomes slightly chafed, the part should be at once covered Avith adhesive plaster. For Avant of this simple precaution many soldiers have become disabled, and have thus fallen into the hands of the enemy, and in contests Avith savages have lost their lives. In hot weather, the heads of the soldiers should be protected by means of straw hats or of IlaA'elocks. 12 V. Supply and preparation of food and drinJcs. This is a subject of great importance to the health and ef- ficiency of armies, and the neglect of which is apt to be fol- lowed by the most disastrous consequences. It is highly important, not only that the supply of food should be ample, but that its quality should be good, and that it should be in such a form that it can be prepared for use as speedily and with as little labor as possible. Hard biscuit or pilot bread may be furnished alternately Avith soft bread ; and care should be taken to prevent the use of any bread of inferior quality. Butter and cheese may be added -with the morning and eve- ning meal, on Avhieh occasion coffee or tea should also be provided. The coffee Avhieh is furnished to the men should be already roasted and ground, so that it can be prepared with little labor. There should always be a sufficient allow- ance of sugar and milk. Where fresh milk cannot be obtain- ed in sufficient quantities, solidified milk may be used as a substitute. There should be a regular allowance of meat and vegetables at dinner, Avhcncver it-is practicable to fur- nish them. Soldiers should not be confined for a long time to salted meat ; but fresli meat should always be allowed whenever it can be obtained. The use of fresh vegetables is of very great importance as a means of guarding against scurvy. There are many herbs or Aveeds groAving in the fields and by the roadsides, Avhieh can be employed for this purpose Avhen better vegetables cannot be obtained. Thus the French soldiers in the Crimea derived the greatest ad- vantages from the use of dandelion, (Leontodon Taraxacum,) dressed with oil and vinegar, and eaten as a salad. Fruits should also be provided in their season, either in a fresh or dried state. When fresh vegetables cannot be obtained, their 13 place may be in part supplied by the use of vegetables desic- cated in a rarified atmosphere. There seems to be no good reason why soldiers should not be fed as well, under ordinary circumstances, as the better class of laboring men at home. It would be very desirable that there should be at least one good cook for every company of soldiers, as the Avholesome- ness of their food depends very much on the manner in which it is prepared. Gen. Scott is reported to have said, that a man who cannot make good bread is not fit to be captain of a company. An ample supply of good water, for drinking and cooking, is a matter of great importance to the health and comfort of soldiers. It would be avcII if every regiment were supplied with a distilling apparatus, by means of which the water of marshes or even of the ocean could be purified. Distilled Avater, agitated so as to mix with it a sufficient quantity of air, might often be substituted with great ad- vantage for the impure and unAvholesonie water Avhieh sol- diers are compelled to drink. Great care should be taken to guard against the excessive use of alcoholic drinks. It would be Avell for the young men in our armies to make no use of these beverages, except when they are prescribed for medicinal purposes. There can be no reasonable doubt that the health of ar- mies has been in many instances greatly impaired, and that multitudes of valuable lives have been lost in consequence of the insufficient quantity or the bad quality of the food which has been furnished. The errors which have been committed in this respect have sometimes been due to mis- takes at headquarters, sometimes to a want of knoAvledge or of attention on the part of the commissaries of regiments, and sometimes to the knavery of contractors, who have committed wholesale murder by depriving the soldiers of the 14 full supply of good food Avhieh they have engaged to fur- nish, and for which they have receiA'ed ample compensa- tion. It is not improbable that the Austrian army Avas defeated at Solferino in consequence of the soldiers being exhausted by long fasting, the Commissary General having appropriated to his OAvn use the funds which were furnished him for the purpose of providing rations for the army. It is important that the rations of the soldiers should, under ordinary circumstances, be issued daily. When rations are distributed at one time for several days, there is often at first an unnecessary waste, in consequence of Avhieh the soldiers afterwards suffer from want, or supply themselves by plunder. With regard to the hard biscuit usually fur- nished to the soldiers as a part of their diet, M. ScriA^e says, that it should be made thinner and more friable, as by its thickness and hardness it irritates and inflames the gums. M. Scrive also says, that when fresh meat cannot be supplied to the army, it should be replaced by preserved meats and soups; and that salt beef should, as far as possi- ble, be abandoned as ah article of food for soldiers, espe- cially in long campaigns and in distant regions, as it is very apt to become spoiled. Borden's meat biscuit may be a valuable article of diet Avhen fresh meat cannot be obtained. When soldiers have long been confined to the use of salted and smoked provisions, and fresh meat is afterwards libe- rally supplied to them, they are very apt to be attacked with severe and often fatal dysentery. The precaution should therefore be adopted to furnish to the men at first a very limited supply of fresh meat; the quantity may be gradu- ally increased, as they become accustomed to its use. The dysentery, occurring under these circumstances, is stated by 15 Dr. HeAvitt, formerly surgeon in the U. S. army, to be most readily cured by purging Avith sulphate of magnesia. VI. As a means of preserving the health of soldiers, great care should be taken, as far as military necessities Avill alloAv, to avoid excessive and exhausting labor, and to allow ample time for sleep. There is no doubt that a large part of the mortality among the troops Avho Avere engaged in the Crimean war Avas OAving to the perhaps unavoidable violation of these rules. The men Avere engaged in almost incessant labor, and their sleep Avas very often disturbed, Avhile, at the same time, they A\rere exposed to the heat and cold, rain and snow, wdth very insufficient protection. Whenever it is necessary to haA^e a large amount of labor performed, it is better, if practicable, to hire laborers, than to require an excessive amount of work from the soldiers. Under the head of military therapeutics are to be con- sidered the preparations Avhieh are required for the practice of medicine and surgery under the peculiar circumstances attending the movements of armies, and the actual treat- ment of diseases and injuries occurring under those circum- stances. In laborious marches, in obstinate and protracted sieges, in sudden and unexpected assaults, in severe and bloody engagements, the military surgeon is called in rapid succession to the treatment of large numbers of sick and wounded soldiers. There is no time for calm deliberation and careful preparation; he cannot send his prescriptions to an apothecary, nor can he send to a manufacturer for neAV instruments or apparatus. The feAV medicines, instru- ments, and dressings which he requires, must be at hand, or his patients must be deprived of the benefits Avhieh they would have derived from them. A Avise foresight must 16 therefore be exercised in providing such materials as are indispensable to the care of the sick and Avounded, and in conveying them to every place Avhere they may be needed. All bulky and heavy articles which are not absolutely es- sential should be dispensed Avitb, on account of the diffi- culty and delay in conveying them from place to place. The best Avay of con\Teying the apparatus of an army sur- geon is a box-cart, similar to those Avhieh are often used by pedlars. In going over a country too rough for wdieel car- riages, a pair of panniers slung over the back of a horse or mule is the best substitute for a cart. The Aveight of the panniers Avith their contents should not exceed 200 lbs. Each surgeon should be provided Avith a case of amputat- ing and trephining instruments, Avith scalpels, bistouries, lancets, and other instruments for minor operations. He should ahvays have about his person a good case of pocket instruments, and a canteen containing Avine or brandy and water, ready to be used as a cordial in any case of emer- gency. He should also carry in his pocket a phial contain- ing pills of opium. In the cart or panniers containing his apparatus there should be a supply of sponges, bandages, lint, toAv, cotton batting, old linen or muslin for compresses, ligatures, tin basins, splints, adhesive plaster, pins, needles, matches, candles, catheters and bougies, a stomach-pump, an enema pump, and a suppository syringe. There should be a dozen tourniquets, and the orderly men, Avho act as assistants to the surgeon, should be instructed in their ap- plication. There should also be a supply of anaesthetics and of medicines suitable to the emergencies of military life. On the field of battle, each surgeon should be imme- diately followed by an orderly man, bearing a knapsack, containing a feAv of the most indispensable instruments and 17 dressings for immediate use. Previously to an engagement, a certain number of men from each company should be de- puted to take charge of such soldiers as may be wounded, and to remove them at once to a place of safety in the rear of the army. For this purpose, litters should be at hand, made of stout canvas, Avith stretchers, and provided Avith rings, into Avhieh bayonets or poles may be inserted. Am- bulance carts should also be brought as near as possible to the scene of the engagement, and the wounded soldiers should be speedily deposited in them, and driven off to the place selected, Avhere they may receiATe proper surgical at- tention. ■The U. S. Army medical board recommend that the fol- lowing; schedule of transports for the sick and AArounded, and for hospital supplies, be adopted for a state of Avar with a civilized enemy : "For commands of less than three companies, one tAVO- wheeled transport cart for hospital supplies, and to each company, one two-Avheeled ambulance. " For commands of more than three and less than five companies, two two-Avheeled transport carts, and to each company, one two-Avheeled ambulance. "For a battaliou of five companies, one ibur-Avheeled ambulance, five two-Avheeled ambulances, and tA\*o tA\o- wheeled transport carts. For each additional company, less than ten, one two-wheeled transport cart. "For a regiment of ten companies, two four-wheeled ambulances, ten two-Avheeled ambulances, and four two- wheeled transport carts : and for greater commands in pro- portion." Also, that "horse-litters may be prepared and furnished to \)oM^. Avhence they maybe required for service on ground 18 not admitting the employment of tAvo-Avheeled carriages ; said litters to be composed of a canvas bed similar to the present stretcher, and of two poles, each sixteen feet long, to be made in sections with head and foot pieces, construc- ted to act as stretchers to keep the poles apart." Also, that "the allowance of hospital attendants in the field Avill be, for one company, one steward, one nurse, and one cook ; for each additional company, one nurse ; and for commands of over five companies, one additional cook." The Army Board also recommend hospital tents of the folloAving dimensions: "In length 14 feet; in Avidth 15 feet ; in height (centre) 11 feet, Avith a Avail 4| feet, and .a fly of appropriate size. The ridge pole to be made in tAvo sections, and to measure 14 feet when joined." The Board contemplate that such a tent will accommodate 8 to 10 pa- tients comfortably. It is evident, hoAvever, that the space allowed for each patient is altogether too small, amounting to only a little more than 160 cubic feet for each patient. In making arrangements for the care of sick and wounded soldiers, there should be hospital tents erected as near as possible to the field of battle, so that dressings and opera- tions Avhieh are urgently required, may be performed with- out any unnecessary delay. There should also be regi- mental hospitals, Avhieh may be constructed as tents, huts, or more permanent buildings, according to the season of the year and the character of the military operations. Each regimental hospital should have accommodations for fifty to one hundred patients. There should also be gen- eral hospitals at the base of operations, and in these there should be ample accommodations for all the patients which may be sent to them from the regimental hospitals, or di- rectly from the camps or the battle-field. The regimental 19 and general hospitals should contain sufficient space to al- low not less than eight hundred cubic feet of air for each patient. The horizontal space should be not less than 6 by 6 feet for each patient. Large public buildings, such as churches, concert-rooms, and public halls, are commonly employed as general military hospitals. It is often neces- sary to make extensive alterations to adapt them to their new use. Special regard should be paid to ATentilation. The doors and AvindoAvs usually require to be enlarged, es- pecially in an upAvard and doAvmvard direction : or numer- ous holes six inches square may be made through the Avails near the floors and ceilings. There should be doors and AvindoAvs opposite to each other, so as to alloAv the air to pass freely through in all directions. The patients should not be placed in stories below the level of the ground, or but slightly raised above it, as experience has shoAvn that the upper stories are much more salubrious. The beds should be raised from the floor, being placed on iron bed- steads Avhenever they can be obtained. Xo tAvo bedsteads should be in contact, and none should touch the Avails of the room. No unnecessary articles should be in the Avards, as they occupy valuable space, and absorb noxious vapors. Care should be taken that the AvindoAvs do not open upon any receptacles of foul air. Besides the principal hospital buildings there should be small detached houses reserved for special cases. Near the entrance of the toAvn some building or tents should be selected as a receiving hospital, where the Avounded should be brought and properly cleansed, AA'ounds dressed, and suitable hospital clothes provided ; and then they should be forwarded to the per- manent hospital. Great attention should be paid to priA'ies and drains connected with the hospital, to prevent them 20 from contaminating the atmosphere. Patients who arc able to rise from their beds should eat in adjoining rooms or tents. The wards of the hospitals should be divided into three classes, viz: surgical, medical, and convalescent. To every division of one hundred beds there should be at least one Avard superintendent and six orderly men. When the hospital is prepared, the compound fractures should be placed in the most accessible wards, and injuries of the same character should be placed in the same wards. When wine or spirits are directed, the surgeon should see them administered. To preserve the purity of the air, the wards should be frequently whitewashed with lime. The adjacent grounds should be well drained, and the sewers should be frequently flushed. Excretions should be as soon as possible removed from the wards. The tem- porary hospitals attached to camps are subject to terrible mishaps. Bazancourt speaks in the following terms of the effects of a hurricane upon the frail structure used as a military hospital by the French army in the Crimea: "The ambulance barracks are shattered by the fury of the wind; and whilst their roofs, carried up in the air, whirl around and disappear, the broken timbers fall upon the Avounded and the sick, whose beds are overturned into the pools of rain Avhicli inundate them. Most of the patients are unable to move, being quite prostrated by illness, or by severe Avounds. and lie Avaiting with resignation that which the will of God may determine respecting them." In the French army in the Crimea each ambulance for ten thousand men had three caissons, containing materials for six thousand dressings, and eighteen complete tents. Fly- ing ambulances on mules' backs were provided for regions where carriages could not go. As an example of the mariner 21 of taking care of the Avounded during and after an engage- ment, your Committee presents the following directions given by M. Scrive to the medical officers of the French army in .lune, 1855 : "At the ambulance of the trenches shall be assembled before the battle the non-combatant sol- diers—the musicians of the regiment for example, with the infirmary men disposable in the different services. One or several officers of administration -will direct them in the trenches to take up the Avounded, and transport them to the ambulance. An officer of administration having a fixed position at the ambulance, Avill attend to placing the A\~ounded, on their arrival, in an order ahvays the same, and determined beforehand to avoid confusion. The visits to the Avounded shall be made by one or more surgeons, assisted by two or more infirmary men carrying dressings, ivc.; one of these last Avill inscribe the name of the patient, his regiment. and his matriculated number. The surgeon Avill determine Avhether the Avound requires to be dressed immediately, or if the patient can be at once transported to the ambulance of the division. In the first place, the wound may be dressed on the spot, or if an immediate operation is re- quired, the patient may be conveyed into the operating room. After the dressing or operation, the patient may be placed upon the litter or ambulance cart. Where four to six Avounded persons are ready, they shall be conveyed to- gether to the ambulance of the division ; and in these little successive journeys, the muleteers, under the direction of an officer commanding the train, shall betake themselves to the ambulance, whose number shall have been designated by the military sub-intendant or his aid, who shall mark upon the list of vacant places, at the different stationary ambulances, the names of the Avounded Avhom he Avill send 99 there successively. In this manner the exact situation of the ambulances will be precisely known. When the Avounded are very numerous, no operations shall be performed, excepting those Avhieh are absolutely necessary. One- third of the surgeons shall be constanly occupied in visit- ing the Avounded, and judging as to the necessity of im- mediate operation or dressing, especially Avhen the num- ber of the AATounded is large ; the remaining tAvo-thirds shall attend to the necessary operations and dressings, fol- lowing, except in cases of great urgency, the order of ar- rival and the rank of the patient. In the ambulance of the trenches, the services of the infirmary men may be conve- niently divided in the following manner ; two infirmary men for each surgeon engaged in dressing ; tAvo infirmary men for each surgeon on his visits—one to write, and the other to assist the patient to get on the litter; four infirmary men for an operating table ; and, finally, eight to twelve infirm- ary men engaged as porters, to attend to the transportation of the Avounded. It is very important to prevent the croAvd- ing of the ambulance of the trenches by soldiers Avhose aid is not required. A guard should therefore be placed at the door to prevent such persons from entering. In the ambu- lance of the division, on the day of battle, two surgeons should be on duty to receive the Avounded coming from the trenches, and to examine minutely each wound. They shall make a definitive dressing in cases Avhere an immediate op- eration is not indicated." The general practice of the French surgeons in the Cri- mea Avas to extract foreign bodies from Avounds at an early period, whenever they Avere easily accessible. The most efficient styptics in arresting hemorrhage, Avhere the blood- vessels could not be conveniently tied, were the perchloride and the persulphate of iron. Amputations Avere generally 2o resorted to in severe injuries of the limbs, and the results Avere more favorable than when conservative surgery Avas attempted. Primary amputations were much more success- ful than secondary. Scrive makes an exception to this rule in the case of amputation of the hip-joint, Nine primary amputations at this joint were performed by the French sur- geons in the Crimea, and in all death took place within a feAv hours after the operation. There were three consecu- tive amputations at the hip: the patients severally lived five, tAvelve, and tvventy days. Resections Avere generally fatal, except in the upper extremity. Scrive remarks, that when amputation was performed a day or two after an injury, it Avas much more difficult to induce anaesthesia than when the amputation was performed on the same day. The amputa- tions were as follows: hip, 12; thigh, 1,512; knee, 58; leg, 915; foot, 241; toes, 220; shoulder, 168; arm, 912: elbow. forearm, and Avrist, 278; hand and fingers, 282. The average dressings for each patient were: of linen, 2,482 grammes: roller bandages, 891 grammes; charpie. 1,181 grammes. The weight of dressings during the campaign amounted to 196,000 kilogrammes. (A gramme is about 15 grains; a kilo- gramme 2 lbs. 8 oz. troy Aveight.) AArerage number of dress- ings for each Avounded person, 35; total number of dressings, 1,400,000. Number of surgeons Avounded by the fire of the enemy and by the explosion of magazine, 19. One died in consequence of his Avounds. The labors of the surgeons Avere excessively severe. Each surgeon, on an average, Avas obliged to visit daily more than 100 patients. Eighty-three French army surgeons died during the Avar. It is very evi- dent that the amount of labor thrown upon the medical officers of the French army Avas unreasonably great, and that the number of these officers should have been largely 24 increased. When an army is called into active service, and is exposed to pestilential diseases and to bloody engage- ments, a much larger amount of medical service is required than can be reasonably expected of a surgeon and an assist- ant surgeon to each regiment. Your Committee does not consider it necessary to enter into the details of the treatment Avhieh is required in gun- shot Avounds, and in other injuries to Avhieh soldiers are exposed, as these subjects are treated at considerable length in the text-books of surgery, Avhieh are in the hands of most of our practitioners. There are, hoAvever, some practical lessons to which a passing allusion may be made with advan- tage. When the attention of an army surgeon is first direct- ed to a number of wounded persons, Avho have been brought from the field of battle, it is important to determine the order in which his services should be rendered to them. In order that the greatest amount of effectual relief may be afforded, certain rules may be laid doAvn for the guidance of the surgeon under these trying circumstances. The cases to Avhicli the first attention of the surgeon should be given are not those of so severe a character as to be almost neces- sarily fatal, nor, on the other hand, those which are com- paratively slight and unattended with danger. But his first attention should be directed to injuries Avhieh are severe and dangerous, but Avhieh at the same time afford a good pros- pect of recovery. The cases most urgently requiring imme- diate treatment are those in Avhicli there is alarming hem- orrhage, the source of Avhieh is not beyond the reach of sur- gical skill. The cases next in order of urgency are those in Avhieh, from the shock of the injury, there is more or less prostration, requiring the use of cordials and stimulants. Then come the cases of compound fracture, some of these 25 requiring amputation or resection, and others mechanical support to prevent distortion and the irritation arising from muscular spasm, causing spiculae of bone to penetrate the soft parts. Next in order come the slighter cases of injury of the viscera, always attended Avith danger, but not neces- sarily fatal. After disposing of those cases which are more or less hopeful, the surgeon may direct his attention to the comfort and relief of the more severe injuries, in which a fatal result is almost certain to ensue. And lastly, he may attend to the minor operations and dressings in cases of injury Avhieh are not regarded as dangerous to life. The result of primary amputations at the hip-joint is so uniformly disastrous, that, in the opinion of your Commit- tee, these operations should be discarded from military surgery. If the patient should in any case recover from the shock of the terrible injury Avhieh seems to require so formidable an operation as amputation at the hip-joint, the operation may be performed consecutively Avith better pros- pect of success, Avithout diverting the attention of the sur- geon, at this period, from a more hopeful class of cases. There is another subject Avhieh your Committee would bring to the notice of the surgical section of the Academy, viz: the injurious consequences resulting from the hasty removal of the sick and Avounded by a discomfited and re- treating army. Under these circumstances, your Commit- tee would suggest the expediency of leaving the sick and wounded, with a sufficient number of medical attendants, to fall into the hands of the enemy as prisoners of war, in all cases in Avhieh there is a large number of patients Avhose lives Avould be greatly endangered by the removal, and in whieh reliance could be placed on the magnanimity of the victorious party. There might be a previous understand- 3 26 ing betweon the belligerent parties, that hospital buildings, or tents, so abandoned, and surmounted by a flag of truce, or some other preconcerted signal, should be safe from attack. There is another subject to Avhieh the attention of the section might have been directed at an earlier part of the report, viz: the importance of a thorough inspection of re- cruits Avho present themselves for admission into the army. The admission of sickly and feeble men into an army is an evil of the greatest magnitude, not merely depriving the government of the services of such individuals, but exert- ing an injurious influence upon the health, spirit, and efficiency of their comrades. Every recruit should there- fore undergo a most thorough inspection, and if deficient in the physical qualities Avhieh are necessary for a soldier, he should Avithout hesitation be rejected. A soldier should be a full grown man, and not a boy. The most eligible age for a recruit is twenty to tAventy-five years. A soldier should be strictly temperate in his habits, as intemperance is one of the most fruitful sources of disease as well as of insubor- dination and of crime. He should have perfect sight and perfect hearing, as a failure in either of these senses Avould render him incompetent to perform the duties wdiich are expected of a soldier. He should be sound in all his vital organs, and should have a good degree of muscular develop- ment. The medical inspector should examine the recruit, divested of his clothing, investigating the condition of every vital organ, testing the sight and hearing, and subjecting the head, trunk, and limbs to occular inspection, and to manual palpation. The condition of the urinary organs should not be overlooked, and the candidate should be re- quired to pass his urine in the presence of the inspector. 27 A careful investigation should be instituted Avith reference to the existence of hernia or aneurism. Ulcers or cicatrices on the legs, varicose veins, corns, bunions, and inverted toe- nails, should lead to the rejection of the candidate. If the inspection of recruits were more thoroughly conducted than it usually is, it would greatly add to the vigor and efficiency of armies. All which is respectfully submitted. ALFRED C. POST, M.D., WM. H. VAN BUREN, M.D., Committee. New York. June 21, 1861. SANITARY COMMISSION.