deposited, are not visible. During the Crimean war, cotton gauze net was issued for use in the hospital tents and huts as a protection against flies. It was laid over the parts of the body in which the wounds were situated, whenever these were exposed in order to be cleansed or dressed; and as the flies, even when prevented from reaching the wounds themselves, irritate patients by their habit of hovering in multitudes about them, the net was also used for covering the faces of the wounded men to enable them to get peace and rest. Linen moistened with a weak solution of chlorinated soda or zinc, or with a solution of creosote in water, laid loosely over the dressings, was found to be useful as a protection. Dr. Brougham, whose vivid account of the distressing annoyance caused by the multiplication of flies and maggots in the hospitals during the siege of Delhi will not be forgotten by those who have read it, states that he found the application of lotions containing oil of turpentine and camphor the most efficacious treatment against them.

When larvæ burrow, and they will sometimes do so in hot climates to a considerable distance, injections must be employed. These will cause them to approach the aperture of the wound, whence they must be removed by the aid of a forceps. On one occasion I had under my care in Bengal a contused wound of the head. It was progressing favourably, when at one of the morning visits I discovered to my astonishment that the scalp was burrowed in all directions by larvæ. The wound had been carefully dressed, and my native dressers were all that I could desire them to be. The accidental appearance of one of the larvæ in the wound led to the discovery of the state of the scalp. No more irritation had attended their presence than the injury to the head itself had seemed to account for. The removal of the nuisance was tedious, and recovery was only attained by diligent extraction of the larvæ singly, and by injections with weak solutions of creosote. In the West Indies, tobacco-water, under the name of Chigoe-water, from its employment in destroying chigoes after they have entered the skin, was used as a remedy in my time for ridding wounds of maggots. It is not improbable that flies sometimes find their opportunities of getting at wounds during the night-time, owing to the disturbance of dressings by movements of patients during their sleep. It becomes important, therefore, to take especial care at the evening visit that the dressings and protective coverings are well secured, so that access of the flies to them may be prevented during the interval which will elapse before the visit in the morning. Happily for surgeons whose duties are limited to dealing with wounds in the hospitals of temperate climates, the treatment of this repulsive complication can scarcely ever concern them.

SECTION IX

ADMINISTRATIVE ARRANGEMENTS FOR THE CARE AND TREATMENT OF WOUNDED SOLDIERS IN TIME OF

WAR

Preliminary remarks.-The means which are provided for the care and treatment of the wounded men of an army engaged in active military operations, together with the system authorised for applying them-whether on the field of action, in the hospitals, or while the wounded are in course of removal from the one to the other-must always have so considerable an influence on the ultimate results of the injuries which the wounded men have received, that a description of these matters could not be omitted from this work without neglecting an important part of the subject of the general treatment of gunshot injuries as they occur in time of war. Whatever amount of knowledge has been gained of the proper course to be pursued in the management of gunshot injuries individually, it will all be of little avail in practice, especially when this practice has to be conducted on a large scale, if the surgeons have not at their disposal suitable articles for the due protection and treatment, as well as for the care and nursing of their patients. The truth of this statement forces itself most strongly upon the attention when the circumstances in which troops are usually placed during the progress of a campaign are considered. It is one of the functions of the Army Medical Department to study these subjects, and to make recommendations on them to the War Department of the Government, especially as to the kinds and numbers of hospital establishments necessary to be provided on the outbreak of war; while it is the province of the supreme authorities to determine how far the recommendations are to be complied with. Some of the questions that arise in considering these subjects are by no means easy of solution; so many and so various are the circumstances which exert an influence on the decisions that may be formed regarding them.

On attempting to review the arrangements which have to be made in order to carry on the business of the medical department of an army in time of war efficiently, it soon becomes evident that the subject is as complex as it is important. Its complexity makes

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itself apparent when the varied kinds of military operations adopted for purposes of attack and defence are remembered; for, in regard to nearly all these undertakings, forethought has to be devoted, and, in many of them, special provision has to be made by the Army Medical Department in order that the health of the men composing the army may be preserved, and the sick and wounded duly cared for. Its importance is rendered obvious on studying the histories of campaigns; by observing how much the welfare and confidence of the troops, the maintenance of the strength of armies, the prevention of delays, and the consequent facilities afforded to commanders for carrying out their strategical designs-not to mention ultimate economy as regards expenditure -have depended upon there being a sufficiency of medical aid on the spot, upon the equipment and essential hospital supplies being adequate in amount, and ready whenever needed for meeting the necessities of the sick and wounded, and also on the plan of hospital administration being well contrived and systematically executed.

The provisional arrangements which particularly influence the results of the treatment of gunshot injuries in time of war are most conveniently divided for purposes of study into two principal parts; one being that of organisation and administration, the other that of equipment. Of these two divisions the former is certainly the more important. According to the plan on which the Field Medical Service is organised, and to the intelligence and energy with which it is carried out and adapted to the varying contingencies of war, so will be the degree in which the hospital staff, whatever its numbers, and the equipment, whatever its amount, are turned to useful account. When the organisation is good and well administered, the services of all the functionaries included on the establishment will be utilised, and they and the articles of equipment will be in the places where they are most required; when the organisation is bad or badly administered, a considerable amount of personal capacity will be misdirected and probably wasted, while many needful things which have been provided will be absent from the places where they are urgently wanted. Under the first-named condition, when an engagement occurs, the wounded will be systematically attended to, have their wounds dressed, and be moved to their appointed hospitals with all the promptitude, regularity, and care that the surgeons and means at command render possible; under the second, there will be confusion, needless delay, and, as an inevitable consequence, an increase of suffering, prolonged hospital treatment, and, ultimately, very probably a higher rate of invaliding and mortality among the sufferers. Even though the hospital staff may be comparatively limited in number, and the supply of transport and other hospital equipment only moderate in amount, yet, if well organised and handled, they may enable the requirements

of the wounded to be more quickly and efficiently met. than a far more numerous staff, and more abundant stores and transport, under opposite conditions. Substitutes, more or less perfect, can be found for many articles of equipment, while extra zeal and devotion may make up for deficiencies in the numbers of the medical or subordinate staff; but nothing can prevent the evils which follow in the wake of imperfect organisation and careless administration. The quality of the administrative arrangements of the medical department of an army is quite as important, indeed, under some circumstances, may be even more so, than the quality of the executive medical service. The amount of professional knowledge of the medical officers, and of their practical expertness in the performance of surgical operations, will doubtless determine the results of many individual wounds and injuries; but it must depend upon the general administration how quickly, and under what conditions, this knowledge can be applied. Thus, though the surgeons may possess all the skill and dexterity which will enable them to decide exactly what ought to be done in each particular wound and injury that may fall under their care, and to do it, yet their science and ability may be rendered comparatively fruitless by an ill-advised or ill-conducted system of administration. It is from this cause that army medical officers have come to be employed in two capacities, administrative and executive. The former officers are required to see that the authorised plan of dealing with the wounded is carried into effect, to settle the various questions and to remove the difficulties which may arise while it is in process of execution, and, in short, to take the necessary steps for ensuring that all the parts of the field medical system work regularly and smoothly in concert. The right performance of these functions requires much previous acquaintance with military arrangements, particular tact and energy, and an amount of supervision which can only be given by an almost exclusive devotion of time and attention to the duty.

A description of the arrangements which are necessary for preserving the general health of troops in the field, and of the steps to be taken for their practical execution, although they indirectly influence the effects of injuries when they occur, does not belong to this work: they are treated upon in books on army hygiene. Only those matters can be noticed here which have a special bearing on the wants of wounded men. These will be considered under the four following heads, viz.: (1) Hospital organisation; (2) Hospital administration; (3) Hospital equipment; and (4) Sick-transport equipment.

CHAPTER I

ARMY HOSPITAL ORGANISATION

Organisation in peace-time relatively to time of war.-As an army is only maintained for purposes of war, either defensive or offensive, it is obvious that the organisation of its several parts in time of peace should accord as far as practicable with the organisation which will be necessary when war occurs. This applies to the medical equally with all other parts of the army. The constitution of the hospital staff, medical and subordinate; the system on which the hospital duties are conducted, their distribution and direction; the transport arrangements; the forms of the transport vehicles and of the hospital equipment, should all have reference to the necessities of time of war. The staff will thus be trained and accustomed to the duties which they will have to perform in the course of a campaign, often under very difficult circumstances; and they will become familiar with the equipment which will be at their disposal for use in the field. Many improvements will suggest themselves from the experience which may be thus gained; and, in the end, the various demands which are made on the medical service with very special urgency in time of war will be more easily, more systematically, and more successfully answered.

But though the principles on which the constitution and general economy of the Army Medical Service are based may be alike for peace and war; and though unity of pattern may be attained in most of the instruments and articles of equipment in daily use by the officers of the department; such complete and perfect accord as may be attained in the organisation, exercises, equipment, and many of the administrative arrangements of the combatant parts of an army, cannot be accomplished in the medical branch. The circumstances of peace and war differ too greatly to allow the same details of hospital administration and duties to be employed in the two conditions of service. In time of peace, the wants of the sick and hurt of an army can be more economically, and more satisfactorily, ministered to in permanent hospitals furnished with standing equipment. In time of war, when once troops have taken the field, such fixed establishments are only available under very exceptional circumstances. It is uncertain where battles, entailing the necessity for surgical attendance on an enormous scale, may be fought, and, independently of these occasional demands, there is a constant need of medical and surgical help on the line of march, in the bivouac, and, indeed, in all situations where soldiers may be placed