full benefit of the fresh air and the light are obtained. Even in fractures the beneficial effects are to be remarked."' Baron Larrey, in his useful work,' describes the plans adopted by the French in the Italian war of 1859. At Constantinople, during the Crimean war, the French were apparently very well installed; the best buildings in Constantinople were assigned to them, and they were arranged with all the accuracy of organization which distinguishes the French. The results were not, however, favorable, especially in the spring of 1856, when typhus spread through many of the hospitals, and caused great mortality.' Taught by this experience, in the Italian war of 1859 the French distributed their sick in small hospitals whenever they could find a building, and in this way the extension of the specific diseases was entirely stopped. In the great Franco-Prussian war of 1870-71, the Germans made great use of temporary hospitals, and distributed their sick and wounded over almost the whole of Germany. The plans were very similar to those used in the Crimean and American wars. In some of the large cities, as at Berlin, immense hospitals, with railways and every appliance, were fitted up. The experience as regards hospital gangrene and erysipelas was favorable, but there were many cases of pyæmia in some of these hospitals. To sum up, the hygiene of field hospitals in war (the rules are derived from our own Crimean experience, and that of the wars which have taken place since) is as follows:-The field, including the intermediate, hospitals to be made of tents; the tents being well constructed, of good size, thoroughly ventilated, the flaps being able to be raised so as almost, if desired, to make the tent into an awning. The most convenient and best are the hospital marquees of the new pattern, except for their considerable weight. The new double circular tents will now be used in all probability: they are a great improvement on the old bell-tent, and lighter than the marquee. Each weighs 100 tb dry, and four patients are put in a tent. For operating purposes, the central pole can be removed and a tripod support substituted, so as to leave the centre free. The ground round the tents to be thoroughly drained, kept very clean, and replaced from time to time. The tent floor to be covered with clean, and, if possible, dried earth, or charcoal, and to be then covered with a waterproof cloth, or boarded, if the camp be one of position. In either case the greatest care must be taken that the ground does not get soaked and filthy. Every now and then (if possible every ten days or so) the tents should be shifted a little. If it can be done, the sick should be raised off the ground. Iron bedsteads are cumbrous, but small iron pegs stuck in the ground might carry a sort of cot or hammock. The advantage of a plan of this kind is that by means of holes in the sacking wounded men can have the close-stool without much movement. For fever cases it permits a free movement of air under the patient. 1 On Hygiene, p. 397. 3 Larrey mentions some striking instances of the effects of overcrowding. At RamiTchifflick, the hospital was fixed for 900 by the surgeon in charge, who allowed no more; it remained healthy. His successor increased the beds to 1,200 and then to 1,400. Typhus became most severe, and spared no one (ni infirmiers, ni sœurs, ni médecins). In the hospital at Pera there was the same mistake and the same results. Typhus caused 50 per cent. of the deaths. At the hospital of the École Militaire no crowding was permitted, and typhus caused only 10 per cent. of the deaths. In the French ambulances in the Crimea the same facts were noticed. Double and treble numbers were crowded into some, and they were ravaged by typhus; others were not allowed to be crowded, and had little typhus. 2 Notice sur l'Hygiène des Hôpitaux Militaires, 1862. The stationary general hospitals in rear should be of tents or wooden huts, but never of converted buildings, or of hospitals used by other nations. Here, of course, iron bedsteads, and all the appurtenances of a regular hospital, are brought into play. Whenever practicable, the rear hospital should have water-closets and sewers. At Renkioi, in Turkey, Mr. Brunel supplied square wooden sewers about fifteen inches to the side; they were tarred inside, and acted most admirably, without leakage, for fifteen months, till the end of the war. The water-closets (Jenning's simple siphon), arranged with a small water-box below the cistern to economize water, never got out of order, and, in fact, the drainage of the hospital was literally perfect. Dr. Parkes had little doubt such well-tarred wooden sewers would last two or three years. There is one danger about wooden hospitals, viz., that of fire. The huts should, therefore, on this ground alone, be widely separated; each hut should have, about ten feet from it, an iron box for refuse. Wooden boxes do not answer, as in the winter live cinders get thrown in, and there is danger of fire. These boxes should be emptied every morning by the scavengers, and the contents burned as soon as possible. Water must be laid on into every ward. The arrangement of the buildings is a simple matter, but must partly be determined by the ground. Long open lines are the best. An hospital of this kind, completely prepared in England, can be put up at a very rapid rate,' supposing there be no great amount of earth-work, and that the supply of water and of outlet for sewage be convenient. So that, if commenced at once at the beginning of a campaign, accommodation would soon be provided. Circumstances may of course render it necessary to take existing buildings for hospital purposes, but it ought always to be remembered that it is running a very great risk, and nothing but rigid necessity ought to sanction it. Laundry Establishment. This part of an hospital must be organized as early and as perfectly as possible. The different parts must be sent out from England, viz., boiler, drying-closet, washing-machines, and wringing-machines. The washing in war can never be properly done by the people among whom the war is carried on. Every appliance to save labor must be used, and after calculating what amount of laundry work has to be done for a presumed number of sick, just twice the amount of apparatus should be sent out, partly to insure against breakage, partly to meet moments of great pressure. The drying-closet, especially, is a most important part of the laundry, as its heat can be used to disinfect. 1 The hospital at Renkioi, in Turkey, in the Crimean war, was made of such large huts (50 men in each) that its rapidity of erection is no guide to others; yet it was marvellously soon put up. The first beam was laid on May 24, 1855; on July 12th it was reported ready for 300 sick, every ward having water laid on, baths and closets, and an iron kitchen and laundry being also ready; on August 11th it was ready for 500, and on December 4th for 1,000 sick. In January, 1856, it was ready for 1,500 sick, and in a short time more 2,200 could have been received. The number of English artisans was only forty, but we had native workmen, and if we had had eighty English artisans it would have been ready for 1,000 sick in three months. Smaller huts could be put up in much less time if the ground requires no terracing. Amount of Hospital Accommodation. This must not be less than for 25 per cent. of the force, with reserve tents in rear in case of need. Cemeteries in war must be as far removed as possible; the graves dug deep, and peat charcoal thrown in if it can be procured. Lime is generally used instead, but is not quite so good. If charcoal cannot be got, lime must be used. If the army is warring on the sea-coast, burial in the sea might be employed. But cremation would be best, and forms of ambulatory furnaces have been proposed. Sanitary Duties connected with a War Hospital. In addition to the usual sanitary duties of an hospital, there are one or two points which require particular attention in the field. The first of these is the possible conveyance of disease by the exceedingly dirty clothes, which may perhaps have been worn for weeks even without removal, in the hard times of war. Typhus, especially, can be carried in this way. To provide for this, every hospital should have a tent or building for the reception of the clothes; here they should be sorted, freely exposed to air, and the dirty flannels or other filthy clothes picked out. Some of these are so bad that they should at once be burnt, and the principal medical officer, at the beginning of a campaign, should have authority given him to do this, and to replace the articles from the public store. The articles which are not so bad should be cleansed. The cleansing is best done in the following way :-If the hospital have a laundry and drying-closet, they should be put first in the drying-closet for an hour, and the heat carried to 220° Fahr. Then they should be transferred into the fumigation box; this is simply a tin-lined box or large chest. The clothes are put in this, and sulphur placed above them is set on fire, care being taken not to burn the clothes; or nitrous acid fumes should be used. After an hour's detention in the fumigating box, they should be removed to the soaking tubs. These are large tubs with pure water, put in a shed or tent outside the laundry. A little chloride of lime can be added to the water. They should soak here for twenty-four hours, and then go into the laundry and be washed as usual. This plan, and especially the heating and fumigation, will also kill lice, which often swarm in such numbers. Another point of importance is to bathe the men as soon as possible. The baths of a war hospital at the base of operations should be on a large scale, and the means for getting hot water equally large. The men's heads, if lousy, should be washed with a little weak carbolic acid, which kills the lice at once. The smell is not agreeable, but that is not of real consequence. In a war hospital, also, the use of charcoal in the wards, antiseptic dressings, the employment of disinfectants of all kinds, is more necessary than in a common hospital. As a matter of diet, there should be a large use in the diet of antiscorbutic food, vegetables, etc., and antiscorbutic drinks should be in every ward, to be taken ad libitum-citric acid and sugar, cream of tartar, etc. The bread must be very good, and of the finest flour, for the dysenteric cases. Sieges. The sanitary duties during sieges are often difficult. Water is often scarce, disposal of sewage not easy, and the usual modes of disposal of the dead cannot, perhaps, be made use of. If sewage is not washed away, and if there is no convenient plan of removing it by hand, it must be burnt. Mixing it with gunpowder may be adopted if there is no straw or other combustible material to put with it. If food threaten to run short, the medical officer should remember how easily Dr. Morgan's process of salting meat can be applied, and in this way cattle or horses which are killed for want of forage, or are shot in action, can be preserved. For sieges, as vegetables are sure to fall short, a very ample supply of lemon-juice and of citric acid, citrates, and cream of tartar should be laid in and distributed largely. One other point should be brought to the notice of the general in command. In times of pressure, every man who can be discharged from the hospital is sent to the front. This cannot always be avoided. But when there is less pressure, the men should go from the rear hospitals to a dépôt, and while there should still be considered under medical treatment, so that they may not too soon be subjected to the hardships of war. They should, in fact, be subjected again to a sort of training, as if they were just entering on the war. If this is not done, a number of sickly or half-cured men get into the ranks, who may break down in a moment of emergency, and cause great difficulty to the general in command. Some officers think that a man should either be in hospital or at his full duty; this seems a misapprehension both of the facts and of the best way of meeting them. To transfer a man just cured, from the comforts of a hospital at once to the front, is to run great danger. A dépôt, which should be a sort of convalescent hospital, though not under that term, is the proper place to thoroughly strengthen the man just recovered for the arduous work before him. APPENDIX A. STANDARD SOLUTIONS FOR VOLUMETRIC ANALYSIS. 1. For Chlorine. (a) Silver Nitrate Solution. 4.788 grammes of silver nitrate in 1 litre of distilled water. 1.00 milligramme of chlorine. = 2.10 milligrammes of potassium chloride. This solution may be standardized with a solution of pure sodium chloride, 1.648 to the litre, 1 CC. of which equals 1 mgm. of chlorine. (b) Potassium Monochromate Solution.-50 grammes of potassium monochromate are dissolved in one litre of distilled water. Solution of nitrate of silver is added until a permanent red precipitate is formed, which is allowed to settle. 2. Hardness. (a) Soap Solution. Dissolve some soft soap (pharmacopoeial) in diluted spirit, and graduate by means of this barytic solution. Nitrate of barium Distilled water 0.26 gramme. 1 litre. 2.2 CC.s (or 22 measures) of standard soap solution produce a per- 1 measure (CC.) of soap solution = 0.00025 gm. = 0.25 mgm. of Correction for lather= 2 measures of soap. Short factors (when 50 CC.s of water are taken for experiment). 66 Metrical " (1 : 100,000) = 0.50. (b) A weaker solution, each measure (CC.) of which is equal to 0.07 mgm. of CaCO, is sometimes used. The correction for lather would be 7 measures of soap. The corrected number of measures, divided by 10, gives the hardness in Clark's scale directly, or multiplied by 0.14 the degrees on the metrical scale. |