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SANITARY  COMMISSION.
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DIRECTIONS TO ARMY SURGEONS OX THE  FIELD
                     OF BATTLE.       >
                     •   ______          $
                    BY G. J. GUTHRIE,
     Surgeon General to th-j British Forces during the Crimean War.

[A<loptcil by the Commission and printed for the use of U. S. A. Surgeons
             By order :  Fked. Law Olmsteij, Secntary.]
                   [third edition.]
           1. Water being of the utmost importance to wounded men,
        care should  be taken when before the enemy,  not only that
        barrels attached to conveyance-carts are properly filled with
        good water,  but that skins for holding water,  or such other
        means as are commonly used in the country, for carrying it,
        should be procured and duly filled.

          2» Bandages or rollers, applied on the field of battle, are,
»        in general, so many things wasted, as they become dirty and
        stiff, and are usually cut away and destroyed, without having
        been really useful.  [Nevertheless, in connexion with splints,
        in cases of fractures of the limbs, they are indispensable.]

          3. Simple  gun-shot wounds require nothing more, for the
        first two or three days, than the application of a piece of wet
        or oiled linen, fastened on with a strip of sticking-plaster, or,
        if possible, kept  constantly wet and cold with water.  When .
        cold disagrees, warm water should be substituted.
          4. Wounds made by swords, sabres, or other sharp-cutting
        instruments,  are to be treated principally by position.  Thus, 
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a cut down to the bone, across the thick  part of the arm,
immediately below the shoulder, is to be treated by raising
the arm to or above a right angle with the body, in which
position it is to be  retained, however  inconvenient it may
be.  Ligatures may be inserted, but through the skin only.
If the throat be cut across in front, any great vessels should
be tied, and the oozing stopped by a sponge.  After a few
hours,  when the oozing is arrested, the sponge should be
removed, and the head brought down towards the chest, and
retained in that position without ligatures ; if this is done too
soon, the sufferer may possibly be suffocated by the infiltration
of blood into the areolar tissue of the parts adjacent.

   5. If the cavity of  the chest is opened into by a sword or
lance, it is of the utmost importance that  the wound in the
skin should be effectively closed, and this  can only be done
by sewing it up as a tailor or a lady would sew up a seam,
skin only being included ;  a  compress of list  should be
applied over the  stitches,  fastened on by sticking plaster.
The patient is then  to be placed on the wounded side, that
the lung may fall down, if it  can, upon, or apply itself to
the wounded part,  and adhere to it, by which happy and
hoped-for accident life will in  all  probability be preserved.
If the lung should be seen protruding in the wound, it should
not be returned beyond the level of the ribs, but be covered
over by the external parts.

   6. It is  advisable  to encourage previously the discharge of
blood from the  cavity of the chest, if  any have fallen  into
it; but if the bleeding from within should  continue, so as to
place the life of the sufferer in danger, the external wound
should be  closed and events awaited.

   7. When it is doubtful whether the bleeding proceeds from
the cavity of the chest, or from the intercostal artery, (a
surgical bugbear,) an incision through the skin and the exter-
nal intercostal muscle will expose the artery close to the edge 
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of the rib having the internal intercostal muscle behind it.
The vessel thus exposed may be tied, or the end pinched by
the forceps,  until it  ceases to bleed.   Tying a string round
the ribs is a destructive  piece of cruelty, and the  plugs,
&c, formerly recommended, may be considered as surgical
incongruities.

   8.  A gun-shot wound in the chest cannot close by adhesion
and must  remain open.  The position of the sufferer  should
therefore  be that which is most comfortable to him. A small
hole penetrating the cavity is more dangerous than a large  /
one, and the wound is less dangerous if the ball goes through
the body.  The wounds should be examined and enlarged if
necessary, in order to remove all extraneous substances, even
if they should be seen to stick on the surface of the lungs ;
the opening should be covered with soft oiled or wet lint—
a bandage when agreeable.   The ear  of the  surgeon and
the stethoscope are invaluable aids, and ought always to be
in use ; indeed no injury of the chest  can be scientifically
treated without them.

   9.  Incised and gun-shot wounds of the abdomen are to be
treated in nearly a similar manner ; the position in both being
that which is most agreeable to the patient, the parts being
relaxed.  In incised  wounds of the abdominal parietes great
care should be taken to include in the sutures all the  tissues
except the peritoneum.

   11. In  wounds of  the bladder, an elastic or silver catheter
is generally necessary.   If it cannot be passed, an opening
should be made in the perineum for the evacuation of the
urine, with as little  delay as possible.

   12. In  gun-shot fractures  of the skull, the broken pieces
of bone and all extraneous substances are to be removed as
soon as possible, and depressed fractures of the bone are to
be raised.  A deep cut made by a heavy sword through the
bone into the brain, generally causes a considerable depression 
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    of the inner table of the bone, whilst the outer may appear-
    to be merely divided.

     13. An arm is  rarely to  be amputated, except from the
 x-* effects of a cannot-shot.  The head  of the bone  is to be
    sawn off, if necessary.   The  elbow-joint  is to be cut out, if  , , i£
    destroyed, and the sufferer, in either case, may have a very
    useful arm.

     14. In a case of gun-shot fracture of the  upper arm, in
    which the bone is much splintered, incisions  are to be made
    for the removal of all the broken pieces which it is feasible
    to take away.  The  elbow is to be supported.  The forearm
   is to be treated in a similar manner ; the splints used should
    be solid.

     15. The hand is never to be amputated, unless all or nearly
   all its parts are destroyed.   Different bones of it, and of the
   wrist, are to be removed when irrecoverably injured, with
   or without the metacarpal bones  and  fingers or the thumb  ;
    but  a  thumb and one  finger should be  preserved  when
   possible.

     16. The head of the thigh bone should be  sawn off  when
   broken by a musket-ball.  Amputation  at the hip-joint
   should only be done when the fracture extends some dis-
   tance into the shaft, or  the limb is destroyed  by cannon-
\  shot.  [There is little  encouragement for the performance
   of primary amputation or resection at the  hip-joint.]

     IT. The knee-joint should be cut out when irrecoverably
   injured ; but the limb is not to be amputated until it cannot
   be avoided.

     18. A gun-shot  fracture of the middle of  the thigh,  at-
   tended by great splintering, is a  case for amputation.  In
   less   difficult cases,  the splinters should  be removed  by
   incisions,  particularly when they  can be made on the upper
   and outer side of the thigh.  The limb should be placed on 
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a straight, firm splint.   A broken  thigh  does not admit of
much and  sometimes of no extension,  without an unadvis-
able increase of suffering.  An inch or two of shortening in
the thigh does not so materially interfere with progression
as to make the sufferer  regret having escaped amputation.
[The sufferings of the patient will be greatly alleviated by
judicious extension  with strips of adhesive plaster,  and a
more useful limb will thus be secured.]

   19. A leg injured below the knee should rarely be ampu-
tated in the first instance, unless from  the effects of a can-
non-shot.   The splinters of bone are all to  be immediately
removed, by saw or  forceps, after due incisions.  The limb
should be  placed in iron splints, and  hung  on a permanent
frame, as  affording  the greatest  comfort, and  probable
chance of  ultimate  success.

   20. An ancle-joint is  to be  cut  out, unless the tendons
around are too much  injured, and  so are  the tarsal and
metatarsal  bones and toes.  Incisions have hitherto been
too little employed in the early treatment of these injuries
of the foot for  the removal of extraneous substances.

  21. A  wound of  the  principal  artery of the thigh,  in
addition to a gun-shot fracture, renders immediate amputa-
tion necessary.  In no other part of the body is amputation
to be done  in the first instance for  such injury.   Ligatures
are to be placed on the wounded artery,  one  above, the
other below the wound,  and events awaited.

   22. The occurrence of mortification  in any of these cases
will be known by the change of color  in the skin.   It will
rarely occur in the upper extremity, but will frequently  do
so in the lower.  When  about  to  take place, the  color of
the skin of the foot  changes,  from the natural flesh color to
a tallowy or mottled white.   Amputation  should be  per-
formed immediately  above the fractured part.   The morti-
fication is yet local. 
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  23. When this discoloration has not been observed, and
the part shrinks, or gangrene has set in  with more marked
appearances,  but yet  seems to have stopped at the ankle,
delay is, perhaps, admissible ; but if it should again spread,
or its cessation be doubtful, amputation  should take place
forthwith,  although under less favorable circumstances.
The mortification  is becoming, or  has  become,  constitu-
tional.

  24. Bleeding,  to the loss  of  life, is not a common occur-
rence in gun-shot wounds,  although many do  bleed con-
siderably ;  seldom, however, requiring the application of a
tourniquet  as a matter of necessity,  although frequently as
one of precaution.

  25. When the great artery of the  thigh is wounded, (not
torn across,)  the bone being  uninjured, the sufferer will
probably bleed to death, unless aid  be afforded, by making
compression above, and on the  bleeding  part.  A long, but
not broad stone, tied sharply on with a  handkerchief, will
often suffice until  assistance can be obtained,  when both
ends of the divided or  wounded artery are to be secured by
ligatures.

   26. The upper end of the great artery of the thigh bleeds
scarlet  blood,  the  lower end  dark venous-colored blood ;
and this is  not departed from in a case of accidental injury,
unless there have  been previous disease in  the  limb.   A
knowledge of this  fact or  circumstance, which  continues
for several days, will  prevent  a mistake at the moment  of
injury, and at a subsequent period, if secondary  hasmorrhage
should occur.   In the upper extremity both  ends of the
principal artery bleed scarlet blood, from the free collateral
circulation, and from the anastomoses in the hand.

   27.  From this cause, mortification rarely takes place after
a wound of the principal artery of the arm, or  even of the
armpit.  It frequently follows a wound of the principal artery 
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in the upper, middle, or even lower parts of the thigh, ren-
dering amputation necessary.
   28.  It is  a great question, when  the bone is uninjured,
where, and  at  what part,  the amputation should be per-
formed.   Mortification  of  the foot  and  leg, from such  a
wound, is disposed to  stop  a little below the knee, if it
should not destroy the sufferer ; and  the operation, if done
in  the first instance,  as  soon  as the tallowy or mottled
appearance  of the foot is observed,  should be  done at
that part; the  wound  of the  artery, and the operation for
securing the vessel above  and below the wound, being left
unheeded.  By this proceeding, when  successful,  the knee-
joint is saved, whilst  an amputation above  the middle of
the thigh is always very doubtful in its result.

   29.  When mortification has taken place from any cause,
and has been arrested  below the knee, and the dead parts
show some sign of separation, it is usual to amputate  above
the knee. By not doing it, but by gradually separating and
removing the  dead parts, under the  use of disinfecting
medicaments and  fresh air,  a  good stump may be  ulti-
mately made, the knee-joint and life being preserved, which
latter  is frequently lost after amputation under such cir-
cumstances.

   30.  Hospital gangrene,  when  it unfortunately  occurs,
should be considered to be contagious  and infectious, and
is to be treated locally  by destructive  remedies,~such as
nitric  acid,   and  the  bivouacking or  encamping  of  the
remainder of the wounded, if it can be effected, or their
removal to the  open air.

   31. Poultices have  been very  often applied in gun-shot
wounds, from laziness, or to  cover neglect, and should be
used as seldom as possible.

   32.  Chloroform [or  ether]  may be  administered in all
cases of amputation of the  upper  extremity and below the
knee, and in all minor  operations ; which cases  may also 
                 •                SANITARY COMMISSION,
                           8               B.

be deferred, without  disadvantage, until the more serious
             ft
operations are performed.
  33. Amputation  of  the  upper and middle parts of the
thigh are to be done as soon as possible after the receipt of
the'injury.   The administration of chloroform [or ether] in
them, when there is much prostration, is doubtful, and must
be attended to, and observed with great care ; the question
whether it should or should not be administered in such
cases being undecided.

  34. If the young surgeon  should not feel quite equal to
the ready  performance  of the various operations recom-
mended, many of them requiring great anatomical knowl-
edge and manual dexterity, (and it  is not to be expected
that he  should,)  he should avail himself of every oppor-
tunity which may offer of  perfecting his knowledge.

  [It is to be hoped  that  the medical officers of the army
will aim to equal the  surgery of the civil hospitals of the
country, and that they will not only correct any errors into
which their predecessors  may have  fallen, but  excel them
by the  additions  their  opportunities will permit them to
make, in the improvement of the  great art and science of
surgery. ]