and summer of 1864. The Sanitary Commission, desirous to relieve the suffering thus caused, ordered the construction of a number of hospital cars, from drawings made by Elisha Harris, M. D. In these cars the seats are removed, and the stretchers in which the patients are brought suspended upon gutta percha or rubber loops, and secured from swaying.. There were five or six of them on the Atlanta, Chattanooga, Nashville, and Louisville route, with the surgeons' car in the centre of the train, with kitchen, dispensary, nurses, assistant-surgeons, and apothecaries in attendance, and the sick and wounded had the same care and attention they could have had in the best regulated hospitals. The same number have been constantly running between Washington, New York, and Boston.

The introduction of new and more deadly missiles into modern warfare has considerably

modified the methods of treatment as well as the diagnosis and prognosis of gunshot wounds. The old round bullet produced wounds far less formidable than those inflicted by the Minié ball, or the shell, which have played so prominent a part in the battles of this war. The round musket-ball had a much lower initial velocity, was readily deflected from its course by coming in contact with bone, tendon or even firm muscular tissue, and if it penetrated the large cavities usually made a clean perforation of a diameter but little larger than its own. The Minié, on the contrary makes a ragged ugly wound, and passes straight on through muscle, tendon, cartilage, and bone, producing terrible comminuted fractures of the latter; and if it does not pass entirely through, usually comes to the skin on the opposite side from that which it perforated, and lying there, presenting its long diameter to the surface,

leaves a large and ragged cavity in its last resting-place. The wounds made by fragments of shell are still more severe, mangling the unfortunate subject most cruelly, and producing destructive fractures and sloughing wounds.

The treatment of these gunshot wounds must necessarily be different in many respects from those of the musket-ball, treated of by the older surgical writers. The extraction of the ball is, as a general principle, the first work of the surgeon, the hemorrhage from the wound having been previously checked. This is often a matter of considerable difficulty, though from the frequency with which the Minié bullet approaches the surface on the opposite side from that which it entered, it may often be reached speedily. Dr. Frank H. Hamilton, late Medical Director in the U. S. Army, has invented a probe (fig. 11) and two pair of forceps, one of which is shown in fig. 10, for extracting the bullets when lodged in the soft tissues, the other when impacted in the bony structures, which prove very serviceable for this purpose. Surgeon Isaac Moses, of the army, also invented a somewhat complicated instrument working in a canula, through which are forced three hooks to seize the ball when the instrument strikes it (fig. 12). This is also said to prove serviceable. George Tiemann & Co. have invented a pair of forceps (fig. 13) with two teeth set obliquely forward, like the incisors of a mouse, which proves admirable for removing buckshot, light balls, or fragments of lead,

but does not answer for the removal of fragments of harder metals. Nelaton's probe (fig. 14), which has a small ball of unpolished porcelain on the end, is invaluable for discovering the presence of a bullet by the marks of the lead on the ball.

The military surgeon in the field at the present day rejects all those medicaments and processes formerly deemed essential in the primary treatment of gunshot wounds; and having removed if possible not only the missile which caused the wound, but any fragments of clothing, bone, or other foreign substance in the track of the wound, confines himself to the use of water as a dressing for the wound, as the simplest, most convenient, and most efficacious application which can be made. The water is generally applied cool or at its ordinary temperature, but of course becomes tepid speedily. When inflammation sets in the temperature should be lowered, and this is effected best by the method of irrigation, by means which the ingenious surgeon or nurse readily devises even in the rudest or most poorly supplied hospital tent.

The part which is wounded, and several inches of the integument beyond the margin of the wound, being covered with a piece of patent lint, or in default of this woollen or flannel cloth, the water is suspended over the limb, or placed on a table beside the bed, and from it is conducted either by a syphon tube filled with candle-wicking or thread, or in default of any

Hamilton's Compound Bullet Probe.

Hamilton's Strong Bullet Forceps. thing better a piece of candle-wick or a strip of cotton or woollen cloth, the water in small but constant drops falls upon the cloth or lint covering the wound. This usually reduces the temperature sufficiently, and is besides very grateful to the patient. When the wounded man is to be transported a long distance, simple cerate spread upon patent lint is used for a dressing, and this is covered with a broad and pretty thick dressing of cotton-batting, tow, or some other soft material, secured in its place by adhesive plaster or a few turns of a light roller. The subsequent treatment of gunshot wounds, which is usually conducted in the general hospital, presents little that is novel. In the treatment of secondary hemorrhage (that occurring after the sloughing of the dead tissues), the ligation of the bleeding vessel in the wound, if possible, without embracing a nerve with it, or when this cannot be done the use of perchloride of iron, or what is better, perhaps, Dr. Pancoast's hæmostatic (carbonate potassa, one drachm; castile soap, cut fine, two drachms; alcohol, four fluid ounces), is generally resorted to; if these fail, no time is lost in applying a ligature to the main artery above the wound. For the removal of decomposing tissues and acrid pus, the method of irrigation is again adopted, as being the most gentle and speedy, and as imparting a healthier tone to the granulations. When the water develops a fine papular eruption, as it will after a time, it is medicated by the addition of one drachm of

Nelaton's Probe.

super-acetate of lead to the quart of water, or the milder zinc ointment is substituted. Meddlesome surgery, such as the squeezing of a wound to press out the pus, or probing and picking to remove suspected spicule of bone, during the suppurating stage, is wholly interdicted. In the treatment of gunshot fractures of the limbs, and especially of the lower extremities, the methods of treatment and apparatus devised for securing perfect rest, easy dressing, moderate extension, and the prevention of bed-sores, are ingenious, efficacious, easily constructed, and of moderate cost.

Tiemann's Bullet Forceps.

In gunshot wounds of the head, trephining is sometimes though rarely necessary. In fractures of the skull from blows of blunt instruments, as the butt of a musket, &c., or from injuries from fragments of shell, &c., it is very generally advisable. Among the circular trephines employed for this purpose, we have seen no instrument equal to Galt's spiral trephine (fig. 15).

The tendency with the army surgeons to

FIG. 15.

TIEMANN-CO

Galt's Spiral Trephine.

conservatism, in regard to amputation in gunshot fractures of the thigh, has been very strong; amputation having been attempted in not more than one-third of the cases brought under treatment, and in not more than onehalf of those of gunshot injuries of the kneejoint. Some of the most eminent surgeons, Dr. F. H. Hamilton among the number, regard this conservatism as excessive, believing that in a considerable number of the cases life, easier locomotion, and sounder health would have been secured by amputation than by the attempt to preserve the limb under the adverse circumstances of transportation to a distant hospital, great comminution of the bones, spasms, or intense and continued pain, great contusion or laceration of the soft parts, or the participation of the principal arteries or nerves in the injury. Still this conservatism is more to the credit of the surgeons than the reckless and indiscriminate resort to capital operations, so characteristic of young and inexperienced surgeons, would have been; and it gives an incidental testimony of great value to the ability and discretion of the thousands of surgeons, called so suddenly from civil life to the serious and unaccustomed responsibilities of the camp and battle-field. Of those cases of gunshot fractures of the femur or thigh bone in which amputation has not been attempted, the proportion of recoveries cannot be stated with certainty; but judging from the results at several of the larger hospitals, it may probably be safely reckoned as at least two-thirds. In some hospitals, as for instance in the City General Hospital, U. S. A., at St. Louis, it has approached three-fourths. The apparatus adopted for the treatment of these cases is entitled to a considerable share of the credit for so satisfactory a result.

The indications to be observed in the successful treatment of a gunshot fracture of the femur, without amputation, are, perfect quiet and rest for the injured limb, without possibility of displacement of the fractured portions of the bone, gentle but continuous extension and counter extension, to obviate the danger of any material shortening of the limb, accessibility to the wound in order to observe its condition, to prevent hemorrhage or the secretion of foul and irritating pus, and the removal of the necessary evacuations and the change of the bed without disturbing the patient. If the knee-joint be involved in the injury, it is necessary to lay it open; and in these cases a somewhat different apparatus is required from that adopted in fractures of the femur at a higher point. Although the treatment of these cases has generally taken place in the larger post or general hospitals of

the United States Army, yet they were so numerous, and the labor devolving upon the dressers and assistant-surgeons was so incessant and exhausting, that a resort to the complicated operation and processes of the old civil hospitals was impossible, and fortunately it has been proved unnecessary. The first and one of the most admirable of the inventions for the treatment of these cases is Dr. Frank H. Hamilton's canvas frame. This is simply a wooden frame, a little longer and wider than the mattress on which the patient reposes, covered with firm canvas, and this reënforced a little above (the side-rails extending perhaps six inches at each end beyond the cross-rails), the centre by a second piece two feet in width, stretched across from one side-rail to the other, and firmly stitched to the upper canvas; through this central portion, or a little above the centre of the canvas, a hole one foot in diameter is cut, and firmly bound with tape. In the foot crossrail is a broad slot into which an upright board six or eight inches high, and having in it a spool or other contrivance for a pulley, is inserted. The patient is laid upon this frame, it having been previously covered partially by two sheets, folded in half, and laid one above and the other below the central opening. The wounded limb has a long wide strip of adhesive plaster applied to each side of it, and maintained in place by a roller carefully applied to the leg below the knee; the ends of these adhesive straps are firmly attached to a small piece of board applied to the sole of the foot, but wide enough to prevent any pressure by the straps on the malleoli, and the leg from the thigh downward is a little elevated by being placed upon a thin cushion, which should be filled with bran. Attached to the board which is bound to the foot, is a strong cord, which, passing through the pulley in the upright board in the bottom rail, has at its other end a bag of sand or a pail of the same, not exceeding at first five or six pounds in weight, but to be gradually increased afterward as necessary. This constitutes the whole apparatus for extension, and counter-extension is made by raising the foot of the bed from three to six inches by means of bricks, and thus making the weight of the body the counterextending power. When it is desired to change the bed, use the bedpan, or move the patient, the canvas frame is lifted carefully with the patient on it, and transferred to a couple of movable stands or "horses," or laid on blocks (figs. 16, 17 and 18). Another form of invalid bed adapted not only to these injuries but to other cases, like severe typhoid or yellow fevers, where it is difficult to move the patient, is Dr. Josiah Crosby's invalid bed, recently introduced by the Army Medical Board into several of the U. S. general hospitals. It is so constructed that while the patient lies suspended upon broad and firm bands of webbing, the bed can be lowered, one of the straps loosened, and a bedpan used; or the bed may be run out and aired or changed, or the wounds