Conservative Surgery on the Battlefield and First Aid to the Wounded, N. SENN, M.D., Ph.D., LL.D. COLONEL AND SURGEON-GENERAL OF THE ILLINOIS NATIONAL GUARD; PRESIDENT OF ASSOCIATION OF MILITARY SURGEONS OF ILLI- NOIS ; EX-PRESIDENT OF THE ASSOCIATON OF MILITARY SURGEONS OF THE UNITED STATES. CHICAGO. REPRINTED FROM THE JOURNAL OP THE AMERICAN MEDICAL ASSOCIATION. JULY 6 and 13. 1895. American Medical Association Press. CHICAGO: Conservative Surgery on the Battlefield and First Aid to the Wounded. N. SENN, M.D., Ph.D., LL.D. COLONEL AND SUEGEON-GENEEAL OF THE ILLINOIS NATIONAL GUARD; PRESIDENT OF ASSOCIATION OP MILITARY SURGEONS OF ILLI- NOIS ; EX-PRESIDENT OF THE ASSOCIATON OF MILITARY SURGEONS OF THE UNITED STATES. CHICAGO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, JULY 6 and 13, 1895. American Medical Association Press. CHICAGO; CONSERVATIVE SURGERY ON THE BATTLE- FIELD AND FIRST AID TO THE WOUNDED. Conservatism will characterize the military sur- gery of the future. The two great sources of danger that face the wounded soldier upon the battle-field— hemorrhage and infection—will be greatly dimin- ished by additional and improved hemostatic meas- ures, and the more general and effective application of the principles of aseptic and antiseptic surgery. Mutilating primary operations will be limited to in- juries with extensive destruction of the soft parts and complications involving large vessels and nerves which in themselves are sufficient to arrest the nutri- tion of the injured limb. Gunshot injuries of bones and joints will no longer determine the propriety of primary resection and amputation, and the danger of penetrating wounds of any of the large cavities of the body will be greatly diminished by the prompt employment of measures calculated to prevent septic infection, and other immediate and remote complications. I take it for granted, that lam ex- pected on this occasion to discuss briefly the salient topics which will engage the attention of the military surgeons of future wars, and which will enable them to reduce the death rate, diminish suffering, save limbs, and prevent painful remote complications in case of bullet and other wounds which heretofore demanded primary mutilating operations, or, if treated upon conservative plans, subjected the sol- dier to imminent danger to life from septic compli- cations. Conservative surgery on the battle-field consists in rendering prompt and efficient aid to the wounded. 4 rhage. Fig. I.—Elevation of the upper extremity in the treatment of hemor- 5 To accomplish this successfully is the desire and aim of the military surgeons of all civilized nations. A well-trained hospital corps is now looked upon as an essential constituent of every modern military body. In our own country the Army and Navy, as well as the National Guards of the different States, are mak- ing ample preparations for effective first aid to the wounded, in the event of war, by the careful training of soldiers selected for Hospital Corps service. The practice of conservative surgery upon the battle-field will, of necessity, be intrusted largely to the educated, well-trained, non-combatant soldier. It is the char- acter and efficiency of his work that will determine the fate of the wounded. I shall limit my remarks to the discussion on the work to be done by the sur- geon and his helpmates, the members of the Hospital Corps, in caring for the wounded upon the battle- field, which will embrace : 1, the treatment of hemor- rhage ;2, to counteract shock; B, primary dressing; 4, immobilization; 5, transportation. Temporary Hemostasis. A large percentage of deaths upon the battle-field has been caused by the immediate result of hemorrhage. It is to be ex- pected that the small calibre . bullet, owing to its greater velocity and penetrating power, will cause death more frequently from primary acute hemor- rhage than the round or large conical bullet of the past, because the wounds inflicted by it resemble more nearly incised than contused wounds as was formerly the case. There can be but little doubt that the old weapon produced wounds which were more liable to be followed by secondary hemorrhage, induced by the sloughing of the large area of con- tused tissue surrounding the tubular wound made by the bullet. The absence of this extensive area of contusion and laceration in wounds of large blood vessels made by the new bullet will increase the dan- ger from primary hemorrhage, and will, consequently, demand more frequently and urgently in their treat- ment the employment of prompt and efficient hemo- 6 static measures. The treatment of hemorrhage upon the battle-field will be governed by the size and character of the vessel wounded and the part or organ injured. A distinction between arterial and venous hemorrhage is impracticable as far as the Fig. 2.—Gun-stack for elevation of the lower extremity. immediate treatment by non-professional assistants is concerned. Ligation of a blood vessel upon the battle-field, either at the point of injury or in its con- tinuity, will be done only in exceptional cases. In 7 the majority of instances this part of the treatment will be consigned to the surgeons in charge of the first dressing station or the field hospital. In ren- dering the first aid to the wounded, hemorrhage should be diminished or arrested by such means and measures as are always at hand, or that can be read- ily extemporized and can be safely and efficiently applied by members of the Hospital Corps. Elevation of Limh.—The force of gravitation an- swers an exceedingly useful purpose in arresting hemorrhage from the smaller vessels of the extremi- ties. By placing the injured limb in a vertical posi- tion, intravascular pressure is so much diminished that spontaneous arrest of hemorrhage is often effected by this simple procedure, even when a vessel the size of the palmar arches is injured, but its great- est value and widest range of application will be in the treatment of venous and parenchymatous hemor- rhage. The elevated position should be maintained for some time after the hemorrhage has ceased, or until more efficient measures can be employed. The manner of effecting and maintaining elevation as a hemostatic agent is shown in Figs. 1 and 2. Digital Compression.—In the treatment of hemor- rhage from large vessels accessible to digital com- pression, this method offers a reliable means of controlling hemorrhage. The members of the Hos- pital Corps are familiarized with the exact location of the principal arteries of the extremities and the method of arresting hemorrhage by digital compres- sion. The compression must be continued uninterrupt- edly until the bleeding vessel can be tied, or pressure can be replaced by elastic constriction or the anti- septic tampon. Flexion.—Forced flexion as an hemostatic agent was introduced by Adelmann. Genuflexion is a prompt and efficient method of arresting hemorrhage from the popliteal artery and its branches. Brachial hyperflexion answers the same purpose in the treat- 8 ment of hemorrhage from the brachial artery from a point opposite the elbow joint or any of its branches below this point. In making genuflexion, the belt, suspender, gun- strap, or triangular bandage should be passed through a slit in the shoe or boot above the heel, after which the ends are firmly tied over the base of the thigh where it is fastened to the pants or drawers Fig. 3.—Digital compression of brachial artery. with a safety pin. Forced flexion of the forearm can be made with an ordinary handkerchief. Elastic Constriction.—Elastic constriction, properly applied, is a safe and absolutely reliable hemostatic agent in preventing and controlling hemorrhage from any of the vessels of the extremities. Introduced and popularized by the greatest military surgeon of 9 the present time, von Esmarch, it is applied wher- ever surgery is practiced, but its employment is of special value upon the battle-field. The elastic con- strictor has displaced almost entirely the ordinary tourniquet. Preliminary compression of the limb by an elastic bandage is unnecessary, as simple eleva- tion continued for a few moments will render the limb sufficiently bloodless for all practical purposes. The harmful effects of elastic constriction improperly ap- plied are temporary, and even permanent paralysis of one or more of the principal nerves injured by the linear compression. To prevent such a complication it is necessary to compress the limb at a point where the main nerves are adequately protected by muscles and to bring to bear no more pressure than is neces- sary to realize the object for which the constriction is made—to interrupt completely both the venous and arterial circulation. The arm should be constricted at a point corresponding with the middle of the del- toid muscle or over the top of the shoulder and the thigh near its base. To avoid harmful linear constriction it is advisa- ble to use an elastic band at least an inch in width or a suspender, and if the constrictor encircles the limb more than once, to bring each turn separately down upon the surface of the limb and not overlap each other. An assistant should hold the limb firmly in a vertical position when the constrictor is applied over the side of the limb where the large blood vessels are located, and the constriction quickly and firmly made so as to interrupt at once, completely, both the arterial and venous circulation. How long is it safe to exclude from a limb the circu- lation by elastic constriction? This is an important question which presents itself with special force in the practice of military surgery. I made, a few years ago, an interesting series of experiments on dogs for the purpose of formulating an authoritative answer to this question. Elastic constriction was applied by using rubber tubes the size of an ordinary 10 lead pencil, and the constriction was continued from one to twenty-six hours. Temporary paralysis was observed in a number of cases. Gangrene of the limb below the point of constriction resulted only in one case, and in this instance the constriction was continued for twenty-four hours, while the dog in which the constriction was continued for twenty-six hours recovered in a short time perfect use of the limb. The blood contained in the arteries and veins below the point of constriction remained fluid and retained its intrinsic functional properties for this length of time after complete exclusion from the gen- eral circulation. Elastic constriction is not attended by any special danger from this source. Every sur- geon has had cases in which elastic constriction was continued for several hours, in the performance of Tig. 4.—Digital compression of femoral artery. 11 difficult and tedious operations, without witnessing any untoward, immediate or remote results from the prolonged interruption of the circulation. I have learned of a number of cases of railway injuries in which elastic constriction was continued from seven to twelve hours without any obvious harmful results. From the results of my owrn experiments and the clinical data on elastic constriction as a hemostatic resource, I am satisfied that it is safe to exclude the circulation from a limb for four to six hours without incurring any special risks of gangrene or permanent damage to large nerve trunks. The exact limit of prolonged constriction in man has not been deter- mined, and I should consider it unwise to continue it beyond the time specified. In the majority of cases during this time the wounded will be brought to the attention of surgeons when the injured vessel is ex- posed and tied, or elastic constriction is replaced by direct compression. Antiseptic Tampon.—The antiseptic tampon is a convenient and very useful hemostatic agent in the treatment of accidental hemorrhage. The antiseptic package with which every soldier of civilized war- fare will be supplied can be used advantageously for this purpose. It will prove of special value in the arrest of hemorrhage from the vessels of the scalp, face and intercostal arteries, and in the treatment of open lacerated and sabre wounds. The surface to be compressed should be dusted with the antiseptic powder contained in the package, and with the hy- groscopic antiseptic material composing the balance of the package a graduated compress is made, the apex of which is placed in contact with the bleeding vessel, and the necessary degree of pressure secured by a circular bandage with or without the use of an extemporized splint according to the location of the vessel, or the relations of the injured vessel to the underlying bone. Vessel injuries treated by antiseptic tamponade will seldom require ligation as the tampon, if the 12 wound remains aseptic, is allowed to remain until the lumen of the vessel has become obliterated per- manently by thrombosis and cicatrization. Internal Hemorrhage. The prompt and proper treatment of internal hemorrhage will constitute one of the crowning triumphs of surgery upon the battle- field. The direct treatment of the injured vessels by early invasion of any of the three large cavities of the body will be the means of saving many lives which heretofore were doomed to certain death. This Fig. s.—Genuflexion in the treatment of hemorrhage from the pop- liteal artery and its branches. part of the surgeon’s work will be done at the first dressing station or the field hospital. What can be done behind the fighting line in such cases to bridge over the time until such services can be rendered to the injured? In hemorrhage from the intracranial vessels caused by bullet wounds, it would be dangerous to plug the wounds of entrance and exit as the accumulation of blood in the cranial cavity would result in death from cerebral com- pression. The escape of blood should be favored by inserting into the track made by the bullet a strip of 13 aseptic or iodoform gauze. This will not only serve a useful purpose as a capillary drain, but by bring- ing in contact with the injured vessels an aseptic for- eign substance the spontaneous arrest of hemorrhage by thrombosis is favored. The gauze drain should be secured on the surface of the wound with a safety pin and the wound or wounds protected against in- fection by an antiseptic dressing retained in place by the triangular bandage. By this treatment many cases will reach the field hospital for a timely intra- cranial operation. In bullet and stab wounds of the chest, complicated by hemorrhage from the inter- costal arteries, the antiseptic tampon is the proper treatment. Packing of the tubular wound with an antiseptic hygroscopic material will not only succeed in arresting the hemorrhage, but will serve at the same time as an efficient capillary drain and protect the cavity of the chest and its contents against infec- tion. In hemorrhage from injuries of the organs of the chest, firm circular compression of the chest directly over the wound already protected agaiust infection by an antiseptic dressing constitutes a val- uable indirect hemostatic measure. Immobilization of the chest wall by circular com- pression diminishes the functional activity of the lungs, and in doing so exerts a favorable influence in arresting hemorrhage from this organ. The cartridge belt or gunstrap can be used to the greatest advan- tage in limiting the respiratory movements of the chest. I believe that this conservative treatment of penetrating wounds of the chest will yield better re- sults than injection of filtered air, absorbable aseptic solutions, or treatment by rib resection, free incision, and attempts to ligate the bleeding vessels. In pene- trating wounds of the abdomen the prime indication in the future treatment of such injuries will be to prevent death from hemorrhage. Visceral wounds of the abdominal organs, notably the liver, spleen and mesentery, usually give rise to profuse and often fatal hemorrhage. The hemorrhage is more fre- 14 quently venous and parenchymatous than arterial. In my address last year before this Association, I urged the importance of early operative interference in such cases, and mentioned hemorrhage and the Fig. 6.—Forced flexion of forearm in arresting hemorrhage from the brachial artery opposite the elbow joint or any of its branches below this point. direct treatment of visceral wounds as ample indica- tions to justify prompt, active interference. In in- juries of vessels below the bifurcation of the abdom- inal aorta, attempts should be made to prevent death 15 from hemorrhage upon the battle-field by resorting to the use of some sort of compression with a view to interrupting the circulation in the aorta above the bleeding point. Esmarch’s method, shown in Fig. 11, can be extemporized in a few moments, as it re- quires no instrument of special construction and meets the indications more completely than the various instruments devised for this purpose. The method of Brandis is equally simple and effica- cious. As hemorrhage from any of the vascular organs and large vessels of the abdominal organs requires prompt treatment, and as in large engage- ments a considerable length of time will necessarily intervene between the first aid and the permanent arrest of hemorrhage by laparotomy, and as in many instances the location of the wound is outside of the range of successful treatment by compression of the Fig. 7.—Elastic constriction of upper extremity. (After Seydel.) 16 abdominal aorta, it appears to me that in such cases it would be good treatment to resort to direct and circular compression as has been described in con- nection with penetrating wounds of the chest. The wound of entrance and exit, if the latter exists, should be protected by an antiseptic dressing. Over the wound corresponding with the yielding part of the abdominal wall a large compress which may be composed of a compress made of a blanket, an arti- cle of clothing, a cartridge belt, or canteen should be placed and over it firm circular compression made with a belt or gunstrap. The direct compression made in the direction of the track of the bullet will do much toward diminishing the vascularity of the underly- ing injured parts, while the circular compression will immobilize the abdominal wall at the seat of injury and limit the movements of abdominal organs, con- ditions which can not fail in materially diminishing the risks of hemorrhage and in aiding thrombosis, nature’s resource, in effecting spontaneous arrest of hemorrhage. Permanent Hemostasis.—Forcipressure.—The best and most successful military surgeon is the one who accomplishes the most with the least number of instruments. Complicated instrument cases look well and make a favorable impression upon lay- men, and can be used to advantage in a well- equipped hospital; they are out of place on t]ie battle-field. The fewer the instruments in the treatment of emergency cases, the less the danger of infection. The writer has recently devised an operating pocket case which contains all the in- struments a military surgeon is expected to use when in active service. It contains among the instru- ments needed for emergency work seven hemostatic forceps, by the use of which he is in a position to meet the emergencies incident to hemorrhage upon the battle-field. The use of aseptic hemostatic for- ceps upon the battle-field will meet the indications successfully in many cases in which other hemostatic 17 measures are inapplicable. If the bleeding vessel is so located that it can be grasped with hemostatic for- ceps, but can not be ligated without performing a formidable operation, the forceps should be allowed to remain and should be incorporated in the antisep- tic dressing and a note made to this effect on the diagnosis tag. Fig. 7 a.—Suspender constriction of arm. Ligature.—Ligation of blood vessels, arteries and veins will usually be done upon the battle-field after temporary hemostasis by other means, either at the first dressing station or, more frequently, at the field 18 Pig. B.—Elastic constriction of lower extremity. (After Seydel.) Fig. 8 a.—Elastic constriction of thigh. 19 hospital. Silk is the proper ligature material in military service. Silk can be sterilized repeatedly by boiling and is, consequently, a much safer mate- rial than catgut in emergency practice. Aseptic silk in an aseptic wound invariably becomes encysted. Catgut sterilized in Boeckmann’s sterilizer and kept ready for use in sterilized envelopes, as advised by Boeckmann, could be made serviceable for military surgery. As a rule, the vessel should be tied at the seat of injury by enlarging the existing wound and using it as a guide to the injured vessel. Cases, however, will present themselves in which it is im- possible to apply this rule, and where the artery has to be tied in its continuity in a more accessible place on the proximal side of the bleeding point. Anti- septic precautions in the treatment of wounds and the employment of the aseptic ligature will materi- ally diminish, if not entirely overcome, the risk of secondary hemorrhage, which proved such a terror to the surgeons, aud such a frequent source of dan- ger and death to the injured during the great War of the Rebellion. The ligature should never be tied sufficiently tight to rupture any of the tunics of the vessel. All that is necessary to obtain an ideal per- manent obliteration of the vessel is to approximate and hold in uninterrupted contact the intima. If the vessel requiring ligature in its continuity is a large one, a double ligature with a bloodless space between the two ligatures is preferable, as the space interposed between them offers the most favorable conditions for an early and permanent obliteration of the lumen of the vessel. Under aseptic and anti- septic precautions the ligation of large veins is as safe a procedure as ligation of the accompanying arteries. Vein Suture and Lateral Ligature. —ln small wounds of large veins, lateral ligature and suturing with fine silk or catgut secures permanent hemostasis with preservation of the lumen of the vein, and for these reasons should receive in this kind of vein in- 20 juries the preference to ligation in continuity. This method of treatment receives particular value in the Fig. 9.—Antiseptic tamponade of wound of deep palmar arch- case of wounds of the superior longitudinal sinus and the large veins at the base of the neck in the 21 axillae and the groins, as well as the large veins in the abdominal cavity. The lateral ligature is applied by seizing the margins of the vein wound with a sharp tenaculum and tying the base of the cone with a fine silk or catgut ligature. In suturing of vein wounds the margins are inverted toward the lumen of the vessel in the same manner as in closing an intestinal wound by Lembert’s sutures. Hot Water and Styptics.—Hot water at a tempera- ture of 120 to 130 degrees F. coagulates the albumin upon the surface of the wound and in doing so seals the orifices of small vessels, and on this account has become a popular hemostatic in arresting parenchy- matous bleeding in parts and organs accessible to this method of treatment. The employment of styp- tics in arresting hemorrhage, on the whole, should be discountenanced, as their use interferes with an ideal healing of the wound. Their application can only come in question in the treatment of bleeding wounds of the mouth and pharynx where antiseptic tamponade is impracticable. Saline Infusion.—Patients who have become debili- tated by hemorrhage to the extent of endangering life, require restoration of a normal degree of intra- cardiac and intravascular pressure by saline infusion. Transfusion of blood, whole or denbrinated, has been proved clinically and experimentally a failure in preventing death from the immediate and remote results of dangerous hemorrhage. The transfused morphologic elements of the blood do not retain their vitality and are destined to be removed from the receiver sooner or later, by elimination through some of the excretory organs, von Bergmann and others have shown that the immediate cause of death from acute hemorrhage, subnormal intracardiac and intra- vascular pressure can be avoided more successfully by substituting for animal or human blood a physio- logic solution of common salt. Every field outfit should be supplied with a defi- nite quantity of salt from which the solution can be 22 prepared in a few moments when required. Szumann’s solution is the one usually preferred. It consists of: Natr. chlorat 6.0 Natr. carbon 1.0 Aq. distillat 1000.0 The chloride and carbonate of soda in the above Fig. 10.—Treatment of penetrating wound of chest by antiseptic tamponade and immobilization by circular compression. proportion should be carried in every pannier so as to be available in all cases in which a saline infusion may become necessary. The simplest apparatus for making a saline transfusion is a glass or hard rubber funnel with two or more feet of rubber tubing and a 23 small glass tube with a tapering point. The median basilic vein is usually selected for making the injec- tion. The vein is exposed by a small incision after having rendered it turgid by proximal compression in the same manner as in performing phlebotomy, After exposure of the vein it is incised transversely, and the point of the glass tube is inserted and fas- tened in place by a ligature previously inserted. Before inserting the glass tube the precaution is taken to fill it and the rubber tube with the saline solution to prevent the introduction of air. The saline solution to be used should be heated to the Fig. 11.—Compression of abdominal aorta. (After Esmarch.) temperature of the body and infection is prevented by using only sterilized water for the solution. The quantity of solution to be used to fulfill the therapeutic indications will vary from 500 to 1,500 grams, 1,000 grams being a fair average dose, and for the preparation of which the necessary quantity of powder should be kept in readiness. If the symp- toms of improvement which follow the employment of a saline infusion should come to a standstill or disappear, it may become necessary to repeat the in- 24 travenous injection in the course of an hour or more. The same object gained by intravenous injections of salt solution is attained more indirectly and with greater loss of time by copious hypodermatic and rectal injections. Autotransfusion.—In threatening danger to life from hemorrhage much can be gained from autotransfu- sion. The exclusion from the general circulation of unessential parts of the body will often secure for the vital organs an adequate blood supply. Auto- transfusion for this purpose is secured promptly and efficiently by elastic constriction of one or more extremities at their base. This can be accomplished by Esmarch’s constrictor, suspenders, or in the absence of elastic material, by the use of the Spanish wind- lass. According to the urgency of the symptoms presented, the base of one or more extremities is constricted after rendering the limb comparatively bloodless by elevation. By exclusion of the circula- tion from one or more extremities, intravascular pressure compatible with essential functions is re- stored and life is bridged over for a sufficient length of time for the employment of remedies of more lasting value. Shock.—Next to hemorrhage, shock should receive the surgeon’s attention. It is often difficult to differ- entiate between the symptoms produced by shock and hemorrhage. The non-professional assistant should be made to understand that the maximum symptoms of shock are developed almost immedi- ately after the receipt of the injury, while in hemor- rhage the intensity of the symptoms increases pro- gressively. Even in a complete transverse tear of an artery the size of the common carotid, it requires at least five minutes to produce death from hemorrhage in intense shock, symptoms pointing to a fatal issue appear almost immediately upon the receipt of injury. Shock is the result of a reflex vasomotor paresis and, consequently, if severe, calls for the most energetic and prompt treatment. A patient suffering from 25 shock should be kept in the dorsal recumbent posi- tion and treated by active stimulation. Inhalations of nitrite of amyl and hypodermatic injections of strychnia in doses of from one-fifteenth to one-twen- tieth of a grain, repeated every half hour, until re- action takes place, constitute the most successful treatment. The administration of alcoholic stimu- lants, camphor and ammonia is also indicated, as well as the external application of dry heat. In the transportation of patients suffering from shock, the greatest care should be exercised not to subject them to any unnecessary movements, and it is of special importance that the recumbent position should be Fig. 12.—Cartridge belt with package sewn on inner surface. maintained until reaction is established. No opera- tion of any considerable importance should be per- formed until the patient reacts from the immediate effects of the injury. Primary Dressing of Wound.—Perfect aseptic sur- gery upon the battle-field is a happy dream which will probably never be realized. The bullets, as re- cent experiments have shown, are frequently con- taminated with pathogenic microbes, and often carry with them infectious fragments of clothing and other foreign substances, as well as microbes from the surface of the injured part. Again, in large bat- tles the number of wounded is so great and the number of those to whom their treatment is intrusted so small, that the necessary antiseptic precautions to 26 obtain an antiseptic condition of the wound can not always be carried out. The duty of the surgeon upon the battle-field in rendering the first aid to the wounded, after having given proper attention to the treatment of shock and hemostasis, will be to pre- vent subsequent contamination of the wound by Fig. 13. protecting it with an antiseptic occlusion dressing. Shaving and disinfection of the surface in the vicin- ity of the wound will be out of the question under such circumstances. Search for bullets and efforts to secure their removal must be postponed until the 27 patient reaches the field hospital, where these proced- ures are facilitated and the attending danger of causing infection diminished by a more complete instrumentarium and more efficient means to secure asepticity of the wound and its vicinity. Behind the fighting line, and at the first dressing station, the primary dressing of the wound should consist of the antiseptic package which every soldier should carry with him. The best place where this package should be kept has not been determined. Fig. 14. 28 Esmarch suggests that it should be sewed in some part of the uniform. It appears to me that no part of the clothing of the soldier would be a sufficiently safe place for this most important outfit when in active service. In the heat of battle the soldier often relieves himself of a part of his clothing, his knap- sack, but there are two things which he will not part with willingly, and these are the cartridge belt and gun. It appears to me that this package could always be found upon the wounded soldier if it were sewed updfn the inner surface of the cartridge belt. The package should be thin and correspond in width with the cartridge belt. Esmarch’s package used in the German Army contains : one triangular bandage, one safety-pin, two compresses of salt sublimate mull, 10 cm. wide and 100 cm. long, each wrapped in im- permeable paper, one salt sublimate cambric band- age, 10 ctm. broad and 2m. long. All these articles are wrapped in gutta-percha paper. This package is too cumbersome and contains articles which can be dispensed with in the dressing of wounds upon the battle-field. In the majority of cases the first dress- ing is only a temporary one aud is replaced later when the wound is subjected to thorough examina- tion and treatment by a more efficient one. The package should be as small and compact as possible and should contain only such articles as are abso- lutely necessary to protect the wound against infec- tion during the interval between the receipt of the injury and the arrival of the patient at the field hos- pital. Cotton is the most compressible hygroscopic dressing material and the most efficient filter in pre- venting the access of microbes to the wound. Two drachms or half an ounce of compressed salicylated cotton will furnish the necessary material for a pri- mary occlusion dressing. This can be held in place in almost any part of the body by a triangular gauze bandage, assisted, if circumstances make it neces- sary, by the cartridge belt, gunstrap, or articles of the patient’s clothing. A safe and efficient antiseptic 29 powder which does not easily deteriorate should invariably constitute a part of the package. A com- bination of boric and salicylic acid is the one I should propose for this purpose. Two grams of boric acid and half a gram salicylic acid, thoroughly tritu- Figs. 13,14,15.—Showing primary dressings of the head, upper and lower extremities. rated, should be incorporated in the center of the com- pressed cotton, the cotton surrounded by the tri- angular gauze bandage and with the addition of a safety pin wrapped in gutta-percha tissue. 30 In applying the dressing, the compressed cotton is loosened, the wound freely dusted with the powder contained in the center of the package, the wound Fig. 16.—Immobilization of arm and forearm by fastening the sleeve to the coat near the wrist and elbow joints with safety pins and inserting hand underneath coat on opposite side between two buttons. well covered with the cotton which should overlap its margins, and the dressing held in place by the tri- 31 angular bandage and such additional extemporized means of retention as may be necessary. For the purpose of preventing rapid decomposition of the blood which will soon saturate the primary dressing, and with a view of guarding against infec- tion of the wound from this source, it is absolutely necessary to incorporate with the dressing material and bring in contact with the wound a safe and effi- cient antiseptic which, in this package, consists of a combination of boric and salicylic acid. Immobilization of Injured Joints and Fractured Limbs.—In the case of fractures and joint injuries, the affected limb should be properly immobilized to prevent additional injury and pain during the trans- portation of the patient to the field hospital. As it is impossible for the surgeons and Hospital Corps to carry with them upon the battle-field, material for splints in sufficient quantity, they must depend upon articles which can always be found upon the battle- field, in securing for the limb a proper mechanical support. A few of such extemporaneous dressings will be shown in the following figures : The splint should be well padded with the blanket, or articles of wearing apparel. In compound frac- tures and penetrating wounds of joints, perfect immo- bilization by a plaster-of-Paris splint should be secured as soon as possible, but as this can not be done behind the fighting line, for obvious reasons, the temporary improvised dressing should be replaced by the permanent fixation dressing at the field hos- pital. Antiseptic precautions and perfect immobili- zation will be the most important elements in the conservative treatment of compound fractures and penetrating injuries of large joints. Transportation of Sick and Wounded.— Increased and improved facilities for rapid transportation of the wounded from the fighting line to a place of safety, will be an essential requirement in securing the greatest amount of benefit from conservative surgery upon future battle-fields. The general intro- 32 dnction of the new infantry weapon will make it necessary to establish the field hospital farther in the rear of the line of battle than formerly. Unless a natural protection by a hill or deep ravine is avail- Fig. 17.—Mitella by fastening lapel of coat on injured side with two safety pins in such a position as to support the forearm in a flexed position. 33 able, it will be necessary to locate the field hospital at least 3,000 meters from the line of action. This will necessitate an improved ambulance service. The latter will be resorted to in transporting the severely wounded from the point where the first aid is ren- dered to the first dressing station. A well-trained Hospital Corps, and the use of im- proved litters and ambulances will be instrumental in securing prompt and easy conveyance of the wounded from the line of duty to their destination. An efficient bicycle litter is a much needed desidera- tum in the transportation of the wounded from the fighting line to the first dressing station and field hospital. The Surgeon’s Work at the Field Hospital.—The con- servative work begun on the battle-field is continued at the field hospital, which offers additional facili- ties for the practice of ideal conservative surgery. It is here that efficient measures can be employed to correct the injurious effects of profuse hemorrhage and to overcome the symptoms of prolonged shock. It is here that every serious wound will be thoroughly examined and under strict antiseptic precautions will be subjected to the necessary treatment. It is here where permanent hemostasis will be substituted for temporary measures. It is here that the abdo- men and cranial cavities will be opened for penetra- ting wounds requiring such intervention for the arrest of hemorrhage, the removal of foreign infected bodies and the direct treatment of visceral wounds. It is here that permanent plaster-of Paris splints will be substituted for the temporary fixation dress- ings, in cases of compound fractures and penetrating wounds of joints. Indications for Probing and Extraction of Bullet.— The modern small caliber bullet will render a resort to the bullet probe much less frequent than was the case in the wars of the past. Owing to its greater velocity and power of penetration it will pass through the different parts of the body, regardless of the 34 resistance offered by the osseous structures at a dis- tance intended for shooting to kill. In the presence of a wound of entrance and exit, the use of the probe should be dispensed with, as an exploration of this Fig. 18.—Saber pplint for leg and thigh. Fig. 18 a.—Gunsplint. kind would yield no indications of diagnostic value and might become a source of infection or a cause of renewal of hemorrhage. The jacketed bullet is less liable to undergo deformation in striking a hard object such as bone, and is also less likely to become deflected than the leaden bullet. Additional modifi- cations of the character of the bullet wounds will render the use of the probe less frequent in the future than the past. Search for the bul- let under antiseptic precautions is justifiable in gunshot fractures, penetrating wounds of the cra- nium and joints. It is absolutely contra-indi- cated in penetrating wounds of the chest and abdomen. In bullet wounds of the soft parts, an attempt in this direction is warranted when the sur- geon has reason to believe that the bullet is located in a place accessible to its safe removal. Probing for bullets, on the whole, has done more harm than good in the past, and the limits of the indications for this procedure will be greatly narrowed in the future. If the bullet can not be removed without performing a formidable operation it is much better to permit it to remain and wait for additional indi- cations than subject the patient to additional risks incident to the operation. The modern bullet in an antiseptic wound* will become encysted like the leaden bullet and, in the majority of cases, will remain permanently in the tissues as a harmless foreign sub- Fig. 19.—Stick and blanket splint. 36 stance. If the nature of the injury makes the search for and an attempt at its removal necessary, the exploration should be made systematically and under the strictest antiseptic precautions. The metal jacket of the modern bullet detracts from the value of the famous Nelaton probe, and has made the equally famous American bullet forceps obsolete as an instrument of extraction. The porce- lain bulb of Nelaton’s probe will, however, answer a useful purpose in following the track made by the bullet and in demonstrating the presence of a for- eign substance in the soft tissues. The porcelain bulb of the ordinary Nelaton’s bullet probe is too small, especially in searching for bullets of large caliber. It is much easier to follow the tubular wound made by a bullet with a probe, the porcelain bulb of which approximately corresponds in size with that of the bullet. As in instrumentation of the urethra, a false passage is more likely to be made with a small than a large instrument. I have had a bullet probe made which is supplied at both ends with a porcelain bulb, one of which corresponds in size with a 22 caliber bullet, the other with that of a 38 caliber. The porcelain bulb of the ordinary probe is very liable to become detached in exploring deep wounds, and may be lost in the wound, as happened in one of my cases. To prevent such an accident, the bulbe of my probe are drilled through, the ends of the sil- ver probe pass through, and are clinched in a depres- sion on the surface of the bulb. In searching for bullets it is of the greatest importance to bring the parts and tissues of the body as nearly as possible in the exact position they occupied when the injury was received. That no more force should be employed in using the bullet probe than in passing a catheter is simply to repeat a cardinal rule to which there should be no exceptions. Skill in the delicate manipulation of the instrument, patience and perseverance will ac- complish more than force in these cases. Bullets 37 which can be felt under the skin opposite the wound of entrance are extracted without exploration of the wound canal. If the bullet occupies a locality where its presence would be incompatible with a good func- tional result, as the cavity of a large joint, it becomes usually necessary to enlarge the wound with the knife, chisel and mallet to follow the course of the bullet and to effect its extraction. In one case I re- moved a 22 caliber bullet from the center of the knee joint by such a procedure, in a boy 14 years of Fig. 20.—Bark splint for forearm and wire splint for arm. Fig. 21.—Litter transportation. 39 age, who recovered with nearly perfect use of the limb. A similar case is reported by Volkmann. The metal jacket of the modern bullet will make it necessary to construct bullet forceps with great grasping power to facilitate its extraction. In pene- trating gunshot wounds of the skull, Fliihrer’s alu- minum probe and his technique in removing a bullet from the cranial cavity merit the earnest attention of every military surgeon. Craniectomy.—Operative interference is indicated in every case of penetrating gunshot or stab wound of the cranium. The object of such operation is to secure asepticity of the wound and its environment, removal of loose spicula of bone and infected foreign substances, arrest of hemorrhage by torsion, ligation or tamponade and, if feasible, removal of the bullet. The wound of entrance is enlarged with chisel or rongeur forceps sufficiently to enable the surgeon to meet the indications for the operation. If the bullet is lodged in the interior of the skull, it may become necessary to make a circular craniectomy in the course of the bullet at a point opposite the wound of entrance, for the purpose of establishing thorough drainage and to facilitate the removal of the bullet. Laparotomy.—ln my address at the last annual meeting, I discussed the advisability and feasibility of laparotomy upon the battle-field in cases of pene- trating bullet and stab wounds of the abdomen, and I shall not occupy your time on this occasion by further remarks on this subject. Amputation.—The object of conservative surgery upon the battle-field, as well as in civil practice is to obviate, whenever possible, the necessity of mutila- ting operations. Prompt and careful hemostasis, antiseptic precautions, immobilization of compound fractures and injured joints, and early and careful transportation of the wounded from the field to the temporary hospital are the most fruitful resources of the modern military surgeon in the prevention of complications that so often necessitated intermediate Fig. 22.—Manner of transferring patient from litter to ambulance. 41 and secondary amputations in the wars of the past. A primary amputation for gunshot wound of the extremities is only justifiable by extensive injuries of soft parts and fractures and joint wounds compli- cated by injury of large vessels and nerves. In other words, the indications for a primary amputation will be studied and sought for, more by the character and extent of the injury of the soft tissues than the ex- tent of the bone or joint lesion. In doubtful cases the patient will be given the benefit of the doubt, as under antiseptic precautions the risk to life is greatly diminished in the attempt to save a limb by conserv- ative treatment. The conditions which will demand an intermediate or secondary amputation in cases thus treated will prove less perilous to life than in the past, an additional inducement to practice con- servatism in doubtful cases. Resection.—Primary resection for gunshot wounds of joints for obvious reasons has become an obsolete operation in modern military surgery. The most brilliant results have already been obtained by con- servative treatment of such cases. The military sur- geon will make it his duty in such instances to re- sort to such measures as will prevent complications necessitating secondary resection and amputation. Thorough disinfection of the wound, removal of loose fragments of bone and infected foreign substances including the extraction of the bullet, if this is found within or in the immediate vicinity of the injured joint, gauze drainage and immobilization of the limb in a circular plaster-of-Paris splint are the most effective measures in accomplishing this end. I have briefly sketched in this paper the essential Fig. 28.—Senn’s bullet probe. 42 topics which will engage the attention of the military- surgeon in the future in keeping pace with the rapid advances of modern surgery, and which will enable him to extend the blessings of conservative surgery to the wounded upon the battle-field of the future. The members of this Association should regard it as their duty to so perfect themselves in the principles and details upon which rests ideal conservative sur- gery, as to apply it in practice should they be called upon to serve their country upon the battle-field.