Sasebo is the chief naval base of Japan, being possessed of a large, deep, and completely land-locked harbor, closely surrounded by fortified hills. The mouth of the harbor opens deviously and picturesquely on the west coast of Kiushiu, the first island a ship touches in coming up from Shanghai or across from Chifu, Tientsin or Port Arthur. It is at most, therefore, only two days' journey for the sick and wounded of Admiral Togo's fleet, to be comfortably transported in the Kobe Maru or the Saikio Maru-the hospital ships belonging to the Japanese Navyto the ample comfort and professional skill of Surgeon-General Totsuka and his base-hospital at Sasebo. The traveller, however, reaches it only by a five hours' journey northward from Nagasaki or seven hours' down from Moji, in the Straits of Shimonoseki, and then he is admitted only as an exceptional favor with a permit from the Minister of Marine at Tokyo. Sasebo, moreover, is under martial law, and every foreigner on the railway is closely crossexamined by the police. Few foreign visitors have visited the town, but amongst them must be reckoned the crews of a good many British colliers, twelve of which were in harbor on the day of the visit described in this article. The other chief naval stations and the only other naval hospital of importance are in the Inland Sea, the hospital with thirty beds being at Kuré, where the first two ironclads built in Japan have recently been laid down, a large naval station, situated an hour by boat or rail south of Hiroshima. Hiroshima, on the other hand, three days' journey by sea from Port Arthur, is the chief military medical base, with hospitals for 4000 sick and wounded, from which the slighter

cases and the convalescent are drafted on to Tokyo or Osaka, while the Russian prisoners are taken straight to the equally admirable hospital and prison quarters at Matsuyama in the island of Shikoku, which closes in the Inland Sea from the south.

The essential feature of the work at Sasebo naval hospital is that 90 per cent. of the cases of ordnance-wounds are inflicted by shell and not by bullet. Here then, for the first time in history, the science of shell-wounds is being studied under good modern conditions. For in South Africa hardly 5 per cent. of wounds, even early in the war, were inflicted by shell, and these were scattered up and down the country through a dozen different hospitals, so that a concrete study of their peculiar features was impossible. In the SpanishAmerican and Chinese wars there were few casualties from artillery, and earlier wars are of as little use to the modern surgeon as to the modern officer of artillery. During the first six months of the present war 180 cases of naval shell-wound had survived to reach Japan. The report, therefore, of the medical department of the Japanese Navy at the conclusion of the war will make a definite addition to surgical science. It will be of all the greater interest in that the three surgeongenerals of the navy know English well, and will, it is to be hoped, issue a report in our language on the precedent of their valuable report after the war with China in 1894. The DirectorGeneral, Baron Sareyoshi, was educated at St. Thomas's Hospital, and is a Fellow of the Royal College of Surgeons of England. In both of these spheres he is on common ground with Surgeon-General Totsuka, and with one of his predecessors, Dr. K. Takaki, who

at the age of twenty-five became Director-General of the Medical Department of the Navy, improved the rice-diet, and stamped out the scourge of beri-beri from the ships by introducing a thorough system of sanitation. The Director-General ranks as a vice-admiral, with two small stars on a broad gold stripe down the shoulder-strap. The other two naval surgeons-general rank as rear-admirals, with one star on a small stripe of gold; and medical officers of lower degree are called doctor, rank with captains, commanders, and lieutenants according to seniority, and wear the corresponding marks of rank.

The difference between explosive shell-wounds and bullet-wounds is absolute. The effect of the bullet depends upon what important structure it may strike-bone, nerve, artery, or internal organ. If it pass through flesh only and strike no such structure, and if the wound be kept clean from the first, the patient is perfectly recovered in a few days, the wound healing by primary intention. The effect of the explosive shell, on the other hand, is a laceration. The wounds of those who survive to reach Sasebo are either surface wounds or mutilations of a whole limb. The treatment is usually that of any other surface injury, or else amputation. Shrapnel wounds take an intermediate position. They are caused by half-inch leaden balls, scattered in large numbers in various directions on the bursting of the case; and owing partly to their comparatively small momentum, partly to their rough, leaden surface, partly to their having no screw-like rotary motion, which gives to the rifle-bullet its great penetrating power, and partly also to the particles of sulphur in which they are embedded in the case, they frequently remain in the body of the patient they hit, and introduce sufficient contamination to set up suppuration,

abscess, and occasionally blood-poisoning. Put tersely, then, the bulletwound is a shot through a roomful of machinery; the shell-wound is an explosion in or near the machine house; the shrapnel is a lucifer match thrown in through the window.

Cases of gun-shot or shrapnel wound in the navy of to-day must almost invariably indicate fighting on land, and these cases at Sasebo were incurred by men landed from the ships to assist in the fighting round Port Arthur. It is seldom now that men-o'-war approach each other near enough to make it worth their while to fire shrapnel. For the object of shrapnel is to kill or wound men, not to injure ships, and the aim in modern fighting on sea is essentially to sink or damage ships. In Nelson's days naval battles were necessarily at close quarters, and it was an attainable object to sweep the decks and to tear the sails and rigging with musket- and grape-shot and with cannon-ball, so as to deprive the ships of all control. Now with torpedoes and long-range rifled guns, with machinery instead of sails, and the whole protected in armor-plated bulwarks, conning-towers, barbettes, or 'neath decks below the waterline, the only methods of disabling a ship are to ram, to torpedo, or to breach the steel protection and damage the contents with heavy shell. Wounds on board ship, therefore, are usually the result of ragged splinters and sections of shell, although torpedo-vessels, with plating only three-sixteenths inch thick, offer little protection to their crew, and may occasionally be subject to raking shrapnel-fire.

The only case of shrapnel-wound that detained us at Sasebo was that of a man hit a fortnight previously in the fighting round Port Arthur, in which the shrapnel-shot passed in behind the shoulder and lay buried there. It was extracted, and the patient was in a

fair way to recovery. Another shrapnel-shot had passed through the flesh in front of his elbow, without touching bone, nerves, or artery, and had made its exit without causing any serious damage. There was not a single case in the hospital of a penetrating wound of the abdomen. Head wounds were limited to wounds of the scalp or fracture of the face-bones. There was one case in which a depressed fracture of the skull had been successfully treated by operation.

During the first six months of the war there had been two cases of chestwound, in which bullet or shrapnel had remained in the chest and were extracted, two or three in which they had passed in and out again.

The other cases noted were all of limb-wounds. G. Ishii, of torpedo-boat No. 67, had been severely wounded by shell in the month of May. A photograph showed clearly what his original condition had been, with the humerus broken, nerve severed, causing paralysis of the hand, and a gaping wound a foot long on the outer side and back of the arm. Amputation had been necessary; and now, early in August, the man was sitting up comfortably in bed with the wound healed, waiting for his artificial limb. One other case of a stump after amputation was pointed out. The leg had been well amputated through the knee-joint, and the artificial limb, light and well made, with good thighpiece, waist-belt, knee-, ankle-, and foot-joints complete, had just been tried on for the first or second time. These limbs were presented by the Empress, and are made, of course, in Japan, whose carpenters, joiners and cabinet-makers are perfect craftsmen, especially in bamboo. But very few cases had been serious enough to need amputation, from which fact two inferences may be made, firstly that few hopeless lacerations of a limb survive, and secondly that conservative surgery

is now an attainable ideal in almost all cases that reach hospital. The myth that surgery on the battle-field consists of amputation and ligature of arteries is fully exploded.

Five fatal cases had occurred in the hospital during the first six months of the war. Deaths, it is commonly understood, are now of rare occurrence on the surgical side of a military or naval hospital, a change due to Lister's and Pasteur's work. And the further removed a base hospital is from the scene of operations the more complete should be the sifting out of serious cases before the remainder are sent down the line or across the sea to the base. But this is less so on sea than on land; for the wounded at sea find the analogue of a field hospital in their hospital ship, which might just as well convey them to the base as remain with them in the neighborhood of naval operations. Indeed, hospital ships and hospital trains might well be equipped and scheduled as mobile field hospitals; and the twenty luxurious hospital trains on the Russian side in Man. churia are so equipped, with operating rooms, baths, kitchen, and full quarters for a full staff as well as for no less, on the Czarina's magnificent train, than 200 lying-down and 200 slighter cases, as compared with the hundred odd that were taken by each of our five hospital trains in South Africa. Thus one of the patients who died at Sasebo, M. Ono of the Fuji, was able to be transported by ship, although suffering from a shell-wound in both legs, resulting in double gangrene and death. If anything could have saved him, it could have been done in transit in the operating theatre of the Saikio Maru.

Shell-wounds, then, are mostly lacerations of the soft tissues. But there is another effect which comes into increasing significance with modern artillery. When a shell bursts, all men within a radius of several yards are

in severe danger of burns from the explosion. When watching the two days' artillery duel of Ta-shih-chiao, the junction of the branch line from Newchwang with the main Siberian Railway, on July 23 and 24, every explosion towards dusk seemed to us, fifteen miles away, as a flash of light half as high as the hills on which it exploded and as broad as it was long. Although the duration of this light cannot have been one-fifth of a second, yet its brilliancy and extent suggest the injury it may inflict. At Sasebo they have had a large number of cases in which burns have complicated wounds or have constituted the sole injury. These burns are clean, at least to the naked eye, and not of great depth; they are treated like ordinary burns, and redressed with aseptic gauze every other day. They have healed well, and so far there had been no case of complication or after effect. The scar is simply lighter in color than the surrounding skin.

One man who had suffered from clean cut wounds, now healed, behind the elbow and shoulder, had probably been struck by shrapnel. He belonged to the Shikishima, and was one of the many hundred who volunteered, and of the few who were selected, to take the six tramp-steamers into the mouth of Port Arthur harbor, and to sink them there in a perfect typhoon of artillery from ships inside and forts above. He survived, however, to be nursed by Mrs. Totsuka, wife of the Surgeon-General, as a photograph shows. This lady wore the serviceable white uniform of all who nurse under the Japanese Red Cross. The female nurses employed in the military and naval base hospitals and ships-for none go out to Manchuria-are all engaged and paid by the Red Cross Society of Japan. Many Japanese ladies are also in this war for the first time admitted to help in the work, although their untrained assistance is now re

stricted to the rolling of bandages and the preparation of first-field dressings, little packets that are sewn into the tunic of every soldier when he goes on active service. The social importance of this development can hardly be appreciated in England. Nursing in Japan has long been a tradition of Japanese women, but of women only of the lower classes. Considering that the feudal system was abolished only thirty-six years ago it is not surprising to find that hitherto there has been little mixing of the classes. For the last ten years, however, the Ladies' Volunteer Nursing Association, working under the control of the Red Cross Society, has been busily engaged in raising the credit of the nursing profession. Every day of the week the ladies of Tokyo work at the Red Cross Hospital, Europeans one day, Japanese five days a week; and it was an interesting sight on a fine July afternoon to see fifty of them of all ranks-from the Princess Nashimoto and Baroness Nobeshima, her mother, downwardsin their white cotton uniforms and caps busily engaged in rolling bandages. Twenty thousand of these bandages had recently been sent out on the Hitachi Maru and sunk by the Vladivostock squadron; but the ladies with characteristic courage set to work now at seven o'clock each morning to roll 20,000 more bandages-a somewhat typical incident in the present war.

waiting, and shook hands with the foreign visitor; the court ladies talking freely with all comers when the demonstration was over; the delicate models on a side-table of every kind of improvised stretcher and apparatus for carrying the sick and wounded,— such a scene could not fail to strike the least vivid imagination with a sense of its many-sided importance.

The Red Cross uniform for nurses is simple, clean and neat, consisting of a white cotton overall, tied with a cotton sash round the waist, and a high starched cap, which, although not becoming, has the merit of confining those stray locks that prove a source of anxiety to the aseptic surgeon. This cap usually bears over the forehead the distinguishing mark of a plain red cross. There are no English nurses in the Japanese hospitals, and none are wanted. One English lady-a British officer's widow-has contrived in her enthusiasm to be employed in elementary work at Tokyo. Fifteen American nurses, headed by Dr. Miss Gee, found employment at Hiroshima. But the difference of language, custom and food entail endless complications; and, except in scientific knowledge, which can only be gradually and systematically acquired, the westerners have not much to teach the dainty-fingered, patient, light-hearted little nurses of Japan. The Red Cross Society numbered on its books this summer 2391 nurses, 717 male attendants, and 150 stretcherbearers; and more are by now without doubt under training, sufficient for all probable demands. Moreover, it must be remembered that the Japanese work willingly for almost double the 8% hours' day which is considered the proper limit even in a London general hospital; and finally the Japanese nation have every desire to carry this war through to a successful termination with their own unaided resources, for the sake of the national credit.

The same reasons apply equaily to the question of medical aid. An offer made to the Japanese Government in August last to raise and bring out to Japan a band of young surgeons from England, to be supported probably by a charitable fund in this country, as was done from a fund raised by the Daily Chronicle in the Turco-Greek War, was declined with thanks, on the score of such help not being required. The reasons given above were doubtless largely responsible for this decision.

This hospital at Sasebo of 600 beds, early in August only half full, is built in ten pavilions of light gray wood, plastered on the inside, roofed in gray tile, simply floored in plain wood, standing two feet above ground on brick foundations, and connected by raised wooden corridors with overhanging roofs and wooden sides up to three feet from the floor. The spacious operating theatre, simply built with a proper view to light, space and cleanliness, measures 20 feet by 30, with walls 12 feet high and the unceiled roof rising another 8 feet to the centre of the room. Commendation of a cheap theatre may perhaps be challenged; but there is without a doubt much to be said in favor of simplicity in theatre construction, seeing that, so long as dust and rain are excluded, surgical infection can only arise from unclean hands, unclean ligatures or unclean dressings. If this be admitted, it is best to have a cheap theatre, which can be replaced at slight cost, to meet the varying needs of successive surgeons, and the successive stages of surgical opinion, and can be multiplied so as to permit of each surgeon having his own theatre, as he has his own wards. On this view it is wanton waste to spend money on marble halls, with complicated patent tables and regal fittings, as is too often the case in English hospitals, a relic of the early