will leave the hands of the men free for performing their carrying work as bearers, or for doing other duties which they could not do when engaged in stopping bleeding by digital pressure. In an urgent case, and in the absence of the necessary instrument, such men would of course understand the mode of stopping hæmorrhage by digital compression, whether within the wound. itself or along the course of the principal artery leading to it.

Internal remedies at dressing-stations. In respect to internal remedies, the only one likely to be required in the field, other than the ordinary diffusible stimulants and restoratives, is morphia. An opiate will often be of use in cases of abdominal wounds, in wounds accompanied with excessive pain or great nervous excitement. Morphia prepared in proper doses, and arranged in small packets, was used with great advantage during the war of the rebellion in the United States; but the use of this drug in solution, administered in the form of a hypodermic injection, has been proved during recent wars to be a source of so much more ready and quick relief in all severely painful wounds, that the necessary injection syringes and morphia solutions for thus employing the drug are now included in all field medical cases.

Index tablets or 'tallies.'-As soon as the necessary attention has been given to a wounded man at a dressing-station, especially if any surgical operation has been performed, such as the ligature of an artery, the removal of a missile, or if a morphia injection or dose of opium has been administered, the name and designation of the patient, together with a description, as brief as possible, of the situation of the wound, and of what has been done, should be written under the proper headings on one of the 'tallies provided for the purpose. The tally can be filled up by an attendant at the dictation of the surgeon, and when signed, should be carefully attached to a button or some conspicuous part of the soldier's tunic. It is to be remembered that the object of the tally and of the information given on it is to prevent needless re-examination of the wound while the patient is on his way to the field hospital or after he reaches it, as well as to direct the attention of the surgeon under whose care he may be placed on his arrival to any circumstance which it may be important for him to be aware of in the man's interest, or as affecting the subsequent treatment of his wound. Three or four words will generally suffice to give the indications referred to, and the few moments spent in writing them will be fully repaid by time saved subsequently, as well as by the advantages resulting to the patients. The form of these field tallies is described elsewhere in the chapter on Field Equipment.

CHAPTER II

GENERAL TREATMENT OF WOUNDED MEN ON REACHING A

FIELD HOSPITAL

IN the preceding chapter the chief points to be noted in the preliminary treatment of gunshot wounds on the field of action. have been described; their further treatment, as soon as the wounded men have arrived at a field hospital, will now be considered. The name, regiment, regimental number, and general nature of the injury of each patient, taken from the tally label attached to the man's uniform, or from observation at the time he is brought in, should be briefly registered for future reference in the Admission and Discharge Book by some one deputed for this special duty; and as soon as circumstances admit of its being done, if not already done, a proper and complete diagnosis of each wound and injury should be established, and its treatment systematically settled and commenced. It is not possible to make a definite classification of the wounded while they are being brought in quick succession to the field hospital, but an approach to one may be made, so far as noting whether the examination instituted. at the dressing-station, and dressing applied there, suffice for present needs; whether an examination of the wound for diagnosis, or for settling matters of treatment, is still required, or whether the necessity for some important surgical operation appears to be urgently indicated. The patients can then be distributed in accordance with these several categories, and dealt with in regular order by the surgeons engaged in the treatment. An important point in a field hospital is to keep lists ready of those who have been attended to, and are in a suitable condition for being sent away whenever an order, however sudden, for the evacuation of a portion of the patients may be received, and of those who are not in a fit condition for removal.

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Arrangements according to the accommodation at field hospitals. Some of the arrangements for the custody and care of the wounded, and for the surgical management of their injuries, will necessarily vary according to the position and circumstances of a field hospital-especially its distance from the front, the nature of the accommodation afforded by it, and whether it is within easy distance of a highroad, railroad, or navigable water, affording ready facilities for the evacuation of patients. If it be established at a farm or a country house at no very great distance from the scene of action, as will often happen in European warfare, it will soon become overcrowded; and some of the wounded, after having had their injuries attended to, will probably in a

short time have to be removed to other hospitals farther in the rear. Many of the wounded as they arrive will have to be laid on straw on the floors of rooms, in barns and outhouses, under any shelter that may be available, or on ground in the open air. If it be established at a warehouse or other large building in a village or town, better accommodation will perhaps be got, some bedsteads will probably be available, and more complete hospital arrangements can be established. If only a few bedsteads can be obtained, these should be reserved for cases of badly fractured limbs and for those in which amputations or other grave operations are performed. The difficulties in their treatment will be greatly enhanced if the patients are lying on the ground. In other cases temporary bedding should be provided by means of mattresses of straw, hay, or any other convenient material, laid upon the floors. Some proceedings will have to be modified in proportion to the time the patients are likely to be able to remain in the field hospital. It will be useless to remove all the clothes of men who will have to leave the hospital beds within a few hours, or even within a day or two, after their admission. If, on the contrary, there is a fair prospect of the patients being able to remain under treatment in the same place for several weeks, they will be placed systematically on their beds, will in turn have their clothes carefully removed, first from those parts of the body which are not injured, and next from those parts in which the fracture or other injury is situated; in short, the patients will be treated and placed as nearly as possible under the same conditions as they would be were they admitted for treatment in a fixed hospital. Other circumstances, which are noticed in the chapters on Transport of Wounded, Equipment of Field Hospitals, and Field-Hospital Administration, will perforce modify the decisions of surgeons as to the proper treatment to be adopted in particular instances of gunshot wounds. The description of the hospital treatment of gunshot injuries, in this and in the following chapter, is only intended to afford information on the general plan to be followed when and so far as circumstances admit of its application. In the practice of field surgery, military surgeons are compelled to resort to all sorts of shifts to ensure the welfare of their patients, and these expedients must vary according to the peculiar conditions in which they find their patients placed at the time they require professional assistance.

Persistent shock.-Should a wounded man, on being carried into the hospital, be found to be still labouring under shock, and this shock is of an extreme character, it must not be forgotten that the condition of the patient is one of great hazard from this cause alone, and that special attention must be given to extricating him from it. All practicable efforts should be made to equalise the circulation, to restore warmth to the body, and to increase sensi

bility as speedily as possible, but at the same time very cautiously, and with no undue disturbance of the patient. Caution is required lest in trying to restore vital action the remedies applied may cause the reduced powers of the patient to be strained beyond endurance, and so the remedies themselves cause death. The heart that is scarcely acting, if subjected to excess of stimulation, may cease to act altogether. The judgment of the surgeon will always be greatly taxed in severe cases of shock; not so much in respect to the nature of the remedies to be employed, as in respect to the extent to which he can employ them with safety. His difficulties are increased when the shock arises from a wound in itself of extreme gravity, or when it is aggravated by collapse from hæmorrhage. When the last-named complication exists, the case becomes one in which the operation of transfusion of blood may be attended with benefit. In all cases of shock, freedom from constriction of the surface of the body and the maintenance of a perfectly horizontal position are essential. Nature sufficiently indicates the necessity of this injunction. If the upper part of the body of a patient suffering from extreme shock be carelessly elevated, it may happen that life will shortly be extinguished, for the heart may become overloaded, and respiration cease. Artificial warmth should be applied to the body of the patient in any way most handy, due consideration being given to the nature of the wound or injury which is the source of the collapsed state of the patient. Hot water, which should be got ready by the men of the medical staff corps as soon as the site of the field hospital is determined, for use in preparing nutrient drinks and for various surgical purposes, may be applied in bottles to the legs, and in metal warmers to the abdomen. Wrapping in blankets may be serviceable for the purpose. At the same time, while applying artificial warmth to the body, fresh air should be freely admitted to the patient's face. If he can swallow, the administration of a little brandy by a spoon from time to time, sufficient to maintain the heart's action without exciting it unduly, is valuable; or, if deglutition cannot be performed, the advisability of the administration of a subcutaneous injection of ether, or a stimulating enema, should be considered. After a time, if consciousness of pain in the parts wounded be exhibited, or if any interest be taken in surrounding circumstances, these will be signs. that the efforts to remove the effects of shock are being followed by success. As soon as this amount of improvement occurs, perhaps a little simple nourishment, such as beef essence, may be taken, and this will prove valuable as a further restorative. On no account should opium in any form be administered to a patient in a state of extreme shock or severe collapse; even a minute dose under such circumstances may lead to a fatal result. Nor should any surgical operation of a grave kind ever be undertaken before

a patient labouring under extreme shock begins to rally from it, and exhibits some return of general and local sensibility. The wound itself, however extensive and serious, provided it be free from hæmorrhage, does not call so urgently for notice under such circumstances as the constitutional condition of the patient.

Temporarily arrested hæmorrhage. If the surgeon finds that a wound has been plugged or that other local means have been used for the control of hæmorrhage, and especially if the required notice is given on the tally ticket of the dressings having been applied with this view at the dressing-station, while no fresh symptom has since occurred to call for special interference, the patient should be placed where he can remain quiet for some time, so that he may be disturbed as little as possible; at the same time, the treatment already adopted for securing closure of the divided vessels should be seconded by perfect rest of the injured part in a favourable posture, that is, one in which the structures involved in the wound are relieved from all strain, pressure, or call for action. The application of cold, and generally the administration of an opiate, may also be advantageously resorted to. On the next day, or before, if symptoms occur to indicate a need for the interference of the surgeon, the pressure may be relaxed, and if the tendency to bleeding appears to have been arrested, the ordinary treatment of the wound may be proceeded with. If the hæmorrhage recur, it will then have to be dealt with according to the situation of the source of the bleeding, and the particular circumstances of the case.

Primary hospital treatment of gunshot wounds in general. -But supposing that the patients brought in are free from intense shock and tendency to active hæmorrhage; that any shock which is present exists only in a moderate degree; that, if weakened by exposure, pain, or the effects of a long transport in a jolting vehicle, some suitable restoratives have been administered; and presuming further that the nature of the injury has not already been determined, and is not sufficiently obvious without further examination; the following are the points to which the surgeon should give his attention as he visits the wounded in

succession :

1. Examination and exploration of the wound with a view to establish a definite knowledge of its nature, extent, and complications, and to determine the operative proceedings to be adopted if any are found necessary;

2. Removal of any foreign bodies which may have lodged; 3. Adjustment of lacerated structures if the wound be of a kind to require it;

4. If not told off for immediate surgical operation of importance, the disinfection of the wound and surrounding parts, and the application of the primary dressings.