Hospital, West Philadelphia, a very short time before I was ordered to the Christian Street Hospital. As Executive Officer it was my duty to assign new patients to the wards and also to transfer the cases in the specialties, such as the eye, nervous diseases, and injuries, etc., to the special hospitals. One morning as I sat at my desk a soldier applied for assignment. On looking up at him I said to myself: "You are Dalton's cat." Those of you who are familiar with Dalton's good old text-book of physiology will remember a picture of a cat whose right cervical sympathetic nerve had been severed. The left pupil is very large, the right one very small, and the moment I looked at this man I was struck with the similar condition of his pupils. I quickly asked him: "Where were you wounded?” and when he pointed to his neck I said to myself again: "That ball destroyed the sympathetic nerve." I immediately transferred him to the Christian Street Hospital, and a few days later followed him. His case is reported in full in our little book on "Gunshot Wounds and Other Injuries of Nerves," p. 39. In the autumn of 1864 I took a copy of this book to Claude Bernard in Paris, the discoverer of the function of the cervical sympathetic and the effect of its division upon the pupil and the blood-vessels. He exhibited true Gallic enthusiasm when I showed him the first recorded case in the human subject, which confirmed his brilliant researches, which were the beginning of our knowledge of nature's beautiful automatic regulation of the blood-supply.*

The results of injuries of nerves have been dwelt upon fully by Dr. Mitchell, and I need say little about them. All of our patients, of course, were convalescents. The phenomena of fatal cases we had no opportunity of observing, but I can never forget the extraordinary contractures,

*This was the real starting point of our knowledge of the functions of the sympathetic nerve, although Pourfour du Petit, in 1727, had noticed the effect of its division on the pupil. (de Schweinitz.)

paralyses, and other results of the extensive wounds of nerves such as we studied there for the first time. One poor fellow (since then I have seen one similar case) was shot directly through the posterior portion of both eyeballs; another had necrosis of a large part of the body of the third cervical vertebra. The sequestrum discharged through the mouth, showing the anterior portion of the foramen for the transmission of the vertebral artery, which, fortunately, did not suffer either by the original wound or the secondary necrosis and suppuration.

Very naturally among so many soldiers of diverse character, and especially of men with wounds and injuries of the nervous system, we had perhaps more than our usual proportion of malingerers. In the "American Journal of the Medical Sciences" for October, 1864, p. 367, in a paper on Malingering," especially in regard to simulation of diseases of the nervous system, a number of our conclusions were stated. From the necessity of the case, we devised some new means for discovering such malingerers. We first suggested the use of ether (alone or in combination with other means) as a test in a number of alleged diseases and conditions in which it had never before been used. It proved a most efficient method of detection. For instance, in asserted blindness, we suggested that the man should be etherized, the sound eye then covered with adhesive plaster, and when recovering from the anesthetic, before he was able to reason and guard himself against making mistakes, that his sight should be tested by very simple means, such as holding out to him in the hand some water or some whiskey, or any other act which would reveal the presence or absence of sight in the supposed blind eye. So in deafness we discovered some malingerers by the old trick of gradually lowering the voice; but hearing, like sight, can best be tested during the recovery stage of ether when the patient is taken unawares, as Parr, in his "Medical Dictionary," speaks of

a man who pretended to be dumb, of whom a sympathetic passer-by, with most insidious humanity, inquired: “How long have you been dumb, my good friend?" "Three weeks, sir," replied the uncautious deceiver.

We also recorded what Da Costa first called our attention to: that in feigned lameness the cane is apt to be put down after the leg instead of before, whereas a really lame man, needing the support of a cane, always will put the cane down first. In some instances the substitution of the urine of a soldier known to have renal disease by a malingerer for his own of course was readily detected by having him pass his water in the presence of the ward-master or of the

surgeon.

In both paralysis and ankylosis we again resorted to the use of anesthesia, a means which now, of course, every one is familiar with, but which at that time was a novelty. Sometimes it was not needed, as accident would disclose the fraud. Thus, one of the most persistent and successful malingerers at last unmasked himself. His right arm had long hung useless by his side. One day as he was going out on leave a high wind suddenly blew the cape of his overcoat over his head, and in an unguarded moment both arms were raised to throw back the cape so that he could see. The Army of the Potomac speedily received a reinforcement of one. A necessary precaution is to be noted,namely, that sometimes malingerers who had been in the ward a considerable time and had seen other patients etherized, not only feigned disease, but feigned complete anæsthesia long before it actually existed, and thus very nearly deceived us. A little extra dose, so that one is absolutely sure that the etherization is real and not imitated, of course, will avoid this danger. In this manner we detected one man whose arm had been "paralyzed" for a long while, and left him yawning and stretching himself with both arms far above his head and every effort to move them down

resisted by his deltoid, which, previous to this test, had been entirely useless. The same test served us well in some cases of alleged aphonia. The old adage "In vino veritas might well be applied to anæsthesia. The supposed blind will see, the dumb will speak, the lame will freely move paralyzed limbs, deaf ears will be unstopped, and all in spite of the malingerers' best efforts.

In one of our cases of aphonia, detected without the slightest difficulty, the patient, however, quickly recovered himself and fell at the surgeon's feet with clasped hands, exclaiming with a voice and attitude worthy of a Garrick: "Thank God, Doctor, you have restored my voice!"

Our means of detecting fraudulent epileptics are fully described in the paper above mentioned. For want of time I cannot do more than refer those interested in the subject to it for details.

Three things are impressed upon my mind as a result of this review of the Surgery of the Civil War. The first is the utter inadequacy of our present system of enlargement of the medical corps of the army when war or a great battle suddenly precipitates this necessity upon us. The parsimony of Congress has cut down the numbers of the medical military establishment below what is necessary for a proper performance of its duties even on a peace basis. The SurgeonGeneral always is forced to employ a large number of acting assistant surgeons, who, faithful as they may be, can ill supply the place of men trained in the regular medical corps. When war suddenly comes, an enormous number of barely competent or often incompetent men must be put in charge of the lives and health of the soldier, men who are as utterly untrained as I have shown I was when I entered the army. The Medical Corps of the army should be enlarged, as was urged upon the last Congress by the President, the Secretary of War, and the Surgeon-General; all vacancies should be filled, and measures taken either under existing or future

laws to have a supplementary Medical Corps ready for instant service.

A second reflection is that, subject of course to imperative military requirements, medical officers should have substantial control over sanitary matters, such as camping places, latrines, water supply, &c. These are often vital to the efficiency of an army. Our later experience in the SpanishAmerican War and by contrast the extraordinary results which have been obtained by the Japanese methods reinforce this suggestion in a most striking way.

The last reflection is that those who made such a fearful outcry as to the sufferings of our soldiers in the SpanishAmerican War, though justified to some extent, did not know what suffering was as experienced during the Civil War.

When a battle occurs, the survivors of the regiment must march away with the army and some of their surgeons must go with them. When, therefore, tens of thousands of men are wounded in a day or two the number of surgeons available is totally inadequate for the sudden emergency. It is absolutely unavoidable, no matter what progress is made in the scientific treatment of wounds by first-aid packages and other devices, or in methods of transportation, that men, especially those of the defeated army, must often lie on the battlefield one, two, three, or more days before they can possibly be attended to. The horrible suffering this entails is part of the grim penalty of war. Those of us who went through the Civil War are the most anxious to avoid another war. Only a righteous and noble cause can justify such sacrifices and suffering.*

* See an excellent paper by McCaw, Jl. Assoc. Military Surgeons, May, 1905, p. 334.