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necessary. The prevailing conviction now is, that although under their influence excess of inflammatory action may be reduced, the vital power of the patient is reduced beyond proportion, so that he is often left without the means necessary for a favourable reparation of the structures which have been mutilated by the shot, or for the healing process in case amputation has to be resorted to. He is also rendered less able to resist the deteriorating effects of confinement and loss of exercise, as well as the influence of the morbific agents to which he must be more or less subjected during a prolonged period of hospital treatment. At the best, after such depletory treatment, the rate of the patient's convalescence is slow. It is on this reasoning that modern surgeons avoid abstraction of blood in all but exceptional cases, and employ only the mildest forms of remedial agents in their attempts to keep the vascular excitement during the condition of reaction within due limits. Rest, as complete as possible, by the aid, if necessary, of chloral or morphine, the simpler kinds of diaphoretics and diuretics, acidulated drinks, are joined with the usual applications at the seat of injury, in order to calm the inflammatory excitement, local and general, which is occasionally met with at this stage.

If there be much pain about the wound, opium in some of its forms may be freely given with advantage. The value of this remedy consists not merely in the reduction of the local pain and in soothing spasm, but also in lessening the irritation which. results from them. It procures that ease and repose which are essential for the restoration of the balance between the variously disturbed functions of the patient's frame. During the last few years the hypodermic administration of morphine has come into general use; and when due precautions are taken as to the quantity employed, as to the state of the patient, that he is free from severe shock or collapse, there can be no doubt that it possesses many advantages over all other modes of administering opium in gunshot wounds accompanied with pain, and that, under the conditions named, it may be used from the first with much advantage. Relief from pain is afforded by it with much greater certainty and with much more speed than when any form of the drug is given by the mouth. The stomach and digestive organs in patients suffering from the irritation of painful gunshot wounds are often in such a condition that considerable quantities of an opiate may be swallowed without much apparent effect; it remains inert, or nearly so, for the time, while a very minute quantity injected under the skin suffices in a few minutes to induce the desired result. The means of administering hypodermic injections of morphia are now contained in the Field Hospital Equipment of all European armies.

Chloral was extensively used as a calmative remedy in gunshot wounds during the Franco-German war of 1870-71. Baron

Langenbeck praised its employment highly, especially for allaying spasm after amputations necessitated by gunshot wounds. He considered it superior to opium for this purpose. The combination of the bimeconate of morphia with the chloral has been stated to give increased efficiency to the drug. Fifteen grains of the hydrate of chloral with a third of a grain of the bimeconate have been recommended for forming a soothing draught to allay local traumatic irritation and to induce sleep in all painful gunshot injuries.

The mention of sedatives leads me to refer to the use of tobacco. Although smoking is only permitted under certain restrictions, and in exceptional cases, in the wards of English permanent military hospitals, it is rarely objected to in field. hospitals. The only sound objection to the consumption of tobacco is the danger of setting light to the bedding or tents, for there are few non-smokers among soldiers to whom the smell of tobacco is disagreeable, while to the majority it is not simply a luxury, but, from long habit, a daily necessary. Cleanliness, notwithstanding its use, can easily be provided for. It is questionable whether there is not more danger from fire when tobacco-smoking is not allowed, than when it is; for under the former arrangement the men, on the approach of an officer, frequently conceal their lighted pipes under the clothing, or they smoke at hours when they are not likely to be visited, and as this will be chiefly at night, it will be at a time when they are not unlikely to fall asleep and drop their lighted pipes unconsciously on the bedding. It is not, however, because smoking is a habit with soldiers the loss of which becomes a source of discomfort when it cannot be gratified, that the use of tobacco in field hospitals is to be recommended, but on account of its sedative qualities. No one can doubt that it has a soothing effect on men suffering from the pain of wounds, and produces a state of calm which is very beneficial under the circumstances. The contentment it affords to the patient helps the surgeon in his work, and enables a man to submit cheerfully to many unavoidable deprivations which, without it, would fret and worry him. Perhaps none of the presents from Aid Societies in time of war have been so much appreciated in hospitals as the presents of tobacco in various forms; for they have usually arrived at times when it has been difficult for patients to obtain supplies from other sources. It is not among the hospital supplies, though, considering its utility, it is doubtful whether it might not be made one with advantage for issue on special occasions.

Constitutional treatment during the third stage.—When the stage of reaction has subsided, when the tumefaction and inflammation about the seat of injury are declining, sloughs in progress of separation, suppuration fully established, and when the desire for food is improving, it is essential that no judicious means of com

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plying with this appetite, and so supporting the strength of the patient, should be neglected. No medicines are necessary, unless required for assisting the excretory organs, which are liable to become inactive from cessation of the movements to which the body has been accustomed when in a state of health. What the patient chiefly requires under such circumstances is food of a sufficiently varied character, as pure an atmosphere and as full a supply of it as can be obtained, and such cheerful diversion of his thoughts as the position in which he is placed will allow. Should hygienic rules have been enforced during the campaign, and the soldier have been in a good state of general health at the time he was wounded, if the treatment named can be provided for him while he remains under hospital care, the wound will progress towards recovery with regularity, and the constitution of the patient will not be impaired in any material respect. When special states of constitution are met with, they must of course be specially dealt with; but the general principles of treatment ought always to remain the same as they have been described. It is during the stage of suppuration, which is liable to be protracted in some cases of gunshot injury, that the advantages of having fortified the wounded man by a supporting diet and regimen will be particularly made manifest. When the vitality of a patient, already in all probability lowered by previously exhausting agencies, has been further reduced by want of an adequately supporting treatment, he is unable to resist a tendency to morbid degenerating processes when he is placed in conditions which favour their development; he becomes unduly sensitive and irritable, and readily falls a victim to suppurative fever or to pyæmia, or becomes the subject of visceral disease, which ultimately leads to a fatal issue. There can be no doubt also that many of the cases of secondary hæmorrhage which occur in field hospitals among the wounded are attributable quite as much to lowered systemic vitality and septic influences as to the local injury.

At the same time that the necessity for well-cooked, attractive, and easily assimilated food is dwelt upon in the treatment of patients with gunshot wounds of a severe character, it is equally necessary for a surgeon to put the attendants on their guard against allowing an excess in quantity to be given to them. Cramming a patient who is unable to take exercise will in many instances not simply be of no use, but will be a positive source of detriment. Excess of food will disturb the digestive functions, irritate the constitution, increase the amount of suppuration, and impede the progress of cure. The food, while nutritious in character, should be limited to the amount that can be properly assimilated. It is the digestible quality of the articles, and not their largeness of quantity, that is of importance. The diet, so far as concerns the amount which is suitable, must be adapted to

the circumstances of each particular case. In addition to the ordinary articles of diet, fresh or dried fruits, if they are procurable, should be freely given; in their absence, vegetable-acid beverages-lemonade, tamarind, or lime-juice drink, rendered palatable or other articles of a similar nature,32 should be substituted for them. It is not to be expected that such things will be found among the regular supplies of field hospitals; but occasions will not unfrequently occur when they can be procured in general hospitals to which wounded men are removed from the field hospitals for further treatment, and these occasions should. never be neglected. The necessity for the strictest cleanliness of hospital tents and wards with their precincts, of bedding and articles of apparel, of the clothing and persons of attendants, and the importance of regular and speedy removal of all soiled dressings and excreta, and of the constant purity of utensils and all hospital equipment, in order to maintain the atmosphere immediately about the wounds themselves in as pure a state as practicable, have been already adverted to when describing their local treatment. Purity of atmosphere is, however, of even greater importance as regards the constitutional health of the patients. A vitiated atmosphere, crowded with pathogenic micro-organisms, acts deleteriously enough on wounds locally if they are not sufficiently protected; but far more does it seem to act on them indirectly by its toxic effects on the general constitutional state of patients. In proportion as constitutional health becomes impaired, the healing process becomes less vigorous, takes place more slowly, and in deep gunshot wounds the tendency to diffusion of purulent secretions followed by unhealthy sinuous tracks and openings, as well as to accidents of a still graver nature, becomes more and more marked. Unfortunately, although all the necessary manipulative details to ensure cleanliness and to carry out antiseptic treatment may be duly attended to, there are often great difficulties in maintaining a sufficiently pure atmosphere in field hospitals. The accumulation of large numbers of wounded, which is usually unavoidable for some days after a great battle; the employment of buildings for intermediate hospitals which are of unsuitable construction, or objectionable from the condition of their environs; the want which frequently exists of means for separating the wounded from patients struck down by fevers and dysentery; these and other such circumstances entail special difficulties in the way of securing that purity of atmosphere which is essential for the favourable progress of patients labouring under sloughing and suppurating wounds. Special attention has been paid during recent years to the subject of distributing the sick and wounded of armies, as they accumulate, as widely as possible in tents or comparatively small hospitals, instead of aggregating them in a few large hospitals; and the importance of this dissemination,

and the steps necessary for effecting it, are better understood now than they were formerly.

When the plan of dispersing the wounded in small and widely separate hospitals cannot be carried into effect, and when, therefore, many wounded men have to be treated under the same roof, it must be borne in mind that the amount of fresh air to be supplied to the apartments in which they are placed ought always to be greater than need be given to patients affected with ordinary diseases. Perfect ventilation of the wards should be ensured whenever practicable; so that not only the air which is deteriorated by the ordinary causes of respiration and transpiration, but also the emanations from wounds, may be carried off as fast as any arise. To obtain this result there should be such arrangements with regard to inlet and outlet openings as will admit of about 3000 cubic feet of air traversing the ward hourly for each patient contained in it. We know how constantly this very essential part of the treatment of wounded men is neglected in the temporary hospitals employed in time of war, or is rendered impracticable from the nature of the buildings converted to hospital purposes; and this fact alone explains the often-repeated remark, that there would probably be a lower rate of mortality among the wounded if they were treated in the open air, notwithstanding exposure to rain and cold, than is usual among them when treated in buildings which appear to be all that is desirable from the protection and comfort they afford to the inmates.

The means of affording mental diversion to wounded soldiers in military hospitals in time of war have been greatly extended of late years. This improvement has been one of the results of the advance of civilisation. It has become understood that the exercise of the intellectual faculties, by means and within limits suited to the condition and circumstances of patients, is one ingredient in helping them towards recovery. The increased facilities of communication, locomotion, and transport have assisted in bringing these means within their reach in sufficient variety. The spread of sympathy in regard to the concerns and necessities of those who most directly suffer from the effects of war has also effected much in this direction. But it is questionable whether, with all the improvements that have been made in this respect, there is any form of diversion which satisfies for long together the mental wants of badly wounded men-who must often remain for considerable periods of time in a disabled conditionexcepting complete removal to their own homes from the theatre of warfare when it is far away from their native country. To return to their own country and relatives is usually the one longing wish of wounded men, as soon as they have recovered so far as to feel themselves able to undertake the fatigue of the transport.

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