wounds, that the soft tissues near the wound of the exit are torn and displaced. Rasing wounds by small projectiles, and wounds over some of the superficial bones, are often accompanied with a good deal of laceration. In such cases, on dressing the wound, attention must be first given to rendering it free from any foreign matters there may be upon it, and as far as possible aseptic, and then to readjusting the disjoined structures in their normal relations to each other. In thus bringing the parts together, the purpose is not only, with the aid of antiseptic dressings, to try and obtain speedy union, as well as to give ease to the patient, but also to prevent avoidable irritation and malposition of parts during the subsequent stages of cure. This readjustment, if carefully done, will give the structures an early tendency to adapt themselves to one another in the same relations in which the surgeon hopes they may be ultimately united. The best method of clearing away clots, and such extraneous substances as dust, fibres of cloth, earth, and grit, from the surfaces of wounds, is by squeezing some antiseptic lotion from a sponge, or by pouring the fluid from an irrigator or other convenient vessel upon them. Such things as small gravel and dust are as often pressed into the exposed tissues as removed from them by the use of tow, sponges, and similar articles, when directly applied to their torn surfaces.

The additional bruising and irritation which would be caused by the incautious use of such substances, and the increased impediments to a favourable healing process, are so obvious as not to require mention. If oozing of blood continues, measures should be adopted to prevent as far as possible its spreading over the adjoining integuments. This can be readily done when the wound first receives attention, but can only be accomplished with considerable inconvenience after the blood has become dry and adherent to the skin, especially after inflammatory action has begun, and the parts involved in the injury have become heated and very sensitive.

The dressings to be applied, and the further treatment of wounds. produced by small projectiles, will be considered in the next chapter.

CHAPTER III

LOCAL TREATMENT OF GUNSHOT INJURIES

Moistened lint as a dressing.-In perforating gunshot flesh wounds, as well as in gaping and lacerated wounds from the smaller kinds of projectiles, after the torn and divided tissues had been duly cleansed and brought into proper apposition, the

dressing which was most generally employed by British surgeons in field hospitals, when they were of a sufficiently stationary character for the patients to remain in them for a suitable time, was lint moistened, and kept moist, with plain water at the prevailing temperature of the time. Such moist dressings cannot be conveniently employed in the field itself, either at the regimental line of help or at the regulation dressing-stations, nor would they generally be suitable for use in the movable field hospitals, in which sufficiently close and frequent attention cannot usually be given to particular details of treatment, and where patients are liable to be disturbed by sudden removals. But in hospitals where adequate time and attendance are available, lint kept moist with water has proved itself to possess many advantages as a dressing. It is grateful to the sensations of the patient; the water is easily medicated as required; it is easily renewed; and the lint can generally be got in any required quantity in British field hospitals. Well-made lint, too, has the advantage of being of all substances the softest and most agreeable to sore and inflamed surfaces; it imbibes a large quantity of any fluid in which it is properly steeped; the saturation is easily maintained; and in this moistened condition it yields and readily adapts itself to the shape of any parts of the body to which it may be applied. All kinds of dressing that involve stiffness, pressure, weight, and undue warmth are objectionable.

Poultices of linseed-meal, though they have been used by some surgeons with gunshot wounds, and that, too, within comparatively recent periods, have most of the objections just named in a marked degree. Moreover, to make them well, more time is required than can usually be given in time of war in field hospitals, even in the rear; the materials for their manufacture are not easily transportable, owing to their bulk; they cannot be renewed in war hospitals as frequently as they may be in fixed hospitals in towns; and they soon become rancid, especially in hot climates, and act as irritants in the neighbourhood of the wounds. After a time, too, probably by preventing evaporation owing to their oily constituents, they sodden the parts over which they are placed, lessen their tone, and thus impede a vigorously healthy action. There is, besides, some difficulty in getting rid of them after they have been removed from the wounds, and it requires the close attention of surgeons to prevent them from being thrown away as refuse in some obscure place in the neighbourhood of a hospital where they are not likely to be seen, but where, if they are allowed to remain, they soon begin to attract flies as well as to contaminate the surrounding atmosphere. Linseed-meal poultices ought to be excluded entirely from use in camp hospitals. Ordinary waterdressing is far better, for it is free from the objectionable qualities which have just been enumerated.

In using water-dressing, the lint may be kept moist either by dropping water occasionally upon it from a sponge, a vessel of water being kept at the bedside for the purpose; or, what generally answers better, from a fixed irrigator adapted to the position and other circumstances of the wound. Sometimes the waterdressing is employed covered; the lint, which is usually in several folds, being kept moist by preventing evaporation. Oiled silk, gutta-percha tissue, waxed paper or linen, or an upper cover of lint on which some ointment has been spread, are the materials generally used for the purpose. On consulting a patient's sensations in the selection of either of these modes of dressing, climate and temperature will mostly be found to determine his choice. In hot climates cool evaporating applications are the more grateful, and by lessening the degree of reaction and checking the amount of inflammation, as well as circumscribing its extent, are usually the more advantageous; in cold climates the non-evaporating applications are the more agreeable. But, as a rule, they cannot be long maintained without inducing objectionable conditions similar to those which result from the use of poultices, and then other dressings have to be substituted for them. This was the system of dressing gunshot wounds generally adopted by English surgeons in the Crimean, Indian, New Zealand, and other wars, and under it, on the whole, the results were very favourable. For some years past, however, when water-dressing has been employed, the liquid has been medicated by some of the antiseptic ingredients which are mentioned farther on.

Charpie.-Charpie, or linen separated into short threads about two or three inches long, has been the material in most common use on the Continent, instead of lint as manufactured in England. It has never been in general use among British surgeons, and the absence of it from the regulated dressings of military hospitals has not been regarded as a loss. In consequence of the common use of linen by persons in most Continental countries, even among the poorer classes, all kinds of linen articles, when no longer fit for their original purpose from age, have been converted into charpie, and used in military hospitals in time of war. New linen is considered unfit for charpie, on account of the fibres being too rigid and hard; while half-used linen, having become soft and flexible, is found suitable for the purposes for which charpie is wanted. In the civil Continental hospitals the half-worn-out bedlinen and old articles of personal clothing used generally to be converted into charpie. However clean the linen might seem to be before being pulled asunder for making charpie, it is difficult to believe it could be free from taint from some of the emanations, liquid and gaseous, with which it had probably been long impregnated while in hospital use. Discharges from sores, and the other decomposable substances with which such articles are apt to be soiled,

naturally occur to the recollection in thinking of the origin of charpie thus prepared for surgical purposes. And after it has been collected, cleansed, and stored for use, charpie is so absorbent from its light, fibrous, and porous character, that it must, like charcoal, readily absorb any gaseous emanations among which it may happen to be placed; while, unlike charcoal, it contains no quality which may help to neutralise or correct their deleterious effects. Instances are on record of disastrous effects having followed the use of charpie which had absorbed the germs of specific diseases, and in this way infected the wounds to which it had been applied.

Charpie has one advantage over lint, viz., its superior capacity for absorbing a thick viscous fluid, such as pus. In any wound from which purulent matter is discharged in considerable quantity, charpie may be advantageously employed in conjunction with the lint, not instead of it, as a dressing. But the charpie should be itself strictly pure, and should be impregnated with some reliable antiseptic material. In such a case, the lint being laid on the sore surface, an arrangement is made for the escape of any discharges at one of its edges, where the antiseptic charpie is placed rather loosely to absorb it as it drains away; or the perforated or lattice lint may be employed, and the charpie laid over it and lightly retained in its place, so as to be enabled to absorb the pus as it passes out through the open spaces of the lint. Similar means may be employed in deep hollow wounds when the discharge is profuse in quantity.

Charpie containing a moderate proportion of tar dissolved in a solution of carbolic acid has been specially manufactured in this country, and may be advantageously employed in the way named, owing to its deodorant and antiseptic qualities. Calvert's carbolised charpie has all the characteristic features of simple charpie, but is readily distinguished from it by its brown colour and tarry odour.

Carded oakum as a dressing for gunshot wounds.-During the war of the rebellion in the United States, common picked oakum made from ships' ropes-an old application to wounds among sailors-was introduced as a cheap substitute for lint and charpie, and became extensively used in the field and general hospitals. Picked oakum has since been used in some civil hospitals in Europe, and was reported to be largely employed in the military hospitals in France during the war of 1870-71. The particular advantages possessed by it consisted in the great abundance with which it could be readily and cheaply obtained; in its capacity as an absorbent, owing to the curled and twisted condition of its fibres; in its antiseptic qualities, due to the tar with which it had been imbued; and lastly, in the facility with which, after having been used, it could be got rid of by combustion, owing to the substance last named entering so largely into its composition. Its chief demerit, as it was originally used,

was the coarseness of its fibre, so that it acted as an irritant upon tender and sensitive sore surfaces. To get rid of this inconvenience several finer sorts of oakum, carded by machinery, were introduced as articles of commerce.12 The more delicate texture of this specially prepared oakum does not appear to interfere with its absorbent power. At the same time, being softer, smoother, and less resilient, it can be applied without inconvenience in case of need to the proximity of inflamed and tender orifices of wounds, or to the neighbourhood of granulating

sores.

For most of the hospital purposes to which surgeon's tow' has been usually applied-for removing discharges from the neighbourhood of a wound, for making small pillows and pads by enclosing it in bags of suitable texture, for padding splints for cases of fracture after being overlaid by lint or soft linen-well-picked oakum will serve equally well, and probably better, owing to its antiseptic qualities, when the hospital cases under treatment mainly consist of injuries produced by gunshot.

Antiseptic and deodorant applications.-The efficacy of the antiseptic treatment of wounds, as generally understood, has been so abundantly demonstrated, the plan of the treatment itself has been so greatly simplified of late years, and the materials adapted to its application have been so multiplied, that its fitness and advantages for the treatment of gunshot wounds under the various conditions of warfare are no longer subjects of question. The only matters which still remain sub judice among military surgeons are not whether antiseptics are to be employed for the treatment of gunshot wounds in time of war, but rather which of the various kinds of antiseptic preparations available for use are the most suitable for military purposes in a campaign.

It has already been noticed that substances possessing more or less antiseptic qualities had been employed for a long time prior to the general acceptance of the principles founded upon the researches of Pasteur, and advocated by Sir J. Lister. The general use for long years of spirits of wine in the various kinds of tinctures in vogue as a topical application to wounds, with the view of counteracting the tendency to putrefactive changes, lessening suppuration, and exciting a healing action; the use of absolute alcohol by many eminent military and civil surgeons with the same objects; a variety of astringent substances applied with the intention of controlling and diminishing wounddischarges; the tow imbued with tar or oakum, so largely used during the great civil war in the United States, are examples of such substances. Others of the same nature formerly in use might also be quoted. During the war of 1870-71 between Germany and France, the permanganate of potash and carbolic acid, especially the latter, were more extensively employed. in both the field and