Sanitary Corps 
NATIONAL GUARD, STATE OF CALIFORNIA ANTISEPTIC METHODS AS APPLIED 
IN ACTIVE MILITARY FIELD 
OPERATIONS 
FROM THE FRENCH OF 
E. b rary 
SURGEON FRENCH ARMY AND PROFESSO ft' AT TH IJT.y. B (H C1N Er G 
MONTPELLIER* 
I 
hy 
PROFESSOR LOUIS BAZET, M. D. 
President San Francisco Polyclinic 
TRANSLATED AND PUBLISHED FOR THE USE OF 
THE SANITARY CORPS, NATIONAL GUARD 
STATE OF CALIFORNIA 
BY DIRECTION OF 
COLONEL WM. E. HOPKINS 
SURGEON GENERAL THE STAR PRESS-JAMES H. BARRY-429 MONTG'Y ST., S. F. SURGICAL ANTISEPTICS 
IN 
SANITARY ORGANIZATIONS ON THE FIELD, 
REGIMENTAL SERVICE, AMBULANCES, FIELD HOSPITALS. 
PREFACE. 
It would be a mistake to imagine that the complete 
methods of asepsis, as practiced in the clinics, can be 
applied to surgery in time of war, or, on the other 
hand, that the ordinary rules are entirely sufficient to 
meet the exigencies of the battlefield. 
In the sanitary organizations at the front, the sur- 
geon will have to meet difficult and critical situations. 
The changes in the line of battle, losses in the medical 
staff-for bullets fly wild and do not always respect 
the Red Cross-medical supplies exhausted, the sud- 
den influx of wounded after a hot fray, the necessity 
for swift action: all these conditions peculiar to sur- 
gery of the battlefield cannot be compared to the quiet 
and thoroughly organized methods of hospital service. 
Regimental surgeons, surgeons in charge of ambu- 
lances or of field hospitals, will have to act not only 
with decision and firmness, but they must be ready to 
improvise with intelligence. Of course, it is impossible 4 
for us to foresee all the hazards of war. The case 
changes according to the fierceness of the action, 
the number of wounded, the topography of the country 
and the results of the fight. However, it is useful and 
wise to consider in advance the general conditions of 
these organizations under different circumstances; to 
determine the ordinary difficulties and how to over- 
come them; to map out a program, with ample room 
for changes or additions, according to events. This 
is the purpose of these pages. We wish to give a 
course of technical and practical instruction. As 
asepsis is so firmly established, we need no theoretical 
preamble. 
Following the concise style of the Rules and Regu- 
lations, we intend to give a set of formulae, avoiding 
doctrinal arguments and impracticabilities. We very 
well conceive that in modern warfare a program meets 
with unexpected obstacles: our organizations on the 
front line will often be thrown out of order by the 
rapid firing of the infantry and by the long shots of the 
artillery. Even when the staff of an emergency post 
believe themselves out of gun range, they will present 
to the enemy the appearance of a confused mass and 
will soon become an excellent target. In spite of all, 
however, a plan is useful, as it prevents false moves 
and delays in organization. Finally, the best condi- 
tion for a well regulated assistance is Victory. I. 
REGIMENTAL SERVICE. 
FROM THE LINE OF BATTLE TO THE EMERG- 
ENCY TOST. 
Section 1. The wounded must be picked up and carried 
off as soon as possible; transfer must precede dressing of 
wounds. 
One cannot repeat it too often, said Percy: the 
first aid and the first comfort given to the wounded 
is to carry him off promptly and comfortably. To 
carry off the wounded man is the important duty of 
the stretcher-bearer; to dress the wTounds will be more 
specially the duty of the more competent and well 
organized staff at the emergency post. 
The precept of Volkmann must be observed with the 
greatest care: the first dressing decides the fate of the 
patient and determines the subsequent course of the wound. 
How many infections are caused by a hasty temporary 
dressing (in spite of all subsequent antisepsis). Imme- 
diate cleanliness is worth more than all secondary 
cleaning. On the battlefield, can true antisepsis be 6 
practiced? Let ns admit that material contained in the 
air and water-tight dressing-truss may, after being 
opened and taken out of its wrappings, remain in a 
satisfactory condition of cleanliness. Let us take for 
granted that, due to its superior make and its perfect 
wrapping, the individual package remains, even after 
many contacts of campaigning and of camps, pro- 
tected against rain, dust and unclean soakings. There 
will always be lacking to that antisepsis of the first 
hour the essential condition: asepsis of the hands. It 
is one of the most difficult principles to drive into the 
heads of half-instructed people-among whom the 
majority of our stretcher-bearers are recruited-that 
manual disinfection is of the utmost importance. 
These aids, therefore, must be particularly well taught 
on this point. But, however well instructed, you can- 
not expect from them the impossible: can a stretcher- 
bearer lift a wounded man, touch his clothes, cut or 
unbutton them, strip him of his arms and of his equip- 
ment, sometimes of his shoes, and still keep his hands 
in a sterilized condition? Disinfection on the very 
spot is practically out of the question; everything is 
lacking, water first and time as well. 
In serious cases, such as comminuted fractures with 
large openings of egress, wounds caused by fragments 
of heavy projectiles, and lesions of the abdomen or of 
the thorax, it is better to avoid possible contamination 7 
from an imperfect first dressing. Jn these cases it is 
more to the interest of the wounded to ask of the bear- 
ers a service of rapid transfer, rather than of kindly 
nursing. Through awkward and hurried manipula- 
tions, the patient runs many risks. A badly regulated 
exploration or an inopportune displacement can be 
followed by most damaging consequences, such as 
inoculation carried into the inner depths; complete 
separation of splinters still attached by periosteal at- 
tachments; production of irreducible overriding; vas- 
cular ruptures or breaking off of clots that have rea- 
lized spontaneous haemostasis. 
That our bearers should have the moral energy and 
the physical strength to insure transportation at full 
speed of the wounded towards the emergency post, 
will be their best antiseptic work. They should, fur- 
thermore, be trained to handle, take hold of and carry 
with the most careful precautions the seriously 
wounded, especially cases of fracture. The emergency 
apparatus spoken of in the regulations are simple ways 
to insure the immobility of fractured limbs, especially 
the lower limbs, which, for the reasons mentioned 
above, is an important factor in antisepsis. But it 
takes time, and as dressings applied by inexperienced 
hands will have to be inspected at the emergency post, 
one might wonder if this time and this care ought not 
to be given up to the rapid transportation of the other 8 
wounded. A large sling under the back made of sack- 
ing, looped strings, and elastic suspenders for binding 
the lower limbs together and attached to the stretcher 
itself, will afford a means of rendering the limb im- 
movable, and will insure a fair condition of the in- 
jured man until the relief post is reached. Bichloride 
compresses placed at the openings of ingress and 
egress, and retained by a sling knotted or by a few 
rolls of bandage, will be far better and safer than the 
direct contact with the garments; but it must be done 
quickly, without shaking the limb and without any 
contact between the fingers and the wound itself, the 
haemostatic forceps being used to push in and block 
the compress. 
Sec. 2. Directions in the case if severe hemorrhage. 
One fact is established by numerous experiences, 
and that is the frequency of hemorrhages in wounds 
caused by modern bullets of small caliber and great 
speed. We must, therefore, teach our bearers a few 
simple and rapid methods of accomplishing immediate 
haemostasis. It is greatly to be feared, however, that 
these first haemostatic dressings will prove to be the 
source of serious contamination to the wound. This 
has been noticed even in ordinary surgery, and is 
easily explained. Copious hemorrhage always makes 
a startling impression on inexperienced persons: at 9 
the sight of blood gushing freely, our bearer may be- 
come frightened and act against all the rules of anti- 
septic dressing. Indeed, one must have a long surgical 
experience to acquire precision and coolness in a case 
of serious hemorrhage. We cannot hope to teach our 
regimental assistants the course of the blood vessels 
and the principles of direct haemostasis, but we can 
teach him to swiftly bind a limb at its head by an im- 
provised tourniquet, making compression either by 
means of a knotted string or of an elastic suspender. 
Do not expect hini to attempt arterial haemostasis 
with the only haemostatic forceps contained in his 
truss, forceps sterilized on the spot in the flame of a 
match or of a twist of lighted paper. Instruct him to 
use it to push up into and pack the wound with a com- 
press of bichloride gauze; to strengthen this packing 
with the solid pressure of several windings of band- 
age, and thus produce an antiseptic haemostasis. This 
is especially useful in wounds of the head, the neck, 
the arm pit, the groin, the hand and the foot. Well 
trained to this, our bearers may accomplish fine 
work. ''One of my soldier-nurses,'' says Lustreman, 
"named Verdun, whom I had promoted to first private, 
twice was able to stop, by good compression, a very 
profuse hemorrhage of the femoral artery, giving me 
time to come and tie the vessel." 10 
Sec. 3. Slight wounds and light dressing. 
To dress the wounds of the soft parts, superficial 
sword cuts and the slight wounds caused by side arms, 
is, primarily, the work of the bearer, the work more 
congenial and natural for him. In these cases, imme- 
diate antisepsis is less important, contamination less 
dreaded and dressing more rapid, being reduced to the 
mere closing of the wounds. Powder lightly the 
wound with iodoform, or other dusting powder, cover 
it with a folded compress and a layer of wadding or 
oakum, then fasten all with a few turns of bandage. 
This can be very quickly done, and constitutes for 
these traumatisms sufficient antiseptic protection. 
But one must never forget that the first care is to the 
seriously wounded: humanity calls for it and surgical 
therapeutics demand it. It would be unpardonable 
to dilly-dally with minor dressings, when wounded 
men would soon die if their speedy transfer were 
delayed. 
Sec. 4. Cases when immediate transfer is impossible. 
In these cases there is no absolute formula, for the 
battle does not take place according to rules of tactics, 
nor the strict lines drawn in sham battles. The condi- 
tions of the battle may be such that both as bearer 
and as nurse the assistant's capacities will be taxed 
to the utmost. During the preparation for battle, the 11 
troops march to the front, utilizing all the natural pro- 
tections of the ground-the hillocks, hollows, etc. 
Under such circumstances, the following cases are 
very probable: 
A group of wounded are gathered and placed under 
shelter by one or two squads of bearers; they cannot 
be transferred to the relief post, for the intervening 
space is open here and there and is being fired on by 
the enemy. 
Or it may happen that the conflict has been so fierce 
that large numbers of wounded have accumulated at 
several points; to carry them off takes time, and 
immediate relief is absolutely necessary. 
A dressing shelter must be improvised on the spot, 
and the stretcher-bearers are compelled to make the 
first antiseptic dressing. If this dressing is a sufficient 
one, the soldier-nurses will deserve the greatest praise. 
The first requisite is to select a place behind a raise 
of ground out of danger from the enemy's fire. 
Cans of water are put to boil over fires made of any 
handy material. 
The wounded are placed in as comfortable a position 
as possible, the garments slit up and the wound un- 
covered. 
Having sterilized the hands in as hot water as can 
be borne, the helper proceeds to wash the wound, 
sprinkle moderately with dusting iodoform powder, 12 
pile on bichloride compresses; on top of this several 
layers of oakum, and finally wrap up with absorbent 
cotton fastened by several turns of bandage. What 
has already been said of the treatment of hemorrhage 
is sufficient. In case of fracture, the limb can be ren- 
dered rigid by means of any emergency apparatus, or 
when such is lacking, by the use of guns, bayonets, etc. 
Remember that when there is time, the irrigation of 
all wounds with water (at a temperature of 125 deg. 
or 135 deg.) that has been boiled for half an hour is 
the very best antiseptic treatment. 
AT THE EMERGENCY POST. 
Summary. 
I. General disposition. 
II. Organization of the post. 
(а) Rapid getting up of a field stove. 
(б) Necessity of strict distribution of the 
work. 
(c) Improvising of a dressing table for imme- 
diate surgery. 
(d) Classification of material. 
III. Asepsis of the surgeon and his aids. 13 
IV. Asepsis of the materials. 
V. Surgical functions: 
(а) Slight wounds. 
(б) Fractures without complications. 
(e) Operations of immediate urgency. 
I. GENERAL DISPOSITIONS. 
According to the rules, emergency posts are not far 
behind the reserves of the regiment-that is, about 
3,000 feet behind the front line, or 6,600 feet or so from 
the artillery of the enemy. These distances are not 
absolute, but they are the average, and serve to point 
out under what dangerous circumstances the sanitary 
service is called to serve. 
It must be understood, once for all, that to do good 
work, not of surgery, but of simple dressing, the 
emergency post must have a certain fixity in its set- 
tings. To observe antisepsis, even in its simplest 
form, means that materials and personnel cannot be 
constantly on the go. When in a good place a dress- 
ing-station is once established, it is to the interest of 
the wounded, and essential to proper antisepsis, that 
it remain fixed and not following the changes in the 
line of fire. Of course, the battle will not be as rapid 
as the sham battles; with the smokeless powder and 
the strength of the guns, the preparation for attack 
will be slow, and there will be pauses and interims- 14 
sions, which will allow us to go and come more 
quietly. 
First, the chief surgeon of the regiment must not 
hasten to locate the emergency post; otherwise he 
will deprive himself of a part of his resources. It 
would result in false moves, useless unpacking, danger 
of loss of materials, loss of time and possible disorder 
when the real attack begins. During the preliminary 
contests it is wiser to utilize the trusses of the bearers 
and the kits of the soldiers. 
Next in order, the chief surgeon groups his staff and 
materials; he has at hand all the doctors and all the 
nurses of the regiment to insure the proper workings 
of the emergency post. Unity of action is the indis- 
pensable condition of discipline and method required 
by antisepsis. "The scattering" in vogue among the 
combatants is most perilous in sanitary tactics. The 
chief surgeon will assign places according to aptitude 
and functions, will appoint the dressing-squad, will 
prescribe the unpacking of materials, the fixing up of 
the post. Thus organized, under one direction, the 
personnel and the materials constitute a regular sani- 
tary corps, able to divide itself according to the phases 
of the battle, able to separate into three posts, well 
linked, corresponding to the three kinds of material 
of the battalion, and to follow the battle front without 
moving the first post or disturbing their work. 15 
II. ARRANGEMENT OF THE POST. 
An emergency post is to be prepared. The shelter is 
rather scanty, but the volleys will not reach it; it may 
be near a wall, but better behind a slope or high em- 
bankment, so as to be protected from bullets and long 
shots of artillery. 
The personnel and wagons are grouped in order at 
that place, marked by two pennons. Each squad of 
bearers has taken its stretchers and cans. The chief 
surgeon gives the order for unloading baskets, cans 
and kegs, which must be constantly filled. As water 
is used freely, a man must be sent to find out the possi- 
ble means of fresh supply. If wagons cannot come 
near, then the materials are to be brought on 
stretchers. 
Rapid getting up of a field stove-its usefulness for the 
asepsis of the materials. 
This is imperative: hot water for the antiseptic 
washing, for grogs and stimulating drinks; boiling 
water for sterilizing metal instruments, plugs, com- 
presses, draining-tubes, suture and ligature threads. 
Without delay, two men will build a field stove, with 
three or four fireplaces. It would be wise to always 
carry, on each battalion wagon, a provision of dry 
wood, dead branches, etc., and not to wait until the 
last moment to hunt up wood. 16 
Now, the fire is lit in the stove. The plates or 
dishes are found in the camping materials. There are 
always enough sacks available: to have the utensils 
clean, and to do away with greasy cans, the chief sur- 
geon can easily make up the necessary set, which will 
not add much to the load of the wagon. In one or two 
large kettles several quarts of water are kept boiling, 
for following purposes: 1st, for washing hands and 
immediate surroundings of the wound; 2d, for com- 
presses; 3d, for antiseptic liquids; 4th, for irriga- 
tion of contaminated wounds. Add to this water a 
handful of salt to the quart: according to the experi- 
ments of Tavel, salted water boiled for fifteen minutes 
is sterilized, whilst ordinary water must boil thirty to 
sixty minutes to attain the same condition. The 
doctor must have taken a provision of salt: under 
ordinary circumstances it is easy to take in a good 
supply beforehand. In another kettle a dozen or two 
linen compresses should be boiling; they are to serve 
as an antiseptic protection for the operated parts, and 
will be slipped under the limbs or the wounded region; 
they can be used as aseptic cloths, on which can be 
placed the unpacked materials of dressing and for 
urgent operations. Plenty of medium and small linen 
and gauze compresses should be boiled; there are 
never enough of them; they are the best sponges to 
wipe the bleeding parts; they will protect the flesh, 17 
keep in place the viscera, cover all the epidermis, 
except the spot where the surgeon works, are useful for 
haemostasis, and even serve temporarily as iodoform 
compresses by rapid and light sprinkling of the drug 
over them 
The assistant surgeon, having asepticised his hands, 
must begin at once the preparation of wads of ab- 
sorbent cotton for use as sponges. These wads are 
dipped into some antiseptic solution, pressed together 
and tied with a few strings, then thrown into a basin 
of boiling water. The same basin may be used for 
sterilized threads and drainage tubes. The cover of a 
kettle will serve to hold metal instruments that have 
been sterilized in the salt solution. 
Strict distribution of the work is absolutely neces- 
sary. The various duties should be assigned in ad- 
vance, and as far as possible the same helpers should 
always perform the same functions. Give orders clear- 
ly and distinctly, order silence and set a personal ex- 
ample for coolness. By strict discipline and by the 
co-operation of the various squads all preparations 
will be made without confusion or loss of time. 
Improvising a dressing table for emergency work. 
It is fatiguing to dress a wound bending over or 
squatting down by the side of a stretcher. The results 
are less satisfactory and there is more danger of 18 
sepsis, particularly if the ground has been recently 
ploughed over by cavalry or artillery. There are sev- 
eral ways of converting a stretcher into a temporary 
table. First, if a ditch is near by, the stretcher can 
be placed across it. If the post is behind a slope, a 
step may be dug out with a pickax or bayonet, the 
head of the stretcher placed on it and the feet sup- 
ported by forked branches planted in the ground. 
A light folding frame of steel tubing built specially 
for supporting stretchers would be exceedingly useful. 
When the stretcher is in place it should be covered 
with a waterproof cloth, which can be easily cleaned 
with a cloth after each dressing. 
Classifying of material. 
Antisepsis requires that all materials and instru- 
ments should be placed in separate groups according 
to different surgical needs; otherwise there is loss of 
time, with consequent confusion and impatience. 
In the emergency post there is no table upon which 
to spread out materials, but the tail-board of a wagon, 
or a stretcher laid across two empty baskets will 
answer the purpose. Upon this improvised table the 
following articles are to be laid in order: 
First, beside the usual enameled dish for instru- 
ments, kettle covers can be used, after purifying them 
by burning a little alcohol in them. 19 
Keep the enameled dish for haemostatic forceps, a 
lid for other instruments, and a third for suture imple- 
ments, threads and needles. 
Second, a basin of small compresses and another of 
sponges; a reserve basin of sponges, of which there 
can never be too many. 
Third, the dressing basin of carbolized or bichloride 
solution. There should also be an extra dish of anti- 
septic solution and a basin of warm boiled water. 
Fourth, a large platter containing large boiled 
compresses lying upon sheets of cotton, packages of 
oakum and rolled bandages, in the order of their in- 
tended application. 
All this should pass directly from the aseptic hands 
of the helper to the hands of the surgeon. 
III. ASEPSIS OF THE SURGEON AND OF HIS 
ASSISTANTS. 
If the regiment wagon contains but one operating 
apron, it will be found necessary to supplement it by a 
towel tied around the neck. 
The sleeves must be rolled at least half-way up the 
forearm; with our uniforms, it is all one can do. 
Perhaps it would be more advantageous for the sur- 
geon to have sleeves open on the side, or at least but- 
toned on the cuff. 20 
In the basket are two cakes of antiseptic soap, and 
two nail brushes. Two basins are required for asepsis 
of the hands. In the first one, brush thoroughly with 
soap the nails, which must be kept short, the subun- 
guial space and the articular folds; three to five min- 
utes are needed for this most important cleaning in 
order to dissolve thoroughly the greasy substances 
rich in bacteria. Brushing in alcohol to complete the 
scouring of the skin, rubbing on permanganate, fol- 
lowed by discoloration in oxalic acid, etc., are practi- 
cable in clinics, but not in field surgery. The hand, 
after a thorough soaping, is to be rubbed for two or 
three minutes in the second basin, filled with the anti- 
septic solution; carbolic acid seems to us better than 
bichloride, and we agree with Lister when he claims 
for carbolic acid an affinity for the epidermis, a more 
thorough permeating action and a power of combina- 
tion with fatty substances. Once aseptic, the hands 
must preserve their purity and avoid all doubtful con- 
tact. This detail should be carefully carried out, and 
it would be well to continually inspect the hands of 
nurses. 
IV. ASEPSIS OF MATERIALS. 
We will briefly consider this paragraph, not having 
to study it theoretically, nor to describe the methods 
in vogue in hospital surgery. Here, we must be satis- 21 
tied with swift and simple methods: work well with 
small means and work quickly. 
Disinfection through boiling seems the most normal 
method for a relief post. To have boiling water is 
possible under all circumstances and in all places; we 
have already outlined the organization of that service. 
On our stove can boil: 1st, several quarts of salt 
water; 2d, a lot of large and small compresses; 3d, 
wads of absorbent cotton for sponging wounds; 3d, 
silk-wormgut and spools of braided silk; 5th, the 
metal instruments. In all, four to five basins: one 
kettle for salt wmter, one or two for the compresses, a 
large,.basin for the sponges, gathered in a knotted 
compress, and for the threads and drainage-tubes; 
lastly, a cover of a large kettle for the instruments. 
All this to be on the stove as soon as the post is' orga- 
nized, so that when the surgeon begins work every 
article will have been boiled thoroughly. Our dress- 
ing materials, if carefully prepared and well packed, 
do not need long sterilization. 
Compresses and sponges. 
Bichloride gauze and sponges remain aseptic and do 
not need sterilizing, but linen compresses and ordinary 
cotton sponges must positively be sterilized if they are 
to come in contact with open wounds. 22 
Instruments. 
When pressed by circumstances, metal instruments 
can be disinfected by alcohol; pour in the enameled 
basin some alcohol, put in the instruments, and let it 
blaze for a few minutes. When there is time, it is 
safer to boil them, adding to the water bicarbonate of 
soda in the proportion of 1 to 100; this salt should be 
kept in a tin box. Asepsis of instruments is most im- 
portant. We will consider it at length in the ambu- 
lance section: at the emergency post, operating is not 
so extensive and the instruments are limited. A diffi- 
culty arises in attempting to render aseptic such in- 
struments as are provided with wooden handles, as 
well as those whose blades are set in fusible cement; 
heating or boiling is out- of the question. With such 
instruments, there is only one way of guarding against 
contamination: keep the handles and blades extremely 
clean; before and after using wipe carefully the blade 
in a sterilized compress, moistened with a strong solu- 
tion of carbolic acid, and wrap the handle with aseptic 
gauze. 
V. SURGICAL ORGANIZATION OF THE TOST. 
The surgeon highest in rank will distribute the 
cases and specify each man's duties. 23 
(a) LIGHT WOUNDS-A squad should be de- 
tailed to care for minor injuries. If, however, the staff 
of the emergency post is too small to handle the num- 
ber of wounded, one or several squads of nurses and 
musicians, according to the arrival of the wounded, 
can be employed for the simple dressing, such as bullet 
wounds in the soft parts, shallow wounds without 
fractures of the limbs or without visceral injuries. 
(ft) UNCOMPLICATED FRACTURES -Another 
group would attend to fractures uncomplicated by 
hemorrhage, requiring but antiseptic dressing and 
immobility, this squad to be under the immediate di- 
rection and the constant control of an assistant sur- 
geon. In these two groups, use antiseptic washings 
with great care: first, to save water, the supply being 
limited; secondly, because a bullet does not carry 
septic germs,excepting when dragging in fragments of 
clothing; thirdly, because, according to Schimmel- 
busch, there is no better irrigation for cleaning the 
wound than the aseptic blood gushing from the inner 
parts; and lastly, because a badly regulated irrigation 
could bring to the wound some diluted dirt from 
neighboring integuments. When the soiling by mud 
or detritus calls for cleaning, the nurses should keep 
the wound covered with a compress or a large sponge 
while the neighboring skin is scoured. The dry dress- 
ing is the best in these cases. The wound should be 24 
sprinkled with iodoform, covered with an aseptic com- 
press and a layer of cotton or oakum. 
(c) OPERATIONS OF IMMEDIATE URGENCY 
-Serious cases requiring immediate surgical inter- 
ference are to be turned over to a squad consisting of 
a surgeon and three or more of the best nurses. One 
will directly assist the surgeon; this helper, if possi- 
ble, should be an assistant surgeon; a second helper 
will have charge of the sponges and compresses, an- 
other will hand the instruments, and toward the end 
of the operation, the drainage-tubes and the threads: 
thus we count at least three helpers, to w'hich add a 
bearer, whose duty is to hand the basin filled with 
warm antiseptic solution for washing the hands, to fill 
the irrigator and to receive the parts cut off. In very 
few cases, during a battle, will the surgeon be able to 
do anything save a rapid cleaning of the wound; if a 
bony fragment show's itself free, or if a strip is visible, 
it must be excised, but time and facilities will be want- 
ing for a splinter operation, according to rules. What 
is absolutely required is a dressing as aseptic as possi- 
ble and then perfect immobilisation. Hemorrhage 
will demand instant attention. Many die on the field 
from hemorrhage of a main artery. Others reach the 
emergency post, either because the external tunic 
being stretched or tom, has produced spontaneous 
haemostasis or because compression has been applied 25 
in time to stop the loss of blood. The circular bandage 
or tourniquet has frequently to be applied at the ex- 
tremity of the limb and over the clothes. The rules of 
antisepsis and the ischaemia resulting from the com- 
pression together with the fact that possible fracture 
must be looked for, render it imperative that the. cir- 
cular pressure be done away with as soon as possible. 
The surgeon gradually loosens the constriction and 
applies the haemostatic forceps to the bleeding artery. 
If possible, he is to ligate the vessel at both ends. If 
impracticable, allow the forceps to remain in the 
wound well covered with compresses, but without put- 
ting on any pressure or giving any cause for movement. 
If the forceps are aseptic, they may remain during 
the time necessary for complete haemostasis: twenty- 
four hours for average sized arteries, forty-eight hours 
for main arteries. This method has been frequently 
applied with success. No so-called preventive incision 
must be made-only those strictly necessary to catch 
bleeding vessels or to secure antisepsis. No probing 
of wounds of the chest, abdomen or skull and no pri- 
mary amputations-that is to say, no amputations 
other than the mere trimming of a limb irremediably 
mutilated, as by the explosion of a large projectile. 
One saw cut and a few incisions to clean up the rag- 
ged stump are all that is permissible. 
This surgical work, rather limited in its scope, must 26 
be done dry, as much as possible. The warm stream 
from an irrigator may be used, however, to cleanse a 
traumatic focus, to dry up capillary hemorrhage and 
to disinfect the deeper parts. But these washings 
should be minimized and wet dressings should be used. 
Dust with iodoform, cover with several layers of 
bichlorided gauze and use cotton for wrapping. This 
dry dressing is the best and can remain a long time in 
position. There is produced a sort of antiseptic crusty 
cicatrisation. The deep layers of the dressing aggluti- 
nate in an adherent shell when the blood has dried. 
This we have often observed. If the wound has no bad 
odor, the dressing need not be changed right away. 
Frequent changes of dressing are to be avoided; it is 
a loss of time, causes pain to the patient and only irri- 
tates the granular formation, and by exposing the 
wound allows of the possibility of bacterial infection. 
Dry dressings; few dressings: this is the motto in 
military surgery. 27 
THE AMBULANCE. 
II. 
I. General dispositions. 
II. Organization of the ambulance. 
(a) Fireplaces. 
(b) Water. 
(c) Tables. 
(J) Organization of the squads. Distribution 
of the materials. 
III. Asepsis of the surgeon and of his assistants. 
IV. Asepsis of the materials. 
(a) Basins, etc. 
(i) Instruments. 
(c) Compresses and sponges. 
(d) Sponges of absorbent cotton. 
(e) Linen compresses. 
' (/) Silk thread. 
(g) Silkworm gut and metallic thread. 
(h) Catgut. 
(i) Draining-tubes, probes, tourniquets. 
(/) Antiseptic solutions. 
V. Surgical rules. 28 
I. GENERAL DISPOSITIONS. 
The ambulance presents more favorable conditions 
for thorough antisepsis than the emergency post, and 
the shelter is better and more permanent. 
Usually it has been conceded that the ambulance is 
located at some 5,400 feet from the line of fire of the 
enemy and at some 9,000 feet from the artillery. As 
a rule, yes; but in some cases the ambulance has had 
to co-operate on the very front; we know several chief 
surgeons who did not hesitate to go, marching under 
the cannon and taking their positions with the emerg- 
ency post. So here again we meet with the same diffi- 
culties as in the organization of an emergency post, 
the only difference being a distance between them of 
several hundred feet. But the ambulance has the ad- 
vantage of a superior stock of instruments, and will 
have the prominence in surgery. 
The ambulance must be well located to insure good 
antisepsis, and must also be so divided as to answer 
emergency calls during the battle. Antisepsis is not 
possible with frequent changes and movings about. 
II. ORGANIZATION OF THE AMBULANCE. 
(a) FIREPLACES AND STOVES-If the chief 
surgeon has chosen a house for the location of the 29 
ambulance, the arrangement is simplified; the kitchen 
stove can be used for boiling of the surgical materials; 
the household crockery and kitchen ware will be very 
handy; water, wood and salt are there. The division 
of the work proceeds more rapidly. Frequently the 
ambulance, or at least its second section, is compelled 
to go to the front, so as to remain in touch with the 
emergency posts. There is no dwelling in the vicinity, 
and the work will have to be done in open air, sheltered 
by some obstacle of height corresponding to the dis- 
tance of the enemy's batteries. The more distant the 
batteries, the higher must be the obstacle. The same 
conditions then are present as for an emergency post, 
except for the advantage of having more materials 
and a more thorough organization. 
This second condition is half-way between the ordi- 
nary post and the sheltered ambulance. Fireplaces 
must be built immediately, as in the posts. 
What has been said regarding the emergency post 
pertains to this section of the ambulance. 
(J) SUPPLY OF WATER-The supply of water 
is of the first importance. Modern surgery, for 
asepsis and washings, uses it abundantly; the thirst 
of the wounded is well known, and the condition of 
shock in which they are necessitates the preparation 
of hot and tonic drinks. The wagon carries fifty 
quarts of water, in two reservoirs. That is enough to 30 
begin with, but a continuous supply must be provided 
for, and when the ambulance is in the field the possi- 
bilities of steady supply should be carefully consid- 
ered. On top of the baskets in the wagon is a ten- 
quart iron pail and six pails for carrying water. 
When the ambulance is in a house, of course these 
difficulties do not exist. 
(c) OPERATING AND DRESSING TABLES-In 
the wagon there is an operating table with a back. 
Cover it with a narrow mattress or a thick sheet and a 
waterproof cloth. If strong kitchen tables are to be 
got, so much the better, for they are steadier and en- 
able the surgeon to dispatch his work more swiftly. 
It will be necessary, however, to arrange temporary 
tables for the two or three dressing squads. For this 
purpose stretchers on poles may be used, if out doors, 
or, if in the house, boxes or an unhinged door will 
answer. 
(d) ORGANIZATIONS OF THE GROUPS AND 
DISTRIBUTION OF THE MATERIALS-"The chief 
surgeon must direct the service so as to avoid any 
tumult and confusion, which would hinder good work. 
He will divide his staff into three squads: the first, 
for receiving and sorting the wounded and for the 
ordinary dressing; the second squad, foi' surgical 
operations of immediate urgency; the third, for com- 31 
plicated dressings requiring the use of apparatus for 
immobilizing." 
Each squad unpacks and assorts in its appointed 
place the materials pertaining to its function. 
On the tables covered with boiled compresses each 
squad spreads out its materials. 
First, the articles for disinfection of the hands: 
three iron basins, two antiseptic brushes and two anti- 
septic soaps. 
The same basket (one for each squad) contains three 
enameled dressing basins. In one, place the sponges 
of sterilized cotton or the gauze compresses for dress- 
ing, which may take the place of the sponges if neces- 
sary. In the second, place the boiled linen compresses. 
In the third, a carbolized or bichloride solution for 
washing. Put the materials for suture and ligature, 
catgut, silkworm thread, thread, needles and reels, 
etc., into a separate dish. 
The two dressing squads will not need many instru- 
ments: scissors to cut the threads, a couple dressing 
forceps and a few haemostatic forceps, which are all 
easily contained in one basin, preferably rectangular. 
The operating squad will not need more than six 
enameled basins. The largest of these basins will 
contain the haemostatic forceps; the second, the 
scissors, dressing forceps, grooved directors and re- 
tractors; the third, the knives and bistouries; the 32 
fourth, the instruments for osteotomy; and the fifth, 
the rubber bands for haemostasis. 
When the ambulance is in or near a house, various 
pieces of crockery can be added: basins, soup-tureens 
and platters, which will allow further subdivision of 
these articles. 
III. ASEPSIS OF THE SURGEON AND OF HIS 
ASSISTANTS. 
A basket should contain eight gowns. If these are 
are wanting or soiled, use an apron (the same basket 
should contain at least ten aprons) and a napkin or 
towel tied around the neck; the sleeves rolled up as 
high as possible. Twenty aprons are reserved for the 
nurses. 
We need not repeat how important is asepsis of the 
hands. The methods we have already discussed under 
the rules for the emergency post apply equally to the 
ambulance. 
IV. ASEPSIS OF MATERIALS AND INSTRU- 
MENTS. 
(a) We must again emphasize the necessity of abso- 
lute cleanliness of materials, basins, etc., and instru- 
ments, all of which must be continually scrubbed with 33 
soap and hot water and afterward brushed with 
alcohol and then left in the salt solution. 
In cleaning instruments by burning in alcohol care 
must be taken not to allow the steel to become too 
hot and thus tarnished. 
(&) Where a large number of instruments are to be 
asepticized, the most practical method is that of boil- 
ing in a one per cent, bicarbonate of soda solution for 
about ten minutes. 
If bicarbonate of soda is not obtainable, borax will 
do, or in extreme cases even lye, wood ash, etc., can be 
used. 
After boiling, the solution should be strained off, 
leaving the instruments dry. 
Kitchen utensils that have double bottoms with 
perforations in the upper bottom, or wire strainers, 
etc., are very convenient to hold instruments while 
they are being boiled. Small instruments and needles 
should be wrapped in a compress before boiling, so 
ihat they will not be lost when the liquor is decanted. 
The method of overcoming the difficulty of making 
aseptic such instruments as have wooden handles, or 
whose blades are set in cement, has already been ex- 
plained. 
(&) COMPRESSES SPONGES-The disinfection of 
sponges is always risky, for they can only be sterilized 
through chemical process, which is tedious and un- 34 
satisfactory. Gauze compresses are the best artificial 
substitutes. From a bolt of gauze cut pieces about 
one yard square; fold them over and over four times 
and baste quickly. These compress sponges are per- 
fect and easily handled; they fill up bleeding cavities 
well, and wipe off the surface smoothly; they are 
superior to absorbent cotton, because no bits of cotton 
stick in the wound, which is to be feared, particularly 
when operating in the abdomen or at the contact of 
bony fragments, upon which the wadding catches; 
they are absorbent and are well sterilized in half an 
hour's boiling. 
(d) ABSORBENT SPONGES-These sponges, pre- 
pared as stated in paragraph concerning the emerg- 
ency post, and tied together in a compress to prevent 
their scattering, will all be perfectly asepticized by 
boiling. 
(e) LINEN COMPRESSES-Linen compresses, 
which are also sterilized by boiling, have many uses. 
The large ones surround the operated zone or isolate 
the limb to be operated. The medium ones are used to 
push aside strips of flesh, and in amputations they 
may be folded into other complicated compresses. In 
resections or removal of long splinters, they will 
shield the fingers of the assistant who opens the 
wound and will help to keep open the edges of the 
wound. They will be very helpful in covering and 35 
separating the haemostatic forceps, which, in a pro- 
fuse hemorrhage, are numerously employed and are 
very embarrassing. It is therefore well to have a 
large supply on hand. 
(/) SILK THREAD-After thirty minutes boiling, 
braided silk thread is thoroughly sterilized; and pieces 
of thread, cut according to need, should pass directly 
from the sterilizing apparatus to the sterilized hands 
of the surgeon. 
(g) SILKWORM GUT AND METALLIC 
THREADS-Silkworm gut is asepticised by boiling, 
as well as silver thread. Their advantage over 
braided threads is their smoothness, which prevents 
imbibition and consequent carrying of septic material 
from the surface to deeper parts of the wound. These 
sutures are the more valuable the more the likelihood 
of external contamination. 
(A) CATGUT-Catgut we do not approve for surg- 
ery on the battlefield. Its asepsis is obtained only by 
a long and careful process; its adhesiveness is vari- 
able, its absorption irregular. Silk for ligatures, vis- 
ceral sutures, deep stitches, and operations on the 
neck; silkworm gut for superficial stitches and silver 
thread for bony unions are specially recommended. 
(i) DRAINAGE TUBES, PROBES AND BAND- 
AGES FOR HAEMOSTASIS-Drainage-tubes and 
rubber bands for haemostasis can be sterilized by boil- 36 
ing. Boiling spoils quickly the probes made of gum: 
it is best to clean them by rubbing soundly their sur- 
face with a sterilized compress and by injecting into 
their canal some antiseptic solution. 
(;) ANTISEPTIC SOLUTIONS-On this subject 
there is but little to say. Iodoform, carbolic acid and 
bichloride of mercury are the three best bactericides, 
and the ambulance has always a large quantity of 
them. Iodoform remains the same, never varying in 
its effects; it neutralizes chemical toxines, a most 
valuable property in the prophylaxis of lockjaw,which 
if of frequent occurrence in surgery of the army. In 
quantity, however, it is dangerous, and it will have to 
be given cautiously. The carbolized and bichloride 
solutions are easily prepared from concentrated solu- 
tion or compressed tablets. The water used must first 
be boiled and poured into purified basins. Carbolic 
acid is far superior to the bichloride for cleaning the 
integuments, on account of its biting action on the 
skin and of its affinity for organic substances. The 
bichloride exerts, in a very small quantity, a great 
antiseptic force: diluted to 1.2000, 1.3000, it will de- 
stroy at least the ordinary bacteria. 37 
V. SURGICAL OPERATING IN THE AMBU- 
LANCE. 
(a) ORGANIZATION-"Operative intervention," 
says M. Demmler, "is connected with the examination; 
the incisions, the removal of splinters, already consti- 
tute intervention, and it would be dangerous to inter- 
rupt it and let another person continue. It would 
increase the chances of contamination." 
We believe, on the contrary, that division of the 
work is a guarantee of its good execution. All will 
depend upon how the wounded are sorted, and for this 
it is necessary to have an experienced surgeon. This 
classifying is not absolute, and a patient sent to the 
group of one operating table may be passed on to the 
third group. The two groups will operate near each 
other, in adjoining rooms in the same hall, or in the 
open air, in the case of flying organization. The trans- 
fer of a patient from one group to another causes no 
trouble, no delay, and, with a few precautions, no risk 
of infection. On the contrary, if the group in charge 
of the apparatus of immobilization, being exposed, 
naturally, to contact with non-sterilized material- 
metallic cloth to be cut, gutters to be lined, plaster to 
be manipulated-is compelled to operate also, how 
much time is lost in bringing about a proper condition 
of asepsis? And if the operating group must handle 38 
the apparatus of immobilization, there is contamina- 
tion, and necessarily a new sterilization. It is safer 
and quicker to pass over to the group of immobiliza- 
tion the patient who has been operated upon, the frac- 
tured man after the antiseptic removal of the splinters 
and the artrotomised patient after the cleaning of the 
articulation. Through this regular order of work, 
materials will be saved, confusion of orders avoided 
and antisepsis preserved. 
(Z>) SIMPLE DRESSING-As in the emergency 
post, the best one is a dry iodoform dressing covered 
with absorbent cotton. 
(c) CLEANING OF THE WOUNDED PARTS- 
At the ambulance, where one has time, and the cases 
are not very serious, the parts adjoining the wound 
must be carefully cleaned, otherwise, under an anti- 
septic covering, there would remain a septic surface, 
capable of infecting the region. Warm soaping, 
scouring with alcohol or ether, final brushing with 
carbolized solution: such is, as for disinfection of the 
hands, the proper order. An important precaution is 
to protect the open wound by a large absorbent sponge 
or a thick sterilized compress to prevent contamina- 
tion by water during the washing. During the cam- 
paign one must expect greasy skins, soiled with blood, 
perspiration and mud. In such cases turpentine 39 
seems to us the best thing for cleaning the epidermis, 
and an ample supply of turpentine should be provided. 
(d) ASEPTIC TREATMENT OF COMPOUND 
FRACTURES-To the operating squad belongs the 
duty of maintaining strict asepsis in this division of 
the work. 
Incisions should be as few and as small as possible, 
and should be always made in the direction of the 
long axis of the limb. The wound should be explored 
with the index finger, followed by antiseptic irrigation. 
Fragments of clothing are first extracted and float- 
ing splinters completely separated from the bone. 
If the wound is infected deeply, swab it with a plug 
of absorbent cotton on the end of a haemostatic for- 
ceps, moistened with 1-8 chloride of zinc solution or 
carbolic acid, one part to ten parts of alcohol. Irri- 
gate thoroughly and insert a drainage-tube or a strip 
of iodoform gauze at the dependent points. 
If asepsis is complete, splinters still partly attached 
and sufficiently covered with periosteum will reunite 
with neighboring fragments; the medulla will adhere 
to the bone from which it has been detached and intra- 
medullary effusion of blood will be reabsorbed. 
Recollect the rule: remove only what is crushed and 
detached, and asepsis is complete with simple early 
removal of splinters. 40 
(e) ANTISEPSIS OF ARTICULAR WOUNDS- 
Articular wounds caused by firearms are of great 
surgical interest. In those cases where a bullet has 
pierced an articulation, grazing or furrowing the head 
of the bone, simple closing of the wound is sufficient. 
As a rule, however, more extensive wounds are en- 
countered. Articulations must be emptied of blood, 
bony fragments taken out, and if the synovial mem- 
brane is infected, touching with chloride of zinc or 
carbolized alcohol is necessary. After this irrigate 
with boiled water, 135 deg., insert drainage-tubes or 
gauze, and dress in the usual manner. 
In wounds of the larynx, tracheotomy is indicated 
more frequently than in ordinary surgical practice. 
Injuries to the urethra call for the insertion of a per- 
manent catheter to prevent constant dribbling of urine 
through the wound. 
All that has been said of emergency posts and 
ambulances pertains to field hospitals, with the excep- 
tion that the latter have a more secure and permanent 
location, and therefore the ordinary rules of asepsis as 
practiced in clinics and city hospitals can be applied 
more thoroughly and satisfactory.