The Journal of the Royal Naval Medical Service contains four papers dealing with the treatment of wounded in the battle of Jutland, in its issue dated October, 1916. Fleet Surgeon Alexander MacLean and Surgeon Horace, E. R. Stephens, both of H.M.S. Lion, describe their experiences in the hope that these may prove interesting to others, since the conditions under which naval medical officers have to work in action differ so widely from any that they may have encountered in other practice. Staff Surgeon J. McA. Holmes gives an account of the treatment and disposal of the wounded in a light cruiser during action. Mr. L. Fraser discusses the treatment of wounds received in naval action, and Fleet Surgeon John R. Muir, attached to H.M.S. Tiger, writes: "Hints for the use of Medical Officers in Action," based on his experiences in the battles of Jutland and the Dogger Bank.

The medical organization on H.M.S. Lion possessed two distributing stations for the shelter of the medical staff, stretcher parties, instruments, and medical stores. These were divided as equally as possible between the two stations. The forward station was small, though well protected. As it would accommodate not more than a dozen wounded, only walking patients proceeded to it.' The after station was too small for the accommodation of wounded, so that stores and instruments were kept in it. During action the mess-deck, which was behind armour, received all the stretcher cases which were placed in bathrooms or on mess tables. The wounded were not carried further than necessary. Those wounded in turrets and isolated compartments were only moved out of the way, and were not brought to the mess deck until a lull occurred in the action. Elaborate precautions and preparations were taken, but ought to be avoided. The part of the mes's deck which had been thoroughly 'prepared for the reception of wounded could not be used at all, as it was rendered untenable by fumes and smoke at the outset of the action. Most benefit was derived from canvas bags containing antiseptic and picric acid dressings, a tourniquet and bandages. These were placed in turrets, engine-rooms, boiler-rooms and other compartments as well as on the mess deck itself. These bags were replenished as needed from the stations. Well-trained first-aid parties, made up of writers, cooks, stewards, and canteen hands, did most valuable work, as the rest of the ship's company shrank from dressing Wounds, although they would tend fallen shipmates with brotherly affection. Ventilating fans were run on the mess deck until the action started, when they were switched off. On the lower decks they were kept running during the action. The delivery openings for fresh air were filled with shavings medicated in the same way as the tubular respirators. Respirators and anti-gas goggles were issued to each turret compartment, and to the mess deck. Although there was much trouble on the mess deck from smoke, burning débris, and T.N.T. fumes, no cases of gassing occurred. The simple respirator of gauze and waste proved so efEcient that the tubular respirators were not called into employment.

Nearly all the casualties on this ship occurred within the first half hour. A few patients found their way to the fore station, but the majority remained on the mess-deck. During the first lull the medical officers made a tour of inspection of the ship. The scenes that greeted them beggared description. Most of the wounded had already been dressed. Tourniquets had been applied in one or two , instances, though haemorrhage was less than might have been expected from the extensive lacerated wounds. As there was much water about the wounded were kept dry and warm on tables. Morphine in 0.04 gm. doses was given hypodermically by the medical officers alone to all the wounded. The Wildey syringes were excellent, though the needles might have been stouter. The medical officers state that these maximal doses of morphine relieved pain and controlled haemorrhage instantly. Such large doses caused nssymptoms of overdose when administered soon after the receipt of the injury and before the reserve of stamina of the healthy men had been lowered by pain. The battle was thrice renewed in the evening, but the

wounded were all carried in lulls to the mess-deck. No splints were applied since tthe Neil Robertson stretcher answered the purpose admirably. After the action was over the injured were kept warm throughout the night with blankets and hot bottles, while they were fed occasionally with bovril and medical comforts. During the evening ten of the desperately wounded and burned died. It was impossible to move any of the wounded during the night owing to the probability of a renewal of the action at dawn. Many of the wounded slept undisturbed.

At 7.30 o'clock the next morning the medical officers were informed that it would be safe to bring up the wounded from below. The Vice-Admiral's and captain's cabins, which were full of smoke and water, were cleaned, dried, and thoroughly ventilated. A start was made at 8.45 a.m. with the treatment of the wounded, the captain's bathroom serving as an operating theatre. Fifty-one patients were dealt with, and a general anaesthetic was administered to twenty-eight. Two officers gave much assistance by administering anaesthetics. After operation the patients were placed on bedding on the decks of the Vice-Admiral's and captain's quarters. No mishaps occurred, and all the wounded were discharged without a further death. Urgent operations only were performed. Full exploration of large wounds was impossible for lack of time. Two amputations were postponed for a similar reason. Three amputations of the lower limb were carried out. Five compound comminuted fractures of the leg were treated with splints. The surgical toilet of wounds consisted of swilling them out with eusol, draining, trimming and suturing when needful. Abdominal injuries were absent. Although the wounds remained with first-aid dressings from sixteen to thirty hours sepsis was much less frequent than the conditions warranted the medical officers to expect.   Eusol was the only antiseptic applied to the wounds. General burns, invariably due to cordite fires, were severe. and fatal. Almost 50% of the wounded suffered from burns of the face and hands alone. These burns were caused by the flash of high explosives in a confined space. The flame was so momentary that clothing. completely protected the rest of the body. The ankles were scorched in a few cases, but this did not occur when the trousers were tucked inside the socks. The eyes being closed in time escaped injury. Masks and gauntlets would probably prevent many casualties among repair, and fire parties on the lower decks. The picric acid dressing was most satisfactory as a first-aid dressing to burns. This dressing was, however, liable to become dry if left on too long, despite the covering of mostig batiste. The dressings were difficult to remove when dried. As a second dressing eucalyptus and olive oils were applied, and covered with fomentations. Notes on every case were taken in shorthand at the time. These notes included the name, age, rating, nature of injuries and treatment. They were found most valuable later. Prior to leaving the theatre each patient was labelled with the notes. The last case was finished at 12.15 o'clock on the morning of the next day, when the medical staff went to a much-needed rest.

On arriving at the base on the same day forty-six wounded were transferred to the hospital ship "Plassy," while five cases of slightly wounded were retained on board. Nine days later a report was received from the medical officers on the hospital ship "Plassy," giving an account of fourteen of the extensively wounded patients. These were cases not of burns but mostly of multiple injuries, including the five compound comminuted fractures. Nine wounded had no septic wounds, while five patients had septic wounds. In all the septic wounds portions of clothing had not been removed at operation. The medical officers record with gratification the work of the their staff, which was sadly depleted during the action, as many as 44% of the sick berth staff coming into the casualty list.

The light cruiser in which Staff Surgeon J. McA. Holmes served, came into contact with the enemy on the evening of May 31, 1916. The ship was engaged on and off at intervals throughout the night. A severe engagement occurred with three enemy cruisers about 9.45 p.m., when all the casualties were received. Forty-one wounded were noted, of whom twelve died almost instantaneously. The wounded were sent to two dressing stations. one forward and the other aft. These dressing stations were on the lower or main deck, and were close to galleys, so that a supply of hot water was always available. Open hatches were conveniently situated to the dressing stations, and patients who could walk descended by them. As the crew had been previously trained in man-handling wounded and passing them down canvas chutes in the hatches, stretchers were not used. The effect of the previous training was noted in the speed with which the wounded were brought to the stations. The whole of the wounded were received within five minutes of any lull in the severity of the engagement. The crew put on clean clothing one hour before the action started, and as many as possible took a bath with water containing izal. Twenty-six patients required treatment. Eleven of these had slight wounds, while fifteen suffered from severe injuries. As soon as the injured reached the dressing station they received an hypodermic injection of morphine if they had not been given a dose of anodyne mixture. The wound was washed with corrosive sublimate solution, and covered with cyanide gauze wrung out from 1 in 40 carbolic acid. Any patients who had been dressed on deck were examined, and a fresh dressing applied. At 1-0.45 p.m. all the wounded had received first aid. As it appeared that thirty-six hours would elapse before the patients could be transferred to a hospital ship it seemed desirable to give more active treatment. The operating theatre was brought into use, and by 9 o'clock next morning all the wounded had been dealt with. As the ship was engaged during the night much difficulty was experienced in this work. The sick-birth steward gave the anaesthetics until 5 a.m., when the surgeon in the forward station was able to come to the aft station. The operations consisted of one amputation of the forearm, several amputations of fingers and toes, removal of splinters from wounds, trimming and suturing of lacerated parts. Among the more severe wounds, all described in detail, was a compound comminuted fracture of the frontal eminence on the left side. The left eye was disorganized. Ten splinters of bone were taken away under chloroform, and a portion of disintegrated bone shaved away. The wound was drawn together with catgut and a drainage tube inserted. No burns were caused on this light cruiser. Fifteen severe cases were transferred to the hospital ship "China," on June 2, 1916. No record was received of their progress. Of the eleven kept on board all had recovered by the fifth day with one exception. This patient had a perforating wound of the wrist, with some loss of skin at the entrance and exit wounds.

Mr. Lachlan Fraser describes forty-three casualties from the battle of Jutland, admitted into the Tynemouth Jubilee Infirmary. Sixteen cases from H.M.S. "A" were received upon June 2, 1916, and twenty-seven cases on June 3 from H.M.S. "B." The first batch of cases had been dressed by Surgeon Probationer Bell, R.N.V.R. The dressings consisted of antiseptic paste and gauze. Some of the men had had serum administered. In the case of H.M.S. "B" almost the first shell had struck the sick bay, killing the surgeon probationer, wounding the sick bay steward, and destroying most of the dressings. The sick-bay steward was admitted with the other wounded. He said that the only dressings left by the shell were 1 lb. boric lint, 2 Ibs. white lint, 1 bottle of san cresol, 4 oz. tinct. iodi, some picric acid and some bandages. The steward carried the dressings aft, where the wounded were collected. The wounded were dressed by him and given a dose of morphine. The dressings were changed three times on the way to the base. As the dressings gave out he used pieces of clean sheeting. The burns were dressed with picric acid. Four patients died on board soon after being injured, but the rernaining twenty-seven did well.

On admission fo hospital the patients were placed in bed between hot blankets. They were then labelled "ward" or "theatre." Those not requiring an anaesthetic were treated in the wards. Three surgeons worked at once in the theatre, so that the whole of the wounded were treated rapidly. Sixteen cases required three hours, and twenty seven cases five hours. The cases which were most collapsed on admission were left to the last. The routine treatment of the wounds was as follows: The surrounding parts were scrubbed and thoroughly cleaned. The wound was washed with normal salt solution, all pockets freely opened, and any visible foreign bodies removed. These foreign bodies consisted of pieces of clothing and fragments of shell. No attempt was made to find hidden pieces of shell. If the wound was not clean it was washed out with 1 in 40 carbolic acid, and afterwards with normal salt solution. When deep cavities existed gauze wrung out from hypertonic salt solution was applied, and continuous irrigation with the salt solution kept up. During the first week in hospital radiographs were laken of all patients. Fragments of shell found in this. way were removed.

Among the severe cases was that of R. B., aged 21 years. The left foot had been blown off by a shell. The surgeon probationer had trimmed and dressed the stump. There was a fearful shell wound of the left calf just below the knee, the bruising extending up the lower third of the thigh. The patient had lost much blood, was blanched and almost pulseless. He was given saline solution and brandy per rectum. The stump was dressed and treated witb hypertonic salt solution. Four days later, as the patient had rallied, the stump, which was offensive, was amputated through the middle of the thigh. The stump became septic, and consequently one month later it was opened up and thoroughly cleansed. The flaps were dried and covered with bismuth and iodoform paste. Two days later there were signs of poisoning with iodoform. A severe secondary haemorrhage occurred, which necessitated the further opening of the wound. The bleeding was found-to be derived from one of the perforating arteries, which was ligated. The patient slowly rallied, and six weeks later was able to get about on crutches. Mr.. Fraser says that the wounds received in the naval actions were similar to severe machinery accidents in which much laceration and contusion of the soft parts, splintering of bone, haemorrhage and shock took place. Except when haemorrhage was profuse shock did not occur among the picked able-bodied men of the naval ratings. Reaction was also slight aYter operation. A man whose arm was amputated upon admission wrote a letter with his left hand the following day, and strummed on the piano in a week. He did not progress so quickly after the formal "flap operation" done "in cold blood" some days later. A man with a trephined ski-ill consequent to a fracture played the mandoline while the sister was absent from the ward three lays later with no ill effects.

Fleet Surgeon Muir gives much information of the experiences in action as illustrations of the usefulness of his hints for the guidance of naval medical officers in action. He points out that contrary to the pre-war conception casualties arrived in numbers from the time that the first casualty occurred. Instead of the patients drifting in slowly, so that they could be treated as they arrived, there was nothing to do until twenty seriously wounded men, representing sixty extensive wounds, were brought in for treatment. The Admiralty instructions directed that two distributing stations should be manned, one forward and one aft. In the "Tiger" these stations were supplied in the design of the ship, and their positions could not be altered. As the aft dressing station did not appear to be well protected from plunging shell fire, the surgeon in charge of the station in the first battle was directed to withdraw his parties into the ammunition passages on the disengaged side. The experience in this first battle at the Dogger Bank led to the aft dressing station being rigged in compliance with the Admiralty instructions, but with the consent of the Captain the party in charge proceeded to the forward dressing station on the order "Man the after dressing station." If this had not been done in the battle of Jutland, the whole of the party in the ~,ft dressing station would have been annihilated.

When the bugle sounded "Action stations," the medical staff received their full complement of assistance. In addition to the regular medical party, six stretcher parties were provided. Each party consisted of three persons. These had special training and were most expert in finding their way to the forward station from any part of the ship by the quickest route. As soon as the ratings had assembled, the roll was called by the principal medical officer. Life-saving waistcoats and respirators were served out.

Each stretcher party received a stretcher and a first-aid bag. The senior rating examined the bag and reported any deficiencies. The latest authentic information was given, and the parties are told to do some simple thing. It was found necessary to occupy the time with some work while waiting for the special duties. In one action two hours passed before the first casualty arrived. This waiting was most trying. The noise of the guns was deafening, and the concussion and vibration was so severe that it seemed as if the body was held by the shoulders and violently shaken every half minute, The smell of cordite was sickening in its intensity and penetration. The rumours running along the deck were alarming, and the stampede of fire parties made the heart beat more quickly. The inaction tried the    nerves. On receipt of information that stretcher- bearers were needed, the parties set out from the station. Having sighted the wounded, they covered the more obvious wounds and placed the wounded in the Neil Robertson stretcher.    The patient was borne to the station, removed from the stretcher and placed on a couch. Two cooks, under the supervision of an officer, stripped the patient by means of large scissors. When unclothed, the injured man was wrapped in a blanket. The medical officer overhauled the patient and applied dressings. The Chief Writer took down the patient's name and added notes at the medical officer's dictation. The Chief Writer searched the clothing stripped from the patient, and reported to the principal medical officer any valuables found. One man had £19 upon him. The clothes are tied up and labelled with the patient's name. The patient was placed in a cot or upon a table, and served with a half-pint of hot bovril.

After the action the work of the medical-ratings was heavier. On the bugle sounding "Secure," all the supernumary workers, cooks, stewards, writers,  and others placed at the disposal of the surgeons, were called to other duties. As the principal part of the medical department's duty can be attempted only when the action is over, this depletion of the staff is quickly felt.

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